How to design a fairer healthcare system, with Layal Liverpool and Tessa Davis

LL: 00:00

There is obviously a lot of excitement about AI at the moment. I think it has a lot of power to kind of revolutionize medicine, but I think we need to be really cautious because all of the racial bias we see in society, but you know, particularly in medicine and healthcare, I think that risks becoming embedded into algorithms and essentially being automated in the worst case.

TS: 00:25

TS Welcome to Made For Us the show where we explore how intentional design can help build a world that works better for everyone. I'm your host, Tosin Sulaiman.

This week, we're exploring a topic that captured our attention five years ago, our health, and how race continues to affect healthcare around the world.

We'll be asking why medical professionals sometimes struggle to diagnose health conditions across diverse skin tones, and we'll also look at the potential of AI to reveal inequities in healthcare. I have two guests on the show today. First, I'll be speaking to Layal Liverpool, a science journalist and author of Systemic: How Racism Is Making Us Ill, who you heard at the start of this episode.

Systemic was published in: 2024

You'll also hear from Tessa Davis, a pediatric consultant at the Royal London Hospital in the UK. She leads the Skin Deep project, which aims to improve the diversity of pediatric skin images online.

TD: 01:25

Traditionally, if you looked up chicken pox or eczema, 'cause you're a parent, the child with it, and you think, oh, is this chicken pox? Or if we are clinicians and a patient comes in, you Google it, you will find images of chickenpox on lighter skin tones. That's just the way it's always been, and that's not representative of the population we see. And if you have a child with a darker skin tone, it's not representative of what you're seeing either.

TS: 01:57

Before we dive in, a big thanks to everyone who's been listening over the past few months. It's been amazing seeing the audience grow and hearing your reactions to the show. As we plan for season three, we'd really like your input. Tell us what's working, what's not, and if there's anything you'd like more of, we have a super quick survey, just six questions, and it's linked in the show notes. So if you've ever thought, I wish they'd cover X, or I really enjoy Y, this is your chance to let us know. I'd be genuinely grateful if you could take a moment to share your thoughts.

Now, here's today's conversation, starting with Layal Liverpool.

LL: 02:36

I'm Layal Liverpool. I'm a science journalist and the author of Systemic: How Racism Is Making Us Ill.

TS: 02:43

So it was published in June and it's already getting a lot of praise.

I listened to a podcast where Chris van Tulleken, the author of Ultra Processed People, said that Systemic is gonna be one of the most important books of this year, and thought it was brilliant and incredibly well researched, and it's especially great how you were able to humanize the data with real life stories.

LL: 03:05

That was something that was really important to me is that there's obviously a lot of research and statistics, but there's also obviously real people behind those, and so being able to talk to people and share their stories, I think is really powerful.

TS: 03:19

So let's start with the central argument in your book, which is that racism is an urgent global health crisis. For those who are yet to read the book, could you give us the elevator pitch and explain why you believe this?

LL: 03:33

So I recently became a mom, and I was really aware going through pregnancy that we're in a world where there are huge inequities when it comes to maternal health. So globally, almost 90% of maternal deaths happen in Sub-Saharan Africa and Southern Asia.

But even in wealthy countries like the UK for example, black women like me are four times more likely than white women to die during pregnancy and childbirth. So in researching systemic, I was really shocked by. The scale of that problem that you know, it's not just the UK. In countries around the world, people belonging to marginalized racial and ethnic groups have much worse health outcomes.

And it's not only during maternity, but also in infectious diseases that we saw this during COVID, also in cardiovascular disease, cancer, mental health conditions. Across all these different conditions, we see this pattern, and obviously this is a horrific situation for those of us in society who are most marginalized.

LL: 04:26

But in the book, I also argue that it's a terrible situation for everyone. As you said, I characterize racism as a global public health crisis. It permeates medicine and science. It makes our healthcare systems really unfair, but also inefficient. It wastes time and money. And it makes medical research also less effective for all of us.

So I think this is an issue that we should all care about, and that's why I don't use the word health crisis lightly, but I think it is a term that we should use because when we recognize racism as a crisis, it means that it's something that we can dedicate resources to tackling that we can do something about.

And I think that for me is really the goal with the book, is to kind of galvanize and, and bring attention to those people and organizations who are already working to tackle this problem.

TS: 05:11

So I wanna come back to many of the points you raised, but you talk about how there's growing recognition of ethnic health disparities, but there is also some resistance to the idea that racism is behind this and not genetic and biological differences. And obviously when we think of doctors and medical professionals, these are people who've devoted their lives to helping others. They go into the profession because they want to do good. So it, it's actually quite hard to square that with some of the issues that you document in Systemic.

LL: 05:42

Absolutely. And that's something that really came through to me interviewing people, especially people working in healthcare and medicine.

It is a caring profession. People do want to help people and that's why they come into this. And actually I would say that many of the people I spoke to really care about this issue and they want to do something about it, but sometimes maybe feel that the education is lacking. You know, there are issues with lack of skin tone diversity in medical textbooks, and I think that people working in medicine, at least in recent years, and especially some of the younger generations, like medical students who I interview in the book, this is something that people really care about. And I think thankfully in recent years there's been more recognition also by, you know, global scientific and medical authorities that racism is a health crisis. And I think that helps to kind of legitimize this issue and also bring. Help bring people together to tackle the problem.

LL: 06:32

So for example, the Medical Journal of the Lancet published a series of articles a couple of years ago examining how racism, discrimination, xenophobia, harm health. The Lancet has also characterized racism as a public health emergency. Also, the World Health Organization has recognized how racial discrimination can harm people's health. So I think having those kind of prominent organizations in recent years kind of coming and highlighting the issue is really helpful.

And I think with the book, I also wanted to reach just a wider audience because health is something that affects everyone. You don't need to be, you know, have a medical degree to care about this.

TS: 07:06

Yeah, and it's worth mentioning that while some of the stories in the book are quite sad and sometimes shocking, you do say that your message is one of hope. So, as you said, people are talking about this a lot more. There's doctors and medical students, innovators who are trying to find solutions, and so what struck me is that your book is about people challenging the status quo in medicine and they're saving lives as a result.

LL: 07:30

Yeah, absolutely. And I think that's, it's great that there is more of that happening and that perhaps in recent years, maybe there's been greater reckoning with racism in society in general. And obviously medicine is part of society. So I'm glad that there is that reflection in medicine as well. And I think it has really, really great potential to boost people's health.

Uh, in the book, I kind of say that I think anti-racism could be the next great advance in human health, and I really, really mean that. I think talking especially to some of these medical students who really question sometimes their superiors about what they were being taught in medical school, that can be really difficult when there's that kind of hierarchy that you're facing in medical school.

I think it's great that people have been able to challenge some of these racial stereotypes, for example, in medicine, and I hope that that work will continue and that people will also be kind of galvanized by the book. And at the back of the book, I have a list of kind of advocacy groups and resources, so people who are working to tackle these problems. And yeah, so I think this can be a resource for people in medicine, but also for all of us who care about our health, who care about helping others.

TS: 08:31

And the book builds on your work as a science journalist and before that as a medical researcher. So I imagine a lot of the issues would've been familiar to you, but I'm curious, was there anything that surprised you as you delved more into this topic?

LL: 08:46

I was really shocked by the scale or, or the kind of extent of the problem. So this was something that I was maybe superficially aware of, but I was shocked kind of how deep it ran. So maybe to give an example, in the book, I also took about my own experience. As a teenager, I experienced a skin problem that took a really long time to get diagnosed. And eventually I saw a doctor who just happened to have darker skin, similar to mine. And he was the one who said to me that, oh, what you're experiencing is actually a classic case of eczema or atopic dermatitis. So this is a really common skin condition. Many people may have experienced it. And I was shocked that he had taken years for me to get that diagnosis.

And he thought that the reason it had taken that long might be because many of the doctors I had seen before may not have been used to recognizing how eczema can look on darker skin like mine. At the time, I thought, oh, that's kind of interesting and could be a problem. But I also felt that, okay, I'm in a privileged situation. I have access to healthcare. Eczema isn't, in my case, wasn't too bad. I was able to get treatment and I kind of didn't think that much more about it.

LL: 09:45

But then years later, I'm researching the book and I interviewed a young British Nigerian woman named Kanayo who had, in some ways, a similar experience, but with a much more kind of life-threatening, I should say, situation. Kanayo experienced Stevens Johnson syndrome, which is a, a life-threatening condition that does also present on the skin, but has internal effects. It can be really, really dangerous, and she presented to a and e multiple times. But was turned away, kind of dismissed and sent home with paracetamol and so on until eventually the third time that she presented to the hospital, she collapsed and she had to be resuscitated.

And Kanayo also has, you know, darker brown skin. And she felt that there was also bias in the way she was treated because of perhaps failure of healthcare workers to recognize the condition on her skin. And she's done amazing work since then. She's shared pictures of her during that episode, shared that with healthcare workers to kind of educate them, but researching the book, I was shocked how that is kind of reflected in statistics as well.

So, for example, there's research in the US showing that 75% of the images in widely used medical textbooks showcase health conditions on lighter skin, just 5% show how those conditions look on darker skin.

LL: 11:00

But I think more shocking to me was there was a, a survey of users of an international medical teaching platform and it found that just 5% of those medical professionals who were surveyed said that they felt confident diagnosing health conditions across diverse skin tones. And I think that's really surprising when you think that, I mean, humans come in many different skin colors, and this seems to be a really basic thing that should be taught in medicine. But a lot of healthcare workers just aren't feeling confident in doing that. And I think that's kind of a call for change, a call for better medical education. And there are people doing great work on this. Maybe I can just shout out Malone Mukwende, who's a medical student in London. He kind of went viral a few years ago because he developed a handbook showing clinical signs on black and brown skin.

And since then, there've been lots of other examples of people trying to kind of diversify the curriculum, particularly in dermatology, but also, you know, in other fields. These are some of the examples of the things that are giving me a reason to be hopeful. Sometimes people say, oh, this problem is just overwhelming, you know, how are we gonna fix racism? But there are just even these small things that we can do. Just making medical education more inclusive, more representative.

TS: 12:08

What I found really interesting about the book is the global scope. So you are not just looking at disparities in the US and in the UK, but you also look at inequities in countries like Brazil, between indigenous and white populations in Australia and New Zealand between different costs in India.

LL: 12:25

Yeah, I think that racism. Exists, and perhaps it manifests in different ways in different countries, but the pattern is the same, that where we see discrimination, we see inequity in health. And I think really by tackling racism, we could have a really, really big impact on people's health around the world.

TS: 12:42

And I wanna spend some time talking about pregnancy and childbirth. This is a topic that you devote the first chapter of the book to. As you said, you've recently become a mom. So can you paint a picture of what we know about this topic from the research.

LL: 12:57

I was actually editing the, the kind of final version of my book while I was pregnant, and it was really difficult to kind of come face to face with some of the statistics on racial inequality and maternal health at that time.

id a survey which came out in: 2022

I mentioned this before, but just to reiterate that black women in the UK are dying four times the rate of white women in pregnancy and childbirth. So this is a really, it's a big health gap. Some of the examples that came up through that survey, people had stories about having their pain dismissed because of stereotypes, like black women's pelvises are shaped differently to white women's or these kinds of harmful ideas that persist in medicine.

And we see similar inequities beyond the UK as well. So in the US for example, black, indigenous, Hispanic and Asian women are all more likely than white women to report experiencing discrimination from their healthcare providers during maternity. So what I think is really positive about this organization Five Times More is that they have resources on their website, including advice for black women and birthing people about how we can advocate for ourselves in the healthcare setting.

They also provide education to healthcare workers. So I think their work is really brilliant. At the same time, the reason I wanted to highlight this in the first chapter of the book is that I don't think that the owners should be only on us as black women and birthing people to solve racism and its health harms.

So I think this is an issue that should be important within medicine within gynecology. The field needs to reckon with its racist history and think about how that legacy is still affecting patients today.

TS: 14:42

One thing that I found surprising is that you write about how these inequalities can't be explained by income alone. They actually persist even as people move up the income ladder.

LL: 14:54

Yeah, in the example that we're talking about, maternity and also infant health, you also see that like there's research in the US comparing women of different educational levels, which is often used as a proxy for income. And you see that even in the highest income and educational groups that black women are still experiencing higher rates of death during pregnancy and childbirth, or also infant deaths compared to white women who sometimes are even at lower levels of education. So clearly, you know, inequality and income on racial lines also has a profound impact and contributes to racial health gaps.

But I guess what this research is telling us is that there's more to it, that in addition to that kind of structural inequality, that economic inequality, there's also other forms or other ways in which racism is affecting our health and wellbeing.

TS: 15:40

And before we continue, I guess we should talk about an important point that you make in the book, which is that race is a social construct and not a biological characteristic. So from a medical standpoint, it doesn't actually make sense to group people into racial categories.

LL: 15:55

Race and ethnicity are social constructs. They don't have a biological basis, and there's research as far back as the 1970s that's shown us that there's far more genetic variation, for example, within so-called racial groups or geographic populations around the world compared to between those groups.

But unfortunately, I think the construct of race has been used in medicine for decades really to adjust, for example, people's test results or to guide decisions about their treatment. This is a practice that's often referred to as race-based medicine. So, to give an example, for years, lung function tests have been adjusted for race based on this assumption that black people's lungs work differently from white people’s.

And that's an idea that can be traced back to a physician and slave holder in the US in the eighteen hundreds. And his name was Samuel Cartwright, in case people want to look him up. He had this idea that black people's lungs were weaker and so they benefited from being enslaved. And I think, I mean, it's just wild to me when you hear that, but you have to think about the historical context at that time.

So this is an era of European colonization, transatlantic slavery. So you can imagine there was a kind of. a need to justify the oppression of black people. And so science and medicine were kind of weaponized in that effort. And I think it's so crucial that we remember that history when we take some of these stereotypes or assumptions in medicine at face value.

LL: 17:10

But thankfully, this is an example that has a kind of somewhat positive end because last year, the American Thoracic Society and the European Respiratory Society, so these are kind of medical organizations that publish recommendations for doctors. They changed their joint recommendations on lung function testing last year in 2023.

So they acknowledged that race is a social construct. It doesn't have a biological basis. They recommend against the use of race adjustment in lung function tests. But yeah, this is just one example of race-based medicine. There have been similar race adjustments used, for example, in kidney function testing, but this is something that's also started to change in recent years.

So I think this is an area where we are seeing changes. We can remove racial bias from medical algorithms and that can have positive outcomes for people. But maybe I'll just add that, in addition to these kind of guidelines, there are also these myths and stereotypes in medicine, but also kind of in wider society that are quite pervasive and can also be really harmful, even if they aren't specifically embedded into guidelines.

So I mentioned for example before the idea that black people are less sensitive to pain, that our pelvises are shaped differently. When it comes to pain, for example, to some extent this has been documented. You know, there was a study in the US which surveyed medical students and residents about differences between black and white patients, and it found that many of the residents, I think about half endorsed one of a number of false beliefs that like black people's nerve endings are less sensitive, so they feel less pain, or that their skin is thicker than white people's.

So in that survey, the medical students and residents who endorsed those beliefs were more likely to then rate pain differently in a kind of fictional scenario. So they're assessing patient's pain in a different way, depending on their race. But also there's studies in the US showing that in emergency rooms, black and Hispanic patients are kind of undertreated for pain.

So yeah, I just really wanted to underline that these stereotypes, they're not just like, oh, silly ideas. They really can cause harm to patients.

TS: 19:06

Just to go back to what you said about race-based medicine, 'cause you also talk about kidney function tests, and that's another area where there's some positive change. Could you talk a little bit more about that?

LL: 19:18

So this is also an area that I've reported on a lot as a journalist. A few years ago I got to know a medical student in the US called Naomi Nkinsi. So she's one of the medical students who I kind of referred to before who's been questioning things that she's being taught in medical school.

And one of those things was this idea that black people's kidneys work differently to white people's. And based on that assumption, there for a long time has been an adjustment for kidney function tests, accounting specifically for black race. So this has come under a scrutiny in recent years from prominent nephrologists in the US, but also more widely in medicine.

So there was a study in the UK which showed that using this adjustment in kidney function tests was leading to less accurate results, overestimating kidney health in black people. And so the result of that is it means that you're underdiagnosed with kidney disease. And I should say that in the UK and in the US, black people experience kidney disease and die from kidney disease at higher rates. And so this leads to inequalities because also you might be using this to assess whether someone should get a kidney transplant or should get dialysis.

LL: 20:23

So I highlighted that research to NICE in the UK, the National Institute for Health and Care Excellence, which sets medical guidelines and eventually NICE changed its guideline to remove the recommendation to adjust kidney function test results based on race and also in the US, the National Kidney Foundation and the American Society for Nephrology, they also changed their guidelines to remove this recommendation to adjust kidney function test results for black race.

Seeing those changes has been really powerful. I think this is the way that we're gonna see change because this is a systemic issue, so it doesn't matter if there's one or two doctors who are racist. It matters much more if there's a guideline which is systemically discriminatory against people. So I think obviously both of those things are problematic and we need to tackle both. But tackling those systemic issues, I think can have a really big effect. It can affect a lot of people's health.

TS: 21:12

Yeah. 'cause I do remember the section in where you talk about kidney function tests. You said that there's a study that showed if that race adjustment had been removed. The study was in the US. So the study said if that race adjustment had been removed, it would've resulted in over 30,000 additional black patients becoming eligible for transplant.

LL: 21:34

Yeah, that's right. And so that's another example of just putting a number on this of how many people's lives can be affected. And maybe some people might not have experienced what it's like to have kidney disease or to need a transplant, but this is really a life-saving intervention.

And already it can be challenging. You can wait a long time for transplant, but to have that additional barrier for black patients is just, it's devastating and it's really horrific situation that that was happening. I hope that this is an area where we are seeing positive changes, but it would be great to see this systematically across medicine because the more I kind of dug into this, I keep coming across more and more of these race-based assumptions in medicine.

So I think it would be great if we could have a much wider reckoning where all kind of medical guidelines that use race can just be systematically reviewed to question, okay, where does this idea come from? Can we look at the history behind that and just reevaluate whether that's still relevant in our world today when we recognize that race is a social construct.

TS: 22:31

And that's especially important given the increasing use of AI in medicine, which you talk about.

LL: 22:37

Yeah, I definitely see that there is obviously a lot of excitement about AI at the moment and including in healthcare. I think there's massive investment in healthcare industries in this technology, and I understand that. I think it has a lot of power to kind of revolutionize medicine, but I think we need to be really cautious because all of the racial bias we see in society, but you know, particularly in medicine and healthcare, I think that risks becoming embedded into algorithms and essentially being automated in the worst case, and this is something that's already happening.

So in: 2019

And I interviewed the researcher who led that study for the book and he's actually since been working with the developer of that algorithm to remove that observed racial bias. But I think we shouldn't have to wait for these algorithms to be widely used and for some researchers to kind of happen to do a study to detect these problems.

I think we really need much more regulation when it comes to the use of AI in healthcare especially. And that example, I think, also shows the potential that AI has to reveal existing biases in our society or in medicine.

TS: 24:11

So we mentioned at the beginning of the conversation that there are reasons for hope. So I wanna end with that. Give us three reasons why you are optimistic.

LL: 24:21

Thank you so much for asking that. I think that just by recognizing that racism is behind so much unfairness in health, it does mean that we can begin to, to tackle the problem. And there are a lot of really amazing people and organizations sounding the alarm on this, but also working towards changes that I think are really positive.

So they're showing us that, number one, we can teach healthcare workers how to recognize conditions on diverse skin tones. I think this is such an easy win. Skin is really often an early warning system for illness, and I think it can be really beneficial to increase diversity in medical education.

Number two, we can also remove racial bias from medical algorithms. And again, there's been a lot of progress in, for example, kidney and lung function testing with the removal of race, adjustments from medical recommendations in various countries in the last few years. We can do more of that. We can systematically review the use of race in medicine. And also we can make medical research more diverse. So number three.

And yeah. At the same time, maybe this is number four, I'm sneaking it in. We, I think that we can all just feel, yeah, empowered to take control of our health journeys, demand fair treatment, whatever our background. I really hope that the book will empower people and validate them in their experiences.

There's nothing wrong with me as a black woman, for instance, that should make me more likely to die during childbirth or develop heart disease or all these conditions where we see racial inequalities. Instead, it's living in a racist society that is harmful to our health, and that's something that we can change.

We can change our society. We can think about our day-to-day interactions with colleagues, neighbors, friends, and yeah, I think if we can tackle racism in wider society, but especially in medicine, in healthcare and in science, then I think we can all be healthier, but also happier because I think this is just beneficial to everyone.

TS: 26:09

So how can people learn more? How can they follow your work?

LL: 26:12

So the book, it's called Systemic, how Racism Is Making Us Ill. It's also available in the US. The title in the US is Systemic, how Racism is Making us Sick. Slight Difference. So people can find me via my website, layalliverpool.com. Follow me on social media at Layallivs. So L-A-Y-A-L-L-I-V-S.

TS: 26:36

Now let's hear from Tessa Davis, a pediatric consultant at the Royal London Hospital, who'll be sharing more about the Skin Deep project.

TD: 26:45

So my name's Tessa Davis. I'm a pediatric emergency medicine consultant in a hospital in London, and I run Don't Forget the Bubbles, which is educational community websites, resource for other healthcare professionals who look after children. So Skin Deep is a project which is joint between Don't Forget the Bubbles, and the hospital where I work in London at the Royal London Hospital. And the aim of Skin Deep was to increase the diversity of pediatric skin images online. So it's a website that hosts images on diverse skin tones.

TS: 27:21

So I believe Skin Deep started in June 2020. Was there a particular catalyst for the project and how did you come up with the idea?

TD: 27:30

Well, I work at in a busy children's emergency department and we see a lot of children come in with the range of skin problems, including injuries, but also various rashes. And some of the families in our population were starting to tell us, like, they were looking up online to try to find what it was 'cause they didn't know what the rash was and all they were seeing was pictures of skin conditions on light colored skin. And it didn't reflect what they were seeing on their child, so they were getting frustrated. And because we already create a lot of online content, we know how to put resources together and make them easily digestible, then it was a good match to use our expertise from that with the problem that our patients were facing. And so that's kind of where the idea came from to start Skin Deep.

TS: 28:21

So I'd love to understand how it actually works, who it's aimed at, and how is it being used today.

TD: 28:26

It's aimed at families, but also clinicians. So I think one of the things that we realized and that we see in the literature in studies, and we've done a couple of studies ourselves looking at clinicians and how they interpret skin images and how they interpret diagnoses in their patients is that we, when we get trained in university or in training courses, then we get taught about skin conditions using the same images that you could have look up online. And unfortunately they are mostly in lighter skin tones. Traditionally, if you looked online, if you looked up chicken pox or eczema or you know, 'cause you're a parent with a child with it, and you think, oh, is this chickenpox? Or if we are clinicians and a patient comes in and we wonder if it's chickenpox and you Google it, you'll find images of chickenpox on lighter skin tones.

That's just the way it's always been, and that's not representative of the population we see. And if you have a child with a darker skin tone, it's not representative of what you're seeing either. But for us as clinicians when we're trying to diagnose a condition and we look it up and the resources we look up don't look like what we're seeing in front of us, it makes it very difficult.

And that's the same with traditional textbooks we've used to learn from or be taught from through university through training courses. And so what that means is that we're likely to be less accurate at diagnosing skin conditions in patients with darker skin tones, maybe not recognizing what it is, what we're seeing, or not diagnosing correctly.

And so what we really want to do is be part of changing that. And so our images are very searchable online, so over time, and hopefully now when you look up eczema or chickenpox, you will see a range of skin tones and that will be then more reflective and more helpful for clinicians treating patients diagnosing conditions.

So we've created this resource to help our peers, which is to help other healthcare professionals who look after children, but also we know that is used by our families as well.

TS: 30:34

And so it's essentially a, a database of, of images, sort of open source images that are available on your website?

TD: 30:41

Yeah, that's right. So we collaborate with lots of other hospitals and organizations and people can submit as well online, like anyone can submit images. We have a consent process. We have a screening process where they're looked at by dermatologists as well, and then they go up on our website and anyone can look through them. You can search by diagnosis or appearance or body part, you can kind of test yourself if you're a clinician or if you're a parent and you wanna look, you can just browse through them.

TS: 31:13

And so these are anonymized and they're submitted, you know, with parental consent, et cetera.

TD: 31:18

Yeah, so there's a proper consent process. There's no patient details that we take. So it's just the interpretation of what the image that you see is. So without the context or the background, it doesn't exactly replicate what you would see in real life. 'cause you'd know the story, like, is it itchy? How long has it been? So you don't have any of that, but it's just looking at the image are you able to work out what it is?

TS: 31:43

And can you give an example of, you know, some of the skin conditions that are depicted and are there any that would present differently on people of different skin tones that maybe kind of trip people up?

TD: 31:54

I mean, we'll have probably a hundred different conditions on there, so all sorts of different skin infections, rashes, viral infections that cause different types of rashes.

We also have burns images because they can look different on different skin tones as well. And it's all just part of having more images out there that are being ranked by Google, that are able to be searched, that people can find online and access easily. One of the times where it was used very heavily was when there was a scarlet fever or a strep outbreak, because Scarlet Fever is a rash that's kind of red can be quite hard to detect, and certainly in darker skin tones, it can be easy to miss, not to see.

And there was a lot of public information going out about how to recognize scarlet fever when lots of people were getting it, how to diagnose it. And so we had, I think, probably the only images of Scarlet Fever on darker skin tones in the uk, and so it was used by the BBC. It was used by the NHS website. So what we were able to do was help improve awareness and improve recognition, which is the goal of what we're doing with the websites.

TS: 33:08

Just out of curiosity, how does Scarlet Fever present on darker skin tones?

TD: 33:13

Well, it's just a sandpaper rash, so because it's like sandpaper, it's kind of bumpy and a bit red, but it doesn't show up as red on darker skin tones.

So it can be harder to see if you don't know what you're looking for. And because if you, you're used to seeing it on lighter skin tones where it's really obvious 'cause it's bright red, then it's, you could easily just not notice it or not think about it. And so yeah, it's just. It's more subtle, it can be harder to pick up, and it's really important that people are aware, like how it presents differently on, on different people.

TS: 33:44

And what was the reaction when you first launched the project?

TD: 33:48

The reaction was very positive. You know, we, we love doing it. We don't get paid to do it. We do it for free and we set it up, you know, for free with our own money. So we do it to try and increase awareness, to try and help educate our peers and deliver better care for our patients.

We've had lots of doctors and other healthcare professionals using it for teaching resources. We've had it used in lots of. Journal publications to illustrate when people are delivering papers or education around particular skin conditions. They've really been widely used throughout the UK and beyond for teaching for education and to help ultimately improve the care that we're giving our patients.

TS: 34:31

And do these images make their way into medical textbooks? I mean, how does this affect the curricular in medicine, for example?

TD: 34:39

Yeah, I hope so. So the images have been used in a, in a range of resources 'cause people contact us to ask to, to use them. So they're, they have been in medical textbooks, they have been used in exams.

So when you have some written exams, some of them you'll get images. And so various colleges and exam boards have. Used our images for these as well. So it's a slow process, but the images are being integrated and are being used. So they're definitely part of undergraduate teaching, postgraduate teaching used in exams, used in journals, and used in textbooks.

TS: 35:12

With the growing use of AI in medicine in dermatology, how do you see that impacting this project and you know, the impact that you could potentially have?

TD: 35:21

I think it could have a massive impact. We talked about it for a while, but we haven't been able to progress it. But essentially we are collecting a, a large bank of skin images that could be used to train an AI model to then recognize, is this, you know, a worrying type. So with eczema, I know it seems like it's not a significant problem, but there's certain infections you can get with eczema that can make you really sick. And one of the common things we get when children come and with eczema is do they have the worrying thing, which is eczema, herpeticum, or not?

And that's a common thing that we have to think. So is this eczema herpeticum or not? If we can train an AI model using images to say, yes, this is, or no, this isn't, then that would make a massive difference to the care of the patients. I know that that requires a lot of images and a lot of work, and so we just kind of started to talk about it.

We haven't progressed it, but hopefully someone in future, if not through this project, I think that's definitely a way that it, it could be really useful.

TS: 36:19

And how has your involvement in the project changed the way you practice medicine, perhaps, or, or shifted your perspective in, in a personal way?

TD: 36:27

It's definitely made me more conscious of thinking about when we share content online and we create a lot of educational resources, what we're contributing to global education, it impacts what comes up when people search, and that has an impact on what people are trained on, what other clinicians are trained on, how they then treat their patients.

So it's definitely made me more aware of that and it's also created a lot of really nice conversations with. With families, being able to talk to them about their experience of, you know, looking up skin conditions online, the impact of, of the project on them, and even just how they respond when we consent them. I tell them about the project, I show 'em the website and they get to have a look through. That's been really positive experience. So yeah, it's made a massive difference to, to me personally and hopefully to our whole team at, at the Royal London.

TS: 37:20

And you mentioned earlier that this is one piece in the puzzle when it comes to addressing, you know, disparities in healthcare. What other innovations are you seeing to tackle this problem? Is there anything else that you would like to see more of?

TD: 37:34

For us, it's just recognizing what the needs are of our population, and so that's making sure that our services are accessible, we communicate effectively. You can feel that you're delivering great care, but if it's not received as great or not understood or not accessed, then it’s not great care.

And so we really just, I think that's what's important is to really understand the needs of whatever population it is that you are serving as clinicians. I know that having a workforce that reflects your population means that we're going to deliver better care because we're going to better understand the needs of the community that we serve.

And we also have the breadth of ideas. So you've not just got one group of people giving ideas that they think are great, but you've actually got a diverse range of opinions. So I think it's really important that our patients see. Themselves reflected in our workforce, but also that we can then support our patients better when we've got a diverse workforce who reflects them.

TS: 38:37

And what's next for Skin Deep? How do you see the project evolving over the next few years?

TD: 38:43

We just wanna keep building the resource. I always thought that Don't Forget the Bubbles was like the big project and Skin Deep was just a side project and I didn't realize until a few months ago when I looked at like our analytics to see the stats.

So, Don't Forget the Bubbles gets about one and a half million views a year, and I just assumed Skin Deep was a lot smaller. But then when I looked a few months ago, I actually realized that Skin Deep was getting more views than, Don't Forget the Bubbles. I think it was about 2 million, two to two and a half million views a year.

And that was just an amazing realization for us that we have created something that people are accessing, they are using. And even if it just stays there and it doesn't grow, it's actually reaching a lot of people and hopefully it's having a positive impact.

TS: 39:26

And how can people learn more? How can they follow your work?

TD: 39:30

So they can go to the website, which is the dftbskindeep.com, and they can contact us through there. I'm quite easy to find online, so I'm on Twitter and Instagram. I'm very happy to chat with anyone who's interested in the project. I'm very happy to collaborate.

TS: 39:46

Are there any final thoughts that you'd like to leave people with?

TD: 39:51

Just that if you've got an idea for a project that you can get off the ground, that it can be difficult, there's challenges, but actually just trying new things and putting yourself out there with your team. So I think one of the key things is that it's not me doing this. We have a large team of people and actually, if you get people together who work together and collaborate, you can build great things.

It doesn't need to be a financial thing. We do it for free, but you can make a meaningful contribution to the community. So yeah, hopefully encourage other people to do the same.

TS: 40:24

Thank you so much for joining me. It's been a pleasure speaking to you, and thank you for sharing the impact that you've been having.

TD: 40:30

Thanks very much for having me.

TS: 40:36

Thanks for joining me on this episode of Made For Us and a huge thank you to Layal Liverpool and Tessa Davis for sharing their insights and giving us reasons to be hopeful. If this episode resonated with you, then please share it with a friend or leave us a five-star review on Apple Podcasts or wherever you are listening.

And if you have a moment, don't forget to share your feedback in our listener survey. I'm Tosin Sulaiman. See you next week on Made For Us.