An illustration of a Black fetus in the womb went viral last December with many people commenting on social media that it was the first time they had seen a depiction of a dark-skinned fetus or pregnant woman.
The attention came as a surprise to Chidiebere Ibe, the Nigerian first-year medical student who created the image, and describes it as “just one of my drawings to advocate for diversity in medical illustrations.”
The image started a discussion about a lack of representation in these illustrations – images that are mostly found in textbooks and scientific journals to show medical pathologies and procedures.
Ibe, 25, who is creative director at the Association of Future African Neurosurgeons, has now been invited to have some of his illustrations published in the second edition of a handbook designed to show how a range of conditions appear on dark skin.
“Mind the Gap: A clinical handbook of signs and symptoms in Black and Brown Skin,” was first published in 2020. Co-author Malone Mukwende, a medical student in London, wrote over email that “Chidiebere’s work … unearths some of the biases that exist in medicine in plain sight that we may not be aware of. Representation in healthcare is imperative to ensure that we do not allow implicit biases to cultivate in our heads.”
Ibe, who earned a chemistry degree in Nigeria and is now studying medicine in Ukraine, only began his medical illustrations in 2020. He has already created images depicting anatomy and a range of conditions, such as the skin disorder vitiligo, cold sores, a chest infection and spinal injuries, all in Black people.
Ibe says that a lack of illustrations of skin conditions in Black skin makes it hard for medical students to diagnose them. Mukwende hopes that together they can create “the blueprint for the world” in terms of what diverse medical textbooks should look like and that “Mind the Gap” will be known as “the go-to textbook for representation of a variety of skin tones.”
A “big gap” in representation
Dr. Jenna Lester, an assistant professor in the department of Dermatology at the University of California, San Francisco, describes Ibe’s illustrations as “incredible.”
Lester is director of the university’s Skin of Color program, which provides a space for Black, Asian, Latinx and indigenous people to understand conditions that affect them and become more comfortable seeking care. She says she realized that there was a “big gap” in representation in dermatology back when she was a student, and a lecturer told the class a certain condition would look different in dark skin, but not how the condition would appear. Lester says that she is “grateful” that now “people are actually responding and recognizing it as a big problem and making changes to address it.”
“I think it’s important to increase representation across the board because … who knows what young mind this inspires when they see themselves represented in this way, who might be inspired to go into science or become a physician or nurse or something like that, by seeing themselves depicted in these illustrations?” she adds.
Studies have shown this lack of diversity. A 2014 study by researchers at the University of Wollongong in Australia examined gender bias in anatomy textbooks and found that of more than 6,000 images with an identifiable sex published between 2008 and 2013 in 17 textbooks, the vast majority were White and just over a third were female. About 3% showed disabled bodies and 2% featured elderly people.
Covid-19 has exposed healthcare disparities
In some Western countries, people of color have been disproportionately affected by the Covid pandemic. Research by the CDC found that racial and ethnic minority groups have had higher rates of hospitalization and emergency care for Covid-19 than White people in the US.
Lester says that “Covid-19 has highlighted a lot of issues of disparities, and that has led us to think about disparities and all the ways that they show up, including in dermatology.”
Lester co-authored a research letter published in the British Journal of Dermatology in May 2020 which found that scientific articles describing the skin manifestations of Covid-19 “almost exclusively show(ed) clinical images from patients with lighter skin,” with no published photos of the manifestations in dark skin. It noted that this may make it more difficult for dermatologists and the public to identify the virus.
This is compounded by the issue of some medical equipment not working as effectively on people with darker skin tones. Pulse oximeters, which measure a patient’s oxygen level by using light and a sensor to detect the color of the blood, and which have been increasingly used during the pandemic, have been found to provide less accurate readings on darker skin. If they are not calibrated for darker skin tones, the pigmentation could affect how the light is absorbed.
“It’s not just about the skin conditions,” says Ibe. “It’s just about giving everybody the value that they deserve. Black, White, Asian – let’s all have equal healthcare that we deserve.”
A network of African medical illustrators
Despite making up an eighth of the world’s population, Africa accounted for less than 1% of global research output between 2012 and 2016. Even in Nigeria, White skin images dominate the medical literature, says Ibe. His goal is to help remedy that by setting up a network of African medical illustrators.
Ibe plans to become a pediatric neurosurgeon and is also working on a textbook on birth defects in children, which will be illustrated with Black skin images.
“I want it to be a norm that whenever a person searches online for a particular skin condition, a particular health challenge, that the first pop-ups are Black illustrations or are illustrations of people of color,” he says.