It has been more than a year since Immediate Past President of the American Academy of Pediatrics (AAP), Sally Goza, MD, FAAP, warned against the threat severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) posed to children and families, including the harm coronavirus disease 2019 (COVID-19)–fueled racism and xenophobia could cause the Asian American community. Sadly, as the COVID-19 pandemic spread, racism and violent attacks on Asian Americans spread along with it.

Since March 2020, increases in racist rhetoric have coincided with increases in racist abuse, bullying, and attacks. According to Human Rights Watch,1  an organization that investigates abuses happening throughout the world, reports of discrimination and violence against Asians and people of Asian descent have surged both in the United States and worldwide. A new study of police department statistics2  from 16 of America’s largest cities reveals that hate crimes against Asian Americans rose nearly 150% in 2020, despite overall hate crimes dropping by 7%.

Stop AAPI Hate,3  a national coalition that tracks incidents of violence and harassment against Asian Americans and Pacific Islanders in the United States, reported nearly 3800 instances of discrimination against Asians between March 19, 2020, and February 28, 2021. Although these reports may represent only a fraction of the hate incidents that occur, it is an indication of how vulnerable Asian Americans have become to racial attacks and discrimination.

Widespread media coverage of violence committed against elderly Asian Americans in cities across the country is stirring up fear and a sense of increased vulnerability. These horrific, unprovoked attacks are not only heartbreaking to witness, they erode the sense of personal safety and well-being of the entire Asian American community. In addition, these hate crimes against the elderly are particularly devastating in light of the Asian American cultures influenced by values that promote positive views of aging and teach younger people to respect, obey, and care for their elders. Our Asian American patients tell us that they are afraid to walk or ride the bus to school, go to church, or play outside, because they, too, have been targets of taunts and harassment. But even staying inside the home does not protect them. Many children say they have experienced cyberbullying or feel shunned and anxious because of hateful, racist language online. Their parents tell us that although they themselves have previously experienced anti-Asian racism in the United States, never before have they felt so unsafe. It is no longer a sense of “not belonging,” it is a sense of being on high alert. The alarming statistics and the trauma behind them illustrate that America is again waging a battle against two pandemics: COVID-19 and racism.

Unfortunately, the racialization of a disease and the tendency to offer up scapegoats in times of crisis are not new phenomena. People of Chinese descent were implicated in the 2003 severe acute respiratory syndrome (SARS) pandemic. Such stigmatization invoked widespread fear and distrust and had damaging social and economic consequences for many Asian Americans.

In a 2020 commentary in Pediatrics, Cheng and Conca-Cheng4  wrote about the long legacy of anti-Asian racism in the United States. They pointed to the Chinese Exclusion Act of 1882, which prevented Chinese laborers from immigrating to the United States, the Immigration Act of 1924, which extended these restrictions to other Asian immigrant groups, and President Franklin Roosevelt ordering forced relocation and internment of 120 000 individuals of Japanese ancestry during World War II. In times of crisis and fear, the instinct throughout history has been to find someone to blame. Often, this is targeted at communities that have been historically marginalized and people who are least able to defend themselves.

The 2019 AAP policy statement5  titled “The Impact of Racism on Child and Adolescent Health” declared racism “a social determinant of health that has a profound impact on the health status of children, adolescents, emerging adults, and their families.” The policy states, “The social environment in which children are raised shapes child and adolescent development, and pediatricians are poised to prevent and respond to environmental circumstances that undermine child health.” This is one of those times when we must step up to the plate.

In a 2020 article in the American Journal of Public Health, “Potential Impact of COVID-19-Related Racial Discrimination on the Health of Asian Americans,”6  Chen et al warned that COVID-19–related racial discrimination will exert harmful effects on Asian American health. They pointed to historical precedent of the association between racial discrimination and worsened psychological and physical health outcomes. Examples included the findings that Japanese Americans confined to internment camps during World War II experienced roughly double the rates of suicide and cardiovascular disease compared with their noninterned counterparts later in life and that Arab and Muslim Americans had greater psychological distress and short- and long-term health problems after the increase in Islamophobia, anti-Muslim rhetoric, and hate crimes that stemmed from the 9/11 terrorist attacks. In addition, the basic science and epigenetic elucidation of intergenerational transmission of historically experienced racism is evolving and supports these clinical observations.7,8 

In a 2020 article in Pediatrics, Cheah et al9  examined the rates of COVID-19–related racism and racial discrimination experienced by Chinese American parents and youth and the associations with their mental health. The authors found that nearly half of parents and youth reported being directly targeted by COVID-19 racial discrimination online and that higher levels of perceived racism and racial discrimination were associated with poorer mental health.

For the past decade, rates of suicide, depression, and anxiety have been increasing for all children and adolescents. Many factors unique to the pandemic are adding to the toll on children’s emotional and behavioral health: isolation from friends, family, and other community supports; emotional challenges, such as grief, fear, and disappointment; parental stress; and economic hardship. Asian American youth are further affected by having to wrestle with Sinophobic discrimination, slurs, and attacks, as well as the frightening reality that people from Black, Asian, and minority ethnic backgrounds are at greater risk of becoming severely ill and more likely to die of COVID-19 if infected.10  Although we do not yet have complete data on the pandemic’s impact on children’s mental health, evidence is emerging that suggests both the prevalence and severity of mental health issues have worsened over the past year.

We urge all pediatricians to refamiliarize themselves with the AAP policy statement “The Impact of Racism on Child and Adolescent Health,”5  to examine our own biases, be prepared to discuss and counsel Asian American families on the effects of exposure to racism, and make appropriate mental health referrals as needed.

And we echo and reemphasize the urgency of Dr Goza’s call not only to vaccinate children against COVID-19 but also to strengthen our children’s immunity to the virus of hate. The AAP’s commitment11  to dismantling racism has been, and will continue to be, at the forefront of our highest priorities.

Lee Savio Beers, MD, FAAP, President Moira Szilagyi, MD, PhD, FAAP, President-Elect Sara H. Goza, MD, FAAP, Immediate Past President Warren M. Seigel, MD, MBA, FAAP, Secretary/Treasurer Mark Del Monte, JD, Chief Executive Officer/Executive Vice President

Wendy S. Davis, MD, FAAP, Chair Yasuko Fukuda, MD, FAAP Madeline Joseph, MD, FAAP Joseph L. Wright, MD, MPH, FAAP

FUNDING: No external funding.

     
  • AAP

    American Academy of Pediatrics

  •  
  • COVID-19

    coronavirus disease 2019

  •  
  • SARS-CoV-2

    severe acute respiratory syndrome-coronavirus 2

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.