Tom Sullivan | March 24, 2021
Editor’s note: The tragic incidents in Atlanta last week put in stark relief escalating racism and attacks against Asian Americans, as well as calling further attention to our nation’s gun violence and mental health crises. In addition to expressing our horror, sympathies, and “we stand with” sentiments, we will leverage our unique platform (as with other such societal concerns) to draw linkages to the health care ecosystem, convening and inspiring our community of health care leaders to play a constructive role for positive change.
Despite the ongoing racism, microaggressions and hate crimes against them, Asian-Americans have been something of an “invisible population,” which only serves to worsen existing disparities in health. That’s according to Karen Kim, MD, Director, University of Chicago Medicine’s Center for Asian Health Equity.
The Center published a statement condemning the increase in racist acts against Asians in February 2021, a month prior to the tragic murders in Atlanta that shined a spotlight on the 150 percent increase in hate crimes perpetrated against Asian-Americans during 2020 while the rest of the nation experienced a seven percent decline.
Health Evolution Editor-in-Chief Tom Sullivan interviewed Kim, who also serves as Associate Director of the University of Chicago Comprehensive Cancer Center and a Professor of Medicine, about what she hopes will change because of the Atlanta murders, why health care executives should lead in disaggregating data relative to different Asian-American populations and the need to raise awareness about and within the community.
Health Evolution: Why did it take multiple murders of the magnitude in Atlanta to bring anti-Asian violence into the national spotlight?
Kim: We’re often not classified as a person of color, we don’t have a lot of data collected about the different populations. Politically, this has been an invisible community and despite the discrimination and microaggressions against it, people have not ever been moved to change things. Instead, the stereotype is that the Asian-American population follows rules, makes money, is educated — and that translates into being overlooked. Asian-Americans need to empower their community to finally find its voice, to demand services that are needed because when you don’t, you often get overlooked.
Health Evolution: What should health care executives understand about the problem that many likely do not?
Kim: There are several things to understand. We need to collect relevant data for Asian-Americans and disaggregate that data to look at various subgroups that tell different stories. Asian-Americans are about 6 percent of the US population and speak over 100 different languages. Asian-Americans are the fastest growing population in the U.S., having grown 25 percent over the last 7-8 years and two-thirds of that growth comes from immigrants, while only one-third of the Hispanic community’s growth consists of immigrants.
There have also been a lot of challenges. The Public Charge, for example, which has changed under President Biden but was used by the previous administration to determine who should have legal status based on whether they thought you would use government resources. If they did, you could lose eligibility. So 1.5 million Asian–Americans declined enrollment in Obamacare. The problem now is that we need to get the word out on the street, because we also saw declines in people going to federally qualified health centers. When many households have no one over 10 years old who speaks English and 75 percent of households do not speak English at home, delivering the message to communities is difficult.
But the biggest issue is that hospitals have to make the commitment that, among so many other competing priorities, the wellbeing of vulnerable populations is something they prioritize working to achieve. It’s a challenging problem but we have to take on this challenge now.
Karen Kim, University of Chicago Medicine's Center for Asian Health Equity
Health Evolution: Among the Center for Asian Health Equity’s focus areas is social determinants of health. Which social determinants are unique to Asians?
Kim: Immigration status. Even for legal permanent residents, it takes five years of living here before you are eligible for Medicaid so you are effectively blocked from insurance. As a result, 20 percent of Asian children have no insurance and that’s compared to 4 percent of children overall. That puts Asian-Americans at risk for lack of insurance. This is compounded by the highest rates of limited English proficiency. Hospitals and health systems need to have mechanisms to communicate, but current mandates don’t enable them to be reimbursed so hospitals are not incentivized. We can’t just put that responsibility onto hospitals, however, we have to change policy.
Health Evolution: What can health care leaders do now to address these problems?
Kim: Partner with community-based organizations that do a lot of work communicating to Asian-American communities. Partnerships are essential because hospitals cannot do this alone. Unless you are in a place where you see very large numbers of marginalized populations — like in California where 40 percent of Asian-Americans in the U.S. live — you won’t understand the unique needs of these populations. Many parts of the country do not have large numbers so it’s not for a lack of interest but there is a need to partner with someone to help deliver services in a culturally competent manner.
Health Evolution: Speaking of large volumes, you touched on the need to disaggregate data about Asian-American populations because there are differences between the subgroups. What should health care leaders understand about that need?
Kim: It’s important to understand where individuals come from to risk stratify their ability to achieve health. Also, it’s important to know if someone is an immigrant, if they speak English or not at intake so that is a question providers should be asking. It’s also necessary to know how long they’ve been in this country. The data needs to be disaggregated because you only see patterns in disaggregated data, such as differences between specific Asian ethnic groups, such as Korean or Burmese individuals.
Another challenge is that only 10 percent of data collected by the federal government on Asian Americans is actually reported. We need to stop omitting Asians as a population and stop acting as if the data for one Asian-American population applies to all Asian-American populations. It is only through looking at disaggregated data that we see shocking patterns of health disparities, such as high rates of gastric cancer among Koreans. If you look at the aggregate we fare well and this can impact resource allocation. I’m worried about this year’s Census because if we’re undercounted then there’s no data, there’s no problem, and if there’s no problem, there’s no policy to fix it.
Health Evolution: What do you anticipate that disaggregating health data about Asian-Americans would reveal?
Kim: My research and others around the country looked at individual differences between Asian subgroups. They’re quite striking from immigration history, language efficiency, insurance and disease prevalence. From the perspective of a health care system, it would be very important to understand which populations are going to have higher risk for chronic disease such as diabetes or to understand that South Asians have the highest rates of cardiovascular disease among all racial/ethnic groups. In fact, in Chicago, only the Asian population has diabetes in the top 5 causes of death. You might not associate diabetes with the Asian population since in general, obesity is not highly prevalent. However, research has shown that Asians are a ‘skinny-fat’ population and present with diabetes at a much lower weight. It’s the only population for which the American Diabetes Association guidelines recommend screening for diabetes at BMI significantly lower (almost 20 pounds) than any other population. But we know it is essential to implement these guidelines among providers, but this has not happened in a systematic way and therefore, 50 percent of diabetes goes undetected in this population even when they see a primary care physician.
Health Evolution: You described the challenges of communicating to the Asian-American community but are there systemic or underlying issues inhibiting that information from being disseminated?
Kim: There are multiple barriers to effective communication. First, high rates of limited English proficiency which impede timely dissemination of information. Second, the absence of culturally competent systems that can ensure communication channels are effective and utilized. Lastly, persistence of systemic racism, both explicit and implicit which minimize the importance of Asian American issues. The Atlanta killings are a very real example of the inability to label these senseless killings as a hate crime.
Health Evolution: What do you envision changing as a result of the violence in Atlanta and the attention is has brought to the problem?
Kim: After this most recent set of killings, there has been a reckoning and I’m hoping the sense of urgency that many of us have felt for years lasts. Black Lives Matter has propelled intolerance and sets the stage for all minority communities to rise up together to fight against racism and discrimination. Now that the issues in the Asian-American population are more mainstream, I’m hoping that there will be allyship with other minority groups. The past administration fueled the fire by calling COVID-19 the Chinese Flu, the Asian Flu, the Kung Flu. In 2020, hate crimes declined by 7 percent but rose 150 percent against Asian-Americans. Efforts such as Stop AAPI Hate began because they knew this would become a problem. Raising awareness is the first step. I’m seeing it in the press now. Seeing people step up to address the problem. It has been a long coming. We’ve been waiting to exhale and the Center for Asian Health Equity has been primed and ready to move from an advocacy perspective and serving as a force to demand fair treatment for everyone. That’s really all we want.