The Death Gap: How Inequality Kills (2017) is a nonfiction work by David A. Ansell that examines health disparities in the United States. Ansell, a Chicago physician and public health advocate, draws on his extensive experience working in underserved communities to expose the realities of how socioeconomic factors drastically affect health outcomes. Throughout the work, Ansell explores themes of inequality, systemic racism, and social justice, examining Healthcare as a Human Right VS Commodity; Environmental and Social Determinants of Health Disparities; and The Role of Community Activism in shaping public health outcomes.

This guide uses the 2021 University of Chicago Press paperback edition.

Content Warning: The source text discusses systemic racism and inequality.

Summary

In the Foreword, Lori Elaine Lightfoot, the former mayor of Chicago, discusses the severe health disparities in the USA that were accentuated by the COVID-19 pandemic. In April 2020, data showed that black Chicagoans, comprising a third of the population, accounted for 72% of COVID-19 deaths. The Foreword describes Chicago’s urgent response to the pandemic, including the formation of the Racial Equity Rapid Response Team, aimed at addressing chronic disease disparities and the broader societal inequities shaped by poverty and systemic racism.

In the Preface, Ansell highlights the severe impact of inequality on life expectancy in America. He uses Ogden Avenue in Chicago to illustrate health disparities between affluent and impoverished neighborhoods, revealing a 20-year gap in life expectancy. Ansell’s 30-year medical career along Ogden Avenue has shown him the correlation between neighborhood poverty and health outcomes. Ansell emphasizes that these inequalities result from systemic exploitation and historical practices. He advocates for policy and community solutions to address health disparities.

In Chapter 1: “American Roulette,” Ansell details the critical medical emergency of his long-term patient, Windora Bradley, an African American woman from a disadvantaged Chicago neighborhood. During a hospital consultation, Windora suffers a stroke, which leaves her with irreversible brain damage. Ansell reflects on her health history, attributing her condition to socioeconomic status, race, and location, likening her plight to a rigged game of Russian roulette, which he calls the “American roulette.” He argues that rising inequality since the 1970s, driven by policies favoring the wealthy, has exacerbated health disparities. Ansell criticizes the American healthcare system’s failure to address social determinants of health, arguing that structural violence is embedded in public policies.

In Chapter 2: “Structural Violence and the Death Gap,” Ansell challenges the notion that individuals are solely responsible for their health outcomes, emphasizing the significant roles of poverty, unemployment, and racism. These structural factors cause chronic diseases over time, creating “death gaps”—disparities in mortality rates tied to socio-economic and racial inequities. Ansell compares the 2010 Haiti earthquake, with over 300,000 deaths, to the 1989 Oakland earthquake, which caused 63 deaths, demonstrating the impact of socio-economic conditions on survival. He argues that broader social determinants often go unrecorded on death certificates, obscuring the true causes of health disparities. Using a metaphor of a doctor fixing a hole causing multiple injuries, Ansell illustrates physicians’ roles in treating both patients and systemic issues.

In Chapter 3: “Location, Location, Location,” Ansell explores how historical and systemic forces shape health and wealth inequities, particularly in low-life-expectancy neighborhoods. He references W. E. B. DuBois’s 1896 work, which attributed health disparities between Blacks and whites to socio-economic and environmental conditions, not biological differences. Ansell examines the severe housing discrimination faced by African Americans in the 20th century. Discriminatory policies led to mortgage disparities and exploitative practices, such as destabilizing neighborhoods and purposefully causing economic decline. Industrial job losses in urban centers further impoverished segregated Black neighborhoods. Ansell highlights significant life expectancy gaps between affluent and poor neighborhoods, using examples from Chicago and Cleveland. He emphasizes that while Black Americans are most affected by the death gap, poor whites, Latinos, and Indigenous peoples also suffer high premature mortality rates.

In Chapter 4: “Perception is Reality,” Ansell discusses how contemporary racial and ethnic biases sustain poverty and poor health in segregated communities, despite historical roots in structural violence. He highlights the “empathy gap” whereby affluent communities, controlling much of the national income, show little support for public programs aiding the poor due to reduced tax burdens. Ansell argues that meaningful change in high-mortality neighborhoods requires empathy, solidarity, and substantial investments, funded by wealth redistribution through higher taxes on the rich.

Ansell notes the detrimental impact of the “perception gap”: The way in which affluent individuals often blame the poor for their struggles due to economic and racial segregation. He discusses the “broken windows theory,” which suggests that visible disorder leads to crime and decline. However, sociologist Robert Sampson argues that racial and economic biases in perceiving disorder drive this decline. These perceptions stigmatize and segregate neighborhoods, trapping them in poverty and poor health cycles. Ansell emphasizes the need for structural changes and empathy from wealthier communities to address health disparities.

In Chapter 5: “The Three B’s: Beliefs, Behaviour, Biology,” Ansell recounts a dinner conversation highlighting skepticism towards structural violence as a cause of health disparities. Many attribute poor health to individual choices and genetics, overlooking systemic factors like poverty and racism. Historically, health inequalities have been explained through racial and biological differences. Ansell discusses environmental racism, citing high asthma rates in polluted Black and Latino neighborhoods and the Flint water crisis. He critiques “precision medicine” as reinforcing scientific racism.

In Chapter 6: “Fire and Rain: Life and Death in Natural Disasters,” Ansell explores how events like the 1995 Chicago heat wave and Hurricane Katrina in 2005 exposed social inequities in high-poverty neighborhoods. During the Chicago heat wave, record temperatures overwhelmed emergency services and hospitals, leading to over 700 deaths, primarily among the elderly in impoverished areas. The lack of adequate emergency measures led to systemic failures. Similarly, Hurricane Katrina devastated New Orleans, with poor, predominantly Black neighborhoods suffering the most due to inadequate evacuation resources and emergency response. Media portrayals of Black residents as looters diverted attention from systemic issues. Both disasters underscore how environmental crises exacerbate existing inequalities and highlight the need for reinvestment in neglected communities to mitigate these impacts and close the death gap.

In Chapter 7: “Mass Incarceration, Premature Death, and Community Health,” Ansell examines the impact of mass incarceration and premature death on Black communities. High incarceration rates and premature deaths from heart disease, cancer, and violence create a significant gender imbalance in urban Black neighborhoods. Ansell argues that mass incarceration serves as a tool of racial and social control, disproportionately affecting Black and Latino communities despite decreasing crime rates. He highlights the health detriments of imprisonment, including high rates of infectious diseases, mental health issues, and chronic conditions. Moreover, the removal of men from communities disrupts family structures, placing caregiving burdens on women, who suffer poor health outcomes as a result. Ansell calls for ending mass incarceration and investing in disadvantaged communities to improve health outcomes and life expectancy.

In Chapter 8: “Immigration Status and Health Inequality: The Case of Transplant,” Ansell highlights the challenges faced by noncitizens, including undocumented immigrants, in accessing health insurance due to restrictive policies. Ansell tells the story of Sarai, a 25-year-old undocumented immigrant with Wilson’s disease, who was denied a liver transplant at multiple hospitals due to her immigration status and lack of insurance, leading to her death. Ansell also recounts community protests led by Father Jose Landaverde, advocating for healthcare access for undocumented immigrants. These efforts raised awareness and prompted legislative changes, allowing some undocumented patients to receive transplants. Ansell stresses that true health equity requires universal healthcare access for all, regardless of citizenship status.

In Chapter 9: “The US Health Care System: Separate and Unequal,” Ansell explores three primary causes of healthcare inequalities: Treating healthcare as a commodity; implicit racial bias; and resource constraints in disadvantaged communities. These factors lead to poorer health outcomes for minorities and the poor. Implicit bias among healthcare providers results in differing care levels based on race and insurance status, worsening disparities. Lack of health insurance further exacerbates the problem, with uninsured adults often forgoing necessary care due to cost. Hospitals serving minority populations, like Mount Sinai Hospital, typically face financial constraints and higher mortality rates across various conditions. Ansell stresses the need for structural reforms and national health insurance to treat healthcare as a fundamental human right.

In Chapter 10: “The Poison Pill: Health Insurance in America,” Ansell critiques the Affordable Care Act (ACA) and advocates for a single-payer healthcare system. While the ACA expanded insurance to nearly 90% of Americans, it fails to provide universal and equitable healthcare. Ansell argues that 30 million people remain uninsured and many are underinsured. He states that healthcare should be a right, not a commodity.

In Chapter 11: “Community Efficacy and the Death Gap,” Ansell examines how public policies, social inequities, and healthcare factors impact health outcomes in different neighborhoods. The chapter examines the cases of different neighborhoods in Chicago, such as Chatham, Roseland, and Oak Park. Despite facing decline and violence, Chatham historically maintained better health outcomes than nearby Roseland, due to strong social cohesion and collective efficacy. Ansell emphasizes that collective efficacy leads to better health outcomes but is less common in predominantly Black neighborhoods due to greater structural barriers.

In Chapter 12: “Community Activism Against Structural Violence,” Ansell highlights community activism initiatives on Chicago’s South Side between 2010 and 2015. A key example is the campaign for a Level 1 trauma center led by Fearless Leading by the Youth (FLY), which was successful in advocating for the opening of a new adult trauma center in December 2015.

In Chapter 13: “Observe, Judge, Act,” Ansell emphasizes the duty of doctors to advocate for the poor beyond hospital settings. He once more criticizes the US healthcare system for treating health as a commodity, prioritizing profit over the needs of disadvantaged populations. He argues that physicians must address health disparities and advocate for an equitable healthcare system.

In the Afterword, Ansell reflects on how the COVID-19 pandemic exacerbated existing health inequities, particularly in Chicago. The crisis highlighted the severe impact of structural racism and poverty. Initiatives like the Racial Equity Rapid Response Team aimed to address these disparities. Ansell underscores the need for systemic change, emphasizing human rights and social justice, including universal healthcare, to achieve health equity. He concludes with optimism about the role of narrative, data, and community activism in driving social change and closing health gaps.