At the beginning of the COVID-19 pandemic, the staff of Asian Health Services (AHS) in Oakland noticed something worrisome. The city’s Chinatown district, where the community health center operates a few clinics, had lost its routine hustle and bustle.

“The streets were empty,” said Thu Quach, PhD, chief deputy at AHS. “We were still open, so we saw it — all of our staff members were still going into work. But since COVID-19 began over a year ago, we have basically seen our communities go underground.”

The loss of activity in Chinatown coincided with California’s stay-at-home order, which Governor Gavin Newsom issued on March 19, 2020, but that wasn’t the only reason. When AHS staff members called their patients to find out why they had been missing appointments, patients said they were afraid. “It was really heartbreaking to hear how devastated, scared, and depressed they were,” said Quach. “They went underground both because they were afraid of COVID-19 and because they were afraid of people attacking them.” Asian Americans for Community Involvement (AACI), a Federally Qualified Health Center in San Jose, witnessed the same phenomenon after President Donald Trump referred to the coronavirus as the “Chinese virus,” according to AACI’s president, Sarita Kohli, MBA.

While the pandemic set the high-water mark for anti-Asian rhetoric, assaults on the health care safety net for Asians with low incomes had begun years earlier in the nation’s capital. (In this article, “Asians” refers to US citizens and naturalized citizens of Asian heritage, as well as documented and undocumented immigrants from Asia.) In 2018, the Department of Homeland Security proposed changes to the public charge rule for immigrants, and the Trump administration implemented them in 2020. Although the Biden administration recently withdrew the rule, numerous studies demonstrated that the public charge rule harmed immigrant families. Many avoided using available benefit programs such as Medicaid out of fear of immigration-related consequences, including the denial of green cards. “The concerns from health centers really began as soon as information about public charge was first leaked, then passed by the last administration,” said Jen Lee, MPH, deputy director of the Association of Asian Pacific Community Health Organizations, which has six members in California.

Even with these fears in the community, Asian health centers have been uniquely positioned to support communities in trying times. Health centers serve as care providers, social service connectors, and community advocates — and they have stepped up to help patients navigate the physical and mental health trials of the COVID-19 era.

Asians in America: Deeply Diverse

California is home to the nation’s largest population of Asians, a deeply diverse community (PDF) that is often mistaken for a monolithic group. Filipinos make up the largest Asian ethnic group in the state, followed by Chinese, Vietnamese, Indian, and Korean residents. About 59% of Asian people in California are foreign-born, and 72% speak a language other than English at home.

Over 6,600 hate incidents were reported to the Stop AAPI Hate reporting center in the year ending March 31. Of those incidents, 40% occurred in California.

A persistent trope about Asian Americans is that they have overcome discrimination and racism with hard work and educational achievement to become successful and prosperous. But the “model minority” myth can conceal the realities of distinct economic challenges that Asian subgroups face. Asians are the most economically divided racial or ethnic group in the US, according to the Pew Research Center. In the Los Angeles metropolitan area, the median value of liquid assets held by Indian households is $245,000 (PDF), compared to $130,000 for Chinese households, and $3,000 for Korean households.

The economic diversity among Asians underscores the need for linguistically and culturally competent care, which health centers deliver to communities with low incomes. AHS delivers services in over 14 Asian languages as well as English.

Avoiding Public Places

Once Quach and other leaders at AHS learned that patients were afraid to keep their appointments, they figured out what to do about it. In mid-2020, the health center surveyed nearly 1,300 Asian American adults and teens in the Bay Area. A staggering 73% of respondents said they avoided leaving home to go to public places.

“This avoidance behavior may be associated with the low [COVID-19] test rate (PDF) in this group,” wrote Quach and her coauthors in a preprint submitted to the Journal of Medical Internet Research. The survey found that only 3% of respondents had been tested for COVID-19. That anemic testing rate compared unfavorably to the 20% for all races taken together, and 6.4% for Asians in Alameda County.

AHS suspected that because 75% of its patients have limited English proficiency, language was also a major barrier for COVID-19 testing. The health center established a COVID-19 community testing site that provided culturally appropriate, multilingual services; it also created a multilingual phone service to help people navigate the testing process and connect to food assistance and other social services.

Now that the national COVID-19 vaccination campaign is well underway, with 35% of the adult population fully vaccinated, AHS has turned its attention to documenting how language obstacles impede vaccine access. Despite laws requiring federally funded programs to “take reasonable steps to insure that limited English-proficient speakers have meaningful access to their programs and activities” (PDF), some AHS patients were hitting language barriers to vaccine appointments.

In partnership with the Association of Asian Pacific Community Health Organizations, the Progressive Vietnamese American Organization, One Nation AAPI, and the Asian American Research Center on Health, AHS launched Asian American Voices, a data collection initiative. The project started a website last month that lets people file reports of vaccine access problems in Khmer, Korean, Tagalog, and eight other Asian languages.

Stressed and Depressed

The AHS survey found that three out of four respondents reported feeling stressed by the pandemic, and one out of four reported feeling depressed.

“During the pandemic, both our integrated behavioral health department and specialty mental health department have become completely booked up,” said Quach. “This has not happened in the past because there has always been a sort of stigma around mental health for Asian Americans. Then COVID-19 hit and our mental health staff was getting so many referrals that they couldn’t fully meet the demand.”

The overwhelming demand for mental health services still holds true. AHS is working to expand its mental health workforce, but it has been difficult to find bilingual and bicultural providers.

Nira Singh, PsyD, director of behavioral health services at AACI, said its Family and Children Services Program has gotten more behavioral health referrals during the pandemic, especially those related to children returning to school. “We are hearing about cyberbullying,” she said. “We have youth who were fearful of going back to school, and families afraid to send their children back.”

Wave of Hatred

The pandemic has caused job loss, isolation, illness, and parenting difficulties across many groups. But the wave of hate aimed at Asians, which is connected to the COVID-19 pandemic but rooted in history, has been the most noticeable.

Over 6,600 hate incidents were reported to the Stop AAPI Hate reporting center in the year ending March 31. Of those incidents, 40% occurred in California. Chinese Americans reported the greatest number of incidents, followed by Korean and Filipino Americans.

A survey conducted by the Pew Research Center last June found that 31% of Asian Americans have been subjected to slurs or jokes because of race or ethnicity since the beginning of the coronavirus outbreak, compared to 21% of Black adults, 15% of Latinx adults, and 8% of White adults.

California Attorney General Rob Bonta, the first Filipino American to head the state Department of Justice, has established a Racial Justice Bureau to combat the rise in anti-Asian hate crimes.

Over the summer of 2020, CHCF conducted the Listening to Californians with Low Incomes survey in partnership with the national research organization NORC. Survey respondents were limited to California adults who had seen a health care professional since March 2019. Experiences of COVID-related discrimination because of one’s race or ethnicity were common among respondents with low incomes (16%); Asian respondents (17%); and Chinese-speaking respondents (42%). Twenty-four percent of Asian respondents with low incomes reported COVID-related discrimination, a finding that statistically was significantly greater than Latinx and White respondents with low incomes.

Xenophobia Threatens Mental Health

Lee attributes the findings to xenophobic rhetoric during the Trump administration. “Particularly, all of the finger-pointing at China since the pandemic began, which invited hate and blame that got generalized to any Asian-looking person in the US,” she said.

Research suggests that experiences of racial discrimination can lead to worse mental health, such as general distress, depression, and anxiety. Reports of everyday discrimination are associated with an increase in chronic health conditions like cardiovascular disease, as well as with indicators of pain like chronic back problems or headaches.

To combat the mental health impacts of anti-Asian racism, the American Psychological Association emphasizes the importance of trauma-informed care and culturally adapted mental health services, especially those that may carry less stigma than one-on-one therapy.

With those approaches in mind, AACI is training providers to recognize psychosomatic symptoms of trauma and ask probing questions without making patients uncomfortable. “Our job is to create a welcoming, safe space in our health centers,” said Singh. “We’re able to do this because we have an integrated care team that can identify various needs. Behavioral health is very much a part of wellness.”

The health center members of the Association of Asian Pacific Community Health Organizations have “really stepped up in this time to lead community dialogue or host virtual town halls to keep confronting issues of anti-Asian hate and uplifting our histories and voices,” said Lee.

New Laws Against Hate Crimes

Last month, the US Senate voted 94 to 1 for the COVID-19 Hate Crimes Act, and the House is expected to vote on it this month. President Biden has already said he will sign it into law.

For more than a year, Asian Americans “have been scapegoated, harassed, and assaulted; some have even been killed,” said President Biden in a statement. “Our nation must stand together to speak out against hate and declare unequivocally: These acts are wrong. They are un-American. And they must stop.”

California Attorney General Rob Bonta, the first Filipino American to head the state Department of Justice, announced on May 11 the launch of a new Racial Justice Bureau to combat the rise in anti-Asian hate crimes.

Meanwhile, health centers like AHS will continue advocating and caring for their patients. “Violence against our communities will always affect their health outcomes, whether mental health or physical health,” said Quach. “As with everything else we have done, we will continue to lift up the voices of our patients — those who are immigrants, those who are low income, and those who have limited English proficiency. In many ways, we are the lifeline for those communities.”

Xenia Shih Bion

Xenia Shih Bion is a communications officer at CHCF, where she helps to lead communications around the foundation’s work to create health equity. She is the founding author of the “Essential Coverage” column in The CHCF Blog. Read More

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