At the Intersection of Asian and American

At the Intersection of Asian and American

Elisa Choi, MD, FACP, FIDSA

I have to confess, this essay is very different than the original piece I had written and planned to submit. We, as physicians, do not exist in a vacuum and recent events, specifically the terrible shootings in Atlanta, Georgia, on Tuesday, March 16, 2021, where eight people were murdered by a 21-year-old white man, and where six of the victims were women of Asian descent, four of whom were women of Korean descent, upended my original plans for this essay.

What does this particular event have to do with diversity, equity and inclusion in medicine? Aside from the horrible tragedy of lives lost, how does that event relate to DEI efforts? For me, a self-identified physician, woman and individual of Asian/Korean descent, the events of March 16 struck far too close to home as I visualized the possibility that I could have been a target of the shootings based on my identity. The Atlanta shootings also led to numerous days of contemplation about the role that racism, bigotry and hatred can play in all of our lives, but also in our experiences as physicians and in the lives of our patients.

DEI work cannot exist in isolation from addressing anti-racism. One of the most challenging aspects of being a physician of Asian descent this past year, while we all experienced the COVID-19 pandemic, has been the targeting and racism directed against those of us who self-identify as members of the Asian/Asian American/pan -Asian community. Ironically, the same day the horrific murders were committed in Atlanta, new data from “Stop AAPI Hate” (https://stopaapihate.org/) was released that reported approximately 3,900 incidents of discrimination, harassment, racism and violence directed at individuals of Asian descent in the U.S. since the beginning of the COVID-19 pandemic last year. That number is likely a significant underestimation, as many cases of anti- Asian racism, bigotry or discrimination go unreported. What has this meant for our Asian community during this pandemic?

First, some background information about our Asian/Asian American/pan-Asian community in Massachusetts and in the U.S. Currently, our community represents approximately 6% of the greater population in the Commonwealth and in America. We are also the fastest growing racial/ethnic group, but we have characteristics that can exacerbate health inequities. Our community has the largest proportion of limited English proficiency individuals and the greatest proportion of foreign-born individuals of any racial/ethnic group. Limited English proficiency is one of numerous social determinants that can further aggravate health disparities. In addition, there are numerous biases and stereotypes about our community that are harmful both to our physicians and clinicians as well as to our patients. Namely, that we are a “model minority“ but at the same time we are perpetually viewed as being “other“ or “foreign“ and “not really American.” Moreover, our community is often left out of discussions about race and health disparities or health inequities as often those discussions center around Black/white dichotomies or appropriately focus on Black/ African American, Latinx/Hispanic and Indigenous/ Native American communities.

What are some of the implications of the stereotypes, biases and omissions of our pan-Asian community from conversations about race and health? Starting with the “model minority” myth, this harmful stereotype was initially coined by William Petersen in 1966 when a New York Times story profiled the successes of Americans of Japanese descent in their financial, economic and educational attainment. Unfortunately, this label as the “model minority” has persisted for many decades up to the present and has generated an erroneous assumption that those of Asian descent do not suffer from health inequities or health disparities. Importantly, stereotyping and characterizing our pan-Asian community in this way does real damage, overlooking the concerns and issues faced by many of the more economically or educationally disadvantaged Asian subgroups. The Asian/Asian American/pan-Asian community is the most heterogeneous of all racial and ethnic groups, representing approximately two dozen languages and more than four dozen nationalities without a predominating or unifying language or culture. The circumstances under which our community members made their way to the U.S. have also been varied, ranging from highly educated professionals from East Asia or South Asia who voluntarily immigrated to the U.S. to chase the “American Dream” to refugees from Southeast Asia fleeing from their war-torn home country arriving in America to escape from political turmoil. The experiences of such diverse communities cannot be homogeneously defined.

Also, despite some groups of our larger pan -Asian community being in the U.S. since the 19th century, even in 2021 there is a presumption of Americans of Asian descent as being “foreign.” This had a particularly insidious and hateful outcome with the internment of Americans of Japanese descent who were sent to concentration camps and detention centers during World War II and this “perpetual foreigner” trope continues in the present day in everyday interactions when we as Americans of Asian descent are frequently asked “where are you from?” When we answer, “I am from Massachusetts,” that prompts the follow-up question, “But where are you REALLY from?”

As physicians and clinicians, these stereotypes and biases can manifest as harmful assumptions about us and can impede professional achievements and attainment of leadership positions, and can also undermine our efforts to achieve success. The quiet, hardworking, docile, obedient “model minority”

Asian will not be seen as “leadership material,” but instead as a “worker bee.” We physicians of Asian descent have also experienced “racial microaggressions,” ranging from blatantly offensive racial slurs to less aggressive but still unacceptable jokes about our Asian foods or foreign accents. More concerning still are the instances of blatant racism and racially motivated violence directed against our community, as what happened in the Atlanta shootings.

For our patients, these harmful stereotypes and biases can lead to under-recognition and under-diagnoses of medical conditions, and a failure to address some chronic medical conditions because of the assumption of the “model minority” myth as applied to Asian/Asian American patients’ health. The “model minority” myth of the “healthy Asian patient“ also belies the fact that our patients of Asian descent are often underdiagnosed with diabetes and will suffer from delayed diagnoses with various cancers because of poor rates of cancer screening.

Poor language access, particularly for our patients of Asian descent who have limited English proficiency, is a significant and frequent barrier to care and our medical systems often are under-resourced to address it. Asian patients who speak primary languages which do not have corresponding interpreter services are significantly disadvantaged when it comes to their health care.

COVID-19 has also led to the parallel pandemic of anti-Asian racism, which has had significant consequences for our Asian patients. They are not accessing COVID-19 vaccines to the same degree as white patients. Data from our Massachusetts Department of Public Health COVID-19 vaccine dashboard supports this health disparity. A more difficult outcome to measure is the impact from the targeting and stigmatizing of Asian individuals on access to care. The racialization of COVID-19 may dissuade our Asian patients from seeking care for suspected COVID-19, or even other medical conditions, as a response to racial trauma and stigma.

The events in Atlanta on March 16 and the horrific murders of eight individuals, six of whom were Asian women, did not happen in a vacuum. They occurred with the backdrop of Anti-Asian racism and COVID-19 ongoing over the past year. The COVID-19 pandemic has surfaced a parallel epidemic of anti-Asian racism and has revealed health disparities affecting our Asian community.

The way forward must include active, anti-racist efforts as well as inclusion of our Asian community in those conversations about DEI and health disparities. Do not omit our voices and our lived experiences. We matter, we have been in America for centuries, but now more than ever, we must be seen and heard and accepted for who and what we really are. We Asian/ Asian Americans will stand up to racism, hatred and bigotry and together in solidarity with other Americans and will strive to create a more compassionate, tolerant and humane environment where we can all coexist as fellow human beings.

Elisa Choi, MD, FACP, FIDSA, Governor of the MA chapter of the ACP Conference and Councilor of the Asian American Coalition in MA