The importance of race representation in healthcare education

The COVID-19 pandemic has shone a light onto the healthcare inequalities faced by black, Asian and minority ethnic communities as they have an increased mortality risk, with black people being up to 4x more likely to die than white people, after adjustment for age [1,2]. However, there are many other areas in healthcare where ethnic minorities are disadvantaged, and it’s important to improve healthcare education to reduce these disparities and save lives.

One area where improvements can be made is provision of sufficient training to medical staff regarding race. For example, it has been shown that doctors are more likely to underestimate black patients’ pain compared to white patients. In fact, it has been shown that in hospital emergency situations despite black patients reporting similar levels of pain to white patients they are less likely to receive pain relief [3]. This implicit racist bias can cause a lack of trust between a patient and their doctor and this needs to be changed so that appropriate treatment is given to all patients [4]. Similarly, it has been shown that ethnic minority groups receive worse maternal care than white women: between 2014 and 2016 black women in the UK were five times more likely to die in pregnancy and childbirth than white women and stillbirth rates for black babies were over twice those for white babies in 2018 [5,6]. This 2018 report also stated that Asian newborn babies were 60% more likely to die than white babies [6]. It is clear that more needs to be done to educate doctors to try to decrease the disparities seen between patients of different races.

Rashes have recently been suggested to be a symptom of COVID-19, but even though black and Asian people have the highest risk of COVID-19 infection in the UK and US, there is a shortage of rash images on darker skin tones [7,8]. This is actually a common problem in both the UK and US, where dermatological symptoms are mostly shown on white skin. A 2018 report has shown that the skin tones represented in US medical textbooks were 74.5% light, 21% medium, and 4.5% dark even though the racial distribution of the U.S. population is approximately 62.5% white, 20.4% black, and 17.0% other minority ethnic [9]. This skewed race representation in medical textbooks is problematic, as symptoms can look different on darker skin tones and can be missed if medical professionals are not used to seeing them, resulting in the patient not receiving necessary treatment. Dr. J. Nwando Olayiwola, a professor of Clinical Family Medicine, explained that “As a doctor, if you want to be good at understanding something, you want to see all different variations that are possible” [10]. Therefore, it is necessary to have better representation of different races in medical textbooks and clinical training.

Since most medical education is focused on white people and their symptoms, both patients and healthcare professionals are less likely to know or look for signs of skin cancer in darker skin tones. Locations of melanoma for people of colour are often different to white people, for example on the bottom of feet, and so are commonly missed. This can lead to worse outcomes and it has been reported that the melanoma survival rate at five years was only 65% in black people compared to 91% in white people [11]. It was also found that melanoma diagnoses are more likely to be made at a late stage in minority ethnic patients than in white patients, and this is associated with a poorer survival rate [11]. The lack of timely diagnoses is made worse by the lack of public awareness of the risks of skin cancer in people with darker skin tones. This means that people not only don’t know what to look out for, but often think they can’t be affected by skin cancer because they have dark skin, which although it does reduce the risk of skin cancer, does not prevent it [12].

Another example of lack of race representation in disease awareness is seen with breast cancer, which is considered to be a white woman’s disease. However, black women are more likely to have aggressive tumours and a higher chance of the tumour re-occurring [13]. They also have poorer outcomes compared with women from other ethnic backgrounds and in the US, black women have a breast cancer mortality rate that is approximately 40% higher than for white women [14]. The media play a role in this disparity as pictures of white women are more commonly shown in breast cancer awareness adverts and brochures, suggesting that they are the most affected group. This means that black women are less likely to go for check-ups or know the signs and symptoms, which could lead to late diagnoses and a lower chance of recovery [15]. This highlights the need for greater diversity in public awareness campaigns that help shape society’s perceptions of diseases.

There is hope. There are organisations trying to increase race representation education, such as Skin Deep and Mind the Gap, which provide images of symptoms on a diverse range of skin tones, with the aim of ensuring no person’s diagnosis is missed due to them having darker skin [16,17]. However, it is clear that a lot more needs to be done to improve our healthcare system and this must be done via greater race representation in both education of medical staff, and also in disease awareness of the public.


Ella White



[1] The Health Foundation. 2021. Emerging Findings On The Impact Of COVID-19 On Black And Minority Ethnic People | The Health Foundation. [online] Available at: <>

[2] 2020. Updating Ethnic Contrasts In Deaths Involving The Coronavirus (COVID-19), England And Wales – Office For National Statistics. [online] Available at: <,females%20of%20White%20ethnic%20background.>

[3] Hoffman, K., Trawalter, S., Axt, J. and Oliver, M., 2016. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proceedings of the National Academy of Sciences, 113(16), pp.4296-4301.

[4] Hagiwara, N., Penner, L., Gonzalez, R., Eggly, S., Dovidio, J., Gaertner, S., West, T. and Albrecht, T., 2013. Racial attitudes, physician–patient talk time ratio, and adherence in racially discordant medical interactions. Social Science & Medicine, 87, pp.123-131.

[5] 2018. [online] Available at: <>

[6] 2018. Reports | NPEU. [online] Available at: <>

[7] Sze, S., Pan, D., Nevill, C., Gray, L., Martin, C., Nazareth, J., Minhas, J., Divall, P., Khunti, K., Abrams, K., Nellums, L. and Pareek, M., 2020. Ethnicity and clinical outcomes in COVID-19: A systematic review and meta-analysis. EClinicalMedicine, 29-30, p.100630.

[8] McFarling, U., 2020. Lack Of Darker Skin In Textbooks, Journals Harms Patients Of Color – STAT. [online] STAT. Available at: <>

[9] Louie, P. and Wilkes, R., 2018. Representations of race and skin tone in medical textbook imagery. Social Science & Medicine, 202, pp.38-42.

[10] Healthline. 2020. This Med Student Wrote The Book On Diagnosing Disease On Darker Skin. [online] Available at: <,diagnose%20conditions%20on%20white%20patients.>

[11] The Skin Cancer Foundation. 2019. Ask The Expert: Is There A Skin Cancer Crisis In People Of Color? – The Skin Cancer Foundation. [online] Available at: <>

[12] British Skin Foundation. 2020. Skin Cancer In Skin Of Colour – Why We Should All Be Vigilant. [online] Available at: <>

[13] 2013. Breast Cancer More Likely To Reoccur In Black Women. [online] Available at: <>

[14] Richardson, L., Henley, S., Miller, J., Massetti, G., Thomas, C. 2016. Patterns and Trends in Age-Specific Black-White Differences in Breast Cancer Incidence and Mortality – United States, 1999–2014. Centers for Disease Control and Prevention, 65, pp.1093–1098.

[15] Jones, C., Maben, J., Jack, R., Davies, E., Forbes, L., Lucas, G. and Ream, E., 2014. A systematic review of barriers to early presentation and diagnosis with breast cancer among black women. BMJ Open, 4(2), p.e004076.

[16] Skin Deep. Skin Deep. [online] Available at: <>

[17] Black & brown skin. Mind The Gap — Black & Brown Skin. [online] Available at: <>

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