The other pain crisis
Cleveland, Ohio, USA
A guiding principle of medical care is that humans regardless of their superficial differences are fundamentally the same in their physiology. One of the oldest and most persistent refutations of this premise is the centuries old myth of a uniquely “African body,” characterized by diminished pain response and elevated stoicism, a view that has doggedly persisted even in many public health agencies and especially in literature. Yet this view is untenable in light of studies such as one in which 64% of caregivers surveyed in Botswana listed “severe pain” as a central issue in the care of the seriously ill.1 Similar results were found in Kenya and throughout the region further underscoring that pain-free African bodies are a myth.2
Developed nations are the beneficiaries of the survival of such outmoded views as demonstrated by the seeming acceptance of the fact that 6% of the world’s population uses 80% of the global morphine supply.3 This has taken on new dimensions in light of the American opioid epidemic, leading philanthropists and foreign aid organizations to withdraw support for pain relief programs and leaving twenty-five million people in low and middle income nations in desperate need of pain relief despite sufficient supplies for the entire globe costing only $125 million, a mere fraction of foreign aid funds. As stated by Dr. Kathleen Foley of Memorial Sloan Kettering “I’m increasingly concerned that we are losing this battle because of this panic. Overdose deaths are taking all the oxygen.”4
The persistence of outdated racial perspectives about people of African descent is tragic but not surprising given that much of America’s healthcare edifice was built upon their bodies. In the early days of American research, enslaved and free African Americans as well as poor or transient whites such as seamen, immigrants, and indigents became unwilling participants in experiments designed to advance medicine. One such example is the work of J. Marion Sims. A hero in his own time and still a revered figure across the American south, Sim’s pioneering work on the repair of vesicovaginal fistulas remains the standard of surgical care that has saved thousands of women from incontinence, social isolation, and death. But this beneficial and lauded innovation will always be marred by having been built upon the mutilation and death of dozens of slaves and the false myth that African Americans did not feel pain.5
The perceptions which facilitated Sim’s work survived well beyond the nineteenth century, as reflected in a survey conducted by Kelly M. Hoffman, a sixth-year doctoral candidate at the University of Virginia. Hoffman’s research revealed that “a substantial number of white laypeople and medical students and residents hold false beliefs about biological differences between blacks and whites, and… these beliefs predict racial bias in pain perception and treatment recommendation accuracy.”6
To come to this conclusion Hoffman asked 222 white medical students and residents to rate on a scale of zero to ten the pain levels they would associate with two mock medical cases for both a white and a black patient, and to recommend pain treatments based on the level of pain they thought the patients were experiencing.7 The survey also tested their belief in the propositions that black people age more slowly than whites, have less sensitive nerve endings, and that their blood coagulates more quickly. Over 100 medical students believed these fallacies to be factual and rated black patients’ pain lower than they did white patients. This helps to lend credence to an hypothesis which has emerged from several past studies “that black Americans are undertreated… because physicians… might not recognize the pain of their black patients in the first place.”8 Studies at the University of Virginia have also found that Caucasian children believe African American’s feel less pain, a belief already present at the age of seven and prevalent by the age of ten.9
Beyond the clinic, the perception of diminished pain in those of African descent has also consequences in its extreme variant of viewing them as somehow superhuman. One tragic instance can be found in Officer Darren Wilson’s testimony on the night he encountered Michael Brown. The officer, by no means a frail man, portrays his engaging Brown as “like a five-year-old holding onto Hulk Hogan,” even though the two were of similar weight and the officer arguably the more experienced.10 Wilson further describes Brown as “a demon.”11 Tragically, the persistence of the idea that African Americans are in some way physiologically different helps to alienate them and reinforce racial resentment. It highlights the importance of critiquing the continued existence of the outmoded concept of a medically unique “black body” in clinical care and pain management in a nation where nominally “all men are created equal.”
- Julie Livingston. Improvising medicine: An African oncology ward in an emerging cancer epidemic. Durham: Duke University Press, 2012.
- Donald G. Mcneil, “‘Opiophobia’ Has Left Africa in Agony.” The New York Times. December 04, 2017. Accessed December 12, 2017. https://www.nytimes.com/2017/12/04/health/opioids-africa-pain.html?_r=0.
- Jeffrey S. Sartin, “J. Marion Sims, the Father of Gynecology: Hero or Villain?” Southern Medical Journal 97, no. 5 (2004): 500-05. Accessed February 17, 2017. doi:10.1097/00007611-200405000-00017.
- Kelly M. Hoffman, Sophie Trawalter, Jordan Axt, and M. Norman Oliver. “Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites.” PNAS 113, no. 16 (March 1, 2016): 4296-301. Accessed April 30, 2017.
- Paul Rosenberg. “Everything the Darren Wilson Grand Jury Got Wrong: The Lies, Errors and Mistruths That Let Michael Brown’s Killer off the Hook.” Saloncom RSS. November 26, 2014. Accessed December 4, 2014. http://www.salon.com/2014/11/26/everything_the_darren_wilson_grand_jury_got_wrong_the_lies_and_mistruths_that_let_michael_browns_killer_off_the_hook/.
ADIL MENON is a student at Case Western Reserve School of Medicine. Before medical school he received his Master of Bioethics degree from Harvard Medical School. His written work includes Joseph Goldberger: Epidemiology’s Unsung Hero and Is There a United Hippocratic School? in Hektoen International, a book review of The American Healthcare Paradox in HMS Bioethics Journal, and Social Contracts and the Commodification of Life in Foreign Medical Trials in the Rutgers Journal of Bioethics. He has also been acknowledged for editing work on the paper Global Health from a Cancer Care Perspective in Future Oncology.