Racism in Pain Medicine

Racism is “a belief that race is a fundamental determinant of human traits and capacities and that racial differences produce an inherent superiority of a particular race,” according to the Merriam-Webster Dictionary. Racism also refers to the racial biases that people with systemic power have towards individuals of a different racial or ethnic background that do not have that same power. For example, in the United States of America, people whose ancestors are of European-White descent historically have been the dominant group in the United States, having the privilege to go to school, vote, eat, and/or live in areas that people belonging to other racial and ethnic groups could not. Despite the hundreds of years of racial disparities in the United States, from microaggressions to the enslavement of human beings (particularly the enslavement of African Americans and Indigenous Americans), most people are surprised to find out that there are no biological differences separating races. Race is a social construct, something that humans made up to describe or separate themselves from those who they saw as inferior. Race is not something that can be found in someone’s genetics. The racial category that someone fits into will often change depending on the place and time period that they live, even if their ancestry does not. For example, on the United States census in 2020, there were five recognized racial categories to define oneself in; White, Black or African American, Asian American, American Indian/Alaska Native, and Native Hawaiian/Pacific Islander, as well as people who are two or more races. On the 2020 U.S. census, people could also say whether they are of Hispanic or Latino origin. However, in 1890, the census race options were White, Black or Mulatto [someone of mixed Black and White ancestry), Indian [referring to Indigenous Americans], and Asian (with the options of Chinese, Japanese, Filipino, Korean, or Hindu [Asian Indians regardless of religious affiliation]). This didn’t mean that suddenly a certain type of “race gene” appeared or disappeared to mark someone as fitting the newly introduced or no-longer-in use racial categories, it simply means that the words used to describe people of a certain ancestry and how different people were grouped together changed. There are many ways that racism can take form. Systemic racism specifically refers to racism that has been upheld by an institution, or a system. One example of systemic racism is segregation and racism in hospitals and medical facilities. According to the digital History of Medicine Exhibit publicized by the U.S. National Library of medicine, one of the reasons that racism in the American healthcare system was able to become so central to medical practice is because “organized healthcare for African Americans first developed as a result of the slave owners' need to tend to illness and disease within the enslaved populations on their plantations,” making the doctor-patient dynamic seen as the repairing of an object, not the treatment of a human being’s illness, injury, or pain. “After the [American] Civil War white communities gradually began to establish segregated, white owned and operated hospitals, primarily in the South, to care for the newly freed slaves. Although they admitted only black patients, these “separate but equal” hospitals were often inadequate, provided substandard care, and rarely provided access for black physicians or nurses.” Interpersonal racism is different from systemic racism, however both uphold and enable the other to exist. Interpersonal racism describes personal beliefs and attitudes toward other races that affect the way a person treats or thinks of someone from a marginalized ethnic or racial group, not the description of policies or behaviors within a system that enable it to further harm racial and ethnic minority groups. Not every healthcare worker or person who holds racist beliefs is openly or intentionally hateful towards other races. Someone may hold biases that they do not know that they hold, yet it does not mean that they are incapable of causing harm because of those biases. Explicit racism is overt, more obvious. It is something that most people can see and point out. Overt racists are people who are openly prejudiced or hateful towards racial minority groups, for instance, people who use racial slurs or people who commit racially-motivated hate crimes. Explicit racism is something that people know and understand is racist, but continues to be practiced or thought with the intention of harming certain racial group(s). An example of explicit systemic racism in healthcare would be a segregated hospital, where there are specific policies in the practice telling medical professionals to treat people differently based on their race or ethnicity. An explicit non-policy based racist example in a healthcare setting would be a doctor calling a patient a slur or saying that people of a certain race cannot feel pain and refusing to treat a patient on the basis of that misinformation. Implicit racial biases are, according to the U.S. Department of Health & Human Services, “a form of bias that occurs automatically and unintentionally, that nevertheless affects judgments, decisions, and behaviors.” People who have implicit racial biases do not usually think of themselves as hating or being prejudiced towards another race; many people even have good intentions. Nonetheless, when medical professionals unknowingly hold biases and false beliefs it causes harm to patients. The dangerous effect that someone’s bias has on the patient they treat is always going to be unethical and hurt the patient, regardless of whether the original intention was malicious. This is why it is important to have conversations about racism in healthcare, so that current and future medical professionals can explicitly address and work to combat these biases so that they can provide the best care for their patients. A study published in the Proceedings of the National Academies of Science found that 40% of first- and second-year medical students endorsed the belief that “Black people’s skin is thicker than white people’s.” Another study published by the same scientific journal (PNAS), reported that “physicians were more likely to underestimate the pain of black patients (47%) relative to nonblack patients (33.5%)” (Hoffman, Trawalter, Axt, & Oliver 2015). Quoted in Alicia A. Wallace’s Healthline article, “Race and Medicine: 5 Dangerous Medical Myths That Hurt Black People,” Gunjan Mhapankar, MD, a pediatric resident physician at Children’s Hospital of Eastern Ontario (CHEO) explains, “In medical education, we learn primarily on white patients, so medical students have a poor understanding of how common illnesses present in BIPOC [Black, Indigenous People of Color] patients.” Many people are left wondering, where are these myths coming from and how are they still so prevalent today? Many of these myths stem from even older medical myths which used pseudoscience to justify slavery of African and African American people. These myths often included the idea that ‘Black people have “...thicker skulls, less sensitive nervous systems, and diseases inherent in dark skin”’ (Hoffman, Trawalter, Axt, & Oliver 2015). These myths spread rapidly and became deeply set in American culture and the American mindset. These myths were upheld by institutions in the United States, and falsified evidence to back up these claims was pushed by overtly racist physicians and scientists. An infamous physician, Dr. Samuel Cartright, claimed that “blacks bore a ‘Negro disease [making them] insensible to pain when subjected to punishment’” (Hoffman, Trawalter, Axt, & Oliver 2015). These myths, while originating during the transatlantic slave trade (where enslaved African and Indigenous-American people were sold throughout trade routes spanning from Europe, Africa, and the Americas), persisted as standard practice much longer than most people would picture. According to Proceedings of the National Academy of Sciences of the United States of America, a peer reviewed scientific journal, “the [United States] military covertly tested mustard gas and other chemicals on black soldiers during World War II, and the US Public Health Service, in collaboration with the Tuskegee Institute, studied the progression of untreated syphilis in black men from 1932 to 1972” (Hoffman, Trawalter, Axt, & Oliver 2015). However, as shown previously, these myths are still believed in more covert and implicit ways today, harming Black patients seeking treatment for pain. It may be surprising for many people to find out that even today, students entering fields in healthcare (such as medicine, nursing, physical therapy, etc) can be taught these myths in school. Many people who are teaching do not understand the false or stigmatizing way information is worded in the lessons or textbooks they are teaching from. An example of this would be the nursing textbook shown below, which attempted to address cultural stigmas around addressing a patient’s pain. However, the writing received backlash for using stereotypical tropes that further perpetuate medical myths. As mentioned in the 2017 DailyDot article “Nursing Textbook Pulled for Racist Suggestions on Treating Black, Jewish patients” by Ana Valens, there was a wave of criticism on various social media platforms by readers of the textbook, including bioethicist Kelly Hills, for its reliance on stereotypes to provide medical information and treatment methods to future nurses. Valens also showcases some backlash the book received on Amazon through reviews; “‘I am shocked & dismayed to see a page from inside this book that is extremely racist, antisemitic, & not even factually accurate,’ one Amazon user wrote, giving the book a one-star review. ‘This book should cease to be printed. The fact that this is taught in schools makes me quite literally sick.’ Another reviewer points out that the information in the textbook could cause distress to patients, and that following its advice could end in legal action. ‘This book is racist and if you apply [its] concepts you will hurt your patients and possibly get in some uncomfortable situations or even litigation,’ the review states.” (Valens 2017). The idea that “Blacks often report higher pain intensity than other cultures” emphasizes to the students reading the textbook the trope that ‘Black people exaggerate their pain/feel less pain than what is actually said.’ It also draws on historical caricatures of multiple other marginalized groups, including when it declares “[Native Americans] tend to be less expressive both verbally and nonverbally,” which mirrors the age-old stereotype that Indigenous American people are stoic or unfeeling. Under that same heading the textbook also implies that Indigenous American patients will “pick a sacred number,” or are creating a false narrative instead of accurately evaluating or addressing their own pain. This gives the student reader an impression that the mentioned groups are lying about their own pain, which has led to harm done to patients from marginalized backgrounds in a medical setting for hundreds of years. Black/African American patients are 22% less likely than white patients to receive any pain medication for the same conditions as their White peers. As explained by the Association of American Medical Colleges, “racial and ethnic disparities in pain treatment are not intentional misdeeds: health care providers do not decide that some groups deserve pain relief while others should suffer. Instead, inequities are the product of complex influences, including implicit biases that care providers don’t even know they have” (Sabin 2020). Like mentioned previously in this article, implicit biases are one of the biggest obstacles that racial and ethnic minority patients, especially Black patients, face when trying to get equal access to healthcare in the United States. Dr. Sabin from the AAMC also explains that “in cases of medical ambiguity — as when pain isn’t caused by an obvious physical condition such as traumatic injury — providers rely more heavily on their own judgment, which can be influenced by personal perceptions and biases.” (Sabin 2020). A Professor of Emergency, Internal, and General Medicine Knox H. Todd et al found that black patients “were significantly less likely than white patients to receive analgesics for extremity fractures in the emergency room (57% vs. 74%), despite having similar self-reports of pain” (Hoffman, Trawalter, Axt, & M. Norman Oliver 2015). In 2005, the National Academy of Medicine found that “racial and ethnic minorities receive lower-quality health care than white people—even when insurance status, income, age, and severity of conditions are comparable” (Bridges). There are countless examples of the real-world consequences of seemingly harmless mistakes doctors make when evaluating patients as a result of their own biases. It is crucial for us as future healthcare workers to recognize and combat our own biases, and to call out biases in our communities and classrooms. Listen to patients about the pain that they are in. Together, we can work to make the future of medicine and healthcare inclusive and safe for every patient. If medicine is progressing and our treatment of Black patients is not, then the work to provide care and improve the lives of patients is not complete. Author’s note: Since the publication of many of the studies cited in this article, the APA guidelines regarding the spelling of the terms “White” and “Black” in regards to a racial context has changed. When referring to racial categories, the first letters in “White” and “Black” should be capitalized, however this was not the recommended spelling prior to 2020. To learn more, visit the APA website HERE. 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