Challenging Whiteness as the Norm in Nursing Education Imagery

Dr. Lydia Wytenbroek & Nicole Hildebrand-Edgar

Images in nursing and medical textbooks reinforce whiteness as the norm. A growing number of studies report that nursing and medical textbooks overwhelmingly depict clients with white or light skin and/or show how various dermatological conditions appear on white skin.[1] A study carried out in the United Kingdom explored lecture material pertaining to pressure injuries in five undergraduate nursing programs in London and found that teaching and learning activities around pressure injuries centered on people with white skin.[2] This means that nurses are less prepared to identify conditions like pressure sores on patients with darker skin. And indeed, there is a higher prevalence of severe pressure injuries in people with darker skin tones.

This lack of diversity is also prevalent in medical education. A 2018 study that analyzed more than 4000 images in four major medical textbooks in the United States, found that only 4.5% of images showed darker skin.[3] Another study analyzing dermatology textbooks found that skin disease was overwhelming depicted in light skin. The notable exception was that STIs were more frequently depicted on black skin.[4]

The lack of images depicting how various conditions appear on darker skin tones has led to healthcare inequities.[5] Dermatologists note that the lack of attention to black and brown skin is one of the reasons why many conditions, such as Lyme’s Disease and skin cancers, can go misdiagnosed or underdiagnosed in patients with darker skin. The five-year melanoma survival rate is 94% for white patients, but only 70% for Black patients.[6] Thus, BIPOC patients are left seeking equal care in a system that is designed largely with the white patient as the normative reference point. Pulse oximeters, for example, which were calibrated using white patients, have been shown to overestimate oxygen levels in people with darker skin by up to seven percent. These inaccuracies can lead to negative health outcomes for patients.

Historical analysis shows us that measurements and instruments have been designed with a strong bias towards people with white skin. The Fitzpatrick scale of skin phototypes demonstrates this. In 1975, Thomas Fitzpatrick, a prominent white dermatologist at Massachusetts General Hospital, developed the Fitzpatrick Scale, a tool to be used to categorize skin colour into one of six gradations or phototypes. Three of the phototypes pertain to white skin, two phototypes represent brown skin, and only one phototype exists to represent the many variations in black skin.

To tackle the lack of knowledge about how conditions present in individuals with darker skin, some scientists and practitioners are raising awareness by developing handbooks for teaching and learning purposes. In 2019, medical student Malone Mukwende, along with Peter Tomany and Margot Turner, developed Mind the Gap: A Clinical Handbook of Signs and Symptoms in Black and Brown Skin, a photo-drive reference guide to the way that signs and symptoms present on Brown and Black skin. The first edition is freely available online, and can be found here: https://sgul.figshare.com/articles/online_resource/Mind_the_Gap_A_handbook_of_clinical_signs_in_Black_and_Brown_skin/12769988. In the United States, a mother from North Carolina, Ellen Buchanan Weiss, discovered that there was a lack of images detailing conditions on brown skin when her biracial son developed a rash at age two. She started an Instagram account called Brown Skin Matters where individuals can submit images of what a skin condition looks like on a person of colour. A medical doctor reviews the photos before Weiss posts them.[7]

In December 2021, a twitter user posted an illustration of a black fetus, which was shared over 47,000 times; many users commented that they had never seen a black fetus illustrated before. The illustrator, Chidiebere Ibe, is a Nigerian medical student and self-taught medical illustrator. He told NBC News: “I wasn’t expecting to go viral, I was just sticking up for what I believe in, advocating for equality in health through medical illustrations. I made a deliberate action to constantly advocate that there be inclusion of Black people in medical literature.”[8] Chidiebere will now have some of his illustrations published in the second edition of Mind the Gap.[9] Ibe plans to continue illustrating and sharing medical images of people of colour. He told CNN: “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.” His illustrations can also be found on his Instagram account: https://www.instagram.com/ebereillustrate/.

A historical lens can prompt us to think about why tools and images exist and how they are used. To achieve more equitable healthcare, we need to understand how systemic inequities are created and then work to address these barriers, like Chidiebere, Mukwende, and Weiss have done.

Lydia Wytenbroek is an Assistant Professor at UBC School of Nursing and Co-Lead of the Consortium for Nursing History Inquiry. She is a historian of twentieth-century health care, with a particular interest in the history of nursing.

Nicole Hildebrand-Edgar holds a master’s degree in linguistics from the University of Victoria, where Nicole’s research focused on the linguistic aspects of social inequality. After finishing the BSN program at UBC, Nicole is interested in working in health promotion and education in the community.

[1] Massie, J., Cho, D., Kneib, C., D Sousa, J., Morrison, S., & Friedrich, J. (2021). A picture of modern medicine: Race and visual representation in medical literature. Journal of National Medical Association, 113(10), 88-94. doi: 10.1016/j.jnma.2020.07.013; Louie, P. & Wilkes, R. (2018). Representations of race and skin tone in medical textbook imagery. Social Science & Medicine, 202, 38-42. doi: 10.1016/j.socscimed.2018.02.023

[2] Gunowa, N., Hutchinson, M., Brooke, J., Aveyard, H. & Jackson, D. (2021). Pressure injuries and skin tone diversity in undergraduate nurse education: Qualitative perspectives from a mixed methods study. Journal of Advanced Nursing, 77, 4511-4524.

[3] Singh, N. (2020, August 13). Decolonising dermatology: Why black and brown skin need better treatment. The Guardian. https://www.theguardian.com/society/2020/aug/13/decolonising-dermatology-why-black-and-brown-skin-need-better-treatment

[4] Adelekun, A., Onyekaba, BS., & Lipoff, J. (2020, April 23). Skin color in dermatology textbooks: An

updated evaluation and analysis. Journal of the American Academy of Dermatology. https://www.jaad.org/article/S0190-9622(20)30700-3/pdf#articleInformation

[5] Lester, J.C., Jia, J.L., Zhang, L., Okoye, G.A., and Linos, E. (2020). Absence of images of skin colour in publications of COVID-19 skin manifestations. British Journal of Dermatology, 183(3), 593-595.

[6] McFarling, U. (2020, July 21). Dermatology faces a reckoning: Lack of darker skin in textbooks and journals harms care for patients of color. STAT. https://www.statnews.com/2020/07/21/dermatology-faces-reckoning-lack-of-darker-skin-in-textbooks-journals-harms-patients-of-color/

[7] Gilman, S. (2021, September 27). Too many doctors are misdiagnosing disease on skin of colour. Everyday Health. https://www.everydayhealth.com/black-health/too-many-doctors-are-misdiagnosing-disease-on-skin-of-color/

[8] Adams, C. (2021, December 10). Meet the student bringing Black illustrations to the medical field. NBC News. https://www.nbcnews.com/news/nbcblk/meet-student-bringing-black-illustrations-medical-field-rcna8277

[9] Orie, A. (2022, January 18). The creator of the viral Black fetus image will have his illustrations published in a book. CNN Health, https://www.cnn.com/2022/01/13/health/chidiebere-ibe-medical-illustrations-published-nigeria-spc-intl/index.html

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By Lydia Wytenbroek & Emily Peacock

Dr. Lydia Wytenbroek:
Indigenous people in Canada experience widespread disparities in health outcomes. I have found that undergraduate students come to recognize this through discussions about the incidence, morbidity, and mortality of various chronic illnesses. Students have also explored how chronic illness statistics can be reflective of the structural discrimination and racism that shapes health care policies and practices. In class discussions, we have considered the ways in which health disparities between Indigenous and non-Indigenous people are rooted in Canada’s colonial history. In the fall of 2020, I invited students to attend several academic talks on the history of health and colonialism. On October 30, 2020, the Department of History at the University of Lethbridge held a lecture by zoom as part of its Driedger Lecture Series. The lecture was delivered by guest speaker Mary Jane Logan McCallum, a Professor of History and Canada Research Chair in Indigenous People, History and Archives at the University of Winnipeg. McCallum’s talk was called Structures of Indifference: An Indigenous Life and Death in a Canadian City and was based on a book by the same title that McCallum co-wrote with historian Adele Perry.

Structures of Indifference focuses on the life and death of Brian Sinclair, an Anishinaabe man, who died in 2008 from an easily treatable infection after spending thirty-four hours in the emergency waiting room at the Health Sciences Centre in Winnipeg. Hospital staff ignored and dismissed him, assuming he was homeless or intoxicated, and failed to provide him with necessary medical care. Following his death, an inquest found that no single person was to blame and that the situation could have happened to anyone. Instead of focusing on racism and discrimination, the inquest linked Sinclair’s death primarily “to multiple failures in the policies and procedures of processing patients in the ER” (McCallum & Perry, 2018, p. 132). In Structures of Indifference, McCallum and Perry challenge the findings of the inquest by placing Sinclair’s life and death in historical context and exposing the structures of indifference that undermine and devalue Indigenous lives. Historical methodology is one tool that nursing students can use to explore broader issues of racism and systemic discrimination in healthcare, as well as foster discussions about ways to promote health equity. What follows is Emily’s critical reflection on Mary Jane Logan McCallum’s talk on October 30, 2020.

Emily Peacock:
Nursing students are continually reminded of the caring and benevolent nature of the nursing profession. If that is so, then why do Indigenous people suffer neglect from healthcare providers time and time again? In a transformative lecture, Dr. Mary Jane Logan McCallum discussed the prevalence of racism in Canada’s health care system by talking about Brian Sinclair’s death. McCallum began by reviewing the history of colonialism in Winnipeg. Even though Winnipeg’s Health Sciences Centre was established on Indigenous land through Indigenous displacement, Indigenous people were denied access to quality health care. For much of the twentieth century, Indigenous people in Manitoba received medical care in segregated hospitals that were often understaffed and under resourced. Indigenous people wanted access to modern healthcare facilities and were interested in adapting and combining various forms of medicine to best support their communities. Despite this, they were met with significant resistance by a health care system created to benefit predominantly white settler Canadians.

Fast forward to 2008, when Brian Sinclair wheeled himself into the Emergency Department of the Health Sciences Centre where he was seeking care for a treatable bladder infection. During his time in the Emergency Department, health care providers ignored and neglected Sinclair. On multiple occasions, members of the public alerted health care providers to Sinclair’s deteriorating condition, but health care professionals dismissed these concerns by suggesting that he was likely homeless or intoxicated. Ultimately, it was their indifference that led to Sinclair’s death only thirty-four hours later. This indifference, as McCallum and Perry (2018) point out in their book, and the related neglect, continue to influence the provision of healthcare. Their book has not lost any of its relevance, as in September 2020, we witnessed how nurses taunted 37-year-old Atikamekw woman Joyce Echaquan, who captured the nurses’ failed actions and abuse on her phone as she died. While the Quebec premier condemned the actions of these nurses, two of whom were subsequently fired, he was also quick to assure the public that this situation was a ‘one-off’ and not an issue of racism. Yet, Indigenous lives, like Brian Sinclair and Joyce Echaquan, continue to be lost. In addition, individualizing the nurses’ actions also avoids any consideration about how these might be indications of larger health care system failures. This begs the question: How can this possibly not be an issue of systemic racism?

McCallum, M. J., & Perry, A. (2018). Structures of indifference: An Indigenous life and death in a Canadian city. University of Manitoba Press.

Lydia Wytenbroek is an Assistant Professor at UBC School of Nursing. She is a historian of twentieth-century health care, with a particular interest in the history of nursing.

Emily Peacock graduated from the University of Victoria with a BSc in Psychology. She has spent the previous four summers working for the B.C. Wildfire Service and is currently a nursing student at the University of British Columbia.

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