Introduction

There is no library collection that is without bias – this situation is due to the nature of the way that collections are maintained and created. Anything that begins in human hands will retain the fingerprints of whoever worked on it. Library collections are biased because librarians themselves have biases, whether they are overt or not. This problem is particularly evident in medical collections, which in addition to these biases must also reckon with biases of the systems that create its materials. Health research and publishing practices have been rife with systemic issues regarding the health of women and people of colour, often skewing materials to be overwhelmingly in favour of White cisgender male patients.

While the full expression of human identity is important and should be considered when collecting literature for medical collections, this chapter’s primary focus is on the disparities that are linked to ethnicity, race, and gender, thus limiting our scope. Other aspects of identity tied to disadvantaged groups, such as individuals with physical and/or mental disabilities, are impacted by systematic issues in health libraries, but are not discussed in detail here. Many of the issues regarding race, ethnicity, and gender in medical library collections that will be discussed are similar to the ones concerning other aspects of identity and experience. This chapter intends to provide context to some of the major issues present both historically and currently in the practice of medical and health sciences library collections and diversity and describes the challenges that librarians face when building a collection with medical materials and examines potential ways to mitigate these difficulties.

Definitions

Within this chapter, we use a number of terms that are commonly used in the medical field or terms that can have different meanings depending on their context. We provide a set of definitions for these terms as we use them here in the chapter.

DEI: Diversity, Equity, and Inclusion. This acronym has come to be a common ambition within the medical field. It is meant to emphasize goals in medical libraries and institutions that are geared towards including more diverse voices and providing them equal opportunity (Medical Library Association, n.d.).

Evidence-Based Practice: “The process of collecting, processing, and implementing research findings to improve clinical practice, the work environment, or patient outcomes” (Wilson & Austria, 2021). Evidence-based practice is meant to ensure that accurate and good quality materials are being produced and used. Health sciences librarians should be dedicated to providing evidence-based materials to their users in order to best serve their communities.

Health Sciences/Medical Libraries: There are several different roles that a medical or health sciences library can take on. Most libraries will have a parent institution, commonly a hospital or a university (or both) which provide funding and guidance for the materials needed. The most common groups served by medical libraries are academics (students and faculty), clinicians, and other medical staff, such as nurses. This approach means that medical library resources are most commonly used to teach students training to be health professionals, support health research, and provide evidence-based materials to practicing health professionals for patient care. In many instances, individual libraries will not perform all these tasks, with some libraries focusing exclusively on academics or assisting medical staff. While there are differences between the fields of health sciences and medicine, these differences are nuanced, and for the purposes of this chapter, we will be using the terms interchangeably.

Minority or Marginalized Groups: In regards to this chapter, diversity is defined as a realism-based understanding of the mixture of ethnicities and races that more accurately reflects the reality of living populations today. Minority or marginalized groups can be loosely considered to be those that fall outside of the bounds of white, cisgender, male parameters that are not equally represented in collections due to system racism (Jones et al., 2023).

Background and Current Content

It is known that current medical collections are often not inclusive of diverse communities and fail to accurately represent the health issues that are exacerbated by disparities in gender, race, sexual orientation, religious belief, and socioeconomic status (Brillant et al., 2022). Despite this misrepresentation, medical collections acutely fail to represent large swaths of the population. Medical history has been exclusionary since antiquity. This practice has continued throughout history, with cis women and any other demographic that is considered to be Other (as compared to the cis male form) being underrepresented in medical literature and in medical understanding (Pun et al., 2023).

Medical library collections are unique in the sense that they both inform and are informed by medical practice. Perpetration of systemic racism in the medical field is reflected in medical collections and vice versa. Their relationship is a cycle; medical literature shapes how doctors perform their practice and conduct their research, and research and practice shape what materials library collections hold. However, the ongoing prioritization of colonial experiences and practices in libraries’ collections have worked in conjunction with this cycle to perpetuate systemic racism while also having the cascading effect of influencing the larger system of collections. Medical professionals cannot learn from materials that have not yet been collected because of systematic prioritization of certain viewpoints. Such an example can be found in the biological classification systems created by scientists based on race, and the devastating effects of classifying bodies as Other or lesser to medicine that can be seen in such examples as the Tuskegee Study of Untreated Syphilis in 1932-1972. This study was an experiment performed on Black men because they were believed to be medically separate from their white contemporaries due to their race (Pun et al., 2023). The study has resulted in a racial hierarchy scheme in research that has exacerbated the cycle of libraries and collections perpetuating systemic racism (Pun et al., 2023). A natural extension of this type of exclusionary collection style is that racialized bodies are also under or misrepresented in collections as well as medical understanding (Hoffman et al., 2016; Zhang et al., 2021).

Historical bias in both research and publishing has been maintained in collections (Connor, 1989). This bias has further reduced the availability of resources, causing an implicit prejudice within collections that will be further discussed later in this chapter. It would be remiss to recognize that certain types of people have been harmfully othered in historical medicine and not to refer to how this harm contributed to active abuse and mistreatment at the hands of medical and research professionals. This abuse and mistreatment was done to obtain data that can still be found in historical and contemporary medical collections. In particular, the field of obstetrics is an area of historical and contemporary medicine that must be brought to the forefront when discussing medical abuse and lack of diversity, particularly in its role in the abuse of Black and other Women of Colour (Barbosa et al., 2023). Other fields also suffer acutely from a lack of diversity in medical literature where it can have devastating effects in its narrow focus. Systemic or understudied health problems often plague minority or marginalized populations, such as heart disease and high blood pressure, which are overrepresented in Black populations in the United States, in part due to the extra associated stress of systemic racism. A phenomenon that is made more harmful from lack of diverse medical care (Ossom-Williamson et al., 2021).

Lack of representation began long ago but continues to be a real problem in current medical collections, one that is codified in the basic organizational systems that collections use. The Dewey Decimal Classification system is an excellent example of a tool that retains the bias with which it was created, but is nonetheless entrenched in modern understandings of knowledge-organization systems despite the fact that it is unfairly skewed towards a White, male, Christian, heterosexual worldview (Higgins & Stark, 2021). Though it is perspectives such as Dewey’s that dominate research and literature, library and information science as a field is dominated by non-disabled, middle-aged, White women (Akers et al., 2021) whose identities and biases have further shaped collections. Although there is little information about the demographics of health sciences librarians specifically, studies on health sciences librarians that provide demographic data about their participants show a similar skew towards white women (Mi & Zhang, 2017; Nicholson et al., 2017). More recently there have been initiatives towards DEI. These initiatives have resulted in efforts focused on making library spaces more comfortable for marginalized groups and supportive of more diverse librarianship. Despite the acknowledgement that there must be an increased effort to promote diversity, these issues continue to persist. Medical libraries present a difficult combination of poorly-diversified materials within the larger medical field and a lack of diverse librarianship that makes collection building especially vulnerable to bias, and therefore to harm. The self-sustaining cycle of poorly-diversified collection selection and a lack of diverse librarianship in both historical and contemporary medical library collections is evidenced by not only the lack of available literature, but also the potentially outdated literature that does exist within these collections.

Due to the nature of the medical field as research-driven and thus ever-changing, currency in particular is a ‘canary in the coal mine’ for medical literature in collections. Libraries that focus on medicine or social science generally do not purchase titles or materials that are older than six years (Donatiello et al., 2004). Medical libraries need to be a host to diverse literature because they rely on evidence-informed decision-making and learning (Bradley-Ridout et al., 2023). Despite this reliance, numerous examples demonstrate that collections are not keeping up with this practice for wider medical collections. An audit of a Midwestern metropolitan university found that a significant percentage of 2SLGBTQ+ health-related titles (57%) were at least 20 years or older and those that were present did not adequately address whole body health and focused mostly on neuroscience instead (Blackburn & Farooq, 2020). Scholarly publishing is rife with systemic inequities and biases against diverse contributors, with content not representative of the majority voice (Akers et al., 2021). More telling, perhaps, is the number of libraries’ collections who are currently in the process of attempting to very explicitly fill in the gaps in their proverbial shelves. Libraries lack the time and resources to assign valuable assets towards initiatives that seemingly present with insufficient importance. It is the role of medical librarians, outside of information that is intended solely to be representative of the history of medicine, to not only be aware of the implicit biases that might exist in their collections, but also to understand the forms they take and the impact on medicine and its ability to deliver “high-quality medical care, to all members of society, regardless of gender, race, ethnicity, religion, sexual orientation, language, geography, origin, or socioeconomic background” (Martin, 2019 p. 293). In understanding the role of the history of medicine, publishing and non-diverse librarianship steps can be taken to correct the problem. In effect, librarians must direct their attention to the source of their medical collections’ illnesses rather than solely the symptoms by “assessing and updating health science collections is key to ensuring that the resources available are representative of diverse perspectives and populations” (Bradley-Ridout et al., 2023). Through sustained effort, attention to ethics, and a nuanced understanding of implicit bias, the environment for the growth of diverse and population-wide supporting catalogues can be created and maintained. In order to do so, however, one must identify and work through the plethora of problems that many library collections face.

Challenges

While there are many challenges plaguing the collections of health sciences and medical libraries, they can be grouped into three main groups: systemic issues within the medical literature and healthcare curriculum; how to define and label DEI and its terminology within the field; and financial burdens that exist for libraries trying to diversify medical collections. These topics will be discussed further in the next sections.

Medical Literature, Curriculum and Systemic Issues

Libraries cannot include materials in their collections that do not exist. To be able to talk about the issues surrounding diversity in medical and health sciences libraries, one has to move beyond just the collection itself. Since medical libraries have a dedication to collecting and using evidence-based research to inform their users, their pool of materials to draw from primarily comes through subscriptions to high-impact peer-reviewed journals (Columbia University Irving Medical Centre: Augustus C. Long Health Sciences Library, n.d; Brillant et al., 2022; McKibbon & Marks, 1998; Swogger, 2018). This absence of evidence-based, peer reviewed material presents a challenge: journals often end up lacking a range of materials that represent diverse populations for libraries to include in their collections.

Medical literature has a long history of publishing racist and misogynistic materials (Pun et al., 2023), and although efforts have been made more recently to reduce these harms, problems still remain. Currently, like many other types of publishing, medical publishing has a serious issue with diversity in their materials in all steps of the process, including authors, reviewers, and editors (Watts et al., 2023). In scientific academic journals, women only make up 26% of scientists, 14% of editors, and 8% of editors-in-chief, and White authors and editors are overrepresented in international medical journals compared to all other races (Liu et al., 2023a; Liu et al., 2023b). Journals also frequently take longer to accept and publish papers written by women and people of colour, only furthering inequalities.

Additionally, there is a severe lack of medical research representing diverse groups as research participants, which leads to substantial harm in medical treatment for diverse groups. Dermatology is a painfully understudied field when it comes to different skin tones (Wilson et al., 2021), and this lack of research has had real and harmful consequences for the diagnosis and treatment of various individuals. Black patients frequently get diagnosed with diseases, such as cancer, later than White patients, making treatment more difficult and less likely to succeed (Gupta et al., 2016). Experiences like this disparity in patients of colour being able to be accurately diagnosed in a timely manner occur at least in part because the medical literature is lacking for disadvantaged groups.

Research materials are only one part of a medical library collection that faces these issues. Teaching new medical professionals is a major component of health sciences libraries, and issues similar to those found in research and publishing can be found in curriculum materials designed for students. White people are consistently found to be more represented in visual and textual course materials for medical students, contributing to the taught viewpoint that whiteness is the norm (Louie & Wilkes, 2018). Medical textbooks frequently present more visual and textual material on men compared to women (Dijkstra et al., 2008; Parker et al., 2017). Not only is there a lack of representation, but course materials often do not address common issues in clinical practice that occur when treating diverse patients. There is a persistent issue where people of colour and women have their pain taken less seriously than their White male counterparts, largely because of racial and gender biases (Hoffman et al., 2016; Zhang et al., 2021). These biases are twofold. Not only are women judged to be in less pain than men, but women of colour are furthermore less likely to be assigned appropriate pain management when compared to White women. Despite the knowledge that these biases exist and are impacting patient care, medical course materials do not address these concerns (Shipton et al., 2018; Tsai et al., 2016). Making students aware of the current problematic practices, as well as teaching the historical context that led to these inequalities can help mitigate those harms. In both academic and health sciences libraries, “exposing students to the history of medical science research can help students to understand how and why health misinformation is common even in scholarly publications” (Pun et al., 2023, p. 743). Similar to the issues facing scholarly publishing, librarians can find it difficult to find course materials that satisfy the teaching standards of their institution while also representing diverse populations. Systemic issues in the creation of diverse materials in health sciences make it difficult for librarians to build a diverse collection while still meeting the standards for evidence and education that they are expected to meet.

If materials do not exist in a collection, they cannot be included. Likewise, physicians cannot be trained to fully support the diversity of the human population they are intended to serve. In order to advance DEI in collections, there must be a change in the publishing of the materials that will fill them.

Cataloging, Terminology, and Defining DEI

Library subject headings and catalogue terminology has long been an issue when it comes to diversity in libraries, and health sciences libraries are no different. The terminology used in health sciences libraries is simultaneously poorly organized and actively harmful. Records will often lack relevant terms or use terms that are actively harmful towards various groups (Barnett, 2022; Ferrari, 2022). This practice creates problems for the users of the library who may be forced to use outdated or offensive terms to find information on their culture and health, while also creating problems for librarians looking to assess their collections (Higgins & Stark, 2021). For example, in The National Library of Medicine’s controlled vocabulary of medical subject headings (MeSH), the term “Indigenous Canadians” are still categorized under “Indians, North America” in the MeSH tree structure. Further, the term “Inuit” is categorized under “Indigenous Canadians” (as opposed to part of , and MeSH uses “Eskimo” as a related term. (National Library of Medicine, 2023). The current terminology used for cataloging records in health sciences neither treats the groups being represented with respect nor does it make it easy for librarians to consistently find records on diverse groups to determine how well they are represented by their collection. Librarians may want to assess their collections in order to examine how well they are meeting DEI goals, but can find the process challenging due to the lack of consistency with terminology (Brillant et al., 2022). Deciding what terms should be used to catalog and search records remains a difficult task, however. By using harmful terminology in the cataloging of records, librarians run the risk of further ostracizing people of colour who come to use the library resources and make the materials more difficult to reach to improve health information disparities with respect to DEI.

Brillant et al. (2022) describe the process of assessing diversity within hospital libraries. They emphasize how finding terms to use to assess collections can be a balancing act between having a standardized set of terminology while also considering the wide variety of ways that diverse peoples will refer to themselves. Having a set of terms that allows librarians to adequately assess their collection for DEI is critical to the successful implementation and discoverability of the materials that address inequalities in health literature. As it stands, many librarians struggle with their current collection terms around diversity, but are met with challenges around how to develop those terms to be inclusive while still staying close enough to common standard terms so as to not create further confusion. For example, MeSH has been criticized for how it defines race-related terms, for having terms be too wide in scope, and for removing important distinctions (Williams & Weeks, 2022). Librarians will need to work with this common standard when considering how to catalogue their own records and how to help their users find materials using these sources.

DEI initiatives and the implementation of best practices allow librarians to weed and configure collections in ways that exclude harmful materials and allow terminology to be updated while still retaining searchability and useability of collection materials. DEI initiatives make libraries a safer, more inclusive place for librarians and visitors alike.

Cost

Like most, if not all other library collections, the cost of materials continues to be a major challenge for health sciences collections. The field of health sciences libraries has a dedication to developing and maintaining collections that are primarily composed of evidence-based research. This approach means health sciences libraries tend to primarily spend their budgets on subscriptions to peer-reviewed journals that provide up to date work (Swogger, 2018). Unfortunately, these journals have been following the more general trend of serial pricing, leading to exponential increases in prices over the recent years (Meadowcroft, 2020), creating a strain on the budgets of health sciences libraries that rely on them.

This situation creates numerous problems. Firstly, as was discussed earlier, peer-reviewed journals have struggled to have diverse researchers, reviewers, and editors be a part of the process of published literature. Since journals often make up the largest portion of spending for health sciences libraries (Sowards & Harzbecker, 2018), the diversity of their collections suffers the same pitfalls that are found in the journals themselves. Secondly, libraries can lack flexibility in regards to their ability to pick and choose individual materials within medical journals. Some libraries rely on a system where entire journals must be purchased and journal subscriptions can be part of a larger deal around materials for the larger library (Swogger, 2018), commonly referred to as “big deal” subscriptions in other areas of library studies. This pricing model was originally thought to be potentially beneficial, as librarians could be provided access to an entire publisher’s journal content for one payment. Over time however, the power held by these publishers got stronger, which had led to a massive increase in subscription costs, as well as diminishing the role of the collection librarian in making choices about what belongs in the collection (Lemley & Li, 2015). Though libraries can negotiate with vendors for individual materials, it could be prohibitively expensive or interfere with the other agreements that the library has made with the vendor (Sowards & Harzbecker, 2018). Thirdly, high journal can costs also leave librarians with limited funds to spend on other parts of the collection, including diversity. Librarians often want to support a diverse collection, but struggle to find space in their budget for materials which can make their collections diverse while still fulfilling their other requirements (Brillant et al. 2022). Fourthly, budget issues are exacerbated by the fast moving pace of medical collections which are defined by their nature of constant research and discovery. The high turnover rate results in the older materials being destroyed or stored at high-intensity resource facilities, and the current materials often being housed primarily online as digital resources. This approach puts a financial weight on the libraries, as funds are needed to pay for the high-intensity resource facilities as well as to maintain and update the online collections.

Although health sciences libraries rely heavily on journals to fill their collections, there has been an increasing shift away from paid journals to open access articles in recent years (Demeter et al. 2021). Open access articles and publishing give readers of articles access to read for free, often costing the authors a fee to publish (Cornell University, 2024). Disciplines related to health sciences have significantly more publications in open access compared to all other areas (Demeter et al. 2021), meaning that health sciences libraries have growing access to materials that are free to use in their collections.

The lack of diversity in available publishing, the cost of journal subscriptions, the nature of evidence-based research as a subject that requires complexity in vendor and library relations are all factors that contribute to challenges that libraries face. These challenges do not need to persist in the future, for there are six responses below that can help improve the collections.

Responses

As discussed earlier in this chapter, there are broad challenges and problems with diversity in the collections of health sciences and medical libraries that have persisted throughout the ages. There are also six avenues of solutions presented below that the libraries could take for their collections to rectify these challenges. These solutions are: creating diverse management teams and task forces; updating catalogues and terminology; performing (reverse) diversity audits; weeding; exploring and reducing biases; and finding alternate avenues for materials.

Diverse Management Teams and Task Forces

The most frequently documented response to addressing the lack of diversity within health sciences collections is that both libraries and journal publishers are creating  more diverse management teams, establishing  DEI task forces, or some combination thereof. It is common for the majority of editorial boards, management teams, or teams of reviewers to be made up of a majority of white heterosexual members (Akers et al., 2021). With this homogeneity, as previously discussed in earlier sections, it is easy for implicit and potentially harmful biases to make their way into the publications, and thus library collections, while simultaneously preventing other perspectives and experiences from being heard. The goal of creating a diverse management team or a task force committed to diversity is to solve this issue. By having members of multiple ethnicities on a team, it is easier to notice if a collection, such as dermatology, leans heavily towards representing white people and can also help to identify if a collection uses harmful or racist terminology. In addition, it removes the sole weight of emotional labour from individual members of a team if the team itself is diverse and familiarized with diversity policies and their importance.

In 2017, the Medical Library Association (MLA) announced that it would “make diversity and inclusion a strategic goal of the association” (Morgan-Daniel et al., 2021, p. 141 ). Similarly, the Journal of the Medical Library Association (JMLA) recently started selecting new editorial board members every year using a “new selection process focused on creating a more inclusive and diverse board” (Henderson et al., 2022, p. 1 ). The transparency of the MLA’s and the JMLA’s actions, as well as similar actions performed by other associations or journals, serves to show the public their commitment to diversity, equity, and inclusion. It is, however, unclear if these actions are merely performative or if they are genuinely having a positive impact, as other literature would suggest (Watts et al., 2023). While having more diverse management and editorial teams is good, it is only beneficial if the non-White members are supported enough to be able to contribute equally and fairly to decisions, such as accepting manuscripts that use data-interpretation methods common to other cultures or by choosing to center the experiences of the people represented in the materials instead of those that are often against and harmful towards them (Higgins & Stark, 2021). It is beneficial for libraries to purchase subscriptions from journals that prioritize diversity, equity, and inclusion, as well as journals that accurately represent the people portrayed within. In doing so, libraries can better serve those who access their collections. However, as one updates the materials within their collections, it is also important to update the terminology used within the catalogues to better reflect the individuals represented within these new materials.

Updating Catalogues and Terminology

Library subject headings, catalogue terminology, and records have been long-standing issues in health sciences and medical libraries. To help fix this problem, libraries can update the terminology used when it comes to subject headings and classifications, as well as in their own documents. For example, the MLA was recommended to update the MLA Style manual in regards of the use of terms relating to race and ethnicity, and, in 2019, the Diversity and Inclusion Task Force compiled a report of recommended updates and changes that should take place in all MLA documents, such as changing Hispanic to Latinx (Akers et al., 2021; Morgan-Daniel et al., 2021). Additionally, in a presentation by two MLA chairs, Williams and Weeks (2022) suggest a change in the definition of the term “Black or African American” as a means to better represent this group without having to use harmful or offensive terminology to be used in addition to the subject heading.

This solution is by no means a simple nor even a one-time endeavour. Language frequently changes and “people define and describe themselves in increasingly complex terms” (Brillant et al., 2022, p. 431 ), causing stagnant systems to become suboptimal, irrelevant, and/or harmful. It would be beneficial for libraries to build assessment tools for diverse collection development that are continually tested and refined in  order to keep up with this constantly shifting environment (Brillant et al., 2022). Frequently reviewing and updating the terminology used in library subject headings, catalogues, and records is integral to ensuring that the library collections can successfully serve their users in this evolving society.

(Reverse) Diversity Audits

Diversity audits are often viewed as integral to maintaining a diverse library collection because they identify what a collection contains and what topics can be developed further, while also assessing potential systemic biases and inequities within the collection (Brillant et al., 2022). A new, alternative approach, as suggested by Bradley-Rideout et al. (2023), are reverse diversity audits – a process that combines the relatively new diversity audits with classic list-checking methods. Reverse diversity audits not only check for representation in the current collection but also identify potential missing resources. They do this by creating a list of titles that support diversity, equity, and inclusion in a specific area of the collection, such as dermatology, checking the collection for any titles that are on the list, and then purchasing the missing titles if there is room within the budget.

Although both of these audits are beneficial, neither of them are well-known. Most collection development courses in a variety of library science programs do not offer any instruction on diversity audits in their collection development courses (Brillant et al., 2022) and there is no other published research that the authors of this chapter could find apart from Bradley-Rideout et al. (2023) that discuss reverse diversity audits. A way to amend this problem would be to have (reverse) diversity audits discussed in the collection development courses of library science programs, or to even have different organizations come in and train library members on such topics (Morgan-Daniel et al., 2021). While it is integral to keep updating the collection using (reverse) diversity audits or other methods, weeding is also essential.

Weeding

A collection, whether virtual or physical, can only grow if it has the space to do so. Weeding removes the materials that are no longer needed or suitable for the collection, thus making space for the materials that are acquired in the (reverse) diversity audits. During their study of LGBTQIA inclusivity in the University of Nebraska Omaha’s medical collection, Blackburn & Farooq (2020) developed some weeding guidelines that we could adapt to increase the general diversity of medical and health sciences libraries.  They recommend weeding:

1. Medical and health texts based on information that pre-dated 2010.
2. Texts that do not follow current best practices for patient consent, safety, and well-being.
3. Physical condition of the text is not ideal for sustained use.
4. Title and/or content found to be offensive to underrepresented groups when taken out of explicit historical context.

By following guidelines such as these, librarians can make space in their collection for new and potentially more diverse materials, while removing materials that have the potential to cause harm. If there is a lack of appropriate replacement materials, the library should still weed the harmful or incorrect materials. Keeping harmful materials in order to maintain a larger collection size does not act to solve the problems presented earlier, but rather allows them to persist. Weeding is a small but important aspect of the development of a health sciences collection that supports the diverse needs of all its users.

Exploring and Reducing Biases

Bias is a problem that exists in library collections of all kinds, potentially negatively affecting the abilities of patrons to locate materials as well as negatively impacting their overall library experience if they are non-white. To combat the implicit biases in health sciences literature and libraries, Higgins and Stark (2021) created the curriculum “Working on Ourselves: Mitigating Unconscious Bias in Literature Searching.” This curriculum, which is freely available online under a Creative Commons license, aims to help information professionals realize how biases can affect information systems and health science literature among other things, as well as how these participants can recognize and address these biases in their own work. The curriculum was developed with adaptability in mind, allowing librarians to utilize what they learn and apply it to their collections. This approach would result in a collection with fewer biases and more diverse materials.

Several library organizations including the American Library Association (ALA) and the MLA offer continuing education classes that teach participants how to “recognize and address implicit bias in interpersonal interactions” (Higgins & Stark, 2021, p. 45 ). Additionally, as discussed earlier in this chapter, these organizations, as well as others, have tried to combat biases by creating more diverse teams, particularly at the management and editorial levels, as well as hiring task forces specifically designed to point out where harmful biases may lie and recommend ways to resolve it.

Education seems like the best way to combat all types of biases. Some information professionals may not even be aware that hidden biases uphold unspoken, systematic structures of power—such as a White-centric dermatology collection—and how it can influence the collections of their libraries. Once information professionals are aware of these biases, they are able to build better and more diverse collections that will only benefit the already diverse community that they serve.

Alternate Avenues for Materials

Having a strong library collection to support each field is vital. However, since some fields might have different needs, it is beneficial to look at alternate avenues for materials that would strengthen its collection, and these avenues might look different depending on the needs of the field. For example, dermatology relies on the ability of the doctor to correctly visually identify varying skin conditions for assessment and, if necessary, treatment. Diseases such as skin cancer melanoma or breast cancer, or conditions such as jaundice, pallor, and purpura can appear radically different on different skin tones. Physicians who have not been properly exposed to a wide enough range of teaching material are unable to properly serve a diverse population, causing marginalized populations, such as Black individuals in the United States, to have higher rates of harm from skin or breast cancers that were not diagnosed by their healthcare provider (Trabilsy, M. et al., 2023).

Despite this situation, dermatology and similar collections have the severe problem of a lack of diverse representation. Health sciences and medical libraries need more images that represent both the diversity of the patients served as well as the diversity of its students and clinicians (Pierce & Felver, 2021). To address this problem, Pierce and Felver (2021) worked together to create the “Oregon Health & Science University (OHSU) Educational Use Photo Diversity Repository,” which is an online resource that provides access to photos covering a wide range of skin conditions in a diverse range of skin tones. It is important that repositories such as this one use a controlled vocabulary to catalogue the images, such as MeSH, which is often already familiar to those searching for the photos (Pierce & Felver, 2021). This repository can only be used for education within OHSU due to a lack of specific consent documentation. These types of resources have added benefits for considering difficulties around cost as they are typically free to use for members of the organization that created them. Initiatives and repositories that provide resources for free or often at lower costs can have major impacts on filling diversity gaps in library collections without having to stretch a budget beyond its limits. To combat the restriction of users, proper procedures should be followed during the creation of these initiatives and repositories to allow for the highest number of users.

For all their collections, librarians can also pursue the alternate avenue of open access resources. Open access is defined as “free and open online access to academic information, such as publications and data” (Open Access, n.d.). A journal is open access when it lacks barriers, such as cost, to be accessed. Such journals relevant to this chapter are: Journal of Health Science Community (JHSC), Open Access Health Scientific Journal (OAHSJ), and Health Science Reports. These journals are free, and offer valid and diverse academic information, thus making them a valuable resource for health sciences collections that not only broadens access to medical research, but also lowers the cost of the collection.

Conclusion

Health sciences libraries can have a major impact on the way health care reaches patients, but this importance is hindered by challenges that exist within those libraries’ collections, with funds easily being one of them. Some of the challenges are the issues that lie within medical literature and the curriculum, but the collections themselves have systemic issues. Additionally, there are problems with the cataloging and terminology used within these collections.

These challenges have various ways that can be addressed, such as creating diverse management teams and task forces; updating catalogues and the terminology used within; performing reverse diversity audits and more effective weeding; exploring and reducing the biases within the collections as well as those who build it; and by finding alternate avenues for materials. By building a collection that addresses current issues and inequalities within the current healthcare system and research, librarians can help improve care for disadvantaged populations. Everyone deserves to have access to health information, and be treated with respect while doing so. Librarians and information professionals should do everything possible to help achieve this goal.

Sources for Further Reading

Barnett, E. (2022). Collection and vendor relationships: Diversity evaluation and communication. Serials Review, 48(3–4), 253–255. https://doi.org/10.1080/00987913.2022.2119058

A brief written summary of Elizabeth Speer’s presentation at the 2022 North Carolina Serials Conference. The presentation and summary discussed how the University of North Texas Health Science Center Library tried to address diversity both within its collections as well as in the offerings from vendors.

Bradley-Ridout, G., Mahetaji, K., & Mitchell, M. (2023). Using a reverse diversity audit approach to evaluate a dermatology collection in an academic health sciences library: A case presentation. The Journal of Academic Librarianship, 49(6). https://doi.org/10.1016/j.acalib.2022.102650

Bradley-Rideout et al. define a new method for managing an academic library’s collection: a reverse diversity audit. Using this new kind of audit, the authors successfully analyze the dermatology collection of the Gerstein Science Information Centre at the University of Toronto and encourage other libraries to use this approach.

Brillant, B., Guessferd, M. R., Snieg, A. L., Jones, J. J., Keeler, T., & Stephenson, P. L. (2022). Assessing diversity in hospital library collections. Medical Reference Services Quarterly, 41(4), 424–438. https://www.tandfonline.com/doi/full/10.1080/02763869.2022.2131185

The first known report of a diversity audit in the hospital library community, gathering information from 35 hospital librarians, with just less than half of them completing them in their entirety. The authors go into great detail about diversity, equity, and inclusion, as well as defining what diversity audits are and how to execute them.

Higgins, M., & Stark, R. K. (2021). Mitigating implicit bias: Diversity, equity, and inclusion in action. American Libraries. 52(1/2), 44–47. https://americanlibrariesmagazine.org/2021/01/04/mitigating-implicit-bias/

Focusing on health sciences libraries, this article discusses the implicit or unconscious bias of U.S. librarians, and how these biases can be addressed and amended. The authors discuss “Working on Ourselves: Mitigating Unconscious Bias in Literature Searching,” a curriculum created by them to help teach information professionals about implicit bias, how it affects their interactions, the literature they collect, and their information systems.

Martin, E. R. (2019). Social justice and the medical librarian. Journal of the Medical Library Association: JMLA. 107(3), 291–303. https://jmla.pitt.edu/ojs/jmla/article/view/712

This article discusses the role that medical librarians play in contributing to social justice in medicine. It focuses largely on the role librarians can take as educators to teach medical students about inequalities in healthcare and how those impact current care while also describing changes medical libraries can make within their own spaces to improve diversity.

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