During my second year of medical school in New York, I had my first direct brushes with the anti-Asian violence that has characterized the pandemic era. On a single subway trip in 2020, I had back-to-back encounters with different individuals who, unprovoked, hurled slurs and made violent threats due to my ethnicity. Suddenly, the terrible phenomenon I’d read so much about became real.
Over the next year, while completing my core clinical rotations, I found myself battling persistent insomnia. I chalked it up to the stress of trying to balance clerkships, exams, and life during a global pandemic.
But what if something else was also at play?
New research on Asian Americans explores how this wave of racism might be affecting us biologically as well as psychologically, and how even indirect anti-Asian racism can alter physical functioning.
A study published last year, led by academic psychologist and Fordham University professor Tiffany Yip, PhD, showed a link between anti-Asian racism and changes in physical functioning during the pandemic. The study was conducted after the start of the COVID-19 pandemic and surveyed 600 Asian American adults. They did not necessarily experience direct racism, like I did. The researchers specifically examined a less-studied type of discrimination called “indirect” or “vicarious” racism, defined as an individual’s experience of discrimination targeting others within their racial group, but not the individual directly.
Asian Americans experiencing indirect racism during the COVID-19 pandemic suffered poorer sleep — shorter duration, difficulty falling asleep, and less restful sleep. This held true even after accounting for other socioeconomic variables that could affect sleep. Participants who reported being more strongly affected by indirect racism had worse sleep disturbances than those less affected.
The idea that racism impacts health is not new. When individuals experience racism, levels of the stress hormone cortisol rise, and that is linked to problems like high blood pressure, diabetes, cardiovascular disease, and obesity. Indirect racism has also been found to worsen the progression of inflammatory disease. Prior research, including another study Yip was involved in, shows that racism-related stress worsens sleep, and sleep disturbances worsen chronic health conditions and cognitive function.
The recent swell in anti-Asian hate incidents presents a unique opportunity to study the health impact of indirect racism because hate crimes — especially targeting women or the elderly — have been widely shared through traditional and social media avenues, even while COVID-related restrictions limited social interactions for many and reduced the potential for direct, in-person racism. Most Asian Americans, Yip said, knew friends or family members who were targeted in racist incidents, even if they themselves were not.
What does this all mean for an entire population that has entered a new reality of rising hate crimes? In 2020, the FBI reported a 77% increase in anti-Asian hate crimes compared to the year before. Now, the severity of the pandemic has abated and the economy has reopened, but Asian Americans continue experiencing even higher rates of hate incidents. Indirect racism has taken its toll, with more than one in three Asian Americans reporting changing their daily routines for fear of being a hate crime victim. Yet, one in three Americans remain unaware of worsening anti-Asian racism.
As an Asian American and soon-to-be physician, I fear that this sudden increase in racism could manifest as an increase in the prevalence of chronic diseases decades from now, widening health disparities that already exist. I also fear that the medical community may get in our own way of understanding these downstream effects.
Some health professionals dismiss disparities or the need for research in Asian American and Pacific Islander (AAPI) patients, asserting — against evidence — that we do not need additional attention or research because Black, Latino, and Native Americans face worse circumstances. This reductive view is known as the “model minority” myth. Even the National Institutes of Health (NIH) excludes Asian Americans from funding for diversity in medical research by not considering them an underrepresented minority — though clinical research in AAPIs comprised just 0.17% of NIH funding between 1992 and 2018, and remains low despite overall increases in the NIH research budget. The medical community risks implying that improving outcomes and understanding disparities in minority patients is a zero-sum game, when this does not have to be the case.
So far, research on the health impacts of anti-Asian racism in the COVID-19 era has not yet assessed its impact on specific diseases, but history offers clues to potential population-level effects. Japanese Americans on the West Coast during World War II who were forced into inland internment camps based on their ethnicity were 2.1 times more likely to have and to die from cardiovascular disease decades later than their counterparts who were not interned. A historical study showed that Black women with breast cancer born in the Jim Crow era and in states with Jim Crow laws were more likely to develop a worse type of breast cancer than Black women born in states without Jim Crow laws or after that era.
In the face of anti-Asian racism, the medical community can help future patients by acknowledging rather than downplaying their experiences and by remaining knowledgeable about the consequences of racism on physical health. The latter is already partly underway, with increased research interest in the subject; the number of NIH-funded studies including the keywords “racism” and “health” increased more than sevenfold from 2019 to 2022. The number of projects on Asian health, while small, increased proportionally from five to 37.
These studies will shed more light on the physical harms of anti-Asian racism. Mitigating long-term health effects could take the shape of earlier screening for chronic conditions or more frequent sleep specialist referrals. Asian Americans will require increased engagement as they face barriers to seeking care, such as language and cultural barriers, cultural stigma around getting help, and lower utilization rates of some preventive services. But medical professionals should continue speaking up for the health of their Asian American patients and pushing for more research in this community. Remaining proactively attentive to the physical harms of racism might prevent another historical study, decades later, revealing worse health outcomes in Asian Americans living through today’s circumstances.
Jingwen Zhang is a fourth-year medical student at the Columbia University Vagelos College of Physicians and Surgeons.