The Other COVID-19 Crisis: Confronting Anti-Asian/AAPI Microaggressions in Clinical Settings

Jade Connor, MSc1 , Azfar Hossain 1 , Maahika Srinivasan, MS 1
1 Harvard Medical School, Boston, MA 02115, USA

Correspondence concerning this article and requests for reprints should be addressed to Maahika Srinivasan (maahika_srinivasan@hms.harvard.edu)

ABSTRACT

Since the beginning of the COVID-19 pandemic, there has been an alarming rise of racist incidents targeting patients and healthcare workers identifying as Asian, Asian American, and/or Pacific Islander (Asian/AAPI). This is part of a larger wave of anti-Asian/AAPI discrimination spreading across the country. Ongoing COVID-19-related bias in healthcare settings has the potential to engender immediate and long-term consequences, from delays in seeking care among patients to increased rates of burnout among frontline providers. Microaggressions and other acts of discrimination against Asian/AAPI individuals do not occur in a vacuum but are manifestations of historical and structural forces, including stereotypes, systems, and institutions. Unfortunately, due to gaps in medical education and training, many clinicians are ill-equipped to respond to anti-Asian/AAPI bias or understand this underlying context.

Based on the “Stop, Talk, Roll” and 4 R’s frameworks on addressing microaggressions and discrimination in clinical settings, an approach for non-Asian/AAPI providers to support patients and colleagues experiencing COVID-19-related harassment is presented. Allyship, an ever-evolving process of standing in solidarity with marginalized communities, is central to this approach. Although these strategies can help mitigate discrimination during the current pandemic, anti-racism work does not end with the end of COVID-19.

“You’re not welcome here.”

In Boston, a woman in labor refuses care from a concerned resident. In rural South Carolina, a patient shouts down another patient in an urgent care waiting room. In Los Angeles, a family bars a hospice nurse from entering their home, leaving the patient without pain medication for hours.

Though these incidents occurred several days and thousands of miles apart, a through line unites them. First, each event happened in the context of healthcare. Second, all of the subjects of attack identify as Asian, Asian American, and/or Pacific Islander (Asian/AAPI). Lastly, this is the age of the COVID-19 pandemic.

These incidents — examples of microassaults, a subset of racial microaggressions defined as “racial derogations that are verbal, nonverbal, or environmental attacks meant to hurt the person of color” — are manifestations of a larger trend of racism that has infected our society as rapidly as COVID-19 itself [1]. The FBI warns that the pandemic threatens to trigger a “surge” of verbal and physical attacks against Asian/AAPI people; there were over 1,100 incidents recently reported in just two weeks [2,3]. Hospitals and clinics are hotspots for these events given high stress around COVID-19 in these settings, which are among the few places still open to the public.

As the current crisis highlights, however, derogations against Asian/AAPI folks also manifest more insidiously. In the early stages of the pandemic, comments like “This is America, we don’t wear masks here” directed towards Asian American individuals wearing masks represent microinsults — another form of microaggression intended by the perpetrator to reflect a worldview in which racial and ethnic minorities are aliens within their own country [1]. In addition, Asian/AAPI communities experienced microinvalidations when they were told to be “overreacting” to politicians’ repeated use of “Chinese virus,” as their feelings and lived realities were negated [1,4]. Whether intentional or inadvertent, these slights indicate systemic perpetuation of Eurocentric/white supremacy, designating Asian/AAPI folks as inferior. 

COVID-19-related bias in healthcare settings may have enduring repercussions on both individual and population levels. Asian/AAPI patients may forgo care to avoid harassment in hospitals and clinics, a trend well-documented among other groups facing discrimination including Black American, Latinx and transgender individuals [5-7]. Studies also reported correlations between microaggressions and poorer health outcomes, including increased rates of heart attack and hospitalization [8]. At a time demanding more resilience than ever from health workers, racist incidents contribute to burnout, stress and mental illness among providers on the front lines [1,9].

There’s no question this moment calls for solidarity with targeted patients and providers; however, we worry that many clinicians are underprepared to address anti-Asian/AAPI bias. One recent study reported that most medical and dental students found knowing how to respond to clinical microaggressions “very challenging or extremely challenging,” while many others have described the common failure of providers to understand “how racism potentially infects the delivery of services to clients of color” [10,11]. In our own training, we have seen multiple instances of health workers across all specialties ignoring, downplaying or excusing identity-based discrimination on the wards. Whether due to lack of awareness or uncertainty around how to react, not addressing anti-Asian/AAPI discrimination during the pandemic is a choice that threatens to leave many behind.

We are moved by the work already being done by Asian/AAPI activists across the country in response to racism against their communities [12]. For those of us who do not identify as Asian/AAPI: what steps can we take to support those experiencing COVID-19-fueled bias in clinical settings? Based on our experiences researching clinical microaggressions and leading anti-bias workshops with Harvard Medical School’s Racial Justice Coalition, we offer several suggestions.

First, providers and trainees across all specialties must respond to interpersonal incidents, recognizing that Asian/AAPI individuals are at risk of COVID-19-related harassment. Georgetown University School of Medicine’s “Stop, Talk, Roll” tool (Table 1), which we have adapted for allies, provides a three-part approach: stopping the interaction, talking with the person targeted and ultimately “rolling out” an appropriate response [13]. In the case of the Asian/AAPI patient being harassed in the waiting room, this could take the form of stopping the encounter by having the perpetrator removed by security and communicating no tolerance for harassment; talking with the targeted patient to ask how they are feeling; and “rolling out” next steps, such as connecting that person to social work or reporting the incident through institutional channels.

Another approach shared by the University of Washington involves the 4 R’s: Recognize, Reason, Responsibility and Respond (Table 2) [14]. In the case of a patient refusing care from an Asian/AAPI provider, a colleague witnessing the encounter could recognize the refusal as a microaggression; reason through possible impacts of the refusal (could this comment make the provider feel unwelcome?); decide that one has a professional responsibility to take action; and then respond by telling the patient that prejudiced refusals of minority providers are unacceptable, or by checking in with the targeted individual after the encounter. In this response, Paul-Emile et al.’s framework on race-based refusals — which considers patient stability, decision-making capacity and reasoning — could also inform next steps [9].

Regardless of the framework used, it is critical we let those who are most affected by these incidents guide our responses, rather than making assumptions about how we can help. We must avoid speaking on behalf of those we are trying to support, which can silence or undermine others. Rather than stating, “Your comments make my colleague uncomfortable,” one could instead say, “I feel uncomfortable right now” in response to a racist incident. These responses can also involve microaffirmations: simple acts ranging from giving credit to others to actively listening [15].

While these real-time responses to microaggressions are crucial, allyship is not a static concept but rather an intentional and continuous process of checking one’s biases; challenging one’s assumptions; re-examining one’s understanding of the systems that disempower others; and revising one’s approach to the world accordingly. As such, intervention as an ally is meaningless without interrogating the intersecting structural and historical contexts propagating the marginalization of racial minorities. 

Xenophobia and racism did not originate with COVID-19; they have a deeply rooted history in the United States. From this country’s founding, those deemed “non-white” — particularly the poor and immigrants — have been scapegoated as spreading infectious disease, leading to policies that systematically oppressed these groups. During the 1900 bubonic plague outbreak in the western US, people of Chinese descent were labeled as disease vectors and subjected to mandatory quarantines (notably, after all white community members were relocated from the affected area) [16]. During the 2003 SARS epidemic, Asian/AAPI individuals were denigrated in the media [17]. These communities have simultaneously faced other forms of disempowerment outside of disease outbreaks, from imprisonment in internment camps to policies denying citizenship and land ownership [18].

Despite this history, there has been a systemic disregard of racism targeting Asian/AAPI folks due to the model minority myth. Asian/AAPI communities are frequently perceived as “model minorities” who have “made it” in American society due to stereotyped work ethic and intellectual capabilities. They are believed to be inherently immune to the impacts of racism and classism, since they are assumed to have capitalized on the American “meritocracy” [19]. This concept is codified when Asian/AAPI communities are neglected in policy interventions — including in healthcare [20]. By understanding this context, we can improve our ability to identify bias and respond in ways that account for the lived experiences of patients and peers.

While the physiological toll of this pandemic will eventually dwindle, the interpersonal and structural tensions that it underscores will not fade without action. We acknowledge that institutions also play a significant role in dismantling racism and xenophobia through policy and messaging. Healthcare institutions and medical schools should mandate rigorous anti-bias and allyship training for all stakeholders including providers, faculty, staff, and trainees — an intervention called for by many others [21,22]. Furthermore, institutions should implement accountability measures to ensure this training is translated into action. Our focus in this piece, however, is to emphasize how individuals may combat inequities when they take the form of microaggressions — ranging from bigoted and prejudicial comments to overt discriminatory acts.

 Just as we have undertaken the uncomfortable task of social distancing for the health of our communities, we must engage in the process of allyship in solidarity with our Asian/AAPI patients and peers. An effective ally is tasked with complex responsibilities: intentional listening; embracing discomfort; constant self-educating; amplifying the voices of oppressed peoples. Allyship is not confined to a specific time, situation, or group: it is a lifelong approach to engaging with the people around us, constantly striving to improve the ways in which we walk with those who are marginalized. It’s on all of us to engage in this process in support of communities facing discrimination, knowing that our responsibility doesn’t end with COVID-19.

ACKNOWLEDGEMENTS

We would like to express our gratitude to Avik Chatterjee MD, MPH for his continued mentorship in addition to the following faculty and peers who developed the medical education workshop from which many of these themes were drawn: Tamina Kienka, Raquel Sofia Sandoval, Titilayo Afolabi, Jordan Said, and Daniele Ölveczky, MD, MS.

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