Medicine Cannot Remain Colorblind

Attending Harvard Medical School’s Media & Medicine postgraduate certificate program in 2019 and 2020, I learned to pay close attention to the many untold medical stories that impact people’s lives – especially minorities’ — and this is even more critical during a pandemic.

At a recent visit to a clinic in Acton, Mass. – a well-to-do and increasingly diverse outer suburb – a very helpful and kind white nurse, going down the generic list of potential symptoms during triage, asked me if I had noticed any red rash on my skin. I looked down, stared at my arm, and saw dark skin. Mahogany. Skin that Americans would call Black. I raised my head, looked into her eyes, and gently smiled. She smiled back. Wanting to make sure the nurse did not misinterpret my silence, I replied to her that my skin was too dark to show a red rash, and joked that the only red things I could easily notice on skin like mine were blood and red paint.

It is necessary for me to point out that it was a white nurse because I suspect that it probably never crossed her mind that not all races or skin tones exhibit the same changes in color due to skin conditions. It is probably not a conversation that happens frequently, especially in a suburb. Would a Black nurse have asked me the same question? I do not know.

My curiosity was piqued. When I arrived home from my visit to the clinic, I did a quick internet search of skin rash images. To no surprise, there was not a single image of dark skin to look at for comparison on the entire first page of search results. In a world where 17.2 percent of the population is African, how is it that there were hardly any reference images of dark skin? According to the U.S. Census, more than 40 million Americans are Black. The absence of photos highlighting dermatological conditions on dark skin troubles me – it could be playing a big role in diagnostic disparities.

The reality is that our health care system was designed for lighter skin. This creates an inherent racial bias, a significant health care challenge that I refer to as the “color of medicine.” This is confirmed by the exclusion of dark skin in dermatological and diagnostic reference content, leading to diagnostic disadvantages for Black or dark-skinned patients. Some conditions are not easily diagnosed on Black people if health care workers cannot appropriately identify disease manifestations on pigmented skin, either due to inadequate training or limited exposure. This has created a gap in timely diagnoses of symptoms among people in this racial demographic.

Recently, news about the sudden Covid-19 related deaths of a relative and other people I knew drove my curiosity about emergency signs of Covid-19. I browsed through the Centers for Disease Control and Prevention website for information about dermatology-related symptoms of Covid-19. According to the CDC, one sign that you should seek emergency medical care is “bluish lips or face.” I have never in my life seen a Black person with bluish lips or face — this description is applicable to light, white, or Asian skin. What is sad, inexcusable, and dangerous is that the CDC provides no alternative description of how an emergency sign, that can lead to loss of life if undetected, might present on dark skin. A quick image search for “Covid-19 toes” also found no reference images for how the symptom manifests itself in dark-skinned patients.

This is a wake-up call for our health care system. We need to open our eyes: Our research and the information we share should reflect the diversity of skin color that exists in our country, and we need to recognize that people with dark skin deserve equal quality of care.

Medical education must prepare health care workers to appropriately diagnose and treat patients with dark skin — and it must be reflected in medical textbooks and educational content. If providers lack appropriate education or training Black patients and their families face devastating results including incorrect diagnoses or treatment leading to poor physical or mental health, loss of income, and even loss of life.

We must advocate for inclusivity by raising awareness of these glaring gaps. It is time for our health care system to evolve into one which cares for and protects every color.

Vivian Kobusingye Birchall is a graduate of the Harvard Medical School Media and Medicine Certificate Program.

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