Systemic racism still exists in dermatology

Photo credit: Jonathan Storey - Getty Images
Photo credit: Jonathan Storey – Getty Images

From Harper’s BAZAAR

This year’s Black Lives Matter movement against racial inequality has rightfully ricocheted throughout the world. There’s work to be done across the board, of course, but the beauty industry is beginning to recognise just how much it still has to do to affect meaningful change within its ranks, to tackle its historical lack of diversity and the huge part it has played in systemic racism.

Scrutiny has, in recent years, lasered in on such issues as Caucasian-focused foundation shade ranges, a lack of diverse representation within ad campaigns, and a consistent dismissal of black-owned brands by larger retailers. But, somehow, skincare hasn’t been so under the microscope.

And racism spreads far beyond simply the products we see on the shelves. Skincare routines are more often than not founded on the recommendations, for example, of clinical trials that included only white participants.

So, whether it’s shamefully narrow clinical trials, whitewashing of imagery, the limited terminology used when talking about skin conditions, or the lack of education dermatologists and doctors receive around skincare concerns that Black women often face, such as pigmentation, it’s clear that things need to change.

Pioneering the inclusivity movement within dermatology is The Black Skin Directory. Founded by aesthetician Dija Ayodele, The Black Skin Directory is a platform created to address specific skin conditions that people of colour face and helps find professionals that are equipped to deal with these concerns. Sounds easy right? Unfortunately not. One survey conducted by the platform found that, of 75 Black women asked about finding a skincare professional that could meet their needs, 92 per cent said it was a challenge to find, and access, a professional that could do so.

Building on The Black Skin Directory’s work is The Black Aesthetics Advisory Board, founded in June by members Dija Ayodele, Dr Ifeoma Ejikeme, Dr Tijion Esho and Dr Amiee Vyas. The board aims to educate brands and professionals about Black skin and the need for increased representation within the industry. A giant step in the right direction for dermatology, yes, but there’s more work to be done and it goes right back to the core of the medical industry.

As UK citizens, we all have the right to access high-grade medical care when we need it most, regardless of the colour of our skin, but this isn’t always the case in practise. Hoping to change this is a new wave of medical practitioners that have added ‘activist’ to their already extensive CVs, through campaigning for long overdue change within dermatology. But, without recognising the issues, change can’t begin to happen.

So what exactly needs to change? (Spoiler alert: it’s a lot…)

1.Whitewashed Medical Imagery

It might not be your norm to pick up a medical textbook but, if you do, the majority, if not all, of the imagery within it is likely to be of Caucasian skin. The fallout? A whole generation of doctors being inadequately trained.

Take a skin condition such as eczema: the pictures will often involve inflamed, red skin but this isn’t an accurate depiction of the symptoms among those with dark skin tones, leading to a lot of doctors either dismissing or misdiagnosing a condition.

Skin conditions can be debilitating enough as it is, but to be unable to receive the correct medical advice for it is inexcusable.

Dr Ifeoma Ejikeme recently told Sky News: “There’s a lack of training of what different conditions look like in different ethnic types, what we’re taught in medical school is usually on Caucasian skin case studies.”

Skin Deep is looking to change this. The project is building an online platform of medical images on a range of different skin tones for professionals to refer to when diagnosing skin conditions.

“The motivation for the project is driven by our patients,” explains Holly Wakefield, a founder of the project and Paediatric ED Sister at the Royal London Hospital. “Families who have children with skin conditions end up looking online for images and every image they see in the search results is of children with white skin. Similarly as paediatricians and nurses, we need to be able to recognise and diagnose skin conditions in all our patients.”

The aim is to build a library of diverse imagery that the whole medical community can refer to. Another individual adding to those resources is medical student Malone Mukwende who has created a handbook of clinical signs on a variety of different skin tones, addressing misdiagnoses. Named ‘Mind The Gap’, Mukwende hopes it becomes the norm in medical practice to refer to the handbook.

“On arrival at medical school I noticed the lack of teaching in darker skin,” Mukwende told BME Medics. “We were often being taught to look for symptoms such as red rashes which I was aware would not appear as described in my own skin. When flagging this to tutors it was clear that they didn’t know of any other way to describe these conditions on patients of darker skin tones and I knew that I had to make a change to that.”

“I hope the work makes healthcare professionals aware of some of the biases they may have and know what impact this has on patients,” Mukwende continued. “It is important medical professionals are aware of variation in presenting symptoms when treating the diverse range of patients that they serve. I hope the work will help to increase the confidence of darker skinned patients to seek medical advice.”

This thought is echoed throughout the medical community, with one petition calling for medical schools to include better ethnic minority representation in clinical testing and descriptions to make sure the highest quality of care is available to everyone.


2. Genetic Stereotyping and ‘Race-medicine’

White people have benefited from a medical institution whose studies and research has, for centuries, focussed almost exclusively on fair skin tones – a privilege many of us don’t even consider. Being able to trust that a doctor’s diagnosis is based on tried and tested information rather than guesswork is something that we take for granted.

Michaela Coel’s I May Destroy You provided the UK with a prime example of the systemic racism you can face in a doctors office. Waiting for the results of a blood pressure test, Coel’s character Arabella is told by her doctor that she’s “already at an elevated risk due to being of Afro-Caribbean origin”. Arabella immediately points out the racial ignorance of this statement, because she’s actually African. This might be a fictional vignette, but the portrayal of medical ignorance is all too real.

Doctors assuming a patient’s racial origin based on the colour of their skin, without actually asking them, is a widespread problem and nurtures hugely damaging stereotypes. Dorothy Roberts, a Civil Rights Sociologist and Law Professor at the University of Pennsylvania has been campaigning about these injustices within the medical field for her entire career and serves on the board of the American Academy of Political and Social Science.

In Roberts’ TED Talk from 2015, she explains the real issues with race-based medicine and the myths surrounding the concept:

“Doctors tell me they’re using race as a shortcut. It’s a crude but convenient proxy for more important factors, like muscle mass, enzyme level, genetic traits they just don’t have time to look for. But race is a bad proxy. In many cases, race adds no relevant information at all. It’s just a distraction. But race also tends to overwhelm the clinical measures. It blinds doctors to patients’ symptoms, family illnesses, their history, their own illnesses they might have – all more evidence-based than the patient’s race. Race can’t substitute for these important clinical measures without sacrificing patient well-being. Race medicine also leaves patients of colour especially vulnerable to harmful biases and stereotypes.”

Negative stereotyping is also prevalent within the world of prescription medication, where a cultural pain disparity arises. A study by the AMA Journal of Ethics found that African American patients and Hispanic patients were less likely than white patients to receive any pain medication. If they were given medication, it was at lower doses due to a racial stereotype that they would ‘misuse’ the painkillers. The reality? The same study found that white people were in fact more likely to misuse prescriptions of opioids.

“The reason I’m so passionate about ending race medicine isn’t just because it’s bad medicine,” says Roberts. “I’m also on this mission because the way doctors practice medicine continues to promote a false and toxic view of humanity.”

3. Lack Of Diverse Medical Testing

Rigorous testing is crucial before making anything available to the public, but if you’re only testing a product on white people, how are you supposed to know the full spectrum of potential side effects? And why are we still qualifying this limited testing as ‘rigorous’?

A case study investigating the characterisation of clinical study populations by race and ethnicity in Biomedical literature found that after analysing 1,867 medical journals, only 17.3 per cent reported on race. One particular lung-disease study which was published between 1993 and 2013, showed that less than five per cent of the participants were from minority ethnic groups. Considering ethnic minorities make up for 40% per cent of the United States’ population, this is alarmingly unbalanced.

Having a system rigged towards Caucasian patients by only catering to their medical needs is creating a bias in a field that should be helping everybody.

Dr Keolu Fox, a Native Hawaiian Geneticist and indigenous rights activist, is campaigning for genetic research to be more diverse.

He found that 96 per cent of The Human Genome Project (that cost 2.7 billion and was focused on identifying and understanding human genes for scientific purposes) was solely focused on individuals with European ancestry.

“Just like we have different coloured eyes and hair, we metabolise drugs differently based on the variation in our genomes. So how many of you would be shocked to learn that 95 per cent of clinical trials have also exclusively featured individuals of European ancestry?” Dr Fox stated in his 2016 Ted Talk ‘Why Genetic Research Must Be More Diverse’.

To combat this issue, Dr Fox has developed a genome sequencer small enough to fit in your pocket, to make testing more available to all, “for the people by the people”, to inform and educate the next generation.

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