Neither Asian nor American: How COVID-19 impacted Asian Americans’ identity and well-being

Background: Asian American and Pacific Islander races are two distinct groups that continue to be aggregated in many large, national mortality statistics in the United States (US), which leads to structural biases encoded into databases and inaccurate health implications that may deprive Pacific Islander individuals from opportunities for interventions aimed at reducing health disparities. Examining mortality rates for disaggregated Asian American and Pacific Islander populations across all 50 states was not possible until 2018. We compared the leading causes of death between Asian American and Pacific Islander individuals in the US during 2018-2020, stratified by sex and age. Methods: Cause of death among non-Hispanic Asian American and Pacific Islander individuals aged ≥20 years who died during 2018-2020 were obtained from the US National Center for Health Statistics. Age-standardized all-cause mortality rates (MRs) and the 5 leading causes of death were reported per 100,000 person-years separately for Asian American and Pacific Islander individuals, by sex (female/male) and age (20-54/55-64/65-74/75- 84 years). MR ratios (MRRs) were calculated by comparing MRs among Pacific Islander with Asian American individuals (reference group), by sex and age. Results: During 2018-2020, 63,338 female and 85,601 male deaths occurred among Asian American adults, and 4,116 female and 5,512 male deaths occurred among Pacific Islander adults. Compared to Asian American individuals, all-cause mortality was higher for Pacific Islander females (MRR=2.50,95%CI=2.43-2.59) and males (MRR=2.10,95%CI=2.04-2.16). Cancer was the leading cause of death for Asian American (MR=93.8) and Pacific Islander females (MR=181.6) and second for Asian American (MR=100.4) and Pacific Islander males (MR=185.2) after heart disease. Death rates for leading causes were substantially higher for Pacific Islander compared to Asian American females: cancer (MRR=1.93,95%CI=1.82-2.06), heart disease (MRR=3.18,95%CI=2.95-3.42), stroke (MRR=2.41,95%CI=2.13-2.73), diabetes (MRR=4.03,95%CI=3.55-4.56), and COVID-19 (MRR=2.60,95%CI=2.25-3.01) and for Pacific Islander compared to Asian American males: heart disease (MRR=2.56,95%CI=2.42-2.71), cancer (MRR=1.52,95%CI=1.42-1.62, diabetes (MRR=3.14,95%CI=2.81-3.50), accidental death (MRR=2.60,95%CI=2.33-2.88), and COVID-19 (MRR=2.04,95%CI=1.82-2.27). The largest relative cancer mortality rate disparity occurred in those aged 20-54 years and declined with older age among women (MRR range=1.37-2.67) and men (MRR range=1.16-2.26). Conclusion: Cancer was among the leading cause of death for both Asian American and Pacific Islander individuals, but cancer mortality rates were twice as high among Pacific Islander women and men compared to Asian American women and men. These disparities persisted among Pacific Islander individuals for nearly all leading causes of death, regardless of sex and age, underscoring the need to disaggregate Pacific Islander from Asian American race data to improve tailored health equity-focused interventions. Citation Format: Jacqueline B. Vo, Jazmyn L Bess, Kekoa Taparra, Paloma R. Mitra, Amy Berrington de Gonzalez, Neal D. Freedman, Meredith S. Shiels, Jaimie Z. Shing. Leading causes of death among Asian American individuals compared with Pacific Islander individuals in the United States, 2018-2020 [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr A069.

Anti-Asian scapegoating, sentiment, and hate have caused devastating psychological and behavioral challenges among Asians and Asian Americans during the COVID-19 pandemic. This case study aims to understand Asians’ and Asian Americans’ experiences of racial discrimination during the pandemic, examine their reflections on the impacts of anti-Asian racism on their emotions and coping, and explore their perspectives on teaching Asian American history in combating anti-Asian racism. The results of this study showed that the participants articulated an array of profound emotional challenges in response to the deleterious effects of personal and vicarious experiences of racism. They used varied coping strategies, exhibiting heightened vigilance and intentional proactive measures to protect themselves and their communities against anti-Asian racism. The participants also underscored the intersectionality between race and gender, highlighting the vulnerability of Asian women. Additionally, the participants advocated for the inclusion of Asian American history in the school curriculum to dismantle and disrupt systematic racism. This study reveals the emotional and behavioral effects of anti-Asian racism on Asian and Asian American individuals and communities. It illustrates the crucial role of amplifying Asian and Asian American voices in the school curriculum in combating anti-Asian racism beyond the pandemic.

Cancer is the leading cause of death among Asian American individuals and the second leading cause of death among Native Hawaiian and Pacific Islander people. To evaluate longitudinal cancer mortality trends from 1999 to 2020 among Asian American and Pacific Islander populations in the US by demographic characteristics. This cross-sectional study used the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database to obtain age-adjusted cancer death rates among Asian American and Pacific Islander individuals of all ages between January 1, 1999, and December 31, 2020. Data were analyzed from January 12 to March 19, 2024. Age, sex, cancer type, and US census regions. Trends and average annual percent changes (AAPCs) in age-adjusted cancer-specific mortality (CSM) rates for non-Hispanic Asian American and Pacific Islander populations were estimated by cancer type, age, sex, and region using Joinpoint regression. Between 1999 and 2020, 305 386 Asian American and Pacific Islander individuals (median [IQR] age, 69.5 [58.5-79.2] years; 51.1% male) died of cancer in the US. Overall, the CSM rate decreased by 1.5% annually. Men experienced a greater CSM rate decrease (AAPC, -1.8%; 95% CI, -2.2% to -1.3%) compared with women (AAPC, -1.1%; 95% CI: -1.2% to -1.0%). For women, death rates decreased for most cancer types but increased for uterine (AAPC, 2.5%; 95% CI, 2.0%-3.0%) and brain and central nervous system (AAPC, 1.4%; 95% CI: 0.7%-2.1%) cancers. Colorectal cancer mortality rates increased among men aged 45 to 54 years (AAPC, 1.3%; 95% CI, 0.5%-2.1%). Liver and intrahepatic bile duct cancer mortality increased for both men and women in all US census regions, uterine cancer mortality increased in all regions for women, and pancreatic cancer mortality increased in the Midwest for both men and women. Although these findings show an overall decrease in CSM among Asian American and Pacific Islander populations, specific cancer types exhibited increased mortality rates, with further disparities by sex and age. Targeted, culturally adapted clinical and public health interventions are needed to narrow disparities in cancer mortality.

Compared to Western cultures, self-determination needs are expressed and pursued differently in Asian cultures, where interdependence and achieving greater good for the group are prioritized. To accommodate these needs, we propose the use of family-centered decision making (FCDM) to complement the shared decision-making (SDM) practice, fostering collaborative psychiatric care for Asian individuals residing in the United States. This article synthesizes various literature to outline the similarities and differences between SDM and FCDM, discuss implementation steps, challenges associated with implementation, potential solutions, and future research considerations. Our review suggests that FCDM is more responsive to and inclusive of Asian cultural experience, better reflecting these cultures' expression of self-determination. We propose a five-step framework for FCDM implementation in psychiatric rehabilitation for Asian and Asian American individuals, while identifying three further practical considerations: logistical difficulties, intrafamilial differences, and making the decision to use FCDM or not. Given the heterogeneity of Asian individuals in the United States, we urge providers to allow flexibility in practicing FCDM. We outline the important components for providers to help individuals with psychiatric disabilities distinguish between the characteristics of FCDM and SDM, evaluate the potential pros and cons of utilizing FCDM, and then initiate FCDM if appropriate or requested by the individuals. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Asian American individuals are the fastest growing racial group in the US but remain underrepresented in health disparities research, including research on skin cancer risk factors and screening. Improved understanding of preventable skin cancer risk factors and screening may demonstrate unmet needs among Asian American individuals. To examine sunburns, sun-protective behaviors, indoor tanning, and total body skin examinations (TBSEs) for skin cancer screening among Asian American subgroups compared with non-Hispanic White individuals. The National Health Interview Survey is a nationally representative cross-sectional survey in the US that assesses health behaviors. Self-identified Asian Indian, Chinese, Filipino, non-Hispanic White, and other Asian respondents from survey years 2000, 2005, 2010, and 2015 were included. Data were analyzed from July to November 2021. Any sunburn within the last year; sun-protective behaviors included applying sunscreen, staying under shade, wearing long-sleeved shirts, wearing long clothing to the ankles, wearing hats, and wearing caps most of the time or always when out in the sun; any indoor tanning within the last year; any TBSE ever. Of 84 030 participants, 5694 were Asian American (6.8%) and 78 336 (93.2%) were Non-Hispanic White; of these individuals, 1073 (weighted prevalence, 21.0%) were Asian Indian, 1165 (19.4%) Chinese, 1312 (23.5%) Filipino, and 2144 (36.1%) Other Asian. All Asian American subgroups were more likely to seek shade, wear long clothing to the ankles, and wear long-sleeved shirts but less likely to sunburn, apply sunscreen, tan indoors, and receive TBSE than Non-Hispanic White individuals. Asian Indian individuals were less likely than Chinese participants to apply sunscreen (adjusted odds ratio [aOR], 0.55; 95% CI, 0.41-0.74) or wear a hat (aOR, 0.53; 95% CI, 0.37-0.76) and more likely to wear long-sleeved shirts (aOR, 1.89; 95% CI, 1.52-2.33) or long clothing to the ankles (aOR, 1.56; 95% CI, 1.28-1.90). The results of this cross-sectional study found that disaggregated comparisons among Asian American individuals demonstrated differences in skin cancer risk factors that may be used to identify high-risk subgroups and inform culturally aware counseling when indicated. Future studies should further sample Asian American individuals to evaluate for potential masked health disparities through disaggregated analysis.

Interactions between race and county-level factors associated with mortality, such as employment, education, income, and population density, are understudied among Asian American and Pacific Islander populations. To compare all-cause, cancer, and heart disease mortality rates between Pacific Islander and Asian American adults across county-level factors. This cross-sectional study examined National Center for Health Statistics death certificate data on non-Hispanic Asian American and Pacific Islander adults (aged 20-84 years) between January 1, 2018, and December 31, 2020. County-level socioeconomic data were obtained from the American Community Survey, and population density was determined using Rural-Urban Continuum Codes. Analyses were conducted between August 1, 2023, and September 4, 2024. County-level unemployment, educational attainment, median household income, and population density. Age-standardized all-cause, cancer, and heart disease mortality rates and mortality rate ratios (MRRs), comparing Pacific Islander with Asian American individuals by sex and age. Interactions between race and county-level factors associated with MRRs were evaluated using P value for trend across county-level factors. During 2018 to 2020, 43 221 696 Asian American and 1 281 221 Pacific Islander adults resided in the US. A total of 148 939 Asian American individuals (16.7% aged 20-54 years, 17.2% aged 55-64 years, and 66.1% aged ≥65 years; 57.5% male) and 9628 Pacific Islander individuals (29.9% aged 20-54 years, 23.0% aged 55-64 years, and 47.1% aged ≥65 years; 57.2% male) died of any cause. Across all county-level factors, Pacific Islander adults had elevated all-cause, cancer, and heart disease mortality rates compared with Asian American adults (female: MRR range from 1.82 [95% CI, 1.67-1.98] for population <250 000 to 2.93 [95% CI, 2.73-3.14] for lowest unemployment tertile; male: MRR range from 1.64 [95% CI, 1.50-1.78] for lowest income tertile to 2.47 [95% CI, 2.31-2.63] for lowest unemployment tertile). Across all county-level factors, the largest relative all-cause mortality differences between Pacific Islander and Asian American adults occurred in counties with the lowest unemployment (female: MRR, 2.93 [95% CI, 2.73-3.14]; male: MRR, 2.47 [95% CI, 2.31-2.63]), highest educational attainment (female: MRR, 2.71 [95% CI, 2.53-2.90]; male: MRR, 2.39 [95% CI, 2.25-2.54]), highest median household income (female: MRR, 2.67 [95% CI, 2.56-2.79]; male: MRR, 2.25 [95% CI, 2.17-2.33]), and highest population density (female: MRR, 2.79 [95% CI, 2.67-2.92]; male: MRR, 2.37 [95% CI, 2.28-2.47]). No trends in relative cancer mortality differences between Pacific Islander and Asian American adults across county-level factors were observed overall except for greater population density among women (<250 000 population: MRR, 1.49 [95% CI, 1.25-1.76; >1 000 000 population, 2.13 [95% CI, 1.95-2.32]). The largest heart disease MRRs for Pacific Islander compared with Asian American individuals occurred among those younger than 65 years, with the greatest relative mortality among those aged 20 to 54 years in counties with the lowest unemployment (female: MRR, 14.21 [95% CI, 9.89-20.04]; male: MRR, 5.75 [95% CI, 4.58-7.15]) and highest educational attainment (female: MRR, 13.69 [95% CI, 9.68-18.94]; male: MRR, 6.17 [95% CI, 5.00-7.54]), median household income (female: MRR, 11.97 [95% CI, 9.55-14.91]; male: MRR, 5.16 [95% CI, 4.49-5.91]), and population density (female: MRR, 11.77 [95% CI, 9.39-14.62]; male: MRR, 5.48 [95% CI, 4.76-6.29]). In this cross-sectional study, all-cause mortality disparities between Asian American and Pacific Islander populations worsened in counties with higher socioeconomic status and greater population density. Historical aggregation of Pacific Islander with Asian American individuals may have misled health improvement efforts, especially for Pacific Islander adults who lived in high socioeconomic and more populated areas.

Guest Editors' Introduction

This chapter begins with a review of the definition of ethnicity and race. It considers substance use disorders (SUD), posttraumatic stress disorder (PTSD), and comorbid SUD/PTSD among five major ethnic groups represented in the United States: African American or Black individuals, American Indian/Alaskan Native individuals, Asian or Asian American individuals, Hispanic or Latino/an individuals, and Native Hawaiian or Other Pacific Islanders. The chapter deals with a discussion of the ingredients important to improving our understanding of PTSD and/or SUD among ethnically diverse populations, particularly as enhanced understanding can improve treatment approaches and outcomes. It reviews prevalence rates, risk, and preventative/protective factors regarding SUD by ethnic minority group. Substance use is a significant problem across racial ethnicities, and ethnic minorities often sustain greater hardship related to SUD as a result of poorer access to treatment, disproportionate treatment when accessed, and greater environmental, social, and economic risk factors.

The content of the Asian American model minority stereotype is important for understanding how Asian American individuals are perceived. Existing theories about stereotype content may not capture the unique historical and cultural context that could affect perceptions of Asian American individuals. We have identified a more differentiated underlying structure with four dimensions—warmth, competence, self-centeredness, and submissiveness—that differ in their rated typicality and desirability for Asian and White Americans. We then developed the 16-item Asian American Stereotypes Scale to measure perceptions of Asian Americans on these four dimensions. Ratings on the different dimensions predict unique variance in attitudes toward Asian Americans and other minority groups, contact with Asians or Asian Americans, perceptions of size of the Asian American population, and system justification. The four-dimensional model and the Asian American Stereotypes Scale allow us to predict and examine the unique impacts of Asian American stereotypes in a way that differs from more general models.

Asian Americans have been portrayed as the model minority for seemingly having achieved socioeconomic success and being free of problems. Such stereotypes may have lasting and negative impact on Asian American individuals, families, and communities. Utilizing the social justice framework and critical race feminist theory, we interrogate and problematize the model minority stereotype and its impacts by situating Asian Americans in the Black‐and‐White racial hierarchy, offering a brief history of the term, providing disaggregated statistics on Asian Americans' socioeconomic conditions, reviewing recent literature on Asian Americans and their families, and discussing some consequences that this myth generates. We focus on the roles of family and community contexts and acculturation status on Asian Americans' educational achievement, gender, and psychological adjustment and mental health issues. Our review illustrates the diversity and nuance in Asian Americans' educational, psychological, social, and economic outcomes. We conclude with some recommendations for professionals working with Asian Americans.

COVID-19 has disproportionately affected racial and ethnic minority groups, and race and ethnicity have been associated with disease severity. However, the association of socioeconomic determinants with racial disparities in COVID-19 outcomes remains unclear. To evaluate the association of race and ethnicity with COVID-19 outcomes and to examine the association between race, ethnicity, COVID-19 outcomes, and socioeconomic determinants. A systematic search of PubMed, medRxiv, bioRxiv, Embase, and the World Health Organization COVID-19 databases was performed for studies published from January 1, 2020, to January 6, 2021. Studies that reported data on associations between race and ethnicity and COVID-19 positivity, disease severity, and socioeconomic status were included and screened by 2 independent reviewers. Studies that did not have a satisfactory quality score were excluded. Overall, less than 1% (0.47%) of initially identified studies met selection criteria. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Associations were assessed using adjusted and unadjusted risk ratios (RRs) and odds ratios (ORs), combined prevalence, and metaregression. Data were pooled using a random-effects model. The main measures were RRs, ORs, and combined prevalence values. A total of 4 318 929 patients from 68 studies were included in this meta-analysis. Overall, 370 933 patients (8.6%) were African American, 9082 (0.2%) were American Indian or Alaska Native, 101 793 (2.4%) were Asian American, 851 392 identified as Hispanic/Latino (19.7%), 7417 (0.2%) were Pacific Islander, 1 037 996 (24.0%) were White, and 269 040 (6.2%) identified as multiracial and another race or ethnicity. In age- and sex-adjusted analyses, African American individuals (RR, 3.54; 95% CI, 1.38-9.07; P = .008) and Hispanic individuals (RR, 4.68; 95% CI, 1.28-17.20; P = .02) were the most likely to test positive for COVID-19. Asian American individuals had the highest risk of intensive care unit admission (RR, 1.93; 95% CI, 1.60-2.34, P < .001). The area deprivation index was positively correlated with mortality rates in Asian American and Hispanic individuals (P < .001). Decreased access to clinical care was positively correlated with COVID-19 positivity in Hispanic individuals (P < .001) and African American individuals (P < .001). In this study, members of racial and ethnic minority groups had higher risks of COVID-19 positivity and disease severity. Furthermore, socioeconomic determinants were strongly associated with COVID-19 outcomes in racial and ethnic minority populations.

Meeting Asian/Arab American StudiesThinking Race, Empire, and Zionism in the U.S. Sunaina Maira (bio) and Magid Shihade (bio) I am the witness of the massacre I am the victim of the map I am the son of simple words . . . —Mahmoud Darwish, from "Poem of the Land"1 Speak, your lips still have their liberty Speak, still yours is the spoken word . . . Speak, for the truth is alive even now Speak, say all you wish you had said. —Faiz Ahmed Faiz, from "Speak" (1941)2 Why link Asian and Arab American Studies? Why should we speak of Arab American studies in Asian American studies, or have a conversation in ethnic studies about points of convergence and divergence between these two areas? Is it in order to recognize an emerging ethnic studies field in the U.S., with all the limitations that a politics of recognition based on multiculturalism entails? Is it to extend a comparative ethnic studies approach that is increasingly transforming Asian American studies while raising questions about the definition of ethnic and racial boundaries? In our view, the answer is all of these, but much more. We argue here that speaking of Arab and Asian [End Page 117] American studies in the same breath is ultimately valuable because it illuminates a broader and more urgent issue: the need to develop a fuller analysis of U.S. empire. The meeting of Asian American and Arab American studies has been increasingly highlighted in discussions after 9/11 as it has become apparent that Asian American—particularly South Asian—and Arab American communities as well as Muslim Americans more generally, have similar experiences as targets in the "war on terrorism" waged by the United States. The question of how to produce intellectual and political knowledge to respond to the everyday crisis of empire is urgent at this particular moment, but we want to point out that it has always been so—the conjuncture between Asian/Arab American studies helps to situate U.S. empire in a much longer historical trajectory that links movements in, and out of, Asia and the Middle East. Imperial power operates by obscuring the links between homeland projects of racial subordination and minority co-optation and overseas strategies of economic restructuring and political domination. This link between the domestic and global fronts of empire can be exposed only if we expand our frame of analysis to consider the ways in which categories of subjects such as "Asian American" and "Arab American" are positioned in relation to U.S. empire. Ethnic studies has focused in large part on documenting, understanding, and challenging the construction of ethnic and racial boundaries as they intersect with other axes of domination, such as gender, sexuality, and class, within the nation. However, there has also been a movement in Asian American studies to acknowledge the transnational dimensions of Asian communities and histories, on the one hand, and the paradoxes and pitfalls of a multiculturalist identity politics, on the other. So the meeting of Arab/Asian American studies highlights the question of borders, and the political and epistemological work of boundaries in shaping our understanding of power and resistance. It helps us to locate the issue of ethnic and racial borders within the larger frame of U.S. empire, and to understand that the question facing Asian American studies today is how to intellectually and institutionally confront imperial, not just national or ethnic, politics. This has always been the challenge for ethnic studies, which has often remained confined within a national frame. [End Page 118] The purpose of linking Asian and Arab American studies is not to colonize Arab American studies within an ever-expanding rubric of pan-Asian ethnicity, but to do the opposite: to challenge the ever-expanding borders of an imperial project that operates through direct as well as proxy wars, neo-colonial occupation, and client states. Ultimately, it is for Arab Americanists themselves to decide where they want to be situated in the academy and how Arab American studies should be introduced into the curriculum. Research on Arab Americans is growing and gaining more academic recognition through new faculty hires and programs, though it continues to occur in...

Episiotomy and severe perineal laceration among Asian American, Native Hawaiian, and Pacific Islander nulliparous individuals in California.

Asian American individuals comprise over 40 ethnoracial groups but are regularly aggregated into 1 category within health workforce analysis, thus obscuring substantial inequities in representation. To describe trends in Asian American diversity across the 4 most populous US health professions (physicians, registered nurses, nursing assistants, and home health aides) and to characterize subgroup representation within professions. Serial cross-sectional study from American Community Survey (ACS) population estimates of people reporting health profession occupations from 2007 to 2022. The ACS samples US residents every day, with approximately 3.5 million surveyed each year. Based on their sampling methods, the ACS then produces estimates of the entire US population for 1-year, 3-year, and 5-year periods. Data were analyzed from April to August 2024. For each year and subgroup, the proportions of the US population, the profession, and Asian American individuals within the profession were calculated. The representation quotient (RQ) of each subgroup was then calculated, defined as the proportion of the subgroup within the profession of interest divided by the proportion of the subgroup within the US population. Trends were examined over the 15-year period. Over the 15-year period, Indian Americans composed the largest percentage of Asian American physicians (mean [SD], 40.6% [1.6%]), followed by Chinese Americans (mean [SD], 18.9% [1.4%]). Pakistani and Indian Americans had the highest relative representation (mean [SD] RQ, 8.9 [0.9] and 7.8 [0.9], respectively). Conversely, Cambodian and Hmong Americans remained largely underrepresented (mean [SD] RQ, 0.2 [0.2] for both). Filipinx Americans accounted for more than half of Asian American registered nurses and nursing assistants, with high relative representation (mean [SD] RQ, 5.6 (0.3) and 2.9 [0.4], respectively). Bangladeshi and Chinese American relative representation were high among home health aides (mean [SD] RQ, 4.1 [1.5] and 2.7 [0.5], respectively). Asian American individuals accounted for an estimated 22% of physicians (approximately 260 693 respondents), 10% of registered nurses (approximately 420 418 respondents), 4.8% of nursing assistants (approximately 93 913 respondents), and 8.3% of home health aides (approximately 60 968 respondents) in 2022. By examining disaggregated data, this study found persistent inequities among Asian American subgroups in the health workforce. Reducing Asian American populations to a single racialized group erases subgroup differences rooted in histories of racism, colonialism, and xenophobia; enables false narratives of Asian American overrepresentation and success; and hampers progress in advancing health justice.

Asian American graphic narratives typically produce meaning through arrangements of images, words, and sequences, though some forgo words completely and others offer an imagined “before” and “after” within the confines of a single panel. Created by or featuring Asian Americans or Asians in a US or Canadian context, they have appeared in a broad spectrum of formats, including the familiar mainstream genre comics, such as superhero serials from DC or Marvel Comics; comic strips; self-published minicomics; and critically acclaimed, award-winning graphic novels. Some of these works have explicitly explored Asian American issues, such as anti-Asian racism, representations of history, questions of identity, and transnationalism; others may feature Asian or Asian American characters or settings without necessarily addressing established or familiar Asian American issues. Indeed, many works made by Asian American creators have little or no obvious or explicit Asian American content at all, and some non-Asian American creators have produced works with Asian American representations, including racist stereotypes and caricatures. The earliest representations of Asians in comics form in the United States were racist representations in the popular press, generally in single-panel caricatures that participated in anti-immigration discourses. However, some Asian immigrants in the early to mid-20th century also used graphic narratives to show and critique the treatment of Asians in the United States. In the realm of mainstream genre comics, Asian Americans have participated in the industry in a variety of different ways. As employees for hire, they created many well-known series and characters, generally not drawing, writing, or editing content that is recognizably Asian American. Since the 2010s, though, Asian American creators have reimagined Asian or Asian American versions of legacy characters like Superman and the Hulk and created new heroes like Ms. Marvel. In the wake of an explosion of general and scholarly interest in graphic novels in the 1990s, many independent Asian American cartoonists have become significant presences in the contemporary graphic narrative world.