Addressing Social Inequities in Pain Care: An Interview with Carmen Renee Green

By Kayt Sukel | September 27, 2023 | Posted in

“We know that racism exists in the healthcare setting, but we need to do something about it, and that goes beyond just doing bias training. We need to do some rigorous thinking about why we fear ‘the other.’ We need to collect and share the data and history, so people understand how much these false narratives about pain impact care and science.” Carmen Renee Green

Carmen Renee Green, MD, is dean of the City University of New York (CUNY)’s School of Medicine, the Bert Brodsky Chair, medical professor of community health and social medicine, and professor in the Colin Powell School of Global and Civic Engagement. She is also a pain medicine physician, having completed her anesthesiology residency and pain medicine fellowship at the University of Michigan School of Medicine.

Green’s research lies at the intersection of chronic pain management and healthcare equity, looking at how social determinants of health, especially race and gender, influence clinical decision-making, unequal treatment, and overall healthcare quality. She delivered a plenary lecture at last year’s International Association for the Study of Pain (IASP) World Congress titled “The Genesis of the Unequal Burden of Pain: A Selective Review Examining Social Inequities and Unheard Voices.” An accompanying paper appeared in the June 1, 2023, issue of PAIN.

In this Migraine Science Collaborative interview, Green speaks with freelance writer Kayt Sukel about social inequities in healthcare, false narratives about pain, the reaction to her IASP talk and PAIN paper, and why more people need to know about cases like Irvo Otieno, a Black man who was shackled and then died in a healthcare setting in March 2023. The interview has been edited for clarity and length.

What first sparked your interest in pain medicine?

I thought that, in the field of anesthesia, I could do something to help make people better quickly. But, looking back, I see that my work in anesthesia was designed to get me into the work of pain medicine. As soon as I started doing research in chronic pain, I never wavered from that. There is such an unmet need in pain, and I realized that there were many things that established researchers weren’t considering such as race and the intersectionality of race, gender, and class. I also saw the unequal burden that people were experiencing because of their pain.

Tell me about your research on the unequal burden of pain, and why it’s important to give this issue attention now?

I’ve been working on understanding the unequal burden of pain for some time. I’ve contributed to a body of literature that looks at access to care, especially in regard to racial and ethnic minorities, going back to the early 2000s. It really started back when I was an anesthesiology resident and pain medicine fellow. I’d watch patients and see how they were getting their pain care. Women would walk in and have their pain assessed differently than men. If you were a Black or Brown woman, how your pain was assessed – whether you were believed – compared to white men was very different.

I listened as women had to tell stories about their pain that men never had to tell. The women would be asked if they were physically or sexually abused; we never asked that question of men. And Black women, and Black people in general, had to sort of prove they had pain. And if a woman walked into the clinic with three children, that also influenced the experience she had in getting care; men never walked into the clinic with three children. I saw, early on, how bias creeped into the healthcare setting and changed the care experience for different people. I don’t think I had the words at the time to talk about it. But I was a participant observer, and I’ve been thinking about these differences and disparities for a long time.

Carmen Renee Green

Carmen Renee Green

These thoughts really started to come together and become clearer for me during the pandemic – many of us had an awakening during this time – because the pandemic gave us all a lot of time to think. I started asking myself questions about how I was trained, what I accepted as truth in terms of the narratives doctors have about pain, and where those narratives came from. I think about all of this within the context of other things that were happening in our society, like the George Floyd, Ahmaud Arbery, and Breonna Taylor cases. Although, when I think about it now, I realize I was thinking about these things even before that, as far back as other tragedies like Michael Brown in Ferguson and Eric Garner in New York.

I wrote a paper on hospital security calls, which demonstrated there was a two-and-a-half-fold difference in African Americans having security called on them in the hospital setting compared to Caucasians, and I thought about that in the context of respite and care. Why do people go to hospitals? For respite and care. I was going back and forth between these narratives we have about certain people and pain, what I was seeing and hearing, and the data I was collecting. It made me realize how systemic the bias is, the potential for race, sex, and class to influence health, and their role within the healthcare setting for both the patient and healthcare provider. That’s when I really started to ask questions and look at the history of this, especially within pain care.

Last year, at the International Association for the Study of Pain [IASP] World Congress on Pain, you gave a plenary talk on the unequal burden of pain [see related paper]. What was the reaction to it?

When IASP provided me with an opportunity to talk about these issues and what we should be doing so that people really understand them, I already had a rough draft of a paper ready, and I appreciated being able to talk about it and having the honor to give the plenary talk. I’ve had some of my colleagues, people I deeply value and respect, say, “This issue is important, but the pain community is too small an audience,” so I’m looking to position a larger piece that looks at these inequities, in the future. But it’s important for the pain community to think about this because of how pain controls the quality of people’s lives, and how these inequities are hampering our ability to help people get that quality of life back. It is also important to understand the why, the origin story, and the history of disparities and the health professional’s and scientist’s role in creating and perpetuating these disparities and false narratives. Most people are unaware.

Some colleagues – some senior statesmen in the pain field – have written and said that we need to see more reviews like [the PAIN paper], and the work needs to go beyond the pain space. But you are the first person to interview me about it. People ask me if I’m going to continue to speak about these issues, and I am. It is my science. This is one of the most important issues of our time, and it’s not just pain; it’s in other healthcare areas, too.

But thinking about the pain narratives – and I happen to know a lot about the research – where did we get the hypothesis that Black and Brown people experience pain differently than white people? Why do we think they deserve to be treated differently? People have been starting to ask me to give ground rounds on the topic, which I’m happy to do. But I worry that people want a quick fix because this topic is so painful, but, unfortunately, there is no quick fix. Worse yet is when people believe it is too big a problem and it can’t be fixed. This is a huge issue, and I’m glad that it’s getting attention. We need to pay attention to start making the appropriate changes. I am an optimist and believe we can do better.

One of the cases you’ve discussed in your talks is Irvo Otieno, a young Black man with mental health issues who died in a Virginia mental health facility. Why is his case so important?

It’s interesting: In the talks I’ve given recently, people know about George Floyd and Eric Garner, but when I ask the question, “How many of you know about Irvo Otieno?” no one in the audience knows. This man died, yet his mother asked for help because of his mental health issues. He died in a healthcare setting with handcuffs, shackles, and people watching. We need to ask ourselves who is deserving of handcuffs and shackles. Why was he shackled? Was it because he was dangerous? Or just because he was big and Black? We need to dismantle these narratives one brick at a time until we get down to the foundation. But right now, it’s deeply saddening, because people don’t deserve to die in a healthcare setting in this manner. People come to the hospital for respite and care, and we, as healthcare professionals, should be providing that.

Irvo Otieno is more problematic from a healthcare standpoint than these other cases because he died in our care, although there are others. Race-based disparities and stigma in mental healthcare are well described. Mr. Otieno shows that we haven’t eradicated this type of systemic racism from within our own framework, and it also demonstrates why so many people don’t trust us in the healthcare setting. Until we face and understand these things, we can’t get to a state of health equity.

You have published several studies looking at differences in pain treatment between white and Black patients. You’ve found that Black patients often receive substandard care. Did you expect to see these discrepancies?

Every single time I write a paper on one of these studies, the results surprise me [see here, here and here]. I must credit one of my mentors, James Jackson, who recently died, and my social science colleagues who helped me to put these studies together.

Beyond being surprised by the size of the discrepancies, I am hurt by these results, because I know we can do better. Our biggest challenge in confronting racism, and potentially sexism, stigma, and class-based bias and misconceptions within the healthcare setting is understanding how we let these things happen. Who do we think is allowed to cry in labor? Who is supposed to labor in silence? Who is supposed to be silent in their pain? Who is permitted to get loud? As a dean, I’m thinking about these things on a deeper level.

We know that racism exists in the healthcare setting, but we need to do something about it, and that goes beyond just doing bias training. We need to do some rigorous thinking about why we fear “the other.” We need to collect and share the data and history, so people understand how much these false narratives about pain impact care and science. We need to understand who has and is allowed to have pain, while considering who is deserving of having their pain or any healthcare complaint treated. We need to have a reckoning moment in regard to our patients because we can do better.

If bias training is not enough, how do we change these false narratives about pain so clinicians can provide better, more equitable care?

We already know that some of these stories are just false; we have to start in the educational space. These false narratives are often based on what people look like, and to make assumptions about people based on certain phenotypes is problematic. Unfortunately, it’s also inherent within our healthcare system when you consider race-based treatment algorithms.

What is it about our society that allows us to think that someone who walks in front of us is there to hurt us because of their phenotype? That socialization process begins so early. We don’t know it is happening – we don’t even flinch sometimes when we see it happening – and if we do see it happening, we are ashamed and often do nothing. We need to think about who we hear the good stories about and who we hear the negative stories about. We need to start dismantling these narratives one piece at a time. And I think it can start by having conversations with some people who are patients and members in the community. Have them come in and talk to you about what they experience day to day and within the healthcare setting.

People have the right to high-quality care. These are real people, with real lives, who are dragged out of hospitals, and there is no outcry. If people come to the hospital and healthcare system for respite and care, and there’s a population of people who are not receiving it, we need to do something about it. We need to stand up and say, it’s not okay for someone to be labeled as a problem because of the color of their skin or their condition.

I know there are people who harm clinicians in the healthcare setting, and I’m not trying to minimize that. But some of the people in our study who had security called on them were physicians and professors. This again suggests that socioeconomic status is protective for Caucasians, but it is not protective for Black and Brown people like we found in other studies. We need to look at these issues and understand what it’s all about. And maybe the Joint Commission, medical schools, and accrediting bodies also need to look at this to make sure we are educating healthcare workers to understand these inequities.

I go back to the Irvo Otieno story here because that is a case where this education matters – and so many people in healthcare don’t know about his case.

What do you hope that people take away from the research in this area?

The quality of pain care is problematic and unequal – and it’s particularly problematic and unequal for people of color, and their voices are often unheard and their burden unseen. There’s more research to be done, but changing this starts right here, right now, if we choose to do so. It’s important that we put a spotlight on why these things have gotten to this point.

It didn’t happen in one place or in isolation from other aspects of healthcare. These disparities in pain care are interwoven with false narratives that guide how clinicians provide care, and they are the reason why so many people don’t trust us as healthcare professionals. We can do better.

I’m not saying I have all the answers – I don’t. But by bringing this issue forward, by shining a light on these disparities and why they may occur, we have a chance to make a difference and change things for the better. My hope is that people will read the [PAIN] paper as well as others and start to have some thoughtful conversations and work together, including with patients and communities, to continue dismantling all these false narratives about pain.

Kayt Sukel is a freelance writer based outside of Houston, Texas.

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Kayt Sukel is a passionate traveler and science writer who has no problem tackling interesting (and often taboo) subjects spanning love, sex, science, technology, travel and politics. Her work has appeared in the Atlantic Monthly, New Scientist, USA Today, Pacific Standard, the Washington Post, ISLANDS, Parenting, the Bark, American Baby, National Geographic Traveler, and the AARP Bulletin, among others. She has written stories about out-of-body experiences, artificial intelligence in medicine, new advances in pain treatments, and why one should travel to exotic lands with young children.

She is the author of two books: Dirty Minds: How Our Brains Influence Love, Sex, and Relationships (re-titled as This Is Your Brain on Sex: The Science Behind the Search for Love in paperback) and The Art of Risk: The New Science of Courage, Caution, and Chance.

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