Jules Lipoff, a board-certified dermatologist in Philadelphia and clinical associate professor at the Lewis Katz School of Medicine stated that “The white patient is shown as default, while the black/brown patient is the asterisk”. The problems faced by ethnic minorities in healthcare is a complex and prominent topic within the medical community which holds years of history and unequal dynamics at its core. Therefore, it is imperative that the conversation surrounding the lack of ethnic minority representation in medical education is had. As well as how this impacts clinical practice and what can be done to prepare future practitioners in recognising and treating patients of all skin types.

The lack of representation in ethnic minority patients is not a recent phenomenon. This issue stems from the integrated racism rooted within medical history, education and research. The latter has been used to justify the false narratives placed upon different races in attempts to create inaccurate perceptions of certain groups. A prominent example of these historic narratives being exacerbated by healthcare professionals includes figures like Dr Thomas Thomas Hamilton, who was a renowned physician in the 1800s. Dr Hamilton utilized painful practices such as the blistering of darker skin to prove the narrative of differences between darker and lighter skin, such as thickness and pain tolerance. Following this, the Tuskegee syphilis trials from 1932-1972 tragically exposed the dark truth about the origins of medical research and education, highlighting how it holds racism and discrimination within its roots. These effects can be translated into contemporary settings. In 2016, a study carried out in the US asked medical students whether they perceived darker skin to be thicker than lighter skin (an inaccurate theory that was derived from experiments conducted by people like Dr Hamilton). Unfortunately, one-third of those students still held that notion. This highlights that a deep-rooted perception of racial divisions is still prevalent within modern-day medicine

In 2018, the University of Washington published the first study into racial diversity in textbooks. It highlighted the immense lack of representation of ethnic minorities within the medical education system. One notable textbook, The Atlas of Human Anatomy, a popular learning tool utilized by medical schools globally, alongside other textbooks was investigated. The results found that within these textbooks, dermatological presentations allocated 74.5% for light skin tone representation, 21% for medium, and 4.5% for darker skin. While bodies such as the General Medical Council and the British Medical Association have taken steps to raise awareness about diversity and inclusion in medical education, further actions need to be taken to ensure a change is made to medical education in the long term. 

Another paper noticed that skin conditions of sexual origins were twice as likely to be shown in patients who had darker skin compared to light skin. Within this example, there is a harmful association between sexual infections and darker skin, which we know isn't accurate for these conditions and the demographic they affect. The harmful sexual infections associated with darker skin distort the perception of race and sexual health; it also pushes this discriminatory perception further into the education of our future generation of physicians. Following this argument, the research found that non-white patients had a higher rate of mortality associated with dermatological diseases. Another paper also noted that black patients were more likely to die from skin cancer even though skin cancers are more prevalent in white populations. Looking at those statistics, one can magnify how a lack of ethnic minority representation is transferred to the real-life consequences of clinical practice. 

Looking at the National Health Service public resources, there was a disproportionate reliance on descriptors focusing on lighter skin tones; with rashes being described as red or pink, and the colouration of jaundice being orange tinted. While some sentences did acknowledge darker skin tones in conditions such as dermatitis; there was a lack of adequate language and visual stimuli when describing varied skin tones seen in different minority groups. However, figures like St Georges’ alumni, Malone Mukwende, have made steps to tackle this representation problem. His release of Mind the Gap, a medical resource created by Mukwende, has aided medical students and the public in recognising dermatological conditions on a large range of skin tones. Mind The Gap is currently being used at eight UK medical schools in their recommended reading list.

It is vital that the issue of ethnic minority representation is understood and campaigned for in the medical community. This will drive the movement towards a future of proportionate representation within medical education; and in turn, improve the recognition rate and risk perception of diseases in all skin tones.

References

1. Smith, M. and Thorne, T., More Than Skin Deep: Underrepresentation of Brown and Black Skin in Medical Education. in-Training 2020;  Available at: <https://in-training.org/more-than-skin-deep-underrepresentation-of-brown-and-black-skin-in-medical-education-20360> 

2. PARK, J. Historical Origins of the Tuskegee Experiment: The Dilemma of Public Health in the United States. Korean Journal of Medical History 2017; 26(3), 545–578. https://doi.org/10.13081/kjmh.2017.26.545 

3. Bains, C. Lack of racial diversity in medical textbooks could mean inequity in care, studies suggests. CBC website 2018; Available at: https://www.cbc.ca/news/health/racial-diversity-medical-textbooks-1.4562352

4. ‌Cummins, A. Are “whitewashed” medical textbooks putting black lives at risk? The Mancunion 2020. Available at: https://mancunion.com/2020/10/23/are-whitewashed-medical-textbooks-putting-black-lives-at-risk/#The%20First%20Study%20Into%20Medical%20Textbook%20Diversity

5. NHS Choices. Overview; Contact dermatitis 2023. Available at: https://www.nhs.uk/conditions/contact-dermatitis/

6. ‌Usha Lee McFarling. Dermatology faces a reckoning: Lack of darker skin in textbooks and journals harms care for patients of colour. STAT 2020. Available at: https://www.statnews.com/2020/07/21/dermatology-faces-reckoning-lack-of-darker-skin-in-textbooks-journals-harms-patients-of-color/

7. ‌Jewkes, R., & Dunkle, K. Drivers of ethnic disparities in sexual health in the UK. The Lancet Public Health 2017; 2(10), e441–e442. https://doi.org/10.1016/s2468-2667(17)30182-2

8. ‌Buster, K. J., Stevens, E. I., & Elmets, C. A. Dermatologic Health Disparities. Dermatologic Clinics 2012; 30(1), 53–59. https://doi.org/10.1016/j.det.2011.08.002

9. Mukwende, Malone; Tamony, Peter; Turner, Margot: Mind the Gap: A handbook of clinical signs in Black and Brown skin. St George's, University of London 2020 https://doi.org/10.24376/rd.sgul.12769988.v1