JAMA Forum: Health Equity Matters for Asian Americans, Native Hawaiians, and Pacific Islanders

By Howard K. Koh, MD, MPH, and John J. Park, MB ChB

The JAMA Forum tjf-logo-stack-feature-345x210Achieving health equity remains a compelling vision for our diverse nation. But doing so requires clear understanding of health outcomes for all major American populations and their subgroups. In the case of Asian Americans, Native Hawaiians, and Pacific Islanders (AANHPIs)—who comprise the fastest growing racial/ethnic group in the United States—fundamental data challenges have long hampered progress. However, the last decade has witnessed some forward motion.

In 2015, the US population included 21 million Asian Americans and 1.5 million Native Hawaiians and Pacific Islanders. By 2065, the Asian American population alone is projected to almost triple to 62 million (from 6% of the US population to 14%). Many studies have treated AANHPIs as an aggregated group, which has blurred differences, led to misleading extrapolation of findings for 1 subgroup to the entire population, or omitted information altogether. Of note, this group encompasses more than 50 different ethnicities, 100 languages, and half the globe—from the US territories in the Pacific to New England. Two-thirds of Asian Americans are foreign-born and 15% represent more than one race. High-average household incomes and educational attainment for AANHPIs as a group mask stark differences across subgroups, with the Pacific Islander population ranking among the least educated and most impoverished in the nation.

Any meaningful assessment of health disparities must recognize both this dynamic growth and the striking heterogeneity. Doing so provides the context for documenting AANHPI outcomes, overall and by subgroup, and comparing them with those of non-Hispanic whites and other populations. Of note, the Affordable Care Act (ACA) requires that all federally funded health surveys of self-reported information collect disaggregated data by the 7 most populous Asian American subgroups (Chinese, Indian, Filipino, Vietnamese, Korean, Japanese, and other Asian) and 4 categories for Native Hawaiians and Pacific Islanders (Native Hawaiian, Guamanian or Chamorro, Samoan, or other Pacific Islanders). These standards also complement the goals of the first US Department of Health and Human Services (HHS) plan for AANHPI Health,* which calls for greater attention to disaggregated data as well as to specific health and workforce issues.

Some critical themes deserve special attention:

Health Insurance Coverage and Culturally Competent Care

Before the ACA’s passage, uninsured rates for the AANHPI population slightly exceeded or roughly matched the national rate of 16%, but some subgroups bore higher rates, including Korean Americans (27% in 2010). Because about a third of AANHPIs have low English proficiency, improving coverage involves outreach with particular attention to language and culture.

Since 2013, a network of organizations, Action for Health Justice, has provided multilingual AANHPI information and outreach in 22 states. Preliminary (2015) data now suggest substantial decreases in the percentage of AANHPI uninsured. Organizations such as the Asian & Pacific Islander American Health Forum and the Association of Asian Pacific Community Health Organizations also serve as leading voices for access to health care, health literacy, language access, and culturally appropriate services.

Improving Health Outcomes

All-cause mortality rates, and age-adjusted mortality rates from heart disease and cancer, are lower among AANHPIs than among the non-Hispanic white population and other groups. Digging deeper, however, unearths a host of disparities.

Cancer, Hepatitis, and Tobacco: The AANHPI population is the only US group for which cancer, not heart disease, ranks as the leading cause of death (27%). As with the general population, lung cancer ranks as the leading cause of AANHPI cancer deaths. However, a special section in a 2016 report from the American Cancer Society summarizes substantial cancer heterogeneity among subgroups.

The rate of tobacco use among the total AANHPI population is lower than among the general population (11% vs 15%), but higher among Native Hawaiians and Pacific Islanders (28%). Among racial groups, Asian Americans are the only group with a higher smoking prevalence among foreign-born males compared with their US-born counterparts. They include Asian American men who have migrated to the United States from countries where male smoking rates approach 50% or more.

Two cancers deserve special mention. Stomach cancer, which has declined in the United States for decades, particularly affects Korean Americans, who have an incidence rate 5 times that of non-Hispanic whites. High-salt diets may be a contributing factor, among others. Liver cancer is the second leading cause of death in AANHPI men (vs fifth for US men overall). Liver cancer incidence and death rates for the AANHPI population are double that of non-Hispanic whites, which in large part reflects a high burden of hepatitis B. Yet, like most US individuals with chronic hepatitis, only a minority of Asian Americans are aware of their serostatus.

Incidence rates of breast cancer are stable for the US population and colorectal cancer rates are declining. In contrast, increasing rates of the former and sharp increases in the latter are occurring for Korean, Vietnamese, and Laotian Americans. Prostate cancer, the most commonly diagnosed malignancy among AANHPI men, has rates that vary 3-fold across subgroups. Of note, AANHPIs, especially the foreign born, have markedly lower cancer screening rates than found in the general population. This disparity may reflect, among other possibilities, limitations in access, cultural beliefs, lack of trust in the system, and clinician biases.

Cardiovascular Disease, Diabetes, and Obesity: Proportionate mortality from cardiovascular disease was higher for AANHPIs than for non-Hispanic whites. Diabetes and obesity prevalence rates are also higher than for non-Hispanic whites. Such findings, as well as studies that suggest a higher diabetes risk at each body mass index level, have prompted the American Diabetes Association to recommend diabetes testing for Asian American adults with a body mass index of 23 or higher (vs 25 or higher for the general population).

Mental Health: In general, AANHPIs are less likely than non-Hispanic whites to report a need for mental health services. Those with low English proficiency and foreign-born status are least likely to access them, even after accounting for insurance coverage and severity of need. Notably, proportionate mortality from suicide in Korean American men (5%) is more than double that for non-Hispanic whites (2%); rates of suicide among Koreans are higher than for any other Asian American subgroup.

Tuberculosis and HIV: Of the approximately 9500 annual new US cases of tuberculosis, foreign-born Asian Americans have the highest rates of any racial/ethnic group, 28.5 times higher than that among non-Hispanic whites. Around a quarter of AANHPIs with HIV are unaware of their serostatus compared with 13% of the general population. Stigma related to HIV is a primary barrier to testing and access to services among the group.

As these populations grow and contribute further to the fabric of American life, efforts to better understand their health disparities—and the biologic and social determinants that drive them—should continue. Ongoing dedication to health equity can benefit not just AANHPIs but also the nation at large.

*Created in 2010 through the White House Initiative on Asian Americans and Pacific Islanders and while coauthor Dr Koh was HHS Assistant Secretary for Health

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About the authors:

Howard K. Koh, MD, MPH

Howard K. Koh, MD, MPH, is the Harvey V. Fineberg professor of the practice of public health leadership at the Harvard T. H. Chan School of Public Health and the Harvard Kennedy School. He is also the former Massachusetts commissioner of public health and the 14th assistant secretary for health for the US Department of Health and Human Services. A quadruple-boarded physician, Dr Koh has published more than 250 articles in the medical and public health literature, earned more than 70 awards for interdisciplinary achievements in public health, and has received 5 honorary doctorate degrees. (Image: Harvard T.H. Chan School of Public Health)

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John J. Park, MB ChB (Image: Harvard T.H. Chan School of Public Health)John J. Park, MB ChB is Kennedy Scholar at Harvard University and MPH Candidate and Research Assistant at the Harvard T.H. Chan School of Public Health. Dr Park is a medical and theology graduate from Scotland and holds the NHS Academic Clinical Fellowship at Cambridge University Hospitals. He has published 25 articles in medicine and public health and has worked on health policy for the Scottish Government, British Government, UNICEF, and WHO. (Image: Harvard T.H. Chan School of Public Health)

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About The JAMA Forum: JAMA has assembled a team of leading scholars, including health economists, health policy experts, and legal scholars, to provide expert commentary and insight into news that involves the intersection of health policy and politics, economics, and the law. Each JAMA Forum entry expresses the opinions of the author but does not necessarily reflect the views or opinions of JAMA, the editorial staff, or the American Medical Association. More information is available here and here.

 

 

 



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