Dr. Natalie Moulton-Levy, a Manhattan-based dermatologist, told the New York Times in 2020 that she knows physicians are well-intentioned when they say they “do not see color” when it comes to their patients.
“They are trying in a nice, benevolent way to say skin color doesn’t matter,” she told the Times. “But it absolutely matters, in dermatology and all of health care. ‘Colorblind’ is a very difficult term for me to hear.”
The issue begins (and only begins) with the fact that physicians are not seeing color in a very literal sense. They are not seeing images of people of color. Nine of every 10 textbook images display the manner in which skin conditions present themselves on fair skin, which can be very different from the manner in which they present on skin of color. And this dearth of images can lead to various afflictions going undiagnosed or misdiagnosed.
Among the most troubling examples of this is melanoma, which while not as prevalent among Black as whites often proves to be far more fatal, as evidenced by the fact that the five-year survival rate for the disease among Blacks is 70 percent, while it is 94 percent among whites.
It also applies to a wide range of other skin conditions – everything from Lyme disease to spider bites to COVID toe. And as the Times notes, the skin often provides the first evidence of such serious maladies as cellulitis and sepsis, not to mention reactions to certain medications.
Jenna Lester, director of the skin of color program at the University of California, San Francisco, published a study in 2020 about the absence of Black images. It grew out of her own frustrating search to find images of the rashes that result from COVID-19.
She summed up the issue this way to the Times:
“Pattern recognition is central to dermatology, and a lot of the pattern recognition is training your eyes to recognize certain colors that trigger you to think of certain diseases. But the color in question is impacted by the surrounding color. It can look different in darker skin. If you’re only trained to look at something in one color, you won’t recognize it in another color.”
Consider a Black woman named Shania Haynes, who according to the Chicago Tribune was told in 2015 that a dark patch on her head was evidence of ringworm, only to learn after joining the Army four years later that it was the result of lupus. Consider a 13-year-old Connecticut girl who was diagnosed with T-cell lymphoma, five years after she was told that the white patches on her skin were a harmless rash called pityriasis alba.
Pattern recognition? There is very little to be found, though there is a modicum of hope – and not a moment too soon, considering over half the U.S. population is expected to consist of people of color by 2044.
Some of the seminal textbooks in the discipline, like “Dermatology” and “Andrews’ Diseases of the Skin,” continue to be updated to reflect current realities. Another textbook, “Dermatology for Skin of Color,” is considered an essential work for those in the field who hope to be up to speed.
The co-author of the latter work, Dr. Susan G. Taylor, a professor of dermatology at the University of Pennsylvania, also founded the Skin of Color Society in 2004, an organization dedicated to helping those in the field treat people of color. Moreover, she and Dr. Henry Lim, a past president of the American Academy of Dermatology and the senior vice president of academic affairs at the Henry Ford Health System, emphasized during a recent seminar the need to diversify the workforce.
There is little argument on this point, as dermatology is the second-least diverse specialty, behind orthopedics. Just three percent of those in the field are Black, and just four percent are Hispanic.
As Lim once said, “The face of dermatology should reflect the face of our patients.”
He pointed out that awareness has been raised on this front, and action steps taken. Now, he said, a culture change is needed. Taylor, for her part, believes mentorship and sponsorship are vital.
The point is that images, while important, only go so far. It’s going to take more than that. It’s going to take buy-in by all concerned, and a deep-seated commitment to enact real change, and fully meet the dermatological needs of people of color.