Jose and Jorge were identical twins separated at birth. Jose
grew up in a large family in an impoverished slum in the middle of
a crime-ridden and polluted district of a major city. Jorge grew up
in an upper-middle-class professional family with one other brother
in a sub urban community in the same city. Despite the fact the
Jose and Jorge were identical twins, their lives and health could
not have been more different.
Jose had few opportunities for medical care or public health
services as a child. His nutrition was always marginal and he
developed several severe cases of diarrhea before he was 1 year of
age. He received a polio vaccine as part of a community vaccination
program, but never received vaccinations for measles, mumps,
rubella, or other childhood illnesses. At age 4, he developed
measles and was so sick his mother was sure he would not make
As a child, Jose also developed asthma, which seemed to worsen
when he played outdoors on hot smoggy days. Dropping out of school
at age 14, Jose went to work in a factory, but quit when he found
himself panting for breath at the end of the day.
As a teenager, Jose was repeatedly exposed to crime and drugs.
Once, he was caught in the cross fire of gangs fighting for control
of drugs in his community. Experimenting with drugs with his
teenage friends, Jose contracted HIV from use of contaminated
needles. Jose did not know he had HIV until he was nearly 30 years
old and developed tuberculosis (TB). He did receive treatment for
the TB free of charge from the health department, but once he felt
better, he did not follow up with treatment.
By the time the TB returned, Jose had lost 30 pounds and could
barely make it into the emer gency room of the public hospital
because of his shortness of breath. He was hospitalized for the
last 2 months of his life, mostly to prevent others from being
exposed to what was now drug-resistant tuberculosis. No one ever
knew how many people Jose exposed to HIV orTB.
Jorge's life as a child was far less eventful. He received
"well child" care from an early age. His family hardly noticed
that he rarely developed diarrhea and had few sick days from
diseases of childhood. He did well in school, but like Jose, he
developed asthma. With good treatment, Jorge was able to play on
sports teams, at least until he began to smoke cigarettes at age
Jorge soon began to gain weight, and by the time he graduated
from college, he was rapidly becoming obese. In his 20s, he
developed high blood pressure, and in his 30s he had early signs of
diabetes. Jorge had a heart attack in his mid-40s and underwent
bypass surgery a few years later. The treatments for diabetes,
hypertension, and high cholesterol worked well and Jorge was able
to lead a productive professional life into his 40s.
By the time that Jorge turned 50, his diabetes began to worsen
and he developed progressive kid ney disease. Jorge soon needed
twice-a-week dial ysis, which kept him alive as he awaited a
1. How do social determinants of health contrib ute to the
different disease patterns of Jose and Jorge?
2.How do factors in the physical environment explain
differences in the health of Jose and Jorge?
3.What role does medical care play in the differ ences
between the health outcomes of Jose and Jorge?
4.What roles do public health services play in the health
outcomes of Jose and Jorge?