inequality in disease inequality in disease social epidemiology focuses on the patterns in morbidity and mortality rates that emerge as a result of social characteristics. while an individual's lifestyle choices or family history may place him or her at an increased risk for developing certain illnesses, there are social inequalities in health that cannot be explained by individual factors. variations in health outcomes in the united states are attributed to several social characteristics, such as gender, race, socioeconomic status, the environment, and educational attainment. inequalities in any or all of these social categories can contribute to health disparities, with some groups placed at an increased risk for acquiring chronic diseases than others. for example, cardiovascular disease is the leading cause of death in the united states, followed closely by cancer, with the fifth most deadly being diabetes. the general risk factors associated with these diseases include obesity and poor diet, tobacco and alcohol use, physical inactivity, and access to medical care and health information. although it may seem that many of these risk factors arise solely from individual health choices, such a view neglects the structural patterns in the choices that individuals make. consequently, a person's likelihood of developing heart disease, cancer, or diabetes is in part correlated with social factors. among all racial groups, individuals who are impoverished or low income, have lower levels of educational attainment, and/or live in lower-income neighborhoods are all more likely to develop chronic diseases, such as heart disease, cancer, and diabetes. gender in the united states and europe, up until the 19th century, women tended to die at an earlier age than men. this was largely due to the risks involved in pregnancy and childbirth. however, in the late 19th century there was a shift in life expectancy and women started to live longer than men. notably, this is partly explained by biological factors. for instance, there is a cross-cultural trend that male fetal mortality rates are higher than female fetal mortality rates. additionally, estrogen decreases the risk of females acquiring heart disease by lowering the amount of cholesterol in the blood, while testosterone suppresses the immune system in males and puts them at risk for acquiring serious illnesses. however, biological differences do not fully account for the large gender gap in the health outcomes of men and women. social factors play a large role in gender disparities in health. one of the main factors that contributes to the decreased life expectancy of males is their propensity to engage in risk-taking behaviors. some commonly cited examples include heavy drinking, illicit drug use, violence, drunk driving, not wearing helmets, and smoking. these behaviors contribute to injuries that may lead to premature death in males. in particular, the effect of risk-taking behavior on health is especially visible in the case of smoking. as smoking rates have fallen in the united states overall, less men engage in this behavior and the life expectancy gap between men and women has slightly decreased as a result. the behaviour of men and women also vary in regards to diet and exercise, leading to differential health outcomes . on average, men exercise more than women, but their diet is less nutritious. consequently, men are more likely to be overweight, while women are at greater risk for obesity. exposure to violence is another social factor that has an influence on health. in general, women have a higher likelihood of experiencing sexual and intimate partner violence, while men are twice as likely to die from suicide or homicide. markedly, the impact of gender on health becomes especially salient in different socioeconomic contexts. in the united states, there is a large economic gender inequality with many economically disadvantaged women occupying much fewer positions of power than men. according to the panel study of income dynamics, "among adults with the strongest attachment to the labor force, only 9.6% of women earned more than $50,000 annually, compared with 44.5% of men." this gendered economic inequality is partly responsible for the gender-health paradox: the general trend that women live longer than men, but experience a greater degree of non-life-threatening chronic illnesses over the course of a lifetime. a low socioeconomic status in women contributes to feelings of a lack of personal control over the events in their lives, increased stress, and low self-esteem. perpetual states of stress inflict damage on the bodies and minds of women, placing them at risk for physical ailments, such as heart disease and arthritis, as well mental health disorders, such as depression. another significant social factor is that men and women deal with their illnesses in different ways. women generally have strong support networks and are able to rely on others for emotional support, with the potential to improve their states of health. in contrast, men are less likely to have strong support networks, they have fewer doctor visits, and often cope with their illnesses on their own. also, men and women express pain in different ways. researchers have observed that women openly express feelings of pain, while men are more reserved in this regard and prefer to appear tough even when they experience severe mental or physical suffering. this finding suggests that this is due to socialization processes. women are taught to be submissive and emotional, while men are taught to be strong, powerful figures that do not show their emotions. the social stigma associated with expressions of pain prevents men from admitting their suffering to others, making it more difficult to overcome the pain. moreover, neighborhood effects have a greater influence on women than men. for instance, research findings suggest that women living in impoverished neighborhoods are more likely to experience obesity, while this effect is not as strong for men. the physical environment also generally impacts a woman's self-rated health. this effect can be explained by the fact that women spend more time at home than their male counterparts, as a result of higher unemployment rates, and therefore may be more exposed to negative environmental characteristics that take a toll on their health. finally, gender effects also vary with race, ethnicity, and nativity status. notably, christy erving conducted a study in which she examined the gender differences in the health profiles of african americans and caribbean blacks (immigrants and u.s. born). one of the findings from this research is that on average, african american women report lower self-rated measures of health, worse physical health, and were more likely to experience severe chronic illnesses than men. this finding contradicts the gender-health paradox in the sense that researchers would expect morbidity rates to be higher for women, but less of the illnesses that they acquire should be debilitating. in contrast, the opposite trend is observed for u.s. born caribbean blacks, with men more likely to experience chronic, life-threatening illnesses than women. the health outcomes of caribbean black immigrants are somewhere in-between the health outcomes of u.s. born caribbean blacks and african americans, wherein the females have a lower value of self-reported health but experience equal rates of life-threatening, chronic disease as men. this data illustrates that even within one racial category, there can be stark gender differences in health on the basis of social differences within the groups that compose the race. race studies have shown that individuals that are racially and ethnically stigmatized, not just in the u.s., but globally as well, experience health issues such as mental and physical illness, and in some cases even death, in higher rates than the average individual. there has been some controversy around "race" being a determinant of disease and health issues, since there are unmeasured forms of background history that are potential factors in this research. geographical origins and the types of environments individual races were exposed to are huge contributes to the health of a certain race, especially when the environment that they are in now is not the same as the one their race originates from geographically. along with these factors, physical, psychological, social, and chemical environments are all included and accounted for. including exposure over the course of one's life and through generations, and biological adaptation to these environmental exposures, including gene expression. an example of this is a study of hypertension between black people and whites. west africans and people of west african descent levels of hypertension increased when they moved from africa to the united states. their levels of hypertension were twice as high as the levels of black people that were in africa. while whites in the united states even had higher rates of hypertension than black people in africa, the black people in the united states rates of hypertension were higher than some predominately white populations in europe. again, this proves that when a race is taken out of their original geographic environment, they are more prone to disease and illness, because their genetic make-up was made for a specific type of environment. transitioning from the environmental aspect of race and disease, there is a direct correlation between race and socioeconomic status which contributes to racial disparities in health. when it comes to death rates from heart disease, the rate is about twice as high for black men vs. white men. now, death rates from heart disease are lower for both black and white women compared to their male counterparts, but the patterns of racial disparities and education disparities for women are similar to that of the men. death from heart disease is about three times as higher for black women than white women. for both black men and women, racial differences in deaths from heart disease at every level of education is evident, with the racial gap being larger at the higher levels of education than at the lowest levels. there are a number of reasons why race matters in terms of health after socioeconomic status has been accounted for. for one, health is affected by adversity early on in one's life, such as traumatic stress, poverty, and abuse. these factors affect the physical and mental health of an individual. as we know, most of the people living in poverty in the united states are minorities, specifically african americans, so unfortunately there is no surprise that they are the individuals with so many health issues. continuously, race is relevant to health issues, because of the non-equivalence of socioeconomic status indicators across racial groups. at the same level of education, minorities (black people and non-white hispanic people) receive less income than their anglo-white counterparts, as well as have less wealth and purchasing power. namely, one of the biggest reasons that race matters in terms of health is due to racism. both personal and institutionalized racism are very prominent in today's society, maybe not as blunt and easy to notice in comparison to the past, but it still exists. certain residential segregation by race, such as redlining, has created very distinct racial differences in terms of education, employment, and opportunities. opportunities such as access to good healthcare/medical care. institutional and cultural racism can even harm minorities health through stereotypes and prejudices, which contributes to socioeconomic mobility and can reduce and limit resources and opportunities required for a healthy lifestyle. socioeconomic status is only one part of racial disparities in health that reflect larger social inequalities in society. racism is a system that combines with, and sometimes changes, socioeconomic status to influence health, and race still matters for health when socioeconomic status is considered. socioeconomic status socioeconomic status is a multidimensional classification, often defined using an individual's income and level of education. other related metrics can round out this definition; for example, in a 2006 study by authors cox, mckevitt, rudd and wolfe, further categories included "occupation, home and goods ownership, and area-based deprivation indices" in their determination of status. income inequality has risen rapidly in the united states, pushing greater amounts of the population into positions of lower socioeconomic status. a study published in 1993 examined americans who had died between may and august 1960, and paired the mortality information with income, education and occupation data for each person. the work found an inverse correlation between socioeconomic status and mortality rate, as well as an increasing strength of this pattern and its reflection of the growth of income inequality in the united states. these findings, although concerned with total mortality of any cause,