A couple of years ago, my significant other and I decided on a whim to do a language swap; she took evening Mandarin classes at the University of Minnesota, while I attended a Lao language workshop over the span of several weekends. The course was organized by the SEAD Project, a non-profit organization seeking to preserve the languages, cultures and stories of the Southeast Asian (SEA) diaspora. SEA typically encompasses Vietnamese, Filipino, Cambodian, Thai, Lao and Hmong people. Singapore, my home country, is also part of SEA. However, our numbers are relatively low in the U.S.

For my final "capstone" project, I decided to craft an educational handout of coronary artery disease in Lao. I then sourced my institution's patient education material for references, only to find none. The internet also offered little in the way of relevant resources written in Lao. Hence, I went about writing and designing a handout from scratch, cobbling sentences together using a dictionary, Google Translate and thoughtful guidance from a teaching assistant. Thankfully, I was not a complete embarrassment when the day came to showcase my handout (at least, everyone was too polite to point out any errors I made).

Completing the workshop and listening to the amazing stories that my classmates shared about their heritage motivated me to learn more about the history of SEA and other Asian communities in America. This segment of the American tale, as it turns out, is far deeper and variegated than I ever realized. Over the past few centuries, people had made their way across continents under an extraordinary spectrum of circumstances: indentured laborers, war brides, students and skilled professionals, and political refugees and asylum-seekers.

The term "Asian American" is therefore perilously simplistic; initially crafted as an expression of political solidarity, it attempts to compress literally hundreds of racial/cultural groups (speaking thousands of languages) into a singular entity. While seemingly convenient, such a characterization inevitably leads to the creation of harmful stereotypes and concomitant erosion of numerous underrepresented identities. One clear example is the "model minority" construct, whereby Asian Americans are viewed as uniformly hardworking, law-abiding, family-oriented, and overall unobtrusive exemplars of the American Dream. This notion, which remains entrenched in current times, blithely obscures the fact that many Asians in America – including SEA – face a multitude of heartbreaking barriers that impede their advancement in society, including physical/mental trauma from war or exile, poverty, lack of community support, low English literacy rates, and racism within their adopted country. Additionally, the aggregation of all Asians under the same umbrella term obscures vast disparities in morbidity and mortality (including cardiovascular) among ethnic groups, thereby leading to an underestimation of the public health issue at hand.

Xenophobia towards Asian communities is well-documented in American history, and unfortunately this has resurfaced with vigor since the start of the COVID-19 pandemic. The number of racist acts directed towards Asians and Pacific Islanders have risen to all-time highs, at a time when Asian communities are already disproportionately affected by the virus' spread, with many either losing their jobs or working under inadequately protective environments throughout the pandemic. Preexisting barriers to health care, such as lack of physical access and culture- and language-concordant materials (as illustrated by my difficulties in finding suitable materials for my project), have likewise continued to impede COVID-19 prevention and treatment. There are preliminary data to suggest that SEA have higher mortality rates from COVID-19 (e.g., Hmong in Minnesota and Cambodians in Long Beach, CA) compared to other racial and ethnic communities. However, with the "lumping" of Asians into a single category, assessing COVID-19 related outcomes in specific ethnic subgroups once again remains a daunting challenge.

As medical professionals, what can we do to address this inequity? To this end, I postulate the following:

• Be aware that not all "Asian Americans" are alike. We arise from a myriad of social, political and cultural contexts, that do not fit into the "model minority" framework. Recognizing this will help us avoid the stereotypical trappings that have endured to this day.
• Seek out resources and materials that are (as much as possible) specific to the patients' cultural norms and language preferences. If these are not readily available, appeal to your institution to develop them.
• Engage with grassroot organizations and leaders to reach out to their respective communities regarding important medical announcements. Communication is key for public health literacy, especially in the midst of a pandemic. Collaboration can go a long way towards getting the message across and lead to positive patient-doctor relationships (i.e., engagement, alliance, etc.)
• Clearly and unequivocally shut down any racist acts directed towards our patients from other patients or staff. It is past time that we do our part in combating racism at our doorstep and beyond. Engage in creating an anti-racist culture and curriculum.
• Advocate for and conduct research in Asian minorities, given the dearth of good-quality epidemiologic data available currently.

While I am not (and may never be) fluent in Lao, my immersion gave me the opportunity to connect with a community with whom I share roots but never really knew before, and in turn recognize many of the challenges they face in modern society. As physicians, fostering these connections with surrounding communities is every bit as important as developing clinical/procedural skills. If all of us can muster this effort for the people around us, we will definitely make significant strides towards addressing racial inequity in medicine.

COVID-19 Resources for Southeast Asian Communities:

• https://www.theseadproject.org/resources/covid19/
• https://seaacovidhub.squarespace.com/
• https://www.hypu.org/hypucovid19.html (Hmong)

Cardiovascular Disease Risk in Asian-American Subgroups:

• Culhane-Pera KA, Moua M, DeFor TA, et al. Cardiovascular disease risks in Hmong refugees from Wat Tham Krabok, Thailand. Journal of Immigrant and Minority Health 2009;11(5)372-379.
• Gordon NP, Lin TY, Rau J et al. Aggregation of Asian-American subgroups masks meaningful differences in health and health risks among Asian ethnicities: an electronic health record based cohort study. BMC Public Health 2019;19(1)1-14.
• Koirala B, Turkson‐Ocran RA, Baptiste D, et al. Heterogeneity of Cardiovascular Disease Risk Factors Among Asian Immigrants: Insights From the 2010 to 2018 National Health Interview Survey. Journal of the American Heart Association 2021;10(13)e020408.

This post was authored by Nicholas Y. Tan, MD, MS.