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Chronic Pain and Inequality

The role of racism, sexism, queerphobia, and poverty in health and chronic pain

Paul Ingraham, updated

“Chronic pain is not political!” I was told this by a reader who was angry that I made a brief, better-than-nothing public declaration that “black lives matter here.” He’s boycotting PainScience.com. He’ll never buy another book, or visit my website ever again. He was outraged that I dared to write about something other than chronic pain. “Chronic pain has no politics,” he declared.

Good riddance, obviously. Begone! Evanesco! 🧙🏻‍♂️ Black lives still matter here.

Chronic pain is political. In a big way. Anyone who doesn’t get that does not get pain. This is something I’ve known for a long time, but I’m feeling quite sheepish that I had no content about this. I was blinkered by privilege. That is what privilege does.

But my awareness has been raised — by the Black Lives Matter movement. And “silence is compliance.”1

Why chronic pain is (extremely) political

Chronic pain is political because health and healthcare are political — it is directly and strongly affected by public policy and law, and indirectly by many other social issues that are in turn also greatly affected by public policy and law.

The biggest drivers and risk factors for chronic pain are poor overall health and fitness. For example, someone with a really stressful life, a lot of anxiety and depression, and diabetes, is at dramatically greater risk of suffering from chronic pain than someone who does not have those problems.

And guess who’s more likely to meet that description? All other things being equal, it’s the people at a disadvantage in society because of racism, sexism, and queerphobia. And then it all gets worse because of systemic prejudice in healthcare. They are more likely to suffer in the first place… and then much more likely to struggle to get good help.2

Whatever you’ve ever heard about the effects of any form of prejudice on health and healthcare applies to chronic pain too. For instance, when the worst case scenario is higher mortality — like black women dying in childbirth a lot more than white women3 — obviously there’s also going to be more chronic pain too.

Pain and prejudice specifically

Discrimination in general healthcare is clearly relevant to chronic pain in many roundabout ways, but it also affects chronic pain care directly. The Association of American Medical Colleges has a good, recent summary.4 Janice Sabin, PhD, MSW:

“Black people’s nerve endings are less sensitive than white people’s.” “Black people’s skin is thicker than white people’s.” “Black people’s blood coagulates more quickly than white people’s.”

These disturbing beliefs are not long-forgotten 19th-century relics. They are notions harbored by far too many medical students and residents as recently as 2016. In fact, half of trainees surveyed held one or more such false beliefs, according to a study published in the Proceedings of the National Academies of Science. I find it shocking that 40% of first- and second-year medical students endorsed the belief that “black people’s skin is thicker than white people’s.”

What’s more, false ideas about black peoples’ experience of pain can lead to worrisome treatment disparities. In the 2016 study, for example, trainees who believed that black people are not as sensitive to pain as white people were less likely to treat black people’s pain appropriately.

For every relatively obvious and studied source of prejudice in healthcare, there are dozens that are more insidious.

The stigma against the undiagnosable

Everyone struggles get good care for strange and unexplained chronic illness, which is alarmingly common, and chronic pain is one of the most common symptoms of such illnesses. Most people with unexplained widespread chronic pain are labelled with “fibromyalgia” and then dismissed; the stigma is so strong it might as well be called “hopeless weirdo disease.”

Healthcare professionals have a powerful tendency to overestimate the role of hypochondria and malingering in patients they don’t understand — both their medical understanding of the illness, and their social understanding of the patient. Most of this is unconscious, of course — just like with any other prejudice, it’s rarely overt, and routinely cloaked by paternalistic benevolence and good intentions.

Speaking from experience, an articulate, educated, middle-aged white guy can absolutely run afoul of this stigma. My social status and privileges offer only partial protection.

So imagine how much worse it is for everyone else.

“Chronic pain is not political”? Good grief. You’d have to talk to a flat Earthers to hear a more ignorant idea.

About Paul Ingraham

Headshot of Paul Ingraham, short hair, neat beard, suit jacket.

I am a science writer, former massage therapist, and I was the assistant editor at ScienceBasedMedicine.org for several years. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook or Twitter.

Related Reading (tip of the iceberg)

Some key references:

What’s new in this article?

June — Converted to a permanent article, and made several improvements.

June — Publication.

Notes

  1. Not necessarily, but I basically agree, and so this I am going clear what my values are. I have little else to offer (in this context anyway) but I can at least acknowledge what’s going on in America (and the rest of the world too) and make it clear where I stand.

    Sol Orwell, founder of Examine.com and much else:

    If you own a business or lead a group of people, let me humbly suggest something: it's worse to pretend nothing is happening.

    You don’t need to offer solutions or money or some grand plan or even (empty) platitudes — just acknowledging it’s happening is appreciated.

    Acting as if it’s business as usual will, I promise you, be noticed by the very people who are sick of this.

    I knew as soon as I read those words — “noticed by the very people who are sick of this” — that I had to break my silence. I rarely cross the streams of business and politics, but this is 🤬 different. This is a bad time to be quiet. This is not a time for business as usual. This matters.

    Black lives matter. And emphasizing that matters.

  2. Anderson KO, Green CR, Payne R. Racial and ethnic disparities in pain: causes and consequences of unequal care. J Pain. 2009 Dec;10(12):1187–204. PubMed #19944378 ❐
  3. Flanders-Stepans MB. Alarming racial differences in maternal mortality. J Perinat Educ. 2000;9(2):50–1. PubMed #17273206 ❐ PainSci #52573 ❐
  4. www.aamc.org [Internet]. Sabin J. How we fail black patients in pain; 2020 Jan 6 [cited 20 Jun 28].