Introduction

Canada is often held out by scholars as the exception to a disheartening global pattern that suggests that high levels of racial diversity in a society are incompatible with support for generous social policies (Banting et al. 2006). The explanation for this pattern is that it is a real phenomenon (rather than an artefactual one) and it can be chalked up to racist motivations that cause powerful racial groups (whites and those non-white people who ally with whites) from endorsing policies that will benefit Black and other non-white groups (Alesina et al. 2001). One of the social policies that we are most often lauded for maintaining is the Canada Health Act (1985), which mandates that the vast majority of physician and hospital services are accessible free of charge. The prevailing discourse in Canada has been that the Canada Health Act (1985) ensures equal access to healthcare among all Canadians. In addition, polling data suggest that the vast majority of Canadians believe racism is a terrible thing (Bricker and Chhim 2020). However, cases such as that of Joyce Echaquan (Nerestant 2021) who died at a hospital in Saint-Charles-Borromée, QC, as nurses looked on and mocked and demeaned her with their words, or Leonard Rodriques (Allen 2020) who was turned away from an emergency room in Toronto during the COVID-19 pandemic and died shortly after, call into serious question the narratives of an egalitarian and benevolent system, in the context of a society that publicly endorses anti-racism.

In this issue, Dryden (2023) provides a thoughtful and systematic analysis to describe how and why anti-Black racism occurs in the healthcare system. The suite of excellent respondents also provides a cogent and compelling examination of racism in healthcare, both in Canada and in its peer countries. The message from this collection is clear. Racism and, in particular, anti-Black racism are a systemic part of the Canadian healthcare system that must be rooted out with strong, forceful and unequivocal action.

Race Is Not Genetic

Epidemiological evidence from Canada demonstrates that there are significant racial health inequities in Canada that, after immigrants arrive in Canada, worsen over time and across generations (Kim et al. 2013; Ramraj et al. 2016). This pattern mimics the ones observed in many of Canada's peer countries, most notably the US (Hamilton and Hagos 2021) and the United Kingdom (Schneider 2014). It is a pattern whose general causal mechanisms are now well known and are linked to the meaning of race itself.

While the medical literature is rife with research and guidelines that treat race as a genetic category, any population geneticist worth their salt will emphatically tell you that racial groups are not genetic groups. The Human Genome Project put to rest this argument by demonstrating that (a) one's race is not discernable from one's genetic code and (b) the variation in genetic makeup within races is larger than that between races (Prontzos 2019; Rosenberg et al. 2002; Witherspoon et al. 2007). Indeed, journals such as the New England Journal of Medicine (Bailey et al. 2021) and the Journal of the American Medical Association (Merchant et al. 2021) have recently been working hard to hammer home that message (though unfortunately they still sometimes publish papers that use race as a proxy for genetics). As Poteat and Maragh-Bass (2023) point out in this issue, some health equity scholars have abandoned the use of “race” because it is almost impossible to escape the genetic connotation placed on it. Instead, these scholars try to examine what race truly represents.

Racial categories are socially established and, as has always been the case, the ultimate basis for these categories is not about culture or anything so benign. Rather, these categories are created in order for the dominant group – whites – to organize society in a way that continues to enable them to concentrate resources and power. That is the basis for racism. It is not solely name-calling and so on. It is the act of using institutions, policies and the people who represent them to create unjust advantages for whites and unjust barriers for Blacks (Bonilla-Silva 2021). Anti-Black and anti-Indigenous racism is the most pernicious, insidious and inhumane. As young people these days might say, the inhumanity is the point.

The Consequences to Health

In the present context, the issue is that racism has consequences for health. Racist treatment affects health both because it affects access to the resources that support health (such as income, employment, housing and so on) and because the chronic experience of racism has direct, measurable biological effects (e.g., research has found effects on blood pressure, allostatic load and telomere length) (Williams and Mohammed 2013). This results in “weathering,” which Carter and Alang (2023: 49) speak about in their commentary. In summary, when we see measurable differences in health status between racial groups, these differences – with few incidental exceptions (such as skin cancer for which a primary determinant – melanin – both predicts the outcome and coincidentally is used socially as part of the means for identifying race) – are neither inherent nor unavoidable, they are due to differences in experiences of life that are shaped by racism (or, conversely, for whites, by social advantages).

This means that Black people are more likely to get sick and to already face more physical and mental taxing circumstances when they are sick. It is critical that the healthcare system understands this.

Responsibility Lies with the Healthcare System

The healthcare system has the power and the responsibility to provide the best and most dignified care possible for people who are subjected to so much from other institutions. It should be a place where Black people can trust that they will be provided with the highest level of medical care and experience humanity and refuge from ill-treatment.

Sadly, this is simply not the reality of Canadian healthcare. As Dryden (2023) and Rai (2023) both point out in their pieces, the treatment to which Black people are subjected in Canada's healthcare system is rife with racism and, what Rai (2023) terms “medical violence” (p. 56). Moreover, as several author teams in this issue (Helberg-Proctor and Busari 2023; Mokhachane et al. 2023) point out, Canada is not alone and many countries around the world (from The Netherlands to South Africa) have similar dynamics of denial in the face of clear anti-Black racism in their healthcare systems. By contrast, as Poteat and Maragh-Bass (2023) discuss, the US has quite an open discourse and a long history of scholarship on these issues and on anti-Blackness in every aspect of society.

Dryden (2023) and several of the respondents draw on the COVID-19 pandemic as an important event in many respects. The pandemic has hit Black people the hardest in the US and, as evidence from Toronto and Montreal suggests, it seems this is also true in Canada. The pandemic also concentrated many of the issues of racism in everyday life and racism in the healthcare system that Black people face. We hope that the insights that the authors of this issue provide on the COVID-19 era in which we all exist will kick-start a major effort to root out anti-Black racism in all aspects of the healthcare system.

About the Author

Arjumand Siddiqi, MPH, ScD, Professor and Division Head of Epidemiology, Dalla Lana School of Public Health, Canada Research Chair in Population Health Equity, University of Toronto, Toronto, ON

Audrey Laporte, MA, PhD, Director, Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON

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