Erasure is the act of denying or refusing to acknowledge that people’s race and lived experiences in America differ through socioeconomic, historical, political, and legal factors. This concept of colorblindness, also known as erasure, is counterproductive when it results in the inability to recognize the need to include diverse representation and instead results in the use of whiteness as a default or normative model. This is reflected in statements like, “I don’t see race,” “I’m colorblind, I don’t see color,” “We are all equal,” and “But we’re all just one human race.”
The practice of using white bodies as the normative example is widespread in American medical textbooks and exacerbates racial health inequity with inaccurate diagnoses and prognoses. For example, half of dermatologists report that their medical schools did not prepare them to diagnose cancer on black skin (Buster et al. 54). In addition, nearly 1 in 10 dermatology residencies include a rotation in which physicians-in-training gain specific experience treating patients of color (Nijhawan et al. 616). Recent studies in dermatology suggest black Americans with melanoma, a type of skin cancer, are more than four times as likely as white Americans to be diagnosed only after their cancer has already spread to other parts of the body (Cormier et al. 1907-1908). In a study, first-year medical students of color expressed concern regarding their textbook illustrating that “normal” gums are bright and pink, and the criterion for a newborn baby’s health is its pink appearance (Gowda et al. 274).
Such experiences are degrading to the physical traits people of color possess, harm the physician-patient relationship, and contribute to the widening of racial disparities. These are examples of the status quo that continue in medical education including the often-cited description of healthy pink gums and healthy pink babies. Such ideas assert ideologies that white individuals are the standard representations of medicine and medical research. In other words, individuals classified as white are normative or universal, which is understood as “default whiteness.” The lack of people of color represented in medical textbooks, coupled with the physical aesthetics of whiteness as healthy, can be interpreted as white supremacy, which is the belief that individuals who are categorized as “white” are inherently superior and have inherent value compared to people from other racial groups. While medical publishers do not intend and promote such ideologies, the underrepresentation or exclusion of people of color in medical education materials can be understood as devaluing people of color. Other studies have explored the quantity of medical imagery that represents diversity.
In a study about dermatomyositis rashes, a rare systemic autoimmune disease characterized by inflammation of skeletal muscle and skin, “561 images from 93 textbooks and 3 online databases to show the marked under-representation of racial minorities in DM rash images” (Babool et al. 4). In addition, a major study examining 4,146 images from numerous textbooks, “the skin tones represented – 74.5% light, 21% medium, and 4.5% dark overrepresent light skin tone and underrepresent dark skin tone” (Louie et al. 38-39). Another major study had, “5,230 images that could be coded by race/ethnicity, 78.4% (4,100) were white and 21.6% (1,130) were persons of color” (Martin et al. 1004-1005). Medical school students’ experiences along with medical imagery studies suggest that medical publishers are not illustrating an equitable quantity of people of color in medical textbooks. This is not keeping up with the changing demographics within our society with individuals classified as “white” being the minority around the year 2044 (Colby et al.). The changing demographics of our society should be reflected in the medical training literature for current and future medical practitioners.
Furthermore, racial underrepresentation affirms an inferiority or a devaluation when medical students of color’s textbooks and training do not reflect who they are and the communities they come from. The underrepresentation of people of color has dual consequences. First, it deprives white medical students of the development of racially competent training, inclusive pedagogy, and the importance of recognizing the personhood of people of color. Second, racial underrepresentation directly ignores medical students of color’s personhood. There needs to be an intentional culture shift to include people of color in textbooks and teachings because seeing diverse images of patients helps doctors recognize these conditions more accurately, which helps in preventing racial health disparities.
In current demographics, “African Americans, Hispanics, and Native Americans compose only 12.3% of the nation’s physician’s workforce despite representing 37% of the US population…” (Maldonado et al. 605). Prioritizing and creating affirming environments that value and welcome people of color have been used as the solution for this problem. However, in medical education, diversity should be conjoined with inclusion. Diversity asserts that one is different, which can be interpreted as being abnormal, unusual, or “the other.” Inclusion, on the other hand, embraces one’s differences, lived experiences, contributions, and effective perspectives. Ultimately, inclusion fosters a medical culture that fully supports inclusion and emphasizes belonging.
Babool S, Bhai SF, Sanderson C, Salter A, Christopher-Stine L. Racial Disparities in Skin Tone Representation of Dermatomyositis Rashes: A Systematic Review. Rheumatology (Oxford, England). October 2021: 4.
Buster, Kesha J., Erica I. Stevens, and Craig A. Elmets. Dermatologic health disparities. Dermatologic Clinics. 30, no. 1, 2012: 53-59.
Colby, Sandra L. and Jennifer M. Ortman, Projections of the Size and Composition of the U.S. Population: 2014 to 2060, Current Population Reports, P25-1143, U.S. Census Bureau, Washington, DC, 2014.
Cormier, Janice N., Yan Xing, Meichun Ding, Jeffrey E. Lee, Paul F. Mansfield, Jeffrey E. Gershenwald, Merrick I. Ross, and Xianglin L. Du. Ethnic differences among patients with cutaneous melanoma. Archives of Internal Medicine. 166, no. 17, 2006: 1907-1914.
Gowda, Deepthiman, Laura J. Benoit, and Christopher I. Travis. A Common Purpose: Reducing Bias in the Curriculum. Academic Medicine. 92, no. 3, 2017: 274.
Louie P, Wilkes R. Representations of race and skin tone in medical textbook imagery. Social Science & Medicine. 2018;202: 38-42.
Maldonado, Maria E., et al. The role that graduate medical education must play in ensuring health equity and eliminating health care disparities. Ann Am Thorac Soc.;11(4), May 2014: 605.
Martin GC, Kirgis J, Sid E, Sabin JA. Equitable Imagery in the Preclinical Medical School Curriculum: Findings From One Medical School. Academic Medicine. 2016;91(7):1004-1005.
Nijhawan, Rajiv I., Sharon E. Jacob, and Heather Woolery-Lloyd. Skin of color education in dermatology residency programs: does residency training reflect the changing demographics of the United States?. Journal of the American Academy of Dermatology. 59, no. 4, 2008: 615-618.
Image source: A lecture at the Hunterian anatomy school, Great Windmill Street, London. Watercolour by R.B. Schnebbelie, 1839. Source: Wellcome Collection.