I was scrolling through Twitter and came across a tweet, where a Black woman mentioned that her mother had COVID-19. When they checked with a doctor, they informed her mother to go to the ER if her lips turned blue. However, even if her lips were to turn blue, it wouldn’t be visible due to her skin color and this was something that the physician had overlooked. 

This anecdote is not an isolated incident and represents a larger issue with our healthcare system and provider-patient relationships. Medical student, Malone Mukwende at St. George’s University of London, explains that most medical students only learn what symptoms look like on white skin and that “there is a lack of teaching on darker skin tones”.

The lack of diversity in medicine and the lack of work put into creating accurate textbooks showcasing symptoms on all skin tones causes harm and negligence. This also plays a key role in the racial disparities in patient care and treatment. For the 2020-2021 academic year, the Association of American Medical Colleges published demographic data of students currently enrolled in medical school. When breaking down the data by race, the majority of students in medical schools are still overwhelmingly white. (Figure 2). Taking this a step further, a study done by Patricia Louie and Rima Wilkes analyzed 4146 images from “Atlas of Human Anatomy,” “Bates’ Guide to Physical Examination & History Taking,” “Clinically Oriented Anatomy,” and “Gray’s Anatomy for Students”, which are textbooks often used in medical education, and found that the skin tones represented in these textbooks were “74.5% light, 21% medium, and 4.5% dark,”; therefore, overwhelmingly representing lighter skin tones (Figure 3). 

Especially with COVID-19 being such a new virus, the disparities between white people and people of color become ever more apparent and the gap is only widening. Many physicians and even dermatologists are not able to identify signs of COVID-19 and any other virus or disease on darker skin. Redness, which could indicate rashes and even certain cancers, may not even show up on a person with a darker complexion. Failure to be aware of these differences could lead healthcare providers to potentially ignore critical issues that could be a matter between life and death. The lack of awareness by healthcare providers on these signs and symptoms on darker skin tones is contributing to the staggering statistics that we see today. The following figure by the CDC shows the extent to which people of color are disproportionately affected by COVID-19. 

In fact, a recent article by the British Journal of Dermatology explains that COVID-19 can manifest on skin, such as rashes, redness, and even parts of the body turning blue from lack of oxygen. This article analyzed multiple studies in various journals and noticed that out of the 36 articles on the topic, almost all were focused on lighter skin tones, which can be seen in Figure 5. The dermatologic symptoms of COVID-19 are just as important and can sometimes be the first sign that someone has the virus. The lack of studies on and awareness of symptoms on darker skin tones and people of color is detrimental for that individual patient and additionally for people around them, potentially increasing the chance of spreading the infection without even knowing. 

What would COVID-19 symptoms look like on someone with a darker skin tone? Instead of only examining if your lips are turning blue or purple, check the inside of your lower lip. If it is white and not red, this means that there is not enough oxygen being circulated (Figure 6). Nail beds and eyelids are also a place to look for abnormal discoloration. Using a pulse oximeter is also a great, objective tool to quantitatively examine if oxygen is being circulated. If you notice that your skin is paler and more dull, this could also be a sign to seek medical evaluation (Figure 7). Another way to check on breathing is if you’re using the muscles around your neck and collar bones to breathe and get in air. One resource for additional tips is “Mind the Gap: A handbook of clinical signs in Black and Brown skin” by Malone Mukwende. This is a great handbook and resource to use to see what certain diseases and abnormalities may look like on darker skin. 

With COVID-19 being a new virus, it is extremely important that healthcare providers and medical schools look into doing more than just promoting a tagline of “being inclusive and diverse”. There needs to be a change in the materials that students are learning from, as well as  conversations acknowledging current mistakes providers are making by being unaware of the way symptoms can present on people of color. And this is an issue that goes beyond medical neglect related to COVID-19 .Skin cancer, being one of the most common cancers in the US, is disproportionately prevalent in Black communities, largely due to the inability of providers to diagnose and understand what this cancer may look like on Black people and other people of color. There is a long history of negligence based on racial bias in our healthcare system and especially with COVID-19, healthcare providers must take the extra step to do no harm to those in their communities. 

References 

Association of American Medical Colleges. “Table B-3: Total U.S. Medical School Enrollment by Race/Ethnicity (Alone) and Sex, 2016-2017 through 2020-2021”. 11/3/2020. https://www.aamc.org/media/6116/download 

“COVID-19 Hospitalization and Death by Race/Ethnicity.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 30 Nov. 2020, www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html. 

Lester, J.C., Jia, J.L, et al. “Absence of images of skin of colour in publications of COVID‐19 skin manifestations.” British Journal of Dermatology. Wiley Online Journal. 29 May, 2020.  https://doi.org/10.1111/bjd.19258

Louie, Patricia and Wilkes, Rima. “Representations of race and skin tone in medical textbook imagery.” Social Science and Medicine. Volume 202, April 2018, Pages 38-42. https://doi.org/10.1016/j.socscimed.2018.02.023

Mukwende, Malone; Tamony, Peter; Turner, Margot (2020): Mind the Gap: A handbook of clinical signs in Black and Brown skin. St George’s, University of London. Online resource. https://doi.org/10.24376/rd.sgul.12769988.v1 

Page, Sydney. “A medical student couldn’t find how symptoms look on darker skin. He decided to publish a book about it.” The Washington Post. July 22, 2020. https://www.washingtonpost.com/lifestyle/2020/07/22/malone-mukwende-medical-handbook/

Skin Cancer Foundation. “Skin Cancer Facts & Statistics.” Updated April 2020. https://www.skincancer.org/skin-cancer-information/skin-cancer-facts/