Constrained Choice, Race, Gender and Health: The Divergent Pathways of Twins

This paper applies the multi-level Constrained Choice (CC) explanation to a real time narrative of twins, Andrea and Andre born in 1982 in Boston, Massachusetts and who experienced vastly different lives and health outcomes.  Andrea, a 33 year old lawyer and woman of color, was a first time candidate for Boston City Council in 2015.  Her twin brother, Andre died in 2012 at the age of 29 while in state custody awaiting trial on home invasion and other charges.  This paper examines the process and underlying mechanisms of how gender and race and institutional levels of decision-making shaped the divergent pathways.  Theirs was not an easy life from the beginning as they lost both parents at a young age and spent time in the foster care system.  Even in elementary school, they were split up as Andre got labeled a behavioral problem, while Andrea flourished. The CC framework explicates how and why their paths diverged —she moved through Boston Latin School, Princeton, and UCLA Law School, and he went to alternative schools and the criminal justice system. This true case example demonstrates how the various institutions (school systems, foster care, and policies) with whom they came into contact shaped their life courses. In a context of necessity these twins constructed ‘choices’ out of their priorities, values and options over time. None of these ‘choices’ take place in a vacuum.  Rather they were formulated and shaped by the context in which they were made and whatever biological processes may have impinged on them.  Further, this case example illustrates why this is a dynamic process and how making health a priority proved to be more difficult for Andre than for Andrea. This example highlights the broad applicability of a Constrained Choice explanation to both individual and population health disparities.