UK researchers have brought welcome news as the world's largest randomised controlled clinical trial for a COVID-19 treatment, RECOVERY (Randomised Evaluation of COVID-19 therapy), has identified the steroid, dexamethasone, as the first drug to improve survival rates in patients (National Institute for Health Research (NIHR), 2020).
It has also come to light however that COVID-19 occurs at a higher frequency in people of minority ethnic backgrounds (Public Health England, 2020). Despite making up only 14% of the UK population, 35% of coronavirus patients in intensive care were from ethnic minority groups (Siddique and Marsh, 2020) and earlier figures from Office of National Statistics showed that black people are four times more likely to die from the virus than white people (Booth and Barr, 2020). All ethnic minorities appear to be more likely need intensive care than their white counterparts, and newer data suggest that Asians are mostly likely to die from COVID-19 than anyone else, at least in part it seems as a result of their higher rates of diabetes, though the reasons for this association are complex and remain unclear at present (Harrison et al, 2020).
Alongside all of this, our current landscape is littered with stories of racial discrimination, both on individual and systemic levels, and it seems reasonable – and necessary – to consider the potential impact of race and ethnicity on the treatment decision making of independent prescribers.
Racial disparity
Donna Kinnair, head of the Royal College of Nursing (herself no stranger to racism as a black woman living in the UK) points out that patients in black and minority communities have the worst outcomes in almost every category from cardiovascular disease to diabetes (Kale, 2020).
‘There are huge structural issues at work when it comes to how BAME (black, Asian and minority ethnic) communities access healthcare in the UK… In every community we work with, BAME patients suffer the most,’ she said in a recent interview with The Guardian.
‘When you rock up to your GP as a BAME person, your illness isn't taken as seriously’ she said. ‘Sometimes it takes five or six visits before you get into the system. Every step of the way, from services to treatment, some BAME patients have a worse experience of the NHS than their white counterparts.’
Research into racial disparities in healthcare has found that minority ethnic groups are systematically under-treated for pain (Hoffman et al, 2016), particularly in the USA, not only in comparison to white people, but in relation to guidelines set out by the World Health Organization (Samarrai, 2016).
In 2018, Kennel (2018) found that in Oregon, black patients were 40% less likely and Asians were 36% less likely to be administered pain medication than white patients. A recent study originating from Minnesota even found race inequality in the provision of analgesia by student paramedics (Lord and Khalsa, 2019).
There have been many more similar studies over the years, and while most of these are from the USA, a lack of research in the UK is not a reflection of absence of this problem – only perhaps the need to acknowledge and investigate it further (Cox, 2018).
Implicit bias
In 1998, a non-profit international collaboration of researchers set up a ‘virtual laboratory’ to collect data about implicit social cognition – those thoughts and feelings outside of our conscious awareness and control. The organisation's goal is to educate the public about hidden biases. It has been found that about 70% of respondents showed subconscious preferences towards white people, and the same result of 70% was observed where similar tests have been given to doctors and nurses (Cox, 2018).
People who treat others differently based on their race or ethnicity are not necessarily consciously racially discriminatory; they may have friends and even family members from minority backgrounds. However, owing to the bias-laden messaging entrenched in our social discourse, many will still hold inaccurate beliefs about minority groups. In areas where overt racism may be less common, subtle forms of racially preferential treatment persist.
Beyond beliefs such as those that black people – possibly from the ‘wrong side of town’ – who are requesting pain medications must have an opioid addiction (Singhal et al, 2016), health professionals may hold inaccurate medical beliefs about race, such as that a black person's skin is thicker than a white person's or that their blood coagulates more quickly (Hoffman et al, 2016). In a survey of 222 white medical students and residents, 50% of them believed that black patients felt less pain than white patients, and required less medication (Hoffman et al, 2016).
Becoming part of the solution
Evidence shows that medical providers under a heavy cognitive load make use of mental shortcuts to make rapid decision making possible and while it can be argued that this is necessary, there is a high risk of relying on stereotypes (Burgess, 2010; Kennel 2019). There is also evidence that even individuals that actively support racial equality may still consciously or unconsciously feel uncomfortable in mixed-race situations in a way that impacts behaviour (Bonilla-Silva, 2014; Kennel, 2019).
Drewicki et al (2011) suggest training in the form of empathy-inducing perspective-taking interventions to address the issue of racial disparities in pain treatment. They found that empathy plays a crucial role in pain treatment disparities as ‘pro-white empathy biases were found to be highly predictive of pro-white pain treatment biases. Equally then, empathy can be used in the opposite direction to induce empathy towards minority groups.
Implicit bias is interwoven throughout our societies, the awareness of which is essential in beginning to tackle it. Completion of an implicit bias test followed by relevant training and resources can and should form part of the education and training of all individuals in caring professions, including and especially those who hold the power to soften a human being's experience of pain.