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Substance Addiction: A Disease, Not a Matter of Free Will

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by Zijun Zhou, July 27, 2025

In the 21st century, social technology and cultural advances have brought new challenges. One of the most serious is drug addiction, now a major public health and social issue. The latest statistics from the Addiction Group (2024) show that nearly 50 million Americans suffer from a substance addiction or substance use disorder (SUD) each year, but less than 10% receive appropriate treatment. Further, more than 70% of alcohol-dependent people have never sought professional help. Addiction is also deeply intertwined with broader mental health challenges, including a significantly elevated risk for suicidality. While not all of the 13 million adults and 3.4 million adolescents in the United States affected by suicidal thoughts each year necessarily have a diagnosed substance use disorder, research robustly demonstrates that individuals with SUDs face a substantially increased risk of suicide mortality (Sugue, 2024). For example, a large case-control study conducted across eight integrated healthcare systems in the United States found that all categories of substance use disorders, including alcohol, tobacco, and other drug use disorders, were significantly associated with an increased risk of suicide mortality, even after controlling for comorbid mental health and physical health conditions. This methodological rigor is critical, as it provides strong evidence that Substance Use Disorder is not merely an epiphenomenon or symptom of other psychiatric conditions, but rather a powerful and independent driver of suicide risk. This finding offers a solid evidentiary foundation for the article’s central thesis: that addiction is itself a primary pathological process. The study emphasized that the risk is particularly pronounced for individuals with multiple substance use disorders, and that women face a relatively higher risk compared to men (Lynch et al., 2020). This strong association further underscores that substance use disorders likely contribute significantly to suicide risk, particularly among individuals experiencing suicidal ideation and broader mental health crises. Such findings emphasize the importance of addressing addiction as a critical public health concern.

Despite the mounting scientific evidence, a consensus on the nature of addiction remains elusive in both academic and public spheres. A landmark event in this debate occurred in 2014, when the esteemed journal Nature published an editorial, Animal farm, which claimed that the view of addiction as a brain disease was not particularly controversial, at least among scientists (Animal Farm, 2014). This assertion, however, provoked a swift and strong backlash, culminating in a letter signed by 94 international addiction scholars who contested this one-dimensional portrayal. They argued that substance abuse cannot be divorced from its social, psychological, cultural, political, legal and environmental contexts: it is not simply a consequence of brain malfunction. This public debate highlights the complexity of the issue. Therefore, this article’s support for the disease model is not intended to dismiss these vital critiques. Rather, it is to argue that, while fully acknowledging the importance of these psychosocial and environmental factors, the neuroadaptive changes that occur in the brain during addiction are so profound, pathological, and dysfunctional that the disease framework remains the most robust scientific model for understanding its compulsive nature and for guiding effective intervention.

Addiction is a chronic disease characterized by drug seeking and use that is compulsive or difficult to control despite harmful consequences (National Institute on Drug Abuse, 2018). Unlike the traditional concept of addiction as a weakness of will or an individual’s choice, the occurrence and development of addiction are driven by complex neurobiological mechanisms. These neurobiological mechanisms fundamentally undermine voluntary control by profoundly restructuring the brain’s reward system. This restructuring pathologically heightens the motivational value of the drug while diminishing the perceived value of natural rewards. As a result, the individual experiences intense, cue-driven cravings that can overwhelm rational thought. This is compounded by severe disturbances in emotion and stress regulation that create a deeply negative affective state during abstinence, driving a powerful compulsive need to use the drug to escape from this distress. These issues are further exacerbated by significant impairments in executive function, which compromise the prefrontal cortex’s ability to control impulses and weigh long-term consequences, weakening the brain’s inhibitory control system against relapse. The clinical manifestations of addiction are usually accompanied by tolerance and withdrawal symptoms, and its essence is continuous and repeated drug seeking and use. Tolerance and withdrawal symptoms may be present, and the essential elements include continuous and repeated drug seeking at the cost of normal rewards. It is not the result of one’s own choice.

Critics often argue that addiction is not a real disease because they believe that the brain is designed to change throughout life naturally. They support this by pointing out that the growth stages of children and adolescents and learning throughout adulthood are based on similar changes in the cerebral cortex and limbic system (Lewis, 2017). However, this view ignores the changes in brain structure and function that addiction demonstrably causes, which form the core basis for defining it as a disease. These extensive alterations exemplify an abnormal state affecting brain structure and function, accompanied by clear behavioral symptoms, consistent with established medical criteria for a disease (National Cancer Institute, 2011). Indeed, addiction manifests precisely through such pathological changes. For example, a defining feature of drug abuse is the pathological ‘hijacking’ of the brain’s natural reward system and emotional regulation circuits. This hijacking itself represents a fundamental disruption of normal brain function, an abnormal state directly initiated when all addictive drugs drastically increase dopamine release in key brain regions. Dopamine is the central neurotransmitter of the brain’s reward system and is primarily responsible for regulating feelings of pleasure, motivation, and reinforcement learning. However, a drug-induced surge in dopamine is not a physiological adaptation like normal learning, but rather an extreme and abnormal neurochemical event that profoundly alters neural circuits. In addictive behaviors, drugs cause a sharp rise in dopamine levels in key regions such as the nucleus accumbens and the striatum by stimulating dopamine neurons. This abnormal dopamine release alters neural circuits deep in the brain from the ventral tegmental area (VTA) to the nucleus accumbens. Further, it extends to regions such as the limbic system and orbitofrontal cortex (Leshner, 1997). Together, these regions regulate emotions, decision-making, and impulse control. Unlike the gradual changes of natural learning, this overwhelming, drug-induced flood of dopamine fundamentally corrupts the brain’s decision-making architecture, which is a hallmark of a disease state.

While these changes begin with the limbic system, the effects of addiction extend further to higher-order regulatory regions. The ventromedial prefrontal cortex (VMPC) in drug addicts exhibits significant functional impairments.The behavior of people with an addiction is highly similar to that of patients with VMPC damage: both groups often deny or are unaware of their problems (Bechara, 2005). Moreover, when faced with a choice that offers an immediate reward, they tend to ignore the possible long-term negative consequences, including the loss of their job, family, or even reputation. VMPC damage usually includes the medial parts of Brodmann Area (BA) 25, lower 24, 32, 11, 12, and 10. Although patients may retain normal intelligence, memory, and other cognitive functions, they show significant deficits in emotional and social behavior and long-term decision-making abilities, which is highly consistent with the characteristics of drug addiction (Bechara, 2005). Compared with non-addicts, drug addicts (such as cocaine-dependent individuals) have significantly lower resting-state functional connectivity (RSFC) between the frontal hemispheres. This change is particularly pronounced in areas related to the dorsal attention network, including bilateral prefrontal, medial prefrontal, and posterior parietal regions (Kelly et al., 2011). This weakening of RSFC reflects the persistent impairments in executive function, attention control, and behavioral regulation in people with an addiction. This not only makes them more prone to relapse in the face of environmental cues (for example, encountering people who used to take drugs together, going to places associated with past drug use, or seeing items and equipment related to drugs), but also weakens motivation for long-term goals and impulse control (Mennis et al., 2016).This phenomenon reveals that addiction is not only a functional abnormality of a single neural circuit but also the result of impaired collaboration among multiple brain regions.

From a neurobiological perspective, the development of addiction can be divided into three recurring stages: Binge and Intoxication, Withdrawal and Negative Affect, and Preoccupation and Anticipation. This cyclical model, driven by profound neural adaptations within specific neural circuits, clearly reveals the progressive pathophysiological process of addiction as a chronic, relapsing brain disease, rather than a simple issue of willpower or choice. Each stage involves the activation of specific neurobiological circuits and is accompanied by clinical and behavioral characteristics (Koob & Volkow, 2016; Volkow, Koob, & McLellan, 2022). Exploring each of these stages in turn reveals how the disease progresses and systematically hijacks the brain’s circuitry.

During the Binge and Intoxication stage, addictive substances significantly increase dopamine levels by triggering their release in the brain’s reward circuitry. This process bypasses natural reward mechanisms, directly stimulating dopamine transmission in key regions such as the nucleus accumbens and prefrontal cortex, resulting in reward effects from drug use that far exceed those of natural stimuli (Kalivas & O’Brien, 2008). This direct and overwhelming stimulation of the reward pathway represents an initial pathological transformation and an early manifestation of the disease state of addiction, as it disrupts the brain’s normal regulatory processes, disproportionately amplifying the incentive value of drugs. Dopamine signaling not only reinforces the immediate response to drugs but also links drug use to specific environmental cues through conditioned learning. As usage frequency increases, dopamine cells gradually become less responsive to the reward but more sensitive to cues predicting the reward, thereby intensifying drug cravings (Koob & Volkow, 2016). This neural adaptation marks a pathological hijacking, reflecting addiction as a disease where patients’ behavior is increasingly driven by external cues rather than autonomous choice. This neural adaptation marks a pathological hijacking, reflecting addiction as a disease where patients’ behavior is increasingly driven by external cues rather than autonomous choice, thereby setting the stage for the painful withdrawal of the second act.

The Withdrawal and Negative Affect stage is characterized by a critical shift from reward-system dominance to the recruitment of brain stress and antireward systems. This transition is initiated by counteradaptive mechanisms, specifically the opponent process, a neurobiological response that counteracts the drug’s initial rewarding effects. In addition, this process becomes dysregulated; it fails to return to its homeostatic baseline and instead establishes a new, pathological state known as allostasis (Koob & Le Moal, 2008). This allostatic state represents a chronic deviation of the brain’s reward set point, sustained by the extended amygdala’s overactivation of the antireward system (Koob & Le Moal, 2008). The hyperactivity of this system, mediated by neurotransmitters like corticotropin-releasing factor, is responsible for the profound negative emotional states of withdrawal, such as anxiety and irritability (Volkow, Koob, & McLellan, 2022). Consequently, the motivation for drug use is fundamentally altered. It shifts from a volitional act to seek pleasure to a compulsive behavior driven by the need to temporarily alleviate this persistent, aversive internal state (Koob & Volkow, 2016). This shift from choice to compulsion is a core pathological feature of the disease. At this juncture, the motivation for drug use has fundamentally shifted from chasing pleasure to escaping pain—a critical turning point that marks the transition from voluntary use to compulsion.

Regarding the Preoccupation and Anticipation stage, its core feature is dysfunction in the prefrontal cortex and its associated circuits. This stage is primarily associated with significant impairment in executive function, including reduced impulse control, self-regulation, and decision-making abilities. Due to abnormal regulation of dopamine and glutamate signaling in the prefrontal cortex, addicts struggle to resist impulses when exposed to drug-related cues. Additionally, prolonged drug use has led to significant neuroplastic changes in the brain. These changes are concentrated at the molecular level, such as the accumulation of deltaFosB and brain-derived neurotrophic factor (BDNF). These molecular-level changes not only reinforce compulsive drug-taking behavior but also significantly increase the risk of relapse (Kalivas & O’Brien, 2008). Research has shown that short-term withdrawal (e.g., 12 hours) significantly increases an individual’s reactivity to cues, accompanied by enhanced activation of the medial prefrontal cortex (mPFC) and orbitofrontal cortex (OFC). This change is associated with intense craving and withdrawal symptoms (Goldstein & Volkow, 2011; Volkow, Koob & McLellan, 2022). The effects of long-term abstinence on prefrontal cortex activity highlight the complexity of neuroadaptive changes in addiction. While some studies suggest reduced activity in certain prefrontal regions during prolonged abstinence, possibly due to adaptive behavioral strategies, the overarching pattern remains one of significant dysfunction. Such complexity underscores the difficulty addicts face in resisting drug-related cues, reinforcing the importance of understanding impaired cortical function in the chronic relapse cycle of addiction. Due to impaired executive function in the prefrontal cortex, addicts often struggle with decision-making to inhibit drug use, leading to a vicious cycle of repeated drug use. This significant functional impairment of the prefrontal cortex, including imbalances in neurochemical signaling and persistent molecular-level adaptive changes, constitutes the core pathological manifestation of addiction as a chronic brain disease. A key example of such a change is the accumulation of the protein deltaFosB, which acts as a long-lasting molecular switch that structurally rewires neural circuits to reinforce compulsive drug-seeking (Nestler et al., 2001). It directly undermines an individual’s ability to engage in rational assessment, inhibit inappropriate impulses, and maintain long-term goals, rendering self-control exceptionally challenging at the physiological level, thereby contributing to the chronic nature of the disease and its high relapse rate. At this point, the brain’s accelerator (the craving system) is stuck on full throttle, while the brakes (executive function) have failed, trapping the individual in a cycle of relapse that is physiologically difficult to escape.

The profound impact of environmental and social factors on the neurobiologically vulnerable individual—as underscored by the disease model of addiction—is vividly illustrated by the case of Vietnam War veterans. Vietnam War veterans experienced widespread heroin addiction due to the high levels of stress and availability of drugs in the war environment. However, after returning home, many were able to quit relatively successfully due to the disappearance of the war environment and related cues (Leshner, 1997). This case powerfully demonstrates the significant influence of social and environmental factors on addiction, highlighting the need for holistic treatment strategies that address not only neurobiology but also the psychological context in which addiction occurs.

While the end of the war created a positive environmental shift for many, more recently, the COVID-19 pandemic provided a stark counterexample of how social upheaval can catastrophically worsen the addiction crisis. In the wake of the pandemic, U.S. drug overdose deaths surged dramatically, increasing by over 30% in 2020 and surpassing 106,000 in 2021, with opioid-related fatalities showing the most significant rise (Tanz et al., 2022; Spencer et al., 2022). This trend was starkly illustrated at the state level; in New York, a recent report by the New York State Office of the State Comptroller (OSC) found that the increase in opioid overdose deaths in New York between 2019 and 2021 was approximately 68% (OSC, 2022). A perfect storm of factors drove this crisis. On one hand, the pandemic created a widespread mental health crisis, increasing feelings of anxiety, loneliness, and despair, which fueled the demand for substances. On the other hand, lockdowns and social distancing measures severely disrupted access to treatment and recovery support services, leaving vulnerable individuals isolated (Hulsey et al., 2020). This was compounded by an increasingly toxic illicit drug supply, where lethal synthetic opioids like fentanyl became more prevalent (Melamed et al., 2022). This modern-day example powerfully underscores the complex interplay between the neurobiological disease of addiction and large-scale environmental stressors. These cases powerfully illustrate a central tenet of the modern disease model: the neurobiological vulnerabilities established by the disease process are dramatically amplified or mitigated by the external environment. A purely neurobiological focus, therefore, is insufficient. A truly comprehensive strategy must be bimodal, simultaneously targeting the internal pathophysiology of the brain and the external social context of the individual.

Viewing addiction as a disease shapes healthcare policies, treatment approaches, and social attitudes, directly influencing societal outcomes. This disease-oriented perspective provides a clear scientific basis for developing effective treatment protocols, reducing stigma towards individuals with addiction, and guiding evidence-based policy-making. For instance, it supports legislative changes such as improved insurance coverage for addiction treatment and shifts from punitive measures toward rehabilitation. Economically, addiction imposes significant burdens on society; the annual social cost of tobacco, alcohol, and illicit drug abuse in the United States reaches approximately $700 billion (Volkow et al., 2022). This figure is projected to rise due to the ongoing opioid crisis, with opioid-related disorders and overdoses alone accounting for around $1.5 trillion in losses in 2020, including healthcare expenditures, lost productivity, and criminal justice expenses (Lines, 2024). Additionally, over 25% of arrests in the United States involve drug-related offenses (Lines, 2024). Addressing addiction comprehensively as a public health issue, then, is both economically and socially essential.

From a policy and legislative perspective, treating addiction as a disease has driven changes in healthcare and insurance systems. For example, the Mental Health and Substance Abuse Equity Act (MHPAEA) requires that substance abuse treatment be covered under the same insurance as general healthcare services. The implementation of this law has significantly improved patients’ access to treatment. Although there has been a slight increase in spending on substance abuse treatment per insured person, the impact on overall healthcare costs has been relatively small, demonstrating the economic viability and social value of insurance policies with equality at their core (Busch et al., 2014). Moreover, treating addiction is less costly and more effective than incarcerating addicts. Leaders in the police and justice sectors are increasingly recognizing that sending addicts to prison only perpetuates social problems, while directing resources to treatment and rehabilitation services can improve public safety (Williams, 2015). Despite its existence, enforcement has been challenging, leading to persistent coverage disparities. Federal agencies issued final rules in September 2024 to strengthen enforcement (U.S. Department of Labor, EBSA, 2024), but these new rules were immediately challenged by industry lawsuits, ultimately leading the agencies to suspend enforcement in May 2025 pending review (APASI, 2025). This policy uncertainty highlights the ongoing challenges of translating scientific consensus into stable and effective societal responses. Nevertheless, the view of addiction as a disease remains the fundamental driver for promoting fairer insurance coverage and shifting from punitive to rehabilitative criminal justice reforms.

Moreover, considering addiction as a disease may also reduce social stigma, so that more addicts can actively seek help rather than refusing treatment out of shame or fear. Currently, more than 70% of alcohol-dependent people have never sought professional help, and views of addiction as a moral failure or a weakness of the will undoubtedly exacerbate this phenomenon. In contrast, defining addiction as a disease can lead society to invest more resources in treatment, rehabilitation, and prevention services, rather than simply punitive policies. For example, the Patient Protection and Affordable Care Act (ACA) has promoted the inclusion of substance abuse services in basic health benefits, which has greatly improved the accessibility of addiction treatment, further illustrating the important guiding significance of the disease definition for public policy.

Viewing addiction as a disease provides the essential foundation for critical policy and social reforms. Such a perspective underscores the value of evidence-based treatment strategies over punitive approaches, which not only reduces stigma and encourages more individuals to seek necessary care but also promotes public safety by breaking the cycle of addiction-related crime. Ultimately, addressing addiction as a chronic disease rather than a moral failing allows for a more compassionate, effective, and economically sustainable societal response.

In summary, neurobiological evidence clearly indicates that addiction is a brain disease rather than a simple lack of willpower. Addictive substances create lasting changes in brain circuits, disrupting neurotransmitter regulation (e.g., dopamine) and impairing critical functions controlled by areas such as the prefrontal cortex. These persistent physiological alterations undermine self-control, rational decision-making, and the proper assessment of natural versus drug-induced rewards. However, this biological model is not deterministic; as the experiences of Vietnam veterans demonstrate, environmental context and social support are powerful modulators of these neurobiological vulnerabilities. The cyclical and relapsing nature of addiction underscores its chronicity and complexity. Just like other chronic diseases, a short-term cure is a relatively rare outcome; instead, relapses are more common. Recognizing addiction as a disease, one that involves a complex interplay of biology and environment, thus fosters deeper understanding and enables society to respond with greater empathy and effectiveness.

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A Psychological Approach to Understanding and Addressing the Implications of Discrimination

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By Aviram Nessim, May 12, 2025


“Our future survival is predicated upon our ability to relate within equality.” 

– Audre Lorde

Discrimination, in both its overt and covert forms, has been shown to negatively impact individuals and society alike. Beyond its immediate effects, such as increased stress and negative emotions, discrimination affects physical and mental health, reduces productivity, and deepens systemic inequalities. These effects are also often internalized by individuals and can ripple outward to affect entire communities, weakening social cohesion and reducing trust between and within communities (Heiserman & Simpson, 2023; Lei et al., 2021; Yeh & Tung, 2021). The primary objective of this essay is to examine how discrimination affects human psychology and contributes to a less cohesive society. A secondary objective is to propose evidence-based solutions that may help in resolving this issue.

It is first essential to clarify the definition of discrimination and address how it most commonly appears in society, particularly given the term’s frequent misuse and oversimplification (Feagin & Eckberg, 1980). The American Psychological Association (2025) defines discrimination as “the unjust and differential treatment of the members of different age, gender, racial, ethnic, religious, national, ability, identity, sexual orientation, socioeconomic, and other groups at the individual level.” In everyday life, discrimination most frequently arises in interpersonal settings, particularly in workplaces, and disproportionately affects people of color, women, and individuals from lower socioeconomic backgrounds (Murphy et al., 2018; Perry et al., 2013).

From a psychological standpoint, the effects of discrimination can be devastating for both the mind and body. It has been linked to increased rates of depression, disease, economic and social marginalization, and psychological distress (Brown et al., 2000). Krieger (1999) illustrates how perceiving racial discrimination can trigger a physiological stress response: fear and anger activate the “fight-or-flight” response, mobilize lipids and glucose to increase energy supplies, heighten sensory vigilance, and produce transient elevations in blood pressure. When this response becomes chronic, it can lead to sustained hypertension and other long-term health consequences. This stressful reaction serves as one way that discrimination provokes a general state of distress. Beyond physical effects, chronic discrimination can also reduce motivation, diminish overall well-being, and, even worse, lead to complete social withdrawal (Williams et al., 2019). Finding ways to create inclusion and a sense of belonging, then, becomes of utmost necessity, as a fair and inclusive society will only benefit us all. 

One solution to this problem comes through strategically debiasing establishments in a way that both majority and minority individuals feel included. Inclusion is psychologically vital, as research shows that feeling included increases one’s self-esteem, confidence, and sense of self-worth (Boeldt, 2017; Brouge, 2023). One effective approach is perspective-taking, in which individuals from different backgrounds are encouraged to understand one another’s experiences. This can include viewing the world from multiple lenses, practicing active listening, and expressing empathy. Perspective-taking has been shown to reduce stereotype threat among stigmatized groups and decrease in-group favoritism, likely by signaling that the same situation can be perceived and experienced in different ways (Galinsky & Moskowitz, 2000). 

At the organizational level, one effective strategy involves promoting norms of group-based respect, including actively acknowledging, accepting, and valuing differences between and within groups, which has been shown to increase perceived inclusion (Jansen et al., 2015). These effects are amplified when the majority group members who are motivated to be non-prejudiced take an active role in creating inclusive environments (Murphy et al., 2018). Another important strategy involves educating people about the sources of discrimination and identifying structural inequalities in policies and workplace procedures. By doing so, both approaches have been shown to broaden people’s understanding of the factors that contribute to prejudice. For example, Son Hing et al. (2002) found that individuals with aversive racist attitudes, once made aware of their biases, were more willing to support policies designed to address systemic discrimination and promote equality.

Today, America is more racially and ethnically diverse than ever before. With this growing diversity comes a greater need to mutually respect, cooperate with, and include everyone at both the individual and organizational levels. Failing to do so risks exacerbating social divisions and perpetuating cycles of unsupported, unhappy, and unproductive individuals. However, by choosing to respect and include, we have an incredible opportunity to let our diversity become one of our greatest collective strengths.

Works Cited

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Murphy, M. C., Kroeper, K. M., & Ozier, E. M. (2018). Prejudiced Places: How Contexts Shape Inequality and How Policy Can Change Them. Policy Insights from the Behavioral and Brain Sciences, 5(1), 66-74. https://doi.org/10.1177/2372732217748671

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Healthcare’s Youngest Victims: Inequality in Pediatric Healthcare and How We Can Fix It

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 by Cameron Takmil, February 24, 2024

Millions of children visit the emergency room every year with cuts, bruises, and a myriad of other diagnoses. Many are turned away from necessary treatments for seemingly nothing except one thing – race. While seemingly trivial, disparities across racial and ethnic lines persist, underscoring a critical need for systemic reform. Recent research spearheaded by experts at Northwestern revealed that healthcare inequities are widespread, affecting non-white minorities profoundly in pediatric care. 

The most concerning disparity was in pain management. When comparing kids of color to their white counterparts, they were not given proper medication at the same rate (Godoy 2024). 

These disparities manifest in other ways, including but not limited to diagnostic imaging, surgical complications, emergency care wait times, and treatment for developmental disabilities. Children of color often get the short end of the stick in these circumstances, receiving less than optimal care. UCLA researchers determined that white pediatric patients were more likely to receive sepsis treatment, compared to their black counterparts who also were less likely to be given full diagnostic testing through automated sepsis-alert systems (Li et. al 2022).

Premature infants of color tend to have increased rates of morbidities with regard to bronchopulmonary dysplasia, intraventricular hemorrhage, and necrotizing enterocolitis (Fanta et. al 2021). Those same infants generally had a lower birth weight, were born more prematurely, and had a higher mortality rate compared to white infants.

Differences lie not only in physical health, as mental health has seen its fair share of disparities amongst pediatric patients. Post-diagnosis, Latino and Black children receive medication and treatment at a lesser rate than White children (Fanta et. al 2021). Underdiagnosed and undertreated, patients of color were less likely to be evaluated on evidence-based mental health care and be given the correct medication all in all.

These inequalities persist despite the families having insurance, pointing towards the idea that these disparities are caused by other factors (Godoy 2024). Nevertheless, Hispanic and Black populations were much less likely to be uninsured, which is another hindrance in access to ubiquitous healthcare (Zhang et. al 2019).

The source of these inequalities stems from decades-long structural racism. Race-based residential segregation, institutional racism, and concentrated poverty have led and in many cases today, continues to worsen quality of housing, safety, and healthcare access and quality. A Harvard study found that in nearly all of the largest urban areas in the United States, two-thirds of non-Hispanic Black children and more than half of Hispanic children lived in areas graded as low- or very low opportunity (Slopen, Heard-Garris 2021). On the other hand, fewer than 1 in 5 Asian or White children live in low- or very low opportunity neighborhoods, clearly more affluent than their minority counterparts.

Government programs that have kept many afloat are slowly falling to the wayside, exposing vulnerable populations to even worse conditions. The Special Supplemental Nutrition Program for Women, Infants and Children, or WIC, served nearly half of the U.S’s infant population, and over six million children overall (Center for Health Journalism 2024). WIC has been able to improve birth metrics such as birth weight, preterm birth, and infant mortality rates. Despite being seemingly essential, the refusal by Congress to adjust its budget has put close to a million Americans at risk of losing their benefits.

These disadvantages extend into overall health as “toxic stress” – a term used by researchers at the Dana-Farber Cancer Institute – leads to negative consequences in physical and psychological health. Their study discovered that adversity during childhood was associated with poorer neurocognitive, neonatal, and cardiovascular health (Umaretiya et. al 2022). Due to red-lining – residential segregation policy in the 20th century – environmental risk is increased in more impoverished areas, posing a risk of safety and exposure to its residents (Samuelson 2024). Pediatric patients of color who live in these areas with higher density of housing code violations are more likely to be admitted and return to the ED due to asthma and related complications  (Fanta et. al 2021). 

If that was not enough to overcome, this prejudice has been baked into society with false, harmful, and misleading stereotypes, which many internalize, whether consciously or subconsciously. Minority parents, especially Hispanic parents, frequently report that healthcare providers do not dedicate sufficient time to understand their child’s needs, respect their parenting expertise, or align with their child-rearing preferences (Flores 2005). These same populations also reported that topics such as community violence, household smoking, alcohol usage, issues paying for the child’s basic needs, and spouse/partner support were discussed more frequently than white parents.

These sentiments extend far beyond healthcare, as anti-minority beliefs have come to the forefront in the past years. According to a recent national survey, “51% of whites think that blacks are prone to violence, whereas only 16% of whites think that whites are prone to violence” (Flores 2005). In the doctor’s office, we see much of the same, as the prevalence in which community violence was discussed quadrupled and tripled for Hispanic and Black patients respectively. Similar trends were found with regard to substance use, even in families where average income exceeded $75,000 (Flores 2005). 

This gap in communication and understanding only exacerbates the feeling of marginalization and can lead to decreased satisfaction with care and impaired patient-provider communication. These same minority populations have been reported to have higher levels of distrust of their provider, mainly due to implicit and explicit discrimination (Umaretiya et. al 2022). Such interactions might not only perpetuate discrimination but also detract from providers’ ability to educate, inform, and aid these patients.

It is not all hopeless, though, as there is a pathway for solutions to reduce the gap between patients of color and white patients. Addressing and solving disparities in pediatric healthcare is a multifaceted challenge that demands an in-depth and multidisciplinary approach. The strategies to promote health equity in pediatrics can be categorized into three levels: individual, institutional, and structural as demonstrated in research (Fanta et. al 2021). 

At the individual level, healthcare professionals can make up ground by engaging in continuous professional development focused on understanding and mitigating the impact of interpersonal racism, discrimination, and bias on pediatric health inequities (Fanta et. al 2021). It is crucial to educate providers on not only their explicit biases, but more importantly their implicit biases that they might not be aware of. Through this, a mindset of cultural humility and openness, being other-oriented, and recognizing the impact of power dynamics on building trusting relationships with patients and their families can be cultivated. 

These shortcomings of healthcare are not only the responsibility of the providers to ameliorate, as the onus is on institutions to invoke change themselves. Diversifying the workforce can enhance the relatability and effectiveness of the patient-provider relationship (Fanta et. al 2021). This could help patients feel more comfortable with providers who might be more apt to understand their plight. 

In a broader sense, addressing structural disparities requires moving outside of the healthcare system and advocating for policy reform aimed at eliminating inequities in critical social determinants of health. These determinants include healthcare access and quality, economic stability, education, neighborhood and built environment, and social and community context (Fanta et. al 2021). A study from Dana-Farber notes that adopting universal and systematic social determinants of health – coined as SDOH in their paper – screening within pediatric care can identify key areas where interventions can be most effective (Umaretiya et. al 2022). Identifying the specific root causes on a patient-to-patient basis will allow for much more optimized solutions.

Something as simple as integrating SDOH screens into each visit, within national pediatric protocols, can help identify mechanisms driving disparities and opportunities for intervention (Jindal et. al 2024). Developing multilevel health equity interventions that address identified pathways, such as access to care, patient-health-care-system interaction, and the impact of toxic stress, is crucial (Umaretiya et. al 2022).

It will be imperative to focus on improving the various systems that lead to poorer healthcare outcomes for pediatric patients of color. Efforts to dismantle the underlying racism that perpetuates pediatric racial and ethnic health inequities must focus on policies within multiple interdependent systems. This includes challenging housing policies that sustain poor housing, limiting access to resources like high-quality education and healthcare, and increasing exposure to environmental risk factors (Jindal et. al 2024). Enhancing family resilience through evidence-based psychosocial interventions can also play a role in mitigating the effects of toxic stress (Umaretiya et. al 2022).

To effectively reduce and solve disparities in pediatric healthcare, a concerted effort from all stakeholders—healthcare providers, institutions, policymakers, and communities—is required. This involves addressing not only the immediate healthcare needs of children but also the broader structural and social determinants of health that contribute to disparities. By implementing these strategies at the individual, institutional, and structural levels, we can move closer to achieving health equity in pediatrics, ensuring that all children have the opportunity to thrive and reach their full health potential.

Bibliography

  1. Godoy, M. (2024, January 18). Kids of color get worse health care across the board in the U.S., research finds. NPR. https://www.Godoy.org/sections/health-shots/2024/01/18/1225270442/health-inequities-pediatrics-kids-of-color-disparities
  2. Li, E., Ng, A. P., Williamson, C. G., Tran, Z., Federman, M. D., & Benharash, P. (2022). Assessment of Racial and Ethnic Disparities in Outcomes of Pediatric Hospitalizations for sepsis Across the United States. JAMA Pediatrics. https://doi.org/10.1001/jamapediatrics.2022.4396 
  3. Fanta, M., Ladzekpo, D., & Unaka, N. (2021). Racism and pediatric health outcomes. Current Problems in Pediatric and Adolescent Health Care, 51(10), 101087. https://doi.org/10.1016/j.cppeds.2021.101087 
  4. Zhang, X., Carabello, M., Hill, T., He, K., Friese, C. R., & Mahajan, P. (2019). Racial and Ethnic Disparities in Emergency Department Care and Health Outcomes Among Children in the United States. Frontiers in Pediatrics, 7. https://doi.org/10.3389/fped.2019.00525 
  5. Slopen, N., & Heard-Garris, N. (2021). Structural Racism and Pediatric Health—A Call for Research to Confront the Origins of Racial Disparities in Health. JAMA Pediatrics. https://doi.org/10.1001/jamapediatrics.2021.3594 
  6. The Health Divide: Pediatric care is worse for kids of color; federal nutrition program faces worrying shortfall | USC Center for Health Journalism. (n.d.). Centerforhealthjournalism.org. Retrieved February 10, 2024, from https://centerforhealthjournalism.org/our-work/insights/health-divide-pediatric-care-worse-kids-color-federal-nutrition-program-faces 
  7. Puja J. Umaretiya, Robert J. Vinci, Kira Bona; A Structural Racism Framework to Guide Health Equity Interventions in Pediatric Oncology. Pediatrics May 2022; 149 (5): e2021054634. 10.1542/peds.2021-054634, https://publications.aap.org/pediatrics/article/149/5/e2021054634/186711/A-Structural-Racism-Framework-to-Guide-Health
  8. Pediatric care for non-white children is universally worse across U.S. (n.d.). News.northwestern.edu. Retrieved February 10, 2024, from https://news.northwestern.edu/stories/2024/01/pediatric-care-for-non-white-children-is-universally-worse-across-u-s/ 
  9. Glenn Flores, Lynn Olson, Sandra C. Tomany-Korman; Racial and Ethnic Disparities in Early Childhood Health and Health Care. Pediatrics February 2005; 115 (2): e183–e193. 10.1542/peds.2004-1474 https://publications.aap.org/pediatrics/article/115/2/e183/67379/Racial-and-Ethnic-Disparities-in-Early-Childhood 
  10. Jindal, M., Barnert, E., Chomilo, N., Gilpin Clark, S., Cohen, A., Crookes, D. M., Kershaw, K. N., Kozhimannil, K. B., Mistry, K. B., Shlafer, R. J., Slopen, N., Suglia, S. F., Nguemeni Tiako, M. J., & Heard-Garris, N. (2024). Policy solutions to eliminate racial and ethnic child health disparities in the USA. The Lancet. Child & Adolescent Health, 8(2), 159–174. https://doi.org/10.1016/S2352-4642(23)00262-6 

Struggles of Organ Donation: Microcosm of American Healthcare

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by Cameron Takmil, December 2, 2023

In the last year alone, over 42,000 transplants were performed. Yet, 17 people a day of the 100,000 people on the national transplant waiting list die without the transplant they so desperately hope for (HRSA). Those who are fortunate to survive on life-sustaining treatments will likely find themselves without a transplant due to the shortcomings of the process as a whole.

Inequalities in organ transplantation can be sourced back to the frequency in which certain populations require new transplants altogether. African Americans and Hispanics disproportionately suffer kidney failure as well as organ failure as a whole — both over one and half times more likely compared to whites. This disproportionate rate of organ failure can be attributed to increased rates of general comorbidities that stem from poor healthcare access and health education (Harvard Health). 

Dr. Jessica Kendrick, a kidney specialist and researcher at University of California, outlined the two main factors that affect African Americans (UC Health)). “The two most common factors are diabetes and hypertension,” both of which also affect African Americans disproportionately, Kendrick said. She cited socioeconomic barriers as the underlying cause for these disparities in not only African Americans but disadvantaged minority populations as a whole. Organ failure is a culmination of poor health and is much more treatable if one is well-educated on their health and has consistent primary care access — something that many cannot say they have.

Geography plays a role as well, as those who are situated in more impoverished areas will have to battle food insecurity and poor quality of diet (NPR). In turn, they are more likely to develop fatty liver and have a need for a liver transplant. But, in rural and low-affluence areas, completing the rigorous testing necessary to land on a donor list becomes a tall order. The first steps in the transplant process is often one that many fail to even reach or surpass. The extensive work-up and evaluations necessary to get on the waiting list bogs down the many who are already struggling to get their routine check-ups. In 2023, over 1,500 Americans were omitted from the transplant list due to being too sick to receive a transplant, adding on the already 50,000 that die from liver disease every year (NPR).

Costs are not limited only to the surgery itself, as post-operative care and medication can be a toll on the already struggling. Dr. Mary Simmerling, an assistant professor at Cornell University with a PhD in bioethics, highlights this in one of her pieces regarding the implications of organ transplantation. “Even if there were a sufficient supply of suitable organs for transplantation, the reality is that the uninsured, underinsured and the poor do not currently have an equal opportunity to fully realize the benefits of organ transplantation because they do not have equal access to very expensive and necessary post-transplant immunosuppressant medications,” Simmerling states. 

Even those with Medicare are not safe from these expenses as coverage for these post-transplant medications and services only lasts three years – at 80 percent (Centers for Medicare Services). With the cost of nearly 2,000 dollars a month and close to 400 dollars after Medicare, those living off minimum wage salary can expect this to eat a sizable portion of their monthly income and even eclipsing their income if they are unable to obtain coverage (Simmerling 2007).

Recently, in 2022, Medicare introduced a “Part B Immunosuppressive Drug Benefit”, which is an extension of the partial coverage that allows for one to be covered continuously. While a step in the right direction, the caveat is that this only covers the exact medication for immunosuppressants but not additional medication that help treat possible complications arising from the immunosuppressant drug regimen or from surgery (i.e. organ rejection). This is simply not enough to ensure patients won’t be run up with charges if any complications come about post-surgery. 

Sentiments around donating organs have not helped either, as many are hesitant to donate due to a myriad of reasons. A study done by a group of Case Western researchers found that African-Americans’ tendency to donate was related to their lack of trust in the healthcare system. 38.6% of the African-American participants agreed with the statement that “if doctors know I am an organ donor, they won’t try to save my life”, a sentiment that is rooted in historically poor healthcare access and education (Siminoff 2006).

Lack of access can also be attributed to poor procurement by organizations responsible for retrieving and regulating donor organs. Organ procurement organizations, OPOs, facilitate the organ donation and procurement process, making organs available for transplant. Across the board, black families that were potentially interested in donating received less information than their white counterparts, a factor that makes minority families reluctant to donate (Forbes).

Today, there are 56 OPOs, all responsible for handling their respective donor service area (Scienceline). Only until recently have OPOs been responsible for being more transparent about their efficacy and process of procurement. Some estimate that almost 30,000 organs are not correctly retrieved due to inefficiencies and shortcomings of the current systems. These same estimates project that 25,000 additional lives could be saved. Dorry Segev, a professor of surgery at Johns Hopkins, brought up the point that “some OPOs are prioritizing their organs-procured-per-donor rate, ignoring potential donors where only one organ can be procured”. This limits the amount of organs procured, limiting the access down the line for all (Scienceline).

In the words of Elizabeth Warren, “Right now, [United Network for Organ Sharing] is 15 times more likely to lose or damage an organ in transit as an airline is to lose or damage your luggage,” said the Massachusetts’ senator. “That is a pretty terrible record,” (NPR).

Under the Biden administration, promises have been made to double the budget for OPOs and organ procurement programs as a whole, but it will take time to see if that will come to fruition (USA Today).

Plenty of solutions have been proposed, ranging from organs generated stem cells to compensating donors for their donation. Unfortunately, stem cells research is decades away from providing safe and effective generated organs that can replicate the function of human organs. Small scale studies have been successful in creating “miniature” organs, but are still far from creating human-scaled organs (Mayo Clinic).

Some have brought up the potential of allowing the sale of organs, which in theory would increase the available organs for transplantation. A study done at Stanford in 2018 explored the possible implications of allowing the sale of organs, specifically kidneys. The researchers estimated that a donated kidney would equate to $75,000 and the overall value being $1.3 million when considering the extension of lifespan. According to the study, “The study’s calculations showed a positive net benefit, in monetary terms, of $12.4 billion for low-income people overall. The researchers also calculated that the number of transplants per year would increase from 17,500 to 31,000 — enough to supply kidneys for yearly additions to the waitlist.” The proportion of transplant receipts who were considered non-affluent would go from a mere six percent to 30, a fivefold increase (Scope). Nevertheless, while promising, this experiment would be difficult to translate into the real world, due to the reluctance of legislators.

The dilemmas of organ transplantation reflect the greater issues of society today, as a multitude of problems today have coalesced to create the obstacles we face today. In a country that boasts the largest GDP in the world, there should be no reason anyone has to die waiting for their new chance at life.

Bibliography

  1. organdonor.gov, H. R. S. A. (2023). Organ Donation Statistics. Figures of Organ Donation. https://www.organdonor.gov/learn/organ-donation-statistics
  2. J. Kevin Tucker, M. (2021, February 3). What’s behind racial disparities in kidney disease? Harvard Health. https://www.health.harvard.edu/blog/whats-behind-racial-disparities-in-kidney-disease-2021020321842  
  3. Smith, T. (2023a, June 23). Why is chronic kidney disease risk higher for black people?. UCHealth Today. https://www.uchealth.org/today/why-chronic-kidney-disease-risk-higher-for-black-people 
  4. NPR.org. (2023, May 24). One man left Kansas for a lifesaving liver transplant, but the problems run deeper. https://www.npr.org/2023/05/24/1177589739/one-man-left-kansas-for-a-lifesaving-liver-transplant-but-the-problems-run-deeper 
  5. Centers for Medicare & Medicaid Services. (n.d.). Part B – Provider. https://www.cms.gov/partbid-provider 
  6. Journal of Ethics | American Medical Association. (2007, June). Beyond scarcity: Poverty as a contraindication for organ transplantation. https://journalofethics.ama-assn.org/article/beyond-scarcity-poverty-contraindication-organ-transplantation/2007-06 
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  8. Awan, O. (2023, February 22). Disparities of organ donations in America and how to rectify them. Forbes. https://www.forbes.com/sites/omerawan/2023/02/22/disparities-of-organ-donations-in-america-and-how-to-rectify-them/?sh=49f5d8904692 
  9. Scienceline. (2020, January). Organ donation in the US is broken, and we know who is to blame. https://scienceline.org/2020/01/organ-donation-in-the-us-is-broken-and-we-know-who-is-to-blame/ 
  10. NPR.org. (2022, August 17). Damaged and diseased organs: The agency overseeing transplants faces intense scrutiny. https://www.npr.org/sections/health-shots/2022/08/17/1118009567/damaged-and-diseased-organs-the-agency-overseeing-transplants-faces-intense-scru 
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