1Harvard Medical School, Boston, MA 02115, USA
Correspondence should be addressed to N.U (nishant_uppal@hms.harvard.edu)
As medical students of South Asian descent training in the Boston area, we are fortunate to have many role models. We are lucky to be taught and supported by phenomenal faculty, residents, and fellow medical students, many of whom hail from similar backgrounds as we do. Seeing people who look like us, share our culture or religion, or speak the same language as we do allows us to envision ourselves practicing as physicians in the near future. It is particularly inspiring that so many thought leaders in American medicine are of South Asian descent, including physician-writers Atul Gawande and Siddhartha Mukherjee, physician-researchers Ashish Jha and Amitabh Chandra, government leaders Seema Verma (CMS Administrator) and Vivek Murthy (former Surgeon General), and so many others. While this level of representation is encouraging for budding medical students like ourselves, to be of South Asian descent in medicine is to face a troubling paradox.
Defining the Paradox
It has been well established that the recent surge in immigration from South Asian countries (e.g. India and Pakistan) is in part attributed to domestic needs for healthcare practitioners coupled with an immigration pipeline facilitated by the Immigration and Naturalization Act of 1965, which dismantled quotas based on countries of origin that had previously limited South Asian immigration [1]. As a result of this surge in immigration, the proportion of United States physicians identifying as Indian or Pakistani (4.8%) is greater than the proportion of the general population identifying as South Asian (1.2%), an expected result that has led some to use the term “overrepresented” when describing the representation of South Asian people in our healthcare workforce [2,3,4]. We might expect that physicians, as highly educated and socioeconomically advantaged members of society, would enjoy better health, an assumption that has been corroborated by the Centers for Disease Control and Prevention (CDC), which reported that those in higher income and education levels experience chronic diseases at lower rates [5]. However, despite a greater representation in the physician workforce, the South Asian American population paradoxically experiences higher rates of cardiovascular disease compared to white Americans across several metrics.
Recent epidemiological research is beginning to shed light on this paradox. A study of Asian Indian physicians and their family members revealed that the age-adjusted prevalence of myocardial infarction and/or angina in Asian Indian men was 7.2%, approximately three times greater than that of white men [6]. The prevalence of type 2 diabetes mellitus among Asian Indians was more than seven times greater than that among white Americans, despite lower rates of cigarette smoking, obesity, and hypertension in the Asian Indian population [6]. These disparities cannot be completely explained by hyperlipidemia, part of the trifecta of risk factors (i.e. hypertension, hyperlipidemia, and smoking) that has predictive value in the US Caucasian population [7]. Obesity also does not predict cardiovascular disease and insulin resistance in Asian Indians in the way it does in white counterparts; after controlling for age and body fat percentage, it appears that even among young, healthy Asian Indians, higher levels of inflammatory markers may predispose to a pro-inflammatory state that increases their risk for these conditions [8].
South Asian men and women are more susceptible to heart attacks, and these attacks are deadlier than those experienced by any other ethnic group [9]. Nearly one in three South Asians will die from heart disease before the age of 65. While a constellation of risk factors for this phenomenon has been suggested, they are compounded by the absence of specific testing for lipid/inflammatory biomarkers. This is especially true for younger South Asians, despite data demonstrating that even during childhood, South Asians have elevated blood levels of cholesterol and lipoproteins.
Artwork by Leela Breitman
Targeted Interventions
South Asians have received relatively little attention in the disparities literature, a surprising trend given the overrepresentation of South Asians in the medical profession. Though the roles of nutritional epigenetics, exposure to environmental pollutants, lifestyle patterns, microbiome differences, and psychological stressors have all been posited as contributors to South Asian health disparities, there is a need to further explore the corresponding modifiable risk factors [10]. While recent research is uncovering the nuances of South Asian health at the population level, it is important to note that some key findings have long been recognized. For example, higher rates of coronary artery disease among Asian Indians have been reported in the literature for nearly 30 years. However, few targeted interventions for South Asian Americans currently exist [11].
The Stanford South Asian Translational Health Initiative (SSATHI) is one of few programs geared towards tailoring treatment plans for cardiovascular health in South Asians, taking into account dietary and cultural factors to provide holistic healthcare [12]. The Memorial Sloan Kettering Cancer Center (MSKCC) recently developed a similar South Asian Health Initiative (SAHI). This initiative works in conjunction with faith-based and community organizations to sponsor health fairs where South Asians can receive free blood pressure, cholesterol, and diabetes screenings, and also learn about low-cost services and health insurance assistance to enable better access to preventative care [13].
Although these programs are examples of necessary first steps in addressing health disparities, they have yet to be replicated at scale nationwide, and they fall short of the personalized tailoring that is needed to more meaningfully address these disparities. While culturally customized models for prevention, diagnosis, and treatment are still in development, even those that have been proposed as policy recommendations are not widely adopted. For instance, South Asians often do not engage in conversations with their providers about complementary medicine, even though most members of the South Asian community are explicitly aware of the usage of alternative remedies [14]. Interventions targeted towards improving South Asian health also offer value to others seeking to tackle disparities in other ethnic and religious populations, who may face similar cultural and institutional barriers.
Studies show that targeting interventions according to population-level disparities can be effective. For instance, the Indian Diabetes Prevention Programme (IDPP), a 3-year randomized controlled trial conducted in India, introduced lifestyle modification techniques and metformin to individuals at high risk for developing diabetes in order to reduce rates of progression from impaired glucose tolerance to diabetes. In addition to improving patient outcomes, the program demonstrated cost-effectiveness even in the short term and even in settings with limited health resources [15]. In the United States, the ongoing transition of our health system towards value-based care creates ample opportunity for investment in similar cost-effective interventions for the South Asian immigrant population. Doing so would allow us to provide tailored care to a population with significant and unique risk factors while also expanding our understanding of how disease manifests differently in people of distinct origins.
While programs such as the IDPP provide learning opportunities for American medicine, the ability to implement these interventions will require partnership with South Asian community organizations to overcome challenges posed by cultural beliefs and practices concerning health, as well as commensurate efforts by the biomedical research institution to uncover new diagnostic and treatment modalities. An active collaborative comprised of these stakeholders and buy-in from clinicians, researchers, and the South Asian community at large offers the best chance of pioneering targeted interventions and proving scalability for fellow advocates seeking to address these striking health disparities.
References
Ludden J. 1965 Immigration Law Changed Face of America. National Public Radio. Published online May 9, 2006.
Association of American Medical Colleges. “Diversity in the Physician Workforce: Facts & Figures.” 2014.
U.S. Census Bureau. 2012–2016 American Community Survey 5-Year Estimates.
U.S. Census Bureau. 2011–2015 American Community Survey 5-Year Estimates.
Centers for Disease Control and Prevention (2012) “Higher education and income levels keys to better health, according to annual report on nation's health.” National Center for Health Statistics.
Enas EA, Garg A, Davidson MA, Nair VM, Huet BA, Yusuf S (1996) Coronary heart disease and its risk factors in first-generation immigrant Asian Indians to the United States of America. Indian Heart J. 48(4):343–53.
Annaswamy R, Seely EW, Arky RA, Donald C (2001) Body Fat Distribution and Insulin Resistance in Healthy Asian Indians and Caucasians. J Clin Endocrinol Metab. 86(11):5366–5371.
Chandalia M, Cabo-Chan AV, Devaraj S, Jialal I, Grundy SM, Abate N (2003) Elevated Plasma High-Sensitivity C-Reactive Protein Concentrations in Asian Indians Living in the United States. J Clin Endocrinol Metab. 88(8):3773–3776.
Stanford Health Care. South Asians and Heart Disease Q&A. Published online May 18, 2015.
Gany F, Palaniappan L, Prasad L, Acharya S, & Leng J (2017) South Asian Health. From Research to Practice and Policy: An Overview. J Immigr Minor Health. 1–4.
Enas EA, Yusuf S, Mehta JL (1992) Prevalence of coronary artery disease in Asian Indians. Am J Cardiol. 70(9):945–9.
Stanford Health Care. Stanford South Asian Translational Heart Initiative. Available at https://stanfordhealthcare.org/medical-clinics/stanford-south-asian-translational-heart-initiative.html.
Memorial Sloan Kettering Cancer Center. South Asian Health Initiative. Available at: https://www.mskcc.org/departments/psychiatry-behavioral-sciences/immigrant-health-disparities-service/working-diverse-communities/south-asian-health-initiative.
Mehta DH, Phillips RS, Davis RB, McCarthy EP (2007) Use of Complementary and Alternative Therapies by Asian Americans. Results from the National Health Interview Survey. J Gen Intern Med. 22(6):762–767.
Ramachandran A, Snehalatha C, Yamuna A, Mary S, Ping Z (2007) Cost-effectiveness of the interventions in the primary prevention of diabetes among Asian Indians: within-trial results of the Indian Diabetes Prevention Programme (IDPP). Diabetes Care. 30(10):2548–52.