By Marshall H. Chin, M.D., M.P.H.
Richard Parrillo Family Professor of Healthcare Ethics in the Department of Medicine,
University of Chicago
Member, National Advisory Council on Minority Health and Health Disparities
When I was a kid, every Saturday my parents would pack my older sister, younger brother, and me into the family station wagon, and we’d drive 40 minutes on Route 2 East from Boston’s western suburbs into Chinatown. There we gathered with aunts, uncles, and cousins in the home of my grandparents, immigrants from Toisan in southern China. The conversations were loud, the play was very lively, and the wonderful aromas of roast chicken, fried noodles, and sizzling stir-fried vegetables filled the air.
An impressionable young child, I watched intently as my uncles played poker, cigar smoke wafting into the nighttime air. They taught me how to play poker at the ripe old age of 8, and I filled in when one had to take a break for a hand or two. Most of my paternal uncles worked in the laundries. My mother’s side was noodles. My uncles were bright men, but the bamboo ceiling—basically, exclusion from good jobs—limited their opportunities. “I don’t have a Chinaman’s chance,” they’d say as they folded a losing hand of cards.1
Running around Chinatown with my cousins, I saw that my uncles weren’t the only ones whose opportunities were limited. Housing was crowded, and the streets were dirty and smelled of garbage. Years later, when I worked part-time at the Federally Qualified Health Center in Boston’s Chinatown, I cared for many non–English speaking immigrants with limited education. They faced uphill battles as they dealt with their chronic health conditions, paid medical bills without health insurance, and attempted to advance in society.
Entering Asian American and Pacific Islander Heritage Month, a cutting-edge issue is addressing social determinants of health, which are especially critical among diverse Asian American ethnic groups that vary in education, income, and acculturation. For example, some Southeast Asian immigrants were forced to leave their countries because of the Vietnam War and have suffered piercing intergenerational trauma, socioeconomic deprivation as refugees, and major health disparities. Health care organizations are exploring ways to screen patients for social needs, refer them to community partners in fields such as housing and food security, and integrate their medical and social care.
Federally Qualified Health Centers are pioneers. The Association of Asian Pacific Community Health Organizations (AAPCHO), the National Association of Community Health Centers (NACHC), and the Oregon Primary Care Association (OPCA) have created the Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences (PRAPARE) tool to screen for needs such as housing, employment, transportation, safety, and social support.2 AAPCHO, NACHC, and colleagues at the University of Chicago are currently investigating ways to score this screening instrument to identify high-risk patients for intervention, with support from the National Institute of Diabetes and Digestive and Kidney Diseases–funded Chicago Center for Diabetes Translation Research. Under global payment mechanisms and alternative payment models such as Accountable Care Organizations (ACOs), health systems have strong incentives to improve care for their most costly resource-intensive patients, who often have significant social needs.
Yet a deeper issue beyond caring for individual patients is inherent within social determinants of health: addressing the underlying structural drivers of inequities that faced my uncles and the many low-income Asian American immigrants I saw at the South Cove Community Health Center. We must have free, frank, and fearless discussions about structural racism and social privilege, the systems that insidiously drive many health disparities.3 Inequities in fields that ultimately affect health—such as employment, housing, education, and the criminal justice system—are the result not only of individuals’ implicit biases but also of concrete laws, regulations, and business decisions that have marginalized the poor and racial/ethnic minorities. These structural determinants have created an unequal playing field that contributes to health disparities. Solutions include intersectoral partnerships—collaborations of health and non-health sectors, drawing upon community assets—and recognizing that eliminating health disparities is a moral and social justice issue.4 Inspirational grantees in our Merck Foundation Bridging the Gap: Reducing Disparities in Diabetes Care program are transforming diabetes care and engaging in innovative community partnerships around challenges such as food security and medical/legal services for immigrants.5
Ultimately, our nation will need to align key stakeholders to achieve health equity. In the Robert Wood Johnson Foundation’s Advancing Health Equity: Leading Care, Payment, and Systems Transformation program, state Medicaid agencies, Medicaid managed care organizations, health care organizations and systems, patients, and consumers will develop and evaluate innovative care transformation and payment efforts to achieve health equity.6 Research addressing individual patient and societal factors will be critical for achieving health equity7 and for blasting through the bamboo ceiling and other structural and exclusionary barriers that limit the health of Asian Americans.
1 Liu E. A Chinaman’s Chance: One Family’s Journey and the Chinese American Dream. New York: PublicAffairs, 2014.
2 Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences. PRAPARE: Available at: http://www.nachc.org/research-and-data/prapare/. Accessed April 18, 2019.
3 Chin MH, King PT, Jones RG, Jones B, Ameratunga SN, Muramatsu N, Derrett S. Lessons for achieving health equity comparing Aotearoa/New Zealand and the United States. Health Policy 2018; 122:837-853. pii: S0168-8510(18)30131-3. doi: 10.1016/j.healthpol.2018.05.001.
4 Chin MH. Movement advocacy, personal relationships, and ending health care disparities. J Nat Med Assoc 2017; 109:33-35.
5 Bridging the Gap in Diabetes Care: Reducing Disparities in Diabetes Care. http://bridgingthegapdiabetes.org. Accessed April 18, 2019.
6 Advancing Health Equity: Leading Care, Payment, and Systems Transformation. http://www.solvingdisparities.org. Accessed April 18, 2019.
7 National Institute on Minority Health and Health Disparities Research Framework. https://www.nimhd.nih.gov/about/overview/research-framework/nimhd-framework.html. Accessed April 18, 2019.