In considering medical discrimination, researchers typically take a micro-level approach that focuses on the biases of individual healthcare providers. Yet, individual biases alone cannot clarify the noticeable racial gaps in affirmative healthcare. Instead, careful analysis of resources in medical training may reveal the consequences of white-centric approaches to medical education. For instance, a google search of any common disease results in very few illustrations without light-skinned patients. Even worse, most ordinary medical journals or textbooks contain mostly illustrations of white patients. By investigating the lack of visual diversity in medical textbooks, researchers can minimize the effects of macro-level influences on medical discrimination.
Medical journals and textbooks remain the primary form of medical education, yet medical imagery and medical language both fall behind in ensuring diverse representation. Medical illustration was not a professional industry until the late nineteenth century; currently, there are less than 2,000 trained medical illustrators, with nearly 8% being people of color. This lack of diversity within the medical illustration industry plays a large role in disproportionate representation in textbooks provided for medical training. A leading study of over 4,000 images in four of the most common medical textbooks in American medical schools found that less than 5% of illustrations in all of the textbooks depict darker skin. Notably, in one of the four textbooks, less than 1% of images represent dark skin. A similar analysis by Jules Lipoff, an assistant professor of clinical dermatology at the University of Pennsylvania, found that the portion of illustrations portraying dark skin in medical textbooks can be as low as 4% .
Within the small quantity of images that do depict dark skin, they typically represent infectious diseases, primarily sexually transmitted diseases. Jenna Lester, an assistant professor of dermatology at the University of California San Francisco, found that less than 30% of illustrations for infectious diseases use images of darker skin while over 50% of illustrations for sexually transmitted infections use images of darker skin. This pattern of unequal representation is also present in professional medical language. The National Health Service (NHS) website, as a common source for public health information, frequently uses white-centric descriptions regarding the symptoms of various medical conditions. For instance, terms like “blue lips” describing pneumonia, or “pink rashes” describing excema, make it challenging to identify both conditions in non-white patients.
While textbooks provide the essentials for medical training, racial underrepresentation can lead to a lack of diagnoses and serious misdiagnoses within the healthcare field that promote unequal health consequences by race. For example, there is an absence of imagery depicting skin cancer types on Black skin. To diagnose skin cancer, doctors search for pigmentation on the nails, hands, and feet. However, in a previous study of American medical textbooks, researchers found no images of skin cancer pigmentation on darker-skinned patients. In relation to this phenomenon, there is a gap in skin cancer diagnosis between Black and White patients. Data indicates that over 50% of skin cancer patients who are Black receive their diagnosis at an advanced stage while only 16% of skin cancer patients who are White receive their diagnosis at an advanced stage. Accordingly, researchers contend that mortality rates for certain cancers, including skin cancer, are higher for Black patients due to the gap in early-stage cancer diagnoses. For doctors to appropriately assess diseases, in patients of color, they need access to textbooks and journals that have diverse imagery of various medical conditions. Furthermore, if medical imagery expands to be more reflective of darker skin tones, this may inspire more diversity within medical schools and institutions.
The dearth of diverse medical imagery also has negative implications within the context of the COVID-19 pandemic. While rashes are cited as a COVID-19 symptom, medical literature fails to illustrate rashes related to COVID-19 on Black skin. Online resources fare no better, with articles on COVID19 nearly always displaying rashes on lighter-skinned patients. Failure to provide diverse COVID-19 medical imagery may play a substantial role in Black patients' higher COVID-19 mortality rates.
Although studies indicate that medical imagery in today’s textbooks has had little transformation within the past 15 years, notable steps are being taken to improve this lack of visual diversity. For instance, the Association of Medical Illustrators introduced a diversity committee in 2018, promoting more racial representation in the medical illustration industry. Additionally, there have been instances of dermatology clinics aimed at treating patients with darker skin. In the late 1990s, dermatologist Susan Taylor founded America’s earliest “Skin of Color'' dermatology clinic. By 2004, Taylor established the Skin of Color Society to support the dermatology industry in treating darker-skinned patients. Moreover, younger medical students have also joined the initiative for diverse medical imagery. Malone Mukwende, a St George’s medical student, created a handbook titled Mind the Gap, showing medical symptoms on a variety of skin tones. Following the success of his handbook, Mukwende created a public database for people to submit images of various conditions on different skin tones. With new steps being taken to increase the presence of diverse skin tones in medical illustration, it remains imperative that medical institutions continue to modify their curriculum and training to appropriately incorporate these changes. As we shift away from a white-centric mode of medical training, healthcare workers will be better equipped to diagnose and treat patients of color.
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