AAPI misleading data overlooks the devastating toll on Filipino American health workers

By Carlos Irwin A. Oronce, MD, MPH

REPRINTED FROM THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION (JAMA)

In the United States, Filipinxs are the third largest Asian subgroup and have represented a crucial part of the country’s health care workforce since the mid-20th century. Although the 2.9 million Filipinxs in the US represent about 1% of the population, approximately 1 of 4 Filipinx working adults are frontline health care workers. 

The COVID-19 pandemic has exacted a disproportionate toll on Filipinx communities in the US and on Filipinx health care workers, specifically. The absence of disaggregated race/ethnicity data for COVID-19 has masked how the pandemic has affected Filipinxs in the US. 

Policy makers and researchers must recognize that these disparities are not limited to COVID-19 but are a critical example of how data aggregation under a single Asian category has hidden the health needs of the Filipinx population.

Missing in the Data, Missing in Policy Discussions

Aggregate race/ethnicity data for COVID-19 cases and deaths mask the disproportionate burden on Asian subgroups, including Filipinxs in the US, leaving these disparities unrecognized and unaddressed. 

Asians comprise nearly 6% of the US population but only about 3% of COVID-19 cases and 4% of its deaths, suggesting that Asian Americans are not disproportionately affected by COVID-19. 

Yet a different picture has emerged for Filipinxs in Hawaii, the only state which publicly reports disaggregated Asian data: Filipinx residents comprise 16% of the population but 22% of COVID-19 deaths. Similar analyses are not possible nationally or in any other state. 

While some states may collect data on Filipinxs, these data are typically restricted and only available through public information requests. For example, Filipinxs comprise 42% of COVID-19 deaths among Asian adults (18-64 years) in California despite making up just 20% of the state’s nonelderly Asian adult population. No other Asian subgroup accounted for more than 15% of deaths.

Importantly, this disparate impact of COVID-19 would have remained undetected without the media, research, and advocacy efforts that exposed the higher burden on Filipinxs, especially among health care workers. The grassroots transnational organization, AF3IRM has a poignant online tribute to fallen Filipinx health care workers (https://www.kanlungan.net/). A report by National Nurses United5 showed that Filipinxs comprise an estimated 32% of COVID-19 deaths among nurses in the US despite representing only 4% of nurses nationally.

Moreover, the lack of disaggregated COVID-19 mortality data in public health surveillance systems hides the mortality burden among Filipinx health care workers. Researchers have undertaken “work-around” studies that use the conventional data available to corroborate inferences made by online tributes and ad hoc reports. One such work-around study by Escobedo and colleagues using data from the 2018 American Community Survey 5-year estimates showed that having a higher percentage of Filipinxs in a county’s health care workforce was significantly associated with a greater share of COVID-19 deaths among Asian Americans. In the conventional data surveillance infrastructure used to assess health disparities, the toll of COVID-19 among Filipinx communities has not been recognized.

The disproportionate mortality among Filipinx nurses is particularly alarming given the historical reasons that contributed to the high representation of Filipinxs in the health care workforce. US-sponsored nursing schools were established in the Philippines during the American colonial period (1898-1946), followed by a deliberate immigration policy that recruited health care workers from the Philippines to address US workforce shortages. 

Currently, nurses from the Philippines represent a majority of internationally educated nurses in the US and are more likely to work in inpatient and critical care units, thereby facing a higher risk of occupational exposure to COVID-19. 

Moreover, 18% of Asian Americans live in a household with at least one health care worker, the second highest percentage across all race/ethnicity groups. This proportion is even higher among Filipinx households, 38% of which are both multigenerational and include at least one health care worker. 

These data suggest that occupational and structural factors have contributed to a greater risk of COVID-19 exposure and transmission among Filipinxs.

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Filipinx Share of COVID-19 Deaths Among Asians and Share of the Asian Population of California in 2020, by Single Race Non–Latino Asian Subgroup of Adults (18-64 Years)

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Data Aggregation as a Contributor to Filipinx Health Disparities

Data aggregation has not only obscured the disproportionate effect of COVID-19 on specific racial/ethnic subgroups, but it has also hampered the ability to monitor for preexisting risk factors contributing to higher mortality among subgroups. Efforts to identify health disparities among Filipinxs often rely on data from the California Health Interview Survey because, to our knowledge, it is the only large-scale health survey in the US that disaggregates Filipinx data and therefore allows robust analyses. A study of this survey data by Adia and colleagues found that Filipinxs were three times more likely to have hypertension and 2 times more likely to have diabetes—both of which are risk factors for severe COVID-19 — compared with White individuals in California. 

The aggregation of Asian groups in most public health data has systematically obscured Filipinx disparities related to long-term conditions, limiting the ability to leverage official statistics to garner support for investment and interventions focused on addressing these disparities.

The idea that data disaggregation is imperative for identifying health disparities among individual Asian American groups, including Filipinxs, has long preceded the COVID-19 pandemic. While efforts by organizations in civil society have provided important signals regarding Filipinx health, these organizations do not have the same capacity as federal and state governments, which carry the ultimate responsibility for collecting data to guide public health response. The success of the California Health Interview Survey in drawing attention to health disparities for Asian subgroups, such as Filipinxs, illustrates that high quality race/ethnicity data can be collected feasibly.

Without disaggregated data for Asian subgroups, Filipinxs have been ignored in public health planning efforts, perpetuating health disparities within a community that has shouldered a disproportionate share of the frontline health care work. Therefore, the inaction of government and health care institutions to collect and report detailed race/ethnicity information must be reframed not as the default choice, but as an active choice that perpetuates preventable disparities.

Implications for COVID-19 and Beyond

While the increased availability of COVID-19 vaccines will provide an end to the pandemic, policy makers should take concrete steps to ensure an equitable recovery that will also prepare the country for a more equitable response to future health challenges. Public health surveillance and health care delivery systems must adequately capture granular self-reported race and ethnicity data. 

The routine collection of these data would be consistent with the proposed data collection standards issued by the US Department of Health and Human Services for population surveys. Adoption of such policies are important first steps toward keeping an equity focus during the post–COVID-19 recovery, particularly for Filipinx health care workers and Filipinx communities in the U.S.

Carlos Irwin A. Oronce, MD, MPH, National Clinician Scholars Program, University of California Los Angeles, These contents are the authors’ own and do not represent the views of any author’s employer or institution, including the US Department of Veterans Affairs and the US Government.