61 pages • 2 hours read
David A. AnsellThe Death Gap: How Inequality Kills
Nonfiction | Book | Adult | Published in 2017A modern alternative to SparkNotes and CliffsNotes, SuperSummary offers high-quality Study Guides with detailed chapter summaries and analysis of major themes, characters, and more.
Part 4-AfterwordChapter Summaries & Analyses
Part 4: “The Cure”
Part 4, Chapter 11 Summary: “Community Efficacy and the Death Gap”
Ansell explores the impacts of public policies, social inequities, and healthcare system factors on health outcomes across different neighborhoods. He examines how some communities manage to resist structural violence and achieve better health and longer life expectancy despite facing similar challenges.
The chapter opens with the story of Officer Thomas Wortham, who was killed in Chicago’s Chatham neighborhood. Wortham’s death was a result of a robbery gone wrong, in which Wortham was a bystander. The Chatham community faced issues like increasing crime and economic decline. Despite these issues, Chatham had historically maintained a middle-class status and better health outcomes compared to neighboring Roseland, a community with similar demographics but poorer health metrics.
Ansell suggests that the difference lies in social cohesion and collective efficacy. Social cohesion refers to the connectedness and trust among neighbors, while collective efficacy is the willingness of a community to work together for the common good. Chatham’s strong social fabric and community engagement have helped it achieve better health outcomes, even in the face of economic and social challenges.
The chapter also looks at Oak Park, a suburb bordering the impoverished Austin neighborhood in Chicago. Oak Park successfully managed racial integration and maintained good health outcomes through proactive community policies and strong social cohesion. Key actions included passing a fair housing ordinance, retraining real estate agents to prevent racial steering, and establishing a housing center to promote integration and prevent blockbusting. These efforts helped Oak Park become a diverse and integrated community with a high level of social capital and collective efficacy.
Ansell contrasts Oak Park’s success with the challenges faced by Chatham. While both communities exhibit strong social cohesion, Oak Park’s economic and social privileges have allowed it to better weather economic downturns and maintain lower mortality rates. Chatham, despite its strong community bonds, struggles with the additional burdens of economic decline, racism, and limited healthcare access.
The chapter then develops the concept of collective efficacy, which is “social cohesion plus the willingness of a group of neighbors to act together for the common good” (147). Ansell notes that the Project on Human Development in Chicago Neighborhoods (PHDCN) found that neighborhoods with high collective efficacy have significantly better health outcomes, including higher life expectancy.
However, Ansell notes that collective efficacy is less common in predominantly Black neighborhoods, which often face greater structural barriers. This discrepancy highlights the role of privilege in enabling collective efficacy and social capital. Communities that have historically faced exploitation and resource deprivation struggle to build the same levels of collective efficacy as more privileged areas. Ansell concludes that while community action and collective efficacy can mitigate the impacts of structural violence, broader public policy changes are necessary to address health inequities effectively.
Part 4, Chapter 12 Summary: “Community Activism Against Structural Violence”
Chapter 12 recounts different community activist initiatives that took place between 2010 and 2015 in Chicago’s South Side area. The initiatives were spurred by gun violence and longstanding distrust between residents and institutions like the police and city hall.
For example, the fight for a Level 1 trauma center on Chicago’s South Side, led by the youth group Fearless Leading by the Youth (FLY) began with the shooting of Damian Turner in 2010. Turner, a youth leader and FLY cofounder, was shot and died because the nearest trauma center was 10 miles away. This incident prompted the community to demand the University of Chicago open an adult trauma center, given the high rates of gun violence in surrounding Black neighborhoods and the university’s historical placement close to the neighborhood. The University of Chicago had closed its adult trauma center 25 years earlier due to financial losses. Despite maintaining a pediatric trauma center, the university was perceived as avoiding responsibilities toward the local Black community.
FLY’s activism included protests, sit-ins, and building coalitions with other community groups, healthcare professionals, and local leaders. This grassroots movement faced significant resistance from the university, which cited financial constraints and argued that existing trauma centers in other parts of the city were sufficient. Finally, in December 2015, the University of Chicago announced plans to open an adult trauma center on its campus, marking a significant victory for the South Side community.
Part 4, Chapter 13 Summary: “Observe, Judge, Act”
Chapter 13 draws from the principles outlined in humanitarian physician Dr. Paul Farmer’s book Pathologies of Power, encouraging a proactive attitude from doctors, who, according to Farmer and Ansell, have a duty to society beyond their work in the hospital.
Ansell argues that medicine must advocate for the poor but often falls short, especially in the US, where healthcare is treated as a commodity. This approach prioritizes profit over the health needs of disadvantaged populations, leading to significant health disparities. Physicians, as “natural attorneys” (176) for the disadvantaged, must recognize and address these disparities.
Ansell emphasizes the need for immediate and comprehensive action to address health inequities and the structural violence that maintains such inequities. This includes advocating for a fair and equitable healthcare system that treats health as a human right. Health institutions, Ansell argues, must be held accountable for serving high-poverty communities with the same standards as wealthy communities.
The chapter also recounts an example of pragmatic solidarity, where Dr. Paul Farmer’s organization, Partners in Health, provided food alongside tuberculosis medications to Haitian patients, addressing their immediate needs and improving treatment adherence. Similarly, Ansell highlights the importance of listening to, and understanding, the social and economic conditions affecting patients, as demonstrated by his interactions with patients like Windora Bradley.
Moreover, Ansell argues for hospitals and health systems to adopt “anchor missions” (188) to revitalize neighborhoods through job creation, housing, and other community investments. By acting as anchors for community health, these institutions can address the structural and social determinants of health.
Ansell concludes by acknowledging the complexity of social, economic, and racial inequities, but remains optimistic. He cites historical progress in civil rights, women’s rights, and other social justice movements as evidence that meaningful change is possible. He urges collective action to bend the moral arc towards justice, emphasizing that achieving health equity is within reach if everyone works together.
Afterword Summary
In the Afterword, Ansell reflects on the COVID-19 pandemic and its exacerbation of existing health inequities in the United States, particularly in Chicago. The crisis highlighted the severe impact of structural racism and poverty on health outcomes. In early April 2020, Chicago Mayor Lori Lightfoot responded to alarming statistics showing that 72% of the first 100 COVID-19 deaths in the city were among Black residents, despite them constituting only 30% of the population.
Rush University Medical Center, under the leadership of Dr. Omar Lateef, prepared for the pandemic by focusing on reaching out to disadvantaged communities. This proactive approach was crucial as the pandemic hit hardest in neighborhoods already suffering from systemic neglect. The publication of The Death Gap three years earlier had already brought attention to the life expectancy gaps across the US, with Chicago having the largest disparities.
As COVID-19 cases surged, Ansell observed patterns in hospital admissions, noting that many infected individuals contracted the virus through their frontline jobs. The pandemic highlighted how workers in disadvantaged neighborhoods were more exposed due to their essential roles and inability to work remotely.
In response, Mayor Lightfoot reached out to West Side United, a collaborative formed by Rush and other hospitals to address health inequities. They proposed the Racial Equity Rapid Response Team (RERRT) to coordinate resources and focus on community capacity and healthcare coordination. This initiative became a national model, illustrating the importance of targeted, data-driven efforts to combat racial health disparities.
Ansell notes that the murder of George Floyd in May 2020 further emphasized the systemic racism ingrained in American society, including healthcare. The cumulative impact of COVID-19 deaths, police brutality, and economic collapse underscored the need for racial and economic equity. Many hospitals, acknowledging their complicity in perpetuating racial health injustices, began to support movements like BlackLivesMatter and declared racism a public health crisis. Ansell stresses that real change requires restructuring society around human rights and social justice, including universal healthcare.
Ansell concludes on a note of optimism, highlighting the importance of narrative, data, and action in driving social change. He believes that community activism, partnerships, and a commitment to equity can close the death gaps and improve health outcomes for all.
Part 4-Afterword Analysis
Ansell underscores the critical role of social cohesion and The Role of Community Activism in achieving better health outcomes in communities plagued by structural violence. Ansell explores the stark differences in health outcomes between neighborhoods, using the examples of Chicago’s Chatham and Roseland neighborhoods.
To aid his analysis of the two neighborhoods, Ansell develops the concept of collective efficacy, which combines social cohesion and a community’s shared expectation for collective action. Collective efficacy is used as an umbrella term for a set of conditions and behaviours that result in communal wellbeing. Ansell looks at vulnerable neighborhoods, such as Oak Park and Chatham which, nevertheless, have a high collective efficacy. Ansell asserts that there is a link between collective efficacy and health outcomes: “Not only may it feel good to live in a community with high levels of social cohesion and efficacy, it can greatly affect one’s health—and the likelihood that one would survive a heart attack, a heat wave, or a bout of breast cancer” (154).
This sense of social responsibility, reflected, for example, in higher rates of bystander CPR, significantly influences health outcomes, enhancing the likelihood of surviving critical health events. The correlation between collective efficacy and improved health outcomes underscores the importance of fostering social cohesion as a means to combat the adverse effects of structural violence and inequality. However, Ansell points out that collective efficacy is often less prevalent in predominantly Black and other vulnerable neighborhoods due to historical and structural barriers. These communities, having faced systemic exploitation and resource deprivation, struggle to build the same levels of social capital and collective efficacy as more privileged areas. This discrepancy highlights the need for broader public policy changes to support these communities in building stronger social cohesion and collective efficacy.
Nevertheless, as Ansell cautions, it is easy to rely on concepts such as collective efficacy and social cohesion to justify the systemic violence of disadvantaged neighborhoods. On one hand, the need for collective efficacy may seem to only exist in such vulnerable communities, where neighbors need each other for survival. Equally, the lack of collective efficacy and social cohesion may be blamed on the inhabitants of those vulnerable neighborhoods, placing all the responsibility for the disparity in resources, income, and health back onto those communities. In fact, as one study found, collective efficacy is no longer considered by some sociologists a cause of social wellbeing in a community. Rather, collective efficacy reflects the physical, social, and human resources that a community has access to. A positive change in physical environment—such as the introduction of parks, the improvement of lighting on streets, and the introduction of spacious community centers for congregation—may be the cause of collective efficacy rather than the result of it.
In conclusion, Ansell argues for a paradigm shift toward treating health as a human right and calls for systemic changes to ensure equitable access to healthcare. While health is at the center of Ansell’s book, it is not an isolated concept but tightly connected to the way infrastructure is planned and built, and to the mentality of a society that should care for its most vulnerable.
