Proceedings of a Workshop—in Brief

COVID-19, Health Equity, and the Asian American, Native Hawaiian, and Pacific Islander Communities

Proceedings of a Workshop—in Brief

The National Academies of Sciences, Engineering, and Medicine’s (the National Academies’) Roundtable on the Promotion of Health Equity planned and hosted a 2-day public workshop titled COVID-19, Health Equity, and the Asian American, Pacific Islander, and Native Communities. The workshop focused on the impact of the COVID-19 pandemic and the unique obstacles faced by the Asian American, Native Hawaiian, and Pacific Islander (AANHPI) communities¹ in achieving health equity. Discussion topics included the lack of health and other data that lead to a poor understanding of AANHPI health and well-being, and the convergence of the COVID-19 pandemic with the epidemic of racial discrimination and violence against AANHPI populations.

DAY 1

Winston Wong of the University of California, Los Angeles (UCLA)–Kaiser Permanente Center for Health Equity noted that this workshop was an important and long overdue area of focus for the National Academies, which have not conducted a workshop that focused specifically and solely on the AANHPI communities. The COVID-19 pandemic has significantly affected these communities in several ways, including reports of increased incidents of xenophobia and violence, particularly against women and older people. Members of these communities report a heightened fear of slurs and physical assaults on top of the already present anxiety of living through the pandemic, said Wong.

Studies indicate that anti-Asian discrimination and violence are associated with an increase in anxiety, depressive symptoms, sleep problems, physical pain and suffering, and sometimes death (Abrams, 2021). Additionally, the AANHPI communities also face a lack of availability of culturally and linguistically competent health care (Chau and Chan, 2021). Health care providers offering vaccination, testing, and mental health services often cannot provide access to the range of languages spoken by subgroups. This can contribute to poor-quality care and a reluctance to seek needed health care, noted Wong.

Victor Dzau, president of the National Academy of Medicine, shared brief welcoming remarks by first noting that the AANHPI communities “too often don’t get the attention we deserve.” As an example, he explained that in a recent report on equitable vaccine allocation (NASEM, 2020), Asian Americans were not considered

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a vulnerable population and were not included. A stereotype exists that Asian American communities are well educated and have high incomes; however, this perception obscures that large portions of AANHPI populations are poor and vulnerable. They also face language and health literacy barriers. Dzau noted that 69 percent of Asian Americans are born outside of the United States and almost one-third report difficulty with English (Pew Research Center, 2013). Language barriers also contribute to social isolation.

A lack of systematic data collection about these populations is also a major knowledge gap. However, the available data indicate that Native Hawaiians and Pacific Islanders have the highest COVID-19 mortality rates in at least 16 states that disaggregate data (Chang et al., 2020). Dzau ended his remarks by saying that “to advance equity for all, we must address equity in every population, including AANHPI populations.”

TOWARD HEALING AND HEALTH EQUITY FOR ASIAN AMERICANS, NATIVE HAWAIIANS, AND PACIFIC ISLANDERS

Keynote speaker Howard Koh of the Harvard T.H. Chan School of Public Health and the Harvard Kennedy School opened by citing demographic estimates that the United States would become a “minority majority” country by 2045. The AANHPI population, which nearly doubled between 2000 and 2019 and represents the fastest-growing U.S. racial group, is expected to surpass 46 million by 2060 (Budiman and Ruiz, 2021). Notably, this highly diverse American population features roots in more than 19 countries and encompasses more than 50 different ethnicities and more than 100 languages. Major disparities in income and education levels also contribute to making the AANHPI population extremely heterogeneous, Koh noted.

Koh continued that the AANHPI community is often invisible and/or misunderstood. Examples he shared include the following:

• The “model minority” myth;
• Treatment as “perpetual foreigners and outsiders” in American society;
• Underrepresentation in leadership across all sectors, including medical schools and academic medical centers;
• Underrepresentation in political office and Congress; and
• The disturbing rise of anti-Asian violence and hate crimes associated with the COVID-19 pandemic.

Data collection issues, said Koh, are driving poor understanding of AANHPI health challenges. For example, during COVID-19, detailed case numbers for AANHPI communities have been difficult to find. However, the UCLA Center for Health Policy Research’s Native Hawaiian and Pacific Islander (NHPI) COVID-19 Data Policy Lab (2021) has data showing that the NHPI communities have the highest number of cases in California and Hawaii. Koh noted that “in our public health discussions, when there’s no data, too many assume there’s no problem.”

Other health disparities also affect the AANHPI community, such as chronic viral hepatitis, cardiovascular disease, cancer, and diabetes risk that can be greater for at least some AANHPI subgroups. However, disparities can be narrowed, Koh explained. In 2009, overall health insurance coverage for AANHPI Americans was lower than that of White people; this gap had closed by 2016 through the significant outreach and enrollment efforts of advocates who helped people gain insurance through the Patient Protection and Affordable Care Act (ACA) (Park et al., 2018).

As the former U.S. Assistant Secretary for Health under President Obama, Koh shared some critical federal initiatives designed to improve health outcomes for the AANHPI communities. Aside from the ACA coverage initiatives, federal efforts he oversaw included the Department of Health and Human Services’ Action Plan to Reduce Racial and Ethnic Health Disparities, updated data collection standards for AANHPI individuals and others in federal surveys, and major national initiatives on viral hepatitis and tobacco control. More recently, President Biden reauthorized the White House Initiative on Asian Americans, Native Hawaiians, and Pacific

Islanders and signed the historic 2021 COVID-19 Hate Crimes Act.

Koh closed by noting that the wave of anti-Asian hate crimes during the pandemic, while greatly painful and disruptive, has also led to some efforts by the media and others to more explicitly recognize AANHPI individuals as an integral part of American society. As one example directed at youth, he noted Sesame Street just created Ji-Young, the first Asian American Muppet, to join its cast. The show describes her as “a 7-year-old Korean American with passions that include rocking out, electric guitar, and skateboarding,” he said. The new character represents “a small but hopeful sign,” Koh concluded.

The discussion included a question about how data are tracked regarding hate crimes targeting the NHPI communities. Koh commented that while “good data on this ha[ve] been very difficult to come by,” an innovative database from San Francisco State University has helped shape the national dialogue. Additionally, the recent COVID-19 Hate Crimes Act signed into law by President Biden will improve data collection efforts across multiple sectors of law enforcement and public safety, he said.

A second question was how public health advocates elsewhere could still be sensitive to the needs of the AANHPI community, given that it has so much higher representation in western states such as California. Koh responded that “we can signal to everybody that we have a national effort here, and we can support each other. We must identify leaders in all parts of the country,” citing Chicago and the Midwest, where robust AANHPI efforts exist in joining academia and the community.

HISTORICAL OVERVIEW OF THE MODEL MINORITY

The first panel addressed the emergence of the “model minority” myth and how that affects the AANHPI community. Nadia Islam of New York University pointed out that it serves as “setting the context for any discussion of health equity in Asian American communities.”

Two distinct, mutually reinforcing ideas underlie this stereotype, Islam explained. First, is that Asian Americans are more educated, work harder, and earn higher incomes. This myth can be seen as far back as the 1970s and has been consistently perpetuated. Second, building on decades of sociological literature, she notes that “this stereotype is rooted in anti-Blackness … the idea was developed by a conservative majority to oppose the Black power movement of the 1960s. This arose from the knowledge that the United States is fundamentally a racist society that is structured to keep minorities in subordinate positions.” Individual underperformance, rather than institutional racism, is presented as the explanation for racial inequalities.

A second concept explained by Islam is that Asian Americans are “perpetual foreigners.” Members of the AANHPI community are perceived as not belonging in the United States, which is the basis for legislation such as the Chinese Exclusion Act of 1882 and was reinforced with the internment of Japanese Americans during World War II and the Trump administration’s Muslim ban. During the COVID-19 pandemic, the consequences of institutional racism and the notion of Asian Americans as the “perpetual foreigner” is evidenced through an increase in hate crimes against these communities, Islam noted.

The model minority myth in combination with the perpetual foreigner stereotype, said Islam, “is important because it is both driven by and results in the lack of data equity in AANHPI populations. When data are aggregated, the findings for any of the 30 unique subgroups [of the AANHPI community] renders our communities invisible.” Drawing from an American Medical Association report, she noted that “what is measured is valued; what is undercounted tends to be counted out” (AMA, 2020).

AANHPI communities have been especially hard hit by the pandemic, Islam said. High rates of limited English proficiency can make it far more difficult to access testing, vaccines, and overall health care. Low-wage essential workers and AANHPI small business owners disproportionately suffered from negative social and economic consequences. In New York City, members of the AANHPI community, particularly Chinese individuals, had high rates of hospitalization and mortality. This may

be exacerbated by the concentration of Asian Americans in multigenerational housing, where COVID-19 can easily spread.

Islam suggested several strategies for addressing the health and well-being of the AANHPI community:

• Asking states to collect, analyze, and report disaggregated data separately for AANHPI subgroups. This policy was developed under Koh’s leadership in the past decade.
• Prioritizing language access that goes beyond translating materials; resources to support community-based organizations and other community efforts that facilitate culturally tailored health education and access to care are needed.
• Encouraging researchers and scholars to examine their implicit and explicit biases about the AANHPI communities.

Brittany Morey of the University of California, Irvine, provided historical and political context for the model minority stereotype. The first Asian immigrant contract workers immigrated to the United States in the 1800s, primarily from China and the Philippines. They suffered from poor working conditions, lynching, murder, and blatant discrimination. White Americans blamed them for depressing wages and taking jobs away from “ordinary Americans,” she said. All of this led to laws specifically preventing Asian American immigrants from becoming citizens and restricting immigration from China and other Asian countries.

The Refugee Act of 1980 led to an increase in refugees from Vietnam and Cambodia. However, Asian Americans, even those born in the United States, continue to experience racism and xenophobia. One infamous example is that a Chinese American man, Vincent Chin, was celebrating his bachelor party in Detroit in 1982 when he was bludgeoned to death by two White auto workers (Little, 2020).²

Additionally, 1.7 million Asian Americans make up about 17 percent of undocumented individuals and are the fastest-growing group of undocumented people in the United States (Millet, 2022), Morey noted. Even immigrants who are legal citizens and therefore qualify for benefits, she said, “often do not take them for fear of being seen as dependent on the U.S. government, which might jeopardize their application to become naturalized citizens.”

Morey spoke specifically about how the model minority myth affects the NHPI community and worsens health disparities. Native Hawaiians, she said, were victims of colonization and experienced high poverty rates. And the Pacific Islands have varying status across the islands. Some are U.S. territories; American Samoan citizens are U.S. nationals, while those born in Guam are U.S. citizens. Some fall under Compacts of Free Association (COFA) treaties, which allow island citizens to live, work, study, and travel in the United States in exchange for continued military access to the islands.³ Some people from COFA nations experience the detrimental health effects of the 1945–1958 nuclear testing performed by the U.S. military on those islands (Marshall Islands Dose Assessment & Radioecology Program, 2021). COFA migrants, said Morey, often work in industries such as meat processing; for example, migrants from the Marshall Islands have been highly impacted by COVID-19 due to their employment in poultry processing plants, primarily in Arkansas. Marshallese migrants also face challenges due to restrictions in accessing health care coverage (Choi and Constance, 2019).

Morey closed by offering the following suggestions for improving the health and well-being of AANHPI individuals:

• Disaggregating health and demographic data for all AANHPI subgroups.
• Increasing multi-level interventions to address issues at the local, county, state, and national levels.
• Increasing resources to AANHPI-serving, community-based organizations to bolster

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community capacity and to bolster youth leadership through investments.

• Addressing the prevalent model minority myth. Rather than serving as “a wedge among the various communities of color, there must be efforts to strengthen and build transformational coalitions across racial and ethnic groups to address common issues that affect all communities of color.”

Panelist Sheri Daniels of Papa Ola Lokahi shared more detailed information from the perspective of the Native Hawaiian community, which has residents in all 50 U.S. states. Historically, before contact with colonizers, the Native Hawaiian people were very healthy and lived in an “orderly, organized, highly sophisticated” society. They excelled at natural resource management, feather work, navigation via the stars, and fishing and agriculture. Colonization, however, led to the overthrow of the Hawaiian monarchy in 1893, the introduction of foreign diseases, the breakdown of the Indigenous religious system, and the change to a cash-based economy. Daniels said that this caused the deaths of more than 90 percent of the Native Hawaiian population over the course of 100 years. Additionally, the colonizers diverted water systems to the sugar, pineapple, and tourism industries, thereby affecting fishing and agriculture.

In the 1980s, the two senators from Hawaii (Daniel Inouye and Spark Matsunaga) commissioned a study to recognize and document the health, educational, and economic problems affecting Native Hawaiians. Daniels explained that the findings showed that in 1985, the death rate and diabetes rate for all Hawaiians were 34 and 200 percent higher, respectively, than the U.S. average.

One shortcoming of the report was the lack of information on the strengths and resiliencies of the Native Hawaiian population. A second report was commissioned, E Ola Mau: The Native Hawaiians Health Study, which “identified Native Hawaiians’ physical, mental and spiritual health status and their needs and concerns and placed them in a historical and cultural context,” explained Daniels. This led to the Native Hawaiian Health Care Improvement Act (NHHCIA), which “authorizes funding for the following activities: a service grant to Papa Ola Lokahi for the activities described in the NHHCIA, including the coordination of the health care programs and services provided to Native Hawaiians, and service grants to five certified community-based Native Hawaiian Health Care Systems to provide a full range of services identified by the legislation and tailored to fit the needs of their respective island communities” (HRSA, 2020).

Daniels closed with several suggestions for addressing the health and well-being of the AANHPI community:

• Disaggregating data and enforcing Office of Management and Budget (OMB) directives to ensure accountability.
• Addressing limited English proficiency, but also allow individuals to use the Native Hawaiian language to access health care and other services.
• Reminding and emphasizing the understanding that no two communities are alike.

A question from an audience member was about an explanation for the high diabetes rates. Daniels responded that Native Hawaiians had not taken preventative measures due to health care access issues, such as a cultural belief that hospitals are places one goes to die, a lack of Native Hawaiian physicians, and economic factors leading to purchasing canned, high-fat foods, such as spam or corned beef. The high cost of shipping fresh fruits and vegetables also causes a lack of access to fresh foods. Islam added that structural racism within the health care system makes it difficult to access the appropriate programming and interventions.

THE CONUNDRUM OF DATA AND DATA DISAGGREGATION

The day’s final panel featured three speakers who discussed the nuances and complexities of disaggregating data for the AANHPI community. The first, Karthick Ramakrishnan from the University of California, Riverside, opened by explaining that any such decision should be based on “the context, the kinds of analyses we are doing, and the problems we are trying to solve.”

Ramakrishnan is part of a grassroots effort to address hate crimes against the AANHPI community, largely originating out of a coalition of community-based organizations in California but now nationwide. After the 2021 Atlanta, Georgia, hate crime killings of eight individuals, six of whom were of Asian descent (Fausset et al., 2021), he said it was found that 27 percent of Asian Americans and 24 percent of Native Hawaiians/other Pacific Islanders reported that they had experienced hate incidents (Pinkus, 2021).

High numbers of Asian Americans and Pacific Islanders also reported experiencing microaggressions or everyday acts of discrimination, including “having people ask where you are from, assuming you’re not from the U.S.” (Pinkus, 2021). Compared to Asian Americans, the Pacific Islander group scored higher when asked about being unfairly stopped, searched, questioned, or physically threatened or abused by the police (Pinkus, 2021). He explained that particular groups, such as Cambodian Americans, face “higher problems when it comes to encounters with the criminal justice system.” Pacific Islanders score much higher on “receiving poor services in restaurants and stores.” Reporting hate incidents is challenging for these populations. Ramakrishnan said that while native-born AANHPI individuals are more likely to say this has happened to them, they are less likely to report it to the police or even a community hotline. “We need to increase the reporting among these populations about what is occurring,” he noted.

He concluded by adding that going beyond the hate incident data, COVID-19 death rates are higher for some subgroups, which can be camouflaged by aggregated data reporting. Early data suggested that Asian Americans had a lower death rate compared to other populations. However, the Marshall Project, reporting Centers for Disease Control and Prevention data on disproportionate deaths, noted that in some states, Asian Americans had a higher than average level of disproportionate deaths in 2020 compared to the prior 5-year average; these deaths are likely attributed to COVID-19.

Panelist Karla Thomas, UCLA Center for Health Policy Research, paid homage to the individuals who wrote letters and delivered testimony to support the OMB directive on new federal standards for data collection on race and ethnicity. The collection of NHPI data in the 2000 census was both a beacon of hope for these communities and a starting point to advancing equity, but many data gaps remain that prevent communities and policy makers from adequately understanding the full NHPI experience in the United States, she said.

Thomas explained that three main issues cause the gaps in NHPI data collection. First, sometimes the data are unavailable; local, state, and federal agencies do not provide them. Second, sometimes the data are inaccurate or not up to date and therefore do not paint an accurate picture of the NHPI communities. Third, sometimes the data are inaccessible. For example, she said, “data systems can be complex to navigate, and this continues to be a barrier for NHPI communities who rely upon data to describe their populations.” Data issues, then, have real-life consequences for NHPI populations. Thomas went on to say that “if we do not resolve data inequities, health disparities will only worsen and the NHPI communities and other small communities will grow more and more vulnerable.”

Her suggestions for resolving these data issues are the following:

• Encouraging policy makers and philanthropists to invest in data disaggregation for NHPI communities. “We cannot tackle this problem on our own,” she said, as “data disaggregation can be costly.”
• Investing in small communities, because they can act as “canaries in the coal mine” in understanding how data inequities can affect everyone. Thomas said that the NHPI community will continue to “fight for the health of our people because we matter; no matter how small our community is, we deserve visibility and health equity.”
• Encouraging researchers to “engage NHPI communities and allow them to lead, allow them to be a part of the collection, analysis, and dissemination of data.”

The third panelist, XinQi Dong from Rutgers University, stated that “the conundrum is responsible disaggregation.” In other words, he said, there are times for data aggregation and times for data disaggregation. For example, cultural concepts are important to be able to understand data; “how do you study the concept of ‘filial piety’ across different Asian groups? How do you study the concept of ‘religiosity’ in a Filipino and a South Asian population?” The conclusion, he said, is that those cultural concepts are really important to be able to understand when to disaggregate data.

The second issue is measurement. Dong noted a tendency to just translate measures into another language and believe that is understandable. However, it is difficult to do this, from both the translation and psychometric perspectives. “We really have to understand data disaggregation when we measure concepts across different racial and ethnic groups, to make sure that the psychometric properties for these measures hold true,” he explained. “We cannot assume an English language term is interchangeable when translated into different Asian group languages and assume the terms are sound and measurable.”

Third, it is critical to understand that having access to the community whose data are being collected must occur in partnership with that community, which must be just as invested in maintaining a sustainable partnership. And from this partnership, “how do we think about policy impact from understanding the data we have collected, synthesized, interpreted, and published?” Often, disaggregating data does not translate to policy impact.

Dong’s closing remarks included several data considerations:

• Data aggregation versus disaggregation cannot be considered in a vacuum. When looking at federal funding, he identified “a vast gap with respect to funding for Asian studies.” Asian populations are often not included in studies supported by the National Institutes of Health and the National Science Foundation or in grants that support developing the next generation of underrepresented minorities to conduct research.
• Broader diversity and inclusion of underrepresented and underserved populations must be considered. In traditional academic environments, promotion and tenure are measured by grants received and manuscripts submitted. What is not valued to the same extent is the time it takes to “meaningfully sustain community engagement. We have to fundamentally change the academic paradigm of thinking about community engagement [and its value for tenure] not just for Asians but for Hispanics, Native Americans, and African American populations.”
• Grant funding agencies need to acknowledge the large amount of resources necessary to collect data on AANHPI populations. Translations, cognitive testing, and accounting for cultural concepts all require additional resources during the early phases of a study.

The discussion began with Ramakrishnan describing his work on the California Commission on Asian and Pacific Islander Affairs. Working with the Asian–Pacific Islander Legislative Caucus and a coalition of more than 300 community-based organizations, it has focused on providing the state Department of Social Services with funding to give outreach grants to community groups to focus on community trauma and anxiety. One goal is to increase awareness about the types of services available that may not have been accessed. “We are actively trying to understand what state government agencies can do to be more proactive in providing linguistically appropriate, culturally relevant care to our communities,” he said. Thomas added that this is why community leaders and organizations are so important in fighting for data disaggregation.

Dong described his efforts to promote data disaggregation with other heterogeneous populations, such as Latinx or African American/Black individuals in New Jersey. He is studying the Caribbean population from Haiti and the Dominican Republic, as well as the Nigerian population. “We have to be able to provide community organizations with tools to collect data accurately,” he

explained. Wong noted that the territorial status of some Pacific Islander nations is an additional burden when addressing complex data issues and capturing accurate data. Thomas added that an additional complication is that state and federal agencies cannot always identify where an individual from a COFA nation is located. “To sum up,” she said, “there are more complex data issues when it comes to these other territories of the U.S.”

DAY 2

Wong opened by reminding the audience that the workshop focuses on the unique obstacles faced by the AANHPI communities, particularly with regard to the pandemic. He described these as “two converging pandemics; the COVID-19 epidemic, plus the epidemic of racial discrimination and violence on the health and well-being of AANHPI populations.”

He introduced the day’s keynote speaker, Helen Zia, by noting that she provides an important context to understand all of these issues, from not only a historical perspective but also the critical perspective of the convergence of racial discrimination, violence, and the pandemic. She is a writer who also attended medical school for 2 years, worked in construction, and served as a community organizer.

AANHPI COMMUNITIES: CHALLENGE, RESISTANCE, SOLIDARITY

Zia’s comments went beyond Day 1 discussions on the need to disaggregate data to better understand the health experiences of Asian subpopulations. Her comments focused on race and social justice and the need for the Asian community to build solidarity or unity with other communities. Zia is the Chinese American daughter of immigrants, and she noted that once SARS-CoV-2 was identified in China, it took several months to reach the United States. Even before it did so, however, Asian American communities began experiencing harassment, prejudice, and racism because of its origins. Within AANHPI communities, the people most targeted have been the most vulnerable—older people and women. The website www.stopaapihate.org (created by community groups in 2020; accessed July 6, 2022) allows individuals who have experienced a hate incident to report it; as of March 2022, nearly 11,500 reports have been logged.

When describing depictions of the AANHPI community in popular culture, such as children’s cartoons, she explained that mainstream Americans are “conditioned to believe the things that we have all consumed through the media, and many of these things have been toxic.” Similarly, another media trope is the idea of an Asian American as “the enemy invader, the evil invader, and perpetual foreigner. Drawings have depicted members of the AANHPI communities as rodents, animals, and monkeys. In other words, they are not human.” Movies, video games, and magazine covers have all perpetuated these stereotypes. Zia explained. The female version of these stereotypes is either an evil dragon lady who is exotic, dangerous, and sexy or a submissive girl or woman who is compliant, passive, and sexually desirable. The latter likely underlies the data showing that AANHPI women and girls are the most often attacked “in this current period of anti-Asian violence,” she said, because “they are considered to be easy prey.”

Asian men are sometimes presented as the “model minority geeks who are … called to fix the software but are never considered for leadership.” The enemy invader stereotype has also led to accusing Asian American scientists of being spies for China, including top researchers in medical fields. “Academic research and academic freedom are being damaged by what is really a witch hunt to label many of our Chinese American and Asian American scientists, engineers, and researchers as conduits to the People’s Republic of China,” she said.

When a community is considered to be a “model minority,” she said, this has major mental health impacts. Suicide is a leading cause of death for Asian American Pacific Islander youth aged 15–20 years, and juxtaposed with this, they are less likely to have ever received mental health treatment. Community members with refugee backgrounds are often fleeing crises and suffer stress and posttraumatic stress disorder. Essential workers during the COVID-19 pandemic, many of whom are AANHPI, also suffer from greater stress and anxiety because of racial scapegoating and these toxic stereotypes.

Zia also discussed how Asian Americans have been left out of American history, which she calls “MIH—Missing in

History.” It is typically assumed that AANHPI individuals first came to North America in the late 1800s, but Asian Americans arrived in the 1500s, with the Manila–Acapulco Spanish Galleon Trade. She said that hundreds of AANHPI individuals fought in the Civil War. A U.S.-born Chinese American man, Wong Kim Ark, is credited with taking the question of birthright citizenship to the U.S. Supreme Court in 1898. Because of him, all children born in the United States are citizens. “Yet AANHPI communities are invisible in history,” she said.

Zia added that Frederick Douglass spoke out against the Chinese Exclusion Act of 1882. She showed a photo of people from Hawaii participating in the civil rights marches in Selma, Alabama. Filipino farmworkers fought alongside Cesar Chavez for better working conditions for all farmworkers. Finally, in the fight for marriage equality, three Hawaiian same-sex couples, including individuals of AANHPI descent, filed the first lawsuit that came to national attention.

Zia’s final comments addressed the need for solidarity for political advocacy among different communities, as demonstrated in some of the historical examples she presented. “This solidarity has also gone missing in history,” she said, “and we really have to reclaim our history of solidarity. We need to stop thinking that all our communities are separate. We can be allies together; we need to move to the idea that our communities can build unity. We have a long history of working together, and we have to do that going forward,” she concluded.

An audience member asked Zia if she was optimistic or pessimistic about the future. She responded that what is different about the United States today is the changing demographics. California and 10 other states are already “majority minority,” which means that “if every racial demographic is a minority, then it really behooves us all to cooperate with each other to build the Beloved Community that Dr. Martin Luther King envisioned.”

RACE, COVID-19, AND OUTCOMES FOR AANHPI COMMUNITIES

The second day of the workshop featured two speakers addressing how the COVID-19 pandemic has affected the NHPI communities. The first, Andy Subica of the University of California, Riverside, spoke of his preferred definition of racism: “It’s considered race-based discrimination that is practiced by an oppressive dominant group within a racialized social system, so racism is inherently institutionalized,” he said.

Subica noted the lack of detailed data about mental health and substance use in NHPI communities. However, data that he collected indicate that Pacific Islander adults have three times the national rate of major depression and twice the national rate for generalized anxiety disorder. Alcohol use is also four times the national rate, with about 20 percent screening positive for alcohol use disorder (Subica et al., 2019).

Young adults (18–30 years old) also face mental health risks in these communities, especially for alcohol use and alcohol-related harms. More than half of young Pacific Islander adults engage in binge drinking, and almost half screen positive for alcohol use disorder, putting them at high risk for drunk driving, fights, sexual assault, and alcohol poisoning. Discouragingly, Pacific Islander adults and young adults are only about half as likely to receive needed treatment (Subica et al., 2019).

COVID-19 is also affecting the mental health of the Pacific Islander community. His data show increases in major depression, anxiety, and alcohol and e-cigarette use. However, one positive finding from these communities is that the strongest predictors of vaccine acceptance were older age at vaccination and having previously received a flu vaccination. Subica said that discussions are under way in the broader scientific community about combining COVID-19 and flu vaccines. This could be beneficial for increasing vaccine uptake in hard-to-engage communities.

Tavae Samuelu of the organization Empowering Pacific Islander Communities opened by stating that although data are important, they cannot be divorced from the human impact on daily life. She also spoke of the importance of knowledge production and dissemination, including storytelling, in the Pacific Islander community. “Stories are passed on and tell the stories of the families and the women who put their blood, sweat, and tears

into documenting what is true for their communities,” she said.

Samuelu also spoke of the importance of land acknowledgment, specifically the Sogorea Te’ Land Trust.⁴ Many members of Indigenous groups are asking to go beyond acknowledgment and return the land to Indigenous people. She showed a map of colonial impact, explaining that maps typically do not show the violence against vulnerable communities because the geography is erased along with the existence of Indigenous peoples, such as Pacific Islanders.

This is also complicated by the different status of Pacific Islander nations relative to the United States. For example, the Mariana Islands are both a U.S. territory (Guam) and a commonwealth (Saipan, Tinian, and Rota Islands). There are COFA countries, such as the Republic of Palau. Samuelu said that COFA is currently under renegotiation, so those communities will see shifts. When COFA was first signed in the 1980s, COFA citizens were promised access to Medicaid; however, this did not occur until legislation was signed into law in December 2020. “When I talk about our communities and the construction of our communities, this is deeply shaped by continued colonization and militarization,” Samuelu said.

Regarding COVID-19, Samuelu said that the reason many Pacific Islanders did not seek out health care was a lack of insurance coverage. This led to severely increasing case rates. It is unfair to talk about the comorbidities that lead to higher risks for infection, she said, without considering the systems in which they live and survive. For example, if Indigenous land is taken, foodways are disrupted, and residents are forced into food deserts and other underinvested areas; it is not surprising that they are far more likely to contract the virus. “It is always awful to be a poor person of color,” she commented, “but during a pandemic, it will kill you.”

The first question from the audience addressed the importance of accurate representation. For example, television shows and movies are filmed in Hawaii yet show no Native Hawaiians. Samuelu responded, “it’s actually really painful, and not only painful but harmful.” Pacific Islander storytelling has a principle that you are not supposed to tell the stories of another village because the storyteller may impact the story. Objectivity is also a myth; what is “objective” is actually White male subjectivity, she said. She also noted a distinction among representation, visibility, and power. “So many in our community are hyper-visible and do not have political power, and it has not led to significant shifts in livelihood and other outcomes.”

Subica responded that certain Asian American groups are underrepresented in research and policy; South Asians get very little attention, and some have questioned whether Filipinos are accurately categorized as part of the Asian American community. Although Filipinos are the third-largest Asian American population, they have several unique features that differentiate them from other subgroups, including being the only group to have been colonized by the United States and hailing from the Pacific Ocean near Southeast Asia. “We definitely need to start being more sophisticated,” he said, “as we have the ability now to collect data about these things.” He went on to say that “there are intentional actions that are occurring consistently to suppress Native Hawaiians, Pacific Islanders, and Asian Americans in the U.S.”

The second question asked the speakers to discuss policy actions and research priorities that can help to fight racism. Subica responded that researchers can help with data disaggregation that is actually useful for communities to use, “because data drives advocacy and funding.” If a problem such as COVID-19 can be highlighted, funding can then be provided to address it. Additionally, he said, public health professionals often implement interventions that put the onus on the oppressed to fix problems that are being caused by the dominant oppressive group. “I want to shift the conversation to how do we do that, instead of working with communities that have to raise the funding to help themselves. It’s just not fair,” Subica said.

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Building on this, Samuelu said that the communities themselves are the best equipped and have the most expertise in measuring the efficacy of solutions. Policies are often made far away from the problems of communities. “The situations that people are in are not their fault; they live in systems that are inequitable and are designed to be so, especially, for Indigenous communities,” she said. Political systems are not designed for outsiders, and the policy process is often very slow in meeting the needs of communities. Unfortunately, this leads to a myth that these communities are not self-sufficient.

Discussing the disproportional effects of the pandemic on the NHPI communities, Samuelu said that resources often miss Pacific Islander communities. She said that the impacts of COVID-19 were inevitable, given the long-standing underinvestments in Pacific Islander communities. Equity does not mean proportionality—“you are 1 percent of the community, so we give you 1 percent of the resources”—but rather providing what is really needed, even if that is 40 percent of the resources. Sustaining these resources is also critical because the NHPI communities “will be responding to COVID-19 for the next two or three generations,” she explained. Funding is needed to create infrastructure for responding to future crises.

Speakers were asked about what actions could be taken now to prepare for the next pandemic or crisis. Subica responded that, first, “we have to find ways to rebuild trust with both Asian American and NHPI communities with health care systems that they will actually use when they are sick.” Both Subica and Samuelu discussed the importance of training and building a cohort of leaders to meet the needs of these communities; in particular, leadership training for young people is essential for the future because of the intergenerational component of AANHPI communities. “We have lost so many elders during the pandemic. We need to double down on funding both public health and young leaders for our communities,” Subica concluded.

THE FUTURE AND POTENTIAL WAYS FORWARD

The final session was an informal question-and-answer session between Thomas and Juliet Choi of the Asian & Pacific Islander American Health Forum (APIAHF). Thomas’s first question was what Choi thought were the top priorities right now for the AANHPI communities.

Choi’s response addressed several impacts of the COVID-19 pandemic:

• The continuing anti-Asian violence and the response of many allies of the AANHPI community who were surprised by it,
• The educational and economic impacts, and
• The more than 170,000 young people who have lost a parent or primary caretaker.

Recent census data indicate that, as of December 2021, more than 175 U.S. counties have an Asian population of 5 percent or more, a major increase from 30 years ago (less than 40 counties). Choi pointed out that the AANHPI population is the fastest-growing U.S. ethnic group, and it has now migrated across the country into new areas. This population increase, said Choi, poses the larger question of how to promote allyship within AANHPI communities and encourage participation in civic engagement.

The second question, building on the changing census data, was about current positive policies that will benefit AANHPI communities and how these policies can be improved. Choi responded that there have been things to celebrate; President Biden, on his first day in office, issued a presidential memorandum denouncing the racism and xenophobia against the AANHPI communities. Female leaders in Congress helped to write and pass bipartisan hate crimes legislation. “At the end of the day, this is the right and American thing to do,” she said.

However, during the previous administration, AANHPI communities faced some devastating impacts, Choi noted, particularly from a health care perspective. Immigrant communities were hard hit by the last administration’s immigration policies. This led many

immigrant families to decide not to seek health care before and during the pandemic, out of fear of immigration status violations and potential deportation. Although communities did their best to support and provide services to these families, she said, “this is still something we are fighting; this is still something that we are countering and addressing.”

She went on to say that when considering policy, it needs to be centered on lived experience in communities. A major supporter of working with allies, she advocates for creating a community policy agenda to reflect the diversity of communities. The power of allyship is critical, noted Choi, adding that “it’s really important to highlight why coalitions and allyship really, really matter.” However, it is not only about mobilizing community-centered voices; she emphasized that it’s about “how do we mobilize our voices with impact?” To build and support allyship, we need more thoughtful and difficult conversations about how groups can coalesce while still honoring differences and noting the places that lack full consensus.

Allyship needs to be built within a frame of intentionality, she said, adding that transparency, integrity, and care are all needed to create this framework. An example is the work of a racial equity collaborative funded by the Kellogg Foundation that brings together partners such as the National Association for the Advancement of Colored People (NAACP), the National Urban League, the National Congress of American Indians, faith leaders, and others for discussions about shared topics of interest. One recent conversation focused on reparations and the ability of the Japanese American community to bring its leaders with relevant experience to the table. Another example is the support that the Black and Latinx communities offered to the AANHPI communities in the face of anti-Asian violence and hate. “There’s always so much to do, but hopefully we can take a couple more steps forward a little more quickly and with a little more comfort,” Choi explained.

The next discussion addressed effective public health responses for AANHPI communities. Thomas asked about the enduring features of a community health and public health approach to ensuring equity in these communities. Choi responded based on her experience having worked for the Red Cross. The federal government has always had a standard playbook for responding to a natural disaster (including pandemics). But while it is essential to create an enduring framework for success, “there are not enough people who look like us and have these kinds of lived experiences, who are seated at the table. We need to be at all of the tables, locally, statewide, and federally.”

Choi also discussed the need for public health workers that reflect the community, particularly after many years of underinvestment in AANHPI communities. A pipeline for public health leaders is required, and AANHPI communities must be a part of it, she said. Several community-based organizations are already serving as frontline workers in the pandemic; however, local and state decision makers may not have an adequate knowledge base about AANHPI communities. One way to address this, she emphasized, is that “if there were a clarion call, the one thing I would ask every industry, government agency, foundation, and funder to think about [is] establishing a community advisory council. It is the constancy of dialogue and representation that is going to lead to institutional and systemic change.”

Thomas echoed these comments by commenting that in her hometown, public health leaders had never been in touch with NHPI community-based organizations until the pandemic. “We had to give them a rundown of who is a Native Hawaiian/Pacific Islander and what our health issues are and explain why we are deserving of health equity,” she noted. Although it was sad that this was the first interaction, and health disparities existed long before, “we are now able to bridge our communities more closely with decision makers,” Thomas explained.

Thomas began her next question by noting that hate and racism affect many other communities as well. She asked how AANHPI communities work in unity and solidarity with other communities. Choi responded by sharing an example: during the Hurricane Katrina disaster, much of the United States knew little about the Vietnamese

and Cambodian communities affected on the Gulf Coast. Similarly, the anniversary of the 9/11 attacks affected several refugee communities, such as Southeast Asians, Muslim Americans, and the Sikh community, yet that is rarely discussed during the anniversary events.

The final topic was specific future action steps that could be taken. Choi identified the following:

• Encouraging civic engagement at all levels, from registering to vote to paying attention to local school board and city council issues. Volunteer commissions often need members as well.
• Partnering with new organizations. One example is a new partnership of the APIAHF with an organization that promotes a civil rights curriculum for teachers and schools. Partnering with faith organizations is another example.
• Encouraging the National Academies to partner with the White House on research and initiatives for the AANHPI communities.

Wong ended the workshop by thanking the participants and audience. He shared his feelings of “confidence and optimism” about the direction AANHPI communities and their leadership were moving toward and his hope for continued dialogue.

REFERENCES

DISCLAIMER This Proceedings of a Workshop—in Brief was prepared by KAT M. ANDERSON as a factual summary of what occurred at the workshop. The statements made are those of the rapporteur or individual workshop participants and do not necessarily represent the views of all workshop participants; the planning committee; or the National Academies of Sciences, Engineering, and Medicine.

*The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop—in Brief rests with the rapporteur and the institution.

WORKSHOP PLANNING COMMITTEE MEMBERS ERNEST MOY, Office of Health Equity, Department of Veterans Affairs; MELISSA A. SIMON, Northwestern University; KARLA THOMAS, University of California, Los Angeles, Center for Health Policy Research; MICHELLE WONG, Center for the Study of Healthcare Innovation, Implementation & Policy, VA Health Service Research & Development; WINSTON WONG, University of California, Los Angeles–Kaiser Permanente Center for Health Equity.

REVIEWERS To ensure that it meets institutional standards for quality and objectivity, this Proceedings of a Workshop—in Brief was reviewed by TANIA T. VON VISGER, State University of New York at Buffalo, and GRACE WANG, National Association of Community Health Centers. LESLIE SIM, National Academies, served as the review coordinator.

SPONSORS This workshop was partially supported by The Colorado Trust, Department of Veterans Affairs’ Office of Health Equity, Johnson & Johnson, The Kresge Foundation, Merck & Co., and Takeda Pharmaceuticals USA Inc.

For additional information regarding the workshop, visit www.nationalacademies.org/our-work/roundtable-on-the-promotion-of-health-equity.

Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2022. COVID-19, Health Equity, and the Asian American, Native Hawaiian, and Pacific Islander Communities: Proceedings of a workshop—in brief. Washington, DC: The National Academies Press. https://doi.org/10.17226/26700.

Health and Medicine Division Copyright 2022 by the National Academy of Sciences. All rights reserved.