Addressing Racism in Healthcare with Black Physicians of Canada

At Rethink Breast Cancer, we know that breast cancer and the way it impacts Black people’s lives is a social justice issue. Racism and discrimination are deeply embedded in our healthcare system, and sometimes in ways that are not obvious. We feel it is our responsibility to address these issues collectively which means learning how to better support our community by gaining a better understanding of the reality of navigating the healthcare space as a Black person. That’s why we are honoured to introduce you to Dr. Hadal El-Hadi, a founder of Black Physicians of Canada.

Read on as we explore the importance of having race-based data, microaggressions and misconceptions, tips for Black breasties navigating the healthcare system and ways for us all to do better. 

Why is it important for a collective like Black Physicians of Canada (BPC) to exist? What does BPC hope to achieve?  

Black Physicians of Canada was formed to have a unified organization made up of Black physicians and physicians-in-training who can advocate and intervene on behalf of Black Canadians. Black physicians need to be given the opportunities to be heard and to serve. In June 2020, Canadians saw what was happening in the United States with the Black Lives Matter movement. This time challenged us to reflect on our own situation here in Canada and was one of the largest motivations to create this collective.  

Given the history of anti-Black racism in Canada and around the world, our purpose is to address the systemic issues in the current system and achieve structural changes that lead to a system that is equitable, inclusive, just and fair. What that would look like is advocating to accept more Black students into medical school, supporting them through their medical educations (residencies and fellowships too), as well as into their careers, funding research to address health inequities and then actually implementing the findings from that research and most importantly, demanding a true zero-tolerance policy of anti-Black racism from colleagues, administrators, and patients. It also means deciding as a group that the end of health inequities and disparities is non-negotiable and to hold people accountable.  

How have your previous experiences as a medical student and trainee prepared you for the work you are doing within BPC? When did you realize that you wanted or needed to take an active role in creating an advocacy movement for Black physicians in Canada?  

It goes back to why I pursued medicine as a career. I wanted to be part of a collective where I could help children and adults have a fighting chance to be happy. I was born in Sudan and immigrated to Canada when I was 10, and I just know through my personal experiences that life isn’t always fair. I am fortunate to have been raised by my amazing, educated, and supportive parents who sacrificed relentlessly to allow me and my siblings to have every opportunity life has to offer.

I graduated from the University of Saskatchewan’s medical school, and during my time there I was the Global Health Liaison and I participated on both a local and national scale to pursue global health initiatives. My role was to spark interest and fuel determined communities into bettering themselves and their neighbours. One of my proudest accomplishments in medical school was being the co-chair of the first and second Global Health Conference ever held at the University of Saskatchewan, and this continues to be held every year even though I graduated 6 years ago.  

One person can’t change the world but individuals can ignite the fire within other people to pay attention to those around them and notice that other people are suffering and there are ways that we can collectively decrease the amount of suffering. This is especially true for physicians; we took an oath to do no harm. Our place in society is to help people who are either sick or suffering, and I do think that includes social advocacy. That’s always been a core principle in my medical career and was a large part of what drove me into medicine in the first place.   

We’ve seen people in our community sharing U.S. statistics about Black breast cancer patients having poorer outcomes than non-Black patients. There is a perception that there isn’t enough race-based data collection in Canada. There is also a perception or assumption that outcomes for Black breast cancer patients in Canada would not be as bad compared to the U.S. because of our publicly funded health care system.

What do you want people to know when it comes to inequities and disparities in the Canadian healthcare system?   

As Canadians, our biggest disadvantage is the lack of race-based data. Marginalized communities can never prove to stakeholders the urgency to intervene, because with no data, we essentially get gaslighted. Decision-makers think it’s not a problem because there are no numbers to prove or support our claims. The Black community, however, can see from our anecdotal, personal lived experience that there are patterns, yet no one believes just words and because we can’t prove it, we’re inherently at a disadvantage. The lack of data, however, is not reason enough to dismiss a concern or problem.  

Without race-based data, advocates such as the Black Physicians of Canada and Rethink are in a difficult position to make the real, true systemic changes that we want to make.  

In terms of race-based data from the United States, we know that it is useable because there are a lot of intrinsic and extrinsic similarities within the system and social determinants of health between Canada and the United States. The U.S. data suggests certain types of breast cancer (and other cancers) are more prevalent and aggressive in the Black community.

Racism in the healthcare system often tends to look at the patient experience, but can you tell us more about BPC and your take on how the systemic presence of prejudice, discrimination and bias impacts those working in or affected by the healthcare system and how this leads to negative outcomes for all, including patients? 

It really starts from birth. When it comes to Black healthcare professionals, we have to look at how Black people are treated through the education system where they are not streamlined into advanced courses or they’re punished three times more than their peers or they’re expelled disproportionately more than others. Then there’s the opportunities to even get to the point where you’re applying to medical school, and then admitted. Within the medical system, there are situations where people who are evaluating you may hold conscious and unconscious bias and that negatively affects Black candidate’s evaluations and opportunities. And in your education and training, your mentors and teachers who are supposed to have your best interest at heart may harbour racist ideologies, such as suspicions that you can’t be trusted or you’re actually not intelligent enough to finish the program. Without mentorship, there’s no sponsorship, there’s no one recommending you to a fellowship or career advancement. Sometimes these environments become hostile because there is a lack of support.

When you do eventually become an early career physician, the chances of you being promoted to an even higher position are lower than if you are non-Black. This is why it’s important that BPC gives Black physicians the opportunity to sit at the table. Because we exist, we are now invited to other organizations to make important decisions that impact residency accreditation, medical school selection process, public health initiatives, etc. Had we not created our own table, these discussions wouldn’t include us.  

The higher up you go the less Black people you see, meaning there are few Black physicians and even fewer Black physicians in leadership positions. This is important because if you look at statistics, Black Canadians have greater barriers to healthcare than white Canadians which results in higher rates of chronic disease. If you have more Black physicians in the system, then Black patients will have increased trust in the system. If I’m a Black patient and I have an entirely white staff attending to me, it almost discourages me from using the facility because even if 99.9% of these people are anti-racist, all it takes is on encounter with someone who holds racist ideologies for me to mistrust the system.

It’s also important to understand that systemic racism doesn’t mean that there are many racists in the system. It means that even if there were zero racists in the system, racialized patients disproportionately will have adverse outcomes due to issues inherent to a predominately white system. It’s our previous lived experiences that have taught us that there are certain places and environments we’re not safe in. As a Black patient, sometimes that’s the healthcare system. American statistics show that there are things that a Black physician can truly offer Black patients in a way that a non-Black physician can’t.  

What are some ways you think other organizations like Rethink Breast Cancer can help make a true impact in addressing and changing inequities and disparities in our healthcare systems?  

The things Rethink is doing now are exactly the kinds of things Black patients need. Knowing that there are initiatives taking place that are focused on the Black patient experience is really important. It’s also about providing Black patients a culturally safe environment in the system. This means increasing access to interpreters and training staff to minimize microaggressions and hiring or involving Black professionals to be part of community outreach and public health initiatives. 

More specific to breast cancer, it’s understanding the barriers to mammography screening in the local Black communities and encouraging routine mammography screening to Black patients through the use of reminder letters, local education programs and Black community leaders and experts like BPC. In having organizations like Rethink supporting the representation of Black leaders and medical professionals, we can hopefully better understand barriers to care among Black communities and fund education programs and cancer support groups for Black women. Things like this will make a difference.  

Rethink’s outreach on social media has led us to understand that a common experiences amongst Black women is that they’re not always believed when they see their physician about concerns they have, they’re not being tested and screened, follow-ups are limited, often leading to many being brushed aside, having to seek multiple physicians and, as a result, often having later diagnoses and worse outcomes.

What advice do you have for BIPOC in our community about navigating the healthcare system? 

My advice for BIPOC patients navigating our healthcare system is to understand what you’re entitled to. You’re entitled to non-discrimination and respect. You are entitled to confidentiality and information regarding your health and treatment. You are entitled to choose and refuse treatment. You’re entitled to report adverse outcomes and demand accountability for malpractice or maltreatment. The biggest barrier for patients is not understanding the system. We see this in first- and second-generation immigrants  or in individuals who come from countries that have a very paternalistic healthcare system. In Canada, you should be told what your options are, and you should have all the right discussions to make informed decisions. It’s not entitlement, it’s not asking too much, but these are baseline expectations you should be having of your healthcare provider. These are basic minimums.   

What impact do you think cultural influences within the Black community have on the barriers when it comes to seeking treatment or acknowledging symptoms? What does BPC think Rethink can do in helping address this?

Black people are not a monolith, however, there is a stigma amongst some Black communities against seeking mental health treatment and that can pose a challenge. Mostly, it’s because Black patients figure that it’s not necessary and there are other ways to get help, for example, going to church or talking to a family member, not necessarily understanding that mental illness is a physiological illness, just like breaking a leg. It’s not that those other outlets don’t help, but the stigma of even seeking treatment for certain ailments exists and it exists from both ends.

There is a misconception among non-Black doctors that Black Canadians are just more resilient and that they’ll continue to confront institutional racism, or advocate on behalf of themselves, which is not always the case. Community and education play a large role in providing information and teaching patients how to advocate for themselves. Also, the resiliency aspect is inherent to many marginalized populations and how do you tell someone it’s okay not to be strong?  

Breast cancer is a very well understood disease, it’s very well-funded and, there are so many awareness–raising initiatives, but certain populations are not being reached and this includes Indigenous and Black patients. So, what needs to happen now is expanding the awareness-raising activities further to include populations that have been historically excluded. This means going to reserves and going up North and going into Black communities and actively seeking out Indigenous and Black populations and leaders to be included in these public health initiatives.   

Rethink understands microaggressions and misconceptions about Black women with breast cancer are problematic, yet prevalent. (Ex: obsessions with hair and chemo, pain tolerance and immunity, underprescribing pain medication)  

Why exactly are they dangerous and how can healthcare providers help stop them from happening? What needs to happen in order to create a safe space for patients to speak out?

Microaggressions and misconceptions are problematic and dangerous because they’re symptoms of dehumanization. They take someone’s humanity away from them. Even though these thoughts and actions can be subtle, they cause harm. Implicit and explicit biases hold power over patients’ lives and are deadly for many marginalized populations. If you don’t believe someone who talks about a symptom, you’re not going to do the investigation. Without doing the investigation, you’re delaying treatment. When you delay treatment, you decrease their chance of survival. It takes one wrong belief to set a series of problematic actions. It’s sometimes not so obvious as the case with Joyce Echaquan. It’s not always nurses sitting there saying you deserve to die.

I don’t think some people truly understand what we’re fighting for. Some people think we’re fighting for politeness and niceties, but we’re actually fighting for our lives. We’re fighting for a fair chance to live a happy, healthy life and that includes having dignity as we proceed through life – even dignity through illness and death. That’s usually a given if you are a white Canadian and going through life in this country and you probably trust the system and believe that it will be fair. You trust that whatever the outcome is that you’ve received the best treatment and if something goes wrong, people will be held accountable. I don’t think marginalized populations have that reassurance. If something goes wrong, can we truly trust that the system worked for us every step of the way? 

What advice would you give to healthcare professionals about being more inclusive of patient experience? What specific actions can be implemented to bring about systemic change?  

My advice would be reinforcing that racial equity and justice is a part of the Hippocratic oath that we take as physicians. One of the things we say is we promise throughout our career that we will do no harm. Microaggressions are very harmful, ignoring race is very harmful, not seeing colour is very harmful. A lot of people, especially science-minded people, who think it’s all about illness and pathology, ignore the humanity aspect of medicine. What they’re not realizing is that the humanity part is just as important because if a patient is not even coming into the hospital to see you because they don’t trust the system, then it doesn’t matter how accurate you are with your diagnoses.

Creating a safe space for patients to speak out must come from those in positions of privilege, the onus and burden can’t fall on patients. People who have power need to invest in Black communities, Black physicians and Black leaders. They need to challenge their own biases and they need to speak up when someone says or does something harmful towards others. 

Follow and learn more about Black Physicians of Canada’s work here.

Read Rethink’s Anti-Racism Pledge here.

Dr. Hadal El-Hadi is a graduate of the University of Saskatchewan College of Medicine. She strongly believes in the importance of educating and motivating people into taking notice of injustices and working as a team to improve the lives of those around us. One of the biggest reasons she pursued medicine as a career was because she wanted to be part of a collective that helps children and adults in Canada and globally have a fighting chance to be happy. She recognizes, that given the history and nature of anti-Black racism in Canada and around the world, eradication would be very difficult to achieve. Her hopes for this organization is to have the best interest of Black Canadians at heart and as a fundamental priority create changes to the current system where she can and provide safety nets where she can’t.