Is Medicine Racist?

Medically, skin type is most commonly classified by the Fitzpatrick Scale – which I’d never heard of until researching this article. It was created in 1975 by Thomas B. Fitzpatrick; a well renowned White dermatologist, as a way of estimating the response of a certain skin tone to UV light. You’d like to think that the broad range of skin tones would be reflected in this scale, right? In actual fact, it’s separated into only six skin tones, from type I (pale skin that never tans) to VI (dark skin that never burns). Funnily enough, these were the basis for the different skin colours used in emojis. 

Determining your skin type on the Fitzpatrick scale – CurrentBody
The Fitzpatrick Scale. Image: CurrentBody.

So, is the Fitzpatrick Scale racist? Yes and no. Let’s start with no: it can be a useful tool for dermatologists when specifically used for its purpose which is to determine how skin responds to UV light treatment, although it’s not always accurate. Now for the yes: the scale is unfairly skewed towards White people. That is, types I to III would all be considered White skin tones, types IV and V considered Brown skin tones and only type VI relating to Black people. 

I have a fair few friends that are Junior Doctors. I asked them about representation of different colours of skin throughout their time at university and their responses were unanimous: there were only a handful of times that, either in textbooks or lectures, non-White people were used in examples. One friend even said she was nervous to take blood from a Black person for the first time as it was something that she had never been exposed to before. It’s pretty shocking, but ultimately unsurprising, that during theoretical training on taking blood, medical students had no examples using non-White people. 

A 2018 study looked at all the images within the most commonly used general medicine textbooks in the US using a skin-tone scale separated into 10 types. What they found was hard to ignore: only 4.5% of images showed dark skin, with “21% showing medium skin tones”. These statistics are clear signposts of the systematic racism that is present from day one of medical school.

woman injecting syringe on mans arm
Medical textbooks predominantly feature White patients. Image: CDC/Unsplash.

Dermatology is the study of skin and is largely based on visual assessment. It therefore stands to reason that there should be a broad range of skin colours used in dermatology textbooks, right? Wrong. A 2020 study found that only 11.5% of images fell into types V and VI on the Fitzpatrick Scale. This evident bias means that common skin conditions, such as psoriasis and eczema, often go undetected in non-White people. 

Malone Mukwende, a 20-year-old medical student at St. Georges in London, noticed “a lack of teaching about darker skin tones, and how certain symptoms appear differently in those who aren’t White”. It was this clear lack of representation that prompted Mukwende to produce Mind the Gap: a handbook of clinical signs on Black and Brown skin. This is a useful guide that contains examples of diseases on darker skin and also talks about choice of language when describing symptoms on Black and Brown skin.

Covid has highlighted issues across the whole of the health sector, one of which is systematic racism. For example, asking a patient that might have Covid whether they are ‘pale’ or their ‘lips have turned blue’ is useless for many Black patients. This might sound insignificant to some, but it compromises their medical care from the get-go. Ready for some more image statistics? A 2020 report looked at photos published in Covid-19 studies and classified them using the Fitzpatrick Scale. 92% showed types I-III, 6% showed type IV and 2% couldn’t be identified. There were no examples whatsoever of type V or VI skin tones. I’m repeating myself here, but these statistics are shocking, no matter how you look at them.

This has been an ongoing problem for decades. It’s only now, with the Black Lives Matter movement and age of social media, that the wider public are sitting up and listening. With more non-medics becoming aware of the lack of representation of non-White people within the health sector, there is hope for widespread, systematic change, both in teaching and in treatment of patients.

By Katherine Graves

Header image: Hofstra University