Doctors aren’t taught to look for symptoms that can appear differently on non-white skin, says Malone Mukwende

CBC Radio 

The skin is the body’s biggest organ, and it can say a lot about what’s going on inside.

That’s why physicians pay particular attention to the ways that illnesses manifest on a patient’s skin.

With COVID-19, for example, doctors warned some patients’ families to watch for blue lips and pale skin — signs the respiratory system may be having difficulty delivering oxygen to the body through the bloodstream.

But as Malone Mukwende discovered, these and other symptoms used to diagnose illnesses often don’t apply to people who aren’t white. 

The second-year medical student at St George’s, University of London, has just created a new guidebook to help doctors identify clinical signs on black and brown skin. He co-authored Mind the Gap with two St. George’s academics, Margot Turner, senior lecturer in diversity and medical education, and Peter Tamony, clinical skills lecturer.

Mukwende spoke to As It Happens guest host Duncan McCue. Here is part of that conversation.

Mr. Mukwende, why is a handbook like this necessary? 

A handbook like this is necessary because at the moment in medical education in the U.K., and also around the world, we are often not taught how to identify signs and symptoms in darker skin. So this handbook almost acts as that bridge to fill in that gap in our education at the moment. 

The knowledge gap among medical professionals, how big is it? 

I cannot give a definitive answer to how big it is, but [we can look to] some of the health disparities that exist all over the world.

We saw with COVID-19 in the U.K., for instance, patients that have a [Black, Asian and minority ethnic] background more likely to be affected or more likely to die of COVID. And although there is a whole host of reasons as to why, the lack of education and the gap in knowledge also play a part.

When did it become clear to you that some of your peers, health-care professionals, held white skin biases? 

It became apparent to me long before medical school, because I had heard of instances and stories within members of my own community and the Black community about being misdiagnosed or not being taken seriously by health-care professionals or just mistreatment, really. And I could see the distrust that they had with the health-care professionals.

When I got to university, at medical school, it almost became apparent to me, the other side of the fence, that maybe this distrust and this misdiagnosis, maybe it started from just people not being taught it. So they kind of allow these biases to manifest. And when they qualify and become practising health-care practitioners, that’s where these biases are now having fatal consequences on people. 

Can you give us some examples of how an illness or an injury might look different on different types of colours of skin? 

For instance, we saw with COVID-19, the picture of Kawasaki disease [a rare and potentially fatal inflammatory disease], which was circulating on the internet. In the picture it is clear to see that on white skin Kawasaki will appear very bright red.

However, on dark skin, some people would even argue it looks like goose bumps. So these … conditions are both the same. But if both those patients presented to a hospital, we can almost tell that, if there was not this knowledge, who would be getting sent home and who would be receiving treatment. Consequently, it can mean that someone will end up dying because of that.

I understand that skin cancer can also look different for for Black people.

Some people believe that Black people cannot get skin cancer, and that’s due to the melanin in our skin providing a barrier, which is true to an extent. However, it is found that skin cancer in Black people is often diagnosed at a terminal stage because people and health-care professionals and patients in general often miss the early signs just due to the lack of education and the lack of knowledge surrounding this topic.

Mukwende got the idea for guidebook when he realized there were gaps in medical school education that could lead to misdiagnosis and fatal outcomes for people of colour. (Submitted by St. George’s University of London)

Why do you think it’s taken so long to draw attention to this issue? 

The conversation has been going on for many years. For me to take the credit to say I’m the first person … would be doing a disservice to all the people who have spoken up about it in the past.

I think the difference is … they were getting their issue swept under the rug and people weren’t taking these issues seriously or not giving them the correct airtime. Now, I feel like the world — given the year that we’ve had in 2020 — is kind of receptive and open to acknowledging some of the cracks that are there in the system.

And now that people are aware that these problems exist, I think it’s imperative that we start acting now.

What kind of difference do you think it’s going to make to have this guidebook available with this information for patients?

Fundamentally, I think it will allow some people to live longer, essentially, because they will be able to be diagnosed correctly in the first place. And this can also go back to increasing the trust in health-care professionals, their confidence in the health-care professionals, too. 

And what kind of difference do you think it will make to medical students like you?

I think we will now feel more confidence in our own practice. So we’re not going out into the world being scared that, “Oh, I’m not sure what it looks like in a darker patient and I don’t want to make a mistake.”

So if we are empowered by this, we’ll be well-equipped and be able to better serve the diverse population of people that are in the world.