Medical Schools Usually Do Not Teach How The Conditions Look On Different Skin Tones. Malone Mukwende Try To Change This
When Malone Mukwende, 21, started medical school in London, she identified a fundamental problem: almost all of the images and data used in her teaching were based on studies of white patients. But medical symptoms can present very differently on Black and brown skin, leading to a misdiagnosis, suffering and even death. Still a student, he recently launched a textbook, Mind the Gap, and Hi, a new online platform designed to empower people with knowledge about their health. I asked him what he hoped to accomplish and the broader lessons for all of us.
AJ: For people who don’t know your work, explain it Mind the Gap?
MM: I came to medical school and I noticed that there was a gap in our teaching. If we learned about a particular type of rash or disease that manifests on the skin, I would always use white skin as a reference. I would ask “how does this look in other skin tones?” just for my own learning. Often people would tell me they didn’t know. I decided that something had to be done. Some members of the university staff and I started collecting pictures and descriptions of the various conditions on darker skin, and we compiled them all into a manual we called Mind the Gap.
AJ: The gap isn’t just because there have been no studies on Black and brown skin. That’s why it wasn’t considered important, right?
MM: Yes, that’s true. After the publication of Mind the Gap, someone came to me who is a student in Zimbabwe. They said that all the books and reference images they use are also made of white leather, even if the population [is] predominantly darker skin. It really shows you that the legacies of colonialism will still live on in 2021. A lot of the textbooks they get are the ones we in the Western world have discarded, after a new edition came out. It makes you question and wonder what it will be like on the African continent – I guess the same thing happens in much of Asia – there is no set [local] source or resource. There are so many people locally on earth who know these things. But from a broader perspective and from a teaching perspective, it is not in transition from individual knowledge in textbooks and resources to help teach people.
AJ: I have kids of different backgrounds, and I know that when there was an eruption that everyone had, it looked drastically different depending on their skin color. But every time I looked at the medical charts, the point of reference was always white skin. Recently, my daughter Zahara, whom I adopted from Ethiopia, had surgery, and then a nurse told me to call her if her skin “turned pink”.
MM: That’s the kind of thing I started noticing very soon. Almost the whole of medicine is taught in this way. There is a language and a culture that exists in the medical profession, because it has been done for so many years and because we still do it so many years later it doesn’t seem to be a problem. However, as you just illustrated, it’s a very problematic statement for some population groups because it doesn’t just happen that way and if you don’t you probably won’t call the doctor.
AJ: Now that there’s so much online, it should be a lot easier. So that’s your new digital platform, and that’s why it’s called Hutano?
MM: Hi, in my native language, Shona, it translates directly to “health.” It’s a social health platform, where people from all over the world can connect to form communities and truly discuss these different conditions.
AJ: What do you hope will happen?
MM: We want people living with these conditions to have a platform to be seen and empower their health literacy. For example, someone who has struggled with eczema may come over to Hutano and join or even create an awareness group around their situation, and other people around the world who have this condition may join and perhaps discuss, “oh I recently I was diagnosed with eczema, does anyone know how I can find some cloths that don’t irritate my eczema? “or” I used this cream, does anyone have any experience as to how it worked? ” We want to give people the platform to be able to discuss these things. We need to start empowering the individual, and that, I hope, will start reducing some of the health disparities that exist.
AJ: Do you have any examples of the consequences of these disparities?
MM: In the UK there was a case in the early 2000s, and even if it was a while ago it now shows how serious things can be. There was a little girl, Victoria Climbié, and she was submissive abuse by her older aunt and her husband. She was presented to the hospital, and she had visible wounds on her skin. A doctor concluded that he suffers from scabies and accepted the story of her guardians that she had injured herself scratching the scars. They finally realized that this was a potential case of social services and a case of neglect. Unfortunately he ended up dying due to abuse at the the hands of his guardians. From a health perspective there had been an opportunity to be able to intervene and fully alert social services as soon as possible. In the reports on his death she said she had 128 different injuries. We missed so many different signs on darker skin to be able to identify that this was actually a problem. This is a common problem with bruises and injuries in cases of domestic violence and abuse.
AJ: And that goes beyond just looking at the skin, does it? Are there wider problems with our medical knowledge and our tests and our measurements?
MM: It’s been the politics of medicine, for so long. For example, if you read an old medicine manual, it will tell you from a European perspective that a 25kg (704lb.) male is the benchmark, and if you’re above you are obese, if you’re below that you are malnourished, and who has come up with this ladder? We like to say that medicine is based on evidence, but we need to ask where our evidence comes from. Many studies have included only people from Europe and America. We have all these data sets but in reality we only test 30% or 40% of the world.
AJ: So how do we recalculate?
MM: I can’t say I have a solution because if we decide to group by age that will also open a can of worms; [the same is true] if we group by race, if we group by income. It just depends on the individual circumstances a lot of the time. Are you [individual] people have the power to have an adequate amount of information or an adequate ability to ask the correct questions about their medical care.
AJ: What amazes me is that you managed to publish this manual and you created this new platform while you are still a medical student.
MM: I’m a big believer that age doesn’t have to be a barrier. If there is a problem that needs to be solved, it doesn’t matter if you are a doctor who has been qualified for 25 years or if you are someone who has just entered the doors of medical school, as long as you are committed to the cause.
-With a report from Madeline Roache