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Racial disparities in health care are a well-documented phenomenon, spanning every area of medicine from the birthing room to the ICU. Now, a recent study shows yet another place black people are treated differently from nonblack patients: the back of an ambulance.

In a study reported by NPR, researchers found emergency medical technicians and paramedics were 40 percent less likely to give black patients pain medication than white patients.

The study, which came out of Oregon and was presented at the Institute for Healthcare Improvement Scientific Symposium in Orlando, Fla., last December, analyzed 104,000 medical charts of ambulance patients between 2015 and 2017. Even when factoring in health insurance status or socioeconomic background, the trend held true: Black patients were less likely to be given morphine or other medications that could help treat their pain.

Researchers noted that this was likely not due to outright discrimination, but unconscious bias, where emergency personnel either distrusted black patients’ pain, didn’t see it, or didn’t consider it necessary to treat.

The study builds on an ever-growing collection of data cataloguing how bias permeates American health care. There is the oft-cited 2016 University of Virginia Study, which found white medical students held false beliefs about the differences between black and white patients.

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Among 222 participants, half thought at least one of the following were true: that black people age more slowly than whites, that their nerve endings were less sensitive, their blood coagulated more quickly, or their skin was thicker (none of this, of course, is factual). Importantly, the students who believed these things were more likely to report lower pain ratings for a sample black patient than for a white patient.

Another recent study reveals how implicit bias operates on gender lines as well, finding that women are more likely to survive heart attacks if they’re treated by female doctors; this was largely because of how male physicians “appear to have trouble treating female patients,” the research team wrote.

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One black woman physician and former EMT, Dr. Leslie Gregory, spoke to NPR about her experiences as a first responder, saying the study held true to what she had seen. She noted that while distrust among African Americans toward the medical community could certainly play a role in diminished health outcomes (black people are less likely to trust clinical research, and to visit doctors on a nonemergency basis than their white counterparts)—that distrust wasn’t unwarranted.

“How can a person of color not disrespect a system that is constantly studying and talking about these disparities, but does nothing to fix it?” Gregory said.