Over 35 people registered for our latest Community Forum, which addressed inequities among populations with substance use disorders. Another name for it could have been, “How our current healthcare system reflects our culture and beliefs, and what we must do in order to change it.” Dr Oluwole Jegede spoke of completing his addiction fellowship at Yale School Medicine, with a primary location at APT Foundation, so that returning to speak on this topic felt like coming home.

He began with the learning objectives for the Forum, stating that by the end of the session, attendees would be able to:

  • Identify social determinants of health as risk factors for addiction 
  • Compare concepts of inequality and inequity
  • Describe causal pathways from social factors to addictions
  • Identify racism as a social determinant of health
  • Describe policy and clinical initiatives to address inequities in addiction

Social determinants of health, he explained, consist of non-medical factors that influence health outcomes. For people with substance use disorders, they are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the condition of daily life. The evidence is clear that for certain individuals or groups of individuals, exposure to health vulnerabilities becomes stratified along various social hierarchies. 

Traditional paradigms in health care have tended to ignore social causation. Instead, they have focused mainly on biological models for what causes illness in human beings. Yet things like Education access, Health care  access, Economic stability, Neighborhood and built environment, and Social and community context are all responsible for how a person’s health and wellness unfolds over the course of a lifetime.


Various frameworks have been advanced to help us understand how social determinants affect people’s health. According to Dr. Jegede, upstream or systemic factors must be considered and controlled to have an effect on the downstream or immediately observable factors. Research on these topics has skyrocketed in recent years.

Social and structural vulnerabilities can be transferred to the next generation, a process  termed Intergenerational Transfer of Disadvantage. Specific “pathways” have been recognized as mediators between these social factors and the development or perpetuation of substance use disorders. It is important to understand that these pathways can be points of intervention. Furthermore, it is reasonable to consider social determinants of health as factors that are mutually reinforcing and co-dependent. Together, they create a state of overall structural vulnerability, or being chronically at risk for negative health outcomes.

Many times the financial and institutional arrangements of health care systems can have disparate and negative effects on minorities’ ability to attain quality care. Equality, while desirable, can still have an impact on people being left out. For instance, it’s not enough to provide telehealth services for addictions when there are people who still don’t have smartphones, access to charging stations or even the literacy to assess telehealth visits. 

In fact, racial and ethnic minoritized populations tend to receive a lower quality of care even when access-related factors are controlled. What this means, then, is that substance use treatment is set up in ways that make it difficult to access and maintain care. Black and Brown people who use drugs are 

  • More likely to be involved in the carceral system
  • Less likely to be engaged in addiction treatment and maintenance
  • Less likely to be treated with buprenorphine and more likely to be treated with more stigmatizing treatments, such as methadone, and
  • More likely to die from drug overdoses. Moreover, the more unequal a county is, the higher the number of overdose deaths. 

Social Structures

Race is not the determinant of health, Dr Jegede points out, racism is. Racism is the weaponization of social structures. It underlies the earliest foundations of public policies for treating addictions in this country, including the so-called War on Drugs, abstinence-based approaches like Nancy Reagan’s Just Say No campaign that assigned moral failure to drug use, and the Comprehensive Crime Control Act of 1988 which set mandatory minimum sentences for certain kinds of drugs corresponding to patterns of use defined by racial demographics. Then when we look at current marketing of buprenorphine, we see it is being marketed to people who are white, and people who can pay. Meanwhile, 78% of people on methadone experience harmful stigmas, including being perceived as untrustworthy and incompetent, which makes it harder to achieve education and employment goals.

Social determinants of health are difficult to measure, but there are things we can all do to assess risks and care for people equitably.  We don’t want to reduce patients to numbers; it is a very complex system that requires sensitivity and multi-level interventions. At the end of the day, health outcomes in addictions are related to an individual’s location on various social hierarchies determined by political and economic forces. In changing the framing paradigms we have to acknowledge that disparities exist as well as implement programmatic efforts to improve racial equity in the addiction workforce as a good start to forging a path to racial justice. 

Watch the whole recorded presentation

Oluwole Jegede, MD, MPH

About the Presenter

Dr. Oluwole Jegede, MD, MPH
Assistant Professor, Yale Department of Psychiatry

Dr. Oluwole O. Jegede is a psychiatrist in New Haven, Connecticut who subspecializes in Addiction, Community, and Neuropsychiatry. He is affiliated with the Connecticut Mental Health Center (CMHC), Veterans Affairs Medical Center and Yale New Haven Hospital (Bridgeport Hospital). He received his education from Yale School of Medicine, George Washington University and University of Ibadan in Nigeria and has been in practice for over 15 years.