Anti-Racism | michelle ko md phd

Asian Americans and racial justice in medicine

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AAPI Heritage Month Logo

“I don’t see how that’s relevant to healthcare.”

At the end of March 2021, an (non-Asian American) Associate Dean for Equity, Diversity and Inclusion at a prominent U.S. medical school asked the Dean if they could plan a statement and educational activity about the Atlanta shootings in which 8 people were murdered, 6 of whom were Asian women. At this time, American rhetoric around the COVID-19 pandemic, including language from the former U.S. president, had spawned an exponential growth in anti-Asian hate since 2020. Asian American healthcare workers were experiencing discrimination, harassment, rejection and even violence, from patients, staff and colleagues.

The renewed racial justice movement following the murders of Brianna Taylor Ahmad Arbery and Breonna Taylor had also ushered a wave of discussion about racism in the nation- including in medicine. Medical schools set up anti-racism initiatives, doubled-down on anti-racism commitments, and announced new positions and offices of equity, diversity and inclusion.

The Dean did not see the event- a tragic signifier of the broader issue of anti-Asian American racism in the country- as relevant to the community in their school of medicine.

The continued erasure of Asian Americans within medicine, who make up approximately one-fifth of all medical students, trainees and physicians, and constitute the largest racially minoritized group, will block overall progress on racial justice.

Holding up Asian Americans as a “model minority,” allows for white dominant narratives to deny the existence of racism within the profession. Simultaneously, ignoring Asian American concerns and perpetuating ongoing discrimination will continue to those in healthcare more broadly (not just physicians).

With this commentary in NEJM, we hoped to start a more nuanced conversation about the positionality of Asian Americans in medicine and in the larger movement for racial justice.

Asian Americans and Racial Justice in Medicine

Racism and peer review: When your “peers” are not your peers

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Following George Floyd’s murder and the ongoing racial justice movement, funders and journals in public health announced a slew of new opportunities specific to anti-racism, structural racism, and so on, suddenly feeling the urgency to acknowledge that racism has been killing Americans…since, well, the beginning.

These were important first steps in recognizing how scholars have been shut out of research and academia- but these opportunities were still built off the existing research enterprise infrastructure. Which- no surprise- is racist in its construction.

How so? Besides systematically denying funding and publication on racism and health, to scholars racialized as non-white, we also have:

Systematic underfunding/disinvestment in minority serving institutions, including Historically Black Colleges and Universities- thus less support services for scholars at those institutions and lower ratings on institutional environment (in grant review)
Ignorance (deliberate or intentional) of scholarship particularly those with a critical stance (eg devaluation of the work in ethnic studies, critical race theory and extensions)
Denigration of methods of those scholars, as well as other methods e.g. all of qualitative research, community-engaged work, etc
Lack of diversity and advancement within academia

To name a few.

These conditions have led us to the present conditions which we have new funding and publication mechanisms, reliant upon a traditional peer review system in which reviewers are poorly qualified- and at times oppositional- to any work on racism. Furthermore, editors are not necessarily equipped to identify or mitigate low quality peer review. This is just one pillar of the racism within research.

What happens when you just stack new objects on the same old foundation?

Check out the Health Affairs Forefront essay on the poor quality of peer review and consequences: Peer Review and Structural Racism.

Structured travel time and distance inequities in access to hospitals in the U.S. South

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White sign covers the existing sign of in front of a hospital and says "This hospital is CLOSED, if this is an emergency call 911." The sign is flanked by shrubs and lamps posts.

In 2019, a PhD student in medical geography at the University of Illinois posted on Twitter about her interest in studying rural hospital closures. An assistant professor from UC Davis DM’ed her to say, we should talk! They met up at a cafe near the AcademyHealth Annual Research Meeting in Washington, D.C. And a speedy 4 years, many datasets, analyses, a move, a new baby later…they finally published the first analysis.

Following up from her previous conceptualization on time as a social determinant of health, Arianna M. Planey uses the cases of access to acute care hospitals in the U.S. South to illustrate the construction of racialized inequities in healthcare.

In addition to grounding the motivation and analysis in the theoretical frameworks of structural racism and access to healthcare, Dr. Planey’s approach shows the benefits of drawing from geography methods to improve health services research, including:

Methodological improvements:

-Use of a validated hospital dataset that accounts for closures and mergers to determine actual losses of sites.

-Use of travel time/distance as an outcome. Most analyses of rural hospital closures, which use ‘container’ methods, e.g. documenting changes in hospital supply by county. In this manuscript, Dr. Planey examines travel time and travel distance. She shows that the impact on travel time and distance is relatively smaller than simply examining gains/losses by county.

-Estimates from the population-weighted centroids of Census tracts, i.e. not the geographic center (commonly used) but rather, based on where people live within the tract.

–Examination of both nearest and next-nearest hospital. This is a key consideration in rural hospital analyses, as community members have high rates of hospital bypass- for many reasons, including lack of specialty services and distrust of the nearest facility. For racially minoritized communities, the nearest hospital may not offer the services for linguistically, culturally appropriate care, which can include care that is respectful and trustworthy.

Findings: You can read more, TLDR Black and Latinx communities have longer travel times/distances to next nearest and nearest hospitals, despite being less remote than rural white communities.

And…what? you want to see what the impact is on access to care? Stay tuned….

Planey AM, Planey DA, Wong S, McLafferty SL, Ko MJ. Structural Factors and Racial/Ethnic Inequities in Travel Times to Acute Care Hospitals in the Rural US South, 2007-2018. Milbank Q. 2023 May 15. doi: 10.1111/1468-0009.12655. Epub ahead of print. PMID: 37190885