Cultural Barriers for Asian-Americans in Healthcare
#stopAAPIHate and support AAPI patients in healthcare
What a rollercoaster of emotions this week - came off the highlight of my life from our wedding weekend into arguably one of the most tragic weeks for Asian-Americans in this country. Rather than postponing this weekend’s post, I believe I process better by trying to organize my thoughts into writing. Hope this post can inspire those of us in healthcare who are championing #stopAAPIHate to also consider how we can support AAPI Healthcare.
Wanted to start off by acknowledging the decades of Anti-Asian racism, fetishization, and violence that have resulted in the horrific events of Tuesday in Atlanta. We’ve seen this play out in so many different levels: from the rise in hate crimes here in New York City, to the closing of some of our favorite businesses in Manhattan’s Chinatown, to my own personal experience of walking into a restaurant with my friend (also Asian) to a man who jokingly gave us a wide berth cause he “didn’t want to get the virus”
There’s so many issues to unpack from our former President’s divisive “China virus” rhetoric to the overlooking of Asian-American hate crimes by local authorities. Instead, I’ll focus on the systemic disparities I see in our healthcare system as an Asian-American and someone with personal experience working within the immigrant Asian community.
It’s ironic that the paragon of Asian-American achievement is becoming a physician but Asian Americans significantly underutilize healthcare when compared to white patients (especially when it comes to mental health services). As children of Asian immigrants, many of us were brought up to consider a career in medicine given its job security, ability to provide functional utility for one’s family/community, and (perhaps less overtly) its level of prestige. And though I’m fortunate to have parents who have fully supported me in every evolution of my career interests (from humanitarian global health work to education to entrepreneurial bootstrapping), it’s likely that these cultural forces played some role in my own winding path to medicine.
Barriers to Asian-American Healthcare
Traditional Medicine and Reactive Treatment
Many of the barriers to the Asian immigrant and Asian-American community seeking healthcare are cultural. Alternative and traditional medicines are ingrained in the culture of Asian Americans and often supersede the use of Western medicine, especially prescriptions. Use of healthcare services are primarily reactionary as opposed to preventive or proactive. Patients may hear “you don’t need treatment now” but only hear “you are fine” which disincentivizes the use of screening services - esp conditions like Hepatitis, Osteopetrosis, etc… (Challenges and Opportunities in the Care of Asian American Patients - AAFP)
One patient anecdote comes to mind in a recent Emergency Department shadowing experience where an elderly Cantonese patient explained to me that the reasons he had stopped taking medications for his chronic autoimmune condition is because the symptoms had initially subsided. He had believed in rationing his medications for more serious adverse effects, and chose to rely more on the traditional herbal supplements that he had been using throughout most of his life as the chronic/preventative tool. Even with his daughter and wife in the room, we had a difficult time explaining to him the importance of taking such medications regularly to their full course.
Personally, this resonates strongly with my own personal experiences where my mother would save antibiotic medications when not taken to their full course to be used in cases of self-diagnosed strep throat down the road. My grandpa similarly denied life-changing knee replacement surgery for decades believing that his body would be stronger and more resilient if he suffered through it. There is a strong belief that Western medications should be used only as a last resort and rationed sparingly - this compounds multiple issues in adherence but also more systemic issues in antibiotic resistance or irreversible musculoskeletal damage which I now work actively to educate against as a medical student.
Cultural Silos
Beyond seeking or not seeking care, there is a complicated cultural relationship across generations of immigrant patients especially in matters of end of life and assigning a healthcare proxy. Especially in my own Chinese culture, talking about death is believed to cause additional harm and stress to the patient. This leads to much reluctance in signing advance directives, and families to stress to providers not to share terminal diagnoses with the patient. This extends in the other direction as well - Asian patients often choose to hide serious diagnoses from their own families given the burden they believe they are sparing their loved ones from. These self-imposed silos challenge a lot of physician <> patient relationships with the Asian-American community, especially around end of life care.
“Model” Minority and Mental Health Needs
Mental health has long been a stigmatized topic for the Asian-American population. This study finds that 8.6 percent of Asian-Americans sought any type of mental health services or resource compared to nearly 18 percent of the general population nationwide.
Beyond the traditional stigma of seeking mental health support, there are external pressures related to intergenerational pressure and a cultural disregard for mental health as a true clinical condition that requires treatment. This study noted that “that being ‘1.5 or 2nd generation immigrants’ was a strong contributor to stress in their lives”
The model minority stereotype and image of well-adjusted, high-functioning Asian-Americans persists in American society, which influences both self-realized and societal judgements of Asian-Americans’ mental health needs. This study argues that the influence of the model minority stereotype perpetuates the “invisibility and possible neglect of this minority group’s mental health needs”
Opportunities to bridge Gaps in Asian-American Care
Despite these challenges, there are a number of promising approaches that I wanted to highlight that are bridging some of these cultural and systemic barriers for Asian-American patients.
Rendr Care is a physician group serving ethnic Chinese patients throughout the NYC area. Led by the founding CEO of CityMD, Rendr Care focuses on providing culturally appropriate and bilingual healthcare services to mostly immigrant populations here in NYC. Clever Care Health Plan is a Medicare Advantage plan catering to a wider Asian-American population that uniquely covers aspects of Eastern medicine (e.g., unlimited acupuncture, Tai Chi classes, herbal supplements) in addition to encouraging preventative specialist and primary care services.
Early work by Dr. William Gee and social worker Marie-Louise Ansa with On Lok in San Francisco’s Chinatown laid the foundations for an all-inclusive senior care model which eventually became the PACE Program.
All of these initiatives turn what would have initially been cultural barriers and preferences of this population into a strength to better engage and ultimately care for Asian-Americans and their healthcare needs.
On the mental health side, Anise Health is an early venture bringing culturally competent digital healthcare for ethnic minorities starting with Asian-Americans. Shimmer offers facilitated Slack-like groups with coaches based on their shared identity and experiences and placed into a larger community, many of which have a strong Asian-American emphasis.
Idea: Care Navigation Services for First-Generation Asian Immigrants
The US healthcare system is complicated enough to navigate without the additional cultural and language barriers that so many first-generation immigrants face. Chinatown patient navigation programs like Chicago’s have improved breast and cervical screening rates, but could be expanded to encompass navigation services that extend to the complicated follow-up and administrative hurdles in especially complex healthcare journeys. Culturally-sensitive navigation has proven particularly effective in cancer care, which is simultaneously the leading cause of mortality among various subgroups of Asian-Americans. Though patient navigation programs have been underfunded at the federal level, value-based payments models provide an emerging business incentive for patient navigation services from reducing ICU admissions and improving in-network retention. This article outlines a few examples of how patient navigation generates financial returns to cancer programs specifically. What if we could integrate and train bilingual patient navigators who could better engage Asian-American patients receiving cancer care?
If we could centralize bilingual and culturally-sensitive patient navigation as a service to different cancer centers, we could create a value-oriented offering that multiple comprehensive cancer centers could benefit from. This centralized offering might also explore using eastern medicine as a complementary therapy to cancer treatment as this Lancet review has demonstrated across lung, stomach, and breast cancers. Savings derived from both retention of in-network services and reducing admissions could present a sustainable funding mechanism to support this model of culturally-sensitive patient navigation services.
Big thanks to He Wang, Jen Ren, and Jonathan Wang for their edits and thoughtful contributions to this piece. This piece (like other Margins of Medicine posts) is intentionally meant to be a conversation starter and not a fully researched or thought-out article. I hope this can serve as a starting point for others who want to think more critically and creatively about these issues. Look forward to working with others who are more actively engaged addressing some of the disparities and cultural challenges I touch on above, and would love to hear from others how I can be a better thought partner.
As an endnote, I wanted to acknowledge that inappropriately aggregating all ethnic subgroups into an Asian-American monolith masks healthcare disparities and unique cultural beliefs that exist within subgroups. From the deep-dive I did behind this post, I believe we need more research and data to better identify and understand chronic conditions and risk factors for different Asian ethnicities.
Finally, I encourage folks to consider donating to Asian Americans Advancing Justice and also the Asian American Advocacy Fund based in Georgia.
If you’re interested in reading more about systemic issues in healthcare, I’d love to hear from you and ask for your thoughts as I continue to investigate these issues more as a healthcare venture capitalist and medical student.