Comerford 1

Taylor Comerford
Pol S 456
Term Paper
December 10, 2018

The Color of Pain: The American Medical System as an Institutional Failure

Medical care can be seen as the backbone of human society. Advancements in medical

technology have eradicated illnesses; the creation of new medical treatments have reduced

recovery periods; and the proliferation of access to care has greatly increased life expectancy. In

short, the innovations of medicine have significantly improved the human condition. However,

in American society it is clear those benefits are not received equally. Despite the assertion that

the modern era is one of colorblindness, race most profoundly shapes the lives of Americans

(Omi and Winant 106). Medicine, although a bastion of impartiality and ethical principles, is not

immune to the effects of racial attitudes. Specifically, there are clear discrepancies in the quality

of treatment of pain for people of color. Pain, as perhaps the single greatest affliction of the

human experience, best exemplifies how such stereotypes undermine the very principles medical

professionals espouse. I assert that while racial attitudes have shaped disparate pain treatment

due to political projects, the medical system has refused to take action to combat them

effectively. Therefore, the lack of access to pain treatment for people of color is an institutional

failure of the medical system.

In this paper I will first outline the political history that lead to the racialization of drug

abuse. In the context of these racial projects, I will next present the statistical discrepancies in

pain treatment. The prejudicial attitudes prevalent within the medical community will be

intrinsically linked to the lack of pain treatment provided to people of color. Finally, I will

explain the failures of the medical system- comprised of the American Medical Association

(AMA), Liaison Committee on Medical Education (LCME), and Association of American

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Medical Colleges (AAMC)- to address this practice. In this manner, I will demonstrate the

failure of the medical system in providing a truly equal standard of care for all patients.

The Historic Racialization of Drug Use

To fundamentally understand the issues of healthcare inequity and the politicization of

drugs, it is integral to understand racial politics and projects. Over American history, racial

understanding has shifted from a medical model to a social conceptualization1 (Omi and Winant

120). This perspective understands race as a societally created phenomena, in which

characteristics or assumptions are used to generalize a group of people (Omi and Winant 120).

Race is also utilized in a political role, notably through racial projects. The concept is an

“interpretation, representation, or explanation of racial identity” for the purpose of “organizing

or redistributing resources” (Omi and Winant 125). In essence, racial projects are a tool through

which groups are portrayed in a specific way to intentionally shape policy or action, which

therefore impacts the experiences of that group. These campaigns are infrequently benevolent,

and are often used to formulate policies that are marginalizing in nature.

Furthermore, the United States has entered an era of “colorblindness” in the sense that

highly racialized language is no longer socially acceptable, therefore making racial appeals more

difficult to identify (Huddy and Feldman 426). This decisive shift following the Civil Rights

movement has changed the manifestation of racism in America significantly (Huddy and

Feldman 426). People, out of fear of judgment and the desire to be accepted, suppress prejudicial

beliefs, often to the point of subconsciousness (Huddy and Feldman 425). Modern racism is in

actuality a set of discriminatory beliefs that are unconsciously held or actively unvoiced. This

1
It is important to note that the National Institutes of Health (NIH) both recognizes and promotes this
understanding of race throughout the medical field. Even within the medical field, biological conceptions
of race are viewed as anachronistic.
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shift in racial conception has direct implications on the ways in which racial projects are carried

out. As a direct result of this transition, white political elites have melded implicit racism,

political context, and racial project to create racial “dog-whistles” (Haney Lopez 171). The

rhetoric is successful as it touches upon stereotypical views of minorities held by the white

majority without ever mentioning race (Haney Lopez 180). In this way an individual can support

such policies without ever having to admit his or her racism, and simultaneously feel that his or

her bias has been vindicated.

The dog whistle style of rhetoric gained popularity in the Nixon and Reagan presidencies

as tools to win election. Starting with the neutral phrases “tough on crime” and “law and order”,

Richard Nixon tacitly connected the white fear of crime2 (specifically drug use) to widespread

prejudice against people of color (Beckett 86). Specifically, Nixon was able to generate fear of

heroin addiction by connecting it to black communities (Provine 92). Images of arrested or

incarcerated black men were proliferated throughout television, magazine, and newspaper

coverage; a crime “epidemic” was centered in communities of color (Beckett and Sasson 50;

DuVernay; Gilens 111). The Reagan administration took this trend a step further in the “war”

against illegal drugs (Beckett 92). Heavy sentences for small drug offenses funneled more

individuals into prisons then ever before in American history (Beckett 92). The burden of this

incarceration was felt by black communities, in which policing was the most aggressive (Beckett

92). President Bill Clinton brought this criminalization to the extreme under his Violent Crime

Control and Law Enforcement Act. By 1992, 51 percent of those admitted to prisons were black,

and 90 percent of those incarcerated for drug crimes were people of color (Beckett 89).

2
86% of Americans felt rising crime rates were the nations most pressing issue (Beckett 86).
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What is most important to consider is the lingering sentiment of the war on drugs. Further

disparate portrayals of black Americans as dealers and abusers of illegal drugs has primed whites

to have deeply inaccurate and prejudicial views. By the simple and unconscious process of

association, the white majority is conditioned to associate African Americans with drug crime

and abuse (DuVernay). However, while 13 percent of drug users are black, African Americans

make up 35 percent of drug arrests and 74 percent of drug-related prison sentences3 (Beckett 97).

These claims of black criminality are statistically inaccurate, and are less representative of actual

crime commission than the discriminatory policing practices used in black communities.

Despite the objective reality, the white American majority holds deeply rooted beliefs

about the role of black communities in drug sales, drug addiction, and criminality (DuVernay).

These racist attitudes are prevalent today. As late as the 1990s, 62 percent of whites believed that

African Americans were lazier than whites and 78 percent believed that blacks were more likely

to support themselves with welfare than employment (Beckett 87). Furthermore, black men

especially have been historically and currently viewed as “criminal predators” (Beckett 87;

DuVernay). While research has established that this has led to racial profiling and inequity in the

criminal justice system, it is also deeply reflected in the attitudes of American civilians

(DuVernay). The breadth and simultaneous depth of these beliefs permeate the white majority.

Such sentiment shapes actions of individuals, including medical professionals.

Attitudes in Regard to Pain Treatment

The linking of these implicit biases to prescription pain medications is a very simple

process of association. Prescription opioids are derivatives of morphine and chemically similar to

3
Prison sentencing is different than actually prison stay, which was noted to be 90% black previously.
This is due to options such as parole or early release that are much more commonly awarded to white
defendants.
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heroin (Martin and Fraser 388). Heroin is a stronger substance because it is combined with acetic

anhydride, a chemical reagent, whereas morphine and other similar prescription drugs are more

chemically pure (Martin and Fraser 388). Especially for medical professionals who understand

this chemistry, it is not abstractly speculative to assume racial biases would follow doctors and

nurses into hospitals. Because the stigma of crime and addiction are paired both with heroin and

black communities, this implicit stereotype would affect the rate of prescription opioids provided

to black patients. In this manner, political projects linking race and drug use have shaped the way

practitioners view and treat their black patients’ pain.

Contributing to such discriminatory sentiments is the widespread view that prescription

painkillers serve as a gateway to heroin addiction. To some extent this belief is backed by

scientific findings. Recent and widely published studies have discussed the transition of

prescription opioid abusers to heroin, as the latter is is a more potent and cost-effective

alternative (Mars et al. 257). In a study of two urban metropolises, Philadelphia and San

Francisco, a majority of heroin addicts4 had transitioned to the street drug after abusing

prescription opioids, without having a history of abusing other illegal substances (esp. marijuana

or crack cocaine) (Mars et al. 257). However, the statistics of such a phenomenon are not the

most important facet of this issue. It is the influence such findings have on the medical

professionals that observe them. This established link between prescription drug use and future

heroin addiction also deeply augments preexisting resistance to prescribe analgesics to African

Americans. If doctors already believe black patients are more likely to abuse heroin, the

4
It is noteworthy that the majority of the addicts surveyed were white drug abusers.
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knowledge that opioid prescription is linked to heroin use would further disincentivize doctors

from treating patients of color with appropriate prescriptions.

Qualitative studies of commonly held beliefs in the medical field further indicate a trend

in which prevalent assumptions about black communities are completely contradictory to patient

realities. Aside from the aforementioned association of drug abuse and crime involvement, there

exists a widespread, but tacit belief that blacks are more impervious to pain than their white

counterparts. (Anderson et al. 1190; Etienne 509; “The Long History of Discrimination in Pain

Medicine”). This supposition, however, could not be farther from reality; medical studies have

consistently shown that the white population not only has a higher pain tolerance, but also is

more responsive to pain reduction strategies, which include both analgesic drugs and non-

medical solutions (Anderson 1190). The reality is that black patients actually require larger and

more frequent prescriptions of pain medication in order to adequately prevent their pain. Thus

barring of these patients to pain medication is not only illogical but harming. Notably, this

perception has been generated independently of political rhetoric, further indicating that the

medical system is responsible for the impact of stereotypes on pain treatment.

It is also important to emphasize the disparity of racial representation within the medical

field, and how such inequity allows biased attitudes and stereotypes to flourish. In the data

collected by the 2000 Census, only 4.4 percent of American medical doctors were African

American, as were 8.8 percent of nurses, and 8.4 percent of physician assistants (“Fact Sheet:

The Need for Diversity in the Health Care Workforce”). Furthermore, only 5.1 percent of

pharmacists were black (“Fact Sheet: The Need for Diversity in the Health Care Workforce”).

These statistics indicate that those providing care, diagnosing ailments, prescribing treatment,

and distributing medication are overwhelmingly white, despite African Americans being 13.2
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percent of the population (“Fact Sheet: The Need for Diversity in the Health Care Workforce”).

This lack of descriptive representation is disturbing in that problematic behaviors and biases

often remain unchecked. Without the significant employment of minorities in medical positions,

procedures that reflect implicit racism are less likely to be questioned or exposed for their

prejudicial nature. This structure augments stereotypes and behaviors that reflect such beliefs.

Disparities in Treatment

Prejudice in pain care effects both quality of treatment and access to pain medication for

patients of color. This can be best studied in circumstances of acute pain, in which injury or

illness is very simply observed, diagnosed, and treated in an almost formulaic process. In a

simple study of long-bone fractures treated in emergency care facilities, black patients were 66

percent more likely to not be given analgesic pain treatment than their white counterparts,

despite equivalent notations of pain in their medical charts (Anderson et. al 1188). Furthermore,

in post-operative pain treatment, “white patients received significantly higher doses of opioid

analgesics than did black… patients” (Anderson et al. 1190; Tamayo-Sarver et al. 1). Generally,

when both populations were prescribed an analgesic for any injury or illness, 54 percent of

whites were given an opioid, in contrast to only 27 percent of blacks (Tamayo-Sarver 3). This is

notable as opioids are considered significantly more addictive that other forms of analgesics

(Ling et al. 301). In addition, “there is a perception among many individuals that African

Americans as a group- regardless of socioeconomic status- tend to abuse or use drugs at a higher

rate…” (“Study: Whites More Likely to Abuse Drugs Than Blacks”). This view is inaccurate, as

studies that have controlled the variable of socio-economic status have found that drug abuse
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rates for whites are higher than for their black peers (“Study: Whites More Likely to Abuse

Drugs Than Blacks”).

This understanding clearly indicates a connection between how doctors view their

patients of color and the extent to which they presume addiction to be a risk. Even in the most

concrete cases of injury, black patients are less likely to receive adequate relief, despite suffering

the same trauma and experiencing equivalent pain. Because analgesics are the most common and

effective method utilized to relieve acute pain symptoms, unequal prescription of such treatment

is indicative of racial bias. It has been clearly established that whites, including white doctors,

hold the tacit belief that blacks are more prone to addiction. Thus, implicit attitudes about black

patients explain the aforementioned disparity in drug prescriptions.

Furthermore, African American patients spend less time with practitioners, both in

patient and practitioner-initiated appointments (“The Long History of Discrimination in Pain

Medicine”). In this manner, this racial group receives less comprehensive diagnostics (“The

Long History of Discrimination in Pain Medicine”). This phenomenon indicates that black

patients and their symptoms are taken less seriously. In this manner, doctors may also believe

their black patients are simply malingering to receive pain medication they do not need. The

interpretation of black patients as impervious to pain, drug addicts, and criminals has shaped the

way in which medical care for pain is provided. This has led to an unequal standard of care in

which blacks are not adequately diagnosed and treated for their pain.

Failures of the Medical System

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It is evident through empirical research that the failure to treat the pain of African

American patients is distinct and widespread. However, it is less clear which institution is most

to blame for the phenomenon. As previously established, the political system, notably the

presidential and congressional institutions, manufactured beliefs about drug use and communities

of color. In this manner, one could conclude that inadequate pain treatment is a product of the

failed political system. This assumption ignores the blatant failings of the medical system to train

its practitioners both about the condition of pain and the diversity of their patients, despite

widespread knowledge of the issue.

Although pain is experienced as a symptom of an illness or injury (with the exception of

chronic pain), it is one of the mostly common afflictions doctors treat. Subjective ratings of pain

are a crucial component of diagnosis, and are often required in the process of admitting patients

into medical facilities (Farrar et al. 149). Despite the importance and prevalence of doctor

interaction with pain, American medical students receive poor training on pain as a concept and

condition.

Only 80% of American medical schools require any addressal of pain in their curriculum

(Mezei and Murinson 1199). Thus, approximately one fifth of American medical students

receive no training on the different classifications of pain, its causes, and the best ways to

approach its treatment. Furthermore, of the schools that have an element of pain training in their

curricula, most dedicate mere sessions within courses out of four years of medical training. With

the high reliance on pain measures for diagnosis, and the prevalence with which practitioners

treat pain, this lack of training by medical schools is negligent.

The failings of the American medical system can be further understood in the fact that it

does not meet the international standards of pain education. In comparison with Canada,
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American schools spend half the number of hours discussing pain in courses (Mezei and

Murinson 1199). In considering the curriculum proposed by the International Association for the

Study of Pain (IASP) as the international standard for pain education, American schools also fail.

Most topics asserted as central to the IASP curriculum are not covered in medical schools in the

United States. In fact, in a study performed by Lina Mezei and Beth B. Murinson for School of

Medicine at Johns Hopkins, not one of the 104 American medical schools surveyed included the

full IASP curriculum in their training (Mezei and Murinson 1199).

Medical practitioners in the United States are clearly unequipped to properly diagnose

and treat pain in their patients. This is especially problematic in considering the short time

medical practitioners spend with black patients. A fundamental lack of understanding of pain,

paired with a brief period in speaking with and assessing the needs of patients of color, makes it

less likely that these patients will receive an adequate quality of treatment. Furthermore, in

instances where it is difficult to locate a source of pain (including in cases of chronic pain

disorders), doctors who do not have thorough pain training would be more likely to assume a

patient is lying about their symptoms. In a society like the United States, in which there is the

widespread belief that African Americans abuse drugs, undertrained doctors will more easily

attribute tangible pain to drug seeking behavior. Overarchingly, a lack of standardized and

detailed pain education throughout medical schools creates an environment in which black

patients are erroneously denied pain care. This is a profound failure directly attributable to the

medical system.

There is also a clear lack of diversity present both in the curriculum and student

populations of medical schools. In a socio-medical study and policy recommendation,

Betancourt, et al. describe such education as requiring “cultural competence”, or training with
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the goal of informing medical professionals on how to best treat their patients of varying

backgrounds (Betancourt et al. 293). This standard focuses prominently on ethnicity (while

including minority statuses like gender, sexual orientation, etc.), and suggests training on the

specific medical and social misconceptions attached to racial groups (Betancourt et al. 297). Of

the AMA, LCME, and AAMC, none require medical students or practitioners to have had any

training on diversity, let alone meet “cultural competence” standards (Betancourt et al. 297). In

fact, in a 1998 study of American medical schools only 8 percent offered courses specifically on

cultural issues (Dogra et al. 166). Furthermore, only 35 percent of American schools address the

cultural issues of the largest minority groups in the states they reside in (Dogra et al. 166). Thus,

when these students graduate, they are unequipped by their medical educations to understand or

treat the patients closest to them. As the inadequate access for people of color to healthcare

generally, and pain treatment specifically, are widely known phenomena, a lack of cultural

training in medical schools is unacceptable.

In some states there are requirements for diversity education in order to obtain medical

licensure. Notably, New Jersey in 2005 became the first state to impose such regulation (Dogra

et al. 166). This could be construed to prove that the medical system has made efforts to address

the prevalent inequality in healthcare provided to persons of color. However, the bureaucracies

that license medical doctors are products of individual states, and the standards for diversity they

have imposed were created through the legislature. These efforts to address fundamental failures

in medical treatment (including for pain) are the result of political institutions. Furthermore, it is

still uncertain the extent to which these regulations have impacted medical education in the

United States. While it is true politicians created and proliferated the stereotypes that negatively

impact the medical system, political institutions are the only organizations taking tangible action
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to prevent future abuses. When compared to the inaction of medical institutions, it is clear the

inadequate treatment of pain for persons of color is a failure of the medical system.

The absence of cultural study in medical schools is disturbing considering not only the

historical negligence of the medical system towards people of color, but also the exploitation of

these communities by American doctors. Medical experimentation, notably the Tuskegee

experiment5, has purposefully targeted and caused grave harm to communities of color (Gamble

1773). Not only are doctors negligently unprepared to treat their patients of color, but they are

not made aware of the injustices perpetrated against these communities by their medical

predecessors. In a country in which the medical system has horrifically abused minority

communities, medical schools should be required to provide cross-cultural training. The medical

system, as an overarching institution, has refused to take necessary action to combat past and

present trends in unequal access to treatment. This complacency is a clear failure of the medical

system, and the organizations that comprise it.

Conclusion

The medical system as an institution is venerated for its commitment to service, morality,

and innovation. However, as an organization made up of Americans, it is not impenetrable to the

issues that plague American society. Specifically, the prejudices against persons of color and

drug abuse have had prolific effects on the pain treatment accessible to these communities.

While these views have been built through a long history of political rhetoric, the inadequate

treatment of pain for these individuals is most deeply a failure of the medical system. The lack of

5
A study carried out by the U.S. Public Health Service during which African American men
were purposefully and unknowingly infected with Syphilis and denied treatment in order to study
the effects it had on the body (Gamble 1773).
 Comerford 13

education on pain and culture in medical schools is a direct result of a lack of requirement from

the AMA, LCME, and AAMC. Not only are these institutions aware of the statistical

discrepancies in pain treatment, but also they have remained inactive in combating this

phenomenon. In this manner the medical system in complicit in the widespread discrimination of

medical professionals towards people and communities of color. Thus the failure to treat persons

of color for their pain on a widespread level is an institutional failure of the medical system.

Based on these findings, it would be productive to consider the role of health in racial inequality,

and to utilize reform of medical education to address widespread structural inequality throughout

the United States.

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