Twenty-five years ago, Dr. David Ansell helped expose an appalling practice in Chicago: Private hospitals were routinely transferring uninsured patients — many of them unstable and dangerously ill — to Cook County Hospital, the city's medical refuge of last resort.
The practice was dubbed "patient dumping," and it exploded in the early 1980s when Illinois and the federal government tightened health care spending, according to a study in the New England Journal of Medicine by Ansell and several colleagues. In addition to Chicago, public hospitals in Atlanta, Dallas,Washington, and Los Angeles reported similar experiences.
Outraged, Congress passed the Emergency Medical Treatment and Active Labor Act, which requires medical centers across the country to evaluate and stabilize all patients who come to their emergency departments, regardless of their insurance status. That 1986 law remains the only guarantee of health care for the general population currently in effect in the U.S.
It was a significant accomplishment, but it hasn't fundamentally changed the harsh reality of health care in Chicago. In his new book, "County: Life, Death and Politics at Chicago's Public Hospital," Ansell describes an "apartheid" system, "separate and unequal," both in the 1980s and now.
Lest that be considered an overstatement, consider the shortage of medical services for needy Chicagoans on the South Side compared with the abundance of medical care available in North Side neighborhoods, and higher death rates from breast cancer for African-American women across Chicago compared with rates for white women.
On one level, Ansell's book is the coming-of-age story of a young, idealistic physician from the East Coast encountering racism and bare-knuckle politics in Chicago as he learns the basics of his demanding profession. With unusual honesty, Ansell, now the chief medical officer at Rush University Medical Center, recounts several medical mistakes that badly injured patients or cost their lives — a result of his inexperience and challenging conditions at the old Cook County Hospital.
Though that massive, decrepit facility has since closed, the many ways in which poor patients were mistreated and devalued on its premises are the true subject of this book — a valuable addition to the historical record of Cook County and its problem-ridden health care system.
Ansell takes readers behind the scenes for a look at deplorable conditions. When he comes to Cook County Hospital as a doctor just graduated from medical school in July 1978, he finds daily shortages of soap, towels, toothbrushes, sheets and blankets. The bathrooms are filthy; rats and cockroaches roam the halls. Nurses sleep on the job, and there are no call buttons for patients to get their attention.
"On every floor, patients lay in beds and called out over and over, 'Nurse … Nurse … Nurse,' like a skip in a record, until someone came. Often, no one did," Ansell writes.
Heroin addicts in the hospital get their daily fixes through friends who climb through the windows. In Cook County's infamous "labor line," women in active labor stand in hallways waiting for a stretcher to open up so they can lie down before giving birth. Those lucky enough to make it to the labor room scream in pain for hours; there are no medications.
"We were practicing Third World medicine in Chicago, one of the largest cities in the U.S. I shudder to think how many patients I may have harmed or killed because we could not diagnose or treat them quickly enough," Ansell admits.
Senior doctors known as "attendings" were either off the scene or there but indifferent. Junior doctors like Ansell learned by the seat of their pants, often without any real help. "Our patients declared that they came because County had 'the best doctors.' This was not true," Ansell explains. "There is no way we were the best. We were young. Uninitiated. And worse, unsupervised."
This goes on for years, with incompetent managers running the show until Ruth Rothstein takes charge in the 1990s. For the first time, under her leadership, there is a plan to expand services into needy communities while building a new hospital where better, more humane medical care can be practiced.
That vision was realized, in part, in 2002 with the opening of Stroger Hospital, but Cook County's fundamental medical problems — too many needy people who require medical care, too few resources to meet those needs — extend to this day. Eventually, it dawns on Ansell that the problem isn't really finding more money for the Cook County Health and Hospitals System: It's the very structure of a two-tiered system of medical care, one for the poor, the other for people who are better off, that's at fault.
This is why the history of Cook County Hospital remains relevant today. It teaches us that a two-tiered system of care will always be unequal and unfair to people at the bottom end of the income ladder. Unfortunately, Ansell notes at the end of his book, that kind of system will be preserved under national health reforms enacted last year, with tens of millions of needy Americans set to be pulled into Medicaid, a financially strapped government health program for the poor.
Meanwhile, with a budget crisis besetting Cook County, the health care system targeted for significant cuts and long waits for care an ongoing concern, "the inhumanity of health injustice still persists in Chicago," Ansell warns. It's not a new message, but it's one that citizens and officials would do well to hear.
Judith Graham is a health reporter on the Tribune's investigations-consumer watchdog team.