Shades of Care: Racial Disparities in Pain Treatment
Anoushka Bhatt
Illustrations by Nancy Duer
Pain is a distinctly personal experience; it is internal, often difficult to articulate, and largely invisible to the naked eye. Others can’t see it, touch it, or quantify it in a way that captures its subjective experience. The invisibility can be isolating. Even in the presence of support, people in pain can be left feeling alone and ostracized. For some people of color, these experiences are exacerbated by a medical system that not only fails to see their pain but questions whether their discomfort exists at all [1]. When suffering is dismissed and voices are silenced, it’s more than neglect — it is an institutional betrayal of care [2]. This isn’t just an individual experience; it is foundational to a long history of racial bias in pain medicine that continues to shape outcomes today [3, 4, 5]. In the early nineteenth century, scientists, physicians, and slaveholders propagated myths about Black pain to justify slavery, one being that Black people’s skin was less sensitive to pain than that of White people [1, 6]. The medical mistreatment of Black people continued through the late 1800s, with notable figures in medicine like Dr. J. Marion Sims, known as the father of gynecology, conducting unethical medical experiments on enslaved Black women without anesthesia [6, 7, 8]. Similar maltreatment and harmful beliefs persist in the modern era of medicine [1, 9]. As recently as 2016, 50% of a group of White medical students and residents surveyed at a large public university held at least one false belief about pain in Black people [1]. Some fallacious beliefs included the notions that Black people’s skin was thicker, their nerve endings were less sensitive, and their blood clotted quicker than White people’s [1]. Historical injustices and misconceptions about pain have led to lasting maltreatment of people of color by medical institutions [1]. Medical bias is still entrenched in medical institutions and continues to affect the treatment of people of color today [10].
The Journey to the Hospital: Barriers Before Treatment
A multitude of barriers hinder people of color from accessing timely and effective treatment [11, 12, 13]. People of color face discriminatory obstacles originating from systemic racism, a term that refers to racial biases that are deeply entrenched within policies and practices [14]. Racial biases extend across interconnected systems, including education, housing, politics, criminal justice, and healthcare, all of which together perpetuate a lower standard of care for racial minorities [14] As a result, untreated and mismanaged conditions contribute to increased physical pain, heightened emotional distress, and diminished quality of life for many people of color [15, 16, 17]. Furthermore, racial minorities are more likely to live in areas that lack access to essential healthcare resources, known as healthcare deserts [12, 13, 18]. Individuals living in healthcare deserts face a lack of access to medical facilities, longer wait times, and disproportionately higher costs of health services [11, 13, 19]. Healthcare deserts pose a considerable challenge for communities of color to access even the most basic healthcare needs, including primary care services, emergency medical services, pharmacies, and preventive medications [11, 19, 20].
A lack of access to healthcare not only limits general healthcare services but also hinders the diagnostic process of more severe diseases [21]. People of color face barriers to receiving essential preventive screenings — a crucial step in diagnosis [22, 23, 24]. When access to preventive screenings is impeded, diseases may progress unchecked, symptoms and pain can be exacerbated, and the risk of fatal outcomes may increase [21]. For example, Indigenous American people face significantly lower cancer screening rates despite having the highest risk and mortality rate for various cancers, including kidney, liver, stomach, and cervical cancer [25, 26, 27]. A lack of early detection can manifest in delayed diagnoses and advanced disease stages, potentially contributing to additional pain and the need for more invasive treatments [28, 29, 30]. Indigenous women exhibit the lowest rates of mammography, a form of X-ray imaging designed to detect cancers and other changes in breast tissue [25]. Only 59% of Indigenous women receive mammograms, compared to 76% of White women who are screened for breast cancer [25, 31]. Moreover, Indigenous women experience a higher likelihood of suffering from late-stage cancer complications and have a 30% higher breast cancer mortality rate than White women [25, 31]. Later-stage breast cancer can be excruciatingly painful as the cancer spreads throughout the body and invades nerves and bone [32]. Breast cancer that infiltrates the nerves can result in agonizing, sharp, burning pain that radiates through the body, while cancer invading the bone can cause a deep, aching pain [33, 34, 35]. Furthermore, chronic inflammation associated with breast cancer triggers hypersensitivity in the nervous system, leading to heightened, persistent, and widespread pain that extends beyond the tumor site [36, 37, 38]. In the advanced stages of breast cancer, pain becomes more widespread and often requires more invasive interventions for relief [39]. Lower rates of breast cancer screenings and diagnoses can lead to delayed intervention, resulting in more painful cases of the disease among Indigenous women [26, 27]. Systemic barriers that limit access to preventive care contribute to a cycle of pain that disproportionately burdens communities of color [15, 40, 41].
Data Disparities: Bias in Medical Algorithms
Even for those who receive preventive testing, racial biases continue to disproportionately affect healthcare outcomes through diagnostic tools and algorithms like risk prediction models and machine-learning systems [42, 43, 44]. Medical algorithms, such as those used to calculate stroke risk or predict kidney failure, offer a framework to help healthcare professionals make informed decisions based on an individual’s clinical data [45, 46, 47]. However, not all medical algorithms can be generalized to all races, as different ethnic groups can have genetic and biological differences that may result in the disproportionate occurrence of certain conditions across groups [48]. Thus, generalized references provided by these algorithms are often unsuited to assess people of color [43, 49]. Reference intervals are a key component of medical algorithms, which are sets of values defining the standard range for a given test result [50]. That being said, reference intervals tend to be developed utilizing data from medical studies primarily consisting of White male participants, leading to biased assessments for other racial and gender groups [43, 49, 51]. Over 50% of laboratory tests with reference intervals fail to account for differences in baselines between racial groups, revealing a major representational issue in categorizing diagnostic results [52].
A notable example of an algorithm generalized to people of color is the atherosclerotic cardiovascular disease (ASCVD) risk calculator, which estimates a person’s ten-year risk of heart disease or stroke [53, 54]. The ASCVD calculator factors in age, cholesterol levels, blood pressure, and race — categorizing individuals as White, Black, or ‘other,’ with an option to exclude race entirely from the calculation [53, 54]. However, the limited racial categories fail to distinguish between diverse populations within the ‘other’ group, making it difficult to account for critical variations such as age-related risk and cholesterol levels [55]. Compared to White populations, South Asian populations tend to develop cardiovascular disease at a younger age and have a higher prevalence of heart attacks and strokes [56, 57]. South Asian people also tend to experience more severe disease outcomes at lower cholesterol levels compared to other racial groups, suggesting that traditional reference ranges may not be reliable for assessing cardiovascular risk in this population [57, 58, 59]. Therefore, the ASCVD risk calculator fails to account for unique risk factors that contribute to the underdiagnosis and undertreatment of cardiovascular conditions in South Asian individuals [58, 60]. As a result of undiagnosed ASCVD, South Asian people may endure prolonged chest pain, fatigue, and other debilitating symptoms before receiving an accurate diagnosis [61, 62]. ASCVD can also manifest in neck, back, and even abdominal pain when unmanaged [61, 62]. As risk factors accumulate and progress to heart disease, pain may spread further to the arms or legs, often accompanied by shortness of breath, palpitations, nausea, sweating, or lightheadedness [62]. Beyond cardiovascular disease, the broader implications of biased medical algorithms extend to many other conditions, including kidney disease and vitamin B12 deficiency, exacerbating racial discrepancies in pain management [44, 52, 50]. Racial minorities are more likely to have their pain underestimated and undertreated due to biases in diagnostic tools, contributing to unnecessary suffering and, consequently, lower quality of life [1, 63]. Individualized approaches incorporating genetics, lifestyle, and socioeconomic factors could improve the accuracy and equity of cardiovascular risk assessment [64]. By addressing biases in medical algorithms and ensuring that diverse populations are adequately represented in research, healthcare systems can provide more precise diagnoses and effective symptom management that would ultimately improve pain outcomes across racial groups.
Assessment and Treatment: Whose Pain Counts?
Upon immediate arrival at emergency rooms, people of color face further inequities in pain assessment. [65, 66, 67]. Black people experience 35% longer wait times than White people afflicted with similar conditions, delaying access to critical pain management and medical intervention[66, 68, 69]. Delayed care for Black, Asian, and Hispanic people significantly reduces their chances of receiving timely interventions for potentially life-threatening strokes and often results in prolonged, unmanaged pain [69]. When analyzing an individual’s condition to determine how quickly the person receives treatment — otherwise known as an urgency evaluation — a healthcare provider would ideally base their assessment solely on medical urgency [70]. However, urgency evaluations can be distorted by implicit biases that minimize or dismiss the pain experiences of people of color [70]. The longstanding and harmful myth that people of color have a higher pain tolerance contributes to the systematic underestimation of their suffering, leading to the dismissal of both self-reported pain and even physically evident distress [1, 71, 72]. As a result of discrepancies in assessment, people of color may be assigned lower priorities for receiving care despite presenting with severe symptoms [70, 73, 74]. Lower-priority assignments in healthcare can manifest as longer wait times, reduced attention from medical professionals, and the dismissal of individual concerns [74]. Disparities in access to adequate and timely care not only aggravate immediate suffering but also lead to long-term health consequences, reinforcing a cycle of pain mismanagement and eroding trust in the healthcare system [75, 76].
Once admitted to the hospital, inequities in pain assessment can quickly lead to discrepancies in pain management for people of color [1]. Black people are significantly less likely to receive adequate pain medication than White people, even for identical pain reports [1, 77, 78]. Due to stereotypes about people of color’s drug-seeking behavior, which was partly informed by the opioid crisis, racial minorities are less likely to be prescribed opioids, a powerful and addictive class of pain medication [79, 80]. The opioid crisis was at first characterized by a medical overprescription of opioid drugs [81, 82]. Historically, the crisis was concentrated among White, rural, and working-class communities [79, 83]. However, the impact of the opioid crisis on Black and Hispanic communities has worsened substantially in recent years, influencing stereotypes about opioid use within these communities [79, 83]. As extensive opioid abuse worsened and public health efforts sought to curb overprescription, the rise of fentanyl — a synthetic opioid that is often added to illicit substances — shifted the influence of the crisis from white communities to communities of color [81, 84]. Greater use of illegal drugs laced with fentanyl within Black and Hispanic communities led to a disproportionate rate of opioid overdose and addiction, shaping harmful stereotypes about drug-seeking behavior in medical settings [79, 83, 85]. These stereotypes about drug-seeking behavior contribute to the underprescription of opioids in people of color compared to White people [79, 80]. Even when opioids are prescribed, Black and Hispanic people receive lower dosages than White people for equal levels of self-reported pain as a result of drug-seeking stereotypes [79, 85]. Underprescription may contribute to individuals seeking pain relief from illicit substances beyond prescription medications [87, 88]. Not only do White people have better access to opioids to manage their pain, but they are also more likely to be shifted to alternative pain management solutions in situations of opioid dependence or addiction [80, 83, 89]. Black people, on the other hand, are often denied opioids altogether and are much less likely to receive nonopioid forms of pain treatment, like nerve blocks, physical therapy, and surgery [80]. Limited access to alternative treatments may contribute to the dual burden faced by Black communities, being both underserved in pain treatment and criminalized for opioid use rather than being offered rehabilitation approaches [83]. The long-term effects of prescription and rehabilitation disparities continue to shape healthcare experiences, reinforcing mistrust in the medical system and leaving many Black people without adequate pain relief [83, 90, 91].
Racial differences in pain treatment also extend to vulnerable individuals within minority populations, such as children and pregnant people, whose pain is frequently dismissed [92, 93, 94]. For instance, Black and Hispanic pregnant people frequently report having their pain dismissed or undertreated, both during childbirth and in the pre- and post-partum periods [93, 94]. Disregard for the pain of Black and Hispanic pregnant individuals contributes to disproportionately high rates of maternal complications in these communities [93, 95]. Children of color are also affected by racial disparities in medicine; for example, Black children experiencing appendicitis are far less likely to receive appropriate pain relief compared to White children [92]. Asymmetry in pain treatment is also evident in the treatment of chronic illnesses like type 1 diabetes, where access to effective treatment can significantly reduce disease progression and prevent complications such as nerve damage [96]. Black and Hispanic children are less likely to have access to advanced diabetes management technologies, such as continuous glucose monitors and insulin pumps, which can significantly improve long-term health outcomes [97]. Perceived bias and discrimination, poor patient-provider communication, unequal treatment outcomes, and broader systemic barriers disproportionately affect Black and Hispanic children, contributing to differences in care [98]. Persistent disparities in pain assessment and treatment reflect deeply rooted systemic inequities that continue to harm the most vulnerable members of minority communities [99, 100, 101].
The Aftermath: Long-Term Consequences
The consequences of inadequate pain treatment are profound and long-lasting [102, 103, 104]. Unmanaged pain can have severe long-term consequences due to its profound impact on the nervous system and overall well-being [102, 103, 104]. When pain persists without proper management, the nervous system becomes hypersensitive, amplifying pain signals to make even mild discomfort feel unbearable [105, 106]. Over time, pain pathways in the brain are reinforced by maladaptive neuroplasticity, a process that essentially ‘rewires’ the nervous system to prioritize pain perception [102, 107]. Without early intervention, changes in neurological pain perception pathways can entrench individuals in a cycle of escalating pain, emotional distress, and functional impairment, making chronic pain progressively more difficult to manage and treat [108]. This neurological rewiring does not occur in isolation; it often coexists with psychological responses like anxiety and depression, which further reinforce the pain cycle [109, 110, 111]. As a result, people who suffer from chronic pain due to inadequate treatment often experience diminished quality of life and struggle to complete daily activities [112]. For communities already facing barriers to care, these long-term consequences contribute to broader health disparities and place an additional burden on public health systems [22].
Furthermore, the persistent dismissal of pain concerns can foster medical distrust and discourage people of color from seeking care altogether [10, 91, 113]. Communities with histories of medical exploitation, such as the Black community, continue to feel the effects of unethical studies [114]. In the infamous Tuskegee Syphilis Study, hundreds of uninformed Black men were studied to examine the effects of syphilis when left untreated [114]. While informed consent was not legally required when the study began in 1932, the Tuskegee Syphilis Study was unethical even by the standards of its time [115]. Participants were not told they had syphilis but instead that they had ‘bad blood’ to conceal the true purpose of the study and to recruit more participants [116]. Despite penicillin becoming a widely available cure for syphilis during the study, it was never offered to any of the affected men [114]. The participants were also not informed that medication was intentionally withheld from them or that treatment was even available [114]. As a result of the medical malpractice by the doctors and researchers, these men had to endure the symptoms of untreated syphilis [114]. Those infected with syphilis are subjected to a lifetime of suffering, beginning with sores and progressing to symptoms as extreme as bone and joint damage, cardiovascular problems, hearing loss, and blindness [117]. The impact of the Tuskegee Syphilis Study was not limited only to the participants; due to the highly transmissible nature of syphilis, the spouses and children of the men studied were at higher risk of becoming infected and ill [118]. The unethical deception and neglect displayed in the Tuskegee Syphilis Study reinforced a mindset of medical mistrust that persists today within the Black community [114, 116, 119]. Coupled with the ongoing disparities in pain management and treatment, historical trauma contributes to reluctance in seeking medical care and further exacerbates health inequities [114]. The legacy of unethical practices continues to shape perceptions of the healthcare system, fostering skepticism and fear that prevent Black individuals and other minority groups from receiving the care they need [91, 113].
Forced sterilizations of women of color under oppressive and coercive medical policies further deepened medical mistrust in people of color [120, 121, 122]. In the early to mid-20th century, the U.S. government and medical institutions forcibly sterilized thousands of Black women, particularly in the South [120, 122]. The sterilization was based on eugenics, an ideology centered around the selective breeding of people based on prejudiced, ableist, and often racist perceptions of positive or negative traits [120, 122]. Harmful beliefs popularized by eugenic rhetoric falsely deemed thousands of Black women unfit for reproduction [120, 122]. Similarly, Indigenous women were disproportionately targeted for sterilization in the 1960s and 1970s, with many undergoing the procedure without their consent or true understanding of its permanence [123]. Latina women also suffered this violation, as seen in the 1978 Madrigal v. Quilligan case, where many Mexican-American women were coerced into sterilization procedures, often during childbirth [121]. Racist and unethical medical practices such as these sterilizations were rooted in population control efforts and have had lasting effects on minority communities, fostering profound and persistent mistrust in the current healthcare system [120, 121, 123]. The traumatic legacy of forced sterilizations continues to shape the experiences of women of color within the healthcare system today, deterring them from seeking reproductive care due to fears of bodily autonomy violations [124, 125]. The historical exploitation of marginalized communities in the name of medical progress continues to fuel skepticism of healthcare systems, making it imperative to address injustices to rebuild trust and ensure equitable healthcare for all [126].
Ultimately, the racism embedded in pain assessment and treatment is not an isolated issue but is symptomatic of a much larger, interconnected web of systemic oppression [5, 14]. Just as discriminatory practices in healthcare have long-lasting repercussions on the physical and emotional well-being of marginalized communities, systemic inequalities in housing, education, employment, and the criminal justice system also reinforce and perpetuate racial disparities [14, 22]. These systems do not operate in isolation; they intersect to create compounded disadvantages that disproportionately impact people of color [14]. The dismissal of pain, violation of bodily autonomy, and historical exploitation of people of color are all reflective of a broader societal structure that continues to devalue marginalized lives [127]. Recognizing medical racism as a public health threat that manifests in both physical and emotional pain can begin to rebuild trust, promote equity, and ensure that healthcare operates justly and humanely for everyone [128].
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