Chicago Epidemiologist Coaches Michigan Healthcare System on

How to Confront the Health Effects Bred by Structural Racism

BENTON HARBOR, Mich. – Dr. David Ansell likes to say he practiced internal medicine for decades along “one street” but in “two worlds.” The street is Ogden Avenue, which links Chicago neighborhoods of great wealth, and correspondingly long lifespans, with poor neighborhoods and far shorter lifespans.

One world is predominantly white, the other predominantly black and brown.

The three hospitals he has worked at along that street, though within a mile of each other, are far apart in resources. Patients tend to suffer or prosper accordingly. He writes of these two worlds movingly in his 2017 book, “The Death Gap: How Inequality Kills.”

What’s true in Chicago is also true in Benton Harbor, Mich., where Ansell spoke Sept. 27. “Where you live in America, and actually pretty much across the world, dictates when you die. In many ways, the gaps between the poor and the rich in this country are getting worse,” he said. (VIDEO: Dr. David Ansell’s Benton Harbor Presentation)

Ansell is Senior Vice President for Community Health Equity at Rush University Medical Center in Chicago. The first person named to this pioneering role, Ansell is on a mission to help improve the health and economic vitality of Chicago’s West Side.

At his talk, Ansell showed a number of slides illustrating the growing gaps in wealth and health in the U.S.

He noted that the rich and the poor in the U.S. had about the same life expectancy until 1972. Now, people in some neighborhoods in America live an average 35 years longer than people in the worst-off neighborhoods. In Michigan the gap is around 30 years. Among developed countries, almost none has a gap approaching that of the U.S.

And the gap in wealth has grown in America since the 1980s.

‘Not Accidents’

Wherever they live in the U.S., rich people tend to live longer lives. For the poor, however, some places are better than others, a fact Ansell attributed mainly to local policies.

Source: Waldron. ORES, Social Security Admin, #108, 2007

In a study of 171 U.S. cities containing poor neighborhoods, “there’s not one poor white neighborhood that’s as badly off economically as any poor black neighborhood, and that’s how racism works,” Ansell said. “It’s not exclusively racism, (but) disproportionately racism.

“These are not accidents. It didn’t just rain and make this happen. This happened because of deliberate decisions we have made as communities in the nation about who lives and who dies in this country. That’s the good news: We can fix it.”

As a social epidemiologist, Ansell focuses on what are known as social determinants of health—such things as jobs, the livability of neighborhoods, access to transportation and good health care and good education. Determinants are “the conditions in which people are born, grow, work, live and age, and the wider set of forces and systems shaping the conditions of daily life.”

‘Inequality Kills’

People tend to think of disease as being transmitted through viruses, or of ill health as caused by things like poor diet. “But actually, inequality kills through exposure to poor social conditions,” Ansell said. There is a cascade of effects, and “where you live affects the biology of your body, and exposure to toxic stress actually causes ill health.”

It’s true that differences in access to medical care, and the quality of that care, do matter—and studies have shown that racial inequities are built into health care. But of far greater importance are the social conditions in which people live, and the “life opportunity gaps” separating healthy neighborhoods from unhealthy neighborhoods.

Rush University Medical Center is in the second year of an ambitious effort to close the health inequities on Chicago’s West Side, home to a half million people. Rush is taking a novel approach whose key elements include doing things that hospital systems don’t ordinarily do, such as developing career pathways for high school students in Rush’s neighborhoods, promoting local supply chains, co-locating mental health professionals with other community services, and partnering with several other hospital systems and community organizations to tackle generations-deep social problems.

‘You Can Put Your Arms Around This!’

Ansell found a receptive audience in southwest Michigan at Lake Michigan College near Benton Harbor as he shared Rush’s story of working on community renovation – and working with hope. Though tiny by comparison with the West Side, the two small towns of Benton Harbor and St. Joseph, Mich., in their own way mimic the vast gulf of health, wealth and lifespans – polarized by race – that are found along Ogden Avenue. Ansell noted that, in fact, the 19-year life expectancy gap between the top and bottom rates in Berrien County, Mich., is a bigger gap than in Chicago.

Most notably, Rush University Medical Center, working with many partners, is aiming to narrow by half Chicago’s lifespan gap by 2030.

Ansell offered work-in-progress tips (see sidebar) to people in southwest Michigan who are in the first year of a three-year collaborative effort called Community Grand Rounds: Healing the Trauma of Racism. CGR is a partnership between the Todman Family Foundation and Spectrum Health Lakeland.

He found much reason for optimism, claiming that the problems of health inequities are conquerable. Health systems, in partnership with their communities, can name the problems, make changes, measure results and forge ahead.

“Let’s fail forward. Let’s have honest conversations.”

He said they won’t succeed at everything they attempt, “but let’s fail together. Let’s fail forward. Let’s have honest conversations. We’re America, for God’s sake. We’ve done a lot of incredible things. This is within our capabilities. This is not as hard as it seems. Where we failed in this is being brave enough to think big enough.”

Ansell said Berrien County’s socioeconomic problems are far more focused and far smaller than those on Chicago’s West Side. Berrien County is unified in the sense that it has one health system and one health department. “You have about 30,000 (people) who are in this sort of very low-income zone. You can put your arms around it!”

Naming Racism

Rush’s drive to improve the lives of people in the larger community has met with “remarkable” acceptance by residents who “for so long had so much mistrust” for the hospital that was chartered in 1837.

But first came what might be called personal and institutional “confession,” though Ansell did not use that term. What he did say, over and over, was that Rush’s leaders had to acknowledge the role that structural racism and “structural violence” have played in helping create and sustain racially segregated, poor neighborhoods.

Structural racism is “not the same overt racism of old days,” Ansell said, but is built into society and largely perpetuated unconsciously in “day-to-day little interactions” that over the years take a cumulative toll on people. Structural racism, which is “largely on autopilot,” helps contribute to differential access to goods and services. As “we look at how things get distributed in our world, racism has played a disproportional role in assigning black and brown people to poverty.”

How White Privilege Seduces

Ansell also uses the term “structural violence.” It is “structural because it’s designed into our policies, our procedures, our laws, the way we do things, and it’s violent because people die as a result. And it’s unacceptable, and we can’t tolerate it. If you name it you can fix it. If you don’t name it you can’t fix it.”

As a white man and physician, Ansell said he came to the realization in the last few years that he needed to name the role of racism as a significant root cause in health inequities and the lifespan gap in the communities he served.

It was hard for him to do this. “You know why? Because I got to sit at the table, the doors opened for me. Yeah, I worked hard, it was not easy. But once I got going, I got invitedinto the rooms, I got invited into the board room, and you’re sitting around that board room and something comes up, you know, you don’t want to rock the boat. It’s kind of nice there. There’s something really nice about privilege. You don’t notice it until you pay attention. What were open doors for me were brick walls for other people.”


Through an ‘Equity Lens’

Dr. Ansell advised his audience to “put an equity lens” on policy decisions. Rush did that. “We brought this to our board, and we made health equity a strategy, not a tactic. We said at our board meeting that this is a root cause, this is structural racism. It became central to what we’re trying to do with the health system.”

In 180 years Rush had never put the word “racism” in any report or community health needs assessment.

The institution has reached out and partnered with several other health systems, businesses and nonprofit organizations in what Ansell described as a “private/private” collaborative.

Rush is morally bound to confront problems in its neighborhoods, Ansell said. “We have a moral, ethical mission. We’re here. Our capital is in this neighborhood. Part of our job is to make what’s been invisible visible, because it’s only been invisible to the white people. It’s been very visible to everyone else. And by the way, there are many other people who are suffering, so this is not to minimize the suffering of anybody.

“What we tolerate, we promote. So, to tolerate unsafe conditions, we’re promoting unsafe conditions. If the problem is in the way we design the system, we have to fix the system. And that’s true in the neighborhood as it is in the hospital,” he said.

“We (Rush) were there before the city of Chicago was incorporated. We had to say to ourselves that we were responsible, if not accountable, for the healthcare outcomes. That was a big deal.”