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Academic Medicine Medical Economics

Why Are There So Many Asian Physicians In The U.S.?

People of Asian descent comprise 5.6% of the American population but Asian Americans comprise 19.8% of all U.S. physicians. Two things happened this week that led me to think about this statistic and why Asian Americans are so disproportionately represented in American medicine. First, I listened to the America’s Test Kitchen podcast, Proof, about why there are so many Chinese restaurants in the U.S. (quite fascinating and worth a listen). Second, I listened to this week’s MedNet webcast on Racism and Racial Bias in Medicine that included an exploration of why African Americans are under-represented in U.S. medicine. Part of my interest is because of my own Chinese heritage (albeit only 1/8th).

Several years ago, there was a lawsuit against Harvard University by a group of Asian students who were denied college admission and claimed that the University discriminated against Asian applicants who had superior admission test scores and grades than applicants of other races. The allegation was that Harvard made it harder for Asian applicants in order to keep the percentage of Harvard students who were Asian from becoming too high. The press surmised that Asian American students have a culturally-driven higher study ethic than students of other races. But I think that the reason for the high percentage of Asian students at elite U.S. universities and the high percentage of U.S. physicians who are Asian American has a deeper and darker cause that has its roots in immigration laws that paradoxically were created to keep Asians out of America. As the law of unintended consequences dictates, those laws ultimately resulted in Asian Americans being more academically successful and more overly-represented in American professions such as medicine.

The Naturalization Act of 1790

One of the first laws of the new U.S. government was the Naturalization Act of 1790 that limited naturalization to “free white person[s] … of good character“, thus excluding Asians (as well as anyone else who was not from Europe). This law essentially banned Chinese from immigrating to the United States but this was in many ways a moot point since travel by ship to the Eastern seaboard of the country from China via the Atlantic Ocean was very difficult and expensive. Not until the country’s westward expansion opened California to development did travel from China to the U.S. via the Pacific Ocean become feasible.

The next major event that affected immigration and naturalization of Asians was occurred in 1868. That year, the first section of the 14th amendment to the U.S. Constitution stated: “All persons born or naturalized in the United States, and subject to the jurisdiction thereof, are citizens of the United States and of the State wherein they reside.” The implication was that even if a non-white immigrant to the U.S. could not obtain citizenship himself or herself, their children could become citizens if born in U.S.

The Chinese Exclusion Act of 1882

The California gold rush attracted many Chinese to the west coast of the U.S. where they worked in mines and then when the mines played out, they worked in railroad construction. But soon, these laborers were competing with American citizens for labor jobs and often accepting much lower wages thus making it harder for white Americans to find work. This created a lot of hostility by many Americans toward Chinese immigrants. Notably, 140 years later, that same hostility would be directed against Latin American immigrants who are perceived as “stealing” jobs from other Americans.

The Chinese Exclusion Act of 1882 was enacted to appease this hostility. The act barred Chinese laborers from immigrating to the U.S. and also made Chinese immigrants ineligible for citizenship. The only exceptions were for Chinese merchants and teachers. At the time, Chinese were subject to racial discrimination equal in many situations to Blacks. In fact, in in 1896 Supreme Court case, Plessy v. Ferguson,  Justice John Marshall Harlan wrote in his dissent: “…the Chinese race is a race so different from our own that we do not permit those belonging to it to become citizens of the United States.”.

Because the Chinese Exclusion Act limited immigration to merchants and teachers, the act essentially barred Chinese women from immigration since at the time, the vast majority of merchants and teachers were men. Indeed, by the end of the 19th century, Chinese men in the U.S. outnumbered Chinese women 27 to 1. Many of these Chinese store owners and teachers married white women since there were so few Chinese women in the country. One of those men was my great-grandfather, who came to the United States from China in 1873, opened a Chinese laundry, married a white woman (my great-grandmother), and ultimately became the president of the Chinese Merchant’s Association of America (but that is another story).

The unintended consequence of the Chinese Exclusion Act was that it selected out only educated Chinese men from immigrating to the U.S. And when these men married and had families, they instilled the importance of education into their children. The unwritten message was that if you were Chinese in America, you had to have an education to economically survive. Racism against Chinese created a more educated and middle class Chinese population in the U.S. In contrast, racism against Blacks in the U.S. resulted in Africans being brought to America as slaves and education of their children was suppressed in order to maintain a population of unskilled enslaved laborers.

Many of these Chinese merchants opened restaurants. Chinese restaurants proliferated because their owners had to sell better food at a lower cost than other American restaurants since they had no other employment options than to be a merchant, even if it meant making a lower income by selling inexpensive food.

The Immigration and Nationality Act of 1965

After World War II, the Chinese Exclusion Act was repealed, in part because China had been a U.S. ally during the war. However, immigration from China was limited to only 105 Chinese immigrants per year. The Immigration and Nationality Act of 1965 eliminated national origin, race, and ancestry as basis for immigration. Importantly, it created a “special immigrant” category that was not subject to quotas – included in this category were foreign medical graduates. The implication was that if you wanted to immigrate to the United States, you had to go to medical school first.

Currently, 25% of U.S. physicians are foreign medical graduates. The more medical schools a given country has, the more physician immigrants that country can send to the U.S. There are 348 medical schools in India offering an MBBS degree. There are 154 medical schools in China that offer an MBBS degree and 50 of these teach in English. In contrast, there are only 160 medical schools in the total of the 48 countries in Sub-Saharan Africa; consequently, India and China are capable of producing more medical graduates that can then immigrate to the United States than other countries can.

One of the best predictors of whether or not a person will become a doctor is whether their mother or father was a physician. In the United States, 20% of doctors have a parent who was also a doctor. I’m a perfect example, a third-generation doctor, with my physician-father a descendent of one of the Chinese immigrants affected by the Chinese Exclusion Act. Medicine is the family business.

The counter productivity of Chinese racism

For a century after the inception of the United States of America, Chinese were usually disdained and immigration from China prohibited. For the second century of our country, some Chinese were tolerated, but only those who were well-educated and entrepreneurial. As a result of policies and laws to keep Asians out of the U.S., we now have a disproportionately high percentage of Chinese and other Asians occupying the ranks of physicians. And given the propensity for children of doctors to become doctors, the percentage of doctors who are Asian American will likely grow in future decades.

Racism is always morally wrong. And racism is always bad policy. There can be unanticipated consequences of racism that result in exactly the opposite of what racism intended… your doctor is likely going to be someone like me, a son of a son of a daughter of a Chinese immigrant.

October 30, 2020

By James Allen, MD

I am a Professor of Internal Medicine at the Ohio State University and the Medical Director of Ohio State University East Hospital