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At a young age, Malone Mukwende developed an interest in science, and how people operate when they are well and unwell.
"That kind of curiosity on a scientific level along with my people skills brought me into medicine," Mukwende told Healthline.
However, when he entered medical school at St George’s, University of London, 3 years ago, Mukwende noticed that a large portion of people were left out of study materials, and that medical students were only taught how to diagnose conditions on white patients.
"There was a lack of signs and symptoms on Black and Brown skin… and I didn't understand why we weren't getting taught the full spectrum of people. I'd ask people for answers and I couldn’t get the answer… I decided I needed to do something to challenge this issue myself," he said.
The online handbook includes images and descriptions of clinical signs and symptoms in Black and Brown skin.
"We looked for pictures and clinical descriptors that we could use to define them, understanding that there needs to be a difference in the communication aspect of the descriptors that we use. It was very hard and intense because… there are a lack of images of Black and Brown skin across the internet. Thankfully, we were able to source them and here we are today," Mukwende said.
His work spread worldwide. Since its publication in August, the handbook has been read in 102 countries and added to recommended reading lists at many universities and hospitals in the U.K.
Margot Turner, senior lecturer in diversity and medical education at St George’s, University of London, worked with Mukwende on the project.
"When we first started doing the project, I knew that medical schools would be very interested, but I didn’t imagine my children would be coming in to let me know I was on social media and Instagram. I think the timing of the launch was crucial. Black Lives Matter has hopefully made everyone question their practices. Mind the Gap gave medical schools and medics something very concrete they could do and focus on," Turner told Healthline.
News about the handbook caught the attention of Dr. J. Nwando Olayiwola in Columbus, Ohio, who read about it on Twitter.
As a family physician, Olayiwola provides care to patients who are underserved or marginalized, and treats refugees and asylees from all over the world. Over a decade ago, she started using a software program that allows physicians to enter symptoms people experience. She worked with the software company to include skin conditions in Black and Brown skin.
"We have long struggled with the proper imagery of darker skin people in medicine; not just in dermatology, but in the representation of how we are trained to do many things," Olayiwola told Healthline.
For instance, she says when physicians learn CPR, it is almost always taught on a white mannequin.
"You are constantly bombarded with images or models of people in books who may not look like you or like the patients you are taking care of. As a doctor, if you want to be good at understanding something, you want to see all different variations that are possible. It's exciting to see a medical student like [Malone] working to change this. His work is a great contribution to medicine, and it's helpful because of the patient populations I serve," she said.
Olayiwola also knows personally how lack of information affects patients. When her son was born, he experienced skin-related issues.
"I took him to the doctor who was great, but didn’t know what he was looking at, so I showed it to a colleague of mine. Turns out my son had eczema. Eczema on a Black child looks different than on a white child. No fault to the doctor who saw my kid, but he had not seen enough of dark skin in text books and only had white skin as a norm for diagnosis," she said.
Since then Olayiwola has been even more diligent about finding proper clinical representation for the various nationalities and ethnicities in her patient population.
Mukwende created the website Black and Brown Skin in hopes of growing the content of the handbook. The site allows people to submit their own images or personal stories anonymously to build a portfolio of images.
"The aim of the website is to allow people who have been silenced for many years to be able to add and provide resources, which will be collated in one place to a bank of pictures. We also have a feature if they are not able to share their photo, they can share their stories," said Mukwende.
The handbook and website are not focused on dermatology issues only, but rather include presentations of different conditions.
Turner sees Mukwende's efforts as a way to unpack years of institutional racism and biases.
"When it comes to healthcare, lives are at stake, and it would be dangerous if we stopped at only having pictures of Black and Brown skins. Far more still needs to be done to provide more equitable treatment," she said.
Like many moments of progress, she adds that there can still be some resistance to change.
"We want this book to be the start of a debate and changes in medical education, with a view to working with the community to reduce inequalities in healthcare," said Turner.
Olayiwola agrees, noting that people like her who have been trying to repair health disparities for years are happy that the rest of world is catching on to systemic racism and inequalities in health.
"It's not that the problem is new, but it's that a lot of new people are understanding the scope and the challenges of health disparities and why it contributes to poor health for all of us. Timing is everything. I will call this the beginning of the destruction and ultimate reconstruction of medical education," she said.
Olayiwola hopes that every specialty and area of medicine examines how it is missing perspectives of different populations, and works to reconstruct education curricula to reflect broader diversity.
Mukwende knows that many healthcare professionals like Olayiwola have been addressing these healthcare disparities for years, and in some cases have been ignored or silenced. With more attention about health disparities making their way across the world, he believes healthcare professionals as a whole will be in a better place to treat patients.
"Now that there is a voice for these people it's important that we listen and we are able to implement change so that tomorrow we don’t have the same problems that we have today," Mukwende said.
He is hopeful that Mind the Gap will be a part of history someday.
"The work does not stop here. The aim is that in about 10 to 15 years we can look back and say that 2020 was the year that the shift to reduce some of these healthcare disparities and increase representation of images in medical education happened," said Mukwende.
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