Asian Americans invisible in COVID-19 data and in public health response

The U.S. death toll from COVID-19 surpassed over 110,000 deaths over the weekend, and the pandemic continues disproportionately hurting Black and Latinx communities in Illinois. Unfortunately, because public health departments and healthcare systems in the U.S. do not collect accurate race and ethnicity data, the full toll of COVID-19 in Illinois’ communities of color is unknown, especially for the 700,000 Asian Americans in this state. This lack of accurate, disaggregated data on Asian ethnicity means that the current response to address COVID-19 is at best inequitable, and at worst, nonexistent for these communities.

Illinois is home to the fifth largest Asian American population in the U.S. As of June 15, there were 133,016 total confirmed cases and 6,326 deaths due to coronavirus in Illinois. Among these, 3,813 cases (2.9%) and 298 deaths (4.7%) were reported as Asian. But these numbers are likely unreliable for Asians in Illinois, who are 5.9% of the state’s population, because of reliance on data that inadequately identifies and even misidentifies this population.

In public health data, Asians are sometimes classified as “Other,” which prevents any understanding of their health status. Where “Asian” is available as an aggregated classification, this category still ignores the tremendous socioeconomic and cultural diversity between Asian subgroups that influences how each experiences infectious and chronic diseases.

Early data from the U.S. and abroad show why Chicago and Illinois must more closely monitor COVID-19 in the Asian community. In Britain, South Asian healthcare workers were at significantly higher risk of contracting and dying from coronavirus than white workers. Community organizations in New York report that COVID-19 is devastating Bangladeshi Americans, who are frequently employed as drivers and in corner stores, which makes social distancing challenging. Fifty percent of COVID-19 deaths in San Francisco have occurred in Asian Americans, even though they are a third of that city’s population. Data just released from the Philadelphia Department of Public Health showed that COVID-19 cases, hospitalizations, and deaths are higher for Asian Americans than non-Hispanic white people. As long as Asian Americans are all lumped together, it is impossible to know if some Asian groups are at even higher risk than what these early data show.

Why is the Asian American community especially at-risk? As physicians whose research is dedicated to reducing Asian American health disparities, we know that Filipino and South Asian Americans have a higher prevalence of Type 2 diabetes and heart disease than white Americans. These conditions increase the risk of dying from COVID-19.  But without disaggregated COVID-19 statistics, we cannot know how the underlying differences in Asian subgroups is exacerbating and interacting with COVID-19 to create health inequity.

We also know that in some Asian subgroups (e.g., Bangladeshi, Cambodian, Chinese, Thai, and Vietnamese), more than half have limited English proficiency, preventing access to timely COVID-19 information and care. Across the country, Filipino, Asian Indian, and Chinese immigrants are overrepresented in the healthcare workforce, highly exposed on the front lines of this pandemic. Older Asian Americans often live in multigenerational households, where risk of exposure is higher. The Asian community includes many undocumented individuals who may be afraid to seek testing and care, and recent policies have led to increasing numbers of Asian immigrants in detention centers, where COVID-19 is spreading rapidly. Like other Americans, fear of healthcare costs also delays COVID-19 testing in some Asian communities.

There are several specific actions that should be taken to better understand how COVID19 is impacting Asian American communities in Illinois and beyond:

1. Recently, the federal government mandated that starting August 1, 2020, all laboratories and health systems must report race/ethnicity data for all coronavirus tests . This is an opportunity to create and institute a standardized centralized standard reporting form that includes disaggregated ethnicities, which would facilitate better representation of Asian subgroups in the collected data.
   
2. In the absence of disaggregated ethnicity data, private and public healthcare agencies can implement Census ‘name lists’ to classify Asian Americans, which identify surnames of the six largest Asian American subgroups (Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese). Name lists are imperfect, but can help determine which Asian subgroups are making up the majority of COVID-19 cases and deaths in Illinois. Many have used this strategy to identify Asian subgroups for research studies  when self-reported ethnicity is not available.
   
3. City- and state-level COVID-19 racial equity response teams, which identify and implement strategies to reduce structural inequities causing health disparities, must engage hospitals, clinics, and community organizations working with Asian Americans to obtain qualitative and quantitative data. This will help target resources to reduce COVID-19-related disparities in these communities, alongside other communities of color.
   
4. Asian American service organizations are disseminating culturally and linguistically appropriate COVID-19 materials and providing food, housing, and cash assistance with very limited support. Organizations like the Rohingya Cultural Center in Chicago reach vulnerable Asian groups, but are in danger of closing  because of a loss in regular donations and fundraising. The city and state should target resources to sustain the work of trusted, local stakeholders who meet the needs of marginalized Asian communities. Asian American’s lives are greatly affected by racial inequity. As the country begins to reckon with decades of inaction on social inequities fueling COVID-19 disparities , it is critical to remember that Asian Americans are not a monolithic group. The failure to accurately collect public health data on Asian Americans’  COVID-19 experiences makes it impossible to fully address health equity.