Malone Mukwende was in his first day of medical school when he noticed something odd. As he learned about diseases of the body, all of the diagnostics were grounded in white skin. Red bumps from rashes. Blue lips from oxygen deprivation. Such colors are masked by melanin, meaning these diagnostics don’t work for much, even most, of the world’s population.
“As a person who is of African origin, I knew that the symptoms we were seeing and being told about, on my own skin, they would not appear the same, and that was very problematic,” Mukwende says. “My first year of university, it was almost a curiosity. Second year, I thought the issue would get better. But there was no progress. So I said, ‘Okay, I need to address this myself somehow.'”
Teaming up with two of his professors, Mukwende has spent the past year and a half writing Mind the Gap. It’s a richly photographed and annotated clinical handbook for diagnosing diseases on Black and Brown skin that’s slated to be released at an unannounced time in the future. Mukwende hopes that it will become required reading in medical schools and hospitals around the world.
While he doesn’t claim it’s the first publication to address racial diagnostic bias—indeed, the last decade has brought multiple textbooks on this topic—the need for Mind the Gap is still pressing. There’s plenty of evidence that Black people have worse outcomes when facing the same diseases as white people.
There are all sorts of reasons for this. Genetics may play a role in some cases. But many issues are tied to systemic racism: One study found that diagnostic algorithms used in hospitals are racially biased and recommend treatment to Black people less often than white people for the same symptoms. Another study shows that African Americans and Hispanic people in the U.S. are less likely to have health insurance than white people, because in the United States, proper medical care is tied closely to economic advantage.
“Structural racism in medical education goes beyond skin to nearly every field of medicine,” says Andrew Ibrahim, an MD who is also assistant professor of surgery, architecture & urban planning at University of Michigan and a senior principal and chief medical officer at the architecture firm HOK. Ibrahim points out that the number of Black male doctors is going down rather than up. This sort of exclusion leads to poor practices across the board in healthcare. A new study flagged 10 common diagnostic tests, which software analyzes with different criteria depending on race. “The same lab value may be interpreted as normal in a white patient, but abnormal for a Black patient because medical education has set the normal ranges differently by race,” says Ibrahim. “In making race an objective measurement rather than a social construct, we run the risk of accepting racial disparity as an immutable fact rather than an injustice that requires intervention.”
Of course, treating everyone the exact same way is a problem, too. Mukwende points out that doctors are trained to spot diseases through just one racial lens. Textbooks are racially biased, sometimes to the point of flagrant racism, and as a result, the medical community is beginning to realize that Black people tend to get diagnosed and treated later for the same disease white people might have, at which point, the disease is harder to treat and often more deadly.
Mukwende gives examples of how bad training leads to poor health outcomes. With the rise of COVID-19, which has disproportionately killed Black people, doctors have seen an increase of Kawasaki disease, which is an inflammatory condition that involves swelling across parts of the body. One of its telltale signs on white skin is a bright red rash. But on Black skin this same rash appears without a clear color signifier; to the untrained eye, it might look like goosebumps.
Meningitis is another problem, Mukwende says. “Meningitis is harder to spot in darker skin,” he says. In this case, poor medical training hurts the Black community twice as much, because the disease may be more difficult to see due to melanin, and the doctor is looking for the wrong clues to spot it.
In some cases, these late diagnoses are literally a matter of life and death. “[Take] lips turning blue . . . even with that point, what we describe as blue on white skin. On darker skin it would not be the same blue,” says Mukwende. “It would just not appear the same because of the melanin in the skin . . . [and] if you don’t see that early enough, that person might literally have a lack of oxygen in their blood.”
Mukwende has managed to finish the Mind the Gap while completing his second year of medical school, and that’s largely thanks to his collaboration with two school lecturers who are helping with the book.
“Speaking to others I didn’t work with—some people who teach me time to time—at first the response was like, ‘Surely that’s common sense,’ or, ‘Surely people learn how to just apply their knowledge,'” says Mukwende. “Unfortunately, this gray zone of assumption is what’s leading to people ultimately losing their lives. People are just assuming everybody knows. But clearly people don’t know.”