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."

Copyright 2023 Fresh Air. To see more, visit Fresh Air.