Commentary Commentary: Persistence and Health-Related Consequences of the for

Stella S. Yi, PhD, MPH1; Simona C. Kwon, DrPH1; Rachel Sacks, MPH2; Chau Trinh-Shevrin, DrPH1

Fifty years ago, the term model minority Introduction was coined to describe the extraordinary tive social and health implications, ability of Asian Americans to overcome and the model minority stereotype hardship to succeed in American society. According to the most recent is no exception. The purpose of this Less well-known is how the model minority stereotype was cultivated within the context Census data, Asian Americans com- article is to define the model minor- of Black-White race relations during the prise 5.6% of the United States pop- ity stereotype and present its con- second half of the 20th century, and how ulation, and in metropolitan areas, troversies, and provide examples of this stereotype, in turn, has contributed to the understanding and prioritization of such as (NYC) or the social and health-related conse- health disparities experienced by Asian Los Angeles, up to 13% of the city- quences of this label at the broader Americans. The objectives of this article are wide population.1 The Asian Ameri- to define the model minority stereotype, present its controversies, and provide can category includes East Asian (eg, examples of its social and health-related Chinese, Japanese, Korean), South The purpose of this article consequences (ie, implications for obesity Asian (eg, Bangladeshi, Indian, and tobacco) across multiple levels of society and institutions. A salient theme Pakistani), Southeast Asian (eg, Fili- is to define the model throughout the examples provided is the pino, Cambodian, Thai, Vietnam- limitation of data presented at the aggregate ese), and sometimes Pacific Islander minority stereotype and level across all Asian subgroups which masks meaningful disparities. The intent is to Americans (eg, Native Hawaiians, present its controversies, increase the visibility of Asian Americans as Chamorros, Marshallese), denoting a racial/ethnic minority group experiencing a vastly diverse array of sub-popu- chronic disease health disparities and and provide examples deserving of health-related resources and lations with unique ethnic, cultural, consideration. Ethn Dis. 2016;26(1):133- linguistic and historical profiles, of the social and health- 138; doi:10.18865/ed.26.1.133 stretching across the entire Asian related consequences of this continent and its millions of islands. Keywords: Asian Americans, , Asian Americans were the fastest label at the broader level Health Care Disparities, Minority Health, growing race/ethnic group in the Health Knowledge, Attitudes, and Practice, 1 Emigrants, Immigrants United States in the last ten years; of the public health and nationally, the Asian American pop- 1 Department of Population Health, New ulation is projected to double in size health care sectors. York University School of Medicine 2Independent Consultant to more than 43 million by 2050. A common stereotype that has been applied to Asian Americans is level of the public health and health Address correspondence to Stella S. Yi, PhD, MPH; Department of Population that they are the model minority. care sectors. The authors’ inten- Health, New York University School of Despite the fact that it is a positive tion is to increase visibility of Asian Medicine; 550 First Ave, VZN Suite 844; stereotype, that are in- Americans as a racial/ethnic minor- 212.263.5163; [email protected]. discriminately applied have nega- ity group that experiences certain

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important health disparities, and mentally racist society, structured to sue that is ongoing and documented to raise awareness of the potential keep minorities in a subordinate po- in current media. Even more funda- detrimental and far-reaching effects sition.”2,3 Thus the model minority mentally, critics have demonstrated of the model minority stereotype. stereotype was developed by conser- that the model minority stereotype vatives in the backlash of the Black does not apply equally to all Asian Power Movement to deny the exis- ethnic subgroups, which differ sub- The Model Minority tence of institutional , and to stantially in their cultures, languag- Stereotype: History and illustrate that individual underper- es, historical patterns of immigration Development formance explained racial inequality to the United States and level of ac- and disparities in American society.3 culturation within American society. The term, model minority, was Supporters of the model minor- The Immigration Act of 1965 first coined by two articles pub- ity stereotype have based their argu- may be the single most important lished in 1966: “Success Story, Jap- ment on three points: 1) despite cul- policy change influencing the incep- anese-American Style” in the New tural differences, Asian Americans tion of the model minority stereo- York Times by William Petersen, have overcome structural barriers in type in 1966, and its development and “Success Story of One Minor- American society; 2) labor market throughout the second half of the ity in the United States” in the US discrimination against Asian Ameri- 20th century. This 1965 Act ushered News and World Report. Often at- cans no longer exists, as evidenced in a new era of Asian immigration to tributed to East and South Asians, by the high concentrations of Asian the United States by implementing the model minority stereotype posits Americans in high-paying, profes- three key changes in immigration that Asian Americans are educated, sional occupations; and 3) Asian policy: 1) abolition of the national law-abiding, hardworking, and have American cultural factors, such as origins quota system from Asian high incomes, low crime rates, and an emphasis on education, a strong countries and the setting of an an- close family ties.2,3 From a broad work ethic and working to ‘save face’ nual ceiling of 170,000 visas for all perspective, this stereotype implies keep the unemployment rate low countries outside the Western hemi- that Asian Americans are not an un- in Asian Americans.2,4,5 However, sphere (exclusive of parents, spouses derprivileged racial/ethnic minor- critics of the model minority ste- and unmarried children); 2) em- ity due to their economic success reotype have countered these argu- phasis on family reunification; and compared with other racial/ethnic ments with immigration, economic 3) employment clearances of cer- groups;4 accordingly, Asian Ameri- and education data illustrating the tain immigrants, where immigrants cans merit neither resources nor at- fallibility of the stereotype. For ex- with professional degrees were selec- tention as an ethnic minority group ample, no empirical evidence exists tively preferred.7 As a result of the within the American population. to support extraordinary academic 1965 Act, hundreds of thousands of Conversely, the model minor- abilities in Asian Americans; further- Asians immigrated to America, with ity stereotype implies that minori- more, the occupational advantage the proportion of all immigrants in- ties other than Asian Americans are in professional and engineering and creasing from 8% Asian pre-1965 stereotypically lazy,2 driving a wedge science fields is misleading.2,4,5 While to 43% Asian in the 1980s.8 In ac- between Asian Americans and other Asian Americans may occupy profes- cordance with the new conditions ethnic minority groups. The model sional positions, they are often more set forth in the Immigration Act of minority stereotype was incubated, likely to choose support rather than 1965, many of the Asian American developed and disseminated by con- managerial roles or jobs that require immigrants arriving post-1965 were servatives as a way to directly oppose minimal verbal expression.2 Research highly skilled and educated profes- messaging of the Black Power Move- also demonstrates the existence of a sionals, with a high concentration of ment of the 1960s and 1970s, which glass, or ‘bamboo,’ ceiling for Asian those in the medical profession from claimed that “America was a funda- Americans in the workplace,6 an is- India and from the Philippines.8

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These changes in immigration pat- in a specific Asian subgroup (in this ity myth allows the government to terns contributed to the perception case, South Asian) a bimodal income overlook Asian American problems that Asian Americans were highly distribution exists.10 Demographic that many, including Asian Ameri- educated, fluent in English, success- data on Asian Americans in the ag- cans themselves, may not even real- ful and hardworking – ie, a model gregate bolster the model minor- ize exist. Arthur Fletcher, the chair minority, and obscured dispari- ity stereotype indicating Asians are for the 1990 Civil Rights Commis- ties among Asian ethnic subgroups. healthier than other racial/ethnic sion on Asian Pacific Islanders, wrote minority populations, thus giving li- in a letter to President Bush, “Asian cense to ignore true social disparities. Americans suffer widely the pain Social Consequences These education and income data and humiliation of bigotry and acts of the Model Minority also play out in the college admis- of violence...They also confront in- Stereotype sions process and stitutional discrimination in numer- discourse. While early immigration ous domains, such as places of work The image presented by the and schools, in accessing public ser- model minority stereotype is indis- vices, and in the administration of criminately applied to all Asian sub- Both the stereotype justice…[the model minority] ste- groups, and overstates the success reotype leads federal, state, and local of Asian Americans in terms of re- and this persistent agencies to overlook the problems siliency, health, wisdom and wealth. lack of disaggregated facing Asian Americans, and it often When presented in aggregate, na- causes resentment of Asian Ameri- tional data show that Asian Ameri- data perpetuate a cans within the general public.”13 cans are more likely to have a college The stereotype undercuts the signifi- education and higher income than cycle wherein Asian cance of health and social disparities other racial/ethnic minority groups. experienced by Asian American com- The Pew Research Center reported American populations munities and the need to devote re- that, of adults aged ≥25 years, 49% are excluded from sources to mitigate those disparities, of Asians, compared with 31% of and is marked by a dearth of health Whites, 18% of Blacks, and 13% of consideration for public studies focused on Asian American Hispanics had a college education or communities.14 Both the stereotype more.9 However, huge variation ex- service programming and and this persistent lack of disaggre- ists when these data are disaggregat- gated data perpetuate a cycle wherein ed by Asian subgroup: 70% of Asian funding. Asian American populations are ex- Indians compared to 26% of Viet- cluded from consideration for public namese adults have a bachelor’s de- service programming and funding. gree or more. With regard to house- policy favored professional immi- hold income, the median household grants from Asian countries, elite income for Asians is $72,000/year, colleges and universities now limit Health Consequences while the national average is approx- admissions of Asian American stu- of the Model Minority imately $53,000/year.10 When disag- dents using a higher admissions stan- Stereotype gregated by subgroup, Asian Indians dard.11,12 Asian American students have the highest household income must outperform (ie, have higher test Because of the model minor- at $95,000, while Bangladeshis have scores) than their White, Black and ity stereotype, Asian Americans are the lowest at $46,950/year. These Hispanic counterparts to be given the commonly believed not to experi- numbers further illustrate that both same consideration for admission.11 ence health disparities. Owing in across the ‘Asian’ category and with- More broadly, the model minor- part to these beliefs and in part to

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making up a small percentage of the with all other racial/ethnic groups, Asian Americans should be placed national population, Asian Ameri- whose values ranged from 32.6% to in the larger context of immigration cans are excluded from many na- 47.8%.16 However the advantage ob- and globalization through cross-na- tional health databases. Additionally, served between Asian Americans and tional comparisons and examination when Asian Americans are included other groups may be misleading for of acculturation-related factors, par- in these surveys, current national three primary reasons.17 First, lower ticularly given the increased and sub- survey techniques that utilize ran- BMI cutoffs may be more appropri- stantial burden of diabetes globally dom-digit dial and questionnaire ad- ate to use in Asian populations in or- in rapidly developing countries such ministration in English and Spanish der to meaningfully rank individuals as China and India.21 Thus, within only contribute to small sample sizes at risk for chronic disease morbidity the framework of the model minor- of Asian Americans.15 These data are and mortality.18 The rationale for ity stereotype, Asian Americans may rarely analyzable overall or when modifying these cutoffs is that eth- be excluded from health conversa- disaggregated by Asian subgroup.15 nic Asians tend to have a higher per- tions, policy and planning designed Other databases that include Asian cent body fat for the same BMI as to address the obesity epidemic Americans, such as the Surveillance, compared with Whites, possibly due when they are an at-risk subgroup. Epidemiology and End Results to leg length relative to height and/ (SEER) cancer registry do not ac- or to smaller body frames – of which Tobacco Use in Asian count for the variegated geographic Asians tend to have both versus Americans distribution of Asians across the Whites.19 However, the evidence for Asian Americans are reported to United States. For example, the ma- formal adoption of these modified experience the lowest smoking rates jority of Asian Americans in the West cutoffs is limited.18 Furthermore, ap- compared with other racial/ethnic are Filipino, while Chinese comprise plication of a lower cutoff would im- minority populations,22 portraying the majority in the East, and Asian mediately and significantly increase the group overall in a positive light, Indians comprise the majority of the global obesity prevalence for in line with the model minority ste- Asian Americans in the South.1 Fur- Asians, and the current limited evi- reotype. These findings, however, thermore, the SEER registry does dence is not strong enough to justify are largely based on data from sur- not include a site in New York, the increases in health care spending and veys that aggregate Asian subgroups, city with the largest and most di- changes to health care policy that thus masking substantial differences verse Asian American population. would ensue from these new data. in tobacco use by Asian subgroup. Two examples are presented be- Despite the lack of formal adoption Community-based studies on spe- low to illustrate how the model mi- of these cutoffs, the modified cutoff cific Asian subgroups, as well as lo- nority stereotype impacts the collec- may still be useful to consider and/or cal and regional surveys that allow tion and interpretation of health data present for Asian American popula- for disaggregating Asian subgroups, for Asian Americans and the cor- tions – particularly when reporting have reported elevated smoking responding allocation of resources prevalence of overweight and obesity. prevalence among several Asian and development of initiatives to ad- Second, prevalence of obesity ethnic subgroups.23 In NYC for ex- dress Asian American health issues. differs by Asian subgroup, with the ample, the overall prevalence of cur- highest values observed in South rent smoking is 18.6% in Whites Obesity in Asian Americans Asian Americans,17 who also have and 14.1% in Asians.22 However, Recently, obesity prevalence for the highest prevalence of diabetes.20 when disaggregated by subgroup, the Asian American non-institution- The co-morbidity of obesity and dia- prevalence of current smoking was alized adult population using mea- betes in South Asian Americans – a 35.5%, 17.7% and 10.1% in Ko- sured body mass index (BMI) values specific Asian subgroup – is therefore reans, Chinese and Asian Indians, was presented for the first time as an issue of public health significance. respectively.24 Partly due to a lack of 10.8%; an estimate lower compared Third, the prevalence of obesity in reliable data and other data-related

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Acknowledgments and where are they going? Ann Am Acad Pol challenges, public health and to- This publication is supported by grant Soc Sci. 1986;487(1):150-168. http://dx.doi. bacco control movements have not numbers P60MD000538 from the National org/10.1177/0002716286487001010. Institutes of Health (NIH) National Institute 9. The Rise of Asian Americans, http://www. focused on tobacco control issues pewsocialtrends.org/2012/06/19/the-rise-of- on Minority Health and Health Dispari- among Asian Americans.25 The end asian-americans/. Pew Research Center, 2012. ties, U48DP005008 from the Centers for result is limited capacity and infra- 10. Ramakrishnan K, Ahmad FZ. State of Asian Disease Control and Prevention (CDC) Americans and Pacific Islanders: Income and structure to support tobacco pre- and UL1TR000067 from NCATS/NIH. Poverty: Center for American Progress.; 2014 vention and control efforts among The contents of this publication are solely [[Accessed May 19, 2015]. Available from: https://cdn.americanprogress.org/wp-content/ Asian American communities. the responsibility of the authors and do not necessarily represent the official views of the uploads/2014/08/AAPI-IncomePoverty.pdf. NIH and CDC. 11. Fears of an Asian quota in the . New York Times The Opinion Pages: Room Conclusions for Debate [Internet]. Dec 2012. Available Conflict of Interest from: http://www.nytimes.com/roomforde- No reports of conflict of interest. bate/2012/12/19/fears-of-an-asian-quota-in- the-ivy-league. The prevailing idea in Ameri- Author Contributions 12. Chen C. Asians: Too smart for their own can society that Asian Americans Research concept and design: Yi, Trinh- good? New York Times [Internet]. Dec do not experience poor social and Shevrin. Acquisition of data: Yi, Sacks. Data 2012. Available from: http://www.nytimes. com/2012/12/20/opinion/asians-too-smart- health outcomes undermines the analysis and interpretation: Kwon, Sacks. Manuscript draft: Yi, Kwon, Sacks, Trinh- for-their-own-good.html. nature and obscures the magnitude Shevrin. Statistical expertise: Yi. Acquisition 13. Civil rights issues facing Asian Americans in the 1990s: A report of the United States Com- of funding: Trinh-Shevrin. Administrative: of health disparities experienced mission on Civil Rights 1992 [[Accessed May across Asian subgroups. The model Kwon, Sacks. Supervision: Trinh-Shevrin. 13, 2015]. Available from: https://www.ncjrs. minority stereotype is a myth, based gov/pdffiles1/Digitization/135906NCJRS. References pdf. on selective immigration policies fa- 1. Hoeffel EM, Rastogi S, Kim MO, Shahid H. 14. Ghosh C. Healthy People 2010 and voring skilled, professional workers; The Asian Population: 2010 Census Briefs, Asian Americans/Pacific Islanders: defin- Issued March 2012; https://www.census.gov/ ing a baseline of information. 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per cent relationship. Obesity reviews : an of- ficial journal of the International Association for the Study of Obesity. 2002;3(3):141-6. 20. Gupta LS, Wu CC, Young S, Perlman SE. Prevalence of diabetes in New York City, 2002-2008: comparing foreign-born South Asians and other Asians with U.S.-born whites, blacks, and Hispanics. Diabetes Care. 2011;34(8):1791-1793. http://dx.doi. org/10.2337/dc11-0088. PMID:21715521. 21. Hu FB. Globalization of diabetes: the role of diet, lifestyle, and genes. Diabetes Care. 2011;34(6):1249-1257. http://dx.doi. org/10.2337/dc11-0442. PMID:21617109. 22. New York City Department of Health and Mental Hygiene. Epiquery: NYC Interactive Health Data System - Community Health Survey 2013 [updated [Accessed April 21, 2015.]. Available from: https://a816-healthp- si.nyc.gov/epiquery/. 23. Tang H, Shimizu R, Chen MS Jr. English language proficiency and smoking preva- lence among California’s Asian Americans. Cancer. 2005;104(12)(suppl):2982-2988. http://dx.doi.org/10.1002/cncr.21523. PMID:16276539. 24. Li S, Kwon SC, Weerasinghe I, Rey MJ, Trinh-Shevrin C. Smoking among Asian Americans: acculturation and gender in the context of tobacco control policies in New York City. Health Promot Pract. 2013;14(5)(suppl):18S-28S. http:// dx.doi.org/10.1177/1524839913485757. PMID:23667057. 25. Lew R, Tanjasiri SP. Slowing the epi- demic of tobacco use among Asian Ameri- cans and Pacific Islanders. Am J Public Health. 2003;93(5):764-768. http:// dx.doi.org/10.2105/AJPH.93.5.764. PMID:12721139.

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