Howard Fischer
Uppsala, Sweden

“In the community of living tissues, the uncontrolled mob of misfits that is cancer behaves like a gang of perpetually wilding adolescents. They are the juvenile delinquents of cellular society.”
– Sherwin Nuland, MD, How We Die

Bob Marley (1945–1981) was a Jamaican singer, songwriter, musician, and the son of a Jamaican mother and a white English father. He started singing professionally in 1963, and his music was rapidly appreciated. He and his group eventually became “Bob Marley and the Wailers” and sold eleven albums. Marley was raised a Roman Catholic but converted to Rastafari in the late 1960s.¹

What follows is a short resumé of his terminal illness. After that, this article will explain how each of several systemic and personal considerations interacted to Marley’s detriment.

In 1977, he noted a pigmented lesion on the nail bed of his right great toe. After seeing two doctors, a biopsy was done and a diagnosis of melanoma made. He refused amputation of the toe, which might have been curative. By 1980, he was ill and sought treatment at a clinic in Germany. He died in 1981.²

Diagnosis

When Marley first noted the hyperpigmentation under the toenail, he thought it the result of a football (soccer) injury. The first physician he saw thought that was a reasonable explanation. Since the lesion was growing, he saw a second physician, who was more suspicious—and better informed—and performed a biopsy. Most physicians learn the dermatology they know from lectures and textbooks (or now, online), which usually illustrate skin diseases in light-skinned patients. A study that looked at 4,000 pictures of skin lesions in four major US textbooks showed that only 5% of the images were from darkly pigmented patients. Another study, looking specifically at dermatology textbooks, found only 11% of the photographs were of patients with dark skin. A smartphone app, “Skin Image Search,” had fewer than 10% of its images showing non-white skin. A physician who received his medical education in the UK about a dozen years ago recalled that in school, the appearances of only three skin lesions in patients of color were discussed.³

Common skin diseases may look different or evolve differently in people of color.⁴ There are also some skin conditions seen more frequently in Black patients. If medical students are lucky (and if they are interested), they may have a dermatology elective. They might also learn some dermatology in internal medicine and general pediatric clinics.

Bob Marley’s biopsy indicated that he had an acral lentiginous melanoma, or acral melanoma (AM). The typical location for this lesion is on the palms, soles, or under the nail, especially of the great toe or thumb.⁵ Melanomas are aggressive skin cancers with a tendency to spread to other organs via the bloodstream. Acral melanoma accounts for only about 2–3% of all melanomas, but makes up 36% of all melanomas in Black patients, 18% of all melanomas in Asians, and 1% of all melanomas in non-Hispanic whites. Most AMs (78%) are on the lower limbs. Men and women are equally affected. Overall survival with AM currently is 80.3% at five years and 67.5% at ten years. This is shorter survival than with other melanomas.⁶

Treatment

Marley declined to have the toe amputated because he said it would be against his Rastafari faith. In 1980, he convulsed and collapsed while jogging in Central Park in New York City. He was hospitalized, and it was discovered that the tumor had metastasized to his lungs, brain, and liver.⁷

Not wishing to use traditional Western medical approaches, he went to see Dr. Josef Issels (1907–1998) at his clinic in Bavaria, Germany. Issels claimed that his alternative methods of treating cancers had cured patients considered incurable by their physicians. His “combination therapy” aimed to correct faulty diet, remove any foci of infection (teeth, tonsils), and “fortify” the intestinal flora. He administered oxygen and ozone, transfusions of highly oxygenated blood, and “autovaccines” created to “desensitize the body.”⁸ Marley’s personal physician and friend, Carlton Fraser, MD, (1947–2021) had learned about Issels and sent Marley to him. Fraser was famous for being the “first Rasta doctor” in the Caribbean. In later interviews,⁹ he voiced suspicion that Marley had been deliberately injected with melanoma cells via a needle placed in a pair of sneakers given to Marley as a gift.

Issels had been convicted of fraud and manslaughter nearly twenty years earlier, in 1961. In 1964 the verdict was overturned because “he genuinely believed his therapy would cure cancer.”¹⁰ Bob Marley received these ineffective treatments for eight months and decided to return to Jamaica. The flight home was diverted to Miami because of his deteriorating condition, and he died in the hospital in Miami.

In 2020, about half of practicing dermatologists and dermatology residents said they were not adequately trained to diagnose skin disorders in people of color. Only 3% of practicing dermatologists are Black.¹¹

Progress has been made in the treatment of metastatic melanoma. Biologic immunotherapeutic agents that act on mutated genes responsible for melanomas, or on their enzymes, have been developed.^12,13 Half of patients with metastatic melanoma are alive five years after diagnosis when treated with this combination immunotherapy.¹⁴

References

1. “Bob Marley.” Wikipedia.
2. “Bob Marley,” Wikipedia.
3. Neil Singh. “Decolonising dermatology: Why black and brown skin need better treatment.” The Guardian, May 13, 2020.
4. Ahdi Amer et al. “The natural history of pityriasis rosea in black American children: How correct is the “classic” description?” Arch Pediatr Adolesc Med, 161(5), 2007.
5. “Acral lentiginous melanoma.” Wikipedia.
6. Porcia Bradford et al. “Acral lentiginous melanoma: Incidence and survival patterns in the United States, 1986–2005.” Arch Dermatol, 145(4), 2009.
7. “Bob Marley,” Wikipedia.
8. “Unproven methods of cancer management: Issels combination therapy.” CA: A Cancer Journal for Clinicians, May, 1972.
9. Shirvan Williams. “Bob Marley 40 years after death personal doctor suspects foul play.” Urbanislandz, May 11, 2021.
10. “Josef Issels.” Wikipedia.
11. Roni Rabin. “Dermatology has a problem with skin color.” New York Times, August 30, 2020.
12. “Acral lentiginous melanoma,” Wikipedia.
13. Kat Arney. “Bob Marley, genomics, and a rare form of melanoma.” Cancer Research UK, August 20, 2014. https://news.cancerresearchuk.org/2014/08/20/bob-marley-genomics-and-a-rare-form-of-melanoma/
14. Russell Jenkins and David Fisher. “Treatment of advanced melanoma in 2020 and beyond.” J Invest Dermatol, 141(1) 2021.