Q&A: Amidst COVID-19, anti-Asian racism adds to public health crisis

While the COVID-19 pandemic has put an incredible burden on all health care workers, it has also fueled a resurgence of anti-Asian racism in the U.S. and highlighted disparities in health care research and opportunities for Asian Americans.

Patricia Mae G. Santos, MD, MS, a resident physician at the Memorial Sloan Kettering Cancer Center in New York, and colleagues argued in a recent viewpoint article that racism should be addressed as a public health crisis.

Tracing the history of anti-Asian sentiment, Santos and colleagues discussed the impact racism has had on Asian American physicians and medical students as well as how “monolithic conceptualizations” and research gaps affect the health of Asian Americans. They identified three key areas where improvements are needed to address health care disparities: disaggregation and genetic ancestry in medical research; cultural humility in clinical practice; and workforce diversity.

Healio Primary Care spoke with Santos to learn more about anti-Asian racism in the U.S.

Healio Primary Care: Why did you and your coauthors write this piece?

Santos: The idea of writing this piece came to me at the beginning of this year when the news media first began to take notice of the growing tide of anti-Asian sentiment and racist attacks that coincided with the COVID-19 pandemic. At the time, I was reading about the story of Noel Quintana, a Filipino American man who was slashed in the face with a boxcutter while riding the L train in New York City. He recalled, He recalled, “Nobody came. Nobody helped. Nobody made a video,”—and for me, it echoed this sense of invisibility and helplessness in the Asian American community — that our fears, our concerns and our well-being have been and were being ignored. The following day, my mother was verbally harassed while walking to her car from work. For context, both she and my father are Filipino American immigrants, and both are health care professionals who served on the frontlines at the height of the COVID-19 pandemic in New York City. Both have been taking care of underserved patients in Brooklyn for over 20 years. Yet a man whom she did not know followed her to her car, yelling that the “Chinese virus” was her fault. Thankfully, she made it out unscathed but so many others have not.

But the survivors of these attacks did not just remind me of my parents — they reminded me of my titos and titas, my lola and elders, my friends and neighbors, and my patients — anyone of whom could have just as easily been subject to such acts of violence and harassment.

In collaboration with my co-resident, Edward Christopher Dee, MD (who is also of Filipino heritage), and under the mentorship of Curtiland Deville Jr., MD, we decided to write this piece as a way of exploring the roots of anti-Asian racism in U.S. history, highlighting the ways in which harmful stereotypes and mischaracterizations have manifested in medicine, and ultimately, offering ways in which health care professionals could change the status quo, lending visibility to the Asian American communities who feel unseen and unheard.

Healio Primary Care: Can you talk about the long-term health consequences related to the understudied health disparities among Asian Americans, Native Hawaiians and/or Pacific Islanders?

Santos: In the era of precision medicine and growing efforts to improve quality in U.S. health care, I think that the lack of proper study of health disparities in the Asian American population is truly a missed opportunity.

From an oncology perspective, cancer is the leading cause of death among Asian Americans, yet much of the limited data available is confounded by the lack of disaggregation by ethnic subgroups, which in turn masks disparities. As we discuss in the article, the incidence and mortality associated with various cancer types can vary significantly among Asian American subgroups, once you account for variables like ethnicity, immigration histories, genetic ancestry, environmental exposures, etc.

Moreover, the lumping together of Native Hawaiians and Pacific Islanders (NHPI) with Asian Americans does a similar disservice, with available data suggesting that health care outcomes among NHPI populations are consistently worse than that of Asian Americans as whole. Ultimately, if we are unable to identify patients who are most at risk, we won’t be able to improve screening practices or improve health care access for these groups in need. You can’t fix what you can’t see.

Healio Primary Care: You and your co-authors identified three areas of need. Can you briefly describe each of these?

Santos: In short, all of these areas of need speak to the fact that Asian Americans are not a monolith — they are the fastest-growing racial/ethnic group in the U.S., representing over 20 million individuals from multiple continents. Disaggregation of Asian Americans by ethnic subgroups is the first step, but to really understand the relative contributions of underlying genetics versus environmental exposures, genetic ancestry, which accounts for the geographic origins of one’s recent ancestors when analyzing their genetic data, must be employed.

With respect to cultural humility, it is a concept which, unlike cultural competency, emphasizes that it is impossible to truly be “competent” in another’s culture without their lived experience — a point which is especially salient when caring for Asian Americans given the multitude of languages, sociocultural practices, immigration histories and geographies this group represents. This is why Asian American representation in the physician workforce is so important.

That said, Asian Americans are not considered to be underrepresented in medicine. However, certain subgroups such as Laotians, Cambodians and Hmong physicians remain consistently underrepresented. This point illustrates the pitfalls of the “model minority” myth — the idea that Asian Americans are equally well-educated, wealthy and healthy and ignores issues of rising income inequality and poverty in Asian American communities. The process of becoming a physician is a costly one and many Asian Americans do not have access to the money or opportunities necessary to do so.

Healio Primary Care: If left unconfronted, how will persistent health disparities impact the next major health crisis?

Santos: Inevitably, when major health crises like the COVID-19 pandemic happen, the hardest hit communities are always the underserved — just look at the outsized impact of COVID-19 on Black and Latino communities. But in the case of Asian Americans, these communities are often hiding in plain sight, as evidenced by the high case fatality rates among Asian American patients with COVID-19. Unless we dedicate the time and resources into studying which Asian American subgroups are most at risk of COVID-19, cancer or other health ailments, and understanding the many complex factors that are contributing to that risk, we will likely find ourselves in a similar situation in the future. We will likely see the full impact of such catastrophic health events fly under the radar once again.

Healio Primary Care: If perspectives were to shift to the mindset that racism is a public health crisis, what could this mean for changing health disparities and how medical research is conducted?

Santos: Fortunately, I do feel that the shift to addressing racism as a public health crisis is already underway. There is a new generation of physician leaders and trainees who not only recognize the role that medicine has had to play in perpetuating systemic and structural racism in the U.S. but are also actively working to dismantle it. National organizations have started to step up to the plate as well, releasing long-awaited statements that recognize the importance of promoting health equity.

When it comes to research, there are already numerous studies (both published and in the pipeline) looking at disparities in health outcomes and health care access across disease sites and disciplines. However, what’s still needed is a greater emphasis on supporting interventions that seek to address disparities outright, not just point to their existence. But that takes time, energy and resources. I think the next step is for national organizations and academic institutions to begin providing budding researchers, junior faculty and trainees with the support necessary to conduct this work — recognizing that these are not “soft skills” but rather hard sciences that need substantial funding, academic freedom and mentorship to pursue.

Healio Primary Care: Currently, have you seen any changes that could positively alter the trajectory of anti-Asian racism in medicine in the future?

Santos: As with most things, there is a silver lining: the unfortunate rise of anti-Asian racism in the COVID-19 pandemic has inspired Asian American health care professionals to advocate on behalf of their communities on multiple platforms. Growing public awareness has garnered significant interest from national organizations, academic institutions and major medical journals, which could mean more support for work that aims to address the unique needs of Asian American patients. There are already several prospective studies ongoing that aim to elucidate the factors contributing disease among Asian Americans, including the Female Asian Never Smoker study for lung cancer and the Mediators of Atherosclerosis in South Asians Living in America study for CVD. But there is still more work to do and plenty of room to address factors that harm Asian American health.

Healio Primary Care: What is the take-home message from this opinion piece you would like communicated to physicians?

Santos: The rise of anti-Asian racism in the era of COVID-19, while alarming, is not new. For better or worse, the roots of anti-Asian sentiment are deeply entrenched in U.S. history, and medicine has had a role to play in perpetuating misguided stereotypes that continue to harm Asian American health in the present day. Fortunately, this also means that health care professionals play an important role in dismantling the “Asian monolith” through research, training and advocacy.

Reference:

Santos PMG, et al. JAMA Health Forum. 2021;doi:10.1001/jamahealthforum.2021.2579.