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The Deadly Difference

Black women in Chicago are far likelier to die of breast cancer than white women, resulting in a disparity that’s nearly double what it is nationally. This pattern of racial inequality shows up locally with other diseases—evidence that Chicago is failing at narrowing its racial divide in health. Why? And what must be done?

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“I’m tired of saying goodbye to women who should still be here,” says Martha Haley, who is battling breast cancer.

Surely disadvantaged women in other big cities face socioeconomic challenges similar to those confronting women in Chicago. Yet in New York City, the racial disparity in breast cancer mortality is less than a quarter the size of Chicago’s. New York has also made significant progress in reducing racial and ethnic disparities in diabetes and asthma, according to Kevin Weiss, director of Northwestern University school of medicine’s Institute for Healthcare Studies. One possible explanation for New York’s success is that there are 11 public hospitals distributed across the five boroughs. Those hospitals and the network of health clinics integrated into them sit in close proximity to the people they serve, and are managed by highly qualified professionals who understand how to deliver care where it’s needed most, says Pat Terrell, former deputy chief of the Cook County Bureau of Health Services and now a principal with Health Management Associates, a Chicago-based consulting firm.

The Chicago area would seem to boast its own enviable public health care infrastructure. Among the county’s medical assets is John H. Stroger Jr. Hospital, the state-of-the-art facility that replaced the aging Cook County Hospital in 2002, and a network of health clinics that was expanded in the 1990s to help form what Weiss calls “a remarkably strong and competent ambulatory care system.” The county’s public health safety net was further augmented by partnerships with private community hospitals whose services eased the burden on Stroger Hospital. But now “that network needs specific attention if it is to continue to flourish,” says Terrell. Meanwhile, says Weiss, the county’s ambulatory care system is being “dismantled"—the result of a financial reckoning that has been building for decades, other observers say.

A possible reason for the financial storms buffeting the county health system is that it lacks sufficient funding to accomplish its mission. Indeed, says Terrell, the per capita contribution to health care in Cook County is at the low end compared with similar public systems elsewhere in the country.

Robert Simon, interim chief of the county health bureau, says it has been 12 years since the county passed a tax increase to fund health care, during which time costs have skyrocketed by more than 500 percent. “The leaders in the city, the county, and the state must find a way to provide us with more money,” he says.

But critics argue that the bureau’s financial woes are self-inflicted and due mostly to its wasteful and politicized organizational model—the kind that has been abandoned by almost every other big-city public health system in the country.

In New York City, for example, a public benefit corporation, separate from local government, runs all public hospitals and clinics. It is overseen by an independent board of directors loaded with experience and expertise in the complexities of large-scale health care delivery. By contrast, the Cook County Bureau of Health Services is an arm of county government, overseen not by a board of independent advisers drawn from the health care field but by the politicians who make up the Cook County Board of Commissioners. Strategic planning is almost nonexistent, critics assert. All hiring and firing falls under the authority of the board president, Todd Stroger, who has no experience in health care management, though he is well versed in Chicago’s special brand of machine politics (his father, for whom the new county hospital is named, preceded him as county board president).

Todd Stroger has been in the news a lot this year for acts such as handing out lucrative jobs and raises to friends and relatives—he nominated his cousin to be the county’s $143,000-a-year chief financial officer—while shutting down a dozen health clinics and eliminating hundreds of doctors, nurses, and other frontline medical workers. Critics have assailed him for cutting too little bureaucratic fat from county government, of which the Bureau of Health Services is the second-largest division, though he and Robert Simon have insisted that there is no more bureaucracy or patronage left there to trim. “As a doctor, I can’t bear to see the elimination of primary and preventive care services,” says Simon. “But I challenge the critics to look at our budget and not just find fault with our decisions, but tell us what they would cut instead.”

A chronicle of the ills that plague the county’s public health care system could fill a book. But suffice it to say that the recent budget crisis and service cuts are merely the latest manifestation of dysfunction in an organization that for years has served as a case study in bureaucratic bloat, managerial incompetence, prodigal waste, and nonaccountability. The bureau “has too often been used as a patronage dumping ground for politicians, sucking precious resources away from delivery of health care to people who need it in the neighborhoods,” says Forrest Claypool, a Cook County commissioner who has pushed for reform of the county’s health care system.

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Stroger Hospital’s mammography clinic offers an example of the difficulty the bureau seems to have in anticipating demand for services and allocating resources effectively. By late last year, scheduling problems had created a backlog of more than 10,000 women seeking routine screening or diagnostic mammograms, according to attending radiologist John Keen, producing waits for appointments, other observers say, that stretched for months. “And waiting, of course, translates into later stages of disease and worse outcomes,” says Carol Ferrans. “Two or three or four months can mean the difference between lumpectomy and mastectomy, the difference between catching the disease in time and having it spread through the body.”

To address the problem, the hospital started referring symptom-free women seeking only screening mammograms to other hospitals and clinics. From there Stroger’s radiologists and technicians focused on whittling down the backlog of 5,000 remaining women waiting for diagnostic mammograms—given to a woman with an abnormality or a lump in her breast. Owing to the hospital’s limited resources, Keen reasons, it made sense to focus on the higher-risk cases. And he said the hospital hoped to have its backlog eliminated by the end of September. Still, there’s no guarantee that demand for services won’t swamp capacity again. “There are so many women, and just one hospital,” Elizabeth Marcus says.

Another sign of troubles at Stroger: For a time the hospital operated two mammography vans that traveled through the city’s poorest neighborhoods, offering breast cancer screenings to women who otherwise might not have had the wherewithal to get them. But funding for the vans ran out; their equipment is outdated, dilapidated, and in disrepair; and the vehicles now sit idle. According to Keen, the hospital is working on lining up funding for a new fleet of vans with state-of-the-art digital equipment that can process more breast images and at higher quality.

Despite the hospital’s efforts to fix its mammography problems, the rampant shortcomings at the Bureau of Health Services raise questions about whether the county, neck-deep in the duties of governing, is up to the task of managing an enormously complex public health system. And the bureau’s troubles argue for reforms along the lines Todd Stroger’s own Health Care Transition Committee recommended in a report that has not been released to the public. Among the prescriptions, according to Quentin Young, a Hyde Park physician and former director of medicine at County Hospital who chaired the committee: Launch a nationwide search for qualified leaders; create an independent hospital board of health experts, as other cities have done; and install teams of financial and human resources professionals untainted by patronage.



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