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Gavin: Hello, welcome to another episode of The Lancet Voice. I'm Gavin Cleaver
Jessamy: and I'm Jessamy Bagenal. On this episode, we'll talk about dermatology and skin of colour with Dr Jenna Lester, who runs the Skin of Colour Clinic in San Francisco, to find out how the history of dermatology has been structurally biased against people of colour and the problems this has caused during the pandemic.
Gavin: But first, Jess and me spoke with Professor Arne Ackbar of UCL, who's the president of the British Society for Immunology. Now, you might remember that we spoke with Arne in April about the immune system and COVID 19. So we thought we'd catch up with him to ask what's changed in our understanding of the disease, and especially to find out what's happening with patients suffering these kind of mysterious effects of long haul COVID.
Patients who can't seem to shake the effects of the disease.
Jessamy: Thanks so much for joining us again. We spoke to you last in April. What do you think are the kind of major breakthroughs in terms of our understanding of the virus that we've had over the last couple of months?
Arne: One of the first things that we recognize now is that the virus is not just causing pathology in the lungs, like we thought originally.
It now seems to be multi organ problems as a result of the infection. Probably because the ACE2 receptor is very widely distributed between different organs as well. We're learning that antibody is not the only form of immune immunity you generate. Emerging reports now suggest that your T cell part of the immune system is also very important, that we need to know what is protective and what is not.
And in cases where antibody might be missing from individuals, you might have the T cells there that could be protective. And we need to understand the interplay between both parts of the immune system.
Jessamy: So maybe we could just just go into a little bit more about the immunity. Where are we with our understanding about immunity after having the virus?
Arne: We're restricted by having samples and having a concerted effort in trying to put all the data together. We understand that antibody can be neutralizing. We don't really know if there are antibodies there which are not neutralizing, which might confound the antibody testing. that might be going on. We know a bit more about the T cells, so we know that T cells that are reactive to SARS CoV 2 might actually have been generated from a previous coronavirus encounter, from common cold perhaps, or even the previous SARS virus.
And we also know that these T cells seem to be protective, but we don't know whether all these T cells are protective, or whether they're just there and might react to the virus, but not actually clear. The virus and also give you protection from the disease. So there's still very many unknowns. But if I say one thing that's been really tremendous about the whole situation, in the UK at least, is that the whole immunology community has come together to try to help out, to try to add information as and when it appears, which really is not the case for normal scientific work, where people tend to be very close until they publish what's going on.
Jessamy: And maybe I can just ask, I'll pick up on a point that we talked about last time, which was about, this issue of having a relationship potentially between the severity of your disease or your illness and your potential immune response to that. What's increased about our understanding of that, about whether if you don't have, if you're asymptomatic, whether you produce antibodies or not?
Arne: One sad fact is that the immune system is very powerful, but can actually work against you, as well as working against all the pathogens that try to infect you. What we think might be happening is that some of the long term consequences of having the disease might be in part mediated by the immune system itself being over, overactive.
Either through the production of cytokines and inflammatory mediators, or through somehow the immune system recognising also Parts of the organs that have been infected by the virus. And this all needs to be investigated. But because it's a multi organ problem and not just the lungs, we need to have the input from different disciplines of medicine.
People working in cardiac and renal, as well as people working in pulmonary aspects of medicine, need to share data and to compare what's going on. And, but this is for the future. And this is something that we really must do going forward.
Jessamy: And just to talk a little bit about the briefing that the Society and led by you has recently released on the long term immunological health consequences of COVID 19.
It covers such an important area and one that we've all got questions about, one that there seems to be a lot of uncertainty about. How might the long term consequences of the coronavirus differ from, say, a patient who gets very sick and ends up on ITU?
Arne: One similarity, before we go into the differences, is that the people who normally get hospitalised for both forms of the infection are older or they have comorbidities.
So there's something underlying there that affects a certain group of the population and we need to understand better what that predisposition is. What is the mechanism for that? One reason why the influenza infections might be different is that influenza tends to really affect the lungs mainly, whereas this virus can affect many different organs.
A big difference therefore is that you might get scarring from the lungs as a result of both infections. You might also get scarring, however, of other tissues. and long term effects by having this SARS CoV 2 infection.
Jessamy: And I guess that's something that we've been thinking about here at the journal a little bit, particularly in terms of the renal function of patients that get the virus and potentially the long term sort of consequences of, it deteriorating renal function or chronic kidney disease.
What's the evidence behind that? Is it from autopsy series or Where have we got that evidence from?
Arne: We need more topsy information, but obviously it's quite difficult to get with permissions and everything else. The evidence is It's partly based on previous infections and it's partly through the small amount of available data that we have right now.
And also you can look at the function of different organs by, by ultrasound and by other means. And you can tell if there's, if an organ is defective just by the signatures they produce through all these ways of monitoring function in the lungs or the kidneys or. or elsewhere, in the heart especially.
What is harder is some of the effects that you see might be neuronal. People have slight dementia like short term illnesses, they have hallucinations, they have sleep deprivation. All this suggests that there must be some interaction between the virus or the immunity that the person has with neurons and with the brain.
And that's very little understood at the moment. Once again, because can't have access to tissues.
Jessamy: It's interesting, isn't it, because these so called long haulers, or people that have symptoms for very long periods of time, it's so interesting to try and understand what's going on from an immune point of view for that period of time.
It goes into almost a chronic disease. What's your thinking about that?
Arne: There have been ideas put forward, and no one knows the answer, as you very well appreciate, it's a very recent disease. And the possibilities for the long term diseases might be hidden reservoirs of virus that we don't know where they might be, hiding away and shedding.
It might not be the virus in its actual form itself, it might be virus particles. that continue to be produced from infected cells, though not infectious, they might trigger long term immune activity, nonspecific to some extent, but causing inflammation. And the third possibility for the long term effects might be the immune system itself being overactive and not being able to shut down appropriately.
So instead of having appropriate resolution at this stage, at the end of the infection, it just grumbles along and keeps on producing stuff and it's just not shut down appropriately. These are all possibilities. They're not mutually exclusive. It could be one or all of them.
Jessamy: Interesting. And what's the evidence from previous sort of coronaviruses like SARS 1 and MERS about the sort of long term consequences of those infections?
Arne: Obviously, this infection is very different to all the previous ones that we had before, so it's hard to actually extrapolate. So in, in the document we have some reference to longitudinal studies of sars. One from 2003, 2018, and at least a third had reduced lung capacity afterwards. So there, there's some sort of similarity there, but I don't think there was any evidence that there were organs damage outside the lung as far as I'm aware.
And a similarity with Mers was that a third of survivors had long-term lung damage as well. But once again, we don't know about the other organs. And I think what our document from the British Society for Immunology initially produced together with the Academy of Medical Sciences, but mainly through the BSI now, what it suggests is that the reason we don't have this information now for the current infection is that we didn't carry out the previous studies for long enough.
So there was no understanding and no funding towards understanding long term. of the previous diseases, and that's what we want to try to avoid this time round. And our suggestion is that maybe this time round, in order to be prepared for the, for future and subsequent infections, we should take this out for as long as possible, five, maybe even 10 years.
I know it's difficult, but if we have cohort studies, that we start now, we'll be able to get these answers in the future.
Jessamy: And I think that comes across a lot in the briefing. It does feel like a bit of a call to action in terms of that kind of, we have to try and collect this data. We need to have this evidence.
What is actually starting to be done now? And what would be the dream in terms of trying to set something up?
Arne: The dream and the ambition. And when you wake up, the reality is not that far different, is that the scientists involved with the disease should come together. And the funding bodies should actually work with the scientists to try to fund coordinated research.
Jessamy: Finally, perhaps we could hear your thoughts on vaccine progress. What we all want to talk about.
Arne: There's progress, there are over 100 different vaccines being trialled, and at least a few of them will actually work really well. We know from the Oxford and some of the other vaccines that The first couple of phases have been successful.
They don't cause any pathology overtly. They don't, and they're protective. You generate a T cell. We don't have the protective. They generate immunity. That's very important. The next phase now in phase three trials is to understand that they're protective. One big issue with vaccination is that with all the previous vaccines we've got, including influenza, pneumonia, et cetera, they don't work very well in older people.
And older people are the ones that have the disease most severely, unless you have comorbidities. And so the question is, will this vaccine, even though it might be very effective in young people, work well in older people? And there's different angles to this. It would be useful if the younger people were protected, because then they're less likely to pass it on.
The people congregating now in beaches and everywhere else, we're all young ones, we understand that people need to do that. Yes, they may get infected, they won't get it very severely, but if the vaccine can protect them even more, that will benefit everybody in the end. But in the meantime All the people who are vulnerable still need to be taking a lot of care and self isolating, and hopefully the younger people are responsible enough and they're not actually going to see their parents and grandparents after being in big raves or, big beach parties.
So there's always that hope, but the other thing is But the vaccines, maybe the vaccines alone won't be enough. We know that dexamethasone works very well to block inflammation. Work from my group has shown that blocking inflammation can let you enhance the immune response of older people. And we've done that, it's all being published as well.
So maybe we need to look at adjuncts to vaccination as the only way to boost immunity in older people. Maybe you need a combination of anti inflammatory drugs together with the vaccine. Maybe you need antiviral drugs together with all that in some combination. Inflammation has a central role in the disease and we know that blocking inflammation, at least at later stages, is beneficial for the patient.
But how do you actually protect people who show the early symptoms if they're in the bad age groups, the ones that are more likely to get severe disease? Maybe you should block early in those individuals. But this is, obviously hasn't been proven, but these are considerations that have to be borne in mind.
Jessamy: And I guess the final question that I just wanted to ask is there's been a lot of discussion about the different platforms that are around for vaccines. And obviously we've, published two on adenoviruses and, the fact that this is a slightly sort of new or novel, or not necessarily a novel technology, but unproven.
Where are you in terms of the focus that's happening on potentially some of these new types of platforms away from the traditional inactivated viruses and live attenuated viruses that make up the majority of our vaccines at the moment?
Arne: The perspective of the British Society of Immunology is that as long as it's safe, as long as it's effective, we don't have any bias towards any one or other of the vaccines that are being tested right now.
But both those things are the most important safety and they have to be effective.
Jessamy: Is there anything else that you'd like to talk about? I think that, that really covered a lot of our questions.
Arne: I think going forward, the model of how you combat something like this is the scientific community and the medical community coming together to, to work, not just for their own personalized research agenda, but to also try to contribute to the knowledge that we can actually take forward as a group.
And that's happening. And as a very active member of the British Society of Immunology. has been involved with the task force. It's a very gratifying thing to see that it's actually happening. And this is a good model. Let's do this again for other diseases if we need to.
Jessamy: Here's hoping there's nothing on the horizon for a little while anyway.
Arne: Yes, I share that hope.
Jessamy: All right. Really good to speak to you. Thank you.
Arne: My pleasure.
Jessamy: It was a really interesting discussion with Arnie and I guess, the main point of the briefing paper that they released was to lay out some research priorities and things that we need to address.
But what sort of what comes across is just still how little we know.
Gavin: Yeah, again, we've said it before. It's the ongoing theme of all of our COVID discussions is how it's brand new. We still don't know a huge amount about it. Arnie is one of the people that you would expect to know a huge amount about COVID 19.
And I think what really comes across during that interview is, we're still in such an early stage. We're still trying to grasp the many effects of. of COVID 19 beyond the respiratory effects. We've discussed a lot how it seems to be affecting, it's multi organ disease, it seems to be affecting a huge amount of different areas of the body.
And now we're beginning to see evidence of these so called long COVID patients who are having these very serious effects that stopped them living the life that they did before, months and months after they've. Tested negative for COVID 19.
Jessamy: Yes, it's interesting because, on the one hand, you've got the patients who were hospitalized some of them with very severe COVID who went into ITU.
And obviously for those patients, the recovery will be long and hard as it is. For other either infectious or non infectious diseases for people who end up on ITU, it's an extremely physiological, just a complete change when that happens, just in terms of your muscle mass changes and how you recover from that.
So it's. It's difficult to know, you know how the recovery from COVID 19 after severe COVID 19 change or is different to recovery from other severe diseases where you might have been on intensive care. But I suppose also what's interesting on the other hand are these, people who have had a milder form of COVID 19, and we've had, physicians documenting their symptoms online, some of them very famous who have had mild forms of COVID 19 but are still experiencing symptoms, two or three months after, of fatigue and just general malaise and feeling unwell. And I guess for those patients, it's even more difficult to really measure that and analyze that. I think Facebook, the long haul, Facebook group has got 20, 000 members.
Gavin: Yeah, it's really interesting, isn't it? Especially because the kind of popular depiction of COVID 19 is that in people under 60 at least, it's usually a relatively mild disease. It's been, characterized as having a pretty high survival rate, especially compared to the kind of pandemic coronaviruses that came before it.
And the effects generally in younger people Seem in the popular depiction to be quite mild, but actually this is the kind of long term information that only comes out over time that suggests that actually even in these mild cases, there's still a massive danger to the individual.
Jessamy: Exactly. I think these these support groups are quite important. I was reading one, one piece that was quite nice just about the sort of mental health issues that can happen even after you've had a mild case of COVID 19 because of course there is the added kind of stigma that's associated with that.
I haven't had COVID 19. You haven't had COVID 19. So we probably can't understand that. But I think that there is a sort of added anxiety around it, for these new diseases that we don't understand, because I suppose you can't fall back on historical medical. feeling from your doctor or feeling secure necessarily or people have not had that much interaction with the medical profession because actually they've had mild COVID 19 and been at home, but the symptoms are going on for ages.
Gavin: Yeah, and it's striking the breadth of symptoms that are seem to be resulting from from these COVID 19 infections as well as there's a very interesting article in the Atlantic by Ed Yong, who has been doing some fantastic writing throughout the pandemic which speaks to an immunologist who works at Mount Sinai.
And he's encountered a lot of patients dealing with long term COVID 19 and actually his average patient is female and is 44 of patients dealing with the long term implications, which both of those things are the opposite. We've heard a lot about how men more generally suffer from more severe COVID 19 and how it affects older people, but actually there are there can be very serious long term effects and what it really says to me as well is that we're going to be living at least in kind of medical policy terms with the burden of COVID 19 for a very long time.
We, we will need to set up. specific care programs for people with these long term with long term complications from COVID 19. And as we better come to understand what's going on, it will need to actually be its own kind of area of research separate from the immediate treatment.
Jessamy: Yes, definitely. And as we alluded to with Arnie, there are some great collaborative projects going on to try and start collecting this data, which is so crucial. We wrote, our leader, didn't we, on, NCDs and COVID 19. And I think, something that's that's hard to appreciate.
Fairly, potentially could happen is that COVID 19 will add to the chronic diseases that we have, potentially either through changes in your respiratory system, through lung fibrosis, or, other things that we at the moment can't quite see or envisage. And that's a very difficult concept to get your head around when we're still so much dealing with the acute problem.
Gavin: Yes, it feels as soon as we begin to get a handle perhaps on vaccines and treatment for the original problem, now the long term problems are hoving into view and they're quite serious.
People of color have worse outcomes for problems which present dermatologically. This is due to striking under representation in medical literature and a general lack of knowledge as to how diseases manifest on skins of color. I spoke with Dr. Jenna Lester who runs the Skin of Color Clinic in San Francisco about the importance of a dedicated clinic as well as the structural racism underpinning outcomes.
Dr. Jan Lester, your assistant professor of dermatology at the University of California, San Francisco, UCSF, and you started the Skin of Color program there. Tell us a little bit about yourself and your background.
Jenna: So I'm originally from upstate New York and grew up always recognizing my role in the world and particularly a role of service to others.
And that was something that was emphasized to me as a kid. And so when I, decided that I wanted to go into medicine after a brief idea that I was going to become a Supreme Court judge. I knew that anything that I did had to be in service. And initially I thought I was going to be an OBGYN and thought that would be a great way to impact the health of many generations, which I still believe, but realized what a need there was for specialty care for underserved patient populations.
And that was not something that I had thought of before. But read an article in medical school about how many dermatologists don't accept our public insurance in the U. S. Thought that there was probably a lot of room to do good in a specialty area like dermatology, and then I happened to also be developing an interest in it as well.
And in medical school I solidified this interest and was able to figure out how to maintain My my background commitment to serving others and access to care and underserved populations while still practicing dermatology. And that's what sort of brought me to where I am now. And that was something that was a commitment that I maintained through through residency as well.
And. How I came to start the Skin of Color program.
Gavin: Yeah, so tell us a little bit about the Skin of Color program. What's the kind of day to day like? What's your day to day like?
Jenna: I still, I see all patients, but I would say about 50 percent of my patients are people of color who have had experiences, unfortunately, with other medical and other medical care environments where they felt that the person they were seeing didn't understand their concern, didn't understand their skin.
And so they wanted to see someone who they thought would have a better understanding of that. A big part of what I do is clinical care and excellence in clinical care is what I see as the major goal of the program but also developing an educational program as well, because the research that I've done so far suggests that our educational system is biased against.
patients of color and I think that's something that holds true in many specialties in medicine and dermatology is not an exception. So something I'm trying to do is contribute in various ways to developing educational programs that can be disseminated widely and impact the care of. people of color as a result because I always tell my patients and something I firmly believe is there will never be enough black dermatologists to take care of all the black patients that may want dermatologic care.
And despite some of the research that suggests that race concordant visits are longer and patients report more satisfaction, I think the goal is figuring out why that is, as opposed to saying, okay, We need to make all visits race concordant because that's not possible. And I think that misses the point of medical care.
We all have a, we all as physicians have a responsibility of caring for all patients. I think one of the ways to do that is through improving our educational materials, so that dermatologists are better equipped to care for any patient that walks through their door. And then another goal of the program is research as well, because And in dermatology, like other areas of medicine, there's there are disparities in research in terms of representation of people of color or racial ethnic minorities in research studies.
And I think that has to do, with the way that we recruit patients for these studies. But I also think it has to do with the fact that many institutions don't have a relationship with these groups of people because they're not accessing care. And then you go to them only when you want to do a research study, and I think that is probably not the best way to do it.
And I think many institutions are becoming in tune with that now and working to develop community relationships with groups that they may want to include in studies at some point. But not only when they want to include them in studies. We should be creating care environments where they feel comfortable accessing care.
And then, two, three, four years into a relationship with a patient, we say, Oh, by the way, we have this study that you might be interested in. And that's how people should be invited into research, I think. So that's another goal of the program is to develop an inclusive research environment.
Gavin: So you mentioned that the problems of kind of lack of depictions of skin of color across the medical literature.
What are some of the problems that causes in general terms?
Jenna: So I think one of the problems is lack of depictions. The other that we found is there is disproportionate representation. Of skin of color and sexually transmitted infections and depictions of sexually transmitted infections. So these, all of these things create powerful cognitive biases and as dermatologists or dermatology residents, you see a lot of things in person that the range of what is dependent on where you practice and the patient population of the community in which you practice.
And what happens is we ultimately rely a lot on photographs and textbooks for primary learning. So if you are only seeing pictures of sexually transmitted infections in dark skin, I think one, you may not ever be able to diagnosis, diagnose it in light skin. And you may be more likely to assume that someone with dark skin has that because that input has been overwhelmed with.
Photos of patients with darker skin. Similarly, if you only ever see photos of psoriasis and light skin, you may be less able to diagnose psoriasis and dark skin. And you may not think of that as a potential diagnosis in someone who comes with dark skin, who comes into your office. I also use the example of psoriasis because that's something we consider a clinical diagnosis.
We should be able to diagnose it from the door. It doesn't necessarily require a biopsy. But if you never see it in dark skin, you may be more likely to biopsy something that is actually psoriasis. And while biopsy is part of the bread and butter of what dermatologists do, like any procedure, it carries risk.
And You're opening up certain patients more for that risk because you're not used to seeing common or pretty bread and butter diagnoses in their skin type.
Gavin: So how serious are some of these effects? What are some of the risks that are result of these lack of general knowledge of presentations,
Jenna: I think delays in diagnosis, misdiagnosis, these are things that I've seen. And depending on the particular condition, that could be a matter of life or death. It could be something that is a psychosocial stressor for a patient for many years longer than it needs to be. I think it impacts the position patient relationship because patients can pick up on when a doctor that they're seeing is not confident in what they're diagnosing.
And I hear this over and over in my patients who come to me. They're like, it just was clear she was not comfortable with my skin type or diagnosing this disease. And so I wanted to seek another opinion. And that I always commend patients who give us, us being the medical system another chance, but that feeling of walking into a doctor's office and not feeling confident in what they're telling you erodes at your trust.
I think it perhaps has implications beyond a dermatology visit, because conversely, I have patients who come to me, I identify some other issue in their medical history, and they haven't been seeing a primary care doctor, and I encourage them to see primary care. And I, so I think of, my visit with them as a potential sort of entry point into the medical system and Patients can see their skin so they often are self motivated to come to the dermatologist They can't see their high blood pressure or their high cholesterol So that may not cause them to come to the doctor at the same rate.
So I think of dermatology as a high stakes visit because it could be What turns someone towards more medical care or away from more medical care?
Gavin: What are some of the things that kind of structurally need addressing?
Jenna: I think our educational materials are a structure that needs addressing I think Digital film photography is a structure that needs addressing.
Digital film photography, color film photography, was never meant to depict people with dark skin. And there's a whole history of Kodak Gold film development where, with Shirley Cards that is, shows how it was, that color film was never meant to depict people with dark skin and that is something that I pick up on almost a daily basis when trying to take photos of people with darker skin or looking at the quality of photos in our and their in textbooks, etc.
So I think that it's
Gavin: embedded that deep.
Jenna: Yeah. I think that our clinical structure needs to be evaluated. Certainly in the U. S. our payment system, there's There is a paper that was published in the British Journal of Dermatology about how our fee for service model can bias against patients of color because patients of color in dermatology don't need as many procedures as someone with lighter skin with a higher risk of skin cancer and who develops neoplasms along the way that need to be biopsied or treated with that financially renumerate and patients of color, according to our Medicare data don't need as many of those procedures and have conditions that require much more counseling.
And how does this impact your likelihood to see someone in followup? Because, you would rather put someone in there who needs a bunch of procedures that pay a little bit better. And does that subconscious desire impact the way that you care for patients? Who you know, don't need as many procedures.
So I think. That is a structure that needs addressing as well.
Gavin: Finally then, what are some of your experiences during the COVID 19 pandemic? I've seen you talk previously about how some of the rashes that were a symptom for COVID 19 are not depicted at all in the medical literature. So perhaps tell us a little bit about your kind of experiences there with COVID 19.
Jenna: Yeah, I was really disappointed to see How we were discovering the, that COVID 19 is basically ravaging every organ system in the body, including the skin. And in the early days of discovering what those cutaneous manifestations look like, I was disappointed to see that there were no depictions of patients with darker skin, especially considering that.
People of color worldwide and definitely in the United States were experiencing COVID 19 in a disproportionate way, more likely to get infected. More likely to be hospitalized, more likely to die from the condition. And here we are, like I said, looking at this visible organ that, in my experience, patients are very in tune to and can say, Oh, this is new, this is growing, this is changing.
And in the same way that we can educate patients on what a skin cancer looks like and when to come to the doctor. Would what we learn about manifestations give us the same ability to educate patients about early signs of COVID 19 somewhere down the line? Of course, we're still learning about the cutaneous manifestations and where it fits in on the timeline of disease.
But you wouldn't want to miss out on that opportunity to say this is, for example, an early asymptomatic presentation of COVID 19, this rash. And if you see this rash, you should shelter in place. You should self isolate. You should get a test. And if patients of color are not seeing their skin represent represented, that's a disparity.
And that could potentially mean that we're missing out on a. way to teach them to self diagnose or to look for early signs. So I thought that was a huge injustice.
Gavin: Yeah, really important, especially like you say, given the the unequal impact on people of color. Thank you so much for talking with me today.
It's been really fascinating. It's clear. There's a lot that still needs to change, but it's great to hear about it. Yeah, thank you so much.
Jenna: Thank you for having me. I appreciate it.
Gavin: And it's really fascinating to hear from Jenna there, the depth of this problem. And this is just one relatively small area of medical practice.
So it's really striking to, to hear the level of structural racism, structural discrimination in dermatology. And it really makes you think about how this kind of ignorance has been embedded into medical practice across all areas.
Jessamy: Yeah, earlier on in the year we spoke to Caroline Criado Perez, didn't we, about her book, about the universe.
or male default. And actually I think, the same can be applied for Caucasian white people is that has been the default for much, for many things in medicine, either research related or medical education related. And hopefully. We are seeing the start of serious change for that because it is widespread, it's much wider than dermatology.
It's in obstetrics and gynecology, hematology and oncology basically in ev in every subject. There was a great. There was a great piece in JAMA called Black Kidney Function Matters about how race is used for the calculation of kidney function and how that sort of perpetuates structural racism within the states in America and actually we've had a couple of other recent papers through research that's looking at, either changes in blood testing and the fact that, People of color might, or black people might have different levels of monocytes and white blood cells and that all adds to how how we treat them in terms of what they might then need to have afterwards, whether they need to have extra tests.
or not. Obviously in the States, that's pretty crucial because all of those extra tests mean extra money.
Gavin: Yeah, very much. And it just it feels it feels so insidious across all of these different practices. It feels so so deeply embedded. And as Jenna highlighted, and as you've said, just that there are of course a whole different tranche of considerations when it comes to US healthcare, because so much of it is based around the the market in the way, in a way that European and other countries, their health care just isn't.
So once you introduce the market and payment for services and prioritizing areas that result in more money for the practice, then you have a whole other whole other level of consideration, especially when it comes to to populations who historically have lower resources. It's as Jenna said, and I think it was really striking when she was talking about how she often sees herself as the first point of care, the entry to the healthcare system for so many people, for so many people of color, because they can see their skin and they can see the problems developing, but so often they won't have had the resources to visit a doctor in the past, they won't actually have been able to see, as Jenna said, the hypertension, the blood pressure, et cetera, other problems that they may have developing.
And it's quite sad and it's quite striking that. Dermatologist sees herself as the entry point to whole body health care for for a particular population, but that's the way it is. And it's something that we will continue to highlight on this podcast because it's really something that just needs wider consideration.
It needs to be highlighted constantly because a failure to highlight and a failure to think about it is how this situation perpetuates.
Jessamy: Yeah, and I think that goes across the Lancet journals. There's been lots of really good pieces that, you, the listeners, we can read.
In all of our journals, there's a great perspective in this week's Journal the Sept, September 5th by Cher Blacksmith. Blackstock, sorry, that talks about dismantling structural racism and healthcare. And she know quotes some of the figures which are that 4% of physicians in the states are black and 2%, only 2% are black women.
And she's chief executive of the Advancing Health Equity sort of group. And that's, it's a brilliant perspective on, on structural racism, particularly in the States, but really throughout healthcare.
Gavin: Yeah, there's it really is a great piece and there's a lot to read that our journals have put out over the last few months.
Thanks Lancet Voice. We'll be back in a couple of weeks with a special episode for Peer Review Week. Until then, you can find all of our previous episodes on Apple, Spotify, or wherever you usually get your podcasts. See you again next time.