Asian American Subgroups And The COVID-19 Experience: What We Know And Still Don’t Know.

Even after a full year since COVID-19 was officially declared a national emergency in the United States (US), there is still an incomplete picture of how the pandemic is affecting the Asian American population—particularly how its effects have varied across different Asian American subgroups (Chinese, Indian, Filipino, Vietnamese, Korean, Japanese, and so forth). Poor data quality and lack of disaggregated race/ethnicity data have hampered our ability to identify and mitigate COVID-19-related disparities for Asian Americans as well as identify the mechanisms underlying these disparities.

Since the start of the pandemic, we have systematically captured research articles, news media, and grey literature to broadly understand COVID-19’s impact on Asian Americans in terms of disease outcomes as well as effects on businesses and livelihood.

In this post, we describe the challenges of race/ethnicity data collection, how the pandemic has affected Asian Americans in aggregate, and what we know about its effect on the six largest Asian American subgroups. A comprehensive table outlining our findings and sources can be found here: exhibit 1. In the text below, statements for which sources cannot be directly hyperlinked, will be labeled (exhibit 1) where additional detail and sourcing can be found.  

In addition, we shed light on what we still do not know—specifically the gaps in data and knowledge for how the pandemic has affected different Asian American subgroups. Lastly, we provide recommendations for how researchers, policy makers, and funders must address these gaps in data to effectively allocate scarce public resources and set equitable, data-driven, and community-informed policy priorities going forward.

Challenges Related To Collection Of Racial/Ethnic Data For Asian Americans

Census questions on race/ethnicity in the US date back to 1790, and changes to the race/ethnicity categories are related to the social and political attitudes of the times, changing US demographics, as well as continual research and concerted advocacy to improve race/ethnicity data. Categories for the six largest Asian American subgroups have been collected since the 1990 census, but the Office of Management and Budget (OMB) only requires “Asian” as one of the five minimum categories for race/ethnicity data collected by federal agencies—a standard that is followed for most COVID-19 data collection, obscuring disaggregated subgroup nuances.

As of April 28, 2021, race/ethnicity data were missing for 39 percent of reported COVID-19 cases and 17 percent of deaths nationally. An even larger proportion of race/ethnicity data were missing for vaccine recipients with up to 58 percent of fully vaccinated people missing race/ethnicity information. This is especially problematic because current reporting may underestimate COVID-19 disparities due to missing data and misclassification of race/ethnicity. Research has demonstrated Asian Americans and Hispanics are more likely to be classified as “other” in hospital discharge data, and biased assignment of who counts as Asian American frequently only includes East Asians. The gaps in this data is distressing not only with regards to identifying and eliminating COVID-19 and related disparities, but because in the current climate, incredibly complex ethical decisions about resource allocation including funding and vaccine prioritization are based on these incomplete data. For example, Asian Americans are notably not listed as a vulnerable population under the National Academy of Sciences Engineering Medicine’s Framework for Equitable Allocation of a COVID-19 Vaccine and continue to be inconsistently included in COVID-19 response policies.

COVID-19 Experience For The Asian American Population In Aggregate

COVID-19 Disease Outcomes

Growing evidence suggests that the pandemic is disproportionately affecting Asian Americans especially when compared to their White peers. In an analysis of 50 million patients in the EPIC health system, Henry J. Kaiser Family Foundation reported that Asians were twice as likely to test positive for COVID-19 than Whites, 60 percent more likely to be hospitalized, and 50 percent more likely to die. Similarly, a meta-analysis of 50 studies in the US and United Kingdom found that Asian adults were 50 percent more likely to be infected by COVID-19 than their White counterparts. The Marshall Project further reported that Asian Americans had the second-highest percentage increase of excess deaths (+35 percent increase) in the first seven months of 2020, second only to Hispanics (+44 percent increase). A recent study examining National Center for Health Statistics data on COVID-19 deaths found that attributable mortality from COVID-19 was significantly higher among Asians than Whites, and when stratified by age and race/ethnicity, Asians ages 45 years and older had statistically higher attributable mortality than Whites.

Asian American infection outcomes can partially be explained by the large number of individuals working in high-contact essential worker roles. Asian Americans are overrepresented among frontline and essential workers with approximately two million Asian American essential workers in the US. This is especially evident in the health care industry where 72 percent of high-contact medical occupations have a higher proportion of Asian Americans workers than the total Asian American share of the population. However, even when examining COVID-19 case fatality among health care workers, Asian American rates are still three times higher than the rates for White health care workers, suggesting the need for more research on COVID-19 disparities.

Asian Americans have the highest rates of living in multigenerational households compared to other racial/ethnic groups. About 29 percent of Asian Americans are estimated to live in a household with two or more adult generations, and approximately 18 percent of Asian Americans live in a household with at least one health care worker, increasing the risk of household transmission.

Approximately 30 percent of Asian Americans have limited English proficiency, creating a barrier to care and government relief resources. This barrier is particularly severe for accessing telehealth services, which have become especially important during the pandemic. A recent study found individuals with limited English proficiency were about 50 percent less likely to use telehealth services than individuals with English proficiency.

As of April 28, 2021, the overall vaccination rate for Asian Americans (45 percent) has been higher than that for Whites (38 percent); however, this varies considerably by geography with some states such as Pennsylvania vaccinating 37 percent of its White population but only 3 percent of its Asian American population. When comparing the share of vaccinations among Asian Americans to their share of cases and deaths, there are sharp disparities in specific states. For instance, in Alaska, 5 percent of vaccinations have been received by Asian Americans while they comprise 11 percent of deaths.

Businesses And Livelihood

The pandemic has an unequal impact on the businesses and livelihoods of Asian Americans. Asian American unemployment increased from the lowest rate in the country at 2.8 percent in August 2019 to one of the highest at 10.7 percent in August 2020, only recently stabilizing at 4.1 percent as of March 2021. Among unemployed women, Asian Americans had the highest rates of long-term unemployment at 44 percent compared to other racial/ethnic groups. Asian American community-based organizations report that many immigrant clients are eligible to receive public benefits but are afraid to accept them due to fear of becoming a public charge. In addition, undocumented households have also been unable to receive stimulus aid checks and unemployment insurance throughout the pandemic.  

Asian American businesses are disproportionately distributed among some of the sectors most acutely impacted by the pandemic. Asian Americans comprise 6 percent of the US population, but Asian American-owned businesses make up 26 percent of food and accommodation, 17 percent of retail trade, 13 percent of health care and social services, and 11 percent of education services. Businesses owned by people of color face greater barriers to obtaining a Payment Protection Program (PPP) loan—a federal loan meant to help small businesses during the pandemic, with 75 percent of Asian-owned businesses having “close to no chance of receiving a PPP loan through a mainstream bank or credit union,” according to the Center for Responsible Lending.  

Asian Americans have also witnessed an unprecedented spike in anti-Asian violence, particularly among East and Southeast Asians, as a result of being scapegoated for the COVID-19 pandemic. A report published by the nonprofit Stop AAPI Hate documented self-reported anti-Asian incidents from March 2020 to February 2021. Among the 3,795 incidents recorded, 68.0 percent were verbal harassment, 20.5 percent were shunning, 11.1 percent were physical assault, 8.5 percent civil rights discrimination, and 6.8 percent as online harassment. Asian-American women reported discrimination incidents 2.3 times more than Asian American men.

Impact Of COVID-19 Among Asian American Subgroups

We have closely followed academic research, news media, and local and regional community reports for details on how COVID-19 has impacted different Asian American subgroups. Our findings (exhibit 1) suggest each Asian subgroup is differentially impacted and experiencing distinct challenges during the pandemic. Common challenges include increased COVID-19 exposure due to high rates of multigenerational housing, language barriers to accessing health care and public resources, and anti-Asian violence. In addition, a shared source of relief for all subgroups were the many community-based organizations that had to rapidly pivot programming to provide indispensable culturally and linguistically tailored services to their communities in crisis, connecting individuals to essential food, health care, and unemployment resources. Information on vaccination was limited and not available for all subgroups

Chinese

Recent research suggests Chinese Americans may be at higher risk for death from COVID-19 infection in New York City. An analysis of patient records from New York City’s public hospital system found Chinese patients had the highest mortality among all racial/ethnic groups—44 percent higher mortality than White patients. Nationally, one in four Chinese Americans live in multigenerational households, and many work in essential food services, increasing their COVID-19 exposure risk. Chinese Americans have high rates of chronic conditions including obesity, pre-diabetes, diabetes, and smoking among adult men, increasing their risk for worse COVID-19 outcomes. Approximately 41 percent of Chinese Americans are limited English proficient, a substantial barrier to accessing care and government relief. There is limited vaccination information about Chinese Americans, but one study found 34 percent of Chinese Americans had two or more concerns about getting vaccinated.

Incidents of xenophobia and race-related violence have been especially prevalent in the Chinese American community as China is blamed as the source of the COVID-19 virus. Approximately 42.2 percent of discrimination incidents documented by Stop AAPI Hate occurred among Chinese Americans. These incidents have affected both Chinese Americans as well as other East Asian and South Asian subgroups who may be misperceived as Chinese (exhibit 1). Fear of discrimination has not only affected individual mental health but also willingness to seek COVID-19 testing. Xenophobia has also disproportionately affected Chinese Americans’ businesses. According to Yelp data from February to November 2020, consumer interest in Chinatown businesses across multiple cities declined at greater rates than their surrounding metropolitan areas during the same period. Another study found there were significantly higher permanent closure rates among businesses in Chinese neighborhoods in New York City compared to other higher- and lower-resourced neighborhoods (exhibit 1). In the summer of 2020, New York City-based Chinese community organizations reported between 50 percent to 75 percent of their community members lost their job or income due to the pandemic.

Asian Indian/South Asian

There is little information available on how the pandemic has affected the Asian Indian American population—the second largest Asian subgroup in the US—but there has been some reporting on the South Asian American population, which encompasses Afghani, Bangladeshi, Indian, Nepalese, Pakistani, and Sri Lankan ethnicities. In the New York City public hospital system, South Asian patients were found to have the second-highest positivity and hospitalization rates compared to other race/ethnicity groups. South Asian Americans may be more likely to be infected as many work as essential frontline health care, hospitality, and gig economy workers. Those who are infected may be at higher risk of severe COVID-19 as South Asian Americans have been found to be four times more likely to have heart disease or diabetes than the general US population. Fear of losing employment and stigma from the community are major barriers to testing as one national survey found approximately one in 10 South Asian respondents would not seek testing if it was available for those reasons.

Community organizations have reported increased rates in gender-based domestic violence among South Asian Americans, exacerbated by pandemic stay-at-home orders. Food insecurity among Asian Indian Americans due to the pandemic may also be an issue as a national survey found 17 percent of Asian Indian respondents no longer able to get the food resources they were receiving before COVID-19 and 7 percent not having a way to get to the food store since the pandemic started (exhibit 1). Lastly, there have been several incidents of violence toward South Asians, such as the FedEx shootings in Indiana that killed four members of the Sikh community and the acid attack of a Pakistani college student in Long Island.

Filipino

Evidence suggests Filipino Americans are disproportionately dying from COVID-19. In California, Filipino residents are 25 percent of the Asian American population but account for 30 percent of COVID-19 deaths (exhibit 1). This may be partially explained by the large number of Filipino Americans working in the health care industry where 38 percent of Filipino households include one or more health care workers. In California, 80 percent of Asian health care worker deaths are Filipino (exhibit 1). However, even within the health care industry, Filipino deaths are disproportionate. Filipino Americans are 4.0 percent of the nursing workforce in the US but make up 31.5 percent of COVID-19-related deaths. One in every three Filipino Americans live in a multigenerational household—the highest rate among Asian Americans. When compared to Whites, Filipino Americans have been found to be three times more likely to have hypertension, two times more likely to have diabetes, and three times more likely to be overweight or obese. A nationally representative poll conducted in February 2021 found 13 percent of Filipinos had already been vaccinated and 81 percent intended to get vaccinated.

Filipino Americans are also impacted by food insecurity—8.0 percent of those surveyed reporting not having enough money to buy the food they need and 13 percent no longer getting food resources they were receiving before the pandemic (exhibit 1). About 7.9 percent of recorded Stop AAPI Hate incidents have been reported by Filipino Americans.

Vietnamese

Coverage of Vietnamese American COVID-19 outcomes has primarily focused on Santa Clara County, California, in the Bay Area, which has the largest Vietnamese American population in the US. County-level data has found Vietnamese Americans are being unequally affected by COVID-19, with Vietnamese residents making up 19 percent of the total county Asian American population but accounting for 28 percent of COVID-19 cases among Asian Americans. At 32 percent, Vietnamese Americans have the second-highest rate of living in multigenerational housing among Asian subgroups, increasing their risk of exposure. Vietnamese Americans also have the second-highest smoking rate among Asian American subgroups at 16.6 percent and higher rates of hypertension than the national average (exhibit 1), increasing their risk of severe disease. In Santa Clara County, more Vietnamese adults have been diagnosed with diabetes than for all other Asian subgroups, Pacific Islanders, and Whites combined. Among the six largest Asian American subgroups, Vietnamese Americans have the highest rates of limited English proficiency at 49 percent, limiting their access to care and government resources. In February 2021, a national poll found that 6 percent of Vietnamese respondents had been vaccinated with 90 percent intending to get vaccinated.

Industries frequently serviced by Vietnamese Americans such as nail and hair salons have been hit hard by lockdowns, eroding primary sources of income for many families. This may be reflected in recent research examining food insecurity that found that 7 percent of Vietnamese adults report not having the money they need to buy food since the start of the pandemic (exhibit 1). Vietnamese Americans compose about 8.5 percent of Asian discrimination incidents documented by Stop AAPI Hate.

Korean

There has been almost no reporting of COVID-19 infection outcomes among Korean Americans and sparse coverage of how Korean Americans have been affected by the pandemic. According to data from the California Department of Public Health, Koreans have disproportionate COVID-19 death rates among Asian Americans (exhibit 1). Korean Americans have higher rates of diabetes than the national average (exhibit 1) and the highest rate of smoking among the major Asian subgroups with 20 percent reporting using a tobacco product in the past month, increasing their risk for severe COVID-19. At 37 percent, Korean Americans have the third-highest rate of limited English proficiency, hampering their access to care and aid.

The Korean American Family Service Center in New York City reported a 300 percent increase in domestic violence-related calls during the pandemic, noting rising incidents of both child and elder abuse. At 14.8 percent, Korean Americans compose the second-highest percentage of self-reported anti-Asian discrimination incidents.

Japanese

There has been practically no reporting we are aware of regarding how COVID-19 has impacted the Japanese American population. Japanese Americans tend to have lower rates of multigenerational housing (19 percent) than the general US population (20 percent) and the lowest rate of limited English proficiency (19 percent), but they do have higher rates of potentially comorbid conditions such as diabetes, obesity, and asthma (exhibit 1). Similar to other Asian subgroups, Japanese Americans have been experiencing a rise in anti-Asian incidents. 

Looking Forward

The diverse Asian American population is not a monolithic group, and the findings we pieced together are a glimpse of a more textured and complicated Asian American narrative than the story told by aggregate data. Substantial gaps in knowledge remain regarding the impact of the pandemic on Asian Americans in aggregate as well as disaggregated by Asian American subgroup. We did not find any measures of COVID-19 prevalence or mortality for Asian Indian Japanese subgroups, and more work is needed to further disaggregate South Asian data and better understand the differential impact of the pandemic across subgroups (Indian, Bangladeshi, Pakistani, and so forth).

We discussed what we know for the six largest Asian American subgroups; however, still missing is the COVID-19 impact on smaller Asian subgroups. We still do not know the case, hospitalization, or deaths rates for Asian American subgroups on a national level, and we do not know how these outcomes vary within subgroups across different locations in the US. In some states, even differences in COVID-19 outcomes between aggregate Asian Americans and Native Hawaiian and Pacific Islanders are unknown as their data are still grouped together despite the OMB’s mandate to do otherwise. There is a dearth of information regarding the distribution of Asian American subgroups across essential worker industries, and it is unclear how businesses among different Asian subgroups have been affected. Similarly, there is no disaggregated data regarding how unemployment has changed for Asian subgroups. Lastly, as vaccination efforts continue to roll out across the country, we do not have a clear picture of vaccination rates by subgroup and which subgroups are being left behind.  

The challenges of poor data quality and lack of disaggregated data about Asian American populations existed in pre-COVID-19 times and continue to have significant implications for health research and policy. Standardized racial/ethnic categories, as well as data on preferred language, should be collected and enforced through policies and strategies across sectors at local, state, and national levels. Expanded racial/ethnic categories for Asian Americans should include the census minimum options of: “Chinese,” “Filipino,” “Asian Indian,” “Vietnamese,” “Korean,” “Japanese,” and “Other Asian.” As the US continues to implement the largest public health vaccination campaign in its history, race/ethnicity data standards must be improved to ensure an equitable roll out. In the meantime, it is especially important for policy makers to communicate actively with community-based organizations that have been providing critical resources to their communities throughout the pandemic and have intimate knowledge of what their communities need.

Authors’ Note

The research described in this post is supported by Grant Nos. U54MD000538 from the National Institutes of Health (NIH) National Institute on Minority Health and Health Disparities, R01HL141427 from the National Heart, Lung and Blood Institute, and NU38OT2020001477 from the Centers for Disease Control and Prevention (CDC). The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the NIH or the CDC.