David Ansell, MD, MPH, Community Engagement Core Co-Director
How did your interest in health disparities begin?
In the late 70s, a group of us in my medical school class decided we wanted to go to Cook County Hospital to train because we really wanted to be at that intersection of health and policy and what we now know as health inequities. We wanted to take care of patients who were in the most need. At Cook County Hospital, there were the results of inequitable systems right in front of you. I and many of my colleagues got interested in what underlying social and structural causes could be ameliorated because in our own toolboxes as doctors and nurses, we had very limited tools to treat people, yet it was very clear that the conditions under which people lived were causing them to get sick. It was that exposure in the late 70s that led me to be not only interested in the root causes but in actually fixing the problem.
Were you already seeing the life expectancy gap you wrote about in The Death Gap: How Inequality Kills?
As a practitioner you only see one patient at a time, so the problem was very obvious but at the same time invisible. It wasn’t until the 1990s, when we added it all up and saw where the bodies lay, that we could identify that there were deep and seemingly intractable life expectancy gaps in neighborhoods that were very close to each other. In the beginning, I did not see that. I just saw sick patients dying young. Only when I became an epidemiologist and went to public health school was I able to take the step back. It was actually a well-known Chicago epidemiologist, Dr. Steven Whitman, who was the first in the city to see these neighborhood life expectancy gaps, with white wealthier neighborhoods having the highest life expectancy and Black neighborhoods having the lowest. It just required displaying data on a map, which as an individual doctor you don’t do, but as an epidemiologist you do all the time, that showed how racism itself was causing premature death. The geography of it was so stark.
When I finished my training at Cook County Hospital and decided to stay, I decided it was going to be in the context of getting upstream—preventing disease and not just treating end-stage disease. It was that desire that led me to set up one of the first breast and cervical cancer screening programs in the country in the general medicine clinic at Cook County. My colleagues argued with me that women coming into primary care should have already accessed the best care, but indeed the data showed that none of them were getting screened—which is one of the things about racial disparities: it’s not like doctors don’t know what the best thing to do is, but sometimes the systems themselves produce results that perpetuate inequities. So we started a breast cancer screening program. Prior to our doing that hardly any of the women got screened, but, 20 years later, we looked at what was going on with breast cancer mortality in Chicago, and what Dr. Whitman and myself and others discovered was that in the 1980s, when I started my work with this breast cancer program, there was no Black-white gap in mortality. By the 1990s the gap began to grow, not just in Chicago but across the country. By 2006, when we published our data, there was a 62 percent gap in mortality. So [initially] there was no gap, a gap grew in the 1990s, and now there was a giant gap, among the largest in the country. We actually held a press conference because we hypothesized the problem was structural in nature, connected to access to quality mammography. The academic oncologists around the city began to say, “No, it’s biological, because we see worse breast cancers in black women.”
We decided to do two things. We demonstrated the Black-white gap in Chicago compared to New York City and compared to the United States as a whole—and of course Chicago had the largest gap. New York had a very small gap—and we posed the question, “What happened to Black women’s genes when they crossed the Allegheny Mountains?” The other thing we did was make a map of Chicago in which we overlaid on the neighborhoods with high mortality from breast cancer, which were on the west and south side of the cities, where the hospitals were that had approved cancer programs by the American College of Surgeons—and we did that later for Breast Imaging Center of Excellence—and what we found is that in the Black neighborhoods, the hospitals did not have cancer certification, and that’s how structural racism works.
We wrote many years later a New England Journal of Medicine article called “Structural Racism: A 60-year-old Woman with Breast Cancer” that lays out everything that we did to address this, but the point is, we had to start with a narrative change. The narrative change was informed by the maps and by the data because people want to believe that the paradigm under which they’re operating is unbiased. The oncologists were not “racist” but they were working in a system that produced systemically unequal results based on race, based on neighborhood, based on insurance status, you name it—and yet they were blind to that. Only by reshaping the narrative could we get to action.
At the end of a decade the Black-white mortality gap in Chicago, which had been 62 percent, had been reduced by about half. It wasn’t eliminated, but it was reduced to about the United States rate, which is about a 40 percent gap. In no other city with a large Black population and for no other cancer for which there was a Black-white gap did we see that reduction, and it occurred because we got all the institutions together to share quality data and went into the institutions to help improve the quality of their care and then we navigated women evidence-based interventions and to high quality cancer treatment centers.
Why wasn’t there a gap before the 80s?
There was no gap because from the beginning of the research on breast cancer until the 1980s, there was no screening and there was no adjuvant chemotherapy, and therefore every population who got breast cancer got the same bad outcomes. Unlike hypertension, where you can go home and take your pills, breast cancer is a test of a health care system’s response to a population because everything has to be done in an institution: you have to have a primary care doctor, you have to get screened regularly, you have to get referred for diagnostics, you have to go to a treatment center—all of those things are health-system dependent. Breast cancer is totally dependent on the system working on behalf of those who’ve been systemically marginalized—of course our systems don’t work that way, they work on behalf of those who have more (and sometimes poorly for those people as well)—but it certainly doesn’t work for those who’ve been systemically marginalized.
There’s this idea called the “amenability factor”: as soon as a disease becomes amenable to treatment, particularly treatments that are high tech in nature, those who have more get it faster. I mean, this has been known since the beginning of time. Economist Angus Deaton writes that mortality in medieval Europe was the same for the princes and the paupers until the wife of the British ambassador to Turkey brought back smallpox inoculation and began to give it to the children of nobility—for the first time you began to see life expectancy gaps.
On the topic of biological difference—which you were able to disprove here—isn’t it a problem that most clinical trials are not tested equally on all populations?
Every disease by definition is inherently biological. Let’s just say what we saw with COVID for example vividly was that someone’s social vulnerability or social exposure—basically who’s put in harm’s way—actually determined who lived and died, not just their biological vulnerability. And I would absolutely argue that if Black women have worse biological breast cancer shouldn’t they be first in line for the most advanced treatment? I’m not discounting that there are biological factors, what I’m saying is that the social conditions outweigh them sometimes. If you look at the life expectancy gap, the two largest drivers are cardiometabolic disease and cancer—diseases that are common. For some diseases we don’t need clinical trials, we need dissemination of best evidence.
Can you tell me about your current research projects?
I’m still doing work on breast cancer. I’m on the board of Equal Hope, a not-for-profit that has representation from the various medical centers and community organizations [to reduce health inequities, especially those affecting breast cancer]. We felt that that was a better way to reduce the mortality gap—by the way, the mortality gap has hardly ever been demonstrated in this country to be reduced and so this work that we’ve done in breast cancer Chicago is highly unique. It was called out in JAMA as one of three interventions in the country that have shown to reduce racial disparities from cancer, and it started at Cook County Hospital.
I’m now doing work on cardiometabolic disease. At C3EN I’m involved in Community Engagement Core to create a community-based research network. I’m also involved in other projects, for example Wellness West, which is a collaborative of six or seven hospitals, about 14 FQHCs and about 20 community-based organizations looking at ways to improve cardiometabolic disease outcomes and mental health outcomes across the west side of Chicago. It’s a research project funded by Medicaid. I’m also involved with a project that’s funded by Novartis to redesign hypertension treatment and diabetes treatment from clinic-based to home-based. My understanding is that one out of four black people and one out of four Latinx people last year experienced what they considered racial discrimination in health care—it’s only two percent for whites—so what if we could move treatment out of health care settings and get it into the home? We’re doing a study on that using community health workers.
My work right now is very much action-oriented, not just not studying the problem but how do we fix the problem? My daily work is senior vice president for community health equity [and associate provost for community affairs] at Rush. I’m on the executive leadership of West Side United, which is a racial health collaborative across the west side of Chicago and a member of the C3EN Community Stakeholder Advisory Council. The whole idea is, if we can convene community with healthcare providers, can we improve outcomes?
What are you most proud of in your career?
As a white man who came to Chicago deliberately to work with historically marginalized populations and trained in mechanisms of disease, what I’m most proud of is understanding the importance of seeing how racism and other forms of systemic exclusion and marginalization have to be viewed as vectors for disease. It took me many years to be brave enough to speak honestly or put together what I was seeing and to be able to say, “This has social causation, and part of the social causation is structural racism and economic deprivation,” to the Rush board or other groups at a time when it was not very popular. If I’m proud of anything it was to change the narrative around causation. I’m not the first and I’m not going to be the last, but I think it was important for white leaders to speak to this, because if you don’t get the root cause you can never actually fix the problem.
Of course there’s multiple root causes—we don’t want to totally discount biology—but we can’t discount the social and structural pieces of it. I had to interrogate myself personally because I was benefiting from a persistent unearned advantage that I wasn’t acknowledging and that I wasn’t taking advantage of to say, “Wait a second everyone—what if we don’t have it right—what’s the consequence?” At Rush, we made solving for this death gap the goal of our organization. If we’re going to improve the health of the diverse populations we serve, it’s got to be by addressing the root causes. It’s the most foundational change I went through, and I think it underpins my work and of course that of many others.
Do you have any fun facts?
My grandkids know me as Dodo—and I have an alter ego superhero called Wrinkleman, the most powerful creature in the world. I like the outdoors. I’m an exercise nut. I read a lot. I sing show tunes in the shower.
Did you know that [CSAC member] Dani Lazar also sings show tunes? We should have C3EN talent show—why are we not doing this at the Annual Meeting?
[Singing] If you see a guy reach for stars in the sky you can bet that he’s doing it for some gal …