At the end of 2016, when the seizures began, Casandra London knew something was very wrong. Three years earlier, London had been diagnosed with a rare form of endometriosis, a reproductive condition that primarily affects Black women. Now the 27-year-old was experiencing vertigo and having trouble walking. She was vomiting, falling asleep in public, and having trouble communicating. She also felt awful pain in what felt like her kidney.

As a young Black journalist about to start her dream job, London was worried that the pain and disorientation would keep her from working. That year, she had seen nearly 15 doctors in Scarborough and Toronto, almost all of them white. Many of them quickly dismissed her pain as depression. One diagnosed her with an anxiety disorder, even though London had never experienced anxiety. Another sent her to a neurologist. London says many of the doctors barely even looked at her when they spoke and she was often out of their offices within minutes. And she couldn’t help but feel that the way she was being treated was related to the colour of her skin.

In January 2017, after her kidney pain became unbearable, London was finally sent to a urologist. The doctor was a white man, and while she saw him act friendly with other patients, he wouldn’t look at her or give her time to ask questions. The doctor said he would check to see what was going on with her bladder. Before she could process what he meant she was being ushered out of his office and into another room.

The endometriosis had fused her bowel and bladder together, causing her kidney to become severely swollen. “I actually was going in for minor surgery and didn’t know,” says London.

Three months later, London had to return to the urologist to replace a stent. When he was done, he repeatedly told her to “try not to get pregnant,” even though she wasn’t sexually active and didn’t have a partner. “I find it hard to believe that he would’ve done that if this was a white woman he was dealing it,” says London.

In November 2017, she had a six-hour laparoscopic surgery to remove the endometriosis from her ureter. Immediately after surgery, she says doctors tried to send her home. Nurses told her that her pain was in her head. “They see Black patients as not being in the same amount of pain as white patients,” says London. “I think about the white woman beside me — no one ever asked her to go home or challenged her pain.” When I spoke to London before her major surgery she said she hadn’t lost hope in the health care system. Now, she says, her opinion has changed.

***

London’s experience of the health care system as a person of colour isn’t uncommon. Dalon Taylor, president of the community organization Black Health Alliance and a PhD candidate at York University, says that experiences like London’s — feeling like doctors aren’t taking you seriously and are treating other more kindly and efficiently — can lead patients to lose faith in the system. “Research has shown that all those things compound to create distrust,” says Taylor.

Comprehensive, up-to-date research on discrimination in health care in Canada isn’t readily available (more on that later). But according to 2003 study from Women’s Health in Women’s Hands, a Toronto community health centre for Black women, one-in-five women interviewed experienced racism in the health care system, including “cultural insensitivity or ignorance from doctors, name calling or racial slurs, receiving an inferior quality of care and being overcharged for services.” A decade-old study of Black youth in low-income neighbourhoods in Scarborough found Black males were deeply cynical of the health care system.

Discrimination doesn’t just impact the care that Black people in this city receive — it permeates every aspect of their health.

study of emergency room records in the US found that health personnel rated the complaints of Black as less serious than their white counterparts. Black people experienced longer wait times in emergency rooms, even if they were facing medical emergencies where immediate intervention was necessary. Several studies have also found that physicians spend less time with Black patients and are less likely to see them as being honest about their symptoms compared to white patients.

Discrimination doesn’t just impact the care that Black people in this city receive — it permeates every aspect of their health. Much has been written about the discrimination Black Torontonians face in employment, education, housing, and by the police and justice system. According to a survey by the Black Experience Project, one-third of Black people in the GTA reported challenges at work linked to being Black — from outright racism to simply feeling uncomfortable. Black people are the victims of 85 per cent of reported race-based hate crimes in Toronto and are three times more likely to be carded by the police. But while the city has been looking into ways to address anti-Black racism from a societal, policy and institutional perspective, the health of Black Torontonians continues to be an underreported consequence of racism.

Researchers and health experts in Toronto are warning that Black health in Canada is in a crisis. They’re pushing for the city and the health care system to address these concerns, as well as collect race-based data to begin accurately assessing the health disparities and needs of Black communities. Black Torontonians make up 8.4 per cent of the city’s demographic, one of the largest Black populations in the country. They also have one of the worst health profiles. Toronto may brand itself as one of the world’s most multicultural cities, but when it comes to addressing the health needs of its diverse residents, is it failing them?

***

As the Black health theme lead for the Faculty of Medicine at the University of Toronto, Dr. Onye Nnorom says it isn’t hard to see how racism causes health issues for Black Canadians. She says the social determinants of health — the conditions in which people grow, work, live and age — all play a particular role in the lives of Black Canadians. “You have a population that is denied opportunities because of systemic racism or interpersonal racism. So you’re denied a job, appropriate housing, promotions,” she says. “That affects your income, your socioeconomic status.”

Black Canadians are disproportionately affected by HIV/AIDSmental health issues, heart diseasehypertensionsickle cell and stroke. The rates of diabetes are also highest among Black and South Asian groups, with more than 8.5 per cent affected compared to about 4.2 per cent of white people.

Racism itself is a chronic stressor. A 2013 Toronto Public Health study found that experiencing racial discrimination contributes to poor health outcomes by “triggering harmful biological, psychological and behavioural responses.” Experiencing discrimination or microaggressions every day — or simply living in fear of experiencing them — can cause enough stress to create health issues. For years, studies in the United States have examined and reported that experiencing and perceiving discriminationmicroaggressions and structural racism increases the risk of various physical and mental health issues, including stress, anxiety, depression, suicide or suicidal thoughts, common colds, cardiovascular disease, breast cancer, hypertension, high blood pressure and mortality.

“These people are being oppressed, discriminated, excluded, based on the colour of their skin,” says Dalon Taylor. “How could you as an individual not internalize that?”

When it comes to tracking the specific health experiences of Black Canadians, researchers say they simply don’t have the numbers. In 2017, when the United Nations Human Rights Council announced they would be discussing a report on anti-Black racism in Canada, they were troubled by how difficult it was to assess the scope of the issue. One of culprits, they said, was the lack of race-based data collected in this country.

“I think in Canada there’s been this feeling that we’re this multicultural society and that racism does not exist here.”

Race-based information is not systematically collected across Canada like it is in the U.S. The exception is hospitals and community centres in the Toronto Central LHIN, which collect “equity data” about language, race/ethnicity, disability, gender identity, income and more. “It’s great that in the city of Toronto that they’re collecting it, but that’s not enough,” says Nnorom. “When you want to make a major decision, you need at least the provincial or even better, the national level.”

Nnorom has been extracting research from the U.S. and U.K. to help understand how racism affects Black Canadians. She says there are hardly any large Canadian studies on racism and its direct effects on health. “I think in Canada there’s been this feeling that we’re this multicultural society and that racism does not exist here.”

A 2012 report from the Wellesley Institute argued that there is evidence that “Canadian physicians believe that they are immune from the kinds of racial bias exhibited by their colleagues to the south.” The report cites a study that showed that nearly half of Canadian family medicine physicians believed that race, class, sexual orientation, and other sociocultural differences didn’t create any tensions in their practices. Doctors saw themselves as colour-blind — a position that could lead to “a denial of the role that racism and cultural variation play in shaping differential patterns of help seeking and access to treatment as well as the experience and outcome of these processes.”

Without the substantial numbers that other countries have, Dalon Taylor says, it’s crucial to collect information from sources like community organizations, researchers, and service providers to paint an accurate picture of how racism affects Black health. “We have to be collating this from different sources so we can make more informed assessments and responses that are effective,” she says.

***

Throughout the years that Casandra London has spent in the health care system, she’s rarely seen practitioners that look like her. She says that more Black health care providers, as well as support for Black women, would have drastically changed her experience in the system. “There are stereotypes that Black women are angry, that we’re strong, that we don’t feel pain at the same level as a white woman,” she says. “So when a Black woman walks in and expresses they have pain, it’s seen as an aggravation that we need to get over.”

Nnorom thinks that health care organizations should begin training staff in anti-oppression and cultural safety training, and anti-racism training. Taylor wants more accountability from a country, and city, that has historically left Black communities off the health agenda. “Help us to help ourselves,” she says. “We didn’t create this climate for ourselves, it was imposed on us.”

Most importantly, it’s fundamental that we take seriously the ways that anti-Black racism can cause, directly or indirectly, physical and mental health issues. Black Torontonians are one of the most disadvantaged visible minority groups in the city, especially when it comes to health, and yet there seems to be a lack of urgency to increase funding, create strategies and hiring practices to better address the unique challenges of Black communities.

Researchers and health care providers who are putting Black health at the forefront of the conversation are making progress. The latest federal budget earmarked $19 million over five years for mental wellness in Black communities. Resilient Black residents are sharing their stories. But it will take continued action and a genuine willingness by the city and health care system to make Black health in Toronto a priority.

Correction: an earlier version of this article included a quote that suggested there are zero large Canadian studies on racism and health. There are very few.