Health Equity Research: A Clarion Call to Focus on Racism, Not Race

There is a documented paucity of research regarding health inequities experienced by Asian Americans. The National Institutes of Health allocated 0.12% of its research budget on health inequities among Asian Americans from 1992 to 2000 and only 0.18% from 2000 to 2018.1 This is in contrast to Asian Americans being the fastest growing major racial/ethnic group in the United States since 2000, nearly doubling in size in that time period and projected to exceed 46 million by 2060.2In their article in this issue of AJPH, Yan et al. (p. 671) begin to fill this gap by reporting that the increase in substance use-specifically alcohol, cocaine, and tranquilizer use-during 2020 compared with 2016 to 2019 was significantly greater among Asian American relative to White American adults. This study used data from the National Survey on Drug Use and Health (NSDUH), arguably the leading source of data with respect to national trends on substance use in the United States. Yan et al. also increased the rigor of their findings via the use of propensity score weighting in the analytic approach, thus providing a more causally valid estimate ofthe difference in substance use trends that can be attributed to race.At the same time, the causal inference approach reveals a problem of a fundamental nature. It should be obvious that race-that is, one's phenotype or even underlying genotype-cannot be and is not the actual cause of patterns of substance use, just like race itself cannot drive other prominent health inequities such as the disparate burden of HIV shouldered by Black populations in the United States.3 If the causal factor for racial health disparities is not race, then what is? The answer is racism. This answer is so clear that racism has been put forth as a root cause of health inequities as well as a public health crisis.4,5It is evident that Yan et al. are aware of this because they present anti-Asian racism as the impetus for the study and premise for the stated hypotheses. They articulate that the COVID-19 pandemicdriven increase in anti-Asian racism could drive increased substance use among Asian Americans during the 2020 time period during the COVID-19 pandemic versus the time period preceding COVID-19. Yet, the study by Yan etal. perpetuated the aforementioned fundamental problem that is too often present in racial health equity research: using race as a proxy for racism. In other words, their study did not directly test the putative cause (experiences of anti-A