The picture that shows why we need to talk about health inequality

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Few could forget how pivotal the past 18 months has been, not just for our health in the wake of a devastating pandemic but for race relations as well.

In the wake of the Black Lives Matter resurgence after the death of George Floyd, people have continued to look at ways the experiences of people of colour differ from others.

Among the many ways we are trying to address the inequalities in our society, one of those is how diseases show up on our skin.

Changes in skin, often marked by redness, are one way of raising alarm bells over a medical condition, but darker skin may show no redness at all.

St George’s University medical student Malone Mukwende, 21, heading into his fourth year, felt there was not enough information or awareness about this issue, and a year ago, published a handbook designed to help identify how skin diseases appear on darker skin tones.

Since the publication of Mind the Gap, Mukwende says healthcare professionals have been seeking out his website, blackandbrownskin.co.uk for advice and insights.

Mind the Gap, the brainchild of Malone Mukwende (Malone Mukwende)
Mind the Gap, the brainchild of Malone Mukwende (Malone Mukwende)

It has been read at least 270,000 times in 110 countries and used by London Ambulance, and the US Navy.

“When a patient comes in and they are not entirely convinced of their diagnosis, sometimes the doctor will send them to our website where there is a similar picture and they can get reassurance that this looks the same," he tells Yahoo News UK.

“I have the lived experience so I can tell you what a bruise looks like on my skin, or what inflammation looks like, but that’s only because I’ve seen it on myself, not because I have been taught.

"People need to be taught these things instead.”

The picture below was provided to Yahoo News UK by Brown Skin Matters - a community sourced database of dermatological conditions on non-white skin. It shows a comparison between the way nummular dermatitis, which causes itchy, swollen, and cracked patches of skin shows up on Black skin and white skin. The diagnosis was given by the patient's physician according to Brown Skin Matters.

An example of how darker skin can show no redness at all, appearing less severe (Brown Skin Matters)
An example of how darker skin can show no redness at all, appearing less severe and can therefore be treated with less urgency (Brown Skin Matters)

Malone said the emails and thank you messages he has received show that “people all over the world are being impacted and are benefiting from what we are doing”.

Now, Malone says more needs to be done with healthcare professionals and those affected by the conditions but believes ultimately the onus is on the government.

He said: “Public health is a governmental responsibility and the fact that health inequalities exist is a public health issue. However the time it will take from the government to implement these things will be a very long time, so then it starts to fall down to organisations which are slightly below them and then eventually it just gets to individuals.”

He believes there can be dangerous consequences where this issue may not be addressed properly, as seen with Dr Kanayo Dike-Oduah. She nearly died after being sent home by doctors with just ibuprofen, suffering with Stevens-Johnson syndrome which affects the skin and mucous membranes.

Doctors initially said the symptoms didn't look serious and that they could not recognise her condition.

Her sister showed a photo of her face to a local pharmacist, who said she needed to be taken to hospital immediately.

After being resuscitated at a third hospital, a consultant who looked like her recognised the seriousness of her condition.

She said doctors did not take her medical history, but her initial illness was brought on by a reaction to carbamazepine - a medication that Black women and Asian women are known for reacting badly to.

Dr Dike-Oduah said she was not warned about the potential side effects of the medication, which was given to her for a tooth ache.

She said "...there is history of women who have been turned away because it doesn’t look like what they [some doctors] have seen before."

"If their curriculum doesn’t account for what certain diseases look like on dark skin, then the fault lies in the fact that they haven’t been shown.’

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Malone says there are other major issues surrounding Black experience in healthcare.

Currently, Black women are five times more likely to die in pregnancy and childbirth compared to white women, according to the UK Confidential Enquiry into Maternal Deaths.

“That is a very serious statistic that we should be doing absolutely everything we can to make sure that number is not five times more”, he said.

“The issue I’m raising is just about skin tones and differences in the medical curriculum which in my opinion is at the top of the iceberg, and everything else under that which is precipitating all the other health inequalities are just below the iceberg,” he added.

Malone Mukwende
Malone Mukwende's work has siginificant implications for the healthcare sector. (Malone Mukwende)

Other work in the healthcare sector has also been done to raise awareness and create actionable change.

Dr Tanya Bleiker, President of the British Association of Dermatologists (BAD) said the BLM protests last year gave momentum to existing projects: “Last year’s Black Lives Matter movement was an important moment in history. It started new conversations and saw the start of new projects, such as Mind the Gap.

“The main challenge facing medical schools, with regard to dermatology, remains ensuring that students get sufficient direct clinical experience and patient contact. Effective and sustained change needs several things; national uptake, excellent training resources, real-world experience, and appropriate assessment. The BAD’s undergraduate workstream works with medical schools to support them in this.”

BAD released their third edition of a handbook for medical students and junior doctors last year, featuring new sections on pigmentation disorders, keloid scarring, and more images depicting skin disease in skin of colour.

Dr Bleiker added it was “important not to forget” the work that had been done already, and highlighted that the association established a skin diversity sub-committee which put together a list of resources last year for healthcare professionals looking to educate themselves further.

The association also hosted its first annual Skin Training Day in January this year featuring experts from the industry to discuss what more could be done.

The Catch-up sign up
The Catch-up sign up

Lisa Bickerstaffe, British Skin Foundation spokesperson told Yahoo it is important that their spokespeople reflect the diverse range of healthcare professionals in the UK and can speak from experience about skin of colour.

“We are committed to helping amplify voices of people of colour both within the research and dermatology community and those who have skin conditions. With this in mind we always welcome initiatives such as Malone Mukwende’s Mind the Gap book," she said.

Malone said: “This is something that I know the people from my community will really really benefit from.”

His family members are, he says, “super proud, super excited about the work when it came out and how far it had reached.”

He said his peers were “more than willing” to learn, as it was not something they had considered much before.

The first of the handbook was published last year and is available to read here online. Malone says a second edition will be coming in the future.

He said: “I am committed to fighting for the cause until we have real sustainable solutions and sustainable actions that we can sit here one day and say that what happened in 2020 with Mind the Gap was the beginning of all of this.”

Mind the Gap was part of a student-staff partnership project with lecturers from his university, Senior Lecturer in Diversity and Medical Education Margot Turner, and Clinical Lecturer in Clinical Skills Dr Peter Tamony.