José and Jorge were identical twins separated at birth. José 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 suburban community in the same city. Despite the fact the José and Jorge were identical twins, their lives and health could not have been more different.
José 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 it.
As a child, José also developed asthma, which seemed to worsen when he played outdoors on hot smoggy days. Dropping out of school at age 14, José went to work in a factory, but quit when he found himself panting for breath at the end of the day.
As a teenager, José 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, José contracted HIV from use of contaminated needles. José 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, José had lost 30 pounds and could barely make it into the emergency room of the public hospital because of his shortness of breath. He was hospitalized for the last two 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 José exposed to HIV or TB.
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 José, he developed asthma. With good treatment, Jorge was able to play on sports teams, at least until he began to smoke cigarettes at age 14.
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 kidney disease. Jorge soon needed twice-a-week dialysis, which kept him alive as he awaited a kidney transplant.