Poverty is bad for your health. Inequality causes poverty. In turn, poverty causes illness and death. Therefore, inequality kills. The evidence is extensive. The data is compelling. The logic is impeccable. But is this not just correlation, not causation?
A causal account comes into view. When the evidence is vast and deep enough, we can
connect the dots between the correlated items – in this case, poverty, inequality, and bad healthcare outcomes (i.e., death) – and provide a causal account.
While it remains true that correlation is not causation, a flood of evidence is available – and overwhelming: The high correlation between poverty and ill health points to numerous causes intimately related to low socioeconomic standing, being poor. For example, poverty is stressful. Extremely stressful: “People who are exposed to constant high levels of stress do have biological reactions that can shorten their lives [….] [E]xposure to chronic environmental stress causes biological changes within the body that predispose individuals to develop premature disease” (pp. 66 – 67).
For instance, a person at risk for Type II Diabetes benefits from regular exercise and a balanced, healthy diet, high in protein, fruits, vegetables, and low in “bad fat.” Living in a high crime zip code likely also means they live in a “food desert.” Not only is there no Whole Foods or other high-end grocer available but “convenience stores” are long on junk foods and short on fruits and vegetables. When someone gets hungry, unhealthy calories are a likely outcome – nothing wrong with a Twinkie once in a while, but there is a reason the term “junk food” was invented. The person cannot go out for a vigorous, healthy walk because that results assault by local criminals. This is not a problem that can be fixed by the good advice of a medical doctor in an office visit, beneficial though that advice may be. It requires social change and a confrontation with values that privilege profit and cost reduction over people and their well-being.
This leads the author, David Ansell, MD, to a key distinction, which is itself controversial and unavoidable: structural violence. “It is the cumulative impact of laws and social and economic policies and practices that render some Americans less able to access resources and opportunities than others. This inequality of advantage is not a result of the individual’s personal abilities but is built into the systems that govern society” (p. 8).
Ansell gives a powerful example of one of his patient’s, Windora, who eventually suffers but survives a life-changing stroke that costs her the ability to speak. Ansell becomes her voice in this work.
Windora has a “good job” in the school system but not one that pays enough for her to move out of her impoverished zip code. She has hypertension and would benefit from a vigorous walk everyday, but she can’t go out because the neighbor is unsafe. Joining a gym is too expensive, and there is no YMCA within miles. She would benefit from a healthy diet of fruits and vegetables, but she lives in a food desert with a lot of convenience stores selling junk foods. A double bind? Blame the victim? After a certain point, no amount of personal initiative can overcome the obstacles. But a rental voucher might help.
Part of the “back story” for creating areas of overwhelming poverty, educational disadvantage, and social stress were “racially restricted covenants” in real estate. Even after the US Supreme Court outlawed such real estate deeds in 1947, billions of dollars continued to be spent in building public housing in or near impoverished areas. This virtually guaranteed segregated housing, resulting in de facto segregation in schools, and the resulting loss of upwardly mobile educational opportunities for (mostly) black or underprivileged children. The cycle continues. The examples of stable integrated neighborhoods such as Oak Park or stable black communities such as Chatham were overwhelmed by the unethical, fear inspiring but profitable practices of “block busting,” based on distorted, negative racial stereotypes. (For details on the back-story here see Polikoff’s Waiting for Gautreaux: A Story of Segregation, Housing, and the Black Ghetto (2).)
The media share responsibility for perpetuating stereotypes. In the wake of Hurricane Katrina, white people wading through chest high water, carrying groceries from abandoned food stores are described as survivors “finding” the food they needed in order not to starve whereas people of color doing exactly the same thing with the same bags in the same chest high flood waters are described as “looters” (p. 87). Hmmm.
In addition to structural violence, there is actual violence. Ansell writes: “Between 2007 and 2012, Chicago police shot over four hundred people. There were seventy police fatalities during that period, the most in the nation. Between 2004 and 2014, the cash-strapped city dished out $662 million in police brutality settlements” (p. 164).
Ansell imagines all the good things that could be done with that money for school and health-care. I would add to the list: expanded police training. I do not mean target practice or armored cars. I mean training in conflict de-escalation, community relations, courtesy and conversation. Just because deadly force can be used, does not mean it must be used. Empathy is distinct from compassion (though the world needs more of each). Empathy is a method of data sampling, telling a person what the other person is experiencing. In a police context, this would include whether the other is afraid or angry and, most importantly, is at risk of escalating to an aggressive response. No guarantees, but the widows and orphans of fallen heroes are looking for alternatives to shoot first and ask questions later (my phrase, not Ansell’s).
Meanwhile, Dr Ansell’s recommendation to fellow doctors? A bold statement of the obvious: Follow the Hippocratic oath (Ansell cites the modern version called “the Declaration of Geneva, Physicians Oath”). This action may be more confronting and difficult than most physicians imagine. The language about “consecrating one’s life to the service of humanity” and the first consideration being the health of one’s patients is the critical path. This extends beyond the walls of the office or hospital to personal advocacy.
For example, Ansell cites Paul Farmer reporting that when patients living in poverty took their tuberculosis medication, they got better, but they also got very hungry. The TB actually eliminated their hunger. They were too sick to feel hungry – a well disguised “blessing” indeed – so they stopped taking the medication because they were overwhelmed with hunger. The solution was not to call the patient’s “stupid” for not complying with their doctor’s orders. Once food was delivered with the medications, the patients became adherent with the treatment regime. Is the doctor then responsible to feed the hungry? Well, he who wills the end (health) wills the indispensably necessary means to the end (food + TB medicine).
Ansell makes a powerful case that any doctor refusing to treat a patient who presents with symptoms is violating the Hippocratic oath. Health care is an inalienable human right, along side life, liberty, and the pursuit of happiness (except that it has been alienated to enable monopoly rents to insurance companies, Big Pharma, and the corporate transformation of American medicine). “Health care” is a component of the “life” part of the enumeration of rights with which the Declaration begins.
However, the point is not to force an outcome. No one can force anyone to do something that they do not want to do. (For detailed background on the role of profit in the bio-psychiatry of major mental disorders and “Big Pharma” (a once devaluing term that is now accepted), a vexing trend that Ansell does not engage, see Robert Whitaker (3).)
The point is not to force doctors to make excuses for not treating the poor, which risks impacting the doctors’ livelihood and revenue model. The point is advocacy: to mobilize doctors to take on a system that treats health care as an economic transaction. The point is to mobilize doctors to push back against a system that rations scare resources such that the system, in spite of complex algorithms to determine fairness (see The National Organ Transplant Act (1984)), frequently results in the transplants being allocated to middle-aged white males. It is a disturbing statistic that the poor and people of color are frequently the organ donors while rarely being the recipient of life-saving transplants. Once again, there is something very wrong with this picture.
I hasten to add that Ansell reports a compelling example of community activism resulting in Illinois enacting legislation allowing the undocumented to receive kidney transplants and lifetime medications with State financial support “in part because we listened and tried to help” (pp. 107, 108).
Now I have read Ansell’s book cover-to-cover, including the extensive footnotes as well as the back cover. The one, flat out error I have found is on the back cover. Contra to the back cover, nowhere does Dr Ansell write “Inequality is a disease” or that it must be treated as a disease.
Ansell does indeed argue at length that inequality causes poverty and that poverty and inequality (and a host of related social injustices) set off a sequence of events that, like the falling dominoes, create a death gap, causing poor people, especially people of color, to die prematurely. For example, carbon monoxide can kill you, too, but carbon monoxide is not a disease (my example, not Ansell’s). It is a substance that the human beings cannot process. It is inimical to life. An environment of poverty is like carbon monoxide for the human body and soul. It chokes the life out of the person, albeit slowly, preventing binding with life-giving resources that the person needs to survive and flourish.
As noted, neither poverty, starvation, arsenic, lead, nor similar phenomena are diseases. Structural violence is not a disease; it creates a negative clearing for disease in the context of social injustice.
Contra the back cover, Ansell’s point is precisely that no medical treatment in itself will cure poverty, prevent the resulting fatalities, or undo the death gap. Reducing and eliminating the death gap requires advocacy: structural reforms and political engagement to combat structural violence. It requires honoring one’s commitment to social justice in the community. It requires a redistribution of sometimes scare resources – health care, education, jobs, law enforcement – from the wealthiest and most privileged on the Gold Coast a couple of miles west and south to neighbor whose numbers read like they were from the third world. It seems the editors of the back cover were blinded by privilege, too.
Ansell has recommendations. Practical proposals are forthcoming: “[Concentrated reinvestment in impoverished communities] will require a redistribution of wealth through taxation from the affluent back to the poor in the form of living wages, access to higher education, health care, and safe housing” (p. 54). “These structural reforms could take many forms, from tax and job policy to the ending of mass incarceration. From the perspective of health reform, the adoption of a single-payer health care system is the only way to create equity in health care. Single-payer health care will be vigorously opposed by the profit-driven private health insurers and by those who will insist it is too costly or not feasible” (p. 182). Speaking personally, I am at a loss as to why certain politicians and parties seem unwilling for people to get health insurance and health care at a cost that also enables them to pay rent, eat, and so on.
One final thought. Today evidence-based medicine is the dominant paradigm and with good reason. Evidence is superior to guess work. In peer-reviewed article after article we can read about a 3% improvement of one pharmacological, procedure, or laparoscopic intervention versus another. Well and good. Empathy and compassion are in short supply in the world, and, in any case, are not enough. Leadership is also required, and Ansell provides that here.
If this book, Ansell’s work, dense with evidence, data, facts and figures that support the subtitle (“Inequality Kills”), does not become the conscience of the medical community and a blue print for transformation and reform, then not only am I a monkey’s uncle, but the collective blind spot of the medical community is the size of the dark side of the moon.
We end where Ansell ‘s book begins. Ansell’s opening quote from Martin Luther King is as true today as it was in 1964: “History will have to record that the great tragedy of this period of social transition was not the strident clamor of the bad people, but the appalling silence of the good people” (p. vii). This book is addressed to the good people. Drop what you are doing and get the book: read it, honor your commitments, follow the recommendations.
(1) David A. Ansell, MD, (2017), The Death Gap: How Inequality Kills. Chicago: The University of Chicago Press.
(2) Alexander Polikoff, (2006), Waiting for Gautreaux: A Story of Segregation, Housing, and the Black Ghetto. Evanston, IL: Northwestern University Press.
(3) Robert Whitaker, (2010), Anatomy of an Epidemic. New York: Broadway Paperbacks (Random House).
(c) Lou Agosta, PhD and the Chicago Empathy Project