Disparities—great differences—in health care can include variations in quality of and access to care, in ways groups of people seek care, in the management of chronic conditions, in vaccination rates, in mental health care, health-related habits, pain management and more.

Disparities—great differences—in health care can include variations in quality of and access to care, in ways groups of people seek care, in the management of chronic conditions, in vaccination rates, in mental health care, health-related habits, pain management and more.

Disparities exist for many reasons, including where people live, access to health insurance, socioeconomic factors and bias or racism on the part of health care systems and on the part of health care providers.

In this article, experts in medicine and mental health discuss historic and current aspects of racial disparities in health care, especially related to pain; the effect of those disparities on people who experience them, especially Black Americans; and how massage therapists can provide a safe and welcoming antidote for what can, for many people, feel like an unwelcoming or untrustworthy mainstream medicine experience.

Health Care Disparities

The U.S. medical system’s history is permeated with discrimination. Black Americans were used as unwilling or uninformed study subjects, beginning during slavery and continuing into the late 20th century. The medical establishment worked successfully to defeat more than 20 pieces of progressive health-care legislation before 1930; it wasn’t until the mid-1960s that, “for the first time in more than 300 years, efforts to allow America’s black population access to decent mainstream, health care were made,” according to the article, “An American health dilemma: a history of blacks in the health system,” published in the Journal of the National Medical Association.”

Judy Wright, MD, PhD
Judy Wright, MD, PhD

Deeply ingrained biases, and their effects, are still embedded in our health care system. For example, many studies have shown that People of Color (POC) are undertreated for pain. In U.S. emergency rooms, compared to white patientsblack patients are 40% less likely to receive medication to ease acute pain and Hispanic patients are 25% less. One possible reason for this might lie in a study conducted in 2016 that found that 50% of medical school trainees believed one or more of the following statements: “Black people’s nerve endings are less sensitive than that of white people”; “Black people’s skin is thicker than white people’s skin”; and “Black people’s blood coagulates more quickly than white people’s blood.”

“Translation: ‘Black people do not feel as much pain or pain at the same intensity as do people of other races,’” said Judy Wright, MD. “As a Black woman, I can testify that this is completely inaccurate.”

Jacob Hascalovici, MD,PhD
Jacob Hascalovici, MD, PhD

Such race-based biases exist alongside other data that shows Black patients actually are more likely to report uncontrolled pain scores than are white patients, according to Jacob Hascalovici, MD, PhD, chief medical officer and pain specialist for Clearing, a telehealth platform for chronic pain patients.

Such biases “speak to flaws in our medical education systems and how we may inadvertently perpetuate racial bias as we train the next generation [of health care providers],” said Alisha Liggett, MD, founder and executive director of Empower Her Health LLC. “Studies also show that health care personnel are no more or less biased than the general population.”

Alisha Liggett, MD
Alisha Liggett, MD

According to Liggett, studies indicate that Black Americans receive lower quality pain treatment, even after adjustments for insurance status, access to care, severity of conditions and socio-economic status.

 “They are also less likely to receive life-saving cardiac interventions when presenting with cardiac chest pain,” Liggett said. “In light of these studies, many scholars have concluded that inequities in the design of our health care system, as well as how care is rendered, contribute to health disparities.”

Such experiences erode trust in the medical system, according to Debra Warner, Psy.D, a trauma expert and forensic psychologist whose research focuses on diversity issues connected to mental health—which causes many people to not seek sometimes much-needed medical care.

Debra Warner, Psy.D
Debra Warner, Psy.D

“When POC do go and experience discrimination, it re-enforces why they do not trust the health care system,” said Warner. “Many POC end up dying of cancers and other diseases that could have been very treatable. There are a lot of studies available detailing why POC do not trust health care.”

Disparities Increase Stress and Pain

Receiving poor health care obviously affects health outcomes; it can also contribute to a heightened level of stress.

“The stress of being unsure you will be provided the best care, not be discriminated against or have problems ignored is a reality for many POC,” explained Warner. “Tennis great Serena Williams had to deal with that shortly after giving birth. When a nurse dismissed her concerns, it turns out she had a serious medical issue. “Discrimination like this can be very traumatic, and having to worry about not experiencing this kind of trauma again can also increase stress levels or internalized pain.”

Over time, stress responses add to inflammation, which can increase pain, Hascalovici said. “Pain signaling pathways in the mind and body that get triggered over and over can also become more sensitive, raising the levels of perceived pain and contributing to negative feedback cycles of threat and further pain,” he added.

Studies also indicate that the pain of racism and discrimination can create health conditions in the bodies of POC.

At the University of Miami, researcher Elizabeth Losin investigates the mechanisms underlying ethnic and racial disparities related to pain and pain treatment. She studies the role the brain plays using functional MRI and the effect of social and cultural factors, which include the doctor-patient relationship and such stressful life experiences as discrimination.

Losin and her team have found that Black participants, according to a university statement, “reported greater pain in response to a controlled pain stimulation than Hispanic or non-Hispanic white participants did. [Black] Americans also exhibited differences in their brain responses to pain, which correlated with their personal histories of experiencing discrimination.”

Losin said, “If medical professionals, whether consciously or unconsciously, believe that African Americans feel less pain than others, clinicians may be less inclined to alleviate the pain of their African American patients.” The release also noted that understanding why such pain biases exist can be an important step toward eliminating racial and ethnic disparities in pain and its treatment.

“Anything that causes higher stress levels, including experiencing racial disparities and racism, can increase pain perception,” said Hascalovici. “The mind and body can perceive stress as a threat, and can then prioritize threat responses.”

Steps MTs Can Take

The massage environment can offer the opportunity for stress and pain relief among clients of all races and cultures. (We are not suggesting massage is a replacement for medical care.) Yet, racial and ethnic minorities tend to get massages less often than white people do.

“This could be partially due to how massage is often portrayed as a luxury experience for white women, or possibly also due to lack of diversity among massage therapy teams,” said Hascalovici. “To help decrease disparities, massage therapists can consider how to actively increase team diversity and awareness.”

Massage therapists can also take steps to ensure they are not engaging in what might come across as bias or microaggression. In any type of health care setting, racial microaggressions could be conscious or unconscious actions that make someone feel less welcome and more judged because they belong to a certain racial group, said Hascalovici.

 “A microaggression could be a ‘harmless’ comment about the thickness, dryness or color of someone’s skin, for example” he said. “But though microaggressions can seem small to the person doing them, they don’t feel so small on the receiving end. To avoid microaggressions, stay mindful and think about how you would like to be treated as well as what might offend, alienate or hurt someone else.”

Massage therapists can also make sure they see and listen to their colleagues, especially colleagues who belong to minority groups, said Hascalovici. “This can include sharing information, making sure not to exclude anyone, and refusing to tolerate racist behavior from clients,” he said, adding that massage organizations can remain open to suggestions about how to improve training and support for massage therapists who belong to minority groups, and can create more training opportunities for people from minority groups to become massage therapists.

Massage therapists can also be careful when giving massages to members of minority groups not to imply that they do not belong, said Hascalovici, and so should never make such comments as, “‘We don’t get a lot of clients like you,’” or “‘Isn’t it unusual for people like you to get massages?’”

It’s good to keep in mind that clients and colleagues from minority groups often get a lot of cues that they are different and that they don’t necessarily belong, said Hascalovici, who added, “It’s difficult for them to tell, sometimes, if these cues are due to them as individuals or are because of biases and microaggressions based on race. Massage therapists can actively engage each client in a warm and welcoming, nonjudgmental way that doesn’t draw attention to differences or involve assumptions about race.”

The massage therapist can also consult with POC—both experts and people in the community, said Warner, to find out the best practices for a specific group, in order to provide optimal care.

Being touched can be potentially triggering for some people, due to racial trauma, said Hascalovici. “Touch, in other words, can be both healing and complex, since it can call up certain memories and emotions,” he said. “Staying open, welcoming and willing to hear each person’s perspective can go a long way to counter disparities.”

Karen Menehan

About the Author

Karen Menehan is MASSAGE Magazine’s editor in chief – print and digital. Her recent articles include, “Massage in the Hospital: At Work on the Pain-Care Team” and “This is How Diversity, Equity & Inclusion Practices Make Business Better.”