A new survey of medical students at the University of Virginia found that about half held “false and even fantastical” beliefs that black people feel less pain than white people — fallacies that date to 19th-century doctors justifying mistreatment of American slaves.
“Blacks’ skin is thicker than whites’” and “Blacks’ nerve endings are less sensitive” were among the beliefs documented in the study of 222 white medical students, published earlier this month in the Proceedings of the National Academy of Sciences.
Although pain tolerance varies greatly from one person to the next, the idea that these differences fall along racial lines is unequivocally false. Yet these unfounded beliefs have real effects on public health. In emergency rooms, for example, doctors are less likely to prescribe opioid painkillers for migraines and back pain to black Americans than to white or Latino Americans.
“It turns out racism, in an odd way, was a protective factor,” David Rosenbloom, a health policy professor at Boston University’s School of Public Health, told BuzzFeed News.
Racist medical folklore about pain, draconian drug laws, and less access to medical care due to poverty, all working against black people, has limited their exposure to painkillers. “It’s all mixed up together, and it’s all racism,” Rosenbloom said. “Black patients need to understand that doctors may be looking at them different than other patients when they say they are in pain.”
Ironically, a loosening of painkiller prescribing in the 1990s that led to FDA approval of Oxycontin — today’s best-selling prescription painkiller — came partly as a reaction against medicine’s longtime culture of undertreating all patients for pain.
At the beginning of the 20th century, doctors such as Charles Terry of the Committee on Habit-Forming Drugs realized that they had been needlessly hooking patients on opium, “the narcotic evil,” for a century. “The younger, better-trained practitioners who replaced them were more circumspect about administering and prescribing opioids,” Andrew Kolodny of Brandeis University and colleagues wrote in a recent review of the history of the opioid crisis.
That medical line against pain treatment held fast until the 1990s, when the American Pain Society began telling doctors to think of “pain as the 5th vital sign,” on par with taking patients’ pulse and temperature. Soon, hospital accreditation requirements and med school curricula were recommending far more liberal pain treatment, spurred by pharmaceutical firm marketing.
The pain meds counter-revolution never fully arrived for black patients, however, with unexpected consequences: Simply being white and showing up at an emergency room, one study found, gives you a higher chance of being prescribed an addictive painkiller than showing up (regardless of race) with an injury. If a black person and a white person show up at an emergency room with a similar injury, the black person is 60% less likely to be prescribed a painkiller.
The FDA approved the sale of Oxycontin in 1995, kicking off an unprecedented marketing campaign for opioid painkillers that routinely downplayed the risks of addiction. Today, doctors write about 250 million prescriptions a year for these painkillers, but because of addiction risk, they usually offer more harm than help to people with bad backs and other forms of chronic pain. (The CDC has said the drugs are appropriate for cancer and hospice patients, as well as people recovering from surgery.)
“Almost all opioids on the market are just as addictive as heroin,” CDC chief Tom Frieden said in March.
Death rates from opioid painkiller and heroin overdoses have increased markedly among white Americans in the last two decades, to about 19 per 100,000 people. But the rates have remained flat for black Americans, at about 8 per 100,000, with an uptick only in the last year. A January New York Times analysis of CDC data suggested that for white Americans aged 35 to 44, overdose rates tripled between 2000 to 2014, and for those aged 25 to 34, they rose by five times.
One explanation is that painkillers are routinely denied to black patients at higher rates than white patients. That means they are less likely than white patients to walk out of a dentist's office or a doctor’s visit with a 90-day prescription for painkillers that pose a risk of addiction — leaving many in unnecessary pain.
One recent study found that only 12% of black kids treated at an emergency room for appendicitis received opioid painkillers, compared to 34% of white kids. Another showed that black adults with dislocated joints are about 60% less likely than white adults to be prescribed an opioid painkiller. Another found that black people with back or abdominal pain were 10% less likely than white people to be given any kind of opioid painkiller, and they had to wait eight minutes longer to get it.
“It’s an awkward thing to talk about,” psychiatric epidemiologist Jay Unick of the University of Maryland School of Social Work in Baltimore told BuzzFeed News. “Racism that really hurts kids who are in real pain may also lead to fewer overdoses.”
Race is a social construct and doesn’t make sense on a genetic level, though black and white patients do face different medical challenges. Black people have a higher risk of stroke, for example, due to undertreatment of high blood pressure and less awareness of stroke symptoms. The new survey of medical students mixed in such real differences between white and black patients with bogus ones, such as black people having a stronger immune system or blood that coagulates more quickly.
Most striking to Harriet Washington, author of Medical Apartheid: The Dark History of Medical Experimentation on Black Americans From Colonial Times to the Present, are the modern-day medical students’ similarities with Southern doctors of the 1850s.
Take, for example, the infamous slave doctor Samuel Cartwright of the University of Louisiana, who, in the 1851 medical journal report “Diseases and Peculiarities of the Negro Race,” invented the terms drapetomania, “the disease causing negroes to run away,” as well as rascality, which made slaves “seem to be insensible to pain when subjected to punishment.”
All of the “peculiarities” of these black slaves seemed to add up to one thing: a “lack of enthusiasm for slavery,” Washington told BuzzFeed News. “At the same time they had all these wonderful immunities, to heat, to pain, that made them just perfect for slavery. And also less than human.”
Washington is skeptical that all of the student survey-takers were unconscious of their racism. “It sometimes excuses the inexcusable to say these people are unconscious of their beliefs,” she said.
Unfortunately, telling people they have implicitly racist beliefs doesn’t seem to help correct the problem, either, Daniel Goldberg, a bioethicist at East Carolina University, told BuzzFeed News. “People just pat themselves on the back that now they are enlightened and go on acting the same way.”
In hospitals, Goldberg added, “a lot of unconscious racism comes down to the invisible curriculum — what doctors learn from their mentors outside the classroom.” In the first half of the 20th century, the Civil War medical fallacies about black people were taken up by then-respectable proponents of eugenics who believed in racial purity and extreme racism, and they remain simmering in the culture of medicine today. “There is a long history of doubting people are really in pain in medicine, and that has been transmitted culturally for a long time.”