Q&A: Overlooked health issues that ‘need to be addressed’ in Asian communities

Key takeaways:

• Hepatitis B, diabetes, cancer, CVD, maternal mortality and suicide disproportionately affect AA and NH/PI populations.
• Physicians should know and routinely implement updated screening and vaccine guidelines to prevent AA and NH/PI health disparities.

Asian American, Native Hawaiian and Pacific Islander, or AA and NH/PI, communities continue to face significant racial disparities in health care access and outcomes across the United States, according to an expert.

During the Asian American Journalists Association's National Convention, Rita K. Kuwahara, MD, MIH, a primary care internal medicine physician and Healio Primary Care Peer Perspective Board member, gave a presentation on overlooked health disparities in AA and NH/PI populations.

She noted that AA and NH/PIs are not a monolith and comprise over 50 racial and ethnic groups and speak over 100 languages. However, AA and NH/PI data is often reported as a single aggregated data point classified as “Asian American,” masking existing inequities within the AA and NH/PI communities.

Kuwahara spoke with Healio to discuss ongoing issues, how physicians can better address them and more.

Healio: What are some of the most prevalent or overlooked health issues within AA and NH/PI populations?

Kuwahara: It’s difficult to narrow it to just a few health issues, but this list includes hepatitis B, diabetes, maternal mortality, mental health, cardiovascular disease, cancer, tuberculosis, and many other health conditions, as well as the critical need to disaggregate health data by race and ethnicity and fund research and support health care workforce initiatives that will benefit the diverse health needs of the AA and NH/PI communities.

Up to 2.4 million people in the U.S. have chronic hepatitis B, and about half of these individuals identify as AA and NH/PI. Only 25% of people with chronic hepatitis B, or one in four, know that they are infected. The reason why it’s important to know if you’re infected is because one in four people with untreated chronic hepatitis B will develop liver cancer — currently one of the deadliest cancers — liver failure or cirrhosis. This disproportionately affects the AA and NH/PI communities. Regarding liver cancer, whereas the overall 5-year survival is just 22%, Asian American men are 60% more likely to die from liver cancer than non-Hispanic white men. In addition, although we have a safe and highly effective vaccine to prevent hepatitis B, which was the first anti-cancer vaccine to be developed, only 30% of adults are vaccinated against hepatitis B, and these rates should be much higher, particularly since the CDC currently recommends universal adult hepatitis B vaccination.

Twenty percent of all AA and NH/PI individuals in the U.S. have diabetes. That’s one in five people, which is extremely high. If someone is not aware of their diabetes status, they’re more likely to develop complications from diabetes, which include everything from blindness to kidney disease to cardiovascular disease to lower extremity amputations and more.

In addition, AA and NH/PI individuals develop diabetes at a lower body mass index (BMI), and it’s estimated that among Asian Americans, 50% of diabetes cases are undiagnosed. This is higher than any other racial or ethnic group. In other words, half of AA and NH/PIs with diabetes don’t know they have it, making them more likely to develop diabetes-related complications, since they are not being treated for diabetes and not receiving the appropriate care to prevent complications.

For maternal mortality, from 2017 to 2019, Native Hawaiians and Pacific Islanders had the highest ratio of maternal deaths in the U.S. of all racial and ethnic groups. According to the CDC, the pregnancy-related mortality ratio from 2017 to 2019 was 62.8/100,000 among NH/PIs, which was over 50% higher than the ratio of 39.9/100,000 among Black individuals. However, the CDC has neglected to publish data on maternal deaths in the NH/PI communities since the 2017-2019 report, which is why the most recent maternal mortality reports have only reported data on the high maternal death rate among Black individuals, even though NH/PI maternal death rates were previously the highest of all racial and ethnic groups. Without this knowledge, efforts will not be made to address maternal mortality in the NH/PI communities, resulting in more preventable maternal deaths.

From a mental health perspective, suicide was the leading cause of death for Asian American and Pacific Islander (AAPI) youth from 1999 to 2021. Specifically, among Asian American female youth, there was a 125% increase in suicide during that time period. However, Asian Americans are 60% less likely than other racial groups to seek mental health services. That’s an area that’s often overlooked, and we need to make sure we are properly screening our AA and NH/PI communities for mental health conditions and ensuring they have access to necessary care.

Cancer is the leading cause of death among some Asian Americans, including those of Chinese, Filipino, Korean and Vietnamese descent. In addition, Native Hawaiians and Pacific Islanders were 75% more likely to die from liver cancer and two to three times more likely to die from cervical, stomach, and endometrial cancer than non-Hispanic white individuals. Of note, among Asian American women with lung cancer, 50% never smoked, and up to 80-90% of Chinese and Indian American women with lung cancer never smoked, which is significantly higher than the overall U.S. population.

CVD represents the leading cause of death among Asian Indians and Japanese in the United States. In addition, coronary artery disease rates have increased faster for Filipino, Asian Indian and Chinese Americans than among non-Hispanic white individuals. Of note, South Asians have been found to develop coronary artery disease up to 10 years earlier than the average age for the general population, underscoring the need to appropriately assess cardiovascular risk in these communities.

These are just a few of the health issues that must be addressed in the AA and NH/PI communities. However, due to a lack of clinician awareness, a lack of public awareness, and/or not enough efforts from a policy and funding perspective, AA and NH/PI communities are experiencing widening disparities from undiagnosed health conditions and a lack of appropriate care needed to screen for, prevent and treat these conditions.

Healio: What can primary care providers do to address these disparities?

Kuwahara: For diabetes, a key take-home message is that clinicians should screen AA and NH/PI adults for diabetes at a BMI of 23 kg/m² or above. For AA and NH/PI individuals, a BMI of 23 kg/m² is considered overweight using international guidelines, and a BMI of 27.5 kg/m² is considered obese. Current U.S. Preventive Services Task Force guidelines recommend screening adults who are overweight or obese for diabetes. What clinicians must know is that, while overweight is commonly defined as a BMI of 25 kg/m² for the general U.S. population, AA and NH/PIs should be classified as overweight at a BMI of 23 kg/m², and must, therefore, be screened for diabetes at a BMI of 23 kg/m². However, what is currently happening is that clinicians are not aware of the international definitions for overweight and obese in AA and NH/PI populations, so they are missing opportunities to screen their Asian American, Native Hawaiian and Pacific Islander patients for diabetes starting at a BMI of 23 kg/m², resulting in a disproportionately high percent of AA and NH/PIs having undiagnosed diabetes and developing preventable diabetes-related complications.

Hepatitis B is often overlooked and we need to make sure clinicians know and follow current hepatitis B vaccine and screening guidelines. The CDC’s Advisory Committee on Immunization Practices updated their recommendations a few years ago to recommend universal adult hepatitis B vaccination, and it’s important for PCPs to be aware of that recommendation and ensure they’re implementing universal hepatitis B vaccination for adults in their daily practice, as well as continuing to universally vaccinate infants and children against hepatitis B.

Clinicians should also be aware that the CDC now recommends universal hepatitis B screening for adults and should be implementing this in practice. By screening for hepatitis B, PCPs can identify individuals with chronic hepatitis B and appropriately link them to care and treatment, in order to prevent or ensure early detection of complications, like liver cancer, that can occur in those with hepatitis B. Another critical point to remember is that individuals with chronic hepatitis B can develop liver cancer without first developing cirrhosis, making it vital for patients with chronic hepatitis B to be aware of their diagnosis and have ongoing access to care, including appropriate liver cancer surveillance.

It is also important to note that, while many efforts are currently directed towards hepatitis C testing and treatment, which are absolutely needed, hepatitis B is often left out of the conversation. Hepatitis B and C share similar risk factors, so when we screen for hepatitis C, we should be screening for hepatitis B and administering hepatitis B vaccines to those who are susceptible. In addition, it is malpractice to start hepatitis C curative treatments with Direct-Acting Antivirals (DAAs) without first testing for hepatitis B, since if a person has previously been infected with hepatitis B, the DAAs used to treat hepatitis C can cause fulminant hepatitis, liver failure or death, according to the FDA boxed warning on all DAAs used to treat hepatitis C.

Further, it is important to remember that the hepatitis B vaccine is a highly effective anti-cancer vaccine, and clinicians should emphasize this when speaking with patients and policymakers on the importance of increasing hepatitis B vaccination.

Healio: How can research on disparities in AA and NH/PI communities improve?

Kuwahara: We must disaggregate the data by race and ethnicity, fund AA and NH/PI focused research, and ensure AA and NH/PI individuals are routinely included in clinical trials.

When it comes to research, less than 1% of NIH funding is awarded to research that’s focused on Asian Americans, and even less is focused on Native Hawaiians and Pacific Islanders, so we must drastically increase this funding to better evaluate health outcomes in the AA and NH/PI communities.

Data disaggregation is an issue of health equity, and we must ensure that data from certain communities, such as the NH/PI and certain Asian subpopulations, are collected and not left out of statistical analyses. Comprehensive and accurate data is critical because it can be used to highlight health inequities that exist between different AA and NH/PI communities, and these inequities must be known to effectively eliminate them. However, if we don’t have the data, we will perpetuate existing inequities.

Lastly, it is also important to note that while Asian Americans are not considered underrepresented minorities in medicine, if you look at the actual percentages of Asian Americans who are in academic medicine leadership — for example, deans — there are substantially fewer Asian American physicians who are in those roles. We need to make sure we have more AA and NH/PI physicians who are in academic leadership so that we can help create a pipeline for future AA and NH/PI academic medicine physicians and researchers. We must also encourage all researchers to pursue AA and NH/PI focused research, include AA and NH/PI individuals in more clinical trials, and ensure that the NIH and other funders prioritize funding and support for these research initiatives to make sure that we are comprehensively addressing the health needs of our nation’s AA and NH/PI communities.

Healio: Anything else you would like to add?

Kuwahara: From a health care workforce perspective, we are in the midst of a nationwide crisis, which disproportionately affects the AA and NH/PI communities. For individuals with limited English proficiency, we know that these individuals are more likely to seek medical care from clinics and community health centers where clinic staff speak the languages that these individuals are most comfortable speaking. Therefore, from a policy perspective, it is critical to address the language access component of our nation’s health care workforce shortage and provide the necessary resources to ensure that we are building and training a national health care workforce that will provide linguistically and culturally responsive care to comprehensively meet the needs of our AA and NH/PI communities.

Reference:

• Health coverage rates vary widely across – and within – racial and ethnic groups. https://www.cbpp.org/sites/default/files/5-9-24health.pdf. Accessed Aug. 28, 2024.
• OMB publishes revisions to statistical policy directive #15. https://www.whitehouse.gov/omb/briefing-room/2024/03/28/omb-publishes-revisions-to-statistical-policy-directive-no-15-standards-for-maintaining-collecting-and-presenting-federal-data-on-race-and-ethnicity/. Accessed Aug. 27, 2024.