Honoring Asian diversity by collecting Asian subpopulation data in health research.

Abstract

The COVID-19 pandemic has taken a substantial human, social, and economic toll causing nearly 1 million deaths in the United States (US). The disproportionate impact of the pandemic on morbidity and mortality in minoritized communities could be described as unconscionable—though all have been affected in different ways. In addition to experiencing death and disability from COVID-19, Asians living in the US have been forced to contend with an onslaught of racism, xenophobia, misogyny, and hate crimes fed by the anti-Asian rhetoric by elected officials scapegoating Asian people for the spread of COVID-19. The spike in hate crimes against Asians is predominately experienced by people of East Asian descent. In particular, Chinese, Filipino, Vietnamese, and Korean people reported a definitive spike in anti-Asian hate incidents (Jeung et al., 2021). This is in contrast to the aftermath of the 9/11 terrorist attacks, which spurred hate crimes against South Asians and people from the Middle East (a part of Western Asia), particularly those who are Muslims. The differential impacts of historical and political events on Asian people in the US illustrate how persistent and imprecise use of the broad categorization of Asian people limit nuanced historical understanding of the specific ways communities are impacted by xenophobic rhetoric and structural racism. Today, nearly 60% of all people of Asian descent living in the US were born outside the country and the overall population in the country has increased from 3.5 million in 1980 to approximately 23 million in 2022 (United States Census Bureau, 2021). With the population of Asian Americans projected to double by 2060 (Budiman & Ruiz, 2021), it is imperative that the unique vulnerabilities and diversity of the people who are identified as Asian be recognized—particularly to identify and address disparate health services and outcomes. The purpose of this editorial is to clarify the origins of the terms Asian and Asian American and briefly discuss potentials issues in health and health care that may occur when the diversity of subgroups among Asian people is not well recognized. We also offer recommendations for language and terminology in nursing scholarship, education, and practice in a post-pandemic society. Additionally, we suggest that the term “Asian Americans” excludes Asian people who are residing in the US as noncitizens (permanent residents, refugees, and undocumented/unauthorized immigrants). Instead, we recommend the use of the term Asian people to capture the full range of people of Asian heritage living in the US. As Nava et al. (2022) highlighted in their editorial on the dangers of grouping people by a common characteristic, we also seek to illustrate how the same dynamic can affect people of Asian heritage. Asia is comprised of 48 countries and three territories (i.e., Taiwan, Hong Kong, and Macau). Some of these countries also consider themselves as belonging to other geographic regions of the world, such as the Middle East (e.g., Saudi Arabia and Kuwait) and Europe (e.g., Georgia and Armenia). In the US and some other countries with significant immigrant populations from Asia, it is more common to think of people of Asian heritage as being from the Eastern region (i.e., China, Japan, Korea, Taiwan, and the Philippines), Southeast Asia (i.e., Thailand, Vietnam, Laos, and Cambodia), and South Asia (i.e., India, Pakistan, Nepal, Bangladesh; World Population Review, 2022). Accordingly, our population focus for this article is people of East, Southeast, and South Asian descent (as seen in Figure 1). Asian migration to the US began in the late 18th century as global trade routes began expanding. With the westward expansion of the US, the California gold rush, and the building of the cross-continental railroad, Asian immigration increased rapidly in the first half of the 19th century (Ewing, 2012). Both economic opportunity and labor shortages drove migration from Asia to that region of the world. As with many immigrant groups in the US, as the population grew, so did the legal and economic restrictions. From 1790 to 1952, immigrants from Asia were deemed ineligible to become citizens of the US and experienced some of the most severe immigration restrictions in history, which was driven by a “whites-only” immigration agenda. People from Asia were referred to as the “Oriental Problem” with racist rhetoric describing them as “undesirable coolies” or as the “yellow peril.” This otherizing and labeling of Asian people as perpetually “foreign” led to a denial of equal protection under the US law. Even worse, the laws actively excluded Asian people as evidenced by the Chinese Exclusion Act of 1882 prohibiting Chinese labor migration, the Gentlemen's Agreement of 1908 stopping Japanese migration, the Barred Zone Act of 1917 banning Asian Indians, and the Tydings-McDuffie Act of 1934 excluding Filipinos (Ewing, 2012). Lack of eligibility for citizenship meant Asian immigrants lived under the weight of institutionalized and interpersonal racism without any legal protections to ensure their safety (Ewing, 2012). In addition to immigration restrictions, laws related to marriage, owning land, and testifying against white Americans were also pervasive. The Civil Rights laws passed in the 1960s removed many legal restrictions imposed on Asian populations along with the Hart-Celler Immigration and Nationality Act that passed in 1965. These two significant pieces of legislation were the first steps toward ensuring legal equality in the US. Some positive shifts in attitudes toward Asian populations also began after the Vietnam War ended. By the early 21st century, the term “model minority” began to be applied to people of Asian heritage—a term fraught with undertones of “othering” the population (Ewing, 2012). The term “Asian American” was first conceptualized by Emma Gee and Yuji Ichioka, in 1968 at the University of California, Berkeley (Le Espiritu, 1992). During this time, powerful racial and ethnic affinity groups such as the American Indian Movement and the Black Power Movement were coalescing their focus and activism to address the specific injustices encountered by people from historically oppressed groups—often defined by their racial categorization. Gee and Ichioka created the term “Asian American” as way to unite people from different Asian countries into a larger collective in their fight for greater equality and justice in the US (Le Espiritu, 1992). Before its acceptance into vernacular and scientific use, people of Asian descent in the US would refer to themselves by their specific ethnic subgroup, such as Chinese, Japanese, Indian, Filipino, and so on. At the time, the broad term often used was “Oriental,” which is now understood as derogatory because of its ties to colonization which historically exoticized people and material goods from the East. The creation and use of the term “Asian American” was a conscious political strategy to gain visibility and power for the broader group of people of Asian descent that were often racialized and marginalized. The term Asian American was never intended to erase the specific diverse ethnicities and cultural groups that collectivized under this umbrella term. However, the descriptor “Asian,” over time, has failed to encompass the wide array of ethnicities, cultures, languages, traditions, and history that are represented by people who are captured in this category. The US Census collects population-level data on racial and ethnic groups and uses the term “Asian” as one of the racial categories. According to the US Census, “Asian” refers to a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent. This singular term encompasses people from 48 countries, such as Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippines Islands, Thailand, and Vietnam and reflects the current standard for data collection in health and social research. oftentimes in research and academia, the term Asian American frequently only includes East Asian people (Lee & Ramakrishnan, 2020). Research has shown that there are significant cross-group differences, within each subgroup of people who are Asians. These subgroups have unique histories, cultures, languages, and other characteristics that are idiosyncratic to each group that is left invisible when the broad category of “Asian” is used. Subsequently, the diversity within the US and countries' Asian population is oftentimes overlooked. Due to the terms and context under which Asians have historically been granted entry into the US, Asian people are stereotyped as hard-working, well-behaved, and middle to the upper class. At the same time that scholar-activists Gee and Ichioka sought to amplify the needs of people from Asia living in the US with the term “Asian American,” some political and social movements consisting of mainly White conservative thinkers coined the term “model minority,” to offer a counter-narrative to their racist perceptions of Black and African American people. By suggesting Asians were “models,” Black and African American people were portrayed as squandering the same opportunities as other minoritized groups while not being able to achieve the same level of success (Shih et al., 2019). The image of the high-achieving Asian person remains pervasive in the US, suggesting that they do not suffer from lack of privilege and achieve success despite the challenges of being a new immigrant. However, this image masks the reality of diversity in socioeconomic status and access to societal and health resources (e.g., education and health services) within and between diverse Asian ethnic groups (Fong, 2007). For example, although the median annual income for Asian households in the US was $85,000 in 2019, only two Asian subgroups (Indians [$119,000] and Filipinos [$90,400]) exceed this figure. In contrast, the Hmong and Burmese people had the lowest median household incomes of $50,000 and $44,400, respectively (King et al., 2021). The model minority myth masks both achievements and disparities in productivity as measured by economic earnings. Such masking may result in the inaccurate and inequitable allocation of federal and states resources and investments. This myth is pervasive in health care as Asian people are believed to not experience health disparities and do not need social and civic services (King et al., 2021). This perception has had significant implications during the COVID-19 pandemic. In addition to the increase in xenophobic violence, discrimination, and harassment experienced during the COVID-19 pandemic, our understanding of the risks faced by specific Asian subgroups by the virus itself was limited because of the manner in which data are aggregated (Bacong et al., 2020). A systematic review of studies from the US and UK found that Asian individuals experienced a higher risk of COVID-19 infections compared to non-Hispanic White individuals (Sze et al., 2020). Empirical data, though limited, also show differences in outcomes between different Asian ethnic subgroups of people. One study in New York City, which had high morbidity and mortality rates during the COVID-19 pandemic, disaggregated Asian subgroups to understand the burden faced within the Asian community as it relates to infections and hospitalizations (Kalyanaraman Marcello et al., 2022). This study reported that while rates of COVID-19 positivity, hospitalization, and mortality were lower among the overall Asian group, disaggregating Asians into their ethnic subgroups revealed a very different picture. Chinese patients had a higher mortality rate (35.7%) than South Asian (23.7%) and other Asian (21.0%) patients, and this rate was the highest among all racial and ethnic groups (Kalyanaraman Marcello et al., 2022). Many Asian people living in large urban enclaves were known to have increased risk of COVID-19 exposure and illness. Factors such as multi-generational housing, employment as essential workers, lack of worker protections, and having limited access to culturally and linguistically appropriate health care burdened many Asian people during this pandemic. Most published empirical data aggregate all Asians as a monolithic group, but the reality is there is much diversity within this racial group. Nurses and midwives need to be cognizant that the evolving consensus recognizes the use of the term “Asian American” limits our understanding of the complexities of people from Asia or of Asian descent. Aggregated data prevents the unique health needs of people from different subgroups from being identified or addressed, which undermines equity while simultaneously perpetuating the model minority myth. With the increasing research on people from Asian American subgroups over the last four decades (Yom & Lor, 2021) there has been some national recognition of the heterogeneity and importance of collecting data among Asian subgroups. Policy implications are evident. In 2009, President Obama signed Executive Order 13515 to improve data collection among Asian people in the US. However, this effort focuses on the six largest Asian subpopulations in the US: Chinese, Indian, Filipino, Vietnamese, Korean, and Japanese. If all Asian people are not included, the result is a lack of funding, research, and resource allocation for omitted subgroups. Researchers are encouraged to collect more detailed data on the six specific Asian populations consistent with the Executive Order as well as include options for Asian people to self-identify their Asian-subgroup affiliation. As the theme of this editorial series is “Learning the Language of Health Equity,” there are a few simple steps nurses and midwives can take to demonstrate culturally humble communication efforts in research, education, and practice. First, and most important, is to stop using the term “Oriental” to refer to people of Asian heritage. It is an outdated and racist term that must be eliminated from our vocabulary. If the term is used, the speaker should expect to be corrected. The second step, like with Hispanic/Latinx populations, is to be aware of the dangers of grouping people by their geographic heritage and how this perpetuates health disparities along with cultural stereotypes. These two actions help improve relationships with people of Asian heritage, the quality of care they experience, and facilitate research that captures within-group differences. Additionally, we suggest that it is critical for nurses and midwives to understand the use of the term “Asian” within the broader conversations about race and racism in the US and globally. The lived experiences of people from Asia in the US and other countries are richly diverse, but remain unmentioned in current clinical, health services, and social research. Accounting for the distinct cultures among Asian peoples will not only reveal the diversity within the subgroups but enable the formation of evidence-based policy around the unique culturally specific needs of these diverse communities and identify barriers to access services and resources at the county, state, and federal level in the US. Deepening our understanding of Asians in the US and the wider globe will allow for the formation of equitable and inclusive policies that enable people from Asia to be supported and integrated within societies. Conception, intellectual content development, final version approval and integrity: P. Mimi Niles, Jin Jun, Maichou Lor, Chenjuan Ma, Tina Sadarangani, Roy Thompson, and Allison Squires. No data collected for this manuscript.