Headlines, health experts and policy makers rarely talk about COVID and Asian American disparities. Yet reports show that Asian Americans and Pacific Islanders (AAPIs) suffer from disproportionately high COVID death rates and hospitalizations. To make matters worse, their suffering remains largely overlooked in a form of invisible but deadly racial bias.
In an analysis of 50 million U.S. patients, Asians were most likely to die from COVID and to be hospitalized compared to white patients, according to a September 2020 report from Kaiser Family Foundation and Epic Health Research Network.
Media outlets did not flag COVID’s impact on Asian Americans. Yet among patients who tested positive for COVID, Asians were 57 percent more likely to be hospitalized and 49 percent more likely to die compared to whites with similar sociodemographic characteristics and underlying health conditions. Hispanics were 53 percent and 30 percent more likely to be hospitalized and die compared to whites, followed by Blacks patients at 33 percent and 19 percent respectively, said the Kaiser/Epic report.
Another study of more than 85,000 patients in New York City’s public hospital system also showed high COVID death rates and hospitalizations for Asians, especially for Chinese and South Asian patients respectively.
On a more granular level, COVID has devastated specific groups of AAPIs, such as Filipino nurses. They account for nearly one third of COVID-related nurse deaths although they are just 4 percent of nurses in the U.S. In California, Native Hawaiians and Pacific Islanders (NHPI) had the highest death rates of any racial and ethnic group in the state, according to the NHPI COVID-19 Data Policy Lab at UCLA.
Yet these alarming numbers about Asian Americans and COVID get little attention from mainstream media, academics and public health experts. Thus, resources to prevent and treat COVID are not fully deployed, which results in needless death and suffering. Vulnerable Asians—low-income, elderly, immigrants with limited English, and 1.7 million undocumented who can’t readily access health care—are especially at risk. But they are neglected, sometimes until it’s too late.
LOW TESTING AND BARRIERS TO HEALTHCARE
Many vulnerable Asians work in restaurants, salons, housekeeping, factories, construction and other low-wage jobs where they cannot work from home, don’t have paid sick leave, and commute on public transportation. They are also more likely to live in multigenerational homes in close quarters so are at greater risk of transmitting COVID.
But COVID’s impact on Asian Americans is masked due to many reasons. First, national statistics track positive COVID-19 tests. There are many barriers to testing, including anti-Asian racism. As if a deadly virus weren’t enough to contend with, Asian Americans face rising racist harassment and attacks during the pandemic. In a vicious attack in April, a Chinese man collecting cans in Manhattan was stomped repeatedly in the head.
With Asians getting “spat on, beaten up, killed … we suspect the Asian community was not getting tested for fear of leaving their homes,” says Ninez Ponce, director of the UCLA Center for Health Policy Research. “Testing sites may have been further away from home and not as safely accessible,” she adds.
Many Asians also don’t get tested and treated, because of limited English, cultural barriers, transportation problems and lack of health insurance. In the U.S., more than 13 percent of AAPIs lived in poverty and 15 percent were uninsured in 2012. And 35 percent of AAPIs were limited-English speakers. Language is a big factor for serving vulnerable Asian patients, says Perry Pong, chief medical officer at the Charles B. Wang Community Health Center in New York. The majority of the center’s patients are Asian immigrants. Roughly 10 percent are uninsured, and about 60 percent are on Medicaid.
Lack of internet is another barrier for getting through health care bureaucracy. “If you’re tech savvy, that’s great. But if you’re not, and your child or relative can’t help you, you’ll have a harder time navigating Web sites,” says Pong. The tech divide is wider for elderly Asians, especially during the lockdown when people cannot go to clinics or community centers for help. Even if they can get help in person, accessing health care and services during the lockdown usually requires an email address, which vulnerable seniors might not have. Staff at non-profit Korean Community Services of Metropolitan New York regularly helped elderly set up email accounts and scan documents, says Monica Lee, KCS communications officer. KCS’ bilingual staff can assist seniors, but Lee notes that other sites may not be able to.
HIGH DEATH RATES
Even Asian Americans who can get tested show alarming health disparities, as in the case of Filipino nurses. Across the U.S., 67 Filipino nurses have died of COVID and complications as of September 2020. They account for 31.5 percent of deaths of registered nurses, compared to their 4 percent share of the U.S. nurse population, according to a report from National Nurses United, the country’s largest nurses’ union.
Filipino nurses may be more vulnerable because of living in multi-generational homes and their tendency to work in intensive care units and other acute nursing jobs. They also have underlying health risks such as diabetes and heart disease.
On a much larger scale, the Kaiser/Epic analysis found that hospitalization for Asian COVID patients was 15.9 per 10,000 patients—more than double that of 7.4 for white patients, as of July 2020. There were 4.3 deaths per 10,000 Asian patients compared to 2.3 among whites, according to Kaiser Family Foundation and Epic Health Research Network. The report was based on patients in the Epic health record system, which includes 399 hospitals in 21 states.
The disparities could be partly linked to undertesting of Asians. Barriers to health care might lead to Asian patients delaying care until COVID symptoms are advanced and more difficult to treat.
Indeed, the testing rate for Asians was the lowest of all races in the Kaiser/Epic analysis. For every 10,000 patients, 345 Asians were tested for COVID compared to 489, 461 and 408 per 10,000 for Black, Hispanic and white patients respectively.
Asians, Blacks and Hispanics “were more likely to require oxygen or ventilation at the time they tested positive,” notes the Kaiser/Epic report.
Pong also observed that trend among patients in New York. “We have seen people waiting too long,” he says. By the time they get to the hospital, their oxygen levels were dangerously low.
In the analysis of patients at New York public hospitals, Chinese patients had the highest death rate of all patients who tested for COVID in New York City’s public hospital system. They were nearly 1.5 times more likely to die than whites.
South Asians had the highest rates of positive tests and hospitalization among Asians, second only to Hispanics for positivity and Blacks for hospitalization, according to researchers at NYC Health + Hospitals, the largest U.S. public health care system, and N.Y.U. Grossman School of Medicine. Their preprint study was based on 85,328 patients who tested for COVID at NYC H+H, New York City’s public hospital system, from March through May 2020.
NYC H+H serves more than one million patients, including many lower-income Asian Americans, who are typically underrepresented in national data sets. South Asians were not disaggregated in the analysis, but it’s likely that Bangladeshis were a large proportion of COVID patients. New York has a large population of low-income immigrant Chinese and Bangladeshis, who both have high rates of diabetes. Low-income immigrants are more likely to have poor access to health care and to delay treatment until they are very ill, explains Stella Yi, assistant professor at N.Y.U. School of Medicine and co-author of the study.
Fear of so-called public charge, may also have been a factor, says Yi. The Trump administration rule tracked immigrants’ use of public assistance and could jeopardize applications for U.S. citizenship. Keep in mind that national statistics capture known deaths resulting from COVID-19. They don’t include undiagnosed people or those who died from related causes. One indicator of broader COVID fatalities is “excess deaths”—the number of deaths from all causes, in excess of the expected number for a given place and time.
Excess deaths for Asians were disproportionately high, according to an October 2020 report from the Centers for Disease Control. There was a 36.6 percent increase in deaths among Asians from January to October 2020 compared to the average between 2015 and 2019. Compare that to an 11.9 percent increase in deaths for whites, 53.6 percent among Hispanics and nearly 33 percent rise for Black people.
The cause of Asian excess deaths is unknown. But physicians anecdotally observe that it is common for vulnerable Asians to hesitate before seeking medical care. Amy Tang, director of immigrant health at North East Medical Services (NEMS) in San Francisco, notes that some of her Asian patients were so fearful of both COVID and racist harassment that they ignored routine medical care for diabetes, hypertension and other ailments.
One Asian woman ignored strokelike symptoms and refused to go to the hospital, says Tang. “I was worried people would die from not being willing to seek medical care for other things,” she says. The majority of NEMS’ patients are lower-income Asians in the Bay Area and most speak limited English.
Disparities among Asian Americans also show up in higher case fatality rates (CFR)—the ratio of COVID deaths to infections. In California, the Asian American CFR was three times that of the overall population at 8.4 percent versus 2.6 percent last year. The rate was more than 10 percent in Los Angeles, Chicago, New York City and New Jersey, according to an analysis by researchers affiliated with the Asian American Research Center on Health in San Francisco, using state and local data accessed between May and July 2020. In Clark County, Nevada, the CFR was 16.8 percent when the county’s population of AAPIs is 10.4 percent. Those figures were unadjusted for socio-demographics and health conditions.
Higher case fatality rates for Asian Americans might indicate they “lack sufficient diagnostic testing, face a higher risk of death from COVID-19 on average, or both,” the researchers wrote.
Asian COVID deaths and hospitalizations are high—yet are probably still undercounted. Last year, many states did not collect COVID data for Asians. Data on Asians is collected “haphazardly”, says Tung Nguyen, professor of medicine at University of California, San Francisco. Yet those incomplete statistics set policy agendas and lifesaving COVID response initiatives.
Asian COVID cases might be lumped in the miscellaneous category of “Other.” Or they might be miscategorized and go uncounted. The NYC H+H study identified 4,000 Asian patients who had been categorized as “Other” or “Unknown,” says Roopa Kalyanaraman Marcello, senior director of research and evaluation at NYC H+H and lead author of the study.
AAPIS ARE NOT MONOLITHIC
These racial disparities must be urgently addressed. Disaggregating data on Asians is an important demand. Asians include more than 20 ethnicities. They are socioeconomically diverse and have starkly different backgrounds, from war refugees and the undocumented to immigrants who arrive with expert visas, as well as U.S.-born AAPI with graduate degrees, and the wealthy.
But when Asians are lumped together, those nuances are lost. Their challenges—especially those of poor, limited-English speakers—are rendered invisible when aggregated with well-off Asians.
Even without disaggregation, data already show that COVID is disproportionately killing and harming Asians. But the myth that Asian Americans are “doing fine” is myopic and leads media, policymakers and donors to ignore their suffering.
To fill in gaps, community organizations have launched their own initiatives, such as vaccination drives and outreach with translated information. These efforts are noble, but they are piecemeal; many vulnerable Asians may fall between the cracks. And the longer-term effects of COVID on Asians may also be overlooked.
When overburdened grassroots organizations shoulder more work, that lets government and well-resourced institutions off the hook. Meanwhile, local nonprofits “are sucking it up and doing so much more,” says Nguyen. “If you’re Asian and poor, you’re suffering. But if you’re trying to help them, you’re suffering too." Federal support is necessary to make headway,he adds. “There’s no way we can match what government can do.
Researchers are also doing extra work. NYC H+H and researchers did their study because data on Asians are “not routinely reported by government or by researchers,” says Yi of the N.Y.U. School of Medicine. Academic literature on Asian Americans and COVID did not match the disturbing reality in Asian communities and hospitals.
AAPI public health researchers have formed their own working group “because no one cares,” says Nguyen.
Small, local organizations need more funding and support as they take on roles far beyond their scope, such as when senior centers becoming vaccination clinics. Researchers and doctors who focus on AAPIs also need more support.
Policy makers, academics, media and health leaders must all wake up to COVID’s impact on Asian Americans and Pacific Islanders who desperately need help. Ignoring them is gaslighting and inhumane—and it’s also a form of racism.
This is an opinion and analysis article.