Devon Valera and Dr. Jacqueline Vo — Dismantling the Myth of Asian American, Native Hawaiian, and Other Pacific Islander Populations as a Monolith

>> Diego (narration): Hopefully you took some time this May to celebrate Asian American, Native Hawaiian, and Pacific Islander Heritage Month. Maybe you watched a Bollywood film, or indulged in some Asian-Pacific cuisine, or attend an event showcasing the variety of cultures that make up this diverse community. 

At NIH, there were many opportunities to learn about AANHPI history, including the unveiling of a new exhibit commemorating the 80^th anniversary since the repeal of the Chinese Exclusion Act, which essentially reversed the federal government’s decision to block Chinese immigration from entering the country. 

>> Devon: As it says here, “in the opinion of the government of the United States, the coming of Chinese laborers to this country endangers, the good order of certain localities within the territory thereof.” So it does say endanger. It does imply that these people, quote unquote, weren't American, didn't abide by our culture, and so we're endangering it. 

>> Diego (narration): Historical failings like the Exclusion Act have cast a long shadow of prejudice and discrimination over Asian American, Native Hawaiian, and Pacific Islander populations, the effects of which continue to loom heavy over their lives and wellbeing. 

These populations are often reduced to a single racial-ethnic category, but in reality AANHPI includes around 50 ethnicities that speak more than 100 different languages. So treating them as one masks some major differences that exist between them, even when it comes to their health. For example, research is showing that Pacific Islander breast cancer survivors have a higher risk of dying from cardiovascular disease compared to Asian American breast cancer survivors. Therefore…

>> Dr. Vo: We need to be able to separate Asian and Pacific Islander populations to really get at the true burden of what their experiences are in terms of either the cancer burden or cancer mortality or treatment-related outcomes. 

>> Diego (narration): In this episode, we look at how history has shaped the experiences and perceptions of Asian Americans, Native Hawaiians, and Pacific Islanders and why science is now calling to dismantle the myth of them as a monolithic group.

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Now, I’m no historian, so to unpack the story of the Chinese Exclusion Act, I reached out to Devon Valera.

>> Devon: My name is Devon Valera. I'm the Curator and Collections Manager at the Office of NIH History and Stetten Museum. 

>> Diego (narration): Devon and her team collect, preserve and interpret the history of NIH—everything from the science to the policy, to the culture and the lives of the people that have walked its halls. They are responsible for putting together the exhibits that tell those stories.

 I asked Devon to meet me in front of the display she helped bring to life. 

>> Diego (interview): Thank you so much for coming on the pod. I know we're whispering right now. It's not because we're doing ASMR, but because we are at the NIH Library. But yeah, thank you for coming. 

>> Devon: Thank you. 

>> Diego (interview): So since May is Asian American, Native Hawaiian and Pacific Islander Heritage Month, it felt remiss not to talk about such a big part of a AANHPI history, so maybe you can help me set the scene. How did the Exclusion Act come to be and what did it entail? 

>> Devon: Absolutely, yeah, so the Chinese Exclusion Act came about in 1882. It followed on the heels of a lot of emigration from China to specifically California and the West Coast. This was because of the opportunities for work. Most of the immigrants at the time were young men. Before the Chinese Exclusion Act there were laws in place that restricted women coming over so that men couldn't start families here. And they were doing some of the hardest work out there in the West. 

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At the beginning, they participated in the California gold rush, but following that, they helped establish the Western railroad system, which was some very demanding work. Without this labor, you know, the West would not be as we know it today, so they played a really crucial role in the West's economic development at the time, but unfortunately, after sort of the boom of the Gold Rush, there was a big restriction in the economic sphere. And at that time, some of the laborers, American laborers, not having as many means, were looking around for someone to blame for their current status, and so it was easy, relatively easy to blame the immigrants and specifically the Chinese immigrants. 

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So they were, run out of their jobs, and they moved to cities. And then within those cities, there's even more discrimination that happened, so they were pushed into specific neighborhoods. There was, of course, racist sentiments, but also this perception of economic causes as well. And it isolated the whole Chinese community here.

So California was really the one to begin to push for it. They wrote a new constitution in the late, like, 1860s, I -- no, maybe 1870s. I don't have the date off the top of my head, but in their new constitution, one of the main things they emphasized was that California got to choose who immigrated and stayed in their state, and you can imagine, Chinese immigrants were not on that list. 

The sort of question I had was why did this California immigration problem -- perceived problem, of course -- how did this make it to the national stage? How did this become something that is a national act? And really what it was, it was an election year, in 1976. And so the West demonstrated that this was a huge policy issue to them, and so they were able to make immigration a national problem through that means. So it is, unfortunately, familiar. And then in 1882, they had brought up enough national fervor, this perception that, you know, the Chinese immigrants were taking jobs, that they were able to pass this Chinese Exclusion Act. 

So yeah, no matter how long you've lived here, you couldn't naturalize, you couldn't become a citizen, so they constantly face deportation threats, and so couldn't reenter, you couldn't enter, and it's specified skilled and unskilled, so even sometimes scientists or teachers who wanted to come over, you know, you're a skilled worker, it's still covered in this act that you were not allowed entry. 

>> Diego (interview): Was this the first of its kind, in terms of being like so explicit and specific about a group of people who couldn't come into the country? 

>> Devon: Yes, yeah. That's what's really remarkable about it. It's the first time that a specific ethnic group was declared unfit for immigration. It is very much just legal discrimination, and it's something that I'll also say myself, I didn't learn in class, and so it was great to have this opportunity in order to bring it to light, honestly. 

>> Diego (interview): Yeah, me neither. I had never heard of it before. So then how was it eventually repealed? 

>> Devon: It was repealed in 1943, by Warren Grant Magnuson, the namesake of the Magnuson Clinical Center. Magnuson, and others at the time, knew that it was, long, long past time that this should have been repealed, and especially at the time contemporarily, China was our allies. During the 61 years, World War One happened, so it was something where, you know, how do you look around and say you're our ally, but you're not allowed to come to our country. So that was also an impetus for it. But when Magnuson did make the repeal, when he created the Magnuson Act, it didn't solve this problem. And in fact, it was during the course of even more immigration issues. They cut down on almost all immigration, and they instituted immigration quotas. So, now China was allowed to have its quota, but its quota established by the census was 109 people, so -- 

>> Diego (interview): For the whole country. 

>> Devon: Yeah, for all of China, they only had 109 immigrants who are allowed per year. This is something that you also see is that the immigration, you know, from East Asian countries or Asian countries was very low, and then from Europeans slightly higher, but still, for a country of immigrants, it was a trickle really, when it came to people coming in. But you do see some—sort of the first people to come through were scientists, teachers, people who could establish a visa. 

>> Diego (interview): Right. You mentioned scientists, which brings us to my next question. And you guys hit the nail on the head right here in the second panel of the display. It says, “why should NIH commemorate the 80th anniversary of the repeal of this act?” Yeah, so how does this all fit with the NIH? 

>> Devon: Yeah, so I will do a bit of background on this question. The idea for this display was actually brought to us by an NIHer, Susan Wong of ORS, who was doing her own research and went, "Wait a minute, this is my family's history. My parents were impacted by this. This isn't ancient history. This is relatively recent." So she came to us saying, you know,
“This is NIH history.” And we were so grateful that she brought it up, because we found so many examples of Chinese immigrants who were working at NIH and they were very influential to American health, public health, made wonderful discoveries and even just contributed to NIH and were part of our community.

>> Diego: And three of those people are featured in the display. Can you tell me a little about their stories? 

>> Devon: Yeah, I can. We do have three faces, but I'll do a little bit of a grouping. So Lois Chang and Yao Teh Chang were married. They were a couple. We brought up Lois because part of the goal of the history office isn't to just focus on scientists, because NIH is so much more, and she was a librarian. She worked at NLM, and she specialized in cataloging Chinese publications, so we really wanted to highlight her. And her husband was also just really fascinating. He came to the US in 1947, and he joins NIAMS, which at the time was NIAMD, but while here, he really focused on leprosy, and he was able to both discover a drug that was an effective treatment for leprosy, but he also was the first to cultivate the bacteria that causes leprosy in tissue culture, and so that was—I mean, that's how you study it now. It's a huge advancement in that research, and he did that here at NIH. And then he also did work when it came to imaging cells, cell differentiation, specifically white blood cells and bone marrow. So, he as it says here, he was here for four decades, so he had a lifetime career here. It’s really wonderful. 

And I can maybe drop in the last one as well. Dr. Min Chiu Li, so he came to the US in 1947, but he joined NIH in 1955. And he was able to identify a drug that functionally cured placental cancer, and it was a cure that also allowed women to then continue to bear children in the future, so it was not sterilizing. And it was this discovery that later after he left NIH, won him a Lasker Award, so he won the award in 1972 for his discovery while working at NCI. 

>> Diego: That’s fascinating. Well I want to commend all the work you do in putting displays like this together. I think it’s so important to acknowledge the mistakes of the past to build a better future. It might be a little cheesy, but I mean that’s what science does, it builds on failings of the past, and no reason why society can’t take a similar approach. 

I also think it’s great to see the science and people that make up NIH through a historical lens. I know for myself, I tend get caught up with all the cutting- edge advancements that are happening now, or what’s on the horizon for the future, but it’s refreshing to learn about some of the history that informs all of that. 

>> Devon: Yeah, absolutely. That's something that I think is the most exciting. You see these innovations today, but they have a history, and they've sort of grown and, you know, you can't be doing the cutting edge without having that foundation. And even -- I mean, these people were at the cutting edge of their time, and that's what's so exciting, because we normally focus on, you know, NIH history specifically, but it's great to pull that context in and say what was happening nationally that is affecting our campus because, you know, it is a campus, but it's not in a bubble. The things that are going on outside and nationally and internationally, are affecting the ebbs and flows of our own institution, so we love to bring that in, and this was a great opportunity to do so. 

We also want to make sure that NIH employees see themselves in our exhibits, that they see the diversity and feels that they are part of this larger mission, because they are. And to have modern-day researchers, scientists, employees see themselves in its history and in its future is really important to us.

Diego (narration): One of those modern-day researchers is Dr. Jacqueline Vo. 

>> Dr. Vo: Hi, my name is Jacqueline Vo. I am an assistant clinical investigator in the Radiation Epidemiology Branch in the Division of Cancer Epidemiology and Genetics at the National Cancer Institute.

>> Diego (narration): Dr. Vo is a nurse scientist, clinical epidemiologist, and an NIH Distinguished Scholar. Her research focuses on health inequities of treatment-related outcomes for cancer survivors, particularly in historically minoritized populations, including Asian American NHPI, which she identifies with as Vietnamese American. 

Through her work Dr. Vo has found that the risk for developing cardiovascular disease as a result of heart damage caused by cancer treatments, also known as cardiotoxicity, is not the same across the board. She is looking at how it varies across racial and ethnic groups. 

>> Dr. Vo: We do know that these disparities in breast cancer survivors happen. But we don't have great data in terms of understanding what cardiovascular disease mortality among breast cancer survivors look like. So looking at heart disease mortality across the different racial and ethnic groups, we looked at four different racial groups, white breast cancer survivors, Black breast cancer survivors, Asian American and Pacific Islander breast cancer survivors, and Latina breast cancer survivors, and we compared them to the racial and ethnic matched group in the general population and what their rates of dying from cardiovascular disease were. So for example, white breast cancer survivors compared to white women in the general population. And we matched by age at death, calendar year, and race and ethnicity. 

So what we really found was that Black, Latina, and Asian American and Pacific Islander breast cancer survivors had a higher risk of dying from cardiovascular disease than their racial and ethnic-matched general population, which was not observed among the white breast cancer survivors. It was really interesting. One finding I wanted to highlight was among the Asian American and Pacific Islander breast cancer survivors because when you often compare Asian American and breast cancer survivors to white women, which is often considered the reference group in research, we actually compared them to the Asian American and Pacific Islander general population, and that's where we found increased cardiovascular disease mortality when we stratified looking at specific cancer treatments, such as chemotherapy and radiotherapy, which are known to be more likely to be cardiotoxic. 

>> Diego (interview): Did you see anything in the data that could suggest a reason for the higher rates in the minority groups? 

>> Dr. Vo: There's a number of things that we think might be contributing to those factors, and we believe part of it has to do with the access to healthcare. And there’s an intersectionality aspect to this, too. Are they also living in areas where they're not getting access to the healthcare? Is there a language barrier that might be influencing their issues? Are there stigmas or other issues that might influence why a provider might recommend cardio-oncology clinics? We also think that there might be a relationship with the types of treatments that are being given. So we know that Black breast cancer survivors are often diagnosed at younger ages in more aggressive breast cancer stages. So is it possible that they're more likely to receive cardiotoxic cancer treatments that might be contributing to their increased risk of cardiovascular disease? This data set that we used didn't have some of those level of details that we need to disentangle why these rationales are happening, and this is why descriptive epidemiology is really helpful for us to understand what the lay of the land is, but moving forward, we need to figure out what those causes are. 

>> Diego (interview): Well, continuing with this conversation of descriptive epidemiology and racial-ethnic disparities, you've worked with Dr. Meredith Shiels, who is also a PI in DCEG and has also been on the pod. And when she was on, she talked about distinguishing Native Hawaiian and Pacific Islander from a more generalized Asian-American grouping. Basically, how treating them all as one was actually hiding some pretty stark, and frankly, alarming health differences that actually exist between Asian ethnicities. And you've done some of that research and written extensively on the matter. So why is it so important that we disaggregate these groups? 

>> Dr. Vo: I'm very passionate about this question. So thank you for asking it. In 1997, the Office of Management and Budget released standards, revisions to the race and ethnicity classifications, that distinctively differentiate between Asian and Pacific Islander as separate races. Even though this was revised in 1997, it wasn't until 2018 where nationwide data was available. And this is really important. Asian and Pacific Islander have very different patterns of health behavior. They have different immigration patterns versus colonization patterns, for example. They have a different cancer burden, cancer mortality, and those are things that we aren't able to distinguish if we're continuing to aggregate Asian and Pacific Islander populations together. 

So I mentioned earlier that I looked at Asian American and Pacific Islander breast cancer survivors relative to the Asian American and Pacific Islander general population. And even though I did this, it's because of the limitation that I wasn't actually able to disaggregate Asian from Pacific Islander populations, but I was able to explore this finding further. So I'm now conducting a current study where I'm looking at how cardiovascular disease mortality might differ between Asian versus Pacific Islander. And some early findings that we found were that Pacific Islander breast cancer survivors have a much higher risk of dying from cardiovascular disease compared to Asian breast cancer survivors and are driving those disparities that were concealed when you aggregated these groups together. 

>> Diego (interview): So in other words, and maybe you can clarify better than I can, Pacific Islander mortality rates were so high that they were fronting the burden of cardiovascular risk and skewing the data for the aggregated group. 

>> Dr. Vo: Yeah, so Asian Americans comprised around 95% of the population of Asian American Pacific Islander as an aggregate. So a lot of this data is driven from Asians instead of Pacific Islander populations, just based on the fact that the sample size is just so much larger for Asians compared to Pacific Islander populations, and they comprise about 5% of the population aggregated and even less than 1% in the U.S. 

So I mentioned earlier about how Asian and Pacific Islander populations might experience different burdens because of the different immigration versus colonization experiences. So as Asian Americans our ancestors are often coming from Asian countries and immigrating to the U.S. For Pacific Islander, it's different. For example, Hawaii was colonized by the U.S. So it's a completely different perspective, in that they are living in their home country, in their home land.

When the U.S. colonized Hawaii, it wiped out nearly 95% of the native Hawaiian community because of the diseases that were brought into Hawaii that didn't exist prior to the colonization. So they've had a very different experience being colonized in their own homeland versus Asian Americans, including myself. I've come from a lineage of Vietnamese refugees who came here after a war-torn country. And that brings a really different perspective of how I grew up versus those who are native to their own homeland. And so I think those are some of the factors that are driving the differences that I'm seeing in my research in that Pacific Islander populations are experiencing different issues than Asian populations that I'm still trying to disentangle in my future research. 

>> Diego (interview): Right. And when you really consider the cultural, geographic, historical differences between these groups, it's really a no-brainer that they shouldn't be clumped together as one. 

>> Dr. Vo: Exactly. Asians are not a monolith. Within Asian groups, there are very distinct differences that might be occurring. So for example, in the U.S., Asians have the largest income inequality, in that the top 10% of Asians make 10 times as much the lowest than the lowest 10% of Asians.

And that really has to do a lot with the different ethnic groups within the Asian populations. So if, for example, Asian Indians make substantially more than Burmese Asian Americans. So I think there are also differences that I'm trying to break down in a very meaningful way so that we're not just disaggregating for the purpose of disaggregating, but that we're disaggregating to be very intentional about what our research means and that it brings more depth to what our communities are needing. 

And so that's where I try to ask myself in each of the different research questions, what are we asking? What can we do with the results? We don't want to just do descriptive epidemiology to characterize it. What is the outcome from our research? What can we do about it now that we know these health disparities exist? 

Every context is a little bit different. Sometimes you do want to break down to ethnicity. So understanding Vietnamese versus Chinese versus Laotian versus Pakistani. But sometimes it's more meaningful to use ethno-geographic region, which is grouping East Asians together versus Southeast Asians together versus South Asians together, because that might be a more meaningful way to make impact onto the communities we serve. It's always helpful if you have the data to be able to disaggregate, start there, and then see where the patterns exist and if it makes sense to meaningfully group Southeast Asians together, for example. 

>> Diego (interview): Have you faced any pushback? Say from people who might not really understand the point of disaggregating these groups? 

>> Dr. Vo: There’s pushback in that people don't always understand the Asian and Pacific Islander are a different population, and then there's pushback on impact. Like why does this matter? And that's, oftentimes, really frustrating because as someone who is Vietnamese American, I can very clearly see why it matters. I can very clearly see that my families have experienced different cancer burden than another Asian population, for example. So for me, my role is to be able to answer that question in a very eloquent and persuasive way to say this is why it matters. Here's what the data show. And this is what we can do for the communities that are experiencing these health disparities. 

>> Diego (interview): Right. And like you said, this line of work is largely motivated by your personal experience. 

>> Dr. Vo: Yeah, so I grew up as a child of Vietnamese refugees who came here to seek a better life, quite literally, from war-torn Vietnam. So my parents immigrated here in the 80s. My mom's life story is always just so fascinating to me when I talk to her about it. My mom has a third-grade level education because in Vietnam you had to have money in order to go to school. So when she was finally in her 20s she tried to leave Vietnam and escaped on a boat, tried three attempts, and was actually put in prison twice before she successfully made it out of Vietnam on the third attempt. So when my mom came here and met my dad actually in the States, she tried to learn English, but she couldn't translate her own language to English because she barely knows how to read and write Vietnamese itself. 

And then I grew up in a small town in Alabama where there was only one traffic light when I was in high school, and oftentimes, I felt like the only other Asian person were my siblings. And so it was a very different experience when I grew up as the only person that looked like me, and it didn't always make sense when I had those who were around me tell me that I was smart because I was Asian, and that never made sense to me until I was older to understand where these myths are coming from. Because my mom, like I said, has a third-grade-level education from Vietnam. My dad has an eighth-grade level. I am a first-generation high school, college, doctoral-degree graduate. So a lot of these experiences I've had have been felt very siloed because I was one of the first people in my family to ever go through these experiences. 

>> Diego (interview): Well, that touches on a subject came up when I was talking to other AANHPI folks for this episode, and that is the myth of the model minority came up. The stereotype that generalizes Asian populations is like high-achieving, well-off, smart, healthy even, and therefore, might not require as much attention as other so-called minorities, but in reality, that kind of just flattens the diverse experiences that you mentioned of Asian Americans into like a singular, very narrow narrative, and I think it also perpetuates this like falsehood that AA and HPI folks don't experience systemic racism. And in the first half of the show, we talked about the Chinese Exclusion Act as a clear example that wasn't true, and although it was repealed and marginalization isn't, you know, as overt as it was 100 years ago, we still have, you know, a lot of progress to make. 

Otherwise, we might not be having this conversation right now. Of course, I'm also thinking of the xenophobic, anti-Asian sentiment, and hate crimes that flared up during the COVID pandemic. And on top of that there’s a scarcity in senior leadership, even at NIH. 

So yeah, that’s a lot to throw at you, but I guess I’m wondering, how you see those challenges, those biases, the barriers that hinder advancement.

>> Dr. Vo: Yeah, absolutely. I think during the pandemic, there was the rise of xenophobia and anti-Asian hate crimes.It's not like they didn't exist pre-pandemic, but they were heightened, and we finally brought attention to it during the pandemic. The xenophobic phrases that were said are phrases I've actually heard my entire life, and it wasn't until I was much older and in college that I had learned about the term xenophobia. I didn't know what that was growing up. My parents didn't talk about that, and so, when someone told me this is what xenophobia means, I realized, light bulb moment, this is what people have said to me growing up of go back to your own home country. Where are you actually from? You're not actually American, and this is something that really frustrated me on a, obviously, a personal level because I was born and raised in the United States. This is all I've known. I don't consider any other country my home. And so that xenophobia is a really challenging issue that I think needs to be addressed in the forefront, not just during the pandemic, but lifelong to really address the biases that people have of this feeling that Asians are outsiders. 

I think another part that you really brought up is that there is a lack of Asian in leadership. Asians are not considered underrepresented in science, and it's because Asians are grouped together as one. If you broke down the Asian ethnicity, you would likely see that there is much less representation of Southeast Asians within science. But you cannot see that, and the data are not available. So that's another frustrating aspect for me because I don't often see other Vietnamese American scientists. We exist. And then moving past seeing representation in science is going into that leadership aspect. You're spot on. Asians are not well represented in leadership. And so I see that as a challenge to mentor others who are from diverse populations, I want to be able to create resources that are attractive to them for them to do research in these diverse populations. 

And so one avenue to do this is because I am a co-principal investigator with Dr. Gretchen Gierach of the Kaiser Permanente Breast Cancer Survivors cohort, which is an initiative within DCEG. through this cohort, this started to be able to look at treatment-related second cancers and cardiovascular disease within breast cancer survivors. I've now led the initiative to expand to two more racially diverse cohorts, including Kaiser Permanente, Georgia, which has a large population of non-Hispanic Black patients, and then Kaiser Permanente Hawaii, which has one of the largest populations of Asian American and Pacific Islander populations. 

We're now embedding this data into our cohort, and so, what I'm hoping is that now I'm creating a resource that future individuals who are coming from minoritized backgrounds would be interested in coming to work with me so that I have this opportunity to mentor them and then pay it forward in my research.