The genesis of the unequal burden of pain: a selective review examining social inequities and unheard voices : PAIN

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Biennial Review of Pain

The genesis of the unequal burden of pain: a selective review examining social inequities and unheard voices

Green, Carmen Renee

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PAIN 164(6):p 1258-1263, June 2023. | DOI: 10.1097/j.pain.0000000000002869
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1. Introduction

The impact of the COVID-19 pandemic continues to be revealed. It has challenged the healthcare ecosystem, stressed the public health infrastructure, out-paced the capacity of health professionals, and perplexed scientists.7 As of May 2022, the World Health Organization estimated that there were 514 million cases and 6.24 million deaths (including >180,000 frontline healthcare workers) because of COVID-19 worldwide.7,18,35,50 Unfortunately, the COVID-19 pandemic revealed significant fault lines in the healthcare and scientific enterprise while also exposing an important overlap of the social determinants on health care and quality of life. Concomitantly, COVID-19 enhanced awareness of the disproportionate policing and health disparities associated with racial and ethnic minorities and low-income people who experienced significantly increased morbidity and mortality because of COVID-19 and a range of other diseases (including pain).7

Race-based discrimination and racial disparities in morbidity and mortality are not new. The senseless killing of unarmed Black people by police or disparities in the policing of Black people is also not new. What changed during the pandemic is that stay-at-home orders allowed people to witness overt acts of discrimination, systemic and individual racism, and the killing of Black people in real time. The collective outrage spawned global demonstrations for racial and social justice and demands from the public for fundamental change.43 What is needed today is a longitudinal retrospective and historical lens to consider how and why race, systemic, and systematic biases in medicine intersect.

These considerations prompt increased awareness as well as the need to examine the root causes of persistent race-based health, healthcare, social, economic, education, and environmental disparities, inequities, and inequalities that challenge population health. False, purposeful, and biased narratives generated intrinsically unsound hypotheses and poorly designed research studies that failed to catalyze discovery and produced invalid results that caused harm to people. Moreover, they supported historic and discriminatory practices and scientific dogma that systematically institutionalized racial disparities causing even further harm over generations. With roots in flawed pedagogy and failed policy, they yielded intergenerational trauma, pain, and perpetuated troubling racial and ethnic-based social, educational, and healthcare disparities that diminish public health.

This article uses a case presentation format to explore the intertwined issues of racism, healthcare disparities, and race-based disparities in policing (including brutality and killings). An historical lens is used to reveal how racial biases, stereotyping, and false beliefs and theories permeate the healthcare ecosystem. It also shows how health professionals, scientists, organized medicine, and institutions maintained, disseminated, and benefitted at the expense of racial and ethnic minorities. Lastly, this article provides important insights focused on disparities in pain care and concludes with a set of recommendations to improve the status quo.

1.1 Chief complaint

Structural and institutional racism, and race-based disparities in healthcare, pain, and policing.

1.2 Present state

Today, more non-White than White children are being born. We live in an increased diversifying, aging, female, and global society.7,18 However, the advances in healthcare that have yielded an increasing life expectancy for Caucasians has not translated into similar longevity for racial and ethnic minorities. Minorities are also more likely to experience poverty, be low-wage workers, report lower health and quality of life, and receive suboptimal healthcare with worse health outcomes. The greatest disparities are Black–White, although all minority groups are at risk. Similar Black–White disparity exists in Blacks participating in the biomedical sciences and health professions where the representation of Blacks in the field is far less than their representation in the general population.1,7,14,21,22,33,48,49

1.3 History

The transatlantic slave trade brought the first enslaved Africans to the Americas around 1520. However, human trafficking and bondage existed in ancient times. In fact, slavery was in full force when the first Africans arrived in North America's British colonies in 1619. Moreover, there were no laws sanctioning slavery as American democracy began. Yet, the first Africans were sold into a life of servitude and bondage. A dichotomy existed as Africans were codified as unhuman to justify and legalize their enslavement that has prompted ongoing discussions regarding the full participation of Black people in society today.

Physicians have taken a sacred binding oath since antiquity to guide the ethical treatment of people regardless of their status or station in life. Professional, educational, scientific, and clinical accrediting bodies (eg, licensing agencies) often address the important social contract of health professionals with the public and their duty to ethically respond and to serve. Throughout history, health professionals have put their lives at risk treating patients with contagious illnesses (eg, HIV, AIDS, COVID-19). Racism is akin to an infectious virus and is a social disease associated with micro-aggressions (eg, explicit, implicit, and daily discrimination, unfair treatment, and racism) and macro-aggressions (eg, physical, social, emotional, and generational trauma) that also threaten health and deserve treatment.2,7

Physicians and organized medicine participated in slavery's brutality by owning enslaved humans, assessing their value, and conducting unethical and scientifically unsound experiments on Black bodies. They created and manipulated data while using religion to endorse false race-based theories and pseudoscience that viewed Blacks as idle, stupid, and dangerous. Furthermore, they created spiritual, mental, physical, and social reasons for continued enslavement and for conducting unethical experiments on Black people without their consent, assent, or ability to say no. Thus, organized medicine was complicit in maintaining slavery by failing to address its intrinsic inhumanity, participating, and profiting in slavery's physical and emotional brutality and sanctioning discrimination, condoning segregation, and facilitating the marginalization of Blacks (including physicians and scientists). Recently, Ginther reported Black–White differences in funding NIH grants.7,10

1.4 Social history

Structural racism, bias, and stigma have yielded an unequal burden for African Americans and remains American medicine's original and potentially ongoing sin.7, 18, 37, 46, 50, 53 Several U.S. Presidents, members of Congress, universities, university presidents, medical schools, hospitals, and organized medicine supported segregated healthcare, policies, and facilities. Specifically, public hospitals accepted enslaved people as payment for services received by their owners. In fact, a physician considered the “Father of American Psychiatry,” who also signed the Declaration of Independence, Benjamin Rush (1745–1813; Pennsylvania), was a slave owner and an abolitionist who described “negritude”—a disorder due to having black skin where the cure was to become white.

On March 12, 1851, a pro-slavery southern physician, Samuel Cartwright (1793–1863; Mississippi and Louisiana), presented, “The diseases and physical peculiarities of the negro race,” at the Medical Association of Louisiana meeting where he concluded “Negroes possessed smaller brains, had more sensitive skin, and were ‘a slave by nature’.” He also created several psychiatric conditions to describe and support his scientific conjectures: drapetomania (a mental disorder characterized by the desire to flee) and dysaesthesia aethiopica (a physical and mental disease characterized by skin insensitivity as well as lack of work ethic and intellectual faculties). Cartwright also described “lesions of the body discoverable to the medical observer, which are always present and sufficient to account for the symptoms.” He believed slaves should be kept in a submissive state and treated like children, with “care, kindness, attention, and humanity to prevent and cure them from running away” while also stating, “if they nonetheless became dissatisfied with their condition, they should be whipped to prevent them from running away.” Cartwright further proposed amputations for those who were seeking freedom and noted dysaesthesia aethiopica was “much more prevalent among free negroes.” It is important to note that brutal violent acts were often showcased and witnessed to ensure command and control during slavery. Overall, Cartwright presented theories to rationalize slavery, re-enslave free negroes, and suggested negroes, and supported the need for Whites to direct the lives of Blacks.

In 1842, Crawford W. Long (1815–1878; Georgia), a physician, surgeon, and slave owner made a great contribution to medicine by using ether to provide surgical anesthesia for the first time. During a time when mesmerism, hypnosis, and nitrous oxide and ether parties were common, Long wanted to assess whether ether provided surgical anesthesia and its efficacy by amputating the injured digits of enslaved children with and without ether to confirm ether was not a placebo. March 30 is recognized as Doctor's Day to recognize Long's contributions and his likeness is memorialized in the U.S. Congress National Statuary Hall, in museums, and on postage stamps.

A southern slave holder, physician, and plantation physician, James Marion Sims (1813–1883) is considered the “Father of Obstetrics and Gynecology.” He has received the most public consternation and condemnation for his experimentation on enslaved Black women in a time where their value was linked to their reproductive capacity.54 Although Sims had no training in Obstetrics and Gynecology, from 1845 to 1849, a dozen enslaved Black women (including Anarcha, Betsey, and Lucy) with vesicovaginal fistulas after childbirth became his medical subjects without their assent, consent, or ability to say no. A 17-year-old Anarcha was in labor 5 days when Sims was called and used forceps (for the first time). Anarcha developed vesiculo-vaginal and rectovaginal fistulas; a painful and devastating complication after childbirth that made women social outcasts. It is unknown whether Anarcha's unborn child lived or died. Nonetheless, Sims operated on Anarcha more than 30 times over 4 years and on other enslaved women before inventing the vaginal speculum and pioneering the surgical technique using silver suture (without anesthesia) for the repair. He created a facility “in the corner of my yard for taking care of my negro patients and for negro surgical cases” to conduct his experiments. Sims also invited other physicians to watch him perform surgery on enslaved women stating, “There was never a time that I could not, at any day, have had a subject for operation.” Once he perfected the technique, he performed the procedure on White aristocratic women with anesthesia. Overall, Sim's work was rooted in preserving the economic power of slavery through ensuring reproductive capacity.

Overall, advances in medicine or surgery could not have occurred without the contributions of enslaved and free Blacks, who were often medical subjects in experimental painful treatments and procedures.54 Many antebellum physicians believed Negroes did not feel pain. Drs. Cartwright, Long, Sims, and others' words and actions reveal how race-based biases arose, crept into, and persisted in American medicine. Furthermore, suggestions that African Americans were intellectually inferior and did not feel pain were used to justify denying them anesthesia even when available. These narratives led to biased, racialized hypotheses that contribute to speculations that there are racial differences in pain thresholds. Thus, it is not surprising that hypotheses based on African Americans responding differently to painful stimuli than Caucasians persist and are being tested today.

1.5 Current affairs

Discrimination, racism, and xenophobia exist. The literature is clear about how racial profiling and stereotyping negatively impacts health and well-being. Racism is a deadly, virulent, and pervasive social disease. Its current and tragic toll upon generations of racial and ethnic minorities makes our society sick and contributes to accelerated aging and premature morbidity and mortality. Several premature deaths of Black people in 2020 changed the conversation.15,17,24,45,57

Mr. Ahmaud Arbery, a 25-year-old unarmed African-American man, was jogging in his Georgia neighborhood when he was pursued, confronted, and fatally shot by 2 armed White men. Another White man videotaped the encounter. Ms. Breonna Taylor, a 26-year-old African-American woman, was in bed with her boyfriend in their Kentucky home when a “no-knock” narcotics raid was conducted. Although the primary suspect was in custody, police used a battering ram to forcibly enter their home. She died after being shot >8 times. No drugs were found in their home.

There are numerous false accusations associated with everyday activities made against Black people regardless of their age, sex, and income. Mr. Christian Cooper, an unarmed African-American man, was bird-watching in Manhattan's Central Park when he saw a cocker spaniel digging up shrubbery and disturbing the bird sanctuary. Cooper asked the dog's owner, a White woman, to comply with park rules and leash the dog. She replied, “I'm going to tell the police there's an African-American man threatening my life.” She feigned fear while Cooper videotaped their interaction and her conversation with the police. His experience was consistent with a pattern of White people making false accusations associated with serious crimes (eg, theft, rape, and murder) against Black people (eg, Emmett Till, Central Park 5).

Deaths because of policing have occurred in universities and hospitals, where people come to seek respite, care, and education. Thus, institutional and structural inequalities within healthcare because of interactions with hospital security must be addressed. Attention needs to be directed at why hospitals and universities are increasingly deciding to arm security services.11,38–41 In 2015, a 57-year old African-American woman, Barbara Dawson, had trouble breathing and went to the hospital. Despite her pleas, she was forcibly removed from the emergency room by the police. When she stopped breathing before getting into the cruiser, she was readmitted to the hospital. Mrs. Dawson died of a saddle pulmonary embolus an hour later. In 2016, Mr. Alan Pean, a 26-year-old unarmed Haitian and Mexican-American man with bipolar disorder, went to a Houston, TX hospital seeking psychiatric treatment. Naked and delusional in his hospital room, hospital security was called. He was shot and critically wounded, but survived.

An 8-year study revealed that Black patients and their visitors had security called on them at >2.7 times the rate of White patients and their visitors. The 2018 article raised important concerns: (1) How often nonthreatening situations were escalated because of negative perceptions and stereotypes of Black patients and their visitors and (2) The role of diminished employee resilience, tolerance, and cultural humility, awareness, and competence, especially regarding critical or stressful situations (eg, grief, fear, pain, and loss) leads to security being called on Black patients and their visitors disproportionately.

On May 25, 2020, the world watched the arrest and suffocation of an unarmed 46-year-old African-American man, Mr. George Floyd, by the police in Minneapolis, Minnesota.19,23,34 Accused of using a $20 counterfeit bill, he did not resist arrest and lay prone handcuffed on the pavement as a White police officer kneeled and rocked his knee into Mr. Floyd's neck for >9 minutes. Three officers restrained his legs and prevented onlookers from intervening to help. Reminiscent of >4000 people lynched throughout American history, witnesses heard Floyd plead, “please, please…” and “I can't breathe” (a familiar refrain) more than a dozen times, call for his dead Mother and state multiple times, “they are trying to kill me.” Attempts to revive Floyd in the ambulance failed. Hypertension—a common disease in African Americans and gateway disease to cardiac disease—was initially used to rationalize his untimely death.

1.6 Assessment

A perfect storm exists within an imperfect world where Black bodies are devalued, dehumanized, and criminalized; and where phenotype, regardless of class, prompts over-, bad-, and criminal-policing in communities of color; further magnifying Black–White disparities and potentially leading to premature death. There are 3 ways in which to assess and process these problems.

  1. Segregation, racism, and discrimination: Professional medicine and the scientific community has tolerated segregation in public and private facilities, discriminated against African-American physicians, experimented on Black people (eg, Tuskegee), stolen from Black bodies (eg, Ms. Henrietta Lacks), and allowed unacceptable, unequal, and low-quality healthcare for minority people. In fact, the American Medical Association remained silent during the 1964 Civil Rights Act deliberations and policy-making process.48,52,55,58 It was not until 1997 that President Clinton apologized for Tuskegee. In 2008, the American Medical Association apologized for excluding African Americans from membership. Conversations regarding the ethics and status of J. Marion Sims “contributions” to science are ongoing. Similar conversations regarding Crawford Long should begin. Furthermore, acknowledging the contributions of enslaved and other people who were unwilling subjects in medical experiments should begin.
  2. Macro-aggressions and Policing: The epidemic of police violence directed at unarmed Black men reflects societal ills.3,4,8,25,28 Both experiencing and witnessing trauma can cause physical, spiritual, and psychological wounds.9 Video evidence of police brutality against Black people is not new nor are national protests after unarmed Black men being brutalized or killed by police or surrogates: Rodney King (Los Angeles, CA—1991) and Trayvon Martin (Sanford, FL—2012). However, 2014 was a pivotal year because of the number of unarmed Black men dying because of overzealous policing and brutality: Eric Garner (NYC, NY—2014), Michael Brown (Ferguson, MO—2014), Tamir Rice (Cleveland, OH—2014), Walter Scott (North Charleston, SC—2015), Freddie Gray (Baltimore, MD—2015), Philando Castile (Falcon Heights, MN—2016), and so many others whose stories have yet to be told.

Black men dying in the hands of police is a leading cause of their premature death. Interestingly, police officers are given the presumption of innocence, whereas Black people must prove their innocence. Specifically, even when video evidence of police violence directed at Black people exists, Black people are often considered guilty until proven innocent. The official narrative often comes from the police when a counternarrative may be needed. Although dashcam and bodycam videos were instituted to stop problematic policing behavior, protect police officers, document the person being policed, and to be a neutral and unimpeachable witness, they must first be turned on. Without a victim's narrative, the dead body speaks via the autopsy. Police officers generally get the benefit of the doubt (especially when the victim is Black).

In 2019, Black people represented 13% of the population and represented 24% of the 1098 people killed by police. When compared with White people, Black people are 3 times more likely to be killed by police and 1.3 times more likely to be unarmed. From 2013 to 2019, only 1% of killings by police officers resulted in them being charged with a crime.

  • 3. Microaggressions: The cumulative effects of positive (eg, wealth, positive social support) and negative life experiences and the timing and duration of these effects impact health and quality of life.5,51 Racial and ethnic minorities are at increased risk for accruing race-based micro-aggressions (eg, explicit, implicit, and daily discrimination, unfair treatment, and racism) and race-based macro-aggressions (eg, physical, social, emotional, and generational trauma) over the lifespan. Within and outside of healthcare, the persistence of these aggressions highlights the negative impact of stereotyping, bias, and marginalization yielding decreased quality of life and life expectancy, increased comorbidities, and disparities in the educational outcomes, and the quality of health care and pain care for minorities. The urgency in addressing race-based bias, discrimination, and stereotyping within educational and healthcare institutions is underscored by the physical and psychological harm caused to learners, patients, and others in the education and healthcare ecosystem, including the perpetrator.

1.7 Health disparities

Racial disparities in health and healthcare are well described. Despite controlling for income, education, age, sex, stage and severity of diseases, and presence/absence of comorbid illness, they persist.12,13,42 Even when matched by socioeconomic, insurance status, embedded in the disproportionate morbidity and mortality rates are historical and continuing practices in the United States (eg, segregation) yielding low-quality healthcare and poorer health outcomes for minority patients. This is best demonstrated via social determinants of health framework where unequal and suboptimal access, distribution, and utilization of resources as well as variability in clinician decision making contribute to sociopolitical and health challenges associated with diminished health and well-being.26,29,30 Thus, it is not surprising to find populations at risk for health disparities are disproportionately and negatively impacted by COVID-19 because of inequitable environmental and social conditions shaping health behaviors.16,47,56 In addition, multiple other issues contribute, such as Black people having more chronic health conditions, decreased access to healthcare, increased healthcare costs, and prejudice directed at minority patients within the healthcare system.

For those with or without exposure, COVID-19 has impacted their overall physical, social, and mental health and well-being. Specifically, Black people account for 33% of the hospitalized COVID-19 cases and 23%–25% of COVID-19 deaths (nearly 2–3 times their percentage in the population).5,9,51 Black people are also disproportionately essential workers (eg, bus drivers, nursing home aides, grocery workers, and taxi and delivery drivers), live in urban environments, and are more likely to be furloughed, laid off, and unemployed when compared with White people. Overall, racial disparities in deaths because of police brutality or COVID-19 present opportunities to consider race, systemic, and systematic biases in medicine. Unfortunately, the unequal physical burden, economic hardships, and emotional costs because of (and after) COVID-19 and police brutality have been disproportionately borne by minorities, low-income individuals, and marginalized and vulnerable populations.

These findings prompt the question as to the role of inequality within the medical, scientific, and academic community and to address educational and healthcare inequities, disparities, and discrimination.6,16,36,44 Specifically, the codes of ethics for scientists, physicians, and major medical organizations address a duty to safeguard the public. There are ethical considerations and societal implications when health professionals are deaf, silent, and fail to act.27,32 For instance, physicians, scientists, and others failed to respond to Nazi atrocities during World War II. Mr. Steven Biko died in detention after being beaten by South African police for anti-apartheid activity. Physicians allowed a semi-comatose Biko to be driven >700 miles to a South African prison, handcuffed, and naked on the floor of a police vehicle.

The literature reveals that differences in decision making based on race lead to the systematic undertreatment of pain in African Americans. A 2016 article showed that White lay people as well as most medical students and residents falsely believed there were biological differences in the skin of Black and White people.20 These unfortunate biases contribute to Black–White differences in pain assessment and care, with Black people receiving low-quality recommendations. Furthermore, they are consistent with hypotheses being generated that are focused on Black–White differences in responses to painful stimuli in the experimental pain setting. This suggests that the entire scientific basis for pain may need to be reevaluated with a new lens to generate appropriate hypotheses to be tested.

2. Concluding recommendations

Overall, the literature consistently reveals decreased access to healthcare, physician variability in decision making, and suboptimal health outcomes leading to accelerated aging, premature morbidity, diminished quality of life, and decreased life expectancy for racial and ethnic minorities. These differences persist despite similar socioeconomic and insurance status, suggesting that these factors are not protective for minorities. Because racism, discrimination, and violence are societal issues that persist in societies tolerating them, discrimination and racism must be denounced wherever they are encountered. This includes condemning racist rhetoric and adopting anti-racist tenets into the patient bill of rights, charters for professional societies, and code of conduct for accrediting organizations.

The literature reveals that implicit, conscious, and unconscious bias influence healthcare quality. All biases operate at the individual, systemic, and institutional level leading to suboptimal healthcare access and treatment outcomes. Forward-looking organizations will adopt new metrics and will use data that incorporate the social determinants of health to address racial and ethnic disparities. Organizational change will occur as these key components are incorporated into training programs and lifelong learning, including accreditation activities. Transformation will occur by sharing data across disciplines and institutions and by facilitating a robust research agenda that incorporates a race equity lens.

Minorities report less trust and involvement in their care. Beyond bias, stigma, stereotyping, verbal and nonverbal communication styles, and cultural differences influence clinical interactions. Privilege and bias influence interactions within the health and scientific ecosystem. History teaches us that trust is earned, easily lost, and difficult to regain. An example is the increased COVID-19 vaccine hesitancy noted among minorities. Thus, auditing institutional data and continuous quality improvement processes are needed to assess potential barriers contributing to disparities and suboptimal care.

Representation matters. The lack of racial and ethnic minorities in the health professional and biomedical pipeline contributes to disparities in healthcare quality and diminishes the quality of science. Thus, additional investments in activities designed to diversify and enhance the pipeline are needed to generate appropriate hypotheses, enhance the quality of science, and to improve the quality of care. Several reports speak to the importance of creating an inclusive culture by recruiting, mentoring, and retaining minorities within the health professional and scientific pipeline. However, many minority health professionals and biomedical scientists report feeling unsupported and marginalized within the academy and within their scientific and professional organizations.5,31 Members in professional communities and societies must commit to including diverse voices and leadership by sponsoring and nominating them while extinguishing racism from the recruitment and scientific review processes. To do so requires identifying and nurturing potential leaders by evaluating who is on and who is not on committees while working to change the committee when they are not diverse.

The damage has been done regarding problematic racist rhetoric and narratives as well as flawed hypotheses, methodology, and outcomes including race-based micro-aggressions and macro-aggressions. For instance, the rise of many organizations is intrinsically tied to slavery. Hence, work is needed to build and rebuild trust. Considering the level of harm, a truth and reconciliation process and an apology to those harmed should be considered. Thus, these organizations should dedicate the necessary resources to address and ameliorate the harm caused. Scientific organizations might allocate part of their meeting to plenary talks and seminars within their annual meetings to address these issues.

It is important to examine the legacy of pain research including historical wrongs and missed opportunities for the full participation of minority health professionals and scientists as well as harm done to patients, medical subjects, and their communities. Many hypotheses, methodologies, and subsequent findings from the previous science that were accepted as truth must be reconsidered and authenticated for a new diverse and global society. Specifically, race-based micro-aggressions and macro-aggressions contributed to race-based trauma and disparities. Furthermore, an acknowledgement of how the field may have benefitted from racism, racist theories, and negative racial narratives have caused harm is needed. An apology is due and a new narrative is needed.

Overall, there is debt due. The stories of those negatively impacted by flawed scientific methodology, disproportionate policing, and health and educational disparities must be heard. This requires listeners (eg, health professionals, the police, and other human service agencies) to actively listen, be culturally sensitive and humble, and commit to rectifying the harms to promote authentic discovery and communication.

3. Recommendations

  1. Racism, discrimination, and violence are societal issues that must be denounced when it occurs. Adopt anti-racist tenets into the patient bill of rights, charters for professional societies, and code of conduct for accrediting organizations.
  2. Incorporate implicit, conscious, and unconscious bias training at the organizational level into training programs, lifelong learning, and accreditation activities.
  3. Use the social determinants of health to address racial and ethnic disparities. Share data across disciplines and institutions to address disparities and to facilitate a robust research agenda with a race equity lens.
  4. Audit institutional data and continuous quality improvement processes to assess barriers contributing to disparities and suboptimal care.
  5. Representation matters and additional investments in activities designed to diversify and enhance the pipeline are needed. Incorporate diverse voices and leadership by sponsoring and nominating diverse individuals.
  6. Extinguish racism from the recruitment and scientific review processes by identifying and nurturing potential new leaders. Evaluate committee membership to ensure it is diverse and inclusive.
  7. Trust is earned, easily lost, and difficult to regain. A truth and reconciliation process and an apology to those harmed must be considered. Scientific organizations should allocate part of their meeting to plenary talks and seminars within their annual meetings to address these issues.
  8. Examine the legacy of pain research including historical wrongs and missed opportunities for the full participation of minority health professionals and scientists as well as harm done to patients, medical subjects, and their communities. Furthermore, an acknowledgement of how the field may have benefitted from racism, racist theories, and negative racial narratives have caused harm is needed.
  9. Hypotheses, methodology, and subsequent findings from the previous science that were accepted as truth must be reconsidered and authenticated for a new diverse and global society.
  10. Become an active listener who is culturally sensitive and humble. Commit to rectifying prior harms to promote authentic discovery and communication.

Conflict of interest statement

The authors have no conflict of interest to declare.


C. R. Green wrote and conceptualized this article, is the sole author, and declares no conflict of interest. She wishes to thank Ms. Marie Romani for the technical support in preparing this manuscript for publication.


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