Racism is keeping many Asian Americans from going to the doctor

This story is part of The Aftermath, a Vox series about the collateral health effects of the Covid-19 pandemic in communities around the US. This series is supported in part by the NIHCM Foundation.

Jenny H. loved going out to volunteer in San Francisco, her home city for the past three decades. She even liked getting there and the opportunity to strike up a conversation with strangers while on the bus. But now she no longer feels safe on public transportation. She’s stopped volunteering. She hardly goes out. She struggles even to get to her doctor’s appointments.

Jenny H., who did not want to be identified by her full name for fear of being further targeted, is in her 60s and is Chinese American. She reports having been attacked numerous times, including being shoved so hard near a metro station in 2020 that she lost consciousness and suffered broken bones. Another time, years before, she was hit in the face on the bus, resulting in permanent eye injuries that still require checkups every three months.

With the precipitous rise in hate crimes against Asian Americans over the past two years, she is now “living in a constant state of fear,” she told Vox through an interpreter. “It changes the way I live. … I don’t want to go outside.”

Despite chronic pain and her eye injury, she now waits until a family member can escort her to medical appointments, or relies on the kindness of a 30-year-old civil engineer from the local Chinatown Volunteer Coalition to accompany her.

Jenny H. is one of countless Asian Americans who have struggled with accessing health care in the wake of pandemic-fueled, racially motivated violence.

Discrimination against Asian Americans, which has affected the community since the first major wave of Chinese immigration to the US in the 1800s, has increased across the country in the past two years following President Donald Trump’s 2020 claim that the pandemic was “China’s fault” and his racist branding of Covid-19 as the “China virus” and “kung flu.” (The spread of Covid-19 is most attributable to a worldwide failure to monitor the virus and take active preventive measures early in the pandemic.) Last year, attacks on Asian Americans surged more than 3.3 times higher than pre-pandemic levels, according to a 2022 report from the Center for the Study of Hate and Extremism.

As worry about the virus itself has waned, this metastasis of anti-Asian American racism has accelerated. By late 2021, nearly one in five Asian Americans and Pacific Islanders (who comprise more than 25 million of the US’s population) had experienced a hate incident in the past year, according to estimates from the coalition Stop AAPI Hate. And the percentage of these reported hate incidents that involved physical assaults rose from about 11 percent in 2020 to about 17 percent in 2021.

These numbers parallel a trend in public opinion: In 2021, 11 percent of US adults said that Asian Americans were at least partly responsible for Covid-19 (a belief tied to the “perpetual foreigner” stereotype of Asian Americans). By 2022, that number had risen to 21 percent.

This epidemic of hate crimes has discouraged many Asian Americans from going out even for basic errands for more than two years. As of spring 2022, more than one in three Asian Americans still say they have changed their daily routine because they’re worried about being assaulted or threatened. (Who would want to make themselves a target for physical attacks, racial slurs, verbal threats, or being spat on?)

But the disruption to health care has gone largely undiscussed.

While data is still scarce, experts warn that the pandemic-driven scapegoating could be fueling a public health crisis among Asian Americans.

Internal medicine physician Anthony Tam, who practices in Manhattan and Brooklyn, said he’s recognized a clear drop in visits from his Asian American patients, many of whom need regular care. “They’re too afraid to come out,” he said.

Over the course of two months, Vox reached out to more than 100 Asian American health care providers, advocacy organizations, and researchers to learn more about this underreported problem. Many said they saw their Asian American patients miss doctor’s visits due to the rise in hateful acts. These same patients, they said, were hesitant to talk about their concerns, however. This reluctance was backed up by our reporting: Patient after patient who admitted to these fears declined to speak about the issue for this article (although several, such as Jenny H., eventually did).

Experts and care providers warn that this delay in health care — compounded by its lack of visibility — could cause unforeseen consequences, from unmanaged chronic conditions to undiagnosed diseases, for many in this growing segment of America, and for years to come.

The hidden epidemic

Covid-19’s arrival caused a mass deferral of health care across all demographics due to shutdowns, social distancing, short staffing, and general concern about catching the virus, leading to worse health outcomes for many. But within months, more people began returning to the doctor.

For many Asian Americans, however, the other threat of race-based attacks has remained high, with more than 10,900 reports of hate incidents against Asian Americans and Pacific Islanders reported to Stop AAPI Hate between March 2020 and December 2021 alone (a number experts agree is likely a vast undercount).

Almost half of these incidents happen in public spaces, which makes getting to essential appointments onerous, particularly for the 95 percent of Asian Americans who live in urban areas, many of whom rely on walking or public transportation.

“Families are afraid to leave their homes to get the care they need — and they’re afraid for their loved ones,” said Adam Carbullido, director of policy and advocacy at the Association of Asian Pacific Community Health Organizations.

For many Asian Americans, these fears are such a regular feature of living in America they often feel it’s not worth talking about, or they’re concerned about drawing more attention to themselves. Instead, they would rather put off appointments than risk putting themselves in more immediate danger.

Venkata Jonnalagadda, a psychiatrist in North Carolina, said doctors often have to explicitly ask about anti-Asian sentiment before their patients will talk about it. “One of my male Asian patients said … ‘I’m not going to burden you with that because that’s not why I came to see you,’” she said.

Of course, not every Asian American has delayed health care due to fear of being attacked. But reports from providers suggest that the problem is substantially underestimated. And those who are most likely to become victims of these crimes — which have predominantly targeted older adults and women — also tend to be those more in need of regular health care.

Another point of concern is that population-wide studies assessing health behaviors and outcomes often fail to break out Asian Americans as a separate demographic, further hiding these serious health consequences.

Even many health care providers were reluctant to speak about the issue. “When we got the call to do this interview, none of my colleagues wanted to do it,” Jonnalagadda said. “They said I was crazy for talking.”

Health care providers face a double pandemic

In April 2022, Anthony Tam received an urgent call from one of his patients. The 61-year-old man was slurring his words and reported weakness in his arms and legs — hallmark symptoms of a stroke. Tam told the Chinese American man (who did not want to be identified by name) to go to the emergency room immediately, since any delay could lead to more permanent brain damage or even death. The man said he didn’t want to, for fear not only of catching Covid-19, but also of being assaulted. A day or two later, the man finally went, but the wait may have permanently impacted him: Tam says the patient still speaks with a slur.

Tam has been practicing medicine in Manhattan’s Chinatown for seven years. But since the onset of the pandemic — and a concurrent rise in violence and vitriol against Asian Americans — he has seen how fear has driven many to miss or postpone important treatment.

Mainstays in preventive care such as mammograms, colonoscopies, and blood tests are also falling by the wayside because many patients are afraid to travel around the city, Tam said. And he worries these delays are harming their long-term health, in the form of budding cancers, unchecked diabetes, worsening heart disease, and other serious but avoidable problems.

“Over the last two years, there were people who were managing chronic conditions … in the past they’d come to me every three to six months. [Now] it’s not uncommon to see them once a year,” Tam said. Those with previously well-controlled diabetes are skipping appointments, and Tam is noticing that their hemoglobin levels (which doctors use to assess diabetes severity) are now higher than recommended. (Asian Americans are about 37 percent more likely to have diabetes than white Americans.)

“Diabetes is a silent disease, and for the most part the patient may not even know there’s something wrong unless they come into the office,” Tam said. “Especially for my patients who don’t live in the immediate area of the clinic, there’s been a real drop in their health care,” he said. “They say … ‘I have to force myself to get on the train to see you.’”

Follow-ups are another hurdle. “Sometimes I have patients that need a work-up for blood in the urine,” Tam said. But “they’d rather stay home than go on the train,” to get the lab test.

The rise in Asian American discrimination and violence also rattles Tam as a doctor. His Manhattan office is just blocks from the Canal Street subway station, the site of two high-profile attacks on Asian Americans since 2020, including on one woman who died from her injuries. “That could have been one of my patients,” he said. These concerns trouble him.

“I find myself having to weigh the medical risks of not doing a [test or follow-up] with the very real risk of harassment or violence [for patients] getting to the office,” Tam said.

“It saddens me to know there’s something I have to take into account before … telling them to come to the office unless they really have to — because I don’t want to be the reason they’re attacked or suffer,” he said.

Across the country, Vaughn Villaverde, the director of advocacy for Asian Americans for Community Involvement, a nonprofit organization that provides health services in California’s San Jose area, reports a sharp decline in people participating in the organization’s senior wellness program. The majority said they have reduced their outdoor activity due to anti-Asian discrimination.

Jane Jih, an associate professor of medicine and research director of Asian American Research Center on Health at the University of California San Francisco, has watched patients who normally managed chronic diseases through outdoor exercise suddenly lose control of their condition because they were too afraid to go out. Since the rise in pandemic-fueled racist incidents, Jih has noticed, for example, “patients whose blood sugar for diabetes was really well controlled for a while and then it’s not. They would say, ‘I don’t feel safe having my father walk around for exercise,’ or ‘the public park where we normally went to, we stopped going to, because we heard of people receiving verbal assaults,’” she said.

These aren’t idle anxieties but lived experiences, Jih said. “I’ve had patients tell me stories — if I ask them … they’d be assaulted and no one would come to their defense.”

Helen Lu, a pediatrician in San Francisco, said an attack on one of her teenage patients sent him to the emergency room. “My patient was about to go inside his home, and suddenly someone hit him on the back of his head — the person ran away, and the patient could not see who it was,” she said. She saw him for follow-ups and staple removal, but he told her that he tries not to go outside anymore because of this attack.

Families face disrupted care

Despite a general reluctance to speak publicly, several Asian Americans and their family members talked to Vox about their experiences, which paralleled those shared by providers.

Amy Y., who is in her 60s and lives in the Flushing neighborhood of New York City, says that while she still tries to make all her mandatory checkups, she has limited her other health care. For example, she stopped going to her acupuncturist (whom she used to visit regularly for pain management and wellness) and never went to the physical therapist to whom she was referred to manage severe back pain. “I try to minimize my time outside,” she told Vox via an interpreter. “I believe in the law of attraction — if you don’t go outside, then you won’t have as much trouble.”

Chia Thao, a 66-year-old Hmong American living in Butte County, California, has high blood pressure that requires frequent management, including doctor’s office visits two to three times a month. To get there, she waits until her son can take her to the Hmong Cultural Center, where he works, and from there, relies on one of the center’s shuttles to her doctor — a trip that now takes about an hour and a half each way.

Thao is too worried to make the trek on her own: “I know that ever since Covid hit that we are specified as the people who brought the disease to the US,” she said through an interpreter. “We are afraid to go about in public because of that.”

Richard Chen and his wife live with their three young children in Marine Park, in the far southeast reaches of Brooklyn. But they had long made a point for their family to see doctors in Manhattan’s Chinatown or Brooklyn’s Sunset Park (one of the borough’s Chinatowns), even though they were miles away. As a second-generation Taiwanese American, Chen saw this as a way of staying connected to their family’s cultural heritage.

But when the rise of anti-Asian violence began hitting the news, the software engineer and his wife felt increasingly nervous about shuttling around the city. This was especially a concern with young children, whose pediatrician visits added up to several dozen a year. The Chens made the decision to suspend all health care visits for eight months while looking for options closer to home. This put the kids behind on vaccinations that would protect them against other illnesses and delayed care for issues, including vision trouble, unexplained weight loss, and checkups for their infant, whose persistent fussiness worried the Chens.

Today, the children’s pediatrician, ophthalmologist, and nutritionist are all within walking distance. The parents’ primary care physicians are a bit farther, but easy to drive to. Still, when the Chens make an appointment, they ask for one well before closing time to avoid walking in the dark.

Other Asian Americans have taken even more extreme measures to avoid hate crimes. In 2021, Shirley Ha Chock’s 80-year-old father, a retired jewelry store owner, was diagnosed with aortic stenosis, a serious heart condition that required surgery and frequent cardiologist appointments in Manhattan. Rather than face long trips on public transportation — common sites of anti-Asian violence — he reluctantly gave up his beloved home in the Bedford-Stuyvesant neighborhood of Brooklyn, where he had lived for the past 15 years, and moved to Manhattan’s Chinatown.

The January 2022 surgery, however, resulted in a rare complication when his body rejected a new heart valve. “His cardiologist advised him to stay in New York City to finish up his care,” Chock said. Nevertheless, he and his family decided he should travel to Taiwan to continue his treatment in a safer city. “He would rather take the risk of flying overseas — even though he had complications with the heart surgery — and go to a whole team of different doctors who don’t know his medical history because New York City has become so unsafe for older Asians.”

How to fix a concealed crisis

Addressing the disrupted care for so many Asian Americans will require increased attention and a wide range of efforts.

While pandemic-era adaptations, such as telehealth, could help many Asian Americans replace some in-person visits, they need to be revamped.

For example, telehealth platforms have a long way to go in effectively including language translation to make these sorts of appointments accessible to non-English speakers. Older Asian Americans also face the same barriers to adopting new technology as many other American seniors do, so organizations like Asian Americans for Community Involvement are offering more tech literacy programs. And those living in ethnic enclaves disproportionately still need access to high-speed internet.

The rise in acts of hate has served as an unprecedented call to empower and protect members of Asian American communities. Programs have sprouted up around the country that teach Asian Americans and limited English speakers how to report crimes to the police, bystander intervention training, and even self-defense, in an effort to increase confidence in returning to public places. From spring 2020 to summer 2021, OCA-Asian Pacific American Advocates partnered with Lyft to provide free rides for Asian Americans to safely run errands. And organizations such as the Chinatown Volunteer Coalition have also burgeoned across cities to provide one-on-one support, including connecting older Asian Americans, like Jenny H., with younger ones who could escort them to doctor’s appointments.

Jenny H.’s volunteer is Jonathan Sit, who is Chinese American and joined the group in early 2021. Having grown up in the Bay Area’s Chinatown community, he has witnessed firsthand many of its minority residents being violently targeted. He has also been the target of many “go back to your country” slurs and even beatings. When the pandemic inflamed existing anti-Asian discrimination, it sparked memories of these incidents, and he wanted to do something to help.

“​​There is a sense that if it’s not going to be me looking out for my community, I can’t really expect people outside my community to be looking out for them,” Sit said.

Despite being helpful for some, like Jenny H., these efforts do little to address the underlying, systemic infections behind this public health crisis.

The US government has a long history of anti-Asian American racism — from the 1882 Chinese Exclusion Act to the Japanese internment camps of World War II — to undo. And American policymakers, who have often cast blame on the country’s Asian residents, have fueled racist acts, such as public health officials setting fire to Chinatown buildings occupied by Asian and native Hawaiian residents in an ill-informed attempt to quell an outbreak of the bubonic plague in 1900.

Only recently has nationwide legislation made meaningful steps against anti-Asian American racism, such as with the 2021 Covid-19 Hate Crimes Act. Among other things, this law gives more local resources to facilitate reporting hate crimes. But even in the year since President Joe Biden signed the bill, nearly half of Asian Americans surveyed are still calling for stronger anti-hate crime laws.

In addition, more funding needs to be allocated to data specifically aimed at understanding Asian American health disparities.

To date, Asian Americans are the most understudied major racial or ethnic group in US peer-reviewed literature, and research is severely underresourced. Only 0.18 percent of funding from the National Institutes of Health from 2000 to 2018 has supported Asian American health research. (Seven percent of people living in the US are Asian American.)

“AAPI are often not included as a separate group in studies,” Justin Chen, assistant professor of psychiatry at Harvard Medical School, wrote to Vox in an email. He noted that the “model minority myth,” in which Asian Americans are portrayed as universally successful, means they might be seen as “a group without problems in need of investigation,” he said. “Yet we do have health disparities, especially in mental health, and we need funding agencies to recognize and address these.”

What’s more, lumping “Asian Americans” into a single group — often encompassing those of Chinese, Filipino, Japanese, Korean, and other backgrounds — hides important health risks and disparities among very different populations.

The federal government began to address this problem through a May 2021 executive order, which provides federal funding to improve access to health care, reduce health disparities, and strengthen research for Asian Americans, Pacific Islanders, and Native Hawaiians. Whether this will meaningfully improve health, however, remains to be seen.

In the meantime, these pandemic-era delays in health care for so many Asian Americans remain invisible to the majority of America.

“I just hope that the anti-Asian sentiment subsides and my patients can go about their lives without having to always look over their shoulders,” Tam said. He calls for more people, including those outside of Asian American communities, to speak up about the issue and for policymakers to look for solutions, rather than scapegoats.

“My patients are as much a part of the fabric of our society as anyone else,” Tam said. “They deserve to live peacefully and do very ordinary things, like coming in for an annual physical, without fearing for their safety.”

CREDITS
Editors: Katherine Harmon Courage, Susannah Locke
Visuals editor: Bita Honarvar
Copy editors: Tanya Pai, Tim Williams
Fact-checker: Willa Plank