Book Reivew
Public Service
Author David Ansell shares lessons from Chicago’s Cook County Hospital about working with the underserved and the deficiencies of the U.S. health care system.
By Charles R. Meyer, M.D.
Looming over Harrison Street and Pasteur Park on Chicago’s west side is a gray monster of a building, shuttered in 2002, almost demolished in 2008, and now awaiting rejuvenation as a medical office building. For 78 years it delivered health care to Chicago’s destitute and downtrodden and trained hundreds of physicians using the medical equivalent of trench warfare. Stories of the chaos that was medical care at Cook County Hospital (CCH) abound, and any memoir of medical care at “The County” will inevitably contain lurid anecdotes that add to its lore. But David Ansell’s tale of his residency and attending years at CCH, County: Life, Death and Politics at Chicago’s Public Hospital, isn’t only war stories. It’s also an indictment on how America delivered health care to the disenfranchised when Ansell started his residency in 1978—and on how we haven’t improved all that much since.
Learning medicine seemed almost secondary when Ansell decided to do his internship and residency at CCH after finishing medical school in Syracuse, New York. Most medical school graduates approach residency as a challenge to the mind and body, a time to stuff the most medical knowledge into their brains in the shortest period of time. They choose their training program based on its reputation and what they hope it will do for their education. Ansell describes his 1978 choice of CCH, then in the midst of a battle between the state Legislature and the Cook County board over who would run the hospital, differently: “We came to County Hospital eyes wide open because of its troubles, not in spite of them. We did not come to County Hospital just to learn to be doctors. We came to County because we believed that health care was a right, not a privilege. That as doctors we had to lead the fight for fairness, equity and universal health care in the U.S.”
Those noble sentiments were hard to keep in mind as Ansell experienced the usual wrenching insecurity of new medical trainees made even more emotionally traumatic by homeless people sleeping in bathroom stalls, the cacophonous waiting rooms, trauma befitting a battlefield, and patients with socioeconomic problems that dwarfed their medical ones. His descriptions of his medical experiences are sometimes humorous, sometimes poignant. The general medicine clinic was a “gentle immersion into the intricacies of outpatient medicine,” while the emergency room was the “intern equivalent of being thrown to the sharks,” an instant learning experience with no formal teaching, “the medical equivalent of paint by the numbers” or “see one, do one, and pray.” He developed a feisty assertiveness necessary to care for his patients: “At County I learned to be relentless in trying to help my patients.”
And his assertiveness extended beyond patient care. In response to the rise in transfers of uninsured patients to public hospitals, Ansell co-wrote a paper, “Transfers to a Public Hospital,” that was published in the New England Journal of Medicine in 1986. That article led to the passage of the Emergency Medical Treatment and Active Labor Act, the anti-patient-dumping legislation, later that year. In 1984, when a fellow attending physician who had founded the CCH AIDS clinic and developed AIDS himself was suspended, Ansell campaigned for unionization of the attending staff. Every chapter of County contains at least one paragraph bemoaning the plight of Ansell’s patients, the political system that was contributing to their misery, and his efforts to change it.
Conditions did improve at CCH while Ansell was there. In the early 1990s, a competent, nonpatronage administrator, Ruth Rothstein, began to make the place work better. A replacement hospital, the John Stroger Hospital, was planned, built, and is now operating just behind the “Old lady of Harrison Street.”
But the social morass of CCH patients hasn’t cleared. Ansell summarizes his book: “The story of this singular public hospital is the story of health care in America, and its travails speak to our nation’s failure to declare health care is a right and that Americans should not face early death or disability because they are uninsured.” MM
Charles Meyer is a practicing internist and editor in chief of Minnesota Medicine.