Black Representation in Canadian Health Care — Dr. Jean-Joseph Condé

Alya Niang

COVID-19 revealed a deep racial divide. Black communities and people of colour have been among the hardest hit by the virus and the least likely to be protected by public health measures. But the problems run much deeper.

Studies show that there’s long-standing discrimination in the health care system, fuelled by racism, ignorance and a sad history of neglecting Black Canadians and their health care needs.

Dr. Condé

A patient who’s disgruntled with a white doctor, with a Quebecer, will use religious swear words or Quebec swear words. His initial reaction to a Black doctor is to use the N word, “Dirty N word, go back to your country, I don’t want to see you here.”

Alya Niang

Hello and welcome to the Canadian Health Information Podcast. This is Alya Niang and I’m delighted to host this conversation where we take a closer look at our health care system.

Please bear in mind that the opinions and comments of our guests do not necessarily reflect those of the Canadian Institute for Health Information. However, this is a free and open discussion, and today’s episode is about the inclusion of Black people in Canada’s health care system.

We have with us today Dr. Jean-Joseph Condé, a family physician in Val-d’Or and an active member of the Centre intégré de santé et de services sociaux de l’Abitibi-Témiscamingue since 1987, where he works in family medicine, emergency care and obstetrics.

Dr. Condé also served as president of the Canadian Medical Protective Association from 2016 to 2018.

Hello Dr. Condé, welcome to the podcast, it’s a pleasure to have you with us.

Dr. Condé

Hello, it’s a pleasure to be with you today.

Alya Niang

Dr. Condé, you studied medicine at the Université de Montréal. I’d like to know what went through your mind when you first realized you were the only Black medical student in a class of 360 people.

Was it a “wow, that’s cool” moment, or was it more of a “wow, that’s not cool” moment? And how did your classmates react?

Dr. Condé

When you interview to get into medical school, you know that there are a lot of applicants, and that very few will be selected. So you have no idea until the first day, in September, about how many people from cultural communities will be in the class.

Indeed, I was quite surprised on the first day. I get there and realize I’m the only Black person in a class of 180 students.

At an initiation event, I take a look at the class that’s a year ahead of mine. And I see that there are no Black students in that year. And then I realize that I’m the only Black person in 2 years of medical school. Out of 360 students, I’m the only Black student.

This confirms that it’s very difficult to get into medicine, and it confirms to me that it’s even more difficult when you’re from a cultural community, especially the Black community, to get into medical school.

So, no, there’s no particular rejoicing, but it confirms an observation of a phenomenon we suspected, that there are very few Black physicians, and even fewer Black people are admitted to medical school.

Alya Niang

As a Black physician in a white community, what was it like to start your career?

Dr. Condé

I started my career in Val-d’Or, a small town of 40,000 in a remote region of Quebec. When I started, I was the only Black physician at the hospital, and I think there were 4 Black families in Val-d’Or at that time.

Of course we’re easily recognizable around town, easily identifiable. You go to a restaurant, the movies, the grocery store. Ah, there’s the Black doctor from the hospital, since there are only 4 families and you’re easily recognized as the Black doctor from the hospital.

The direct impact is obviously that we have to be, I think, doubly careful in our practice. We have to be doubly conscientious because we’re easily identifiable. So, a mistake will follow you not only in your professional environment, at your work, but it will follow you all over town. That was my first realization, that you have to be doubly conscientious in your work.

Alya Niang

How did that make you feel to be pointed at, that people were even saying, “Ah, there’s the Black doctor”?

Dr. Condé

I kind of expected it. I grew up in Montréal, where there’s definitely a larger Black community. About 8% of Montréal’s population is Black.

I arrive in a city where there are 4 Black families out of 40,000 people. So I expected to be a very, very, very small visible minority. To be honest, the reception was still positive. People were welcoming, people were warm, people were friendly — but you’re very conscious. I would say that you’re even more conscious of being a visible minority in a small town than you are in cities like Montréal or Toronto. You’re aware that you’re an exception.

Alya Niang

Dr. Condé, do you have or have you had any Black role models in medicine?

Dr. Condé

Yes, my parents immigrated to Canada in the 1960s. One of their friends — he was from a small town in Haiti. It was a profound moment for me to realize that some of their friends who had studied medicine in Haiti, who came from the same small town in the south of Haiti as they did, were doctors in Canada.

In fact, for a young Black person, it confirms your impression that yes, you can become it, yes, you can be it. But of course, that was a different time, these are people who didn’t do their medical training in Canada. These are people who did their medical training abroad and were admitted to Canada as foreign doctors.

We were conscious of the fact that it was more challenging to enter into medicine and do your studies in Canada. But at the same time, it made me happy to see that there were Haitian doctors, Black doctors working in the big hospitals in Montréal. It reinforces our belief that we can succeed and that we can make it in Montréal’s academic medical community.

Alya Niang

You said earlier that you received a warm welcome when you arrived in Val-d’Or and that the people were friendly. But have you ever been confronted with racist comments and attacks?

Dr. Condé

Yes, I think every Black person has been confronted at some point in their life, in their career, with racist comments. I think these are isolated events, but it hurts. It hurts when you hear them, but you have to shrug it off.

For example, in medicine, what do people say to you? You go into the examination room to meet the patient. You introduce yourself, the patient looks at you and says, “No, I’m here to see the doctor. I want to see the doctor. No, you’re obviously not the doctor.”

Those who are even more crass will say... for example, a patient who’s disgruntled with a white doctor, with a Quebecer, will use religious swear words or Quebec swear words. His initial reaction to a Black doctor is to use the N word, “Dirty N word, go back to your country, I don’t want to see you here.”

They insist on making you feel like a minority that doesn’t belong in this environment. Of course that hurts, it’s hard. But at the same time, as I said, we need to recognize that these are isolated events that happen with certain individuals whose level of education surely leaves something to be desired.

Alya Niang

You consider it more like ignorance. How did you react in those moments?

Dr. Condé

Well, it is ignorance. It’s ignorance, these are people who have never been around Black people in their lives. These are people who have never read about Black culture. These are people who are comfortable in their environment with people like them. And to meet an immigrant, a Black one at that, their initial reaction is to spew hurtful comments, racist comments. But I think we have to realize that these are people who, unfortunately, don’t have the same level of education as the majority of the population.

Alya Niang

Dr. Condé, there is certainly some diversity in the medical profession, but I have a startling statistic. In Ontario, Black people make up 4.5% of the population, but only 2.3% of physicians. I want to understand why there are fewer Black physicians. And how do we get more Black practitioners in health care?

Dr. Condé

We are aware that medical programs across Canada are highly restricted. It’s hard to get into medical school. In Montréal, there are 1,500 applications for 200 spots. So it’s very competitive.

We look at the numbers from Statistics Canada, and the data shows that, in general, the Black community is more socioeconomically disadvantaged, meaning the level of education and the number of Black youth who finish their CEGEP is lower.

It’s harder to achieve academic success when you come from a disadvantaged economic background, regardless of race. Regardless of race, when you come from a disadvantaged economic background, it’s harder to achieve success in general.

Why? Because you have less parental guidance. You’re forced to work at a very young age. You have less time to devote to your studies. Ultimately, this means that your grades may not be as good. So you have a less competitive academic record.

In general, the Black community experiences a more disadvantaged socioeconomic status than the rest of the population. Of course the R score, which is the average that universities evaluate for medical admissions, is going to be lower.

When we talk about competition in medicine, we need to remember that universities, such as the Université de Sherbrooke, consider anyone with an R score of 32 able to take a medical course. We can succeed with an R score of 32. We have the intelligence and the skills to pass a medical course.

Unfortunately, getting into medical school is so competitive that eventually only those with an R score of 35 and higher are accepted. That means that anyone with an R score between 32 and 35, unfortunately, isn’t given a chance even though they have the skills and the abilities to complete a medical course.

If there aren’t many students from the Black community who manage to get R scores of 35 and higher for the reasons I mentioned earlier, of course it will be more difficult for them to successfully qualify for medical school.

So what’s the solution? I think the solution lies in what more and more Canadian universities are doing. McGill University in Montréal, the Université de Montréal, the University of Toronto, the University of Calgary, the University of Alberta. It’s having programs that promote access to the medical program for Black people.

That means there are some spots in the university program reserved for people from the Black community to recognize that yes, there won’t be many with an R score higher than 35. However, by reserving some spots, you’ll find highly qualified students with an R score between 32 and 35.

We need to have this kind of program in place if we want to increase the percentage of Black physicians in Canada and have it be representative of the percentage of Black people in Canada.

Alya Niang

Could we say that in relation to the required grades, there’s a lack of guidance among the Black community. Is that fair to say?

Dr. Condé

It’s multifactorial, as I said. Everything comes back to the socioeconomic status. I think if we can raise the socioeconomic status of the Black community, Black students can grow up in environments that will promote learning and academic performance. We’d have Black students with R scores as high as in the non-Black community.

Alya Niang

Are you often approached by young Black students who ask you for advice on what to do?

Dr. Condé

Yes, I am, I absolutely am. I tell them you have to work, you have to be competitive and you have to get the best grades, like any other Canadian student. You have to work on your average, be one of the best in your cohort.

But at the same time, I tell them to look when they apply to university, because more and more schools have access programs for Black students within their academic program. You can apply the regular way, but you can also mention that you’re from a Black community, and the application is treated differently.

Alya Niang

Now, let’s get to the data. I was surprised to learn that hospitals in Canada don’t collect data based on ethnicity. Can you explain why data on different racial groups is important?

Dr. Condé

It’s very important because your goal is to have a medical body that is representative of the population. So, if you don’t have data, you’ll never know if your medical community is representative of the population.

If 3% of Canada’s population is Black, you would expect 3% of its physicians to be Black. If 8% of the population in a city like Montréal is Black, you would expect 8% of its physicians to be Black. It takes statistics to know.

Alya Niang

I would like to add my personal experience on this subject. I’m a Black Canadian of Senegalese origin, West Africa, and I also lived in the United States for years before moving to Montréal 12 years ago. But I realize that since I’ve been here, right up to today for that matter, I’ve never had a Black doctor, either for myself or my child. I’ve never even met a Black doctor. And I don’t think that’s just a coincidence either.

Dr. Condé, does that surprise you?

Dr. Condé

No, not at all. The number of Black physicians currently in Canada is not representative of the percentage of the Black population.

So yes, there are Black doctors in Montréal. Yes, there are some pretty much all over Quebec. But are they representative of the Black population? No, not at all. They’re not representative of the 8% of Black people in Montréal.

And that’s why we need to work to increase the representation of the Black community in the medical profession. Because we know that it’s very important for people from a cultural point of view. For some people, it’s very important to be cared for by medical staff who understand their culture.

Alya Niang

Given that Black physicians remain underrepresented in medicine and aspects of their cultural identity are also ignored, do you think this data can be seen as a visual representation of the profession’s values that can be identified as whiteness or elitism, masculinity or even power? What do you think?

Dr. Condé

That’s not my perception nor my experience. Is it true that there are fewer Black physicians? Yes. And that it’s not representative of the Black population? Yes. But is society changing? Yes. Are we moving in the right direction? Yes. Are university programs making efforts to admit more and more Black students? Yes. Will hospitals recruit more and more foreign doctors from Africa? Yes, absolutely.

So, I think it’s a phenomenon, it’s a society that’s evolving and trying to correct the mistakes of the past or trying to correct the proportionality of cultural communities in its professional bodies.

Alya Niang

Could the lack of Black primary care physicians deter Black people from seeking medical care? What do you think?

Dr. Condé

Yes, I think this has been clearly demonstrated. It’s scientifically proven that patients, whatever their background, like to be treated by people who understand their culture.

Take pain, for example. We know that people of Haitian origin have a way of expressing pain that is different from Caucasians, from white people. They have a tendency to be more vocal, to express pain more loudly.

Could it create some movement and lead to questions or panic if someone doesn’t understand the culture? Yes, but a doctor of Haitian origin would understand that it’s part of the culture. Or an immigrant of Haitian origin who is ill may start praying a lot in the hospital, on his stretcher, praying all day long, and the medical staff may wonder if he’s in psychosis. Is this a religious delusion? For a Haitian doctor, this isn’t a religious delusion at all. It’s a way of putting one’s life, one’s cause in the hands of God. It’s a cultural way of expressing fear and distress, to rely on religion, to rely on God.

But for someone who doesn’t understand the culture, that could be overlooked. I’ve seen cases where it’s been interpreted as “Doctor, I think this patient is having a religious delusion,” when that’s not it at all. She was simply praying in the face of bad news, as she had always done since she was a child. That’s how this person reacts.

Alya Niang

Hence the importance of diversity to better understand the culture. It’s very important.

Dr. Condé

Yes, it’s very important to understand the culture, to understand where people come from, how pain is expressed in that culture, how suffering is expressed, to be able to treat them adequately.

Alya Niang

Dr. Condé, what do we know about experiencing racism and its specific impact on physician well-being? Let’s say, potential impact.

Dr. Condé

I haven’t read anything. I haven’t read any articles. I haven’t read any studies on this. For me, I can imagine, since I have experienced it, that being a victim of racism creates insecurity.

Once you’ve been called a “dirty N word” or told to “go back to your country,” you become insecure, even if you’re very self-confident, and you tell yourself that it’s someone who is probably poorly educated. But you wonder, you question, it throws you off and creates an insecurity that can affect the way you practise, the way you work in the minutes or hours after that event. Because this kind of event, as you said so well, is hurtful.

So, it stays with you. Yes, we get through it, we get over it, but it hurts us. When you’re hurt, you wonder, “How am I going to address my next patient? How will I assess their problems?” So yes, differently, because I am insecure, I question myself, I’ve been hurt, so I’m not the same person.

I think that being a victim of racism brings insecurity, a loss of self-confidence for the victim.

Alya Niang

I’m curious to know, with regard to insults, if you’ve ever been tempted to respond.

Dr. Condé

Of course, as a physician, you know we have a code of ethics, we have rules. We have to evolve and work within the professional standards. As health care professionals, we can’t sink to the level of exchanging insults with a patient. That would not be acceptable.

Alya Niang

It hurts, but we hold back. Black physicians sometimes have obstacles to overcome even before they apply to medical school. Can you explain why?

Dr. Condé

Grades are the biggest obstacle. You feel like you’ve done well and have a good average. You have an average of 34, which is excellent. And yet, it’s not enough to get into medical school, it’s frustrating. Plus, you had to work during your studies to earn money. It’s extremely frustrating because you had to work very hard and study very hard, but you weren’t able to achieve your goal.

You have to overcome that obstacle, you have to keep your spirits up, you have to reapply, you have to enter into a parallel university program for a year or 2 and, above all, not lose the intention of reapplying to medicine. You have to carry on despite the obstacles. Everyone faces barriers to entry to medical school, especially Black people as mentioned before, but you have to keep going. You shouldn’t let yourself become discouraged; it’s the worst thing you can do.

Alya Niang

Absolutely. And where do you think the medical community is right now when it comes to combating racism in the profession?

Dr. Condé

I think the medical community is making great efforts to try to combat racism, and I’m going to refer to Bill C-3 that was adopted in the Federal Parliament last year, in December 2021. Bill C-3 prohibits the intimidation of health care professionals.

A health professional could file a criminal complaint against an individual who makes a racist comment because that’s considered intimidation of a health care professional, and there is a law that prohibits that. It is a criminal law by the Canadian Parliament that can result in a maximum of 10 years in prison.

It’s very serious, you don’t mess around with intimidation and racist comments in medicine. And when I say in medicine, I mean all health care professionals, whether it’s a nurse, a physiotherapist, we don’t accept intimidation or racist comments.

Alya Niang

Are you part of an association that advocates for fair representation?

Dr. Condé

At the Canadian Medical Association, that’s a clear part of our mandate and our objective — diversity within the organization, among its employees, and in the representation of the association. This is clearly one of the association’s objectives.

If you look at the documents, diversity is everywhere in our criteria. And I think that’s a good thing because, as I said, I think we’re headed in the right direction. More and more, we are going to see diversity in professions, companies and organizations.

Alya Niang

If there’s a Black student, intern or practising physician listening to this podcast who is currently experiencing microaggressions, racism or even discrimination, what would you say to them?

Dr. Condé

So, 2 things. First, intimidation, racism and aggression are not acceptable. There is a Canadian law that prohibits that behaviour. You have the right and you should call the police. You have the right to file a complaint. And the police will take charge of forwarding the file to the appropriate authorities. Intimidation and racism are unacceptable. There’s a law in the Criminal Code that protects against these aggressions.

And second, don’t stop there. As I’ve said, most of the time, these are people who have not been adequately educated to understand that racism leads nowhere. And better yet, that we are enriched by embracing diversity.

Alya Niang

Dr. Condé, do you have a message for parents, parents of young students who are starting medical school or students who aspire to go into medicine?

Dr. Condé

You must keep going. You must keep going. Well done if your child wants to apply to medical school. Well done if your child wants to become a doctor. It’s not easy. They’ve put in a lot of work, but the important thing is to not give up.

Remember that 50% of people admitted to medical schools in Quebec have a university degree in another field. These are people who did not choose medicine or did not enter medicine immediately out of CEGEP. These are people who have done additional training, who have gone out to get additional resources, additional skills and have applied to medical school and become physicians. So, you must not become discouraged.

Alya Niang

Thank you, Dr. Condé, for your time and your very thoughtful perspective. This conversation has been extremely important and I hope it helps amplify your voice. Thank you very much.

Dr. Condé

Thank you for having me. My pleasure.

Alya Niang

CIHI now collects and produces data on the racial components of the Canadian health system. Because if you can’t see it, count it and compare the results, you can’t correct it. Thank you for joining our discussion.

Our executive producer is Jonathan Kuehlein and special thanks to Ieashia Minott and Avis Favaro, the host of the CIHI podcast in English.

If you want to learn more about the Canadian Institute for Health Information, please go to cihi.ca, that’s C-I-H-I dot C-A and subscribe to the CHIP wherever you get your podcast.

This is Alya Niang, see you next time!