Black Americans are Systematically Under-Treated for Pain. Why?

When it comes to the healthcare you receive, the color of your skin can make a significant difference, Batten Associate Professor of Public Policy and Psychology Sophie Trawalter told an online audience last week.

Serious racial disparities exist in the U.S. healthcare system. According to the U.S. Department of Health and Human Services, Black and Hispanic people receive worse care on  40% of the department’s care quality measures, Batten professor and social psychologist Sophie Trawalter told an online audience during the most recent installment of Batten Expert Chats. Trawalter emphasized the importance of paying close attention to that data. “The stated purpose of healthcare is to reduce pain and suffering,” she said, “and so to condone healthcare inequalities is to condone the pain and suffering of Black and brown people.”

Racial disparities are particularly striking in pain treatment, Trawalter said, with studies showing that Black patients are significantly less likely to be prescribed pain medication and that they generally receive lower doses of it when they are. One possible reason for this, supported by existing studies, is that white people believe Black people experience less pain. Trawalter is attempting to uncover the root causes of this belief.

In one study Trawalter and her collaborators designed, members of the NCAA Division I medical staff read a case concerning a student athlete with a torn ACL. Participants were randomly assigned either a Black student or a white one, with everything else about the case remaining the same. They then answered questions about the case (How painful was the injury, on a scale of 1-4?) and questions designed to measure their own racial attitudes (Do you agree or disagree? Irish, Italians, Jews, and other minorities overcame prejudice and worked their way up. Blacks should do the same without any special favors.

As the researchers predicted, participants generally assigned lower pain ratings to the Black students. Surprisingly, however, there was no correlation between participants’ answers to the questions about their racial attitudes and the pain ratings they gave Black patients (relative to white patients). In other words, “even participants who have very positive racial attitudes show this bias,” Trawalter said. 

If a person’s feelings about race don’t influence their perceptions of Black pain, what does? In another study, Trawalter and her collaborators showed a group of medical students and residents two cases: one concerning a Black patient and another concerning a white one. They then asked the students to rate the patients’ pain; to recommend treatment; and to report the extent to which they agreed with statements about biological differences between Blacks and whites. On the list were statements such as Blacks age more slowly than whites and Blacks’ nerve endings are less sensitive than whites’. (All of the statements included were false.)

For this study, the team had crafted a new hypothesis: that a person’s belief in the biological roots of race would predict their perception of Black pain. The team based this prediction on false claims made by physicians and scientists in the 1800s, which asserted that Black people were biologically closer to apes, while white people were more evolved. Beliefs about biological differences between the two races have persisted into the modern era, Trawalter pointed out—even today, some people believe Black people are more athletic because of their biology. “What’s interesting about these beliefs is that, contemporarily, they’re actually not strongly related to racial prejudice, meaning that even people who report very positive racial attitudes still think that perhaps the Black body is fundamentally biologically different from the white body,” Trawalter said.

The study results supported the team’s prediction: Participants who endorsed biological differences between Black and white people also believed that the fictional Black patient felt less pain. Participants who didn’t ascribe to those beliefs, on the other hand, actually tended to believe that the Black patient felt more pain. While the reasons for this remain unclear, “one possibility is that the participants are reporting on something that they've observed in the world,” Trawalter said. “We know from some research that in fact Black patients report more pain—are in more pain—when they enter clinical settings.”

When it came to recommended pain treatments, the patterns were similar, but with one disturbing difference: the participants who didn’t endorse the biological statements showed no bias in their treatment recommendations, rather than suggesting more rigorous treatments for the Black patient. “We often think that no bias is good, but in this case, it's worrisome,” Trawalter said— “because remember, these are the participants who said that the Black patient will feel more pain than the white patient.”

Trawalter noted that these studies have important implications for our current climate, due not only to the coronavirus pandemic, but problems with police brutality as well. While she acknowledged that the University of Virginia and other institutions are taking commendable steps to include diversity, equity, and inclusion into their curricula, she argued that it was going to take more than “one-off” efforts to address the problem of racial bias in healthcare. What’s needed, she said, is a paradigm shift—a new kind of education that is actively anti-racist and emphasizes that race is not a biological phenomenon.

“Race was constructed. It was constructed to justify exploitation and violence,” she said. “This notion that race is not true is really powerful, and we need students—we need citizens—who can understand that.”