Community Dumping: Shuttered Emergency Rooms and Black White Death Gaps
July 10, 2011
In the 1980s, public hospitals exploded with sick and uninsured patients transferred from private hospitals for economic reasons, a practice called patient dumping. I was a young physician at Chicago’s Cook County Hospital when my colleagues and I documented the negative consequences of patient dumping and contributed to the passage of federal legislation to ban it. Fast-forward thirty years. Urban emergency rooms have been shuttered (Fewer Emergency Rooms Available as Need Rises, New York Times , May 17, 2011) in the most vulnerable communities in America for economic reasons, a practice that could be called, “community dumping.”
Community dumping, the abandonment of high mortality communities by hospitals and clinics, contributes to a deadly epidemic of premature mortality in US cities. Its victims: working age black men and women. Black men on Chicago’s South side die eight years earlier than whites while black women with breast cancer have almost twice the chance of dying than white women. Detroit and Harlem are not much better. The annual toll of the racial mortality gap in Chicago alone is 3,200 excess black deaths, more than died in NYC on 9/11 or from Hurricane Katrina.
How can US cities be spinning in the wrong direction when it comes to racial inequalities in health outcomes? Adverse racial health outcomes are not merely the result of bad luck, bad choices or bad genetics. There are three drivers of health outcome disparity. The first has its roots in the structure of urban communities. Vast swaths of urban neighborhoods are hyper-segregated, with high unemployment, high poverty rates, and poor health outcomes. Most low-income urban blacks in the US live under these conditions – lacking immediate access to the institutions and resources that can, over time, increase their lifespan. Community dumping is not just an issue of poverty. Over 80% of impoverished whites live in economically integrated white communities and as a result have access to the same grocery stores, schools and health facilities as the more well-off residents of those communities. Low income blacks suffer a triple whammy when it comes to health outcomes- being poor, black and living in a hyper-segregated urban neighborhood. The closing of emergency rooms in these communities is part of a larger pattern of public policy-driven social isolation that contributes to mortality.
A second reason for the racial health care gap is a lack of access to primary health care. Research shows that in Chicago and other urban areas, over 50% of the black/white mortality gap can be attributed to excessive death rates from treatable conditions – such as heart disease and cancer. High un-insurance rates limit inner-city black men and women’s access to institutions and specialists who could treat these conditions.
The third reason for the black/white health care gap is disparity in the quality of health care. Because of the limited health care choices open to most blacks they are less likely to receive the same quality of care as whites Blacks are less likely than white patients to receive mammograms and pap smears. A black patient with cancer is less likely than a white patient to receive evidence-based treatment. Research shows that 80% of Black Medicare recipients are cared for by 20% of the US physician workforce who are less likely to be board-certified and more likely to report chaotic working conditions and difficulty accessing specialists for their patients. At Chicago’s Cook County Health and Hospital System, many of the conditions that made it difficult for patients and doctors alike to access needed services when I was an intern over thirty years ago, persist today.
How do we begin to solve the racial mortality gap? We need to reverse “community dumping” by encouraging capital and organizational investments in community based primary and specialty care in these high mortality neighborhoods. Second, we must implement metrics to measure, track and improve the quality of health care by race and ethnicity. Foremost, we must reform a US health system that segregates patients and communities by insurance status. While health reform legislation will provide many black uninsured working men and women access to Medicaid or low cost insurance, it could actually perpetuate the racial mortality gap as patients on Medicaid often have difficulty accessing primary care and specialists. Only a universal health care program, such as single-payer that allows all people regardless of community or income, equal access to the best our health care system has to offer, can lessen racial health disparities and reverse community dumping.
Why I Wrote "County: Life, Death and Politics at Chicago’s Public Hospital"
Many people have asked me why I wrote “County.” I wrote “County” (a memoir, social history of Cook County Hospital and a reflection on race, poverty and health care in America) because I am shocked by the gaps in health care that have only worsened in the past thirty years in the US. I wrote “County” because what keeps me up at night is the fact that African-American men on the south side of Chicago (it’s only slightly better in Detroit and Harlem) will die eight years earlier than a white man. And half of the premature deaths in these men are from heart disease and cancer- preventable and treatable. I wrote “County” because I am pained that African-American women in that city have twice the death rate from breast cancer than white women and it does not have to be. I wrote “County” because when one examines the problem of racial health disparity in America the chronic underfunding and lack of coordination of the public hospital and private safety net sector in the US is a clear contributing factor. I wrote “County” to make the case for a fair health care system, one that does not discriminate by race, ethnicity, insurance status or residence.
I went to Cook County Hospital as a 25 year old doctor-in-training to fight for the life and the rebuilding of this iconic public institution. It was a fight that brought young doctors and nurses head to head with a corrupt political establishment that would have preferred to have County close or remain in chronic dysfunction. In the course of this struggle we not only got a new hospital rebuilt, but developed a network of community health centers and innovative public health and treatment programs that became national models for the respectful delivery of care to the underserved. But it was not enough.
Despite these achievements, the chronic underfunding of our nation’s public hospitals and other safety net providers leave many out with disastrous health consequences. It’s just that the demand for services outstrips the capacity. I have come to believe that a system of care that sends the poor and uninsured to one set of institutions and the wealthy and insured to another is unfair, likely to provide unequal results and a contributing factor in the premature deaths our nation’s uninsured experience. Only a payment system such as “Medicare-for-all” that allows all US residents freedom to choose public or private institutions to receive their care has the chance to lessen the gaps between the insured and uninsured, rich and poor, white and non-whites.
“County” tells the story of young doctors like me who decided to take a stand for health equity by coming to this renowned public hospital and who stayed on to continue the fight for fairness that should have been available to patients as a simple condition of their humanity. I tell the story through my experiences, through the stories of my patients and through the stories of political fights and demonstrations for fair funding.
The goal of this blog is to share my perspectives on health care in Chicago and the nation linked to the release of my book COUNTY, Life, Death and Politics at Chicago’s Public Hospital. This book was thirty years in the making. It began when, as a young physician at Cook County Hospital in Chicago, I was struck by how little the public knew about health care delivery and the great gaps in access to care and quality that existed. After seventeen years at Cook County Hospital, I moved to Mount Sinai Hospital in the Lawndale community where I gained a deeper understanding of how structural forces of poverty, joblessness and institutional racism contributed to ill health. I began to write this book in 1995 as a way to digest my experience of the prior twenty seven years delivering care to the medically underserved in Chicago. It reflects my perspective of health care disparity, poverty, racism and quality. As I sit on the Cook County Health & Hospitals System (CCHHS) Board for the past three years, I am struck how the problems we faced thirty years ago have yet to be resolved. A few disclosures: The opinions here are mine alone and do not reflect the opinions of my employer, Rush University Medical Center where I am Chief Medical Officer nor those of the CCHHS where I am a board member. I am a proponent of single payer healthcare and this conviction has been forged over thirty years starting as a medical student and reinforced during my stints at County and Mount Sinai. I welcome your comments and thoughts to my ideas.