In the United States, it’s no secret that black people face hurdles and obstacles that their white counterparts don’t encounter. While there are countless examples of this, one noteworthy arena is in pain management, where racist attitudes and beliefs limit the treatment options of black patients.
Today I’d like to discuss the roots of these beliefs in the United States and explain how they still affect black patients seeking care.
History of Racist Beliefs in American Healthcare
In the United States, there was money to be found in proving white supremacy through “scientific” means. Known as eugenics, this discredited pseudoscience sought out objective proof of the inferiority of people of color (particularly black people) and the superiority of whites.
During the 1880s, eugenics first rose to prominence after Sir Francis Galton studied the British aristocracy and concluded that their superior positions were reflective of their superior genetics. Spurred on by these claims, American corporate interests funded eugenics research, which was used to support anti-immigration legislation and forced sterilization of poor, disabled individuals.
This was not a fringe belief, either; respected physicians and researchers came forward with claims of black people having thicker skulls and less sensitive nervous systems. In fact, some physicians even claimed that black patients did not require anesthesia during surgery due to their naturally high pain tolerance.
These beliefs were at best tolerated and at worst accepted as fact well into the 20th century, with attitudes shifting based on location, political beliefs, and education. And this had real effects on black people, who not only faced a “scientific” justification for continued social racism, but also suffered inhumane testing because it was believed they were less susceptible to pain.
Two of the more recent examples include when the United States military tested mustard gas and other chemical weapons on black soldiers during World War II, as well as joint research between the US Public Health Service and the Tuskegee Institute, wherein they studied the progression of untreated syphilis in black men from 1932 to 1972.
These remnants of eugenics usually lead to one of two issues for black patients seeking pain management. In one scenario, a provider may recognize that a black patient is in pain, but not offer them effective pain management treatments due to concerns that they will abuse medication or not comply with medical guidance in other ways.
Alternatively, a provider may simply not trust black patients to accurately report their pain and may think that they feel less pain than white patients. In this case, the patient cannot receive pain management because nobody has acknowledged their pain as real, and this can make life much harder for black people with chronic pain.
As you can see, the beliefs of eugenics did not simply disappear, but morphed into unconscious attitudes and beliefs that still affect black patients today.
Misconceptions About Black Pain
In a two-part study published in Psychological and Cognitive Sciences, researchers worked to determine the prevalence of beliefs that hinder black people from accessing pain management treatments. This study took input from general laypeople with no medical knowledge, students in training to become health care providers, and residents currently working in the field.
In the first study, participants (all of whom were white, born in the United States, and spoke English as a first language) gave their own input as to how painful a certain scenario would be for them, and were then asked to rate the pain of black people in various scenarios. To account for gender bias, each participant rated the pain of a person with the same gender.
“Blacks’ nerve endings are less sensitive than whites’”
The results were that many participants rated black people’s pain as less severe than their personal pain ratings. From this, we can conclude that the factor of race influenced their expectations of pain in the scenarios.
In the second study, the researchers conducted a survey to determine which false beliefs people believed to be true. This list of items included statements like “Blacks’ nerve endings are less sensitive than whites’” as well as true, biological differences like “Black are less likely to contract spinal cord diseases.”
The results? 73% of people endorsed at least one false belief, with results varying based on medical knowledge. That said, many residents still purported false beliefs based on race, with 14% agreeing that blacks age more slowly than whites and 25% believing that black people have thicker skin than whites.
By combining both of these results, the researchers concluded that those who rated black pain highly were less likely to have false beliefs about racial differences. Conversely, those who rated black pain as unusually low were more likely to believe these misconceptions. This highlights the danger of medical professionals who administer treatment while believing these falsehoods; they under-rate black pain and thus are less likely to give proper treatment.
Clearly these issues are deeply ingrained, but what has made them stick around for so long? And is the end in sight?
Why Racist Beliefs About Pain Persist
While eugenics initially gained a foothold through its large corporate backing and the desire of powerful individuals to prove white supremacy, it is now widely understood to have been a pseudoscience and without biological merit.
So why do white people, and white health care providers especially, still have these beliefs?
One possible cause could be the way that we rate pain. When determining someone’s pain, we rely largely on their reactions; grunting or crying, certain expressions, etc. And while that sometimes works, other times people express their pain differently than what a provider may expect, especially if they come from different cultural backgrounds.
This creates a problem when medical professionals can’t identify a cause of pain and have to use their own judgement to identify pain, which is far from infallible. In fact, a 2019 study found that white health care providers had an easier time recognizing pain on white faces than black faces.
Clearly these cultural beliefs are far from relics of the past. And without confrontation, they’ve been allowed to settle into the worldview of countless Americans and worsen treatment outcomes for black patients. Educating yourself on these unconscious biases is a good start, but for white people who may have unconscious bias, there are more concrete steps that we can take.
How to Combat Racist Bias
Bias can be tricky to spot, and we often can’t see it until confronted with it directly. To that end, some of the steps that we can take include:
- Identifying internal bias: If we’re going to remove our biases, we first have to acknowledge them. I’d recommend taking an Implicit Association Test and seeing what you rank. Be prepared to confront some internally defensive feelings, and remember that this is not about judgement, but about acknowledging existing beliefs and working to actively challenge them.
- More research: By tracking larger trends in racial bias, we can better determine where the cultural focus needs to be addressed to confront these issues. If bias exists, it will certainly be reflected in the data.
- Rely less on personal discretion: As we have seen, personal biases can make accurate ratings of pain almost impossible. Whenever possible, providers should stick to clinical guidelines to ensure that their unconscious beliefs do not harm their black patients.
As a nation, we have to confront these issues in order to better care for black people living with chronic pain. Getting quality pain management is hard enough, and these additional barriers only make it more difficult for black individuals. Without proper pain management people can struggle to find work, to retain their mobility, and even complete daily functions of living. Those are the stakes, and that is why each of us must actively combat these biases where they arise and work toward a more equitable health care system.
What topics related to race and chronic pain should we cover next?
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