2020: The Health of the Nation

In late 2019, Americans had come to know of a new coronavirus from an outbreak in Wuhan, China. COVID-19, the official name for the respiratory disease caused by the novel coronavirus SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2), then spread to other parts of the world with significant outbreaks in South Korea and Italy. Although US health officials, politicians, and industry leaders had been talking about the threat of novel coronaviruses for the past quarter century, beliefs in US exceptionalism, chauvinistic assumptions of the country’s greatness, and the cultural emphasis on individual grit contributed to making many Americans feel invincible.¹ The US had dealt with multiple disease outbreaks in recent previous years, including SARS in 2003, Ebola in 2014–16, and Zika in 2015–16. Cases were relatively few in number compared with other parts of the world, and the majority of Americans were left unscathed.

However, on March 11, 2020, the World Health Organization declared that COVID-19 had become a pandemic. Americans could no longer take the health of the nation for granted. By mid-March, the death toll had surpassed one hundred, with coronavirus cases confirmed in every state.² On April 6, the number of deaths increased to ten thousand.³ On May 27, it multiplied to one hundred thousand.⁴ The United States became the epicenter of the pandemic, leading the world in the numbers of coronavirus cases and related deaths.

For Asian Americans in the United States, what unfolded was an American horror story of racism and xenophobia in addition to the existential threat of a deadly disease. On March 16, President Donald Trump first referred to the novel coronavirus as the “Chinese virus” on Twitter. Such inflammatory rhetoric stigmatized China and, by extension, anyone who looked Chinese. The Stop AAPI Hate reporting center launched on March 19, 2020. Between March 19 and April 15, 2020, the center had collected almost 1,500 reports of anti-Asian hate incidents.⁵

As hate incidents spiked, Asian American healthcare workers were on the front lines battling this deadly disease. Beginning in April 2020, stories about Filipino nurses who had died from COVID-19 started appearing in national news coverage. In September 2020, National Nurses United reported that COVID-19 was taking a disproportionate toll on Filipino American nurses.⁶

An Asian American historical lens is useful to understand why this is happening. While the creation of the Stop AAPI Hate research center is relatively new, the phenomenon of associating Asian bodies with disease outbreaks and anti-Asian violence is not. The devastating number of Filipino nurse deaths in this pandemic has garnered the public’s attention, but Filipino nurses have been caring for American patients for six decades.

The intersection of these two histories exposes one of the unique tragedies of anti-Asian, coronavirus-related racism. Targets of anti-Asian hostility include Asian American healthcare workers who labor to save the lives of Americans in the age of COVID-19.

THE LONG HISTORY OF MEDICAL SCAPEGOATING AND ANTI-ASIAN VIOLENCE

The history of associating Asian bodies with disease outbreaks in the United States is in fact as old as the first mass wave of Asian migration. After the discovery of gold in Northern California in 1848, the numbers of Chinese arrivals in San Francisco increased. Their growing presence fueled anti-Chinese sentiment in the region and the state. Many white workers and politicians viewed them as economic competition and an alien race. Anti-Chinese sentiment also had biological and medical components that presented Chinese bodies as a weak and inferior race.

Tragically, the concurrent development of San Francisco’s public health institutions in the second half of the nineteenth century furthered anti-Chinese sentiment. Their municipal reports blamed Chinese immigrants for smallpox outbreaks. As Dr. J. L. Meares, who served as a San Francisco health officer from 1876 to 1888, emphatically stated, “I unhesitatingly declare my belief that the cause is the presence in our midst of 30,000 (as a class) of unscrupulous, lying and treacherous Chinamen, who have disregarded our sanitary laws, concealed and are concealing their cases of smallpox.”⁷ San Francisco public health officials instituted measures that racially profiled Chinese arrivals at the city’s port for smallpox outbreaks. These included quarantine, physical examination, the fumigation of clothing and baggage, and mass vaccinations.⁸

Even with these measures in place, the medical scapegoating of the Chinese extended to ethnic enclaves such as San Francisco’s Chinatown. Dr. Meares repeatedly referred to Chinatown as a “cesspool” and “nuisance.”⁹ The San Francisco Board of Health’s annual reports from 1876 to 1877 did not mince words when they depicted Chinatown as a health threat, referring to it as a “moral and social plague spot,” a “sanitary curse,” and a region “contaminating the atmosphere.”¹⁰

While public health reports presented a scientific and authoritative voice to a social discriminatory narrative about Chinese bodies as disease carriers, popular culture spread these medicalized horror stories to the general public. The San Francisco magazine The WASP commissioned artist George Keller to draw anti-Chinese political cartoons that expressed the downfall of the United States as a result of Chinese immigration. One of these illustrations was titled “A Statue for Our Harbor.”

Published in 1881, “A Statue for Our Harbor” depicts the Statue of Liberty as a Chinese laborer wearing tattered clothing, a human skull at his foot, and an opium pipe in his hand. His queue, or traditional ponytail, is prominently displayed emanating from the back of his head as a slithering snake-like object, while a rat tail peeks out from behind the human skull. Blackened skies warn readers of what is to come to the United States if the Chinese continue to arrive in “our harbor.” Asian sail boats, known as “junks,” outnumber the steamboats in the water. This classic representation of “yellow peril,” Western fears of Asian invasions and the resultant downfall of Western civilization, is clarified through the following capitalized words that emanate from the Chinese laborer’s head in lieu of Lady Liberty’s crown: “FILTH, IMMORALITY, DISEASES, RUIN TO WHITE LABOR.” In 1882, one year after the publication of “A Statue for Our Harbor,” Congress passed the Chinese Exclusion Act, which barred the immigration of Chinese laborers to the United States and made the Chinese ineligible for US citizenship.

While medical scapegoating of Chinese immigrants justified their exclusion from the United States, the belief in Western medical superiority contributed to the nineteenth-century American doctrine of Manifest Destiny—the divine right of the United States to expand westward across the continent and the Pacific Ocean, and into the Philippines. Although Filipino nationalists had been fighting for their independence from over three centuries of Spanish rule, the United States annexed the Philippines in 1898. In his proclamation of “benevolent assimilation,” President William McKinley posited that, unlike Spanish conquerors, Americans came as friends. Evidence of American goodness included bringing Americanized public health to the Philippines.

Benevolent assimilation relied on a racial and medical hierarchy, however. Dr. Victor Heiser, who became chief quarantine officer in the Philippines in 1903 and later served as director of health in the Philippine Islands until 1915, described Filipino bodies as “incubators of leprosy.” In a 1910 article, he presented Filipinos as a primitive people with little hope of progress if not for American tutelage: “We are practically cleaning up these Islands, left foul and insanitary and diseased by hygienically ignorant peoples. . . . We are draining the land, as it were, before beginning the constructive health projects which are going to make these people the strong and healthy race we intend them to be.”¹¹

Although Japan, like the United States, was emerging as a global power through imperialism, the pattern of associating Asian bodies with the threat of disease also applied to the growing numbers of Japanese immigrants in California. In early twentieth-century Los Angeles, public health officials, such as Dr. John Pomeroy, stoked fears of Japanese immigrants, many of whom were farmers, by linking their presence to foodborne diseases such as typhoid. He proposed increasing public health staff to surveil Japanese farms.¹² In a 1920 issue of the California magazine Grizzly Bear, Dr. Pomeroy titled his article on Japanese immigrants “Japanese Evil in California.”¹³

In 1910, when US Public Health Service physician M. W. Glover found that many Indian arrivals at Angel Island’s Quarantine Station had hookworm, the threat of disease became grounds for the movement to exclude them from entering the United States. The 1914 congressional hearings about Indian immigration included an article by Dr. Charles T. Nesbitt, health director of Wilmington, North Carolina, who wrote, “The Chinese, Japanese, and East Indians are racially alien to us. . . . History proclaims Asia as the fountain from which has flowed the most destructive pestilences that are recorded. Asiatic cholera, bubonic plague, typhus, smallpox, and malaria are reported weekly as being present in the ports of China, India, and Japan.”¹⁴

The stereotyping of Asians as disease carriers obscured a historical truth about Europeans and European Americans. They too had contracted a variety of deadly diseases such as cholera and smallpox, and as settlers had brought these diseases to various places across the globe, such as the Caribbean and Central and South America in the sixteenth century and North America in the seventeenth century. There had also been smallpox epidemics in US Eastern cities. As historian Nayan Shah points out, in nineteenth-century San Francisco, “it was just as probable that smallpox arrived with European and American migrants traveling westward by rail.”¹⁵ However, it was easier to track and quarantine smallpox over the longer journey across the Pacific. And, when European immigrant laborers in San Francisco contracted smallpox, public health officials such as Dr. Meares expressed sympathy instead of disgust, diverting blame away from their bodies and emphasizing their misfortune in not being able to afford better housing.¹⁶

Asians and Asian Americans resisted the idea of Western medical superiority and the practice of anti-Asian medical scapegoating in a myriad of ways. In the early twentieth century under US colonial rule, Filipinos continued to consult indigenous healers, such as curanderos. From 1910

to 1940, Chinese detainees at the Angel Island Immigration Station wrote poetry on the barrack walls. One poem harshly criticized the invasive medical examinations: “I thoroughly hate the barbarians because they do not respect justice. . . . They examine for hookworms and practice hundreds of despotic acts.”¹⁷

In 1921, Chinese merchants Hing Pang and Hee Fuk Yuen filed US federal lawsuits, criticizing immigration medical inspections that led to the denial of their reentry into the United States. Their lawyer, Jackson Ralston, argued that the targeting of Chinese arrivals was an “unequal administration of the law.” Ralston noted that Caucasian passengers, regardless of their nationality or class, were not subject to microscopic tests of their feces as Asian travelers were—those traveling first-class being the only exception.¹⁸ However, the federal appeals court and the Supreme Court affirmed that such practices were nondiscriminatory.

Asian Americans protested medical scapegoating because at stake was not solely their livelihood, but also their lives. Once they were labeled as filthy, immoral, and disease-prone, they became regarded as less than human and subject to harassment and violence. Key historical examples go back to the second half of the nineteenth century. In 1871, a mob of over five hundred people lynched seventeen Chinese immigrant men in the Chinese Massacre of Los Angeles. Local newspaper editorials condemning Chinese immigrants as immoral and inferior contributed to the brutality of these attacks.¹⁹ In the 1885 Rock Springs Massacre in Wyoming, at least twenty-eight Chinese workers were killed, their homes and bunkhouses set on fire. Economic and social tensions pitted white immigrants—mostly Irish, Scandinavian, English, and Welsh—against the Chinese. Writer Tom Rea notes, “Although they worked side by side every day, whites and Chinese spoke separate languages and lived separate lives. They knew very little about each other. This made it possible for each race to think of the other, somehow, as not entirely human.”²⁰ These events were not exceptional. In 1885 and 1886, over 168 communities in the US West expelled their Chinese residents, united in their vehemence that “the Chinese must go.”²¹

Although the anti-Chinese movement in the Pacific Northwest was not as intense as California’s, five days after the Rock Springs Massacre, a group of armed white men and several Native American men entered a Chinese camp in Squak Valley (now Issaquah in Washington State) and riddled their tents with bullets. Laborer Gong Heng was asleep in his tent when the shooting began. He described the attack: “So many shot fired it sounded all same [as] China New Year.”²² Three Chinese men died and several more were seriously wounded.

In Oregon and Washington Territory, a surplus of jobs lessened economic competition between white and Chinese residents. Chinese had been working in the lumber and railroad industries in Tacoma since the early 1870s. However, their more established presence did not protect them from intimidation and expulsion. In November 1885, several hundred white men armed with pistols and clubs rounded up Chinese, ordering them to “pack up and leave town by 1 p.m. or face unspoken consequences.”²³

In the early twentieth century, the majority of Indians, Koreans, and Filipinos worked in the agricultural, railroad, and lumber industries in the US West, and much of the animosity that they faced was linked to working-class labor competition. In 1907, a mob of five hundred white working men expelled South Asian migrant workers from Bellingham, Washington. They broke windows, threw rocks, and indiscriminately beat people.²⁴ An angry mob of white workers threatened Korean laborers with physical violence in Hemet Valley, California, in 1913.²⁵ Anti-Filipino riots took place in Exeter and Watsonville, California, in the 1920s and 1930s. In Exeter, white mobs roamed through Filipino agricultural labor camps, beating the laborers, smashing cars, and burning down bunkhouses.²⁶ In Watsonville, sexual as well as economic competition erupted in violence over Filipino men dancing with white women in taxi dance halls, resulting in the death of Fermin Tobera. White mobs roamed Watsonville’s streets, beating or shooting Filipinos on sight.²⁷

During World War II, although Asian American men served in the US armed forces and although Asian American women worked as Rosie the Riveters, Japanese Americans were racialized as an enemy of their own country. Their homes and businesses were targeted for arson, shootings, and vandalism. In 1942, 120,000 Japanese Americans were forcibly relocated and incarcerated in remote internment camps across the United States. Two-thirds were US-born Japanese Americans who were incarcerated without due process.

Non-Japanese Asian Americans also experienced violence and harassment because they too were racially lumped together with Japanese. In her autobiography Quiet Odyssey: A Pioneer Korean Woman in America, about Korean American life in the early twentieth century, Mary Paik Lee recalled the following:

Even after all the Japanese were taken away to concentration camps, other Orientals were subject to all kinds of violence. They were afraid to go out at night; many were beaten even during the day. Their cars were wrecked. The tires were slashed, the radios and batteries removed. Some friends driving on the highways were stopped and their cars were overturned. It was a bad time for all of us.²⁸

Thus, despite the many differences in national origin, language, faith, generational status, and socioeconomic status of Chinese, Japanese, Filipinos, Koreans, and Indians, anti-Asian hate in the United States wove their fates together. The linkage between Asian bodies and diseases was only one strand of this pattern of hatred. Economic and sexual competition, imperial and colonial hierarchies, and wartime politics were others. At moments of various crises beginning in the second half of the nineteenth century, they incited egregious forms of anti-Asian violence in the United States.

These histories seep into our present.

ANTI-ASIAN HATE IN THE AGE OF COVID-19

On February 14, 2020, a bully physically attacked his classmate, a sixteen-year-old Asian American boy, in California’s San Fernando Valley, accusing him of having the coronavirus and telling him to go back to China.²⁹ The case prompted Manjusha Kulkarni, the executive director of the Asian Pacific Policy and Planning Council (A3PCON); Cynthia Choi, co-executive director of Chinese for Affirmative Action; and Russell Jeung, a professor at San Francisco State University’s Department of Asian American Studies to ask California’s Office of the Attorney General to host an online, anti-Asian hate reporting center. When the Office of the Attorney General was unable to do so, Choi, Jeung, and Kulkarni created the Stop AAPI Hate reporting center themselves, launching it on March 19, 2020.³⁰ The reporting center tracked and analyzed incidents of hate against Asian Americans and Pacific Islanders in the wake of the COVID-19 pandemic. Its website included a content area that enabled users to report a hate incident from a selection of twelve languages.

Stop AAPI Hate’s founding emerged from a legacy of six decades of Asian American activism as well as a response to contemporary anti-Asian violence. Choi, Jeung, and Kulkarni were able to establish the reporting center relatively quickly because of the political infrastructure that activists had been building since the late 1960s as part of the Asian American Movement, a social justice movement that advocated for relevant community services and curriculum, among other causes.³¹ Chinese for Affirmative Action was founded in 1969 with the mission to protect the civil rights of Chinese Americans and to advance multiracial democracy in the United States. San Francisco State University’s Department of Asian American Studies was also created in 1969 as a result of student strikes led by the Black Student Union and Third World Liberation Front. A3PCON, which serves the needs of the Asian and Pacific Islander American community in the greater Los Angeles area, emerged from coalition-building among social service programs in the mid-1970s.³²

In early 2020, as the coronavirus spread in China, Choi expressed concern about the impact on Chinese Americans, noting that public references to the “Chinese virus” were worrisome to members of Chinese for Affirmative Action.³³ Between March 16 and March 30, 2020, President Donald Trump used the phrase “Chinese virus” more than twenty times.³⁴ He also referred to COVID-19 as the “kung flu” in several presidential campaign rallies. White House press secretary Kayleigh McEnany defended the use of the term: “It’s not a discussion about Asian Americans, who the president values and prizes as citizens of this great country.”³⁵

Asian American community leaders disagreed. Andy Kang, executive director of Asian Americans Advancing Justice–Chicago, criticized these labels: “With such an emotionally charged political atmosphere, it’s irresponsible and reckless for our political leaders and candidates for our nation’s highest office to engage in rhetoric that incites xenophobic scapegoating and violence.”³⁶

In 2015, the World Health Organization advised that new diseases ought not to be named after nations, economies, and people because of the stigma that becomes attached to them. Dr. Keiji Fukuda, WHO’s assistant director-general for health security, noted that “this may seem like a trivial issue to some, but disease names really do matter to the people who are directly affected. We’ve seen certain disease names provoke a backlash against members of particular religious or ethnic communities. . . . This can have serious consequences for peoples’ lives and livelihoods.”³⁷

Choi, Kulkarni, and Jeung feared that the assault on the Asian American teenager in the San Fernando Valley was not a singular incident. They were right. The Stop AAPI Hate reporting center collected approximately one hundred anti-Asian incidents per day during its first week of operation.

A major contribution of the center was its collection and analysis of qualitative as well as quantitative data on anti-Asian hate in its reports, the first of which was released on March 25, 2020.³⁸ Stop AAPI Hate reports highlighted stories from those who had directly experienced or observed hate incidents. Many of the stories captured not solely how anti-Asian hate was expressed, but also how it felt. They foregrounded Asian Americans’ perspectives about their encounters with racism that have been neglected and dismissed.³⁹ In a story from Stop AAPI Hate’s “Week 1 Report,” an Asian American shared:

I was not seen by the employee at my local post office where I have been a regular customer for over 20 years. After patiently waiting as she pointed to others behind me for nearly 45 minutes, I approached the desk when she prompted me to take several steps backwards in a very hostile tone. She had not requested [that of] any of the prior customers that had gone ahead of me, and they were also all non-Asians. The sting of her racism and coldness towards me made me feel less than and, frankly, dehumanized.⁴⁰

In the center’s “Week 2 Report,” a story about online harassment poignantly revealed the psychological and emotional impacts of being the target of anti-Asian hate:

Yesterday a teammate assumed I was Chinese even though I never said my race; all I said was “that is racist, I’m American FYI” when the teammate called me Chinese. He got everyone else on his team to join in and harass me. I feel ashamed almost to be Asian in America. It hurts. I was being called a “gook,” being told “China has the highest suicide rates, you should think about that :)” or calling me “ling ling” and saying I eat dogs and spread corona virus.⁴¹

The Stop AAPI Hate reports also documented the wide spectrum of anti-Asian hate that was being expressed in the most mundane of situations—for example, while people were riding public transit or shopping in a store—and where there was sometimes no physical altercation but still a harmful expression of hate nonetheless. While the most egregious examples of anti-Asian violence made the national and local news, less sensational incidents did not. In its first two weekly reports, Jeung grouped stories of AAPI hate under the following categories: barred from specific establishments and transportation, coughed and spat on, verbally harassed, harassed online, physically assaulted, shunned, discriminated against at the workplace, and vandalism. In doing so, Stop AAPI Hate was able to present a more nuanced understanding of the hate that Asian Americans and Pacific Islanders were experiencing during the pandemic. Its data collection was also a form of advocacy, conveying to AAPI communities that they were not alone, and that their experiences mattered.

Finally, a major achievement of Stop AAPI Hate was raising awareness about the multiple trends in discrimination that Asian Americans and Pacific Islanders experienced in 2020. In the center’s first national report, covering the period from March 19 to August 5, 2020, these trends included a gendered dimension. Women reported discrimination 2.4 times more than men. AAPI hate was also a nationwide phenomenon. Hate incidents came from forty-seven states, with California reporting 46 percent of the incidents, followed by New York (14 percent), Washington (4 percent), Illinois (3 percent), and Texas (3 percent).⁴²

The center’s national report further highlighted that, although Chinese were the ethnic group most targeted, 60 percent of the respondents were composed of non-Chinese, including Korean, Vietnamese, Filipino, Japanese, Taiwanese, Hmong, Thai, Lao, Cambodian, and mixed ethnicities. This trend reflects the significance of “Asian American” as a panethnic category in two distinct ways. First, it illuminates that an incredibly diverse group of Asian Americans was impacted by the stigma attached to the “China virus” because other Americans could not tell Asians and Asian Americans apart. Second, the Stop AAPI Hate reporting center’s method of collecting data and presenting it in both aggregated and disaggregated ways shows that the shared experience of the AAPI community and the experiences of specific Asian ethnic groups are not mutually exclusive. Rather, it is important to pay attention to both.

FILIPINO NURSES ON THE FRONT LINES

The World Health Organization designation of 2020 as the International Year of the Nurse and the Midwife was meant to be celebratory. Tragically, it was a year of tremendous loss and grief. According to an investigative report by The Guardian and Kaiser Health News, nurses made up the largest percentage of US health worker deaths in 2020.⁴³ A September 2020 report by National Nurses United further revealed that among those deaths, a disproportionate number were Filipino nurses.⁴⁴

Beginning in April 2020, multiple news stories reported that Filipino nurses had died from COVID-19. These nurses included Divina (also known as “Debbie”) Accad, a clinical nursing coordinator for the Detroit VA Medical Center who had cared for American veterans for over twenty-five years; Celia Yap-Banago, who had worked for forty years at a hospital in Kansas City; and Araceli Buendia Ilagan, who died at the Miami hospital where she had worked for thirty-three years. Some of the nurses were only a few weeks away from retirement.⁴⁵

In 2019, Filipino Americans were the third largest group of Asian Americans in the United States, with a population of over 4.2 million.⁴⁶ One of their distinctive contributions has been decades of caregiving. Since the 1960s, over 150,000 Filipino nurses have migrated to work in the United States, constituting the largest group of foreign-trained nurses.⁴⁷ In 2018, nearly one in three foreign-born nurses in the US were Filipino.⁴⁸

In states with a long history of recruiting foreign-trained nurses, such as California, Florida, Illinois, Massachusetts, New York, New Jersey, and Texas, Filipino nurses have been a highly visible labor force. In the mid-1990s, they made up 18 percent of New York City’s registered nurses.⁴⁹ In 2016, Filipinos made up almost 18 percent of California’s registered nurse workforce. Among younger nurses in California, they have been more predominant, with Filipino nurses representing nearly a quarter of nurses between thirty-five and forty-four years old, and more than one-fifth of RNs between forty-five and fifty-four.⁵⁰ These demographics suggest that the future of American nursing will continue to rely on Filipino nurses.

Despite their significant presence in US hospitals, Filipino nurses have been invisible in American culture even in television medical dramas. Some of the most popular TV dramas, such as ER, were based on public inner-city hospitals that were precisely the institutions recruiting nurses from the Philippines beginning in the 1960s. In 2018, the irony was not lost on Emmy Awards co-host Michael Che, who observed: “TV has always had a diversity problem. I mean, can you believe that they did 15 seasons of ER without one Filipino nurse? Have you been to a hospital?”⁵¹

Learning about the history of Filipino nurse migration to the United States is a way to resist their invisibility by acknowledging their long-standing presence. After the US annexation of the Philippines in 1898, benevolent assimilation policies led to the establishment of an Americanized training hospital system in the Philippines. American nurses trained Filipino nursing students in courses, such as practical nursing, the use of pharmaceuticals, and bacteriology, that followed a US professional nursing curriculum. Furthermore, Filipino nurse graduates had to demonstrate fluency in the English language in order to obtain Philippine nursing licensure. Americanized nursing training and English-language fluency prepared tens of thousands of Filipino nurse graduates to work overseas.⁵²

Although American colonial officials had not intended to create a Filipino nursing workforce for export, US hospitals began to recruit Filipino nurses to alleviate nursing shortages in the second half of the twentieth century. The first mass wave of Filipino nurse migration took place under the US Exchange Visitor Program, a Cold War program established in 1948, that sponsored visitors from various professional backgrounds and from all over the world. However, Filipino exchange nurses and their US hospital sponsors began to dominate the program. Between 1956 and 1969, over eleven thousand Filipino nurses participated in the exchange program.⁵³

The exchange program presented Filipino nurses with an opportunity to fulfill social and cultural longings. They had dreams of seeing a place with snow and where apples grow, another legacy of their Americanized education. The exchange experience also exposed them to working and living in the United States. During her exchange visit in New York City in the early 1960s, Epifania Mercado realized that she preferred living in the United States for economic as well as social and cultural reasons. Her salary as an exchange nurse was higher than her earnings in the Philippines, enabling her to help her family financially. “In the Philippines,” she explained, “your salary is just enough for you.”⁵⁴ She also enjoyed American outings: “You can go to Broadway, Lincoln Center. You have enough money to travel. There’s always something going on.”⁵⁵

The predominance of Filipino nurses in US hospitals was catalyzed by three big changes in the United States during the 1960s. First, the establishment of Medicare and Medicaid in 1965 resulted in an increased need for nurses; second, the women’s and civil rights movements resulted in new job opportunities for American women; and third, a more equitable immigration policy, called the Hart-Celler Act, was passed in 1965. Also known as the Immigration and Nationality Act of 1965, it established a preference system that favored the immigration of workers with needed skills. It enabled American healthcare institutions to recruit Filipino nurses to alleviate nursing shortages on a more permanent basis. In a 1969 advertisement in the Philippine Journal of Nursing, a Chicago hospital beckoned, “There’s a job waiting for you.”⁵⁶

Meanwhile, in the Philippines, high rates of domestic unemployment and political instability pushed Filipino nurses overseas. The devaluation of the Philippine peso against the US dollar made the United States an especially attractive destination. By the early 1970s, a Filipino nurse in the Philippines needed to work twelve years to earn what she could make in the United States in one year.⁵⁷ This economic disparity would only worsen in the late twentieth and early twenty-first centuries.

Some Philippine government officials initially criticized Filipino immigrant nurses for abandoning their home country.⁵⁸ But, in the early 1970s, after observing the demand for Filipino nurses in the United States, Philippine president Ferdinand Marcos pivoted the country’s development strategy toward a labor export economy.⁵⁹ The Philippine government began promoting the outmigration of Filipino nurses and other workers, most notably domestic workers and seafarers, to Europe, the Middle East, Canada, and other parts of Asia. Government officials later touted these overseas workers as the Philippines’ new national heroes for the billions of dollars they remitted annually in foreign currency. This Philippine labor diaspora has also included the migration of Filipino nurses who have worked in the UK’s National Health Service for decades. In December 2020, Filipino British nurse May Parsons made history when she administered the first COVID-19 vaccine outside of a clinical trial.⁶⁰

Despite their long-standing contributions to healthcare delivery around the world, Filipino nurse migrants have historically faced numerous challenges including exploitive work conditions, fraudulent recruitment practices, racial and gendered scapegoating, restrictive licensing requirements, and language issues. Contrary to stereotypes of Filipino nurses’ timidity and submissiveness, they have fought back.

In the mid-1990s, Woodbine Healthcare Center in Gladstone, Missouri, petitioned the US Immigration and Naturalization Service to hire Filipino nurses in its nursing home with the promise that it would employ them as registered nurses and pay them the same wages as American nurses. However, the Filipino nurses ended up working as nursing aides, and Woodbine paid them about six dollars an hour less than their US counterparts. Two Filipino nurses filed discrimination charges with the US Equal Employment Opportunity Commission and, in 1999, Woodbine agreed to pay $2.1 million to the nurses and their attorneys.⁶¹

Problems regarding language have occurred when the use of English in the workplace conflicts with the desire of Filipino nurse migrants to speak Filipino languages during work breaks and other noncritical work situations. In 2010, a group of sixty-nine Filipino nurses and medical staff members at the Delano Regional Medical Center shared a $975,000 settlement in a lawsuit filed by the US Equal Employment Opportunity Commission and the Asian Pacific American Legal Center. The Filipino nurses claimed that they were targeted to speak “English only” unlike other bilingual employees and described the workplace language policy as a source of embarrassment, shame, and harassment. Although the medical center insisted that it did nothing wrong, it had to conduct anti-discrimination training under the terms of the settlement.⁶²

The predominant way Filipino nurses have responded to their challenges has been by organizing. Gina Macalino, an RN and California Nurses Association board member, observed, “There is a misconception that Filipino nurses are hard to organize. But if you go to any strike or any action where Filipinos work, the majority of the people you’ll see on the line are Filipinos.”⁶³ A recent study led by scholar Jennifer Nazareno supported Macalino’s point. It found that a higher proportion of Philippines-trained RNs reported being part of a labor union or collective bargaining unit than their white US-trained counterparts.⁶⁴

National Nurses United co-president Zenei Cortez was born and raised in the Philippines and migrated to the United States with her parents and siblings in 1974. As a leader of the largest union of registered nurses in the United States, she has been a staunch advocate for lower nurse-patient ratios and Medicare for all. Cortez’s four-decades-long work history in bedside, direct-care nursing has given her a historical lens to view the shortcomings of the United States’ early response to COVID-19. After photos of nurses in a New York City hospital wearing garbage bags as PPE (personal protective equipment) went viral in March 2020, Cortez decried the shortage of PPE for nurses: “We are in America, one of the richest countries in the world and, yet, nurses who have given themselves to the front lines are being denied something very important to protect ourselves and our patients. I have been a nurse for 40 years, and this is the first time this is happening.”⁶⁵

Beginning in the 1960s, Filipino nurses also organized local Philippine Nurses Associations from New York to Illinois to California that led to the establishment of the Philippine Nurses Association of America (PNAA) in 1979. Over the past forty years, the PNAA has welcomed and mentored new generations of Filipino nurses in the United States and provided them with professional development and leadership opportunities. Past PNAA presidents have become leaders in the broader US nursing profession, such as Lolita Compas, who has served as president of the New York State Nurses Association.

In 2020, the PNAA initiated a Heal Our Nurses Project to assess the well-being of their members and to amplify the voices of Filipino frontline nurses. Riza V. Mauricio, an advanced practice nurse intensivist, related: “Taking care of infants and children during this pandemic brought a lot of internal chaos. . . . Uncertainty and fear abound, especially as we are still learning about pediatric COVID symptoms.”⁶⁶

A major concern for Filipino frontline nurses has been about the risk of exposing their family members to this deadly disease. Evangeline Ver Vicente, an RN and member of the Philippine Nurses Association in Nashville, Tennessee, shared: “I pray every day that I will be safe and won’t be able to transmit this bug to others and my family. For more than a month now, I wear a mask when I interact and see my family, especially my grandchildren. I am so eager to hug and squeeze them, but I am quickly reminded of the possible effect on them for me being a potential carrier. So, I stop and virtually hug them with a heavy heart.”⁶⁷

Filipino frontline nurses have responded to these challenges in creative and spiritual ways. Nurse Mauricio eased the anxiety of one Burmese mother, who did not speak English and whose baby had just been admitted to the hospital, by demonstrating and encouraging the mother to gently touch her baby’s feet. Like Nurse Vicente, other Filipino frontline nurses have relied on prayer and spiritual beliefs to give them the strength to care for others. Arlin Fidellaga, an RN and Northern Regional vice president of the Philippine Nurses Association in New Jersey, recited the “Nurses Prayer” in a nine-day novena for those affected by the coronavirus, including healthcare providers. She and fellow members prayed:

When we enter the room, allow us to project an image of confidence and warmth,

So that our patients will feel at ease with us and trust our judgment.

No matter how many times we see fear in their eyes, or recognize that they are in pain,

Remind us that we should never become callous to their needs.⁶⁸

During the pandemic, the needs of Asian American healthcare workers ranged from adequate PPE to the availability of mental health resources to combat a new deadly disease. They also included the need for safety from anti-Asian hate and violence.

CARING FOR OUR HEALTHCARE WORKERS

One of the tragic consequences of anti-Asian violence in the United States during this pandemic is that it has hurt American health workers of Asian descent. Incendiary rhetoric regarding COVID-19 as a “China virus” and the “kung flu” has belied the fact that US hospitals and other healthcare institutions have historically recruited many Asian healthcare workers during health crises. In 2018, US healthcare delivery relied on an immigrant workforce that made up a significant percentage—almost 18 percent—of healthcare workers. The majority of the 512,000 immigrant RNs in the US hailed from the Philippines, followed by India. Among the 269,000 immigrant physicians and surgeons, Indians were the top group, followed by those from China/Hong Kong, Pakistan, Canada, and the Philippines. Immigrants from China/Hong Kong and the Philippines were also represented among home health aides and personal care aides.⁶⁹

Yet, Asian American health workers have not been immune to anti-Asian hate and violence. In an April 2020 video, Dr. Chen Fu, a hospitalist at NYU Langone Medical Center, reflects on how strange it is as an Asian American doctor during the pandemic and “being celebrated and villainized at the same time.”⁷⁰ The video then cuts to a daily celebratory routine of car horns honking and people cheering at 7:00 p.m. to thank New York City’s healthcare workers, while Fu notes solemnly, “At the same time I read on the news how people of my ilk are just experiencing tensions that they haven’t experienced in modern history.” Fu has experienced these tensions firsthand. He was stopped in the subway by a passenger who started to scream racial slurs at him, even though Fu was dressed in medical scrubs.

Filipino nurses have also been targets of anti-Asian hate. In late March 2020, San Francisco Unified School District nurse Kyle Navarro was unlocking his bike on his way to the post office to exchange a pair of glasses for a student. A man spat in the direction of Navarro, and then yelled a racial slur. Navarro reflected on the incident, “I was scared and I’m still scared. Navigating life as a queer person, I always have some level baseline of fear going out at any time. But even more so now.”⁷¹

What should be done to end this fear, to stop Asian hate, and to heal from this pandemic? Navarro emphasized one path forward: access to comprehensive healthcare, including mental health services, for all Americans.

Despite the presence of so many Asian healthcare workers on the front lines fighting COVID-19, the history of associating Asians with disease is repeating itself. In an April 2020 interview for a Berkeley News story, journalist Ivan Natividad asked me the following questions: “How does this Asian xenophobia and racism impact other ethnic groups? How does it affect our attempts to combat the spread of COVID-19?” I responded:

It’s harmful to everyone. When Asians and Asian Americans don’t go out in public to the hospital when feeling ill because they fear being the victims of anti-Asian hate crimes—that’s a public health problem. While it is important that we modify individual behaviors, like washing our hands and keeping our distance from each other, we need everyone involved to make it effective. So, when you start blaming Asians or Asian Americans, it disrupts that collective response.⁷²

The title of Natividad’s article is “Racist Harassment of Asian Health Care Workers Won’t Cure Coronavirus.” It is an ironic message that demands our attention. Underlying it is a history lesson about the inefficacy of medical scapegoating that we’ve yet to learn in the twenty-first century. As I write, this pandemic is not over. Variants emerge. Anti-Asian hate and violence surge. At stake is the health of the nation.