The Death Gap: How Inequality Kills

The Death Gap: How Inequality Kills


MARCIA DAY CHILDRESS:
Good afternoon. I’d like to welcome you to
today’s Medical Center Hour, a program called The Death
Gap, How Inequality Kills. I’m Marcia Day Childress
from the Center for Biomedical
Ethics and Humanities here in the School of Medicine. And the Center brings
you these weekly medicine in society forums known as
the Medical Center Hour. Today is the last
program in what is our 46th year of
continuous production. It also doubles as
the Alpha Omega Alpha lecture of the School of
Medicine for this year. We hear much these days
about the yawning gap in our country between the
rich and the poor, the haves and have-nots. Inequality is all
around us and it’s taking a serious toll on
personal and population health. The poor die sooner. Blacks die sooner. And poor urban blacks die sooner
than almost everyone else. Indeed, there’s a
35 year difference in life expectancy between
America’s wealthiest and healthiest enclaves
and our poorest and sickest neighborhoods. Internist, David
Ansell, has worked for four decades in hospitals
that serve Chicago’s poorest communities. He’s witnessed firsthand
the structural violence of racism, economic
exploitation, and discrimination responsible
for grim health outcomes among the poor. And he’s written about this in
this compelling book, The Death Gap. The book is informed
by his dual perspective as both a practicing clinician
and an administrative leader in an academic medical center. Dr. Ansell is the Michael E
Kelly MD Presidential Professor of Internal Medicine, associate
provost and senior vice president for system integration
and community health and equity at Rush University
Medical Center in Chicago. He comes to us today as
UVA’s AOA visiting professor sponsored by the National
Medical Honors Society, Alpha Omega Alpha, and
hosted by our local chapter. For all that he’s seen and
done, David Ansell is hopeful. Geography or ZIP code, he
argues, need not be destiny. Individual practitioners,
health care institutions, social forces, and
political players can join together with
at-risk communities to remedy the devastating
socioeconomic conditions that engender the death gap. But this isn’t easy work,
because it will surely spill over into the next generation. We’ve invited a
graduating medical student to offer a response. Toby Ubu– on my far right– class of 2018, will soon be a
resident, training to practice and preparing, perhaps,
to lead colleagues, the clinical enterprise,
and community in efforts to lessen or altogether
erase health disparities. Toby will tell you something
about himself in his talk, but I’ll tell you right now
that he’s one of our generalist scholars– a member of our peer-selected
Gold Humanism Honor Society chapter, and also
by peer selection, this year’s recipient of
the Leonard Tow Humanism in Medicine Student Award. I’d like to thank the UVA
chapter of Alpha Omega Alpha National Medical Honor
Society, and graduating student and lastly, the AOA president
as our partners in this program. And as you saw when you
came in, the UVA bookstore is just outside
the upstairs door with copies of The Death
Gap, which David Ansell will be happy to sign. So let’s begin looking at
the death gap, David Ansell, and Toby Ubu. DAVID ANSELL: Thank you. [APPLAUSE] Thank you. I’m pleased to be here today. Thank you for that
wonderful introduction. My father would have
loved it, and my mother wouldn’t have believed it. [LAUGHTER] But I just want to
say, as a preview– MARCIA DAY CHILDRESS:
Is your mic on? DAVID ANSELL: Is my mic on? Can you hear me? MARCIA DAY CHILDRESS:
Yes, it is. DAVID ANSELL: I have
a very loud voice. Oh, there it is. That’s better. Not everyone is going to
like what I have to say. I mean, in my experience,
some people walk out. That’s totally fine. What I hope to do with
an audience like this, is convince like 5%– three or four people in a room– that if one follows
a certain path, we can actually
make big changes. And I understand
in a room this big, there’s usually about three,
or four, or five people. But just to get
started, I’m going to show you why we as primates
reject inequality as a concept, or as an idea. And I’m going to play
a little video for you. And we’re going to jump
into the presentation. All right, I want
to just show you that experimenting with
the most basic of primates, how inequality is rejected. You could actually look
at the monkey thing as the orthopedic surgeons
versus primary care doctors. There are many different
analogies you can have. So my talk today is the death
gap, how inequality kills. But I really want to spend
the last part of it talking about, what do we do, so we get
beyond just talking about it. I have no disclosures. That’s me in front of the
old Cook County Hospital, where everything
I tell me today, I learned 40 years ago when
I started my internship. I know many of you are thinking,
he looks very, very young. It can’t be 40 years. Just a little bit
about my experience. I’ve been a doctor for
40 years in Chicago– started my internship in 1978. And I spent 17 years at Cook
County Hospital, 10 years at a place called Mt. Sinai, Sinai Health System,
which is a teaching hospital– safety net hospital–
and then, got recruited to Rush
University Medical Center to be the chief medical officer. I was chair of
medicine at Sinai. I was chief of General
Internal Medicine at Cook County when I left. But my patients came with me. And it was along one
street in Chicago– Ogden Avenue– and I call that
street one street, two worlds. Because not only were
there two worlds of health care as I experienced
through my own experience at what was accessible through
the eyes of my patients. But there are people in these
neighborhoods that were served with two different lives. And it was a shock
to me when I got to Rush, an academic
canticles center, where everything was in reach– if you had the right card
to get you in the door. And people on the
inside of Rush did not seem to see what
was on the outside. And so as chief medical officer,
while I was doing that work, I wrote these two books. One was County– Life,
Death, and Politics at Chicago’s Public
Hospital, which kind of tells the story of what was it like
to be an intern at Cook County Hospital in 1978. Come with me, and I’ll show you. And then, The Death Gap– How Inequality Kills,
how is it really working? How does it really work? And so that’s the
topic of my talk today. I’m going to talk
in three parts. I’m going to talk
about how I discovered the problem of inequality
as it relates to health, and how I learned to
practice social medicine. Then, I’m going to talk
about the social determinants of health, but I’m going
to distinguish them from the social
determinants of inequity. It’s really important that we
name these things very, very specifically. And then, I’m going
to turn at the end, this is the prescription
for burnout, for avoiding burnout, which
is practicing medicine with your heart and your feet. So I have three parts,
because if the first part gets really boring, there will be
a second part coming soon. So that was me in my fourth
year of medical school. I’ve grown into my ears here. But actually, I got to medical
school in upstate New York and realized that the issues
that were important to me weren’t really discussed
in medical school. I was really interested
in the intersection between society and health. And there seemed to be
no discussion about this. I was so frustrated
with medical school that first year, that
in Syracuse, there was a forestry school. And I got an application. I was a tree-hugger
type, outdoorsy, crunchy, and I thought I’d
be a forest ranger. But I pulled myself back
from the proverbial woods. I met another group
of medical students. And we started studying the
US health care system back in 1974 and 1975. And all of us decided that there
was something seriously wrong. And when we decided about
how to sort this out, we realized that what we
wanted to do was to be doctors. But I had lost sight
of why am I doing this. And we were inspired
by Rudolf Virchow. And Virchow, who was a
famous scientist/doctor in the 19th century– words like thromboembolism,
cell biology, the modern autopsy was discovered by Virchow. But Virchow was
asked to investigate an outbreak of typhus in the
Silesia region of Germany. And he came back. And in his report was the reason
for the outbreak of typhus was the lack of
democracy in Silesia. And he became known as the
father of social medicine, largely because no
women were in medicine. But when I went from the
what I was doing– which was being a doctor,
going to learn to be a doctor– to
why I was doing it, was health care to human rights. So when I describe myself,
I’m a general internist. I practice general internal
medicine, have for many years. I’m an administrator. I’ve been in many administrative
roles in my life, in medicine, and have done that
while practicing. I’m a social epidemiologist. But I’m also, I call myself
a human rights activist. Because human rights
is the core reason why I went into medicine. It’s my why. And whenever I have to make
a decision as a doctor, as an administrator,
there are many decisions you have to make as an
epidemiologist except put numbers together. But whenever I make
a decision, it’s always through a human
rights social justice lens. And so I have zero ambivalence
when I’m faced with a decision. I make a lot of other
people nervous with my lack of ambivalence. But health care as a
human right is at my core. That’s Virchow. And Virchow said physicians
are the natural attorneys for the poor in our
profession, nursing as well. And we are because social
problems– to a large extent– fall within our jurisdiction. There are narratives–
those are the narratives that we sit up at night
thinking about, oh my gosh, what just happened
in that examination? What did I just hear? What did I just see? So when it came time
to do residency, we looked all across
the country, and said, where could we go? That was at the crossroads
of medicine in society. And so we pick–
like Toby did, we picked– a public hospital,
Cook County Hospital in Chicago. Just to put this
in perspective what that was like,
three years before, it had been discredited. All our professors said it was
career suicide to go there. Public hospitals
were, at one time, the pinnacle of academic
medicine in the United States. But by the ’70s, largely
because the populations they served changed and the
rise of academic medicine, they became very degraded. Many were closing
around the country. Cook County Hospital was
threatened with closure. Here was what
interview day was like. This group of people you
saw, we all hopped in a car, drove 750 miles to Chicago to
meet the chair of medicine, Quentin Young. We go to his office
and say, we’re here to be interviewed by Dr. Young. They said, he’s out of town. And I said, oh my god. And next thing, some people
we knew whisked us to a room. It was like this size,
filled with people. We were sat in the back. Someone put a leaflet
in our hands and said, Cook County Hospital is closed. And people were up front
exhorting the crowd about saying, if
we don’t do this, county hospital
is going to close. And some guy who has a
family medicine resident– he’s now a chair of family
medicine in Kansas– he reached over and said,
what are you here for? I said, we’re here to do an
interview on internal medicine. And he said, oh, you’ve
got to come here. It’s great [LAUGHTER] And somehow, we made
it through the day. The next day, Quentin
Young showed up. We all did a group
interview with him. And when it came time
to match, we only matched one place
on our match list– Cook County Hospital. And so on match day,
we had no ambivalence. We knew exactly where we
were going, because if you’re an American grad and you put
Cook County Hospital down, God bless you. You’re going there. Yeah, so this is where I’ve
learned everything that I’m going to talk about today. Two years before, we went there. The doctors, the house
staff went out on strike. And this is them
marching downtown Chicago to protest outside of the
courthouse, where they had been given a back-to-work order. And so defying the back-to-work
order, they marched downtown. This still is the
longest doctor strike in United States history. And they went out on strike
for patient care conditions– soap, water, Spanish
interpreters, EKG machines. And largely because this
hospital served poor people– all poor people, and
black and brown people– the conditions in
there were nothing short of decrepit
and disastrous. And I’m not going to
go into a lot of detail about what that was like, but
this was to us, saying, OK. There’s a group of doctors
who will fight for patients. We’re going to go there. I want to tell you a little
bit about this guy, Jack Raba. So Jack was 26, a
former seminarian, graduate of Northwestern
Medical School, president of the house staff
association as an intern. And they won the strike,
but the four strike leaders, including Jack, was
thrown into Cook County jail for defying the
back-to-work order, so 10 days in Cook County jail. It’s Thanksgiving. And the doctor doesn’t show
up at the jail hospital. So they go to Jack’s
cell and ask him if he would mind
coming down and seeing a patient, which he does. He sees the patients,
the jail patients. And by mistake at the end, he
walks out of Cook County jail. He’s on California
Street in Chicago and realizes he could hitchhike
home, have Thanksgiving dinner, hitchhike back and go back
to jail, until he realized that that would be a felony. And he was in for a misdemeanor. And so he knocked on the door
of the cell and went back in. Actually, the serious
part of the story is, this is a story about
learning how to speak and speaking up. And as a young doctor, how
these young doctors learn to speak up, and how
Jack learned to speak up. The clock moves
ahead many years. I’m a house staff at
Cook County Hospital. We’re working at
the county jail. It’s a terrible training
situation for residents. So we do a work action. We said, we’re not
going in there anymore. They do a search for a medical
director, and sure enough, who gets to be medical director? Jack Raba. Like I said about Jack, he
knew the place inside and out. But even more importantly in
the story was many years later, one of his doctors
contacted him and said, I’m seeing someone who’s been
brought in by the police. And he looks to be tortured. He has burn marks on him. He has electrical
shock marks on him. Jack went down to the jail
and saw this prisoner. And sure enough, he
had been tortured. And he sent a letter to the
police chief in Chicago. And as a result of that
letter– of Jack speaking up– there was a commander of police
on the south side of Chicago who, with his henchmen, had
been torturing black men into giving confessions. And many of them
ended up on death row by our former mayor who was
the prosecutor, the state’s attorney– Mayor Daley put
him on death row. And because Jack was
willing to speak up, this was not the first
tortured person in Chicago. It had been going
on for many years. It was the first time it
was a doctor speaking up. And $700 million in settlements
against the city of Chicago later, the end of the
death penalty in Illinois as a result of people
being put on death row for being tortured. Jack’s letter is on the wall
of the law office that defended these death row prisoners. And the point of
this talk is, we as health care professionals,
as doctors, have a voice. We have a unique
place to speak up. And Jack’s very mild-mannered
and not a loud mouth like me. But his speaking really
made a difference in the lives of
people in Chicago. When I was an intern, my parents
are immigrants to this country. They came from England. My mother’s family was
wiped out in the Holocaust. So all my relatives
were in England. And a BBC came to
the United States to do a documentary on health
care in the United States, to show the Brits
the comparison. And they came to
Cook County Hospital. The documentary, which
is on YouTube, if you ever want to watch it, is– I call it murder,
because they asked a young doctor was talking
about patients being transferred to Cook County simply because
they lacked insurance, and many of them in very, very
terrible condition, some of them dying as a result
or deteriorating, unstable. And they asked this young doctor
who was a year ahead of me in residency, say, how do you
describe to the British people what’s going on here? And she said, I call it murder. And that became the name
of the BBC documentary. And having never seen it till
I wrote my book, County, I was wondering, why
did my relatives start calling my mother
to ask me if I was OK? Because the documentary
pretty honestly depicts what Cook County
Hospital was like, health care for the poor. So I told you, I
not only learned to be a doctor at
Cook County Hospital, and we learned social medicine. Because we were– I call this– doctors
within borders, because we would see
our patients and round. And then, we would go downtown
to fight for the hospital to stay open. One day, there was
a payless pay day. They ran out of money. There was a rally
and said, what are we going to do with the patients? And someone said, well, if we
have no money, let’s take them over to Rush, because we knew
that the private hospitals wouldn’t take them. And so this is from The Chicago
Tribune, the residents pushing patients from the
emergency room next door to my hospital that
I’m at now, Rush. And it’s not the right thing
to do to do that to patients. But in youthful exuberance,
that’s exactly what we did. It turns out, that my CEO
was chief resident at Rush at the time. And when my book on
County came out, he said, we were furious at you. What kind of crazy
people were you that you’d push these
patients over there? And I said, but Larry,
you have to understand how we felt. And our backs
were against the wall. So this idea of one street,
two worlds of experience in health care drove us. But we did learn that one could
be effective at getting change by being active. It wasn’t enough just
to be good doctors. But that wasn’t enough, either. Just getting up and telling
stories of bad things happening is not enough. So this is a formula that
I’m going to come back to, that narrative, plus data,
plus action equals change. And I think in the
world of fake news, we have to come back
to facts and data. Narrative is not enough, because
everyone has a narrative. But narrative, plus data,
plus action equals change. So this is how I
got into academic. This was probably the
turning point for me. So when you walk in a place
like Cook County Hospital, I think one of three
things happened to you. You are overwhelmed by
the distress you see, overwhelmed by the suffering. And you, yourself, suffer. And you have to leave, not
because you’re a bad person, because it’s really
hard to experience the suffering of poor
people over and over again without relief, if
there’s not a way for you to protect yourself–
again, that’s one thing. Another group of people just
get hardened and cynical. And they put a wall
between themselves in this. And they blame the patients
for their conditions. They get through it
by becoming somewhat– I call them–
bureaucratic doctors. They’ve lost their
sense of caring. And then, there are people
like me, who said, OK. I’m here. I don’t want to just
become part of this. How do we begin to
think about changing it? So this is how I got
into academic medicine. It was the 1980s. The rise of the uninsured in the
United States, we’re at a place now where factories were
leaving neighborhoods. So what happened in some
of the neighborhoods, you had white flight
in urban neighborhoods. Then, the factories left– first for the suburbs, then
to the south and the west, and now overseas. And when the jobs left,
people became uninsured. And when you had hospitals
in those neighborhoods facing the uninsured, they
did the only thing that they knew to do, which
was put someone in an ambulance and transfer them to
Cook County Hospital. Wherever there are
public hospitals– and probably happened here
at the University Hospital as well– that people transferred
the patients. And this has been the
practice from time in Memorial that patients who were
uninsured got transferred to public institution. What happened in
this period of time, a number of phone
calls that occurred went from 100 a month,
to about 300 a month. And so a big increase
in the number of calls. And this is what it was like to
be a resident in the emergency room. There were no attendings
in those days. You’d be standing there,
the phone would ring. You’d look at it. You go pick it up
and say, this is University of Chicago Hospital. We want to transfer
your patient. OK. There was a clipboard
next to the phone. It was chained down,
had paper on it. You’d fill out the paper–
name of the patient, date of birth, condition. And then a checkbox,
the reason for transfer. And what do you think the reason
for transfer was almost 100% of the time? No insurance. And so we decided– this is my foray into
academic medicine– that no one was going to listen
to a group of county doctors to protest about patients being
transferred because they were uninsured to a county hospital. That’s supposed to take
care of the uninsured. But we thought it
was a phenomenon that needed to be documented. So this is how I did. We said, let’s do a study,
and took us– we said, let’s track 500 patients. So it took literally a couple
of weeks to get 500 patients. We tracked every single
patient who was transferred to Cook County Hospital. We went to the ER. We got that little sheet. We went to the bedside
to talk to them. We did chart reviews on
what happened to them. And what we found was that about
20 plus percent of the patients ended up in an ICU. About the same percentage– 25% or so– were unstable
at the time of transfer, and then if you were a medicine
patient being transferred and you had a higher
mortality rate. I want to describe to
you some of the patients. And then, I’ve thought
about some of what the people on the other
side of the phone who were transferring the patients,
and this whole idea of speaking up. So we want to talk
to the patients. And the patients had a very
different story than this check the box that was uninsurance. What do you think
the patients told us the reason they were told
they were transferred? Better care, no beds. And I wondered, why would
people say that to them? And then, I realized the
person on the end of the phone was someone like
you and me who was told by the hospital
administrator what they could do and couldn’t do. So they told a little white lie. And I will tell you, 99%
of the people in this room and in the world
will tell that white lie if an administrator
tells you what you can do and what you can’t do about
taking care of patients. We will violate our Hippocratic
oath if someone tells us we must do it. It’s just the human condition
that we’ll follow the rules. And that’s why they told that. They weren’t bad people, they
were just in a bad situation and didn’t have the
bravery to speak up. We decided we would have
to write a paper on this. And we did. And we decided that
besides the data, we would describe
some of the patients. I’m going to describe
two patients for you. One of them is in the
table in the paper. Gunshot to the head,
on a ventilator, transferred to Cook
County, no insurance. Or here’s one. Woman in the terminal phases of
labor, 10 centimeters dilated– this one’s for you– breech delivery,
foot in the vagina. Transferred to Cook
County, no insurance. Now, imagine being the resident
in that emergency room. You went to church every Sunday. You got into the
best medical school, and you were told by
your administrator if they had a no
insurance, you have to transfer transfer them
to Cook County Hospital. And when this work
got out, our OBs thanked us, because they’ve
seen so many women die in our emergency room
over the years because of this public policy. Oh, by the way, most of the
patients were all insured, and they were about 90%
black and brown patients. So these are just the facts. So people at Cook County
were angry with us for doing this study. I was so shocked. Why would they be angry at us? Because the system works if we
all catch ball with each other. So that’s what County
hospital was here for. We’re supposed to take
care of the uninsured. They are not. And if we don’t take
care of the uninsured, then why are we here? So people were angry with us. In fact, the day before the
paper was going to be released, we went to our public
relations folks. And will you do a press
conference for us? And they said, no. You have to do it yourself. And so we stood there. I was just a young attending. We stood there and we read from
our own self-prepared public relations things, shaking. And in the room next
door to us, they had a counter press conference. So the hospital administration
had a press conference denouncing our paper
in the next room. So I’m saying the
price of speaking up is to be able to resist all
of the things that will come. So we didn’t know where
to send the paper. We sent it to the
only journal we knew. It got published. It was on the front page of the
New York Times, the Wall Street Journal, the Chicago Tribune. I went and testified
before Congress. And the Emergency Medical
Treatment and Labor Act was passed, which is the
only form of universal health care we have in
the United States, was the right to
emergency care as a result of doing this study. And then, I said, oh, I get it. If we show data, we
can change the world. We can really fix this stuff. So that’s how I got
into academic medicine. So now I’m on part two,
social determinants of health and inequity. I’m going to go through
this pretty quickly. You’ve probably all seen this. There are social
determinants of health. Medicine’s focus is very much
on the biological determinants of health. And we tend to be ahistorical. The major criticism I have
of the way that we teach and practice medicine
is the relentless focus on the individual. And there’s been
a lot of benefit from doing this,
don’t get me wrong. Because disease
resides in individuals. And if we’re going to
cure an individual, it has to be treatments
aimed at the individuals. But if we’re going to deal
with the prevalence of disease or the burden of disease, we
can’t treat the individuals. We’ve got to think about these
other determinants of health. And this is the
standard thing you see. And social determinants are
the conditions in which people are born, grow, work, and live. And it’s the environment,
it’s your clinical care and your behaviors, and
then socioeconomic factors. But I’m going to now
ask the question, yeah, but what determines them? What are the determinants
of the social determinants? And that’s where I want to
get into this idea of equality versus equity. Has anyone seen this before? So someone tell
me the difference in equality and equity. What’s equality? Everyone gets the same thing,
or there’s an expression that people use– a rising
tide raises all boats. If the tide rises, we’re
all going to get better. But actually, that’s only
true if you’re in a boat, if there are not lots of other
people in the boat with you to swamp that boat. If that boat doesn’t have holes,
and if you’re in the water, a rising tide is
going to drown you. So what does equity mean? Yes, actually, those who
need more should get more. Think about it. Equity means those who
need more, get more. Those who aren’t thriving, we
need to pay attention to them. If you think of how we measure
quality in health care, it’s averages. It’s a mean, your
mean readmission rate. And if we hit a certain thing,
or diabetes control rates, it’s an average. But equity requires us to look
at the edges of who is not thriving, and then
ask the question why, and then do something about it. So if we think about
what equity means, but what’s wrong
with this picture? So on the left side,
everyone has the same box. Now, they’ve given the
short guy bigger boxes. But what’s wrong
with this picture? This is widely used to teach
about different inequality and equities. But what? AUDIENCE: Defense. DAVID ANSELL: Defense, right? They’re still all
outside the park. What else is wrong with it? Someone’s got to pay for it. Like, who gets the seats? That’s a good thing. Someone’s got to pay for. And we decide, and
we have to decide whether equity in this
country is worth paying for. If grapes are better
than cucumbers– and we all agree that grapes
are better than cucumbers– should everyone get grapes? It’s an important question. What else is wrong
with this picture? They’re all guys, and
they’re all brown people. So our ideas are so embedded,
that we keep replicating. Even in our desire to
instruct, we actually– because real equity
would be in the ballpark. Maybe you would say,
who gets the box? Who gets the seats
behind home plate? But these guys aren’t
even in the ballpark. You would say,
well, at least you should be able to
be in the ballpark. Sometimes, I’ve seen
this with the fence down. Well, it’s better than
being outside the fence. But there’s different
ways you can do it. This is where I tend to lose
some people in the audience. But if you would
just bear with me, I want to talk to you
about why, as a white man doctor who’s been very– as a son of immigrants
to this country, been very, very successful
in my own life and career, have suddenly come to talk about
racism as a social determinant of inequity, and why it’s
important to talk about it separately from poverty
and other things. And so I want to try to
go through this with you. So, how does racism
cause inequity? So in my experience as a doctor
on this one street, two worlds, is a multi-level– there are multiple
insults that make racism as a cause of the
accumulation of lots of social determinants of poor
health in black populations. Racism is not the
only thing, but I’m using this as an example of
something really important for us to understand. So when you talk about social
determinants of health, that seems to lump
everything into one bucket. So I talk about
social, structural, and economic
determinants of health, and political
determinants of health, because they’re
somewhat different. But racism causes
health inequity because there’s a difference
in quality of care that people get. So race, gender,
even age sometimes. There’s difference in access
to care in this country by race, by what race
or ethnicity are. We have in this country,
an unfortunate geographic segregation of black
and brown people, poor people in
particular, that doesn’t exist for the white
poor population the same kind of
geographic segregation. And then, at the bottom
of this is the opportunity for life opportunity
gaps that fundamentally lead to bad health outcomes. So we know that health
follows a social gradient. This is true since
the beginning of time. And that the rich have
better health than the poor, and the educated
have better health than the poorly educated. It’s true, there are countries
that have very much narrowed those gaps. We have very, very large
gaps in this country. But the determinants of
who has the opportunity in this country is driven by
racism, is one of the factors. This is where I ask the
crowd, because sexism is really important as well, in
terms of who has opportunities, and how do those
opportunities get distributed. So I ask the women
in the room now to raise your hand if you’ve
never been minimized, degraded, ignored, or failed
to have opportunities because of your gender. And when I ask that in rooms,
no women’s hand ever goes up. And I’m saying, well,
racism works like that too. So what racism is, is
a differential access to goods and services. It’s a system of structuring
opportunity and assigning value based on how someone looks. It’s bad for all of us because
it saps human potential. We’re leaving human
potential on the table. And it’s difficult
for those of us who are in a position of
privilege to recognize it. It’s invisible to those
of us in privilege, because we’re being
actually benefited from it. I never used the word “racism”. I used to call it
discrimination, segregation, I never used the
word “exploitation”. I called it disinvestment. But I realized the
words were important. And here’s why I think
it’s important to name it. And I’ll tell you why. In a hospital, as a former
chief medical officer, when something went
wrong with a patient– when the patient was harmed– we do a root cause analysis. And we do root cause
analysis that’s really critical, that if
you don’t get the root cause of harm right,
when you go to fix it, you won’t fix the
right thing to prevent the harm from occurring again. So that’s one correlation
with patient safety. The second correlation
with patient safety, this idea of just culture. And just culture in
the hospital– anyone know what just culture means? Just culture means if
something happens and there’s harm that has
occurred to a patient, if it’s because of
a malicious act– intentional malicious
act– we need to address that
individual’s behavior who’s called that
malicious intentional act. But if it wasn’t, we have
to address the system. So when I talk about
racism, I’m not talking about what happened
in Charlottesville last year, though that’s important
not to ignore that. It’s the racism by design,
by unintentional design that actually harms people. And so it’s that
system we need to fix. The last patient
safety analogy is what we tolerate, we promote. When we tolerate,
we can’t do anything about historic injustices. They’ve happened. But what we can
do is look to see how are these injustices
being perpetuated today in our own institutions. And what are we doing about it. And how do we mitigate
against those things? So this is why I think
it’s important to name it. Institute of Medicine has talked
about the bias in unequal care. This is the early 2000s. What we find with any innovation
in health care, anything, it takes about 17
years from the ideas to be generated to begin
to do something about it. And so it’s about 17 years
since this report came out. But for about
every disease there is, there are a
black/white differences. There men/women differences
in the way we actually treat people in medicine. Some of them are unconscious. Sometimes, they’re embedded. Sometimes there’s mistrust
on the part of the patients. So how does racism
cause health inequity? Unfair concentration
of black disadvantaged that leaves resources
in those neighborhoods different than resources
in neighborhoods where advantage is concentrated,
like white neighborhoods– not all white
neighborhoods, but many. Institutional racism, the
way that we in health care, or the police
incarceration practices. The embodiment of
racism, people who’ve had historical mistrust,
things that have happened. I learned today that
this is the home of the founders of the
Tuskegee experiment, University VA medical college grads. But the historical mistrust,
it lasts for a long time. And so maybe I
don’t come into care because my mother
had a bad experience, my grandfather had
a bad experience. But also, the
embodiment of privilege. The gap between our
power and the power that patients have sometimes
is too big to get over. And I will go into more. So I’m going to show
you now how it works. This was work I’ve
done in Chicago. So this is work. I’ve done a lot of work
in cancer disparity When I finished at
Cook County Hospital, I said, if I’m going to stay,
I’m going to get upstream and we’re going to prevention
and early detection. So I started a breast
cancer screening program. And this is how I became
a professor of medicine, of writing articles
on disparity, while the disparity got worse. So when I started,
finished my residency, there was no black/white gap
in breast cancer mortality in Chicago. And I’m going to give you an
opportunity to interpret this. But what happened in the
1990s, the white mortality rate from breast cancer
dropped nicely. Now, this graph is true across
the whole United States, not just Chicago. But we use the example of
Chicago to assemble the data. So the white mortality
rate went down, and no one’s celebrating
white women’s breast cancer. So a lot of gaps. But the black rate
didn’t move at all. So someone explain
what’s going on here. Why did this happen? I’ve got some graduating fourth
year medical students, now’s your chance to interpret
data hypotheses. AUDIENCE: The white
women had access to screening and prevention. DAVID ANSELL: Yeah,
access is one. A lot of what we heard– so
we were a little surprised by this. Because if you look
at other disparities like cardiovascular
disparity, the curves are parallel with each other. And the white rates
have gone down, and the black rates
have gone down. But there’s still a gap. And in this one,
they were equal. So how do you explain
they were equal? We published this. We actually had a
press conference, said we’re going to
create a task force. We’re going to do
something about it. And the blowback in the
newspaper from our colleagues were– what do you
think the blowback was? Explaining black mortality
from breast cancer. Biology, triple negative. So all the oncologists,
oh, my god. Black people have more
undifferentiated breast cancers, which we know is true. They tend to be larger
at the time of diagnosis we know is true. There are more triple negative. And it’s very, very hard to
treat triple negative breast cancer. But we posed the idea
that it was access, and it was quality
of treatment, and it was quality of access
to mammography process we’ve subsequently
proved it was correct. But first, we showed this data. So this is the map of Chicago
with the high mortality areas and the hospitals that have
accredited cancer programs. And you can see,
the cancer programs are located in low mortality
white neighborhoods, and not in black neighborhoods. And then, we showed
this graph that showed the gap
between the mortality in Chicago, the US,
and New York City. And we asked the question, what
happens to black women’s genes when you cross the
Allegheny Mountains? And so, New York
did a lot better, and the US did a lot
better in Chicago. Subsequently, we reduced
this gap in Chicago by 35% by getting into the
institutions and addressing what we call inequality and quality. But this is how structural
racism can work. And we’ve got it
in the newspapers, and this is not good
enough about the grade. We graded hospitals on their
performance not good enough. And their performance
got better over time. And the mortality
gap got better. This is structural racism. This is a manhole
cover in the middle of a mammography unit on
the south side of Chicago in a safety hospital. This is how structural
racism works. Who would tolerate that, right? And it was tolerated year,
after year, after year. This is Chicago’s life
expectancy gaps at 16 years. Our hospital is right here. And it’s a US problem, and
it’s a rich/poor problem. And this rich/poor problem in
life– so life expectancy gaps, there was not such a
big life expectancy gap between the rich and
poor in this country. And now, there’s a giant one. And it turns out– this is
from the New York Times. So this about why
racism matters. This is black and white
boys in wealthy families. And this is what happens. 30 years later, the
green is white kids, and the purple is black kids. And black kids drop in income,
even starting off wealthy. And when you start off poor,
no one makes it up really well. But white kids make it up
better than black kids. But there is a huge gradient. This is the gender gap. And you can see, women
fall to the bottom. So there’s lots of “isms”
we have to address. Lots of black men
missing in this country. I’m not going to spend
a lot of time on this. But when you don’t have
black men in communities– largely because
they prematurely die and because they’re in prison– you have a gap between
the male/female ratio in these neighborhoods. And Ferguson is the worst of
all the cities in the United States. White women are dying and
without college degrees, and white men– and has
lowered US life expectancy, economists call these
diseases of despair. These were not things we
talked about when it was happening in black communities. But actually, white women
mortality rate without a degree has now met black
women’s mortality rate without a college degree. And it’s a national crisis. And it’s dropped
US life expectancy. So it’s not just
a black problem. So here’s how I’m going
to end on this note. What’s the solution? Practice medicine with
your heart and feet here. So this is from the
health care debates, probably when you
guys were in college– some of you. I like this one,
no pubic option. But the whole idea
is that these are issues of urgent public policy. So here’s my
prescription for burnout. So how can you do this? One is act personally. Speech and practice
choices– you can choose to serve the poor. You can choose to speak up
when an administrative policy in your institution is laid down
that requires you to violate your Hippocratic oath. Locally, make health
equity a strategy within your institution. It’s got to be a strategy
because otherwise, we’re never going to close these gaps. Make it a strategy in
your division first. Make it in your department. Have these
conversations instituted about why equity needs
to be pulled out separate from the other things we do. Because if these
things are structural, there are structural solutions. Put the equity lens on, and say,
how does this decision we just made perpetuate a
historical injustice that has white on top and black
and brown on the bottom? Whether that be about
Medicaid policies, what patients get
seen in what clinics, or whether it’s man on top
and women on the bottom, or the wealthy on top. You can look at your policies
for where the Medicaid patients get into your clinics
at University of Virginia. At Rush, we made access
to Medicaid and access to the uninsured available to
all of our academic physicians, all of our employed physicians. A Medicaid patient or a
uninsured patient can see them. We made a policy. We changed policy. They’re not in the
resident clinics only. And then, nationally,
fighting for guaranteed health care for all, or the
marches last weekend. So I’m just going to
end on these notes. This is a young woman who
died at 25 of Wilson’s disease at Cook County Hospital. Our doctors wouldn’t see her
because she was uninsured. I was chief medical
officer across the street. So goodwill alone
doesn’t do this if you don’t change
public policy. I got involved with a community
group who wanted transplants for the undocumented. And after a few years without
going into the details of what we did, we pulled all the
places around the table, and 86 people have
gotten transplants in Chicago who are
undocumented, uninsured– mostly kidney transplants. 75% have gotten organs
from their family members who were no access, and
injustice, and inequity. I got involved with it. This guy, was just in a new
paper, Miguel Perez, deported. A green card holder,
two time Afghan vet, TBI from grenade attacks. Got into trouble with drugs,
was in prison and deported. The community group asked
me to be his doctor. I went into ICE and examined
him and did a medical report that got to a senator to try
to keep him in this country. And I just step
into these things. I wait for them to come to me. Personally, we can do
these kinds of things. So I’m going to
end on this note. This is last week, the March
Against Violence in Chicago. You see doctors demand action. We have a role to play in
public policy in this country. And finally, across the street
from Cook County Hospital, there’s a park it’s
called Pasteur park, Louis Pasteur’s statue is there. And there’s a sign. And this is why I
became a doctor. One doesn’t ask of one who
suffers, what is your country? What is your religion? What is your insurance status– I made that one up there. One merely says, you suffer. This is enough for me. You belong to me,
and I shall help you. And so that’s why I think
we all go into medicine. If we all practice our
oath and live by it, the world will be
a lot better place. Thank you very much. [APPLAUSE] TOBENNA UBU: Good
afternoon, everyone. So I’m going to read briefly,
and discuss some remarks that I have as my response as
a graduating fourth year medical student to
reading The Death Gap and having spoken
with Dr. Ansell. And so a little
bit about who I am. So, I am a child of
two African immigrants, grew up in the suburbs
of northern New Jersey in a relatively
affluent community, eight to 10 miles from
the Bronx, New York, in which resides the
South Bronx, which is one of the poorest
congressional districts in the United States. I’m private school educated,
Duke undergraduate, and now, med student preparing
for a career in medicine. And so, like a lot
of my colleagues who had to leave for our other
internship readiness material, this is the moment that
we’ve been waiting for. We’ve thought about
becoming a doctor for a large part of our lives. And now, finally,
that’s upon us. And so for me, I’m
deciding to go to– well, or the match
is deciding for me– to take me to Jackson
Memorial Hospital in Miami. And so, this is a
hospital public hospital like Cook County, where
Dr. Ansell has been, that takes care of
a large population of undocumented immigrants
from Latin America, immigrants from the Caribbean
and Haiti, and makes it their mission to be able to
take care of this population. They have clinics
for the homeless. They have a mobile van
that goes and takes care of children of
undocumented immigrants. And that’s kind of
where I’m stepping into. And that was, in
large part, by design. And so, I think about the day
of our white coat ceremony, when we were beginning
medical school. Here at UVA, they asked
us to write a phrase to describe what is it that
you want to be true of yourself in medicine. And after reading this
book and reflecting, I looked at the statement that
I wrote, and I found some of it still to be true. And so one of the iterations
of this statement that I wrote down read as follows. I will strive to acquire
the knowledge and skill to apply compassion to
those who are hurting and to those who have no voice. And in thinking
about the remark that says that physicians are
natural advocates for the poor, I think that reading
this book, The Death Gap, reawakens that and
connects me to that as I head into residency in
internal medicine pediatrics in a public hospital. And so, it’s timely for
us as medical students. This is the calm
before the storm. A lot of us are doing
this internship readiness, where we are starting to imagine
ourselves as physicians now– no longer as medical
students, but now with more responsibility. We’re trying to figure out
where we’re going to live, how to move. But we have a small break
to be able to figure out what type of physician is
it that we are going to be. The MD behind our
name is more than just being able to prescribe
medications and sign orders. This now carries weight
in the communities that we’re going
to be a part of. And so, for me, a
lot of the emotions that I had in reading this
were shock, thinking about one of the things that Dr.
Ansell mentions in his book is if we were to look at
the urban African-American in the US as a group. They would look like
a country that we are sending humanitarian aid to. And that was shocking to me. When you learn about
these disparities, for me, that provoked a
pretty visceral reaction and indignation. How is this happening
where I live? I lived close to
the South Bronx. We’re here in Charlottesville. Dr. Ansell is in Chicago,
where block to block, 15 years of life expectancy
or more just vanish. But the thing that was great
was this left me with hope that I, as an MD,
am empowered to be able to demand more of the
institutions that I’m in, of the people that I
work with, and of myself to be this advocate
for the patients who don’t have a voice. And so going forward, some
of the things that I think we can all aspire
to is, we can aspire to have solidarity
with these patients. We can listen. It doesn’t take a lot
to do that, just listen and try to understand where it
is that our patients are coming from, who are they, what
are the barriers to health that they face. And more than that, we
can actually do something when we are in settings where
we have the opportunity to say, my patient needs this because
they do not have the ability to obtain this by themselves. We can be the person to speak
up for these communities that end up being invisible. If we don’t make them
visible often, who will? And so, I just want to
close with the last title of the last chapter of
Dr. Ansell’s book, which is observe, judge, act. We can keep our eyes open. We no longer have
an excuse for not being aware of what’s going
on in our communities. We can look. We can ask questions. We can demand more of the
environments that we’re in. And we can make small
acts of solidarity that will involve
personal sacrifice to try to be able to
provide our patients, despite their background,
with the care that they need. Thank you. [APPLAUSE] AUDIENCE: So we’re going to open
the floor for some questions. And I’m going to
ask the first one. So this is for Dr. Ansell. How do you think
that we in training, as medical students
and residents, can prepare to be social
advocates for our patients? So kind of, to what extent
can it be learned and infused into medical education? DAVID ANSELL: Well, I think
medical education has changed. So these concepts
are being introduced. Can you hear me? I have a pretty loud voice. I think across the
country, medical schools are trying to figure out a
way to teach these concepts, though I don’t think
that’s broadly infused. We tend to be relatively
conservative people going into medicine. When you go into
medicine, you think about what you’re going to do. And when you’re faced with
understanding that there are these huge social conditions
that seem unmanageable, most of us shy away from that. I just think, like
everything else we do, it requires practice. And I will tell you,
it’s not a large step to go from personal advocacy
on behalf of a patient to advocacy on behalf
of a community. And in my own
approach to this, is I stand by the Hippocratic oath. When you think about that
oath, it’s quite powerful. There are only two times in
your life you do a public oath– one is when you get married,
and sometimes, that works and sometimes that doesn’t work. And another time is when
you become a doctor, you do a public oath. And when you marry medicine,
you’re married for life. I know hardly anyone who
gets divorced from medicine. But that oath, we have a
special obligation to that. When you can translate
that into work, it’s much harder to
go up against the will of an institution or the
will of a department. But I think like
everything else we do, practicing speech and
practicing action, medicine demands that of us. Just like everything else,
it requires practice. MARCIA DAY CHILDRESS:
We’re a little over time, but we have time for
a couple of questions. And then, both Dr.
Ansell and Toby will be here for a few minutes
more to take your questions. So other questions or comments,
we’ll bring you a mic. DAVID ANSELL: Mic in
front of you, right here. AUDIENCE: Thanks so
much for your remarks. And my name is Cameron Webb. I’m the director of
health policy and equity here for the School of Medicine. And I got to know Quentin Young
when I was living in Chicago, so I have a little sense
of your background. And he told a story once of Dr.
Jack Geiger, who you’re also probably familiar with, who
was treating some children who were malnourished and wrote
prescriptions for food. And his remark was,
last time I checked, the treatment for
malnourishment would be food. And I’m wondering, that’s
a pretty disruptive thought in today’s medical environment. And what are some of the most
disruptive notions or practices physicians can use
in trying to address some of these social issues? DAVID ANSELL: Well,
I was thinking food is not that disruptive. So I think one of it, when
we think about innovation in health care, we think about
things like precision medicine and these other notions of ways
of improving health outcomes. I think what would be really
disruptive is bringing public health back into medicine
in a much more direct way. If you look at
countries that have done better health outcomes,
even in the midst of poverty– places like Cuba, for example– they’ve taken a public health
approach and gotten upstream. And then, addressing
food not at the point of care of delivery in the
clinic, but food access in the community
and the schools. I actually don’t
think it’s disruptive. I actually think it’s
disruptive if we don’t do it. The other place where I
think we have to advocate– I say for this– is that
universal health care. How can we be the only
country in the world– developed country– that doesn’t
have universal health care? In Canada, for example, you do
not have these poor/rich life expectancy gaps. So health care by
itself reformed will make a difference. I think that these
are two things. We have to get involved
way more directly with public health is part
and parcel of our training and our practice. And we have to advocate
for universal health care– in my mind,
single payer health care. MARCIA DAY CHILDRESS:
Somebody else? I think we’ll close
this formal session. But again, they will be here
to talk with you informally. Also, The Death Gap is available
through UVA bookstore outside. Again, thank you
for your patronage and your participation
in Medical Center Hour across this entire year. Our programs will
resume on September 12. So have a safe and
wonderful summer season. Thank you again to Dr. David
Ansell, and soon-to-be Dr. Toby Ubu. [APPLAUSE]

Author: Kennedi Daugherty

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