On The Topic Of Bame Representation In Medicine

The Problem with BAME Underrepresentation

The white patient is shown as default and the black/brown patient as the asterisk - Jules Lipoff, dermatologist at the University of Pennsylvania

As a medical student, I look at a multitude of cases and ailments throughout my learning. My brain is filled with images of atopic eczema, diabetic rashes or chicken pox scars. However, I notice a defining similarity between these images. They are all presenting white skin.

The lack of representation of BAME (Black and Minority Ethnicities) patients is not a recent phenomena this issue stems from the integrated racism rooted within medical history, education and research. The latter has been used as a means to justify the false narratives placed upon different races- attempting to highlight differences between black and white skin. Dr Thomas Hamilton, a renowned physician utilised painful practices such as blistering darker skin to prove this narrative. Following this, the Tuskegee Syphilis trails tragically exposes the dark truth to the origins of medical research and education- it holds racism and discrimination within its roots and the lack of representation in medical education is product of history. (Smith and Thorne, 2020)

In 2016, a study carried out asked medical students whether they perceive darker skin to be thicker than lighter skin (an inaccurate theory derived from Dr Hamilton). Unfortunately, response from the students confirmed the theory s persistence within contemporary medical education (Baines, 2018). This deep rooted perception of racial divisions is still prevalent within modern day medicine and the lack of BAME representation only exacerbates this issue further. In 2018, the University of Washington published the first study into racial diversity in textbooks. The results highlighted the immense lack of representation of BAME groups within the medical education system. With the Atlas of Human Anatomy a popularly learning tool utilised by medical schools globally, holding less than 1% of images featuring dark skin. The highest percentage reached 8%, in Bate s Guide to Physical Examination and History Taking (McFarling, 2020). These poor results truly magnify the issue of BAME ill-representation in medical education.

The lack of BAME representation is not only limited to images in textbooks and presentations but it affects the reality of medical practice. The scarcity of exposure to skin conditions on all skin tones means that practitioners are ill prepared when treating said conditions on darker skin. They fail to recognise and diagnose the ailment under observation- thus resulting in an increased likelihood of misdiagnosis, misinformation and mismanagement (Prescod, 2018). This notion has been confirmed with non- white patients having a higher rate of mortality and mortality associated with dermatological disease, paired with the fact that black patients are more likely to die from skin cancer even though skin cancer is more prevalent in white populations (Smith and Thorne, 2020). The issue of a lack of BAME representation is fatal.

Contrasting clinical presentations of Kawasaki Disease across different skin colours

(Change, 2021)

While I have been focusing on the limited amount of BAME coverage in physical presentations of skin conditions language is an prevalent driver of this white- centred medical narrative. When looking at the NHS website, descri ptions of symptoms heavily focus on lighter skin tones with a rash being described as red or pink and the colouration of jaundice being orange tinted . These descri ptions are accurate, but only when observing lighter skin (Baines, 2020). Again, this lack of information given to readers means those with darker skin cannot identify with the written symptoms- therefore, failing to recognise certain conditions and thus leading to future complications regarding late diagnosis and infection. During the COVID-19 pandemic, patients were asked if their skin had gone pale or their lips had turned blue . This language catered for lighter tones, meaning those with darker skin fell into a state of confusion and uncertainty regarding their health and physicians were less likely to diagnose the viral disease due to the failure to identify symptoms on darker tones (Prescod, 2020). This lack of understanding and identification stems from lighter-skin being focused on during clinical teaching and potentially, exacerbating the racial inequality seen in healthcare treatment.

Looking towards the future of healthcare, technology is constantly being developed and integrated into clinical practice. It holds the potential to grow and improve the healthcare system however, it also holds the capability to deepen the racial divide within healthcare treatment and management. In order for devices and equipment to be manufactured, trials and research must be carried out. Within this world of innovation, the white -centred narrative still prevails and BAME representation is still undermined (McFarling, 2020). Meaning that algorithms and datasets will be more likely to facilitate and respond to lighter skin tones- forming a potential for inaccuracy and systematic errors when dealing with darker tones (Prescod, 2018). This holds damaging implications for technological advancements focused on critical care and surgical procedures as the programming fails to equally recognise and respond to all skin tones- creating a backdrop which potentially facilitates malpractice on darker skin tones.

When researching this topic, I had noticed an alarming reflection when regarding racial divisions and biases within the medical system. Within medical textbooks, it has been recorded that skin conditions with sexual origins were twice as likely to be shown using a patient with dark skin compared to light skin. This leads to the larger problem with intrinsic racism within the healthcare system (McFarling, 2020). Harmful sexual infections were connoted to dark skin- distorting the perception of race and sexual health and thus, pushing discriminatory perceptions further into the education of future generation physicians.

BAME representation in Medicine: A Solution

Understanding the issue of scarce BAME representation means that the medical world, as a collective, can work towards a future of representation and equality within the healthcare system.

Inspiring organisations like White Coats for Black Lives have been created in response to the poor representation of black patients in clinical education and the discrimination faced by black medical students. These cohorts work towards dismantling the systemic racism grown within the medical system by supporting BAME students and ensuring that they thrive within such a system (Smith and Thorne, 2020).

When regarding education, St George s student, Malone Mukwende, created an educational resource, Mind the Gap, which showed the symptoms of an array of skin conditions on a multitude of skin tones. His inspiration stemmed from the lack of BAME images he saw in his medical students prompting him to reach out to his tutors and work towards making a resource that represents ailments on darker skin tones. He utilised social media posts from the public, displaying their skin conditions and ailments. This was prompted after receiving a lack of support from the British Association of Dermatologists. Mind the Gap has aided medical students and the public in recognising certain conditions on a larger range of skin tones, increasing the likelihood of accurate diagnoses and treatments with darker toned patients. The book is a step in the right direction when concerning BAME representation within the medical world currently, Mind the Gap is being included in 8 UK medical school recommended reading lists (Baines, 2018 and Mukwende et al, 2020). Dermatological textbooks which represent black and brown skin are crucial in tackling the internalised racism present within the medical education system, and hopefully push for a future with equal knowledge and risk perception of diseases on all skin tones

Other sites and organisations include The Black Skin Directory, addressing the differences in presentations of skin conditions on a multitude of skin tones thus allowing the public to easily and accessibility utilise the resource to their advantage. Weiss, a mother from Raligh posted images of skin conditions in darker skin next to images of the same condition in white skin and asked followers to send more photos this formed the Instagram account Brown Skin Matters . The site has been used by medical schools, physicians, nurses and pharmacists as a diagnostic tool, which is currently in the process of being developed with medical experts to create a web based tool for healthcare organisations (Prescod, 2018). As said by sociologist and researcher Rima Wilkes people need to see themselves across all diseases , this sentiment must be used by the medical world. Hopefully, inspiring future textbook publications, manufacturers and researchers to utilise the lessons brought upon by this movement towards BAME representation in the future of healthcare.