WHEN MANY Americans hear “Cook County,” the first thing they think of is the popular television show “ER,” where George Clooney and other dreamy actors sorted out personal and political questions with the illness and violence of Chicago’s urban setting as the backdrop. 

David Ansell’s book County: Life, Death and Politics at Chicago’s Public Hospital, succeeds in painting an even more vivid picture of health care for the poor of Chicago and spells out in plain language why it is in such a desperate state, and at the same time so desperately needed. 

After graduating from medical school in 1978, Ansell started his residency there and continued to work as an attending physician for another thirteen years. As an activist influenced by the civil rights and antiwar movements while in high school, he and four of his fellow graduates wanted to come to County “to find a place to train where we could make a difference, where we could confront head-on the social inequities that we believed contributed to ill health.”

He fit right into a place that had also attracted other like-minded radicals. Two years before he started there, residents (doctors who have graduated medical school and joined a multiyear training program) went out on strike over intolerable patient conditions—the longest doctors’ strike in US history. Seven of the leaders were sentenced to ten days in Cook County jail for defying a judge’s order to return to work. 

Doctor Quentin Young, who is still a lifelong fighter for justice, was Chairman of Medicine during the strike and was fired

for siding with the young doctors. The House Staff took his office door off its hinges so management could not change the locks and held a twenty-four-hour vigil outside his office until he regained his position after a court fight.

In 1847, Cook County began providing health care to the poor in a building just north of downtown Chicago. In 1914, a new location was built that used open wards—where fifteen or more patients were separated only by cotton curtains, sharing bathrooms and a shower at one far end—a layout that remained the same until a new building was built in 2002. What was considered top of the line at the turn of the last century was still in use almost a century later. Such conditions were tolerated only because of who the hospital served. 

Racial disparities in wealth have consistently affected how health care is distributed. “By 1960, County was serving the black community and an immigrant Mexican community almost exclusively. In fact, in this decade, eighty percent of Chicago’s black births and fifty percent of all black deaths were at County Hospital.” 

The triad of racism, poverty and violence has a profound effect on health.

The Sinai Urban Health Institute performed door-to-door surveys on health in communities like Lawndale and found epidemic proportions of diabetes, hypertension, smoking, depression, asthma and obesity. The rates among blacks and Latinos were many times higher than among whites in Chicago. The consequence was higher death rates for minorities in Chicago. By 2010, over three thousand black people died every year in Chicago because they did not have the same health care experience as white people.

Despite the nearly impossible task of trying to meet people’s health needs with severely limited resources, Cook County has been able to make some improvements to people’s lives—only because of the herculean efforts of individuals within the system, who often have to work against those who control it. 

In the early 1980s, the number of patient transfers to County from other hospitals started to go up. Ambulances were bringing more and more patients to the ER, from one hundred each month in the late 1970s to more than six hundred each month by the early 1980s. The trend coincided with a growing number of uninsured and a limit on payments by the State of Illinois for patients on public aid. The same thing happened across the country as the impact of the loss of insurance was felt.

Dr. Ansell and his colleagues started a study following five hundred of these transferred patients to see what happened to them.

Most of the transferred patients had common medical conditions: pneumonia; women in active labor; conditions that could be treated at almost any hospital. Transfer just delayed treatment, for financial, not clinical, reasons. It was unconscionable.

They published their findings in the New England Journal of Medicine in 1986, and the response was immediate. The paper exposed the ugly side of the Reagan “boom” and upset many inside the County system and out. Because of this publication and other reports of patient dumping, Congess passed the Emergency Medical Treatment and Active Labor Act that same year. It forced hospitals to treat patients instead of transferring them, allowing transfers only with written consent and for medical reasons.

Ansell and his colleagues have also tried to redress the racial disparities in the outcome of breast cancer cases. Among white women diagnosed with breast cancer, 19 percent will die from the disease, but for African Americans the percentage is 29 percent. In 1984, Dr. Ansell and two nurses started a program to screen women for breast cancer, having to fight every inch of the way, inside and outside County, to make this happen. Thousands of women went through their program, but by 2006, the racial gap in Chicago was still one of the worst in the country.

Despite the intent of programs like the Breast Cancer Screening Program, regionally it was if nothing had changed or improved for black women with regard to this disease. There was more work to be done to eliminate this mortality gap and it required the whole health-care system to change, not just one program at the County Hospital.

Ansell concludes his book with a strong argument for single-payer health care. He shows how the health reform passed under President Obama in 2010 will preserve “the caste system of health care in America,” and that “at least twenty-five million people in the US will remain uninsured and shut out of the private health system. In the Chicago area, up to 500,000 will continue to have no insurance.”

Fixing Cook County Hospital is tinkering around the edges until the US adopts a single-payer or similar health insurance program, one that provides equal access to all residents regardless of income, race or ethnicity. Without it we will never succeed at achieving health equity—fairness, equality and dignity for all patients—in Chicago or the US. Such a basic human value, so widely accepted across all the major western industrialized nations of the world except the US.

This well-written book gives an inside view to one of the few public hospitals remaining. It accurately describes the struggles of patients and health care workers as they fight to do the best they can with what they have. It is an indictment of our so-called health care system and motivates us to fight for one that actually meets the needs of people.