Today is the oldest nationally celebrated memorial to the end of slavery in the United States. It was on June 19, 1865, when Union soldiers, led by Major General Gordon Granger, arrived in Galveston, Texas, with reports that the war had ended and that the slaves were now free. This was two and a half years after President Lincoln’s proclamation of emancipation, which became official on January 1, 1863. The celebration of June 19th was coined as “Juneteenth” and increased with the participation of former slaves and their descendants.
We, at CHAMP, chose this day to observe Disparities in Headache Diseases Day to bring much-needed awareness to health equity when it comes to migraine and headache. Significant disparities exist among disadvantaged or under-served groups: African Americans, Hispanics, people living in poverty, unemployed or underemployed, uninsured, or under-insured, individuals who have been subjected to long-term traumatic trauma and people who have experienced migraine. Although the burden is excessive, these same groups are consistently under-represented in migraine research (Befus, et al. 2018).
Disparities and Bias in Headache and Migraine
About one in six African Americans in the United States are diagnosed with migraine disease and one in five is diagnosed with tension-type headache. Studies on race-related gaps and possible health care inequalities in people with headache disorders are virtually non-existent. Understanding potential race-related disparities in headache patients may inform the development of culturally contextualized healthcare policies and interventions that are more likely to reduce or eradicate race-related headaches altogether (Bernadette Davantes Heckman and Ashley Joi Britton 2015).
Prior research suggests that if a patient is black, his pain is likely to be underestimated and under-treated compared to a white patient. Nineteenth-century relics that stem from slavery to make slave masters “feel better” about owning slaves have continued to be perpetuated today. In the United States, scientists, doctors, and slave owners championed these beliefs in order to justify both slavery and the inhuman treatment of black men and women in medical research. Prominent doctors in the 19th century tried to establish the “physical peculiarities” of black people that could “distinguish” them from the white person (Hoffman, et al. 2016).
What are some these “physical peculiarities”?
- 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 notions were, unfortunately, found to be endorsed by 50% of medical residents and students in a 2016 study which examined whether racial bias is related to false beliefs about biological differences between blacks and whites (Hoffman, et al. 2016).
What is Bias?
Bias is an algorithm of the mind. We rely on stored information about a person or group of people in order to help make decisions. In the United States, people of color face disparities in access to health care, the quality of care provided and health outcomes. Health care providers’ attitudes and behaviors have been identified as one of many contributing factors to health disparities (William J. Hall, et al. 2015).
Unconscious or implicit bias is ingrained habits of thought that lead to errors in how we perceive, reason, remember and make decisions. Negative implicit attitudes toward people of color can contribute to racial/ethnic health and health care disparities. For the past 20-30 years, unconscious bias has been the leading reason for inequity in our country. Compared to their white counterparts, black headache patients are more likely to:
- be diagnosed with comorbid depressive disorders
- register more frequent and severe headaches
- under-diagnosed and/or under-treated headaches
- discontinue care early, regardless of socioeconomic class
It is likely that patient-physician contact (PPC) and/or level of trust can affect the treatment provided to individuals. It appears that ethnic minorities are more skeptical about the health care system and have a more negative view of perception of the PPC. While assessing potential ethnic disparities in migraine care, it is important to determine not only whether people of different ethnicities living with migraine have access to and receive equal care, but also whether they have similar perceptions of trust and communication with their health care provider.
Owing to a storied history of oppression and violence, African Americans express greater distrust in the medical community than whites (Befus, et al. 2018). Ways that subtle biases can be conveyed that affect PPC are by:
- approaching patients with a dominant and patronizing tone that reduces the likelihood that patients will feel heard and valued by their providers when needed
- doing more or less thorough diagnostic work
- recommending different treatment options for patients on the basis of assumptions about their ability to adhere to treatment
Differences in Headache Treatment
African Americans living with headache disorders face more headache treatment barriers than Caucasian Americans do. In a study of 77 African Americans and 54 Caucasian Americans who had moderate to severe symptoms of migraine and waited for treatment of a variety of primary care diseases, 46% of African Americans were less likely than 72% of the Caucasian Americans to receive treatment for migraine disorder in their primary health clinic. In the prescription of acute medications, African Americans were less likely to receive one (14%) in comparison to their white counterparts (37%). During emergency department visits where headache is the primary complaint, African Americans are 4.8 times less likely to receive computed tomography (CT) than Caucasian Americans to diagnose the etiology of their headache (Bernadette Davantes Heckman and Ashley Joi Britton 2015, 42-43).
Check Your Bias
Know your implicit bias(es) and learn how your brain is primed to see people. These biases influence how you make split-second decisions, especially under stressful situations. Project Implicit is an organization dedicated to “educate the public about hidden biases and to provide a ‘virtual laboratory’ for collecting data on the internet.” This tool is a great exercise in self-awareness. Remember, implicit or unconscious bias not the same as conscious bias. Examples of conscious bias are racism, sexism, antisemitism, islamophobia, and transphobia.
Project Implicit offers a free Implicit Association Test (IAT), a questionnaire that aims to measure the implicit bias of test-takers by challenging them to connect black and white faces with pleasant and unpleasant terms under extreme time constraints. Takers tend to equate white faces and nice words better than with black faces and pleasant words.
One way to hack implicit bias is through social contact. Ask yourself:
- Who are your intimate friends
- What are their backgrounds
- What ethnic backgrounds do they come from
- What are their histories
Begin introducing prejudice habit-breaking interventions that will create long-term implicit bias reductions (Devine, et al. 2012). You can do this by applying the following strategies:
- Replacing stereotypes with unbiased responses
- Counter negative stereotypes and imagery
- Individuate rather than be “color blind”
- Take the perspective of the stereotyped group
- Seek opportunities to engage and create positive interactions with other groups
This YouTube video is another example on how implicit bias impacts health care and creates disparity:
Befus, Deanna R., Megan Bennett Irby, Remy R. Coeytaux, and Donald B. Penzien. 2018. “A Critical Exploration of Migraine as a Health Disparity: the Imperative of an Equity-Oriented, Intersectional Approach.” Current Pain and Headache Reports 22:79; 1-8.
Bernadette Davantes Heckman, PhD, and MSEd Ashley Joi Britton. 2015. “Headache in African Americans: An Overlooked Disparity.” Journal of the National Medical Association 39-44.
Devine, Patricia G., Patrick S. Forscher, Anthony J. Austin, and William T. L. Cox. 2012. “Long-term reduction in implicit race bias: A prejudice habit-breaking intervention.” Journal of Experimental Psychology 1267-1278.
Hoffman, Kelly M., Sophie Trawalter, Jordan R. Axt, and M. Norman Oliver. 2016. “Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites.” Proceedings of the National Academy of Sciences 4296-4301.
William J. Hall, PhD, PhD Mimi V. Chapman, MS Kent M. Lee, Yesenia M. Merina MPH, MPH Tainayah W. Thomas, PhD B. Keith Payne, DrPH Eugenia Eng, MCP Steven H. Day, and MD Tamera Coyne-Beasley. 2015. “Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review.” American Journal of Public Health 60-76.