Myths about the Asian American community -- commonly referred to as the "model minority" -- often contribute to challenges in uncovering the very real health disparities that exist within the diverse populations that fall under the same statistical umbrella.
Last week’s report from the Pew Research Center, The Rise of Asian Americans, has stirred up much controversy. Many advocates in the Asian American and Pacific Islander (API) community are arguing that the findings further a damaging idea about Asian Americans — the “model minority” myth. Advocates have said that these myths, which include the idea that Asian Americans are wealthier, more educated, and happier than other groups (all purported in the Pew report) are damaging because they hide the real challenges that exist for Asian Americans and Pacific Islanders, in particular for certain national and ethnic minorities that fall under the API umbrella.
One place this “model minority” concept can have negative implications is in discussions of health disparities. Whether due to population size or misconceptions about the health of Asian Americans, we do not often hear about the specific health disparities facing the API community. In the discussions about race and health, people of color are often grouped together, and disparities are talked about in terms of the gap between white people and people of color (Asian Americans included). These simplifications ignore the differences between racial groups, and even within nationalities and ethnicities within those racial subsets. Because of the Pew report, and as part of my focus on race-based health disparities and maternal child health, I decided to look further into the data on Asian Americans and Pacific Islanders.
One challenge when looking at data for Asian American and Pacific Islander groups comes simply from defining the community. It’s not always standard who is included when it comes to Asian Americans — sometimes Native Hawaiian and Pacific Islanders are under the umbrella, other times they are distinguished from South Asian and East Asian groups, and still other times they are not represented at all. As a result, conclusions drawn about people from such diverse nations and backgrounds represents, at best, a scattershot approach to understanding the challenges faced by those within the “big tent” surveys are based on.
What we do know is that API women suffer from higher rates of certain negative maternal and child health outcomes than their white counterparts. According to the Asian and Pacific Islander American Health Forum, Asian American women have higher rates of gestational diabetes than all other racial groups. Asian American women also die from maternity-related causes at higher rates than non-Hispanic whites. But the picture is only really clear when these disparities are looked at within the subgroups. Infant mortality, for example, is lower among Asian and Pacific Islanders as a whole than other racial groups, but much higher in certain subgroups. The rates of maternal mortality in the Pacific Islands for example, places like American Samoa and the Marshall Islands, is actually significantly higher than other groups on the U.S. mainland. Laotian and Thai communities in California also experience high infant mortality rates.
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Within the Asian Pacific Islander umbrella it’s important to acknowledge racial, ethnic, and economic differences that often represent major differences in health outcomes. In particular it’s necessary to distinguish and examine the outcomes of Native Hawaiian and Pacific Islanders apart from Asian Americans more broadly because the former group tends to experience higher rates of health disparities. These groups also present a complication to our traditional understanding of U.S. geographic landscape, as they include American territories like American Samoa and Guam, which, while affiliated with the United States, are in many ways more similar to other foreign and developing nations. Their health care delivery systems often lack resources and infrastructure, making this comparison even more faulty.
What’s challenging is that identifying the problem is only the very first step in addressing maternal and child health disparities in the API community. Without comprehensive data that paints a true picture of the community, finding a solution that might address these disparities is still far out of reach. And as the Pew report pointed out, we risk a lot in neglecting the needs of this diverse community, which is the fastest growing immigrant group. One piece of good news on this front is that the Affordable Care Act includes a provision that would improve reporting on national health surveys of a wider variety of identities including race, ethnicity, sex, primary language, and disability status.
Looking in depth at communities of color in regard to this data on race-based health disparities is important because it highlights and debunks some of the more commonly assumed causes on which these disparities are often blamed: economic status, racial group, ethnicity, language, and country of origin. What we find is disparities across all of these markers. What these statistics paint instead is a picture of a society that creates myriad challenges for non-whites, from access to and quality of health care, to economic and educational challenges, to health problems that are more prevalent because of lack of access and economic opportunities. It is in the details and differences, as well as the big picture of race-based disparities where complex solutions to a complex problem will be found.
“We know that we’ve had this problem that Latinos sometimes don’t vote—they feel intimidated, they feel like maybe their vote doesn’t matter,” Huerta told Rewire. Huerta encouraged people to consider both what is at stake and why their vote might be suppressed in the first place.
Republican nominee Donald Trump launched his campaign for president in June 2015 with a speech notoriously claiming Mexican immigrants to the United States “are bringing drugs, and bringing crime, and their rapists.”
Since then, both Trump’s campaign and the Republican Party at large have continued to rely upon anti-immigrant and anti-Latino rhetoric to drum up support. Take for example, this year’s Republican National Convention in Cleveland, where Sheriff Joe Arpaio—whose department came under fire earlier this year for racially profiling Latinos—was invited to take the stage to push Trump’s proposed 2,000-mile border wall. Arpaio told the Arizona Republic that Trump’s campaign had worked with the sheriff to finalize his speech.
This June, just a day shy of the anniversary of Trump’s entrance into the presidential race, People for the American Way and CASA in Action hosted an event highlighting what they deemed to be the presumptive Republican nominee’s “Year of Hate.”
Among the advocates speaking at the event was legendary civil rights leader Dolores Huerta, who worked alongside César Chávez in the farm workers’ movement. Speaking by phone the next day with Rewire, Huerta—who has endorsed Democratic nominee Hillary Clinton—detailed the importance of Latinos getting involved in the 2016 election, and what she sees as being at stake for the community.
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The Trump campaign is “promoting a culture of violence,” Huerta told Rewire, adding that it “is not just limited to the rallies,” which havesometimes ended in violent incidents, “but when he is attacking Mexicans, and gays, and women, and making fun of disabled people.”
Huerta didn’t just see this kind of rhetoric as harmful to Latinos. When asked about its effect on the country at large, she suggested it affected not only those who already held racist beliefs, but also people living in the communities of color those people may then target. “For those people who are already racist, it sort of reinforces their racism,” she said. “I think people have their own frustrations in their lives and they take it out on immigrants, they take it out on women. And I think that it really endangers so many people of color.”
The inflammatory rhetoric toward people of color by presidential candidates has led to “an alarming level of fear and anxiety among children of color and inflaming racial and ethnic tensions in the classroom,” according to an April report by the Southern Poverty Law Center (SPLC). The organization’s analysis of the impact of the 2016 presidential election on classrooms across the country found “an increase in bullying, harassment and intimidation of students whose races, religions or nationalities have been the verbal targets of candidates on the campaign trail.” Though the SPLC did not name Trump in its questions, its survey of about 2,000 K-12 educators elicited up more than 1,000 comments about the Republican nominee, compared to less than 200 comments mentioning other presidential candidates still in the race at that time.
But the 2016 election presents an opportunity for those affected by that violent rhetoric to make their voices heard, said Huerta. “The Latino vote is going to be the decisive vote in terms of who is going to be elected the president of the United States,” she continued, later noting that “we’ve actually seen a resurgence right now of Latinos registering to vote and Latinos becoming citizens.”
However, a desire to vote may not always be enough. Latinos, along with other marginalized groups, face many barriers when it comes to voting due to the onslaught of voter restrictions pushed by conservative lawmakers across the country—a problem only exacerbated by the Supreme Court’s 2013 ruling gutting portions of the Voting Rights Act (VRA) meant to safeguard against voter suppression efforts. The 2016 election season will be the first presidential election without those protections.
As many as 875,000 eligible Latino voters could face difficulty voting thanks to new restrictions—such as voter ID laws, proof of citizenship requirements, and shortened early voting periods—put into place since the 2012 elections, a May analysis from the National Association of Elected and Appointed Officials found.
When it comes to restrictions like this, Huerta “absolutely” saw how they could create barriers for those hoping to cast their ballot this year. “They’ve made all of these restrictions that keep especially the Latino population from voting. So it’s very scary,” said Huerta, pointing to laws in states like Texas, which previously had one of the strictest voter ID laws in the country. (The state has since agreed to weaken its law following a judge’s order).
“We know that we’ve had this problem that Latinos sometimes don’t vote—they feel intimidated, they feel like maybe their vote doesn’t matter,” Huerta went on.
Huerta encouraged people to consider both what is at stake and why their voting rights might be targeted in the first place. “What we have to think about is, if they’re doing so much to suppress the vote of the Latino and the African-American community, that means that that vote really counts. It really matters or else why would they be trying to suppress them?”
Appealing to those voters means tapping into the issues Latinos care about. “I think the issues [Latinos care about] are very, very clear,” said Huerta when asked how a presidential candidate could best appeal to the demographic. “I mean, immigration of course is one of the issues that we have, but then education is another one, and health care.”
A February survey conducted jointly by the Washington Post and Univision found that the top five issues Latino voters cared about in the 2016 election cycle were jobs and the economy (33 percent), immigration (17 percent), education (16 percent), health care (11 percent), and terrorism (9 percent).
Another election-year issue that could affect voters is the nomination of a U.S. Supreme Court justice, Huerta added. She pointed out the effect justices have on our society by using the now-decided Whole Woman’s Health v. Hellerstedt case as an example. “You know, again, when we think of the presidents, and we think of the Supreme Court and we know that [was] one of the issues that [was] pending in the Supreme Court … whether what they did in Texas … was constitutional or not with all of the restrictions they put on the health clinics,” she said.
Latinas disproportionately face large barriers to reproductive health care. According to Planned Parenthood, they “experience higher rates of reproductive cancers, unintended pregnancy, and sexually transmitted infections than most other groups of people.” Those barriers are only exacerbated by laws like Texas’ HB 2, as the National Latina Institute for Reproductive Health explained in its amicus brief in the Whole Woman’s Health case prior to the decision: “Texas Latinas already face significant geographic, transportation, infrastructure, and cost challenges in accessing health services.”
“H.B. 2’s impact is acute because of the day-to-day struggles many Latinas encounter when seeking to exercise their reproductive rights,” wrote the organization in its brief. “In Texas, there is a dire shortage of healthcare facilities and providers in predominantly Latino communities. Texas has the highest percentage of uninsured adults in the country, and Texas Latinos are more than twice as likely as whites to be uninsured …. Additionally, the lack of public and private transportation creates a major barrier to accessing health services, especially in rural areas.”
As Rewire’s Tina Vasquez has reported, for undocumented women, the struggle to access care can be even greater.
Given the threats cases like Whole Woman’s Health have posed to reproductive rights, Huerta noted that “Trump’s constant attacks and misogynist statements” should be taken with caution. Trump has repeatedly vowed to appoint anti-choice justices to the Supreme Court if elected.
“The things he says without even thinking about it … it shows what a dangerous individual he can be when it comes to women’s rights and women’s reproductive rights,” said Huerta.
Though the race for the White House was a top concern of Huerta’s, she concluded by noting that it is hardly the only election that matters this year. “I think the other thing is we have to really talk about is, the presidency is really important, but so is the Senate and the Congress,” said Huerta.
“We’ve got to make sure we get good people elected at every level, starting at school board level, city council, supervisors, commissioners, etc. state legislatures …. We’ve got to make sure reasonable people will be elected, and reasonable people are voted into office.”
Advocates say that U.S. Rep. Tim Murphy's "Helping Families in Mental Health Crisis Act," purported to help address gaps in care, is regressive and strips rights away from those diagnosed with mental illness. This leaves those in the LGBTQ community—who already often have an adversarial relationship with the mental health sector—at particular risk.
The need for reform of the mental health-care system is well documented; those of us who have spent time trying to access often costly, out-of-reach treatment will attest to how time-consuming and expensive care can be—if you can get the necessary time off work to pursue that care. Advocates say, however, that U.S. Rep. Tim Murphy’s (R-PA) “Helping Families in Mental Health Crisis Act” (HR 2646), purported to help address gaps in care, is not the answer. Instead, they say, it is regressive and strips rights away from those diagnosed with mental illness. This leaves those in the LGBTQ community—who already often have an adversarial relationship with the mental health sector—at particular risk.
“We believe that this legislation will result in outdated, biased, and inappropriate treatment of people with a mental health diagnosis,” wrote the political action committee Leadership Conference on Civil and Human Rights in a March letter to House Committee on Energy and Commerce Chairman Rep. Fred Upton (R-MI) and ranking member Rep. Frank Pallone (D-NJ) on behalf of more than 100 social justice organizations. “The current formulation of H.R. 2646 will function to eliminate basic civil and human rights protections for those with mental illness.”
Murphy and Rep. Eddie Bernice Johnson (D-TX) reintroduced HR 2646 earlier this month, continuing to call it “groundbreaking” legislation that “breaks down federal barriers to care, clarifies privacy standards for families and caregivers; reforms outdated programs; expands parity accountability; and invests in services for the most difficult to treat cases while driving evidence-based care.”
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Some of the stated goals of HR 2646 are important: Yes, more inpatient care beds are needed; yes, smoother transitions from inpatient to outpatient care would help many; yes, prisons house too many people with mental illness. However, many of its objectives, such as “alternatives to institutionalization” potentially allow outpatient care to be mandated by judges with no medical training and pushed for by “concerned” family members. Even the “focus on suicide prevention” can lead to forced hospitalization and disempowerment of the person the system or family member is supposedly trying to help.
All in all, advocates say, HR 2646—which passed out of committee earlier this month—marks a danger to the autonomy of those with mental illness.
Victoria M. Rodríguez-Roldán, JD, director of the Trans/GNC Justice Project at the National LGBTQ Task Force, explained that the bill would usurp the Health Insurance Portability and Accountability Act (HIPAA), “making it easier for a mental health provider to give information about diagnosis and treatment … to any ‘caregiver’-family members, partners or spouses, children that may be caring for the person, and so forth.”
For the communities she serves, this is more than just a privacy violation: It could put clients at risk if family members use their diagnosis or treatment against them.
“When we consider the stigma around mental illness from an LGBT perspective, an intersectional perspective, 57 percent of trans people have experienced significant family rejection [and] 19 percent have experienced domestic violence as a result of their being trans,” said Rodríguez-Roldán, citing the National Transgender Discrimination Survey. “We can see here how the idea of ‘Let’s give access to the poor loved ones who want to help!’ is not that great an idea.”
“It’s really about taking away voice and choice and agency from people, which is a trend that’s very disturbing to me,” said Leah Harris, an organizer with the Campaign For Real Change in Mental Health Policy, also known as Real MH Change. “Mostly [H.R. 2646] is driven by families of these people, not the people themselves. It’s pitting families against people who are living this. There are a fair number of these family members that are well-meaning, but they’re pushing this very authoritarian [policy].”
Rodríguez-Roldán also pointed out that if a patient’s gender identity or sexual orientation is a contributing factor to their depression or suicide risk—because of discrimination, direct targeting, or fear of bigoted family, friends, or coworkers—then that identity or orientation would be pertinent to their diagnosis and possible need for treatment. Though Murphy’s office claims that psychotherapy notes are excluded from the increased access caregivers would be given under HR 2646, Rodríguez-Roldán isn’t buying it; she fears individuals could be inadvertently outed to their caregivers.
Rodríguez-Roldán echoed concern that while disability advocacy organizations largely oppose the bill, groups that represent either medical institutions or families of those with mental illnesses, or medical institutions—such as NAMI, Mental Health America, and the APA—seem to be driving this legislation.
“In disability rights, if the doc starts about talking about the plight and families of the people of the disabilities, it’s not going to go over well,” she said. “That’s basically what [HR 2646] does.”
Rodríguez-Roldán’s concerns extend beyond the potential harm of allowing families and caregivers easier access to individuals’ sensitive medical information; she also points out that the act itself is rooted in stigma. Rep. Murphy created the Helping Families in Mental Health Crisis Act in response to the Sandy Hook school shooting in 2012. Despite being a clinical psychologist for 30 years before joining Congress and being co-chair of the Mental Health Caucus, he continues to perpetuate the well-debunked myth that people with mental illness are violent. In fact, according to the Department of Health and Human Services, “only 3%-5% of violent acts can be attributed to individuals living with a serious mental illness” and “people with severe mental illnesses are over 10 times more likely to be victims of violent crime than the general population.”
The act “is trying to prevent gun violence by ignoring gun control and going after the the rights of mentally ill people,” Rodríguez-Roldán noted.
In addition, advocates note, HR 2646 would make it easier to access assisted outpatient treatment, but would also give courts around the country the authority to mandate specific medications and treatments. In states where the courts already have that authority, Rodríguez-Roldán says, people of color are disproportionately mandated into treatment. When she has tried to point out these statistics to Murphy and his staff, she says, she has been shut down, being told that the disparity is due to a disproportionate number of people of color living in poverty.
Harris also expressed frustration at the hostility she and others have received attempting to take the lived experiences of those who would be affected by the bill to Murphy and his staff.
“I’ve talked to thousands of families … he’s actively opposed to talking to us,” she said. “Everyone has tried to engage with [Murphy and his staff]. I had one of the staffers in the room say, ‘You must have been misdiagnosed.’ I couldn’t have been that way,” meaning mentally ill. “It’s an ongoing struggle to maintain our mental and physical health, but they think we can’t get well.”
Multiple attempts to reach Murphy’s office by Rewire were unsuccessful.
LGBTQ people—transgender, nonbinary, and genderqueer people especially—are particularly susceptible to mistreatment in an institutional setting, where even the thoughts and experiences of patients with significant privilege are typically viewed with skepticism and disbelief. They’re also more likely to experience circumstances that already come with required hospitalization. This, as Rodríguez-Roldán explained, makes it even more vital that individuals not be made more susceptible to unnecessary treatment programs at the hands of judges or relatives with limited or no medical backgrounds.
“Forty-one percent of all trans people have attempted suicide at some point in their lives,” said Rodríguez-Roldán. “Once you have attempted suicide—assuming you’re caught—standard procedure is you’ll end up in the hospital for five days [or] a week [on] average.”
In turn, that leaves people open to potential abuse. Rodríguez-Roldán said there isn’t much data yet on exactly how mistreated transgender people are specific to psychiatry, but considering the discrimination and mistreatment in health care in general, it’s safe to assume mental health care would be additionally hostile. A full 50 percent of transgender people report having to teach their physicians about transgender care and 19 percent were refused care—a statistic that spikes even higher for transgender people of color.
“What happens to the people who are already being mistreated, who are already being misgendered, harassed, retraumatized? After you’ve had a suicide attempt, let’s treat you like garbage even more than we treat most people,” said Rodríguez-Roldán, pointing out that with HR 2646, “there would be even less legal recourse” for those who wanted to shape their own treatment. “Those who face abusive families, who don’t have support and so on—more likely when you’re queer—are going to face a heightened risk of losing their privacy.”
Or, for example, individuals may face the conflation of transgender or gender-nonconforming status with mental illness. Rodríguez-Roldán has experienced the conflation herself.
“I had one psychiatrist in Arlington insist, ‘You’re not bipolar; it’s just that you have unresolved issues from your transition,'” she said.
While her abusive household and other life factors certainly added to her depression—the first symptom people with Bipolar II typically suffer from—Rodríguez-Roldán knew she was transgender at age 15 and began the process of transitioning at age 17. Bipolar disorder, meanwhile, is most often diagnosed in a person’s early 20s, making the conflation rather obvious. She acknowledges the privilege of having good insurance and not being low-income, which meant she could choose a different doctor.
“It was also in an outpatient setting, so I was able to nod along, pay the copay, get out of there and never come back,” she said. “It was not inside a hospital where they can use that as an excuse to keep me.”
The fear of having freedom and other rights stripped away came up repeatedly in a Twitter chat last month led by the Task Force to spread the word about HR 2646. More than 350 people participated, sharing their experiences and asking people to oppose Murphy’s bill.
Alexander’s bill has more real reform embedded in its language, shifting the focus from empowering families and medical personnel to funding prevention and community-based support services and programs. The U.S. Secretary of Health and Human Services would be tasked with evaluating existing programs for their effectiveness in handling co-current disorders (e.g., substance abuse and mental illness); reducing homelessness and incarceration of people with substance abuse and/or mental disorders; and providing recommendations on improving current community-based care.
Harris, with Real MH Change, considers Alexander’s bill an imperfect improvement over the Murphy legislation.
“Both of [the bills] have far too much emphasis on rolling back the clock, promoting institutionalization, and not enough of a preventive approach or a trauma-informed approach,” Harris said. “What they share in common is this trope of ‘comprehensive mental health reform.’ Of course the system is completely messed up. Comprehensive reform is needed, but for those of us who have lived through it, it’s not just ‘any change is good.'”
Harris and Rodríguez-Roldán both acknowledged that many of the HR 2646 co-sponsors and supporters in Congress have good intentions; those legislators are trusting Murphy’s professional background and are eager to make some kind of change. In doing so, the voices of those who are affected by the laws—those asking for more funding toward community-based and patient-centric care—are being sidelined.
“What is driving the change is going to influence what the change looks like. Right now, change is driven by fear and paternalism,” said Harris. “It’s not change at any cost.”