Medical research, imagery, and training continue to center on white skin, not on how injuries present differently in patients with darker skin tone. As a result, medical professionals-including nurses and forensic examiners-often miss injuries depending on race and ethnicity. As the mother of children of multiple races, I have seen my children of color be misdiagnosed, at times in ways that endangered their health.
In pursuit of solutions, I visited forensic nurse Katherine N. Scafide's laboratory to better understand one of multiple technological solutions being developed for bruise detection. As she passed a handheld light over her colleague's skin, the bruising that had been invisible to the naked eye sprang into sight. The simple, portable device directed "alternate light"-in this case violet light with a yellow lens-toward the skin. The technique is up to five times more effective at detecting bruising than white light, as much as four weeks after injury. (For more, see On the Cover and Nurse Innovators in this issue.)
Bruising is one of the most common types of soft tissue injury experienced by abuse survivors. Yet even today, bruise detection and diagnosis are usually done by sight in natural light. This fails to take account of injuries to abuse survivors of color, which may be barely visible or entirely invisible to the naked eye, despite causing significant harm and pain.
For abuse victims, evidence of injury is often crucial for accessing legal protection and physical and mental health treatment, making the role of health care professionals critical. Without use of the best available technology to detect bruising, abuse survivors of color are at a significant disadvantage in having their injuries properly identified and documented, are at greater risk for further abuse, and have less of a chance of receiving justice or medical care. Bruising generally takes 48 hours to appear after an assault, a fact that is also not often taken into account by first responders.
Let's be clear: racial bias in forensic evidence collection is only one aspect of much larger societal issues that lead to health care inequities and racially biased health outcomes. Many factors contribute to the unacceptable, disproportionate impact of domestic violence on communities of color in America, and all must be addressed. This is one immediate step within our power.
Nurses are in a trusted profession of care and frontline treatment. Nurses I have spoken to have pointed out that often crucial evidence of abuse goes unrecorded. In addition to screening for and documenting abuse, nurses can and do counsel patients and protective parents of abused children about anticipated coloration changes and swelling to sites of injury, and help to obtain evidence 48 hours after the initial contact (and at additional intervals if the victim agrees).
Based on experience and all that I've learned from experts, I was compelled to advocate for a grant program for nonbiased forensic technology to be included in the Violence Against Women Act Reauthorization Act of 2022, which is now signed into law. This grant program is an opportunity to support health care professionals in their critical work. Advanced technology should be universally available as part of a push to save lives and improve legal outcomes for abuse survivors, including methods to detect and measure heat at the site of injury regardless of skin tone.
Reflecting personally, when my daughter Zahara, who is from Ethiopia, was hospitalized for a medical procedure, the nurse told me to call her "if she turns pink near her incisions." I stood looking blankly at her, not sure she understood what was wrong with what she had said. When she left the room, I had a talk with my daughter, both of us knowing that we would have to look for signs of infection based on our own knowledge, not what the nurse had said, despite her undoubted good intentions.
Even as my family has access to high-quality medical care, simple diagnoses are missed because of race and continued prioritization of white skin in medicine. At a societal level, racial disparities in health care affect outcomes for millions of people. From technology to improving diversity and representation in medical research and training, it is past time to embrace new solutions.