Ngozi Ezike, MD: Hello everyone. I'm Dr. Ngozi Ezike and welcome, welcome, welcome to another episode of More Than Medicine. Today I am humbled, I am overjoyed to be joined by Dr. David Ansell, Senior Vice President for Community Health Equity at Rush University Medical Center and Associate Provost for Community Affairs at Rush University.

Dr. Ansell has spent decades, decades working in Chicago's safety net hospitals, including Sinai, and he has witnessed firsthand how structural forces shape health outcomes. He helped establish the Sinai Urban Health Institute as well as West Side United, and he has written critically acclaimed books including The Death Gap, How Inequality Kills.

Today we'll explore his insights on closing the death gap, the role of hospitals as anchor institutions, and how policy, partnerships and community engagement can advance health equity. Thanks so much for being here, Dr. Ansell.

David Ansell, MD, MPH: Well, I am so thrilled, Dr. Ezike. You know, you're one of my heroes. The great work you've done, the leadership and you and I have tread in the same pathways of the County Health System, Public Health and Sinai. And I like to tell everyone everything that I know I learned at Sinai.

Host: Wow. Well, you've definitely been in the trenches and you've seen inequity up close. What moments early in your career really opened your eyes to how structural forces and not just medicine, actually determine health?

David Ansell, MD, MPH: Yeah, well probably the first was my impulse to come to Chicago to Cook County Hospital. And as a medical student, you know, I understood that something wasn't right, but I didn't really, it wasn't palpable for me to really know what that was. But going to County in those days is the oldest public hospital in the United States, was just an overwhelming experience in both the positive and the negative about the conditions

under which people were treated and the heroics, the glory and the despair of what it was like to be there. And I'm sure when you were there too, it's almost hard to explain to people what that was like, but it was a life changing moment for me to be there in that moment in time. You understood something was going on.

It's a little hard in the West Side Medical District. You saw it in your patients. You saw it in the unequal distribution of resources. I'm at Rush now and being at County in those days, literally across the street. I had these, thought if you came down from Mars and you wanted to describe to the Martians what healthcare in America was like, you would land on one side of Harrison Street, County Hospital and describe one America.

And if you on the other side of Harrison Street, describe another America. And so in the sense that it was so obvious that something structural was going on, it felt like you had to bring the Martians into it to show Americans. It just felt so farfetched. But as a young doctor, as a young person, and also from the background I came from, which was, you know,

being a white middle class kid, it was eye-opening for me and it just made me want to step into it to understand it more, and I didn't understand it more till I got recruited after 17 years at County to be the Chair of Internal Medicine at Mount Sinai.

Host: Yeah, I mean, you've had an amazing journey and what's so great about your journey is that you've used it to try to advance and fight against these inequalities and disparities. You've often said that inequality itself is lethal. Can you break that down a little bit?

David Ansell, MD, MPH: Yeah, so think of where, you know, for the two of us trained as both in as physicians and as public health people, you know, as physicians we sort of look at the disease or the patient who's with the illness. And we try to modify the things we can, with the tools that we have.

People's beliefs, education, their behaviors, their health behaviors, you know, with medications, their biology, they call them the three Bs. But, at some point in time, we began to look at this. I mean, I say we, because my colleague Steve Whitman, who was the inaugural Head of the Sinai Urban Health Institute, I brought him to Sinai.

I said, this is the best corner in the city of Chicago, California, and Ogden. But you began to say if the problem resides within the person, then the challenge we have, is to fix the person. If the problem resides within the system and the structures, then we have to fix the structures. Of course, it's a little more complicated than an either or. It's a both and. That not only did we have to heal our patients the best we could with the tools that we have, which are actually, many of them are tried and true tools, vaccinations, public health, anti-hypertensive medications that control and reduce the risk of heart disease. You name it. The great advances in medicine are pretty spectacular. But if we don't actually fix the systems in which people are residing, we could never actually get to curing the problem at hand, which is inequality. And so I say inequality, we have to look at it as if it's a virus and treat it as we would any other epidemic. And of course we don't, haven't sort of historically thought about our work as physicians or as work as healthcare institutions in that way, but Sinai does, and now Rush does, and I think other organizations as well, and I do think it's a both and. We have to actually do this and we have to treat the conditions which are human made conditions that have promulgated unequal access to opportunity, as within the sphere of medicine itself.

Host: Yeah. Thank you so much and thank you for moving your experiences from County to Sinai and, and really teaching our partners at Rush. So there may be some people who have not read your book. You wrote the Death Gap, I think in 2017. For our listeners who aren't familiar with this book, how do you define the Death Gap and why? Why does it still persist in a city like Chicago to this day?

David Ansell, MD, MPH: Yes. Well, it's kind of a funny story about why I wrote it. You know, after 17 years at County and being at Sinai and getting to Rush, what I realized is that, you know, Rush is a terrific place. But people did not understand things that Dr. Ezike, you understand. I understand, because of our experience and what we've seen in our patients, in our communities, they don't understand it.

And I felt as if I was the Inaugural Chief Medical Officer here, so responsible for quality and safety, and I could see what an institution could do with just fabulous resources organized the right way and could understand what we were unable to do sometimes, same doctors, same patient, but unable to do at a County and a Sinai literally because the maldistribution of resources. No other reason. Same doctor, you know, but suddenly things were available and people didn't see, this was not a passive event. It wasn't like it rained on the west side of Chicago and therefore this happened.

Now these were acts of commission. These were acts of affliction, acts of oppression, and so I wrote the Death Gap when I got to Rush as a way to explain to my colleagues that inequality itself, people use the word inequity. Inequity is, another word, but a lot of people don't know what it means, whereas inequality is very clear. These gaps were unjust, they were unfair, they're unnecessary, and they were caused by human intention and human neglect. In other words, there were intentional policies and other things that happened that created the conditions that led to the unequal outcomes.

And then the neglect allowed them to persist. And so the Death Gap was really about that and really making the case. Doctors can understand, and public health people that, you know, malaria, which is a deadly disease, has a vector. And that vector is the female Anopheles mosquito. And, without the vector, you can't die of malaria.

 We needed to begin to look at the vectors, the social vectors that were responsible for the premature deaths that we were seeing, that were beyond the biology, beyond the beliefs, beyond the behaviors, but actually structural in the system. And so I talked about structural violence as being the framework of this, that there's a way to look at the world that we're in and say there's structural conditions that actually cause harm to the human body and that harm, and that's a vector through which the harm occurs.

Of course, the biological mechanisms are the same, but those vectors, the vector of inequality needed to be thought as like the vector, the mosquito for malaria, and that we needed to then think about, you can't think about eradicating malaria without thinking about eradicating the mosquito. And so you can't think about improving the problem of death gaps, life expectancy gap without eradicating the vectors. And then you have to say to yourself, well, what are the vectors. I'm going to use Martin Luther King's words, structural racism. He called it racism. We didn't call it that. And economic deprivation. The vectors themselves are well understood, concentrated disadvantage.

And if you put a child, any child, poor or wealthy in an environment that's nurturing, good schools, maybe some mentors around, maybe there's sports they can play, children will thrive if you give them the chance to thrive. You take that same child and you put them in a neighborhood of concentrated disadvantage.

Sociologists called. The word, what do I mean by concentration advantage? The neighborhood itself is a high poverty zone, meaning so many people don't have, the means of daily life, access to food, access to exercise, the ability to drive out of the community to go get something if they need it, and they're surrounded by people like that.

And then the next community over. Is the same way. So the people who come into the neighborhood are oftentimes people who are similar and don't have a lot of money to spend. And you get into the vicious cycle, and then the businesses in those communities have left. People call that disinvestment, but it's also, you could look at it as a form of capital extraction.

You know, the capital has been pulled out of the community. Sears is the best example, I never understood it. So I looked out of my window at Sinai and saw that tower. I said, what's that tower? It's the Sears Tower. No, the Sears Tower's downtown. But that four blocks, 27,000 people worked there. And when you remove that asset from a community, it's an act of violence, structural.

 So it allows us to get into a conversation that a lot of people don't want to get into. It's about structural racism and economic deprivation being acts of violence, a vector for disease. And it allows us to get in a conversation that right now a lot of people don't want to be in, but we have to have these conversations.

Host: I'm so protective of this community that I feel privileged to serve and you know, even though have suffered racism and economic deprivation, concentrated disadvantage, I still don't want to picture our communities as, as victims, but really want to see us, you know, as victors. And so even if we haven't achieved everything that we need to thus far, there are strides that are moving us in the right direction.

So what are those, some of those promising signs of progress?

David Ansell, MD, MPH: Well, it's interesting when we talk about these pieces, it's not to diminish the neighborhoods at all. It's really to talk about what's happened. But at the same time, neighbors have incredible strength, resilience, and assets. And just like the child that needs nursery, we need to bring those things back to the communities.

The point I'm making is that they weren't acts of accident. They weren't acts of omission, they were acts of commission. Anyone who's exposed to that kind of harm is going to cause harm. And the solution to it is something that I learned at Sinai, which is really investing into the people, and into the community. The treatment for this is to give the community the nourishment that it deserves and needs. And it comes in many, many forms. But at the end of the day, it's about the people and providing what can you provide for the people. That's why Sinai has been such a tremendous asset in that neighborhood for over a hundred years. And it's because it's always been focused on providing for the people. If you look at sort of what Sinai has done along that Ogden corridor, it's quite tremendous. Because not only investing in people in terms of health and healthcare and providing the care that people need when they need it, in an emergency or even for their chronic disease; you're investing in the community in terms of new structures, new opportunities, employment, and other things as well. And I think that's the work that we just, we have to do. North Lawndale itself is just a spectacular community with great leaders, North Lawndale Employment Network, the NL Triple C, the coordinating committee, to really sort of direct where the assets need to go based on what people want and need.

And there's a lot of examples of that across the west side. And I think we gotta feel pretty good about it. We're not there yet. You know, we went through COVID. We sat at Rush, our board and Sinai, everything we copied from Sinai. That was easiest way for us to do things. It took me a while to get Rush to understand.

So it's interesting, right, to move an institution like Sinai, they were moved already. Sinai made a deliberate decision in 1968. Martin Luther King was assassinated to stay in the neighborhood. And Rush is a late comer to these policies and procedures and approaches that Sinai did, which was, if you want to address the life expectant gap, the death gap. Where do you think I got that from? Sinai Urban Health Institute. That was the work we were doing. You've got to invest in these neighborhoods for the long term. And I think that that's the work of, you mentioned anchor institutions. There's so many reasons why Sinai needs to thrive.

You know, it's a big employer. It's anchoring the neighborhood, it brings assets into the neighborhood, and I think if we all did that work together, we would all contribute to these community rebirths, almost. One of the things that we got involved with was the laundry linen.

In North Lawndale, in the former Calumet baking powder thing, and you know, it's an interesting process for us of investing in the community. So were the first to bring our dirty laundry. Now, it's fabulous benefits. One is our laundry linen is very close to us. It's no longer in Wisconsin. It gets jobs, people lined up for the jobs.

It's amazing. But we also, you realize, and this is the way that racism works, we de-risk the neighborhood for others. Because people have a mental models unconscious, just like unconscious bias that patients face, people have a bias against North Lawndale or Garfield Park. That's based on the unspoken thoughts they have.

And so people would think that if I brought my laundry to North Lawndale, that can't be good. And yet Rush saved 700, $800,000 by doing our laundry local. Now, now that business is taking off and it's by the end of next year, I think it could have 300 employees. Now, not only the 300 employees, but they did a study.

MasterCard looked at a circle around that laundry living. Because almost 80% of the employees are from North Lawndale that the MasterCard sales have gone up 24%. Because these families now each person, probably represent five or six other people and that money needs to be spent somewhere. And so that's the flywheel virtuous opportunity for us as hospitals to do this work.

And like Rush following, really Rush, all we did was follow Sinai and try to get other institutions to follow along.

Host: Thank you for shepherding this work and expanding it beyond just the traditional safety nets. You've definitely given life to the concept that it's not just a hospital thing. It's not the hospitals alone that are going to fix these issues. And you've spent years and have just been the model for building partnerships and communities that have a reason to now trust institutions, but it's not that easy. There are many good reasons that people have distrusted institutions. So tell me just a little bit about what you've learned about creating authentic trust and how do you keep it, how do you maintain it once you think you've earned it?

David Ansell, MD, MPH: Well, when we started this here, first of all, we have well-earned mistrust. The mistrust of healthcare by communities. I think it's worse, worse than now in the environment we're in, the politicized environment post COVID. I mean, if you look at the data on the left and the right, the Republicans, the Democrat, there's a high degree of mistrust in general in the world across multiple types of institutions, government, hospitals, healthcare, as you know, and I'm sure you experience on a personal level, we've never talked, you being the amazing, gifted, inspirational, brings tears to my eyes to listen to you during COVID as a spokesperson for common sense and giving us all this sense of relief, reassurance.

But you know how, and I have other friends in public health who as a result of that honest, heartfelt, thoughtful approach, were not only demonized, but threatened. And so we live in a world right now where there's a high degree of mistrust, but in healthcare, and particularly with historically minoritized populations, we've earned the mistrust.

And it's hard to, once people have an experience or their aunt had an experience or their grandmother had an experience. And those things get passed down, and there's a long memory for that. So we have a lot of work to do. The second part of it is, and this is probably more for a place like Rush than a place like Sinai, you know, you would come in and you say, oh, we want to do this little study, will you be participating and we'll pay you.

And then you're, three years later, you're gone and nothing is left behind. What the community told us, and it makes a lot of sense. When we formed West Side United and Sinai was there at the beginning, County Health System was there at the beginning. U of I, at the beginning meeting with the community, listen, if you're going to commit, you're committing. This is not short term, it's long term. And I think the only way you break down mistrust is make people understand that we're in this permanently. The third thing is, and I think you understand this as well, the partnerships are really important. No one can do it alone.

The authentic need to listen to the community or obligation to listen to the community, ask people what they think and what they want and what they need, and then do what they tell you. So the partnership has to be nothing about us without us. Nothing is ever privileged at the same level. So we can go hat in hand as leader of an institution to the community, and there's disproportional power always. Even if an institution's not a wealthy institution compared to the community, there's always that disproportionate power and we really have to come with huge amount of humility.

And acknowledge the harms that we have committed in the past and we might have even committed yesterday. That side takes a lot to actually do that. And then the work of repair. So people talk about reparations. There's a great article about North Lawndale by Ta-Nehisi Coates in the Atlantic, the case for reparations, I encourage everyone to read, but the verb is repair. What does it take to repair historical injustices, even if you weren't there to cause the historic injustice. The repair is you have to pay it forward, and that has to show up in things like real acts of giving, and that just takes time. And it takes a commitment that most institutions have not had.

You know, the CEO comes and goes, okay, we have a new strategy now. And no, this has to be a long term commitment. I want to add one other word here, which I think is terribly important, or solidarity, interconnectedness. We're all interconnected. We come from different backgrounds and different experiences.

We bring those experiences with us to the table. When you talk about inclusion, these words, diversity, equity, inclusion that have been demonized and mischaracterized it's a false, you know, false accusations about it. But inclusion really is about not only including all of those experienced and voices at a table.

So in an interconnected way with solidarity we can collectively bring to the community what they say they want and need. And then they tell you when you're done. It's an idea called accompaniment. Paul Farmer and others, accompan yours, where we walk alongside our patients with an illness, our community, until we are relieved of that obligation. Now, it's powerful. You just have to commit to it.

Host: Wow. Well, I am so grateful. I just want to end with some of these powerful words that just pack so much. Accompaniment, solidarity, interconnectedness, inclusion, and of course, community. Thank you so much for modeling those words in action and in the community for essentially a lifetime. I am so grateful to you, Dr. Ansell. I am grateful for this time. I'm grateful for your life's work. Just tireless work, advancing health equity in Chicago, and actually being the model for much greater places, larger spaces than just Chicago, but for the whole country. Your leadership, your insights, your dedication have really shown us what community partnerships should look like, and you continue to inspire and guide so many.

So here's to continued progress and closing the death gap in the years to come. Thank you for your efforts. Thank you for your time today. It's been a pleasure.

David Ansell, MD, MPH: Thank you for having me.