As some nurses across the country choose to stop working rather than comply with vaccine mandates, some hospitals are recruiting nurses in the Philippines to fill their staffing gaps. That will only further heighten the burden borne by Filipinx nurses, and other Filipinx health care workers, in the United States.
Since the outset of the pandemic, it has become abundantly clear that social and economic factors shaped by the U.S.’s history of structural racism have caused disproportionate numbers of deaths among racial and ethnic minority groups due to Covid-19. Lost in the conversation have been the experiences of Asian American communities, and Filipinxs in particular.
While the official numbers show that Asian Americans have lower death rates from Covid-19, the few states in which data are broken out by Asian ethnicity reveal sharply higher proportions of Filipinxs who have contracted the disease and died from it. In Hawaii, Filipinxs make up 16% of the population but more than 20% of Covid-related deaths. In California, where Filipinxs make up 20% of nonelderly Asian adults, they make up 42% of Covid deaths in that category.
As several colleagues and I argued recently in JAMA Health Forum, the absence of disaggregated Covid-19 data for Asian Americans has contributed to these disparities and hindered an equitable response for Filipinxs.
As a Filipinx American health care worker, I’m not surprised by the shocking Covid-19 numbers in my community. Growing up in the United States, I often heard how health care, specifically nursing, offered stable and well-paying jobs. I had relatives in both the U.S. and the Philippines who trained as nurses. When I went to college and joined a Filipinx organization, having a family member in nursing was part of the members’ shared cultural and diasporic experience.
The connection between U.S. nursing and the Philippines, however, isn’t an accident. The U.S. established nursing schools in the Philippines during the American colonial period from 1898 to 1946 and implemented an immigration policy that recruited Philippine-trained nurses to the U.S. to fill worker shortages. This history still echoes today, as nurses from the Philippines comprise the largest share of U.S. nurses who were trained internationally. They are also more likely to work in ICU settings, where the most severe Covid-19 patients are treated.
So when the Covid-19 pandemic began in March 2020, I had an uneasy feeling that Filipinxs would be disproportionately affected by it. The first nurse to die from Covid-19 in Los Angeles was Filipinx, and soon after more and more stories emerged about the plight of Filipinx health care workers.
Yet the overarching narrative was that Asian Americans were doing better during the pandemic and were less likely to die from Covid-19 compared to Black and Latino communities. This misguided perception took hold because the data that could provide a more complete picture were missing.
Even now, 20 months after the pandemic began, the absence of disaggregated data for Asian Americans continues to be a persistent problem. It has been left to nongovernmental organizations and media outlets to draw attention to the burden of Covid-19 on the Filipinx community. For example, the transnational feminist organization AF3IRM used media reports to track the deaths of Filipinx nurses and other health care workers on the poignant online tribute Kanlungan.net. The National Nurses United also published a report showing that Filipinxs comprise an estimated 26% of Covid-19 deaths among nurses while representing 4% of nurses nationally.
Why has the impact of Covid-19 on Filipinx and other Asian communities been ignored even though they make up one of the fastest growing racial groups in the U.S.? One potent explanation is the model minority myth, which suggests that Asian immigrants perform well on social, economic, and health indicators due to advantageous and desirable cultural characteristics such as industriousness and a strong work ethic. When further scrutinized, the model minority myth falls apart as it reflects an aggregated average. Despite relatively higher average income, for example, income inequality within Asian Americans is higher than in other racial or ethnic groups. Over the past half century, the model minority myth has obscured inequities facing the Asian American community while reinforcing anti-Black racism.
In health care and public health, the model minority myth has perpetuated an oversimplification that Asian Americans face no health issues or disparities. By treating multiple groups the same, health care institutions ignore the diversity of experiences of immigrant communities across an enormous geographic area and ultimately their unique health needs. The problems are not limited to Covid-19: Analyses examining disaggregated health data for Asian Americans have also revealed that Filipinxs face high rates of chronic diseases, like high blood pressure or diabetes, which also increase the risk of severe Covid-19.
The failure of governmental institutions and public health authorities to collect detailed and disaggregated race/ethnicity data has allowed disparities in Covid-19 mortality among Filipinxs to go unheeded and unaddressed.
The way forward is for health care organizations and public health surveillance systems to invest in processes and the infrastructure to collect detailed self-reported race and ethnicity data that includes distinct Asian ethnicities. To accomplish this, three concrete steps should be taken. First, states should enact legislation similar to California’s AB-1726 requiring state public health departments to collect disaggregated data. Second, health care providers should seek the expertise of community partners experienced in best practices for data disaggregation. For example, the Asian and Pacific Islander American Health Forum has a long history of supporting such efforts. Third, as the forum recommends, electronic health record vendors should also be engaged in ensuring that their products allow for the collection of disaggregated data.
While these steps are not inclusive of all actions that can promote data disaggregation, they are a start. The failure to collect disaggregated data for Asian Americans should no longer been seen as an oversight, but as an active choice that directly contributes to structural racism in the U.S. health system.
To be sure, collecting and publishing detailed disaggregated data about Asian Americans may require new investments, workflows, and training. But as other data collection efforts, such as those in Hawaii and California, have shown, the ready availability of this information ensures that resources can go to communities in need. Moreover, improving the detail and quality of data collected on race and ethnicity in health is consistent with provisions of the Affordable Care Act and ongoing national efforts to improve health care quality for all.
As the pandemic continues to challenge the U.S. public health and health care systems, health equity must be a central part of the response. For Filipinxs, health care work in the U.S. has been an enduring legacy of American colonialism whose health consequences have predictably played out during the Covid-19 pandemic. Ensuring that disaggregated race and ethnicity health data are collected is a necessary step to advancing equity now and in the future.
Carlos Irwin A. Oronce is a primary care physician, a research fellow at the UCLA David Geffen School of Medicine and the VA Greater Los Angeles Healthcare System in Los Angeles, and president-elect of the Filipinx/a/o Community Health Association. The views expressed here are his alone and do not necessarily reflect the views of his employers.
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