The Death Gap: How Inequality Kills

Chapter 2 starts by addressing the common belief that individuals like Windora Bradley are personally responsible for their health outcomes. Ansell argues that while personal choices and biological factors play roles, deeper, chronic causes like poverty, unemployment, and racism are often obscured. These structural factors gradually manifest as chronic diseases, making it difficult to discern their impact over long periods.

Ansell emphasizes that to understand health disparities, one must look at large-scale patterns over time, examining data by gender, income, race, and geography. He introduces the concept of “death gaps” (16) to describe the actual outcomes of health inequities, where people die prematurely due to systemic inequalities. The death gaps reflect significant differences in mortality rates that correlate with socio-economic and racial disparities.

To illustrate the effects of structural violence, Ansell compares the 2010 earthquake in Haiti with the 1989 earthquake in Oakland, California. The Port-au-Prince earthquake resulted in over 300,000 deaths, largely due to inadequate building practices and the quality of the emergency response. By contrast, the Oakland earthquake, though similar in magnitude, caused only 63 deaths. This stark difference exemplifies how socio-economic conditions and preparedness influence survival rates. Ansell links Haiti’s dire situation to its history of exploitation by Western nations, particularly France and the United States, which demanded hefty reparations and maintained oppressive economic relationships, leading to chronic poverty and vulnerability.

Ansell recounts his experience providing medical relief in Haiti, where he encountered a woman suffering from “broken heart syndrome” (19), a condition triggered by extreme stress. This case exemplifies how external stressors, like natural disasters, can exacerbate health issues. He notes that while the immediate cause of death might be a medical condition, the underlying causes often include broader social and economic factors.

Death certificates, which list immediate, intermediate, and underlying causes of death, rarely capture these social determinants. Thus, structural violence remains invisible in official records. Ansell argues that life expectancy is a crucial measure of a population's health status and a barometer of health inequalities. He notes that life expectancy gaps between different communities within the United States are greater than those between developed and developing countries, which reflects profound internal inequalities.

Ansell discusses efforts to address health disparities, such as the Healthy People initiatives by the US Department of Health and Human Services, which aimed to reduce and eliminate health disparities by 2000 and 2010, respectively. Despite these efforts, studies reveal persistent mortality gaps between racial and socio-economic groups, with urban and rural high-poverty areas experiencing entrenched patterns of disease.

Ansell discusses the fact that, while racial mortality gaps have narrowed in some areas, overall disparities remain. He notes that rising death rates among poor whites due to issues like the opioid crisis have narrowed the mortality gap rather than indicating an improvement in health prevention and treatments of disease.

Finally, Ansell uses the story of a country doctor who, after treating multiple patients with broken legs from falling into the same hole, decides to fix the hole himself. He likens the role of the doctor in the story to his own role in the community. The analogy illustrates the dual role of physicians: Treating individual patients and addressing the systemic issues that cause harm.

Chapter 3 examines the importance of location in understanding health and wealth inequity, with Ansell arguing that low-life-expectancy neighborhoods are products of historical and systemic forces, especially in the North and Midwest of the United States.

Ansell highlights the groundbreaking work of Black American sociologist W. E. B. DuBois, who in 1896 argued that health disparities between Blacks and whites in Philadelphia were caused by socio-economic and environmental conditions rather than by biological differences. DuBois’s findings remain relevant today, as the legacy of enslavement and systemic racism continues to impact health outcomes.

The chapter outlines the Great Migration, where six million African Americans moved from the South to northern, midwestern, and western cities between 1910 and 1970, drastically altering urban demographics. The migrants faced severe housing discrimination, with restrictive contracts and violent resistance from white communities, which limited their residential options. Their precarious situation was further exacerbated by racist lending practices, such as redlining, where banks refused loans to predominantly Black neighborhoods, marking them as high-risk.

Ansell describes how the federal government institutionalized these practices during the 20th century, creating residential security maps that classified neighborhoods by racial composition and perceived investment safety: Green areas were deemed safe, while Black neighborhoods were marked in red and considered risky. These policies led to a massive disparity in mortgage availability, with less than 2% of federally-guaranteed loans between 1934 and 1962 going to non-white families. Housing market speculators also used exploitative practices such as blockbusting, in which real estate agencies persuaded owners to sell their properties fast and for lower than the market price due to fear of another racialized group. The agencies then sold the property at a higher price to the incoming migrants. Speculators preyed on both white homeowners’ fears and Black homebuyers’ desperation. These practices caused significant neighborhood destabilization, property value declines, and eventual abandonment and decay of housing stock.

Economic decline also played a critical role, as industrial and manufacturing jobs left urban centers for the suburbs between 1950 and 1980, leading to high rates of unemployment and poverty in newly-segregated Black neighborhoods. Chicago, for instance, lost 60% of its manufacturing jobs during those decades, significantly impacting communities like North Lawndale.

The historical and systemic factors that Ansell describes led to the creation of neighborhoods of concentrated poverty and disadvantage, in contrast to areas of concentrated wealth. These disparities are evident in life expectancy gaps: Affluent neighborhoods like Hyde Park in Chicago have high life expectancies, while adjacent low-income, predominantly Black neighborhoods, like Washington Park, have much lower life expectancies.

Ansell points out that such disparities are not unique to Chicago. Across the US, there are significant geographic gaps in life expectancy between nearby neighborhoods. For example, in Cleveland, life expectancy in the affluent suburb of Lyndhurst is 88 years, while just eight miles away in the poor neighborhood of Hough, it is only 64 years.

The chapter concludes by noting that, while Black Americans suffer the most from the death gap, poor white Americans, Latino communities, and Indigenous peoples also experience high premature mortality rates, especially in areas with a history of impoverishment, such as Appalachia and the Pine Ridge Reservation in South Dakota. Thus, Ansell emphasizes that for the poor, geography is destiny and calls for action to address the systemic issues that have shaped and perpetuated these inequities to reduce the life expectancy gaps.