The Death Gap: How Inequality Kills

Chapter 7 highlights the large-scale absence of Black men from communities due to premature death and imprisonment. Ansell notes that in many urban Black neighborhoods, there is a significant gender imbalance due to high incarceration rates and premature deaths from conditions like heart disease, cancer, and violence. For instance, in Chicago, the incarceration rate in Black neighborhoods is 40 times higher than in white neighborhoods.

Ansell frames incarceration as a tool of racial and social control, affecting predominantly Black and Latino communities. The rise in incarceration rates over the last five decades, despite dropping crime rates, highlights the disconnect between crime and imprisonment. Instead, aggressive policing, stringent drug laws, and harsh sentencing have disproportionately targeted Black communities.

From a health perspective, Ansell discusses how prisons are detrimental to individual wellbeing due to higher rates of infectious diseases like HIV and hepatitis C, mental health issues, and chronic conditions exacerbated by the prison environment. Upon release, former inmates face significantly higher mortality rates, primarily due to drug overdoses, heart disease, and violence.

The impact of mass incarceration extends to families and communities. The removal of large numbers of men disrupts family structures, leaving women to bear the burden of caregiving for returning ex-offenders who often experience substance misuse disorder, mental illness, and infectious diseases. This burden contributes to poor health outcomes for caregivers, who report high rates of smoking, hypertension, anxiety, and depression.

The absence of men in these communities also has social and economic repercussions, contributing to high poverty rates and the lack of stable family units. Children with incarcerated parents face increased risks of future imprisonment and poor health outcomes. This cycle of disadvantage is illustrated by the limited aspirations of children in these neighborhoods, who often see prison or early death as inevitable.

To address these issues, Ansell argues that ending mass incarceration is crucial. The current system of racial and social control through imprisonment perpetuates poverty and poor health in disadvantaged communities. Reforming this system and investing in these communities is essential to improving overall health outcomes and life expectancy in America.

Chapter 8 discusses the difficulties of around 21 million noncitizen residents, among which are 11 million undocumented immigrants, to access health insurance due to long-standing public policies. Ansell tells the story of Sarai, a 25-year-old undocumented immigrant diagnosed with Wilson’s disease, a rare inherited condition that leads to liver failure. Sarai’s mother, Victoria, recounts how they were denied a liver transplant at multiple hospitals due to Sarai’s immigration status and lack of insurance. Despite Victoria securing health insurance, the barriers persisted, and Sarai eventually died because she could not get the life-saving treatment she needed.

The narrative then shifts to Roberto, a 42-year-old man with kidney failure who moved to Illinois to receive dialysis treatments unavailable to the uninsured in Texas. Roberto’s experience in emergency rooms, where he was treated with disdain by the medical staff, exemplifies how structural violence manifests in the healthcare system, where policies and attitudes prevent marginalized individuals from receiving necessary care.

Ansell critiques the role of healthcare workers who, rather than challenging unjust policies, often become the enforcers of these systemic barriers. He underscores the failure of medical professionals to adhere to the principles of the National Organ Transplant Act of 1984, which aimed to ensure equitable access to transplants based on medical need, not financial capability.

Ansell recounts the story of a community-led protest organized by Father Jose Landaverde, who was advocating for equitable healthcare access for undocumented immigrants. The protests, hunger strikes, and public demonstrations led to increased awareness and, eventually, legislative changes. Ansell describes his involvement in facilitating dialogue between community leaders, healthcare providers, and political representatives, which resulted in some undocumented patients finally receiving the transplants they desperately needed.

However, Ansell emphasizes that while these steps are significant, they are not sufficient. True health equity requires comprehensive and universal access to healthcare for all, regardless of citizenship status.