Since March 2020, Asian Americans have experienced an alarming increase in racial discrimination and racially motivated violence.1 Commentators have attributed this distressing fact to the blame placed on China for causing the Covid-19 pandemic, given that the virus was initially discovered in Wuhan. Some top U.S. government officials perpetuated this attitude by referring to Covid-19 as the ¡°China Virus¡± and ¡°Kung Flu.¡± Because non-Asian people in the United States often conflate Asian subgroups, many people have directed their anti-Chinese sentiment toward people of other Asian heritage. Violence against Asian Americans has persisted at high rates throughout the pandemic, most recently involving the shootings of multiple women, leading to their deaths.
But anti-Asian racism is not limited to the Covid-19 pandemic. The 2003 SARS outbreak was similarly racialized, with Asian-American people depicted as uniquely potent vectors. Indeed, the United States has a long history of anti-Asian racism grounded in xenophobia, even during periods without a new infectious disease burden; such racism affects every age group and plays out across myriad settings.2 This discrimination has escalated in the face of the continued racialization of Covid-19. Over the past 12 months, 31% of Asian-American people have reported being subjected to slurs or racist jokes, 26% have feared that someone might threaten or physically attack them, and 58% believe that anti-Asian racism has increased since the beginning of the pandemic.3
The current growing antiracism movement in the United States has largely centered on anti-Blackness, which has been recognized as embedded in institutions such as law enforcement, the prison¨Cindustrial complex, and the health care system. Some scholars theorize that race and racism in the United States operate along a Black/White binary, so that non-Black people of color and the racism they experience are perceived in relation to Blackness and anti-Blackness.4
Given that the recent increase in anti-Asian sentiment occurred alongside the highly publicized and protested murders of Black people, the Black/White binary may help explain why the recent surge in racism against Asian Americans has remained underreported. Though the relative invisibility of Asian Americans that results from this racial dichotomization is a long-standing issue, underreporting over the past year has been particularly egregious. Public awareness of crimes against Asian Americans increased in February 2021 only because of a boost from social media and subsequent attention by national news outlets. This increased exposure has highlighted the vicious nature of these crimes, and Asian Americans are left anxious about the lives of their loved ones and fearful for their own.
During the pandemic, clinicians have been treating many patients experiencing the social isolation, financial hardship, and sometimes overwhelming ennui imposed by quarantining. On top of these common conditions, many Asian Americans are feeling the stress of increased anti-Asian sentiment; they may have emotional distress after a verbal assault or anxiety regarding their physical well-being. Physicians can tailor their practices to meet this moment by creating a welcoming environment for Asian-American patients and identifying symptoms that stem from living in a racist environment (see table). Physicians can then address these symptoms by providing patients with treatments and resources to help reduce this increased psychological strain.
Hate crimes have occurred in a wide variety of locations, potentially causing Asian-American patients to feel unsafe in spaces they previously deemed safe, including hospitals and clinics. To alleviate this discomfort, health care providers can make some changes in their offices to ease patients into clinical settings. Outpatient practices can make Asian-American patients feel welcome by having brochures translated into languages commonly spoken in the surrounding communities of color and displaying them openly. In addition, signs in office lobbies or exam rooms indicating that translators are available can make patients aware of such services. Though inpatient spaces may be less flexible than outpatient clinics, hospitals can take some actions to promote patient comfort; for example, they can accommodate patient requests to move a roommate who has made discriminatory remarks.
Creating a safe space for Asian Americans includes protecting Asian-American health care workers. Many Asian employees, especially those who work closely with patients, such as nursing staff and social workers, experience anti-Asian racism on the job. Most health care workers have undergone some level of cultural competency training, which can be augmented with more targeted techniques such as bystander intervention and crisis de-escalation. Training in these techniques will allow health care workers to more effectively and immediately respond to discrimination against a patient or colleague.
By instituting the aforementioned changes, physicians can create a welcoming milieu that allows for directly addressing race in patient visits. I believe physicians should become comfortable asking whether patients have experienced racism ¡ª a question that could both signal that the physician is open to discussing race and reframe a conversation to permit consideration of the effects of racism on health. Assessing whether Asian-American patients feel safe in their homes, in their neighborhoods, or on public transit could be a way of introducing the topic gently. Undertaking targeted screening for depression, anxiety, and substance use with racism in mind can reveal symptoms that patients may have previously dismissed. Special consideration should be given to the patient¡¯s age, so that, for instance, clinicians screen for elder abuse in nursing home settings and for (in person and online) bullying in children.
If a patient reports having experienced a hate crime, it is appropriate to treat the incident as a traumatic experience. Doing so would require taking a more thorough history of the incident and using a post-traumatic stress disorder (PTSD) screening instrument to assess the patient for psychological distress and loss in function. Broader screening questions allow physicians to capture information about both recent and remote events, such as racial trauma patients may have experienced before the pandemic.
Though physical findings will be rarer than psychological ones, a physical exam including thorough skin and musculoskeletal exams should be done regardless of whether the patient has disclosed a hate crime. Such an exam could reveal some signs of an altercation that a patient may not have disclosed. If there are such physical findings, the physician should consider racially motivated assault in the differential diagnosis, alongside more common occurrences such as domestic abuse and accidental trauma. Thorough documentation of the physical exam is critical, and wounds or injuries that are not healing appropriately should be investigated further.
Clinicians have access to a wide variety of resources, including organizations such as STOP AAPI Hate and Asian Americans Advancing Justice and colleagues in social work, case management, and psychiatry. Physicians can prophylactically address harms from anti-Asian sentiment in part by connecting patients with resources that might not have been considered if the conversation were not directed toward race.
The long history of racist abuse of Asian Americans has caused substantial distress in Asian-American communities. Even if the recent increase in media attention to anti-Asian hate crimes prompts action to curb this violence, the effects of racism will remain. Physicians should act to address anti-Asian sentiment by tailoring their practice both inside and outside patient rooms to make Asian-American patients and colleagues feel safe. These small changes will allow clinicians to capture diagnoses they might otherwise miss and to connect Asian-American patients with resources essential to their well-being, thereby providing holistic care that accounts for patients¡¯ lived experience of race.
Funding and Disclosures
Disclosure forms provided by the author are available at NEJM.org.
This article was published on March 24, 2021, at NEJM.org.
1. Le TK, Cha L, Han HR, Tseng W. Anti-Asian xenophobia and Asian American COVID-19 disparities. Am J Public Health 2020;110:1371-1373.
2. Stop AAPI hate national report 3.19.20¨C8.5.20 (https://secureservercdn.net/22.214.171.124/a1w.90d.myftpupload.com/wp-content/uploads/2020/10/Stop_AAPI_Hate_National_Report_200805.pdf).
3. Pew Research Center. Many Black and Asian Americans say they have experienced discrimination amid the COVID-19 outbreak (https://www.pewresearch.org/social-trends/2020/07/01/many-black-and-asian-americans-say-they-have-experienced-discrimination-amid-the-covid-19-outbreak/).
4. Delgado R, Stefancic J. Critical race theory: the cutting edge. Philadelphia: Temple University Press, 2013.
5. Naz S, Gregory R, Bahu M. Addressing issues of race, ethnicity and culture in CBT to support therapists and service managers to deliver culturally competent therapy and reduce inequalities in mental health provision for BAME service users. Cogn Behav Ther 2019;12:22-22.
Citing Articles (2)
|General Approach and Specific Practices||Examples|
|Creating a safe space in outpatient settings|
|Hanging welcoming signage in lobbies or waiting areas||Include flags from the Asian countries most heavily represented in the local community|
|Displaying welcoming images and literature||Ensure racial diversity of depiction of patients and clinicians in pamphlets, brochures, and posters around the office|
|Creating a safe space in inpatient settings|
|Making rooming accommodations||Provide separate rooms for patients of color and patients who make discriminatory remarks|
|Creating a safe space for staff|
|Augmenting cultural competency training|| |
|Offering institutional support after staff member experiences a hate crime|| |
|Specifically mentioning racism when acquiring patient history|| |
|Screening for depression, anxiety, substance use, elder abuse (especially if patient lives in nursing home), bullying or cyberbullying (especially in adolescents), post-traumatic stress disorder||Use relevant screening questions and instruments|
|Skin exam||Evaluate for TEARS (tears in skin, ecchymoses, abrasions, redness, swelling)|
|Musculoskeletal exam||Evaluate for abnormal gait, pain with movement or on palpation|
|Providing resources specifically addressing anti-Asian sentiment|| |
- Practices for Combating Anti-Asian Racism.