Susan Bonderov used to write two words on her arm before leaving home: “iron deficiency.”

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It was information for paramedics in case she collapsed.

“I would write ‘iron deficiency’ on my arm in Sharpie every day when I went out into the world, in case I became unconscious,” she said. “I wanted to be able to tell the paramedics, because I would be unconscious.

“It was almost like a medical alert bracelet, but I was just writing it myself.”

Bonderov, a 51-year-old teacher and clinical counsellor, has lived with chronic iron deficiency anemia for decades.

The fear changed how she moved through the world. When she walked her dog, for example, she would wrap his leash around her wrist in case she fainted.

Bonderov is one of several hundred thousand British Columbians estimated to be living with iron deficiency or iron deficiency anemia, according to data from the Canadian Health Measures Survey. Low iron levels limit the body’s ability to make enough healthy red blood cells to carry oxygen properly. The condition can stem from heavy blood loss, pregnancy, restrictive diets, poor absorption of iron, chronic illness or other medical conditions.

Symptoms often build so slowly that many people consider their exhaustion, brain fog or dizziness as part of everyday life. By the time they realize something is seriously wrong, some have spent years trying to push through it.

Health Canada says low iron can affect fetal development during pregnancy. In young children, it can lead to developmental delays. Severe iron deficiency anemia can also strain the heart as it struggles to move enough oxygen through the bloodstream.

Dr. Wendy Davis and Dr. Hayley Merkeley, hematologists at St. Paul’s Hospital in Vancouver, said many women spend years with symptoms before receiving a proper diagnosis or treatment.

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“I think 30 per cent of menstruating women are iron deficient, and many of those patients will also have anemia as well,” Davis said.

Health Canada says one in four women ages 14 to 50 have low iron. A 2023 Canadian study in The Journal of Nutrition found iron deficiency affected 16 per cent of premenopausal women, compared to four per cent of post-menopausal women and about three per cent of men.

Diagnosis depends in part on access to blood tests, follow up and a doctor who can connect the symptoms to iron deficiency anemia. But according to the Canadian Institute for Health Information, 5.4 million Canadian adults — 17 per cent — reported having no family doctor in 2023.

Iron deficiency and anemia are often mistakenly treated as the same thing.

“Iron deficiency in and of itself can exist outside of anemia,” said Davis.

Anemia is considered a more serious condition and can also be caused by genetic disorders, chronic illnesses and inflammatory conditions, she said.

“Iron deficiency anemia is a sign that you have severe iron deficiency, and you’ve probably been iron deficient for quite some time.”

B.C. clinical guidelines say iron deficiency can cause symptoms even without progressing to anemia and should be investigated and treated. A 2025 review in the Canadian Medical Association Journal said treatment is indicated when ferritin falls below 30 micrograms per litre in adults who are not pregnant. Ferritin is a key marker of iron storage.

Left untreated, low iron can progress to anemia — and severe iron deficiency anemia is a serious condition.

“It’s a gentle slide,” said David Langill, a clinical pharmacist and head of operations for the Wellness Pharmacy Group, which has 11 locations in Metro Vancouver and an infusion clinic in Vancouver. “You kind of get used to feeling crummy. Every day you just feel a little bit worse than you did the day before. And you just think that’s normal.”

Langill said years of watching his wife struggle with severe iron deficiency changed the way he understood the condition.

“It isn’t until we address the issue and get those iron stores back that people realize, ‘Oh my goodness, I can’t believe I used to walk around like that.’”

Kiran Kaur, a Surrey resident in her mid-30s, spent months trying to push through symptoms she didn’t understand.

Exhaustion followed her through nearly every part of daily life. Staying awake in class, and balancing school, work and ordinary routines became difficult.

At times, exhaustion and physical limitations left her feeling as though she was a burden to those around her.

“I felt like I was holding them back because I experienced heart palpitations, flutters and sometimes chest pain,” she said.

When her doctor ordered blood tests, they quickly identified the problem: severe iron deficiency anemia.

“When you looked at my report, it looked like someone who had a heart attack or a stroke,” she said. “He called me in right away because at that time my iron was at zero and my hemoglobin was pretty low as well.”

If the diagnosis came quickly, treatment did not. Kaur was contacted once by a specialist, but an appointment or consistent followup never came, she said. For months, she sought treatment while cycling through supplements that either failed or made her feel worse.

Mental and emotional toll

Andrea Resendes, a credit risk analyst, initially dismissed her symptoms entirely.

“It was kind of dangerous, now that I see it (looking) back because I didn’t spot my symptoms,” she said. “I felt it, but I didn’t know it was anemia or something like that.”

Resendes stopped questioning the exhaustion after awhile. She continued working, exercising and maintaining her daily routine, even as she felt increasingly drained.

“I was very tired the whole time,” she said. “At the end of the day, I was very mentally exhausted. I didn’t want to know anything about anybody.”

Eventually, she started blaming herself: “I thought that I was not very social or that I was lazy.”

She remembers walking near the Lions Gate Bridge with her husband and friends when they decided to take a short uphill walk.

“I was breathless, and something that only takes five minutes … felt like an hour to me,” she recalled.

Days later, she learned she was severely iron deficient.

That experience is common among people living with invisible illnesses, says Jennifer Caspari, a psychologist and author of the book You Are More Than Your Body.

“Someone can’t just look at you and kind of see the symptoms,” Caspari said. “That can turn into self-criticism.”

Langill said many patients mistakenly interpret the physical exhaustion as a mental health problem: “A lot of people think they’re depressed, and they’re not depressed. The reason they’re always tired is because their iron isn’t where it needs to be.”

For Bonderov, the warning signs started early but at the time, she said, physicians didn’t test her ferritin levels.

“I went unconscious from the time I was maybe 15 or 16 years old,” she said. “The doctors couldn’t really figure out what was going on.”

It was not until years later, after she collapsed twice in one night that another doctor suggested checking further.

“And sure enough, I got my ferritin checked, and it was at four.”

In B.C., anything below 30 is considered low enough to treat.

Without a regular family doctor, though, each attempt Bonderov made to get help meant starting over with a different doctor as she moved among walk-in clinics for years.

Advice often felt dismissive, she said: “’Oh, you just need to drink some beet juice. Oh, you just need to have some bone broth or eat some steak.’ it was very superficial.”

After years of supplements and dietary changes that failed to improve her condition, doctors began suggesting more invasive interventions. One even suggested a hysterectomy.

“Just have a hysterectomy? This major life-changing surgery that will put you into menopause automatically.”

Equally traumatic for Bonderov, the condition also took a toll on her personal relationships.

“I was in a serious relationship, like a very serious relationship, we were living together,” she said. “And at one point, he broke up, and it was because I ‘didn’t have ambition.’

“The whole time, I’m like, ‘it’s because I’m anemic,’” she said.

Much of her energy went toward simply getting through the day.

“All I can do is get through the very most minimal chores of the day,” she said. “It was interesting to hear him call it ‘ambition,’ but for me, I was like, ‘oh, man, I’m just trying to survive here.’

“We’re grieving the life we thought we were going to have.”

Financial and social costs

Among the most common risk factors for iron deficiency are heavy menstrual bleeding, pregnancy and restrictive diets, said Crystal Karakochuk, an associate professor in human nutrition at the University of British Columbia.

Women with heavy menstrual bleeding are particularly vulnerable because they lose significant amounts of iron over time. Vegans, vegetarians and people with malabsorptive conditions, including Crohn’s disease and colitis, are also at higher risk regardless of gender.

During pregnancy, iron demands increase significantly, said Karakochuk. “Your blood volume basically doubles in pregnancy. You have so much additional blood and tissue being built, your iron needs are super-high.”

A University of Toronto study found nearly half of pregnant women in Ontario had low iron levels, while more than one third had not been screened for iron deficiency.

A diagnosis does not guarantee a treatment that all patients can either tolerate or afford. Oral iron supplements are often the first recommendation, but many patients struggle with side-effects.

Langill said side-effects are among the main reasons patients stop taking supplements.

“It’s the upset stomach, it’s the nausea, it’s the constipation … they’re really not tolerated very well.”

For Kaur, treatment became a cycle of trial and error.

“When the supplements don’t work, you can’t really return them, either,” she said. “I spent months of money trying something, and it makes me really sick. So, then I go out and I’m trying $100 on something else, and it’s not covered.”

Some supplements left her so nauseated that she struggled to function at work, where the condition was often minimized or misunderstood, Kaur said.

“I feel like work people don’t take it as seriously,” she said. “I feel like it wasn’t accepted at work as a proper thing … like it sounded like I was making an excuse.”

Karakochuk said rising grocery prices can make iron-rich diets harder to maintain.

“Cost of foods are rising and the forms of good iron rich foods are the ones that are typically red meat, pork, like the meats that are expensive. And so, it’s challenging to kind of balance that out,” she said.

Bonderov spent decades paying for supplements, treatments and other costs associated with chronic iron deficiency.

“Twenty-one years,” she said of supplements that she estimates cost $60 a month.

Patients with severe deficiencies often require iron infusions, which deliver iron intravenously for those who either cannot tolerate oral supplements, do not respond to them, have malabsorption, or have severe or chronic blood loss that cannot be resolved through oral therapies.

But access to infusion in B.C. remains inconsistent.

A 2025 Canadian Journal of Health Technologies study identified 1,097 infusion clinics in Canada providing outpatient care for at least one IV iron medication.

In B.C., access to publicly funded IV iron treatment often depends on referrals, hospital approval and access to a family doctor. No provincewide figures are available on how many British Columbians receive IV iron annually, but demand for treatment has grown nationally.

Grand View Research, a private market research firm, estimates the Canadian intravenous iron drug market generated US$144.6 million in revenue in 2024 and is expected to reach US$241.4 million by 2030.

Pharmacare supports coverage for three IV iron medications: iron sucrose, iron isomaltoside and ferric carboxymaltose. Venofer, an iron sucrose formulation, is typically administered over several visits, while higher-dose options such as Monoferric and Ferinject can reduce the number of appointments for some patients.

When access to publicly funded infusion is delayed or unavailable, patients may turn to private clinics, where treatment can cost thousands of dollars annually. Private clinic pricing across Metro Vancouver varies widely.

Integrated Health Clinic lists Monoferric 1,000 mg at about $530 plus a $235 infusion fee, while Mint Integrative Health lists the same dose at $835, including fees. The clinic says some patients may require up to five Venofer infusions at $360 each.

Some patients are sick enough to struggle, but not sick enough to qualify for faster IV treatment.

At the privately operated Wellspring Infusion Clinic on West Broadway in Vancouver, which Langill oversees, staff treat approximately 25 iron-deficiency patients a week for IV infusion.

“It’s a rather inefficient process right now,” Langill said of B.C.’s infusion administration and funding model. “I would love to take money from the government instead of from private patients.”

In May, hematologists Davis and Merkeley opened Ferra Clinic, a private clinic that focuses on affordable and accessible IV infusion for iron deficiency anemia.

Ferra does not charge direct infusion fees. Consultations for iron deficiency anemia are billed through medicare and, when needed, the clinic makes special authority applications to pharmacare on behalf of patients to cover the cost of medication.

“Generally, it should be very low cost — or no cost — to patients,” Merkeley said of iron infusion.

The clinic’s goal is to offer solutions to patients who know something is wrong but have not been able to get timely treatment.

‘You’re going to feel lonely’

Davis and Merkeley say patients’ tendency to normalize their symptoms is the main barrier to diagnosis and treatment.

Davis said she experienced iron deficiency while pregnant.

“I was iron deficient during pregnancy and could barely function at some points,” she said. “I thought it was just part of the pregnancy, and then I got an iron infusion and felt like a totally different person.”

Merkeley said many women spend years questioning themselves before realizing their symptoms may be linked to iron deficiency.

“You’re going to feel lonely thinking about, ‘Oh, am I just lazy? Is this just normal?’” she said. “Why am I so tired? Or, it feels like doing exercise or anything feels so heavy to do.”

Today, Bonderov says her condition has forced a painful recalibration of what daily life looks like.

After years of pushing through exhaustion and blaming herself for not being able to keep up physically, she is learning not to measure her worth by what her body can do.

“I’ve gone from being really unkind to myself … to just being kind to myself,” she said. “If I need to lay down on the trail, I just lay down,” she said. “And I accept where I’m at.”

Valentina Barrera Arguello is a 2026 recipient of the Langara College Read-Mercer Journalism Fellowship. This feature was produced through the fellowship.