Science Friday - Volume Control, Dermatology In Skin Of Color, Kelp Decline. Nov 15, 2019, Part 2

Episode Date: November 15, 2019

Dermatologists presented with a new patient have a number of symptoms to look at in order to diagnose. Does the patient have a rash, bumps, or scaling skin? Is there redness, inflammation, or ulceration? For rare conditions a doctor may have never seen in person before, it’s likely that they were trained on photos of the conditions—or can turn to colleagues who may themselves have photos. But in people with darker, melanin-rich skin, the same skin conditions can look drastically different, or be harder to spot at all—and historically, there have been fewer photos of these conditions on darker-skinned patients. And for these patients, detection and diagnosis can be life-saving: people of color get less melanoma, for example, but are also less likely to survive it. Dr. Jenna Lester, who started one of the few clinics in the country to focus on such patients, explains the need for more dermatologists trained to diagnose and treat people with darker skin tones—and why the difference can be both life-saving and life-altering. Have you ever met a friend for dinner at a restaurant, only to have trouble hearing each other talk over the din of other diners? And as we get older, this phenomenon only gets worse and can be compounded by age-related hearing loss and conditions like tinnitus. Unfortunately there is no silver bullet for tinnitus or other forms of hearing loss, and researchers don’t even understand all the ways in which the auditory system can go awry. But we now have more sophisticated technology to help us cope with it. Nowadays, there are over-the-counter hearing aids and assistive listening devices that connect with your smartphone. Certain tech allows you to amplify softer sounds and cancel out the noise of a crowded room—it can even focus on the sound waves created by the person you’re speaking with. Ira chats with David Owen, New Yorker staff writer and author of the new book Volume Control: Hearing in a Deafening World about the industry that’s helping millions of Americans cope with hearing loss. Envision California’s lush forests from San Francisco to the Oregon border. Now imagine that 90 percent of those forests disappear within two years. Laura Rogers-Bennett, senior environmental scientist with the California Department of Fish and Wildlife, says that’s exactly what happened to underwater kelp forests off Northern California’s coastline from 2014-16. An analysis published this week in Scientific Reports documents the rapid decline of California’s bull kelp. The study links the reduction in the seaweed’s population to a confluence of environmental and ecological stressors, including a marine heat wave, a sea star die-off and the emergence of an “urchin barrens,” large swaths of subtidal zones overtaken by kelp-hungry purple sea urchins. Rogers-Bennett, who monitors kelp forests in partnership with the UC Davis Bodega Marine Laboratory, says taken together, these strains on the kelp population threaten the greater coastal ecosystem. “We are finding out,” she says, “that if we cross some of these thresholds, that the system will collapse.” Observers are now noting kelp deforestation off the Oregon coast and in California south of San Francisco to Monterey Bay. Subscribe to this podcast. Plus, to stay updated on all things science, sign up for Science Friday's newsletters.

This is Science Friday. I'm Ira Flato, broadcasting today from the studios of KQED in San Francisco. Later in the hour, why having more black dermatologists could improve skin cancer detection and more for patients with darker skin. But first time to check in on the state of science. This is KERNO. St. Louis Public Radio News. Iowa Public Radio News. Local science stories of national significance. The state of California is home to a massive forest, and I'm not talking about the redwoods here. This forest is under the waves, off the coast, a massive forest of kelp.

But in recent years, that forest has been in decline, a decline that's linked to warmer ocean temperatures. Joining me now to talk about that is Peter Akroni. He's a science reporter with KQED Public Media here in San Francisco. Peter Arkony, welcome to Science Friday. Thank you for having me. Let's talk about the kelp decline. Yes. What is it?

What does it look like? So what does the kelp look like? So in California, off the coast of San Francisco, and all the way up north to the Oregon border, we have this massive kelp forest. It's bull kelp. It's 30 to 50 feet long. It roots down on rocks, and it grows in these tubes. And then there's a bulb at the top of it, and these seaweed-like leaves that form a canopy. And really, this forest of kelp is our big habitat for all our underwater species, our sea otters, our fish, our snails, our crab.

So this is where they eat and they live. This is where they eat. It's where they live. It's where they live. It's where they breed. redwoods and all those pine trees, you know, all the way from San Francisco up, up to the Oregon border. Now imagine in two years, 90% of that just disappeared. You know, it sounds to me, because being a scuba diver, I've never dove on the kelp,

but I've used to done a lot of diving in coral reefs, and coral reefs are dying out, and this sounds like it's the equivalent thing that's happening in the kelp bed. Yeah, it's a similar thing with habitat loss. There have been some studies recently that have come out that have tried to unpack exactly why this is happening and what the effects are. So they've really linked it to this intense marine heat wave. On the West Coast, we know it as the blob. And the blob was this gigantic, you know, 1,000 miles long warm water heat wave that

happened around 2014 and lasted for a number of years. In some pockets, the oceans were 7 degrees Fahrenheit warmer than they normally are. Seven degrees. So that is a really significant warming, and that's going to affect so many things. And we're starting to unpack that. So one of the things it affects is kelp. And one of the things that kelp eats really to survive, one of the main nutrients it needs is nitrogen, dissolve nitrogen in the ocean.

But as these temperatures rise, that dissolved nitrogen is no longer available. So the kelp started dying out. But kelp are a species that can rebound, is a species that can rebound quickly. It grows fast. It can grow, you know, 10 inches in a day. No. It's a hardy species. It's supposed to be resilient.

But something else happened around the same time as we started to see this kelp sort of started to decline because of this heat wave. There were other consequences to this heat wave, one of which was a massive C-star die-off. I'm not sure if you've heard about this, but we had this outbreak of C-Star wasting disease. And what happened was, what biologists think, is that this intense, warm water triggered this virus that lives within sea stars. And biologists were noticing these lesions on these sea stars. Their limbs would fall off. They would turn all gooey and eventually disintegrate.

So we had this massive die-off of sea stars happening around the same time as the kelp were already being affected. And one of the things about sea stars is, what do they eat? They eat urchins. And so if you no longer have sea stars, you take sea stars out of the equation, all of a sudden you have this swell of populations of purple sea urchins. And if you've been diving or tide pooling, you know these urchins. They're purple and they're spiking. You don't want to step on one if you're walking in tidal waters. And what urchins eat is kelp.

So you take away the sea stars, the urchin populations swell, and they graze down all that kelp. Wow. Is it possible to get rid of the sea urchins? Right. So that's what we're trying to figure out now. Right now, what they're calling these coastal waters, these subtitle zones, are the urchin barons. Okay? So nothing but sea urchins. You used to have these giant big kelp forest and canopies. Now all these species, these nudibranchs, these sea snails, these abalone, all these things that either relied on the kelp for food or habitat are now all gone, and all you're seeing across the ocean floor are just

armies of the urchins. And so you say, is it easy? Can we just get rid of the urchins? Well, that's, you know, how do we do that? And that's what scientists are trying to figure out right now, how to restore some sort of balance. Now, the sea stars have started to recover. The ocean temperatures have gone down a bit. They're starting to recover.

But not really in this one pocket that we're talking about from San Francisco to Oregon. So how do you get rid of these urchins? Right now, you could say, okay, well, what if we released sea stars? But the problem with the urchins is they're not healthy either, because now they've eaten all the things that they like to eat. They've eaten the kelp. They've not just eaten the stalks of the kelp. They've eaten the leaves and the seeds and the spores and everything. So now they're not doing well, but they're sort of clogging the ocean floor so that nothing else can grow. So how do you solve this? And one of the things that biologists and marine ecologists are coming up with,

it was, hey, what if we start farming urchin? Yeah, because it is a food. People do eat it. It's like a delicacy. It's a delicacy. Sushi is the big thing that you think of when you think of urchin. It's called uni. And really what that is is if you crack open that hard, spiky urchin, shill inside is this gooey, sort of yellow, brown substance. And it's actually the urchin's gonads. And that's a really tasty thing if you have it on

on some sushi, maybe, you know, maybe with something else, and you eat it, and you dip it in the soy sauce, and you eat it. But the problem is right now, the urchants, because they've eaten all their food, they're not that healthy. So what you would have to do is sort of take the urchants out of areas where they're overtaking and grow them or feed them other nutrients on urchin farms. So there's this whole industry that's starting to develop in Northern California of urchin farming, where they would remove urchins from beds, feed them nutrients, so they can get them nice and healthy,

and then put them on the market. I actually had sushi the other night, and I'm going to be responsible and order this uni. And it wasn't from Northern California because the industry is just not here yet. It was from Southern California. I could choose between Japanese uni or uni from Santa Barbara, and I thought, I don't know if this will help, but I'm going to get the Santa Barbara. Good for you. The term that I've heard now is we can start thinking of these types of seafood,

not just as sustainable but as restorative, which is a term I'd never heard before, but I've started to hear it where if we can develop this industry of urchin farming, then we could actually help restore the kelp forest and so many other species. Speaking of restorative, I know that you also follow the fishery industry. That's right. here, and there's been a big issue recently of ocean entanglements. Tell us about that. Yeah, so in the last five years, we've seen a record number of whale and marine mammal entanglements.

So even five or six years ago, you might see, you know, five or ten humpback whales getting tangled up in fishing line or fishing nets or crab lines. But in the last five years, we've seen those numbers skyrocket. 50, 70 a few years ago. Wow. And they think that this may also be related to what we were talking about before, this ocean warming, which is really changing the availability of food for these whales. So humpback males, they migrate. They go from the northern waters down to the southern waters in California to breed each year. And as they're doing that, they need to feed.

And so with this ocean warming and changing where the krill is available or maybe having them seek. out other species like anchovies, while they're migrating, they're coming closer to the coast, which is also where all this fishing is happening. And the tackle and the nets and everything else? Tackle and the nets, exactly. There's two big things that have happened. So one of which is crab, crab fishing. Dungeon is crab is a huge industry here in California.

It's like our lobster. It's like our main lobster, right? I've been down there to the warp, I've seen it. You see it. You go to the wharf. You can get the crab. You can get the whole crabs. It's a big Thanksgiving and Christmas tradition.

But the way crab is fished is in these traps. They put these traps down that are on lines with buoys on the surface. And these lines go down the entire depth of the ocean, and they're left out there for a long period of time. And so now that whales are coming closer to the shore, they're getting tangled in it. They're wrapping their bodies in it. Some people were saying that, you know, they like to play in kelp and things like that. And so they see these big lines. things they can play in and move around in, you know, and they're getting, they're getting caught

and sometimes, you know, dying. So this is sort of an unanticipated reaction to the warming of the waters and climate change. Exactly, exactly. And this seems like a difficult issue to tackle. So how do we untangle these? Exactly. How do we untangle this problem and these whales and other marine mammals? So a couple of things.

One is regulation. So commercial crab fishing in Northern California was supposed to open today on November 15th. That's that right. But regulators have said, we need to give these whales more time to migrate before they're going to have to navigate this route that's going to have all these lines in it. So they've pushed that back. They also ended the season early last year for the same reason. We want to give whales more time to migrate. But at the same time, that's going to really hurt crab fishermen.

And that's a livelihood. We've seen a reduction in salmon fishing. So crabbing even more so in recent years has been so important. So another way to solve the problem would be to develop new fishing gear that's going to be more sustainable. That's going to be more environmentally friendly. And so crab fishermen and other types of fishermen around the state are in the process of testing this ecologically friendly gear. That's interesting. And so for crabs, so if you think about it, so what can you do?

do. You're dropping this crab pot or this crab trap, and you have this line that goes all the way up to the surface. So how can we get rid of that line? And that's what we're figuring out. Thank you for taking time to be with us today. Peter Arconi, science reporter with KQED public media here in San Francisco. We're going to take a break. We come back. We're going to talk about a new generation of tech that is helping people cope with hearing loss. If you'll have a hearing problem, give us a call. We'd love to hear from you or send us a tweet at SciFry. We're talking about something that I have a problem with my ears. We'll be right back after this break. This is Science Friday. I'm Ira Flato. Imagine that you and I are sitting across the table from each other at a crowded restaurant, just a couple of old friends catching up.

Can you say that? What did you say? Sorry, I really can't hear you. Yeah, it's talking, yeah. Does that happen to you, right? It's common. You have trouble making out words. You're not alone. You're in a restaurant. All that background noise gets in the way.

If you're a member of the baby boomer generation like I am, that scene may feel pretty familiar, especially if you have a tinnitus in one ear or both ears I have in one ear. Unfortunately, there is no silver bullet for tinnitus or other forms of hearing loss that come with a ear. and researchers don't even understand all the ways in which the auditory system can go awry. But we now have more sophisticated technology to help us cope with it. These days, there are over-the-counter hearing aids and assistive listening devices that connect, for example, with your smartphone.

Tech that lets you amplify softer sounds or cancel out the noise of a crowded room. Even zoom in on the sound waves created by the person you're speaking with. And in fact, so much has changed about the industry catering to people with hearing loss that my next guest wrote a whole book about it. David Owen is a New Yorker staff writer and author of the new book Volume Control, Hearing in a deafening world, which is out now. David, welcome back to Science Friday. Hi, Ira, thank you. That restaurant gave me the chills. Isn't that really familiar, right?

Yeah, I talked to, when I was working on this book, I'd talk to people and go, ask friends, how's your hearing? How's your, oh, it's pretty good to go, you know, except in restaurants. And it makes a big impression on people. And isn't that one of the first symptoms of having a hearing loss is that you keep saying what? Yes. I didn't hear you. Say that again, right? Yes, and unfortunately, the average wait time between noticing that you have a hearing problem

or suspecting that you have one and actually doing something about it is 10 years. That's the average that people wait. Is that because they think they can just plow through it or that they can't be having a hearing loss? I think there are a number of reasons. I think one is that we don't take hearing anywhere near as seriously as we should. We don't realize how important it is in our lives. Another is just, you know, sort of good old human inertia. And another is it kind of the stigma, the perceived stigma of having hearing aids.

It's a sign of decrepitude, hearing loss. There was Charlie Rose, back when he was on TV, did an hour-long show on hearing and hearing loss. And during that whole time, he never mentioned that he was wearing hearing. hearing aids he had two hearing aids on and one of his guests who was a Nobel prize winning physicist you could see his hearing aids and he also never brought it up so there's some there's some feeling that it's somehow shameful or embarrassing to do something to help your hearing yeah because I and something that comes along with hearing loss is as I mentioned in the intro that I have

a tinnitus ringing in my ear one of my ears my right ear and that compounds the problem yeah I have it too and it's a I've discovered that one of the very worst things you can do for tenetists is to write a book about it because then you're thinking about it all the time. Unfortunately, there's no known cure. Treating it mostly involves helping people learn to just tolerate it or to mask it with other sounds or to sort of make it less apparent by prescribing hearing aids to bring up the sound of other things so that the tenetis is less apparent. But it's a, it's, and it is the number one service-related health claim made by military veterans. It's soldiers from Iraq and Afghanistan and then back through every war that we've fought since the Civil War. It's been a problem for, for soldiers.

Because if you have a, if you have a rifle on your shoulder and you fire it, it's a loud boom. That's right. Right-handed infantrymen tend to go deaf on the left side. That's the ear that's the closest to it. And then it happens in surprising places, too. Violinists lose hearing in exactly the same way in the left ear. We don't think of symphony orchestras as being harmful to hearing. It tend to think of like heavy metal rock.

But classical musicians are prone to it too. And it's often not your instrument. It's the instrument of the person sitting behind you. So it's the French horn right at your head in the chair in back of you. You know, speaking personally, you don't really, you know, the old saying, you don't know what you've got until it's gone. Because I'm almost deaf in one ear, I try to make sure I protect my other ear from any kinds of loud sounds. And living in New York City, walking down the street, you know, I really find myself cupping my ear, closing it off, putting my finger in it when a truck or something goes by.

And a lot of people are just not doing that kind of thing, and we're exposed to loud sounds all the time that may be harmful. Oh, it's so true. You know, it's just watching a football game over the weekend, and the commentators were talking about how. How enthusiastic the fans are, the sound of the cheering, it's so loud, the linemen can't hear the quarterback calling signals. And they actually gave a decibel reading, and it was well above the level that can, you know, with sufficient enough exposure, can cause permanent hearing loss. And it's, you know, it's not a good, not a good thing to be this enthusiastic with

this many people. It's not good for your ears. You know, but the good news about this now is that we have cell phones and electronic devices that might make up for some of the shortcomings we have with hearing loss. For example, I discovered, because I know so many people who have hearing aids, that hearing aids can now be hooked on to your cell phone, on your iPhone, for example, you can hook it right on there, and then you can sort of slide your cell phone across the table, and act sort of like a remote microphone going to your hearing aid.

That's right. You can, they're very expensive devices that do the same thing, but you can do that. I got my mother, my mother's 90. She's had trouble with her hearing. She's been reluctant to go and get hearing aid. So I bought her, I think I spent $80, a device called Super Ear. It is a little unit that's maybe the size of a, you know, smaller than a cigarette, a pack of cigarettes.

It hooks to a wired pair of earphones, and she can adjust it and place it on the table. You know, all she has to be to do is be willing to have this visible sign that she's not hearing. But she did take it to dinner with some friends, and they passed it around. And I've done the same thing with more sophisticated devices. You know, go to a sports bar. I have a pair of headphones called hearphones made by Bose. And they're basically, they have the same chip that hearing aids do. But they have a bigger battery, so they have better Bluetooth.

They have bigger speakers, so the sound is better. They have noise cancelling inside the ear canal as well as outside. So you can, in a restaurant, if we had been in that situation at the beginning of this segment, I could have turned down the sound of the restaurant and focused on you specifically without putting my phone on the table. And, you know, we would have had an easier time talking. That's great to hear. Are there any treatments? Because if you, you know, of a certain age, you hear on TV, you watch commercials that say,

oh, there's this miracle cure for tinnitus, you know? Right. But there is no such thing, is there? No, and you search for it once on Google, and your email inbox fills up with all these claims of, you know, the food you should eat, you know, this thing that doctors don't want you to know. Don't let the American Medical Association know that you know about this. Unfortunately, they don't work. There's some things that people find that help them. One, surprisingly, something that sometimes helps me is to simply pretend that my tinnitus,

this high-pitched sound, phantom sound in my head, is a masking sound that I'm playing to cover up my tinnitus, and that doesn't always work, but sometimes it does. I'll turn on a fan, turn on the air conditioner. I have some earpieces that actually play a masking sound, and they help too. Yeah, some people will put their white noise machine on at night. Right, exactly. And you can get something that's sort of in the kind of covers it. I've walked in places where the traffic noise, just kind of steady hum from an interstate highway,

was right in the right frequency range to make me unable to hear my tenetis. Or in the fall with cicadas and crickets that's kind of in the same range, and then I hear only them. I don't hear this phantom noise in my brain that usually I only notice when I'm lying in bed or writing about it. The new research on tenetis suggests that it's something like, like phantom limb pain, right? It's not there, but you still feel it.

I think this is the beginning to be, being is the accepted idea now, that your brain is used to receiving signals in certain frequency ranges. Now you've lost the ability to hear those ranges, and so it makes its best guess about what ought to be there. It fills something in. And so there are some treatments that work with some people

that involve kind of training the brain to ignore that entire frequency range. Tenet's is tricky because it's not a sound. It's not sound waves coming into your head. It's an electrical activity taking place in your brain. So people at Bose are always asked, well, can't you make noise canceling headphones that will take care of this?

And they say, no, we need, in order to cancel sound, we need sound and you don't have sound. This is something else. But there's hope. There's always hope. You mentioned Bose, and I think about this a lot, because I cover technology also. Why doesn't Bose or Apple or somebody go into the hearing aid business

that they know all about sounds, they make all these phones and they make the headphones? And, you know, there's a whole bunch of baby boomers and people who are youngsters who are going, you know, getting deaf from all the loud music they're playing. This would seem like a great business model, you know? No, it seemed that way to them, and people suggest it all the time. And Bose actually now has been approved for a hearing aid. There will be a hearing aid coming from Bose. And my Bose hearphones, these headphones, they can't legally call them hearing aids, but I can.

I mean, they're hearing aids that I like better than hearing aids. One reason that these companies have not been involved fully yet is that it's really hard to make a hearing aid. And they all thought, well, we have the expertise, we'll get into it. But the processor inside a hearing aid, the circuitry inside a hearing aid, the antennas, it is time. and it had to be invented by the hearing aid industry because there is nothing off the shelf that works. And so Apple has a partnership with a hearing aid manufacturer, but it took them years to do what they thought they would be able to do just immediately based on what they already knew. And they've all discovered that it's much harder than they thought it would be. You know, I always think that there's going to be new research coming out by the Pentagon.

The Pentagon spends so much money, has so many soldiers that are in common. and all kinds of suffering all kinds of losses. And from reading in your book, it seems like they know about, as you say, one of the number one injuries in combat is loss of hearing or tinnitus, and they have a way of getting, of combating that? You know, it's interesting. Military personnel have, we have known for, literally for centuries, that warfare is bad for hearing, that gunfire defends people, that artillery fire, that simply being around, you know, in military

equipment, military vehicles, deafens people, but it's really only in the past few years that the Pentagon has begun to use truly effective hearing protection devices. There are hundreds of pending lawsuits right at the moment over what were supposed to be protective earplugs that were issued to soldiers in Iraq and Afghanistan. They were defective. They didn't work. The Pentagon knew they were defective. The manufacturing knew they were defective. And you think, you know, We knew during the Civil War. We knew before that. We knew in the age of sale that exposure to explosions deafens people.

And yet the focus has always been more on compensation than on prevention. So the Veterans Administration is the largest single purchaser of hearing aids in the United States. But much more money has gone into that than has gone into research to protect the hearing of soldiers. Amara Flato, this is Science Friday from WNYC Studios. Talking with David Owen, New York staff writer and author of the new book Volume Control Hearing in a deafening world. Great book, especially for, you know, if you think you may have a, don't want to admit that you have a hearing problem. And the title is really indicative of the state we are. We are in a deafening world.

There are so many loud things around there. And we have a tweet from David who says, there are also some nice decibel meters available online to improve your awareness. That's true. I have one in my cell phone has a DB meter that I used. One of the difficulties with decibels is that even scientists who understand them have a hard time explaining them. The scale is logarithmic. So 90 decibels is not just a little bit louder than 80 decibels.

It's a lot louder. And the, I came up with a scale of my own, which is, you know, things like whisper, soft voice, chainsaw, rock concert, more items that, more items that we're more familiar with than we are with these numbers that we don't really, that are very hard to understand. The basic takeaway, though, is that we are exposed constantly, especially somebody, you know, living in a big city, but really everywhere, to let really loud sounds. that can hurt our hearing. You know what the loudest sound I, you know, because what I do for a living is listen, the loudest, most annoying sound I have found recently and actually brought my decibel meter to check it out, was in an airline, the airline bathroom. When you flush that airline toilet, it's over 100 dB.

That's loud. And it peaks out there. People thought I was crazy. Yeah. Federal regulations are sounds that are close to painful, are certainly damaging, that workers in covered industries are allowed to be exposed to for, you know, eight hours a day, five days a week, 50 weeks a year. And even the government knows that what regulations we have are not sufficient to protect those people.

It was also, I was thinking, listening to your previous guest, one of the threats to the health of marine mammals is human-generated sound. The largest single input of human-generated sound into the oceans is shipping, ocean shipping, the sound of the engines in ships. But we also, you know, we explore for gas and oil by basically setting off explosions underwater than listening to the seismic echoes. All these things have devastating effects on marine life.

Marine mammals, which have ears like ours, And we don't even know what impact we're having. Yeah, we really, you know, are not aware of how loud the sounds we are and the sounds we are making that might disturb the world we live in. That's true. My wife, I always used to make fun of my wife because she would put on earplugs when she used her food processor. But now I do it too.

You know, she bought me, when I was working on our house, she bought me a set of protective earmuffs, and I would only put them on if I thought that she could see me, but now I wear them all the time, and I carry a pair of musicians' earplugs on my keychain, and I'll put them in even. My wife and I went to see the movie Dunkirk, which is basically one continuous explosion from the opening credits to the end. And it made it tolerable. It was painful otherwise.

Yeah, I get it, because I bring mine to weddings and bar mitzvahs. The bands are very loud. Yes, thank you very much. David Owen, New York staff writer, author of The New Book, A Great Book, Volume Control, Hearing, and a Deffining World. and we have an excerpt on our website at science friday.com slash volume. Thank you for taking time to be with us today, David. Oh, thanks, Ira. Great book.

After the break, a medical field dermatology is, you know, it's literally skin deep, and we're going to talk to a doctor who's working to improve care and diagnosis for people with darker skin. We'll talk about how that's working out. Stay with us. We'll be right back after this break. This is Science Friday. I'm Ira Flato.

Have you made an appointment to see you, dermatologist recently, maybe get a skin cancer screening or check out that inflammation. If you're a person of color, someone with darker melanin-rich skin, it's statistically likely that your dermatologist is not. And while that shouldn't matter, it's also likely that they trained on photos that were more likely to be from light-skinned patients. And in such an intensely visual field where redness and discolour, are important symptoms, what consequences does this lack of diversity in both practitioners and

data have for the patients? My next guest has asked both these questions, and in response to opened one of the few clinics in the country that specializes in patients with melanin-rich-skinned skin, skin of color, the technical term. Dr. Jenna Lester, Assistant Professor of Dermatology, University of California, San Francisco Medical School, and director of their skin of color. clinic joins me here at KQED. Hello. So what

draw of you to open this clinic? A number of factors. When I was a resident, I would always be struck by the reaction that patients of color would have when I'd walk through the room. They pretty much uniformly would say, wow, I've never had a black dermatologist before. I feel

like you're going to understand my skin, especially if it was someone with a hair concern. They would say, you know, dermatologist X told me to use this on my hair and told me to wash my hair. every day, something that if you've ever come in contact with a black woman, you know that that's not something that we do. It just, it spurred me to, well, first of all, I realized what a big issue that was and made me want to create a place where these patients felt comfortable.

To dermatologists, are they able to recognize the differences in the skin? People have darker skin? I mean, when you get training, does the training help you? I think the training does help, and I think that's one of the things that I want to focus on is education, because studies have shown that close to half of graduating dermatology residents don't feel comfortable diagnosing skin conditions in skin of color, and I think that has a lot to do with exposure. Part of it depends on where you trained. If you trained in an area of the country that's less diverse, is opposed to a place that has a lot of racial and ethnic diversity. You may have had differential exposure to these things in the clinic, and so then you rely more on photographs that you look at

from textbooks, et cetera. So I think that is sort of the crux of the issue. Is there any bias in the photograph? So I have found that there is. We took, along with a group of medical students, took a look at photographs in common teaching textbooks and teaching slide sets and found that about a third of those images were of darker skin tones. And you may think, okay, well, a third, that's probably enough. But if you consider that many dermatologists need to know rashes that they may have never seen in real life, you realize how much more important those photos become. And I would say we need one-to-one representation of every skin condition in

every different skin color. That would be ideal. Our number 800-844-724-8255. You can also tweet us at Cy Fry. Why is this training deficiency so important for the patient outcome? Well, there are several disparities in dermatology in general, but in medical, across all specialties in medicine. And I think education on the differences and what color looks like in different colored skin is really important addressing those disparities and not contributing to delays in care and making patients feel comfortable in that you're informed and know what you're talking about. How differently do skin conditions present when your skin is darker?

Something like psoriasis, for example. That's a great question. So there's a concept called simultaneous contrast, which it comes from color theory and was first described in the mid-1800s. And that's the concept that color is dynamic. And so the color surrounding anything in particular that you're looking at really affects how it hits your eye. And so erythema or redness, inflammation in the skin.

When we see it, we describe it as red or pink. And in darker skin, can actually look more what we say in dermatology, violaceous or purple, sometimes dark blue. And if your eyes not trained to see that, then you miss it. So it's harder. You really have to be trained to see that. Yes. And I think repetition is the greatest teacher.

So if you don't see this over and over and over again, in situations where there's time pressure, where you don't have enough information or you have incomplete information, you have to make decisions quickly. This is something that you might miss. Well, so then should people, you know, with darker skin themselves, be more cognizant of changes in their skin because they, you know, they might not feel that they need to. Yeah, I think many are.

And I think what I've heard from patients is they come to the doctor and are told nothing's wrong sometimes. I do also think that there is education that we as dermatologists need to. to give our patients about the fact that, you know, skin cancer, while it's less common in patients with darker skin, still happens. And when patients with African-American patients, for example, when they present with melanoma, are more likely to have advanced disease and are more likely to present with nodal metastases or spread to other parts of the body.

Is that because they've waited so long? I think it's – yeah, I think it's because they've waited. Maybe they've been told skin cancer is not something that can happen to you. And in patients with darker skin, these are more. likely to happen on areas of the body, like the palms of the hands or the souls of the feet. Maybe you don't look in those areas as much. I think people think that, you know, if you have a darker skin color, that the melanin protects you.

Is that a mythology? That's not a mythology. That's absolutely true. And we see that in the different, the incidence of different skin cancers. And oftentimes skin cancers that patients of color get are not UV related to UV or sun exposure. but I still think that you have skin, you can get skin cancer. I think that's kind of the bottom line. So you have opened up a clinic.

Yes. And do you see people coming to you who are sort of refugees from other doctors or other clinics? Patients do travel from far to come see me. And I think that happens for a number of reasons. They want reassurance that the path that they're on is the right one. They've maybe had a bad experience. and I think a lot of people are just, they've never, they want to, they want their doctors to look like them, I think, in a lot of situations. So it's quite powerful.

Is there any part that you see misdiagnosed more often on the body than anything else? You mean any part of the body where there's a misdiagnosis? Face, hair, shoulders. Yeah, I actually see a fair number of patients who come in with issues of hair loss and things that, a particular condition. where we can give a patient a name, we can do a biopsy, we can make a diagnosis and start them on the road to treatment. Maybe was brushed off before and said, you know, there's nothing we could really do about this, so just sort of deal with it. I have a tweet from Chidi who says, are people with darker skin more prone to certain skin problems? If so, what are they?

That's an excellent question, and I think largely that's something we're still discovering. there's a condition that provider at UCSF, Haley Nyak, is working a lot on called Hydridinitis Separativa. We think that there are racial, ethnic differences in that particular condition, but a lot of these studies haven't been done, and so we're working to figure that out. We've talked about skin cancer, melanoma. Are there any other kinds of skin conditions we're identifying it correctly as could be a life or death situation? Yeah, so a particular example that comes to mind is something called toxic epidermal necrolysis. Say that again? Toxic epidermal necrolysis or T-E-N for short.

And this is one of the severe dermatologic emergencies. People think dermatologists don't treat life-threatening conditions. And to the contrary, this is one that dermatologists can have a life-saving impact. And a patient, in my medical training, I trained at many different institutions. a patient with darker skin sat in the emergency room for eight or ten hours because the redness, which can be subtle in patients with darker skin, that's the sort of hallmark feature of this condition, was missed in this person. What about jaundice, right?

You're supposed to skin get yellower from jaundice? Could this be missed with people who have darker skin? It could be missed. I think places where you could still look are the sclera, the eyes, the palms of the hands, but oftentimes jaundice doesn't reach those areas until it's, It's pretty far advanced. Wow, that's interesting. In your clinic, what do you need?

What that you don't have? I have a blank check question. I don't have the real blank check. If you had a blank check and you needed to buy equipment or a better test for something, what do we really need? I think I would need a medical photographer. I need someone who could set up and take photographs of literally every single thing

that I ever saw during the day. because part of the huge issue is this disparity is in the existence of photos. People are interested in including these in their talks, but they don't exist in the numbers side by side with the photos of lighter skin, and we need really good photos. But there are doctors' manuals of skin diseases. They're not good enough, is what you're saying. I say they could be better.

They could be better. They definitely could be better. And there are atlases of patients with skin of color, but they're separate. And if you're a dermatology resident, say, in San Francisco, who's struggling to pay your rent and also eat and doing all of these other things, buying a separate textbook is really something you can't do. And I think it also signifies that this is not something that should be part of the mainstream of dermatology. We have to have a separate book for it. You need to take an extra step to learn about this, so it's optional. And you need to collect more data from people, right?

Yeah. Are they willing to volunteer? I think that's a tenuous question. question because there's a history, there's a legacy in our country of mistreatment and experimentation that a lot of people remember, and there are some very well-known examples, but I think people also have personal examples where they're hesitant to do that. So if they're hesitant to come to you as a doctor or a dermatologist, they may be hesitant to go to another kind of doctor and miss out on a different disease. Have you ever referred to a patient? Oh, all the time. My 10-minute

appointments often extend to 20 and 30 minutes when I get into blood pressure control and other things these patients should be doing because they do see me as someone that they want to tell all of their problems to, and I see it as an opportunity. Any interaction someone has with the medical system is an opportunity where they either turn towards care or away from care. And so I see myself as a gateway for a lot of patients. So what do you say to people? When we have a large audience, I have 2 million people listening, what's your message to them about getting, you know, are going to see they can't all come to your clinic. Right.

What's your message? Or to doctors who might be listening, we need to have more clinics of your type opening? I think that doctors should, we all have a responsibility to care for all patients. Sure, maybe black patients or patients of color want to see me. There's not enough of me or there's not enough of doctors that look like me. So as a medical community, I think we all have a responsibility to fill the gaps in our knowledge and to educate ourselves. This is a field of lifelong learning.

It never stops. So you have a responsibility to all of your patients to do this so that you can adequately diagnose them, treat them, give them the right medications that work for their particular condition. Amara Flater, this is Science Friday from WNYC Studios. Talking with Jenna Lester, assistant professor of dermatology at the UC San Francisco Medical School. Is this a topic of discussion at medical school conventions or dermatology conventions? Do they, do doctors realize this? I think this is something that more and more people are realizing.

And it's catching more traction. I think as we talk about diversity in the specialty of dermatology, dermatology is the second least diverse specialty. So I think this sort of goes hand in hand with the issues and the conversations that happen around diversity of our workforce. Because I know of cases where there have been cases of melanoma, for example. And I know people who have been diagnosed with melanoma, but it was, not the typical, you know, five, six, seven variations that you're supposed to look for.

It was something totally different. And when I talked to a doctor about this, he says, you know, we couldn't list everything that will show up in patients. So we just list the most common types. It seems like what you're saying is the same sort of thing that's happening here. Yeah, I think education is central to this because what I think of when I diagnose melanoma often, patients say, oh, this one has changed. And these are often patients who have been told since they were younger, skin cancer is something you should get. You should wear sunscreen.

You should stay out of the sun. These are the signs that you look for. So when subtle changes are something that's picked up on, you have to think that education is at the basis of that. Yeah. Let's see if we have time for a call before we go. Octavia in Decatur, Alabama. Hi. Welcome to Science Friday. Hi. How are you? You all. Fine. Go ahead. Okay, so my question is, well, I have a doctor, a dermatologist, that's Indian, and his skin is really dark. And a lot of the patients that I see coming in and out of his office are darker skin, you know, people up in Indian descent and African Americans. So I'm just kind of wondering how closely related are our skin makeup?

Because I know with me, he always hits the nail on the head. So is our skin makeup related? That's a really good question. And I think overall there are more similarities than differences. A lot of the differences have to do with skin tone. And so in dermatology, we have something called the Fitzpatrick. scale that was developed as a way to determine someone's likelihood of developing skin cancer, but has also become a proxy or a stand-in for skin tone.

And so it goes from one to six, and six is the darkest, and one is the lightest. And so, you know, there are people of different ethnicities that would fit into the same skin tone. So I think a lot of that has to do sort of draws the similarities between the skin as well. So where do you personally go from here? You can, you're going to expand the clinic or? So, so research is something that I'm, a research program is something that I'm developing now. I'm also developing curriculum, trying to teach the next generation of physicians how to care for patients with all different skin tones. I think education is the way to have. have sort of a reverberating impact, since, as I said, I don't think there'll ever be enough

doctors of color to see all the patients of color that want to see them. We hope we've made it dent in the education process today. Yes, I hope so, too. Dr. Jenna Lester, Assistant Professor of Dermatology at the University of California, San Francisco Medical School. Thank you. Thank you for having me. Thank you for having to be with us today.

Also, thanks again to audio engineer Jim Bennett, Tiffany Mitchell, and all the great folks at KQED for welcoming us into their studio home today. On the Science Friday Vox Pop app, we'll be talking with astronaut Catherine Sullivan next week, and we're asking you, what have you always wanted to know about living and working in space? You can tell us on the Science Friday Vox Pop app, download the app, the question we want you to answer and leave us a message. What have you always wanted to know about living and working in space? We'll ask that of Catherine Sullivan next week. Maybe we'll have your answer on our next Science Friday.

Have a great weekend. I'm Ira Flato in San Francisco.