Just before Christmas, a series of images by student and medical illustrator Chidiebere Ibe went viral on social media. Ibe is a skilled artist, but what drew the most attention in his illustrations was that all the people depicted were black. Most medical textbooks, by contrast, treat white men as the default.
A recent study of medical illustrations showed that only 4.5 per cent depicted non-white skin. The most striking of Ibe’s image was of a black foetus, because even when textbooks include female bodies, these are invariably white.
How did people who look like me become the standard for medical research, when we make up only a single figure percentage of the global population? And how does this affect the practice of medicine?
The earliest surviving medical diagrams are papyrus sheets from the fourth century BC, found in Alexandria. Human dissection was rarely practised over the next 1,000 years (anatomy was instead largely taught from the bodies of apes and dogs), but by 1300 they had resumed at the University of Bologna, where Modino de Luzzi produced the first anatomical textbook in 1315.
Medical practice in the 19th century often reflected racist assumptions, such as black people being naturally resistant to pain
During the Renaissance, the development of the printing press and graphical perspective meant that illustrations could be easily reproduced and more accurately represent the dimensions of the human body. The most famous anatomist of the era was Andreas Vesalius, who popularised human dissection across Europe and published an illustrated textbook.
Soon after, Europeans began to construct the concept of race. During the Enlightenment, scientific practice prioritised categorising the natural world. One result was the creation of racial categories based on observable differences such as skin colour. In the context of colonialism and the Atlantic slave trade, “white” was used to differentiate Europeans from indigenous and enslaved peoples. Racialised assumptions permeated colonial societies; even depictions of Jesus became noticeably whiter and blonder during this period.
Because racial categories were supposedly scientific, they were considered respectable. Medical practice in the 19th century often reflected racist assumptions, such as black people being naturally resistant to pain. In the 1820s, Thomas Hamilton repeatedly inflicted scars and blisters on a slave, John Brown, in a vain attempt to demonstrate that black skin was thicker.
James Marion Sims, "the father of gynaecology", tested his surgical techniques on unanaesthetised enslaved black women in the antebellum South, while offering anaesthesia to his white patients. Unethical research on black people continued into the 20th century. Between 1932 and 1972, 399 black men in Alabama were misled by authorities into becoming subjects of a study into the effects of untreated syphilis. Despite syphilis being treatable, they received no medical intervention, and more than 100 died.
Black people were treated as objects of research, but the assumption of medical textbooks was that treatment subjects would largely be white. Despite the extensive harm inflicted on black people in the name of research, illustrations were invariably of white people. In the 1860s a newly developed device, the spirometer, was used by plantation doctors such as Samuel Cartwright to demonstrate that enslaved black people had lower lung capacity than whites.
Two black former players sued the NFL, arguing that they were unfairly denied a payout because they had to demonstrate more cognitive decline than a white player
Although this generally reflected the horrific environmental conditions that slaves were forced to endure, it was used to argue slavery was beneficial, because rigorous work would help to strengthen the lungs. Even today, spirometer measurements are calibrated such that values for white people are the standard, and those for other ethnic groups are “race corrected”.
In 2013, the NFL reached a $1 billion settlement with former American footballers on concussion-related brain injuries. But the system used to judge cognitive decline is race corrected, and assumes that black people have lower cognitive function. Last year, two black former players sued the NFL, arguing that they were unfairly denied a payout because they had to demonstrate more cognitive decline than a white player.
Black skin may not be thicker than white skin, but it does contain more melatonin. This difference in pigmentation results in skin conditions presenting differently in white and black patients.
Yet because textbooks assume patients will be white, dermatologists are less trained in spotting these differences. Outcomes for illnesses usually diagnosed by observation of the skin, such as meningitis, melanoma and Kawasaki disease, are considerably worse for black patients. Thanks to the efforts of illustrators such as Ibe, this may not be the case for much longer.
Dr Stuart Mathieson is a postdoctoral fellow working in Dublin City University school of history and geography