Changing America: America’s growing education divide
Accounting for the history of disease also requires us to examine why some disparities in disease are seen as proof of a natural order while others are considered evidence of injustice. The 4.3-year life-expectancy gap between blacks and whites in the United States provokes outrage, but the 4.9-year gap between men and women does not. It is tempting to assume that differences between the sexes are natural and those between races are not. But a 19th-century reader might be skeptical of this explanation: men then lived at least as long as women. The survival advantage of women that appeared in the 20th century owed as much to changes in childbearing, improvements in obstetrical practice, and a new epidemic of heart disease disproportionally affecting men as to differences between the X and Y chromosomes. Disparities in health and disease are outcomes that are contingent on the ways society structures the lives and risks of individuals.
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Even as prevailing diseases have changed, health disparities have endured. Inequalities in health status have always existed, regardless of how health has been measured or populations defined. When Europeans arrived in the Americas, they witnessed stark disparities in the fates of European, American, and African populations. During the ravages of 19th-century industrialization, physicians grew familiar with health disparities between rich and poor. Health inequalities remain ubiquitous, not just among races and ethnic groups but also according to geography, sex, educational level, occupation, income, and other gradients of wealth and power.
The persistence of health inequalities challenges our scientific knowledge and political will. Can we explain them and alleviate them? Genetic variations don't explain why mortality rates double as you cross Boston Harbor from Back Bay to Charlestown or walk up Fifth Avenue from midtown Manhattan into Harlem. Nor do they explain why Asian-American women in Bergen County, New Jersey, live 50% longer than Native American men in South Dakota. Although we know something about the relationships among poverty, stress, allostatic load, and the hypothalamic–pituitary–adrenal axis, doctors and epidemiologists need more precise models that sketch in the steps between social exposure, disease, and death.