Shortly after the Atlanta shooting of Asians on March 26, 2021, we read an article in Time magazine that hit us emotionally. Titled “‘We Are Always Waiting Our Turn to Be Important.’ A Love Letter to Asian Americans,” Lucy Feldman wrote “a piece that says the thing I would want to read. A piece that tells me, as an Asian-American person who has deferred and cared and tried so hard to help, that I am worthy of the same. That we are worthy. You are worthy.”1 Constituting 7% of the US population, Asians constitute the fastest-growing racial group,2–4 yet too often Asian Americans and Asians are invisible in America, including in public health practice, education, and policy. The COVID-19 pandemic exposed long-standing racism and discrimination against Asians. Some public officials scapegoated Asians with slurs that helped create an environment conducive to violence such as the Atlanta shooting.5 In this article, we discuss what makes Asians invisible, how invisibility has made them more prone to structural racism, and what the public health ramifications are for physical and mental health. We offer recommendations for how public health professionals at local, state, and federal agencies and at academic institutions can address the pervasive structural racism against Asians by making them visible.
Why Are Asians Invisible in the United States?
“Asia” is a European concept that artificially imposes uniformity on diverse groups. Originating from ancient Greek, the term “Asia” imposes uniformity on the others—lands, peoples, and cultures—beyond the east border of the Western world. Home to more than half the world's population, Asia includes approximately 50 countries, with hundreds of languages, many religions (eg, Hinduism, Islam, Buddhism), and countless social norms. In the United States, Asians are the most rapidly growing immigrant group, with 2 out of 3 Asians being immigrants, and are estimated to exceed Hispanics by 2065.3,4 They originate from East Asia (eg, Chinese), Southeast Asia (eg, Thai, Vietnamese), and South Asia (eg, Indians). Each region has many ethnicities, with distinct physical features and complex histories of dominance and oppression within and across ethnicities that predate US history by thousands of years. Yet, these heterogeneous populations are lumped together by the term “Asia.” Health data sets usually do not disaggregate these populations, masking health disparities.6 Viewed as monolithic, Asian individuals are too often confused with another Asian person with totally different skill sets or physical appearances,7,8 facilitating a discriminatory bamboo ceiling for career advancement to leadership positions.9,10 Subhuman caricatures, offensive words, and images of Asians that originate from historic events such as wars (eg, “Japs,” “Chinks,” “gooks”; fetishized or sexualized images of Asian women) predispose Asians to violence.11
The history of structural racism against Asians in the United States is untold. The United States has a long history of viewing Asians as “perpetual foreigners” since the arrival of the first wave of Chinese immigrants in the 1850s. Xenophobia led to the Chinese Exclusion Act of 1882, the first and only US immigration law that targeted all people of a specific ethnic or national origin. On February 19, 1942, Executive Order 9066 authorized more than 110 000 persons of Japanese ancestry, regardless of US citizenship, to be forcibly removed from their homes, careers, and communities in the western United States to live in American concentration camps, despite no evidence of espionage. Japanese people who underwent physical, mental, and material traumas of incarceration kept silent and seldom talked about the shame of “camp” even with their children.12 Many of their offspring did not know much about their experience until dedicated groups of individuals advocated for justice decades later.13
Stereotypes as “perpetual foreigners” and “model minorities” reinforce monolithic images of Asians as the “Other” and a group that does not need help, encouraging structural racism and blocking opportunities. In 2020, the American film Minari by Korean American director Lee Isaac Chung was placed in the best foreign language film category by the Golden Globes because about 50% of the dialogue was in the Korean language, an example of how media structurally present Asian Americans as the Other.14 The Model Minority Myth, that all Asians are educated, successful, and prosperous, whitewashes health disparities within diverse “Asians” and has been used by the dominant White racial group to divide Asians from African American, LatinX, and American Indian racial/ethnic groups.15 The Model Minority Myth implicitly asks, “Why can't other minorities be like Asians?” The Model Minority Myth has also contributed to the de facto exclusion or discounting of different Asian subpopulations from some programs designed to advance racial/ethnic minoritized populations, whether in NIH or the NFL. When Korean American football coach Eugene Chung was being interviewed for an NFL coaching position, he was told: “Well, you're really not a minority.... You are not the right minority we're looking for.”16 Reflecting on this event, Chung pointed out how Asian invisibility contributes to limited response to anti-Asian violence and anti-Asian actions, “Oh, let's just push it under the rug because it's these people and it'll eventually just go away.”
Lack of advocacy to protest invisibility. Asians have survived racism by keeping their heads low. Activism has long been foreign to many immigrants from East Asia. Their social norms are represented by a well-known Japanese proverb, deru kugi wa utareru, meaning the nail that sticks out gets hammered down, the opposite to the American proverb, “the squeaky wheel gets the grease.”17 Divisions within Asian American communities make it difficult to unite Asians for advocacy. Historical conflicts among Asian countries create tension and distrust. Different languages prevent communication across different ethnic groups. Cultural traditions and social norms associated with age and gender roles can create tension within each ethnic group. Tension also arises between first-generation immigrants raised with social norms of their country of origin and those who were born and/or raised in American majority norms.
Conceptual Model for Public Health Battling Structural Racism Against Asians
This special issue of the Journal of Public Health Management and Practice defines structural racism as “a system in which public policies, institutional practices, cultural representations, and other norms work to perpetuate racial group inequity. It is rooted in a hierarchy that privileges one race over another, influencing institutions that govern daily life from housing policies to police profiling and incarceration. It is associated with the social determinants of health and health disparities.”18,19 Dr Camara Jones notes that institutionalized racism leads to differential access to resources, opportunities, and power.20 Jones defines personally mediated racism “as prejudice and discrimination, where prejudice means differential assumptions about the abilities, motives, and intentions of others according to their race, and discrimination means differential actions toward others according to their race.”20(pp 1212–1213) She defines internalized racism “as acceptance by members of the stigmatized races of negative messages about their own abilities and intrinsic worth.”20(p1213)
Health care and public health constitute systems that may reinforce, or may be reinforced by, structural racism.21,22 Whether intentional or unintentional as shown in the Figure, institutionalized racism reinforces personally mediated racism and internalized racism in public health. For example, policies and prioritization criteria that ignore vulnerable Asian subgroups feed perceptions that Asians do not require resources and attention in public health programs, academic literature, or workforce development.20 These biased perceptions, beliefs and values, and unjust distribution of resources in public health can lead to personally mediated racism such as microaggressions experienced by Asians with specific health needs and a diminished voice for people who represent Asians' health needs. Institutionalized racism and personally mediated racism can cause internalized racism in which Asians believe their health needs are unworthy of attention and may not even recognize racism against themselves. Structural racism (eg, data systems, explicit rules, and implicit norms that treat Asians as monolithic) breeds and proliferates Asians' invisibility. In turn, invisibility facilitates structural racism. Thus, the 3 levels of institutionalized, personally mediated, and internalized racism have a symbiotic relationship with invisibility and ultimately cause health disparities for Asians; that is, racism and invisibility adversely affect the health and well-being of Asians along interrelated physical, mental, social, and cognitive dimensions. Invisibility means Asians' issues will not be addressed and Asians will not receive adequate resources.23 Asians with multiple intersectional issues (eg, age, gender, ethnicity, language, disability, education, income, country of origin, and citizenship categories) are at particularly high risk, such as an older Asian woman with limited English proficiency and low education who is not a US citizen.8,24
These symbiotic relationships among racism, invisibility, and health operate in the contexts of place and time. Place refers to where people live, work, learn, and play. For example, some Asians live in concentrated urban ethnic enclaves and others are isolated in suburbs where few other Asians reside. Structural racism operates in the workplace, schools, and neighborhoods. Time involves historical time, one's chronological age, and cohorts of people who experience historical events at the same age throughout their life course.25,26 Older Japanese Americans who were interned in American concentration camps during World War II have responses to racism and invisibility that are different from those of their children who will have lived through a different set of historical events and social norms when they reach the same age. People who were raised in the era of valuing their identity, rather than denying it to assimilate, are more comfortable speaking up and using a confrontational coping strategy in contrast to the silence used by earlier cohorts.12
Recommendations for Public Health Communities to Address Structural Racism Against Asians by Making the Invisible Visible
We advocate for public health to combat structural racism against people of color with a multilevel life course approach that addresses individual, family, organizational, community, and policy factors, cognizant of their lived experience.27 Public health communities should take every opportunity to make the invisible visible for Asians to battle structural racism as follows:
- Collect, report, and analyze granular ethnicity and language data and complement with qualitative data to shine light on the heterogeneity and intersectionality of Asian populations. Standard government and industry data collection forms and data collection procedures should include granular ethnicity and language elements. Staff need to be taught how to collect these data in ways that engender trust from queried persons.28 Collection and quantitative analysis of granular ethnic categories can be difficult except in communities with a large number of each ethnicity/language. The government cannot report small cell sizes, people are afraid of being identified, and Asians speak dozens of languages other than English. Recommendations include using administrative data, partnering with communities, and recognizing that some data are better than no data.29 Qualitative work should be valued and performed to provide information on populations with small size, to explore intersectional issues of race and ethnicity and other identities, and to provide greater insight into the issues affecting Asians.
- Teach Asian American history including the history of discrimination and structural racism. Education about the Asian American experience is a critical foundation for raising awareness about structural racism.30 Education is important not only for non-Asians but also for Asians so that they recognize their importance in the history of structural racism in the United States.31 Education should target all, from K-12 to higher education to work places and older adult living communities. Massive public education helped achieve the seemingly impossible goal of reparations for incarcerated Japanese Americans and may serve as an inspiration for public health communities to help the public understand and battle structural racism.
- Empower Asians born in the United States and elsewhere to address racism and microaggressions. Asian immigrants may come from societies that limit free speech and political advocacy. Asians may not perceive that racism and microaggressions against them are unacceptable or may not feel that they can advocate for themselves.32,33 Trust is initially challenging if people look different or do not speak the same language. Thus, trust can be difficult to establish between non-Asian Americans and Asians and across ethnic groups among Asians. We need to empower Asians to embrace their entirety, tell their stories,34–36 and advocate for themselves.37,38 In essence, Asians should just “be yourself” as one (M.C.) of our fathers advised throughout life. Such empowerment is critical, and Asians should be an important part of the discussion around racism and health equity. Understanding and appreciating intersectional differences among individuals paradoxically bridge people in different categorical groups.
- Recognize language as a source of racism. Language is a powerful tool of domination used by rulers throughout history39 (eg, American Indians, Spanish and English colonization, Japanese in Korea). Whether and how well one uses the dominant language in a society impacts not only one's ability to communicate and understand health-related information but also one's power to operate in an environment where institutionalized, personally mediated, and internalized racism operate.40,41 Public health communities should advocate for providing interpreter services to allow Asians with limited English proficiency to tell their stories and be heard. Interpreter services are important both for improving their clinical care and for sharing their experiences to inform public health efforts. In addition, public health communities should pay increasing attention to how institutionalized, personally mediated, and internalized racism about language (eg, accents) undermines the health and well-being of Asians.42
- Fight language and media images that slur and stereotype Asians and make them invisible. Change public norms about the acceptability of slurs against Asian Americans. Understand the power of language, imagery, social norms, and culture. Languages carry social norms. Pushback was not sufficiently strong when politicians used dog whistle slurs such as the “Chinese virus” and “Kung flu virus” when discussing the COVID-19 pandemic.43 Stereotypical media images of Asians as geeks, gangsters, emasculated men, and exotic sexualized women hide the truth about Asians,44 and gloss over heterogeneity of Asians across intersectional dimensions such as ethnicity, class, immigration status, language, culture, occupation, and sexual orientation/gender identity.
- Recognize that many Asians are geographically dispersed and isolated, and some live in ethnic enclaves. Place is important for public health approaches,45 and the role of isolation has frequently received insufficient attention. Investing in historically neglected ethnic urban enclaves can improve health,46 but Asians are not always living in Chinatowns or Koreatowns. Asians also live in the suburbs and rural areas surrounded by people who do not look or behave like them. Asians are everywhere but may not be the majority in most places. In Chicago, the Japanese community is dispersed.47 Structural racism, including the experience of being incarcerated in American concentration camps during World War II, made Japanese people not want to be seen as a group in many cities. Asians are diverse with various languages and social norms. Thus, public health approaches will need to be tailored to both dispersed and concentrated geographic contexts for Asians.
- Identify specific health needs and address structural problems with multilevel approaches taking into account the contexts of place and time. For example, many Asians have mental health conditions such as depression and posttraumatic stress disorder due to structural racism, microaggressions, historical trauma (eg, American concentration camps for Japanese Americans; Cambodia genocide), and the Model Minority Myth.12,29,48–50 Appropriate outreach, screening, and treatment are critical. Design and implement culturally tailored, multilevel interventions including public messaging campaigns that destigmatize mental illness.51,52 Partner with community-based organizations and do mobile health outreach. Educate providers with little experience caring for Asian immigrants. Provide culturally appropriate counseling, and develop effective ways to describe antidepressant medications in ways that are understandable and respectful of people's autonomy. Address occupational health issues such as workplace stress caused by microaggressions.53 Improve access to preventive services to increase cervical cancer screening rates in Vietnamese and Cambodian populations.54 Nurture the economic development and health of urban ethnic enclaves such as Chinatowns whose businesses were especially ravaged by the COVID-19 pandemic and worsened by xenophobic and discriminatory messages by politicians.
2021 is an awakening moment for Asians worldwide,53 and for Americans reckoning with structural racism made stark by police brutality against people of color and racial/ethnic inequities in COVID-19 prevalence and outcomes.55 Structural racism is a public health crisis.56 Racism saps energy and strength from organizations, communities, and society. Racism generates stress and health problems in discriminated individuals. If Asians are perpetually waiting to be seen and valued, we cannot create a society in which all people reach their full potential.57 Now is the time to make the invisible visible for Asians who have suffered from structural racism.
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