Confronting Anti-Asian Racism and Health Disparities in the Era of COVID-19

The COVID-19 pandemic has unveiled long-standing inequities that harm communities of color. Alongside racial discrimination that has cost Black lives, the unequal burden of COVID-19 on underserved populations has forced the medical community to reckon with uncomfortable truths about its role in perpetuating structural racism in modern society. A race-conscious conversation in medicine is evolving—which acknowledges race as a social construct that creates and upholds barriers underlying health disparities.¹

Consequently, physicians have slowly begun to draw attention to the rise or resurgence of anti-Asian sentiment in the pandemic’s wake. References to SARS-CoV-2 as the “Chinese virus” or “kung flu” echo the “yellow peril” and “fu manchu” archetypes of the mid-19th to 20th centuries—when Asian Americans were subject to public violence and legislative injustices, including the Chinese Exclusion Act of 1882 and Japanese internment during World War II. Today, such words still come at great cost. In 2020, the New York Police Department reported a 395% increase in anti-Asian violence² and, to date, the StopAAPIHate coalition (stopaapihate.org) has received more than 3800 reports of anti-Asian hate crimes and harassment.

In response, anti-Asian sentiment has been met with widespread public outcry. Less acknowledged, however, has been the devastation brought by COVID-19 on Asian American communities—epitomized by high case-fatality rates among Asian American health care workers and within Asian immigrant enclaves.³ Yet the underacknowledgment of threats to Asian American health is not new. Harmful stereotypes have led to the erasure and exclusion of Asian Americans throughout US history, perpetuating a sense of “invisibility” and ultimately, a worsening of health outcomes within Asian American communities.

Earliest among these historical misconceptions is the “perpetual foreigner,” which labels Asian Americans as inherently foreign, despite being native-born or naturalized.⁴ Rooted in the premise that being American necessitates being White, this “otherization” of Asian Americans sets them apart from rather than a part of US society, thereby permitting the scapegoating of Asian Americans in times of crisis. In medicine, this perception has manifested in the underprioritization of Asian American–focused research. Despite being the fastest growing racial and ethnic minority group in the US—with more than 20 million people whose ancestry can be traced back to East Asia, Southeast Asia, and the Indian subcontinent—only 0.17% of the research funded by the National Institutes of Health in 1992 to 2018 to examine health disparities was focused on health outcomes among Asian Americans, Native Hawaiians, and/or Pacific Islanders.⁵ Moreover, despite being the only racial or ethnic group for whom cancer is the leading cause of death, Asian Americans remain understudied in oncology.

Separately, the “model minority” myth traces its origins back to the 1966 New York Times Magazine article, “Success Story: Japanese-American Style,” which lauded the industriousness of Japanese Americans in the post−World War II era.⁶ Now applied broadly to all Asian Americans, this stereotype perpetuates the assumption that Asian Americans are uniformly well-educated, wealthy, and healthy. Yet while Filipino, Indian, and Japanese Americans are among the highest earners in the US, many groups—including Burmese, Hmong, and Nepalese immigrants—earn far less than the national median income.⁷ As of 2018, income inequality among Asian Americans outpaces that of other racial or ethnic groups, warranting further investigation of the downstream health consequences.

Thus, if physicians are to effectively confront the harms of anti-Asian sentiment on Asian American health, we must go beyond simply denouncing overt violence. Physicians must actively dismantle harmful historical stereotypes through a variety of avenues, from research to clinical training to workforce representation. To that end, heightened public awareness may serve as a powerful catalyst to galvanize efforts aimed at improving the health of Asian Americans. We have identified 3 areas of need: disaggregation and genetic ancestry in medical research, cultural humility in clinical practice, and workforce diversity.

Intertwined with the model minority myth is the lack of disaggregation in studies of Asian Americans. As a social category, race captures important information regarding social determinants of health. However, monolithic conceptualizations of Asian race overlook the complex heterogeneity of Asian American populations with respect to immigration histories, sociodemographics, genetic variation, and barriers to care. For example, Chinese and Vietnamese Americans face disproportionately high mortality from liver and stomach cancers, while Filipina and Indian Americans outpace other groups in breast cancer-related deaths.⁸

Thus, disaggregated data can facilitate a more nuanced study of factors influencing Asian American health. However, care must be taken to avoid pathologizing race; it has become increasingly recognized as an imperfect proxy for biologic variation. Instead, research aimed at understanding disease pathogenesis or identifying molecular targets for therapeutic intervention in Asian American populations must emphasize genetic ancestry, which accounts for the geographic origins of one’s recent ancestors using genetic data.⁹ This approach acknowledges the wide range of geographic regions encompassed by the Asian continent and the high percentage of immigrants in Asian American communities.

Notably, Asian Americans are often underrepresented in many national databases, which may pose challenges to meaningful attempts at data disaggregation and genomic analysis for Asian American populations. Several prospective studies aimed at identifying both environmental and genetic risk factors in Asian American cohorts are ongoing—eg, the Female Asian Never Smokers study of lung cancer (fansstudy.ucsf.edu) and the Mediators of Atherosclerosis in South Asians Living in America study of cardiovascular disease (masalastudy.org). However, future efforts will require additional logistic and financial support from national organizations, including the National Institutes of Health, to build more representative and disaggregated data sets.

Alongside research aimed at elucidating drivers of Asian American health disparities, educational initiatives centered on cultural humility should also be implemented. Unlike cultural competency, cultural humility conceptualizes an understanding of patients’ cultures as dynamic processes that necessitate lifelong learning—acknowledging that it is impossible to become fully competent in another’s culture without their lived experience.¹⁰ This distinction is essential in the care of Asian American patients, considering the multitude of languages, sociocultural practices, and religions represented by this group.

Medical schools and residency programs should ensure that existing curricula emphasize cultural humility over competency and provide ample opportunities for trainees to integrate these principles into their clinical practice. Hospitals should similarly be equipped to provide continuing education on cultural humility to clinicians and help broker successful cultural exchanges with Asian American patients via interpreter services, patient navigators, and readable patient materials. Furthermore, while the US Food and Drug Administration’s guidelines aim to enhance trial diversity, historically low rates of Asian American enrollment into clinical trials suggests that there is still room to identify barriers to participation for more inclusive trial design. Ground-level outreach to neighborhood centers, places of worship, and even grocery stores may improve the enrollment and participation of Asian Americans in community-based research and trials.

Asian Americans are not considered underrepresented in medicine; however, certain subgroups, including Cambodians, Hmong, and Laotians, are heavily underrepresented (aamc.org). Recognized by few institutions, this disparity illustrates the pitfalls of the model minority myth. Asian Americans are also underrepresented among senior faculty across specialties—representing only 6% of full professorships and 3% of chairpersons in US academic medical centers, despite composing more than 20% of US medical students—exemplifying the so-called bamboo ceiling. The exclusion of underrepresented voices from positions of power in medicine limits meaningful initiatives to address health disparities in Asian American and other minority communities. Academic institutions, national organizations (eg, the Association of American Medical Colleges, the Accreditation Council for Graduate Medical Education), and specialty societies must collectively ensure that Asian American trainees and junior faculty have ample opportunities to progress into senior roles—building leadership reflective of our nation’s multiethnic and multicultural population.

Anti-Asian violence is only the latest symptom of the chronic ailment of systemic racism in the US. Our response at this revolutionary time will speak volumes. In addressing racism as a public health crisis, health care professionals must pay closer attention to the unique challenges facing traditionally underserved minority groups, including Asian Americans—emphasizing advocacy, transparency, and compassion for all those unseen. In heeding lessons from history and recognizing the ills of the present, the onus falls on us to move toward equity for all the many diverse communities that we serve.

Published: September 24, 2021. doi:10.1001/jamahealthforum.2021.2579

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Santos PMG et al. JAMA Health Forum.

Corresponding Author: Patricia Mae G. Santos, MD, MS, Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10065 (santosp@mskcc.org).

Conflict of Interest Disclosures: None reported.