BY CINDY H. LIU, PhD AND JUSTIN A. CHEN, MD, MPH
This piece was published in the 32nd print volume of the Asian American Policy Review.
The model minority stereotype initially embraced by many AAPIs was a welcome alternative to the prior “Yellow Peril” label, yielding an uneasy collusion that is now being exposed as the hollow prize it is in the era of COVID-19.
An Important Moment for AAPI Visibility
Escalating violence against Asian Americans and Pacific Islanders (AAPIs) has occurred within a backdrop of xenophobic rhetoric and blame against China, with politicians including President Donald Trump referring to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the disease it causes (COVID-19) as the “China Virus” or “Kung Flu.” Today’s sentiments echo prior and repeated scapegoating of this group for public health crises, e.g., the bubonic plague in the late 1800s.1 Medicine is not exempt from the many blind spots in society’s treatment of AAPIs.
A thorough knowledge of how the “model minority myth” operates within medicine is necessary to understand these blind spots. The “model minority myth” is often applied to AAPIs given the high median income and education levels of certain AAPI ethnic groups, and seemingly positive characterizations portraying the community as hard working, high achieving, and maintaining a low political profile, especially among individuals working within the field of medicine. The term “model minority” may appear to be rather complimentary, especially if it is well-received by AAPIs themselves.
However, the model minority concept conceals and minimizes health issues. AAPI are screened less for cancer despite it being their leading cause of death,2 and providers are less likely to speak to AAPI women regarding postpartum mood symptoms despite greater susceptibility to postpartum depression.3 Most insidiously, the notion of a “model minority” sets up a divisive contrast with other minorities, who are then blamed for their own health and economic disparities. The “model minority” term gained ascendancy in the mid-20th century to strategically undermine efforts to enact race-specific social policies. AAPIs were cast as an exemplar to demonstrate the importance of personal effort, shifting attention away from underlying structural disparities.4 The continued reference to AAPIs as a model group perpetuates the fiction that structural racism is not a concern, manifesting in a “You are doing just fine” attitude toward AAPIs, while relaying to Black and Latinx communities that “Others are doing well, why aren’t you?” The model minority stereotype initially embraced by many AAPIs was a welcome alternative to the prior “Yellow Peril” label, yielding an uneasy collusion that is now being exposed as the hollow prize it is in the era of COVID-19.
Critically, this stereotype misleads policy makers to overlook health issues that affect more vulnerable communities within the diverse AAPI umbrella.5 Limited data and reliance on aggregated data both contribute to the diversion of attention away from significant health risks faced by certain subpopulations. For instance, Filipinos and South Asians show a higher rate of diabetes relative to non-Hispanic Whites;6 in a cancer registry study, Korean and Southeast Asians showed the largest increases in the incidence of breast cancer from 1988-2013.7
Despite their high median economic status, AAPIs have the largest income inequality of any racial/ethnic group in this country.8 Additional contributors to the omission and/or under-sampling of AAPIs in research include limited funding, translation of materials, and community engagement. Despite an urgent need for resources to rectify these barriers, only 0.17 percent of the overall National Institutes of Health (NIH) budget between 1992 to 2018 was committed to research focused on AAPI health.9 Lower rates of NIH funding for major grants and career awards also reflect and reinforce the “bamboo ceiling effect,” or impediments to career advancement among AAPIs across industries.10
Although racism has considerable health impacts,11 racism itself is not well described or taught within medicine as a risk factor. Aside from racially motivated physical harm, AAPIs are exposed to stress associated with everyday discrimination including microaggressions.12 Structural racism is an important social determinant of health, exerting harmful effects on those impacted.13 A major problem is that this history, and the means for addressing racism and discrimination generally, have been omitted from both general and medical education. Prior generations of medical providers have not received any training on these topics, directly contributing to the persistence of structural racism. The limited research that exists on this topic suggests that AAPI medical students perceive their medical school learning environment more negatively and report higher levels of stress than White students, in part due to experiences of bigotry and outright harassment from clinical supervisors as well as inequitable performance evaluations.14 A recent review found that in comparison to other minority groups, there is an overall lack of research on AAPI medical students’ experiences.
Opportunities for Change
Current advocacy efforts for policy change within medicine should include AAPI health needs. Healthcare providers need to be aware of the significant history of anti-Asian racism and structural discrimination such as the Chinese Exclusion Act and understand its impact on both the physical and mental health of AAPI patients.15,16 Clinicians must understand how AAPIs have traditionally been perceived in the US, and how such perceptions can in subtle and complex ways perpetuate anti-Asian sentiments, mask real health concerns, and reinforce negative health impacts. These actions can help facilitate support for AAPI and other marginalized groups without reinforcing a myth that conceals health concerns among AAPIs while diverting attention from other minorities.
Data disaggregation should be planned in advance and supported by government and funding agencies. There is now an opportunity to invest in AAPI health with data collected from COVID-19-related research. Additional resources for engaging the community, including translation and communication of materials for a range of Asian subgroups, can reduce sampling biases which conceal health concerns.
Clinical care should consider the role of racism as a risk factor for health.17,18 Providers should understand the effects of racism on patients’ presenting problems and develop facility in asking their patients if they have experienced racism.19 The effects of structural racism may persist even in the absence of interpersonal discrimination. As part of much-needed reforms within the field of education, anti-Asian racism should be actively examined and taught within medical schools.
The current moment presents an opportunity for the medical field to confront and correct the biases that uphold anti-Asian racism and discrimination.20 The evidence and path for doing so is clear if we can marshal a commitment to engagement and overcoming inertia. We are witnessing a pivotal moment in history in which such change within the medical field is not only possible, but necessary.
We are grateful to Finneas Wong for his assistance in the preparation of this article.
CINDY H. LIU, PhD is currently an Assistant Professor at Harvard Medical School and the Director of the Developmental Risk and Cultural Resilience (DRCR) Program within the Departments of Pediatric Newborn Medicine and Psychiatry at Brigham and Women’s Hospital. She is also a licensed clinical psychologist. Her research focuses on stress across the lifespan and its implications for mental health disparities.
JUSTIN A. CHEN, MD, MPH is Medical Director of the Outpatient Psychiatry Division at Massachusetts General Hospital and Co-Director of Medical Student Education in Psychiatry at Harvard Medical School. As Executive Director and Co-Founder of the nonprofit volunteer-operated MGH Center for Cross-Cultural Student Emotional Wellness, he delivers talks and trainings for families, clinicians, and educators throughout the United States on promoting the emotional health and psychological resilience of diverse student populations.
 Justin A. Chen, Emily Zhang, and Cindy H. Liu, “Potential Impact of Covid-19–Related Racial Discrimination on the Health of Asian Americans,” American Journal of Public Health 110, no. 11 (2020): 1624–27, https://doi.org/10.2105/ajph.2020.305858.
 Alicia Yee Ibaraki, Gordon C. Hall, and Janice A. Sabin, “Asian American Cancer Dispari- ties: The Potential Effects of Model Minority Health Stereotypes,” Asian American Journal of Psychology 5, no. 1 (2014): 75–81, https://doi.org/10.1037/a0036114.
 Cindy H. Liu and Ed Tronick, “Do Patient Characteristics, Prenatal Care Setting, and Method of Payment Matter When It Comes to Provider-Patient Conversations on Peri- natal Mood?” Maternal and Child Health Journal 16, no. 5 (2011): 1102–12, https://doi. org/10.1007/s10995-011-0835-4.
 Kristy Y. Shih, Tzu‐Fen Chang, and Szu‐Yu Chen, “Impacts of the Model Minority Myth on Asian American Individuals and Families: Social Justice and Critical Race Feminist Perspectives,” Journal of Family Theory & Review, 2019, https://doi.org/10.1111/jftr.12342.
 Elsie J. Wang et al., “Type 2 Diabetes: Identifying High Risk Asian American Subgroups in a Clinical Population,” Diabetes Research and Clinical Practice 93, no. 2 (2011): 248–54, https://doi.org/10.1016/j.diabres.2011.05.025.
 Scarlett Lin Gomez et al., “Breast Cancer in Asian Americans in California, 1988–2013: Increasing Incidence Trends and Recent Data on Breast Cancer Subtypes,” Breast Cancer Research and Treatment 164, no. 1 (2017): 139–47, https://doi.org/10.1007/s10549-017- 4229-1.
 Abby Budiman and Neil G. Ruiz, “Key Facts about Asian Origin Groups in the U.S,” Pew Research Center, 8 September 2021, https://www.pewresearch.org/fact tank/2021/04/29/key-facts-about-asian-origin-groups-in-the-u-s/.
 Lan N. Ðoàn et al., “Trends in Clinical Research Including Asian American, Native Hawaiian, and Pacific Islander Participants Funded by the US National Institutes of Health, 1992 to 2018,” JAMA Network Open 2, no. 7 (2019), https://doi.org/10.1001/jamanet- workopen.2019.7432.
 Kristy Y. Shih, Tzu‐Fen Chang, and Szu‐Yu Chen, “Impacts of the Model Minority.” 12 Ibid.
 Zinzi D. Bailey et al., “Structural Racism and Health Inequities in the USA: Evidence and Interventions,” The Lancet 389, no. 10077 (2017): 1453–63, https://doi.org/10.1016/ s01406736(17)30569-x.
 Daniel J. Ahn et al., “Where Do I Fit in? A Perspective on Challenges Faced by Asian American Medical Students,” Health Equity 5, no. 1 (2021): 324–28, https://doi. org/10.1089/heq.2020.0158.
 James H. Lee, “Combating Anti-Asian Sentiment—a Practical Guide for Clinicians,” New England Journal of Medicine 384, no. 25 (2021): 2367–69, https://doi.org/10.1056/ nejmp2102656.
 David R. Williams and Lisa A. Cooper, “Covid-19 and Health Equity—a New Kind of ‘Herd Immunity,’” JAMA 323, no. 24 (2020): 2478, https://doi.org/10.1001/ jama.2020.8051.
 Kristy Y. Shih, Tzu‐Fen Chang, and Szu‐Yu Chen, “Impacts of the Model Minority.”
 James H. Lee, “Combating Anti-Asian Sentiment.”
 Kristy Y. Shih, Tzu‐Fen Chang, and Szu‐Yu Chen, “Impacts of the Model Minority.”