“Overrepresented Minorities”: A Brief History

As a health professions advisor and admissions professional, I have found myself connecting with the frustrations of Middle Eastern/North African (MENA) and Asian-American/Pacific Islander (AAPI) applicants. In the larger discussion of racial equality and equity, students and members of these communities, often referred to as “overrepresented minorities,” feel like their concerns are largely ignored or diminished. Access to minority scholarships or diversity programs is frequently not allowed for applicants of MENA or AAPI descent. Higher education is full of messages that suggest the hard work of MENA and AAPI students will be rewarded if it is much higher quality work than the “average” applicant. These messages are the seed of resentment by these groups towards “affirmative action” policies, particularly when one focuses on admission to a highly selective high school or college.

I have been doing a deep dive into cultural competency in my work with the Becoming a Student Doctor project for the Health Professional Student Association. The chapters on the American experiences of Arab/Muslim/MENA and AAPI communities have striking historical similarities that continue to define the insecurities these communities have in approaching their applications and their reflections on contributing to diversity. While this article cannot substitute for a bonafide study in history, I hope it helps MENA and AAPI applicants better frame their value as healthcare professionals.

Lesson 1: MENA and AAPI applicants want to belong and fight being perceived as foreign.

The term “overrepresented minority” is often used somewhat pejoratively to express how the community feels excluded from being in a preferred group: i.e., “White” or a desired “underrepresented minority” (i.e., Native American, Black/African-American, Latinx). Both communities immigrated to the United States in many cases as a response to world events. 

MENA immigration became a noticeable wave in the late 1880s as Arab Christians from the Ottoman Empire (around present-day Lebanon and Syria) began to escape religious persecution and seek economic opportunity. These first immigrants generally settled in the Northeast and Midwest as merchants and grocers. Still, small Arab communities would eventually be found in every US state. After World War II, immigrants came to the US to work in the automotive industry, especially around Detroit. Others began arriving in the 1980s to 1990s due to political upheaval and persecution throughout the Middle East preceding the September 11, 2001 attacks and the movement of refugees from the Gulf War, Afghanistan, and Syrian conflicts.

With American and UN peacekeeping forces have been stationed in the Middle East for the past few decades, Muslim fears were stoked by the social turmoil from armed conflict in Africa and the Middle East. The terrorist attacks on September 11, 2001, further amplified the contemporary wave of hatred against Muslims and students.

East Asian immigration waves were also linked with significant historical events. Many Chinese and Japanese men were part of the first major Asian immigrant wave in response to the discovery of gold in California in the 1850s. Chinese men became the main labor force for the western arm of the transcontinental railroad. However, their entry into the United States was not welcome. Congress passed the Page Law of 1875, which effectively barred Chinese women from entering the US and made it more difficult for Chinese immigrants to start families in the United States due to laws that banned interracial marriages. The 1882 Chinese Exclusion Act banned any additional Chinese from entering the United States and prohibited those residing from qualifying for citizenship, creating further challenges. The Immigration Act of 1917 also barred other Asian communities from immigrating to the United States. By the time World War II started, the US government had lifted these bans. Further waves of Asian immigrants and refugees arrived following the Indian-Pakistani, Chinese revolutionary, Korean and Vietnam Wars. But the feelings that Asian immigrants could never fully gain acceptance as Americans remain.

The Gentleman’s Agreement in 1907-1908 between the US and Japan capped Japanese immigration. Concerned about the backlash of enacting similar discriminatory laws against Japanese immigrants by the rising Tokyo regime, President Theodore Roosevelt found a compromise that encouraged the Japanese to regulate and limit the number leaving for the United States. Franklin Roosevelt issued Executive Order 9066 during World War II authorizing Japanese internment camps in the United States and the seizure of Japanese (and other East Asian) property. It still has lasting scars that were then exploited during the 1970s with anti-Japanese racism due to car imports. Asian/anti-Japanese hate contributed to the murder of Vincent Chin in Detroit (who was Chinese) in 1982. Anti-Chinese sentiment also has roots in anti-Communist fears after Mao Tse Tung’s victory after World War II, and echoes persist as China becomes a global presence to the present day. 

Filipinos had been US citizens since the 1898 Treaty of Paris with Spain, but their immigration became restricted beginning with the Tydings-McDuffie Act of 1934. The Luce-Celler Act of 1946 and the Immigration and Nationality Act of 1952 reversed many of these restrictions.

Early Asian Americans were not considered equal to Whites or given standing equal to Whites. The California Supreme Court ruled in 1855 (People v. Hall) that Chinese-born individuals had no right to testify in cases against White defendants, upholding the superiority of White status over all other races or those of mixed descent. The California state legislature also passed laws that taxed Chinese business workers to address White laborers’ concerns about increased salary competition. After the Civil War, many Chinese wound up in the Reconstruction South escaping the harassment and cruel conditions they experienced in the Western mines. Many Chinese would wind up working on farms alongside Black freedmen, and many Whites began to prefer Chinese “Coolie” labor over Black labor. Others were able to start businesses and gain economic stability.

MENA and AAPI groups have also had to tolerate racial backlash from public health crises similar to other American Blacks/African-Americans, Latinx, and Native American/indigenous communities. The Ebola and the “Middle Eastern Respiratory Syndrome (MERS) coronavirus outbreaks further contributed to Arabophobia/Muslimophobia in the United States. Although the anti-Asian hate incidents stemming from the COVID-19 pandemic are fresh in our minds, “Asian yellow peril” also occurred during a Bubonic plague outbreak among the Chinese communities in Honolulu and San Francisco at the turn of the 20th century.

Lesson 2: Why Asians are not considered “White,” but MENA people are “White.”

All federal or government Equal Opportunity surveys state that Middle Eastern/North Africans should be included as “White” while Asians remain separated. One should understand the legal history of these definitions and understand that “race” is a social construct that can be arbitrarily applied.

Two Supreme Court rulings occurred in the 1920s that further supported the arbitrary disenfranchisement of Asians from White status. Ozawa v. US (1922) ruled that fairer-skinned Japanese immigrants could not claim “White” status, but Caucasians could. Yet, a few months later, Thind v. US (1923) ruled that Asian Indians who are of Caucasian descent could not claim “White” status since they do not look White according to “the common man.”

While Middle Eastern communities were also excluded for many decades, a breakthrough ruling by the US Circuit Court of Appeals in 1915 (Dow v. United States) ruled that a Syrian and other Arab and North African Christians could be considered “White” since they come from the same origin as the Jewish community (including presumably Jesus Christ) even though George Dow did not “look White.” Arab Muslims would be included as “White” in a subsequent judgment three decades later. The Arab-Israeli conflicts soon after World War II, the Islamic revolutions that brought about the 190 US embassy hostage crisis in Tehran, and the Al-Qaeda terrorist attack on September 11, 2001, amplified tensions.

Lesson 3: MENA and AAPI consist of multiple groups, so self-identity can be more complicated.

Like all other groups, the MENA and AAPI communities are also internally diverse. MENA groups consist of Christian and Muslim religious identities with different branches and nationalities. AAPI communities also include many diverse spiritual communities, including Islam. Additionally, each nationality represented within the MENA and AAPI labels has separate cultural traditions and histories. There are groups within MENA and AAPI that are themselves underrepresented and historically exploited during colonization or conflict.

Because the terms MENA and AAPI are recent, many individuals self-identify according to their heritage country (Lebanese, Egyptian, Chinese, Korean, Pakistani, Afghani, Persian, etc.). Even within each group, experiences may differ depending on where someone or their parents are raised in the US.

Disaggregating Asian data highlights hidden disparities in socioeconomic status and resource access, especially among Filipino, Vietnamese, Thai, and Hmong. “Asians” additionally include South/Southeast Asians from India, Sri Lanka, Pakistan, Bangladesh, Afghanistan, and Iran. Furthermore, disaggregating MENA from “White” data also shows other differences that are overlooked. 

Lesson 4: The historical contributions of MENA and Asian communities to health and medicine are underappreciated.

Medical education traditions frequently highlight the Greco-Roman origins of Western civilization, honoring Hippocrates as the first father of medicine. However, medical knowledge can be traced earlier in the archaeological record. Egyptian doctors and dentists from around 3000 BC recorded procedures to address various diseases. Male and female doctors were adept at infection control and selecting pharmaceutical remedies with their healing rituals. Arabic translations of Hippocrates were maintained throughout the Middle East, and treatises by Ibn Sina (Avicenna), Al Zahrawi (Abulcasis), and other scholars were adopted by European doctors during the middle ages. Arab physicians are credited with following Islamic tradition in establishing hospitals open to any patient regardless of social status or background, with on-site pharmacies and resources for medical trainees. Medicine was also thriving in Asia; Ayurveda, acupuncture, and “Chinese (herbal) medicine” have been practiced for thousands of years.

Lesson 5: Immigration likely caused the overrepresentation of MENA and AAPI in the professional ranks to address workforce concerns, but they are underrepresented in leadership roles.

When laws were passed that limited American immigration, highly skilled and educated immigrants were generally favored to address perceived workforce shortages. Engineers, health professionals, and educated scholars had relatively fewer barriers to entering the United States. But once they arrived, those trained as healthcare professionals faced hurdles in learning conversational English and various licensure requirements to be allowed to practice. It is still estimated that foreign-born practitioners comprise about a quarter of the physician workforce, 20% of all pharmacists, and roughly 13% of all dentists. Once allowed to practice, a disproportionate number found opportunities to practice in underserved rural or highly urban areas where they were welcomed and appreciated. These families were thus able to assimilate and ascend in social stature to support their children and educational pursuits.

Until fairly recently, the shortage of AAPI leaders in corporations reflects the underrepresentation of Asians at the top. Similar trends have been observed in higher education if you look at deans and educational administrators in health professional programs. This “bamboo ceiling” is remarkable in STEM fields and industries. MENA leaders may be more represented in leadership and higher education roles. Still, the exact proportion remains unknown since they are included in traditional “White” categorizations. Such surveys can be confounded further due to a lack of disaggregation of recent immigrants who became naturalized versus those born in the United States.

Lesson 6: Education and “model minority” myths

Education is highly prized by MENA and AAPI communities, and achievement in school work is valued by the heritage societies where the communities originated. Families who emigrated from Middle Eastern nations have seen the decline of a once-proud education system due to political-religious forces, so an emphasis on having a strong educational foundation is not lost on those who left their home nations. Many Middle Eastern political leaders have established partnerships with American and European universities and hospitals to improve access to world-class education and healthcare. However, access to these resources may remain limited to the social elite.

Asian societies traditionally emphasize testing as a measure of student education and potential. For example, social mobility among Chinese students is often determined by performance on high-stakes exams, and the higher the performance on the Gaokao (the second exam which addresses university preparation), the more elite and prestigious level of universities a student may be eligible to attend. Similar standardized exams exist for Korea, Japan, India, and many other countries. Equating merit on high test scores perpetuates the Asian “model minority” myth that Asian students can score higher than any other group. As a result, Asians are thought to require a higher score to be considered for admission.

In the United States, Asian immigrants, however, have had to endure a legacy of segregation since non-Whites had to attend non-White schools. The US Supreme Court ruled that American-born Chinese children in Mississippi could not attend the whites-only high school because, under the “separate but equal” doctrine, they would get the same education from the “colored” high school as part of the “Yellow race” (Lum vs. Rice 1927). This decision would later be overturned by Brown vs. Topeka Board of Education (1954), though this is rarely discussed in American classrooms. This historical lens shapes the interpretations of aggregate admissions data and some support for the conservative-leaning Students for Fair Admissions against Harvard and UNC on the 2022 Supreme Court docket, even for many Asians who support maintaining race-based admissions policies. 

Lesson 7: Checking the box: Is it good to be “White”?

As the demographics of the United States grow toward a “minority-majority” society, White populations have also adopted the term “overrepresented majority” as a race. As many will note, throughout history, being “White” identified one with being part of the group with power and control over American society. MENA and AAPI students generally use the “overrepresented minority” term to raise awareness of their identities which are underappreciated in American society and do not receive the same attention as underrepresented or historically disenfranchised racial groups do. Because ORMs do not qualify for minority scholarships, the term could be construed as one of defiance of affirmative action efforts that address systematic wrongs that prevented Native Americans, Latinx, and Black/African Americans from achieving equal standing. Allies should better include and promote MENA and AAPI voices when discussing their value to an inclusive community (admissions, residency, or leadership), noting how resilience and adaptability are key to their success individually, as families, and historically as a community.

Final thoughts

ORM applicants generally understand the systemic racial barriers that excluded historically underrepresented groups, but their stories are rarely discussed with similar urgency. I hope this brief primer inspires allies to understand better the impact of White privilege on MENA and AAPI groups. Until the cultural and legal history of MENA and AAPI communities in American society is better taught and appreciated, these groups will remain torn about the benefits of checking their race/ethnicity box to be properly counted in admissions or society.

Join the conversation further by accessing the Becoming a Student Doctor course as a Health Professional Student Association member. Dr. Chuck acknowledges significant improvements to drafts of this article from the feedback provided by Joseph Gilbert, Nom Shahid, and Tricia Greenstein.

Citation

Most references are linked within the text.

1. MENA Migration:
   • https://www.history.com/news/arab-american-immigration-timeline  
   • https://www.migrationpolicy.org/article/middle-eastern-and-north-african-immigrants-united-states
   • https://www.state.gov/dipnote-u-s-department-of-state-official-blog/the-story-of-arab-americans-beginning-in-america-and-the-quest-for-fair-representation/
2. Kezian, Steven A. (2020) “The History of the Dental Profession – From Ancient Origins to Modern Day,” Pacific Journal of Health: Vol. 3: Iss. 1, Article 2. DOI: https://doi.org/10.56031/2576-215X.1006 Available at: https://scholarlycommons.pacific.edu/pjh/vol3/iss1/2