Red spots, pink rashes… these are not just presentations of chickenpox but also symptoms of racial bias in medicine.
COVID may have cast a spotlight on health inequalities, but some are still hiding in plain sight.
Third-year medical student Naabil Khan had noticed the textbooks and online images she was studying had a marked bias towards white skin – and decided to rectify this.
She has created a website which demonstrates in words and pictures the varied ways different skin conditions present on skins of different colours.
Her ambition is not limited to improving representation in medical education. She wants to amplify a growing conversation about racial bias in medicine more generally and give patients the tools to start addressing it, too.
‘Everyone deserves to be treated with the same level of competence and respect by the medical profession,’ says Ms Khan. ‘People of colour are not “different”: everyone has their place in society.’
'Going pale'
It was the COVID pandemic – and its lesson about diseases’ potential to affect different racial groups differently – which fuelled Ms Khan’s growing interest in representation in medicine.
‘During COVID, patients were asked if their skin had gone “pale” or their lips had turned “blue”,’ she says. ‘These descriptions are accurate, but only when observing lighter skin.’
So, one of the aims of her website, Skin For All, is to educate medical students. Each condition’s listing has notes which include epidemiology, pathophysiology, investigations and management – as well as photos showing different presentations on different skin colours.
During COVID, patients were asked if their skin had gone “pale” or their lips had turned “blue”.’ These descriptions are accurate, but only when observing lighter skinDr Khan
Lyme disease, for example, which often presents as a bull’s eye rash in lighter skin can appear more like a bruise in darker skin.
The ability to recognise conditions on all skin types is particularly important in conditions such as melanoma where early diagnosis can strongly affect a patient’s prognosis.
Yet, Ms Khan was shocked to find family members studying medicine in Pakistan were also using textbooks with images of predominantly white skin such as Netter’s Clinical Anatomy or Gray’s Anatomy.
‘As medical students and clinicians, we have a duty to treat everyone equally,’ says Ms Khan, ‘and that means being able to understand what a condition looks like and carry out the right treatment.’
Fear and mistrust
Diagnosis, of course, depends on patients coming forward for consultation.
Skin For All is not the first such online directory of skin conditions but it is distinctive in its appeal to a non-medical readership too.
Listings also include explanations in plainer English, common ‘myths’ (such as skin cancers being confined to sun-exposed parts of the body) and ‘Questions to ask your doctor’.
These questions are particularly aimed at people who feel intimidated by the prospect of visiting their GP – which applies to many older members of Ms Khan’s own South Asian community.
She says people still refer to South Asian women in Coventry being given chapatis containing radioactive iron in 1969, apparently without their informed consent, during research into higher levels of anaemia in their community.
People of colour are not “different”: everyone has their place in societyDr Khan
She says people still refer to South Asian women in Coventry being given chapatis containing radioactive iron in 1969, apparently without their informed consent, during research into higher levels of anaemia in their community.
Others fear they won’t be taken seriously because of ‘Mrs Begum syndrome’ – the tendency to dismiss older Asian women as exaggerating their pain.
‘It can take a lot of courage to go to a GP especially if you have that background of mistrust,’ says Ms Khan. ‘And trying to get your point across, when you’ve not had access to resources that show people like you, can be really challenging, too.’
The significantly worse outcomes for people of colour with skin cancer, compared with non-Hispanic whites, despite a lower incidence of skin cancer in darker skins, are partly due to late-stage diagnosis, which is three times more likely to occur.
Inclusive conversations
Momentum to address racial bias in medicine is growing and Ms Khan believes medical schools, including Exeter University where she is a student, are making progress.
She is concerned, however, that the focus on equality, diversity and inclusion can sometimes feel ‘tacked on’ or ‘something to think about in your own time’.
A way medical schools could start to address inclusion is more teaching
on inclusive conversations, she feels.
‘It is important to say to a patient, “I’m here to help you. Is there anything you need? Would you like a female to talk to you? Would you like me to address you in a certain way?” These small things can make a huge difference in building rapport and making the patient feel supported, especially where there’s a lack of trust.’
However, this conversation about representation in medicine needs to be global. Ms Khan can’t help but notice the clinical research she is studying still has a strong bias towards white patient groups. ‘People of colour are either not included or homogenised into one category, such as black, Asian and minority ethnic.’
Ms Khan cites US dermatologist Jules Lipoff and his analysis that ‘the white patient is shown as default and the black/brown patient as the asterisk’.
‘Being treated as “other”, as the asterisk, can be demoralising and dehumanising,’ says Ms Khan. ‘We must make sure that black, brown and other ethnic-minority groups don’t feel like the afterthought or add-on.’