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Wed June 15, 2011
Author Interviews

'Life, Death And Politics' Treating Chicago's Uninsured

Originally published on Thu July 14, 2011 7:26 pm

The first time Dr. David Ansell went into the men's room at Cook County Hospital in Chicago, he immediately ran out. "It was so bad, I couldn't use it," he says. "I ran across the street and had to use the bathroom there. It was quite an introduction to my first day at County."

Ansell is now the vice president for clinical affairs and chief medical officer at Rush University Medical Center. But he began his medical career in 1978 at County, Chicago's public hospital, where he worked as an attending physician for almost two decades. His social history of the hospital, County: Life, Death and Politics at Chicago's Public Hospital, details his own time on the wards — and examines health care in America from the perspective of the uninsured.

Working at County, Ansell says, made him realize just how much the current payment system drives health care inequalities. "There's a misunderstanding that if you just go to the [emergency room], that's health care," he says. "It's not. ... And I don't think the public or politicians really understand that. I think the last health reform attempt which is being bandied about — we don't know what's going to happen — is likely to fall short with regards to equity."

Doctors Within Borders

Cook County Hospital, where Ansell worked, was a public hospital, a place that treated people with nowhere else to go. Physicians and residents who worked at County, meanwhile, were entering an environment with underfunding, mismanagement, high patient demand, safety concerns and antiquated equipment.

"I went into medicine because I wanted to help people, and when I went to medical school, I found it very disillusioning," Ansell says. "County was a place that many of us went because we believed that disease had social etiologies — the idea that disease just emanated from the individual and wasn't somehow constrained or influenced by societal factors. Going to a place like Cook County Hospital was a place where we could live those beliefs out."

Health care at County was very different from care at private or university hospitals. When Ansell first started treating patients, County had no air conditioning, poor sanitation and limited patient privacy. "The beds were lined up one after another, separated by curtains, but there was really no privacy," he says. "Patients would roll in and they'd be lined up around the walls of this one room, and the middle was lined with stretchers and wheelchairs. You were forced to take histories and examine patients under these conditions."

In 2002, a new hospital called the John H. Stroger Jr. Hospital opened in Chicago, replacing Cook County. The facility provides more dignified conditions for patients. But the new facility, Ansell says, cannot compensate for social inequalities and limited access to preventive health care.

"Just yesterday I had a conversation with a physician [who] says there's a many-months wait to see the eye doctor," he says. "There are 4,000 patients waiting to get a colonoscopy. This is not a screening colonoscopy — they've got blood in their stool. ... The new hospital and the doctors and the nurses and the clinics are spectacular, [but] if you look at the whole system and you look at the outcomes we're getting ... people are going blind waiting to see the eye doctor, in a country where it doesn't have to be."

Health Inequalities

On the South Side of Chicago, the life expectancy of an African-American male is eight years lower than that of a Caucasian man, Ansell explains.

"When you look at the reasons for it, at least half of this is [because of] heart disease and cancer and things that could be treated," he says. "One of the problems with our current system is segregating people by insurance status, which ends up limiting the options of care — especially when you get down to the specialty care that people need."

During his 17 years at Cook County, few if any of Ansell's patients could get their hips replaced — or other medically necessary but not trauma-related treatments.

"The only fair way to do this is where people have a card that gets them in, where that card is accepted widely and broadly by everyone, and [giving people] choice," he says. "So you could go anywhere you want, you get the care you want, and choose your own doctors — and that would be some sort of universal plan — Medicare for all, single-payer. We need a system that really gives patients — poor or rich — adequate care."

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Transcript

TERRY GROSS, Host:

This is FRESH AIR. I'm Terry Gross.

C: What is the best way to fund and deliver health care to the poor and uninsured?

H: Life, Death and Politics at Chicago's Public Hospital."

Dr. David Ansell, welcome to FRESH AIR. Hospitals are supposed to be safe, clean places for healing. So let's start with the first time you went to the bathroom, to the men's room, at County Hospital. Describe what that was like.

DAVID ANSELL: Well, it was 1977, and a group of us came to Cook County Hospital to interview with the legendary chairman of internal medicine Dr. Quentin Young.

It turns out he wasn't there, even though we had scheduled the interview, and we were whisked off to a mass meeting that was being held in another area of the hospital. It was full of people, and people were talking about the hospital going to close if we didn't do something. But my head was somewhat spinning from that whole morning's events, and I realized I had to find a bathroom.

And I made my way to the first floor lobby of County, asked the guy at the security desk, who pointed his way to the bathrooms, which were off to the side of the lobby, and I went in it. And it was so bad, I couldn't use it. And so I ran across the street to, which at that time, there's a place called The Greeks, which was a restaurant across the street, and had to use the bathroom there. It was quite an introduction to my first day at County.

GROSS: So did the men's room that was so unsanitary you couldn't use it, did it represent what the rest of the hospital was like?

ANSELL: Well, it was like no place I'd ever seen at the time. You have to remember it was built in 1914 by an architect who was more interested in creating a monument to Beaux Art architecture than to create a patient care institution.

In 1927, the American College of Surgeons came on a tour and said it should be torn down in replaced, and this was now 1977. And it was a very old, worn down, tired institution filled with people, and you can imagine - hard to keep it clean, hard to maintain an institution like that.

GROSS: Since so many public hospitals have closed down in the past few decades, would you just describe what a public hospital is, because I think a lot of people don't even know anymore?

ANSELL: Public hospitals were created originally in the early 1800s, in this country - started as poor houses. The people who lived on the street and couldn't make it on their own had to be placed somewhere. And they went there. And when illness ravaged communities, they transformed into hospitals.

And public hospitals in this country have been the last resort for the poor and uninsured, or actually the undesirable of any sort, for many, many years. But at the same time, they've been hampered, in many cities and localities, by both politics, and they've been part of the larger background of race and poverty in this country.

GROSS: So if a patient went to a hospital, but they didn't have health insurance, were they likely to be sent to Cook County Hospital?

ANSELL: Yes, in the '70s and the time before that, it was quite common for a patient to show up at a hospital, to be in an ill condition, generally enough to require emergency care, and they would get transferred to Cook County Hospital by ambulance - the reason, oftentimes, being no insurance.

That ended, actually, when - after we did a study at Cook County and many others around the country - raised an outcry about the idea that very sick people could just be put in an ambulance - and we called it dumping - and dumped to Cook County Hospital.

Nowadays, it occurs in somewhat different manner because many hospitals in urban areas have closed. Emergency rooms have closed. Communities have been somewhat abandoned by the health care system. And so now people show up, and they show up in cars, they walk in, they come to the emergency room, and these again are the places of last resort in the country.

So they're very special in many ways. They're great teaching places. But the dynamic of this sort of vast population in our country that has no access to health care, coming to institutions like this is quite tragic, on the one hand, and uplifting on the other. Because, where we could provide the best care, we actually provided the best care, but oftentimes we're overwhelmed by what we didn't have the resources to do. Not that we couldn't do it but we didn't have the resources to do all that we could.

GROSS: Before we get to what Cook County Hospital is like now, you're on the board of the hospital now, let's talk a little bit about what the conditions were like for patients when you started working there in the '70s. You describe overcrowding, beds in the hallways, wards - wards that had been state of the art in the early 1900s but at this point were just very - well very what? How would you describe the condition of the wards in Cook County Hospital in the '70s and '80s?

ANSELL: Well, the wards were open wards. And you have to understand, 1978 Chicago, 10 years before, the city was rocked with riots. Much of the West Side of Chicago went up in flames when Martin Luther King died. It was described to be one of the most segregated cities in the country.

County had become a concentrated institution that took care of poor, black, Mexican and immigrant people and in such a manner that they were devalued by the larger society. And the conditions, in some ways, inside the hospital, reflected the conditions out in the community.

They were open wards. There was, again, an old building. There was no air conditioning. They were cold in the winter. They were very, very hot in the summer. There were screens. The operating room had windows. A friend told me about his third-year rotation on surgery at Cook County Hospital. This was many years after my time there.

And he's being taught to scrub and how the proper way to scrub, and he gets gowned, in his gloves and walks into the operating room, and the senior resident says: Your job is to keep the fly away from the incision.

There was no privacy. The beds were lined up one after another, separated by curtains, but there was really no privacy. There was one ward we loved as residents. It was called Ward 35. It was the admitting ward. And what was so great about that place is we were all concentrated there on admitting night, all of us young doctors.

And the patients would roll in, and they'd be lined up around the wall - the walls of this one room. The problem was - is you were forced to take histories and examine patients under these conditions, which would have been okay, I suppose, if there weren't the possibility of having shiny, new hospitals.

So we were across the street from the hospital I work in now, which has single, double bed rooms and privacy and dignity. The contrast was what made this so bad. There was a time in hospital history when all hospitals in the United States were like this.

But by the time I got there in 1978, and until the new hospital opened in 2002, these were the conditions, and unfortunately the patients did suffer from the indignity of these conditions.

GROSS: If you're just joining us, my guest is Dr. David Ansell. He's written a new memoir called "County: Life, Death and Politics at Chicago's Public Hospital." And it's about the 17 years he worked at Cook County Hospital in Chicago. Let's take a short break here, and then we'll talk some more. This is FRESH AIR.

(SOUNDBITE OF MUSIC)

GROSS: My guest is Dr. David Ansell, and his new book "County: Life, Death and Politics at Chicago's Public Hospital" is about his 17 years working at County Hospital, a public hospital in Chicago.

You describe the work that you did at County Hospital, as doctors within borders. I think most people know what Doctors Without Borders, and these are doctors from around the world who go to war zones and disaster areas and help people who need - who desperately need medical help.

And what you're suggesting is that you were doing the same thing, except that it was in the middle of Chicago.

ANSELL: Yes, I went into medicine because I wanted to help people, and when I went to medical school and found it very disillusioning. And County was a place that many of us went because we believed that disease - even as a young 24-, 25-year-old - that disease had social ideologies and that the idea that disease just emanated from the individual and wasn't somehow constrained or influenced by societal factors - which was kind of the teaching in medical school at the time - that disease is - emanates from the individual.

So going to a place like Cook County Hospital, was a place to go live those beliefs out. And when people nowadays, young medical students or nurses, say they need to - want to go to Africa or Dominican Republic - and God bless them for going and doing that - we have great places in this country that need young doctors and nurses to go to, like our public hospitals, where the same problems you're going to see in third world countries are right there, right in our inner cities. We drive past them every day. And that was why I went to County.

GROSS: You ran the walk-in clinic at the hospital in the 1980s, and you say that this was the most challenging and disturbing job of your career. Why?

ANSELL: Well, if you can imagine a clinic that - you open the doors in the morning, and people just came in, and they came in all day long, from beginning until we closed. And if we kept it open all night, they'd be all night long. The problem with this clinic was, the kind of patients we were seeing were people who needed primary care.

And they were walking in to County Hospital to get care that should have been theirs as a right of their humanity, in their communities. And it was quite overwhelming, to both, keep up with the demand, but also keep up with the nature of the diseases that we were seeing there.

GROSS: You write that the clinic was also known as the screaming clinic, because the noise level was so high, and there were periodic eruptions from really angry customers. Were the waits really long? And when people got really angry, did they ever take that out on you as the doctor?

ANSELL: I have to say patients at County were so respectful and patient, and that them - when they got upset about waiting, it was the kind of upset that no one else would tolerate waiting the hours that they waited.

It wouldn't be unusual for someone to come in for a check-up and wait eight, nine, 10 hours, 12 hours - for care. So you really can't blame people for getting upset.

We tried to ameliorate this by putting an appointment system in, but over the years, the numbers of people who have walked in just continues to grow.

That clinic is still there. I revisited it many years later. It was as if time had stood still, and nothing had changed.

GROSS: So you think that - do you think that the new Cook County hospital, the one that opened in 2002, still represents the kind of medical apartheid that you describe from when you worked there from '78 to '95?

ANSELL: There have been many, many improvements. New hospitals provided, you know, much more dignified conditions to patients. But if you take a step back, and you look at the larger issue of access to care - and I look at health care through the lens of being a doctor and the doctor-patient relationship, but actually through a wide-angle lens of being an epidemiologist.

If you look at just health care outcomes, there's things like life expectancy, and you look in Chicago - what bugs me and upsets me every day of the week, is the fact that on the South Side of Chicago that a black man dies eight years earlier than a white man in the United States, that a 16-year-old has a 50 percent chance of living to the age of 65.

And When you look at the reasons for it, at least half of this is heart disease and cancer and things that could be diagnosed and treated if we had adequate health care system and access to health care.

So what we have a new hospital. There are clinics. There are still struggles to access the most basic of conditions. I'm not talking about emergency conditions and emergency care. I'm talking about specialty care.

Just yesterday I had a conversation with a physician and who says, you know, there's a many months wait to see the eye doctor or there are 4,000 patients waiting to get a colonoscopy. And this is not a screening colonoscopy. This is they've got blood in their stool.

And it's what we - again, not what we could deliver under those conditions - so the new hospital and the clinics and the doctors and the nurses are spectacular. It's just that if you look at the whole system, and you look at the outcomes we're getting, and then you look at the sort of the ways that are built in - where in another hospital in the city, you could probably get in the next week.

GROSS: It's politicians, not doctors, who are working on reforming the health care system in one direction or another. Are these things that you feel politicians don't really understand about medical delivery systems?

ANSELL: I think what they don't understand, so much, is how the payment system drives inequality. And I think that they really don't have great understanding of that.

This is a country that, at its best, is built on fairness and equity. You know, if you've got a good education, you can make it in this world, you know, if you work hard. But there's a misunderstanding, that if you just go to the ER that's health care.

It's not. And I think we've got to think this as - in terms of the larger system of care, and I don't think the politicians really understand that. I think the last health reform attempt which is being bandied about, we don't know what's going to happen, is likely to fall short with regards to equity.

GROSS: We've been talking about your work at a public hospital. What happens in places where there isn't a public hospital, where the public hospital was closed recently or decades ago? Where do patients go, and who pays?

ANSELL: You know, people think we have a safety net system out there, and we do. There's some community health centers in many cities. These are health centers that are somewhat federally funded, people can go to. But they fall far short of the needs of communities.

In the old days, we said we had patient dumping. I think what we have now is community dumping, where large communities around the country, generally in urban areas but rural areas, too, have been abandoned, because neither hospitals nor doctors can make it there, financially.

And the patients in these areas either have to drive far, or just, when an emergency occurs, get themselves to a hospital. It's less than ideal.

GROSS: So can I have your brief take on the health reform plan that passed Congress?

ANSELL: Yes, I'm going to - Winston Churchill once said something like: Americans eventually do the right thing after doing the wrong thing many times over. And this is - while maybe a good start though bad outcome, because we're going to put people into - a lot of people into Medicaid, and a lot of people will still be uninsured; and Medicaid system is unfair because people don't have access to specialists, and we're going to end up with disparity persisting, for at least a generation.

There is better solutions. Medicare for all. Take the Medicare card our parents have, I'm soon to be have in a few years, give it to everybody, figure out how we pay for it and manage the cost. And that would be the fairest way to do the health care system.

GROSS: The figure out how we pay for it, I think, is the sticking point for a lot of people.

ANSELL: Well, we are paying for it now. We're paying for it in many different ways. And it's never been an issue of money in this country.

GROSS: Are there costs that we don't see in the health care system now?

ANSELL: Yeah, there's the cost of inefficiency. There's the cost of emergency care. There's the cost of end-stage disease that doesn't have to be. There's the cost of not prevention, not doing prevention. There are huge costs. We're at twice the cost of the next system.

And people talk about rationing. We're rationing care every day in this country to poor people, and, you know, 45,000 excess deaths. Chicago is nine a day. Nine black people die a day in Chicago just because they don't have equal health outcomes to white people.

Now, if this was Iraq and a road-side bomb, it'd be front page of the newspaper, but... And this is occurring in every city, in rural area in this country. We're paying for it. It's just we don't add up all the costs.

GROSS: Well, Dr. Ansell, I want to thank you very much for talking with us.

ANSELL: Thank you for having me.

GROSS: Dr. David Ansell is the author of the new memoir "County: Life, Death and Politics at Chicago's Public Hospital." You can read an excerpt on our website, freshair.npr.org. Ansell is now vice president of clinical affairs and chief medical officer at Rush University Medical Center, a teaching hospital affiliated with the new Cook County hospital, which opened in 2002. I'm Terry Gross, and this is FRESH AIR. Transcript provided by NPR, Copyright NPR.

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