A blog highlighting the barriers in healthcare faced by patients due to the colour of their skin.
The COVID-19 pandemic has brought to the forefront health inequalities relating to the colour of a patient’s skin. However, this is not a new issue and patients have always faced barriers in healthcare due to the colour of their skin. Impacting factors can include explicit racial bias, which includes discrimination and prejudice; implicit racial bias; missing data; lack of trust; and reduced access. These can lead to misdiagnoses and delays in treatment, which can ultimately cause harm and preventable death.
Dangerous gaps in training
Medical training has, to date, primarily centred on diagnosis in white-skinned individuals, leading to conditions being overlooked in darker skin. Lack of understanding on how changes from the norm may manifest in individuals with darker skin could mean that early developing illness is missed. In a column for The Guardian, doctor Neil Singh highlights that during his medical training it was almost always assumed that his patients would be white. He argues that this prejudice is harmful and can be deadly when it comes to dangerous skin conditions.
A lack of diverse imagery
In dermatology, where images are critical for diagnoses, the lack of images of darker skin poses a barrier to proper treatment and medical education. A study in the journal Social Science and Medicine found that only 4.5% of images in medical textbooks feature dark-coloured skin, which makes it difficult for doctors to learn how to diagnose people of all skin tones. Skin conditions that involve redness or pinkness in light skin can be subtler or harder to see in dark skin, and doctors who haven’t been adequately trained with such images are prone to misdiagnose their patients. Dermatologists say the lack of images is one reason why many conditions, including cancer, can go misdiagnosed or underdiagnosed in darker-skinned patients. As a result, the five-year melanoma survival rate for black patients is just 70% compared with 94% for white patients.
Midwifery: monitoring wellbeing
An example of where skin issues are prevalent is in midwifery, where skin assessment is important in monitoring mothers’ wellbeing – looking for changes in skin appearance using visual and tactile cues that might indicate deviation from normality. Although visual signals are more readily discernible in women with light skin tones, they may be more challenging to detect in women with darker skin. It is therefore crucial that midwives are educated to assess and recognise skin changes in all skin tones so that they can care for women with confidence using clinical judgement. Maureen Raynor reports that ‘we need midwives to be colour aware instead of colour blind’ to help improve treatment of their patients.
Pulse oximeters and false readings
Another example where skin colour plays a role in potential poor treatment is in pulse oximeter testing. In a study, the three tested pulse oximeters overestimated arterial oxygen saturation during hypoxia in dark skin participants. These false readings could lead to health deterioration and lack of necessary treatment. This has been evident during the COVID-19 pandemic, where pulse oximeters have been seen to overestimate oxygen levels in black patients. NHS England is issuing updated guidance, advising patients from Black, Asian and other minority ethnic groups to continue using pulse oximeters, but to seek advice from a healthcare professional. Experts believe the potential inaccuracies in pulse oximeters may be a contributing factor to some of the deaths in dark-skinned COVID-19 patients.
An increasing awareness of the need for change
To address biases concerning the colour of a patient’s skin, in some cases clinics have been set up where people can see dermatologists who have greater knowledge around darker skin tones. In the United States, major cities now have such ‘skin of colour clinics’, many operating under the name ‘ethnic dermatology’.
A petition exists urging the UK General Medical Council to require that medical schools include a diverse representation of skin tones in their teaching. Moreover, the handbook ‘Mind the Gap’ has been produced to educate and raise awareness of how clinical signs and symptoms can present differently on darker skin. Concerned members of the general public have also contributed to this issue – Ellen Buchanan Weiss has established the website ‘Brown Skin Matters’, which provides interested parents and doctors with a collection of images showing how skin conditions can present differently in richly pigmented skin.
In conclusion, patients with darker skin experience a greater chance of misdiagnosis than white patients, with higher odds of suffering increased harm from diagnostic errors. This is due to lack of education and medical training, non-representative images and available resources, as well as systemic racism. Much has been done in the way of improving this situation, but a wider movement will be needed to ensure that darker-skinned patients receive equal treatment to white-skinned patients.
- Epstein H. Why the Color of Your Skin Can Affect the Quality of Your Diagnosis. The Society to Improve Diagnosis in Medicine (SIDM) 2018.
- Raynor M, Essat Z, Menage D et al. Decolonising Midwifery Education Part 1: How Colour Aware Are You When Assessing Women With Darker Skin Tones in Midwifery Practice? The Practising Midwife 2021; 24(6).
- Singh N. Decolonising dermatology: why black and brown skin need better treatment. The Guardian 2020.
- McFarling U. Dermatology faces a reckoning: Lack of darker skin in textbooks and journals harms care for patients of color, Stat News 2020.
- Simmons T. I’m a Black Woman and My Skin Cancer Was Misdiagnosed for Nearly 10 Years. Prevention 2021.
- Bickler P, Feiner J, Severinghaus J. Effects of Skin Pigmentation on Pulse Oximeter Accuracy at Low Saturation. Anesthesiology 2005; 102, 715–719.
- Elahi A. Covid: Pulse oxygen monitors work less well on darker skin, experts say. BBC News 2021.
- Mukwende M, Tamonv P, Turner M. Mind the Gap: A handbook of clinical signs in Black and Brown skin, 2020.
About the Author
A volunteer for PSL who loves to blog about patient health and safety.