South Asian communities in the USA trace their roots to multiple countries in the Indian subcontinent (e.g., Bangladesh, Bhutan, India, the Maldives, Nepal, Pakistan, Sri Lanka) and its global diaspora, including descendants of laborers brought elsewhere due to British colonialism (e.g., Caribbean, Fiji, eastern and southern Africa). The 2010 US Census reported 3.5 million South Asians in the USA, which increased by roughly 60% to 5.6 million in 2019 [1]. This comprises roughly 25% of the Asian American population, which itself is 22 million or roughly 6.8% of the US population. It is projected that by 2055, the Asian American community will be the largest immigrant group in the USA; within that, Asian Indians will be the second largest subgroup [1]. However, there is a wide range of inequality among South Asian groups, including in poverty rates (19% among Bangladeshis to 6% among Indians), median household income ($55,000 among Nepalis to $119,000 among Indians) [1], English language proficiency (36% among Bhutanese [2] to 82% among Indians [3]), and educational attainment (with 11% of Bhutanese, 22% of Nepalis [4], 26% of Bangladeshis [5], 29% of Sri Lankans [6], 31% of Pakistanis [7], and 32% of Indians with bachelor’s degrees) [1]. A lack of disaggregated data has contributed to the erasure of marginalized South Asian groups, in particular, and South Asians as a whole, despite accounting for a fourth of Asian Americans. The paucity of disaggregated data and research among South Asian populations serves as a structural disadvantage to the health of these groups.

Immigration from the Indian subcontinent to the USA has been reported since the 1700s [8]. Since then, South Asian immigrants have experienced significant legal discrimination and anti-Asian violence. In 1917, the US Congress passed an Immigration Act to restrict immigration from the “Asiatic Barred Zone,” a geographical region that included the Indian subcontinent. In the landmark 1923 case, United States v. Bhagat Singh Thind, the US Supreme Court ruled that South Asians were ineligible for naturalization [9]; it was not until the Luce-Celler Act of 1945 that this policy was reversed, instead imposing quotas for the number of immigrants from each of these Asian countries, which were removed only with the passage of the Immigration and Nationality Act of 1965 [10].

In addition to legal discrimination, South Asians have been the target of hate, which heightens during periods of economic and political turmoil. In 1907, white laborers rioted in Bellingham, Washington, to attack and expel South Asian immigrant laborers, primarily working in lumber mills, from the city limits [11]. In the 1980s and 1990s, the “Jersey City Dotbusters” threatened and attacked South Asians in the region [12]. After September 11, 2001, South Asians, mainly Muslims and Sikhs, were targeted by hate and violence, including an escalation of state violence such as racial profiling, policing, surveillance, detention, and deportation. Following the 2016 presidential elections and passage of Muslim travel bans, there was another surge in hate crimes against South Asians [13]. Currently, Sikhs are the most targeted group in the country, reporting hate crimes at more than four times the national average [14]. Yet, the model minority stereotype overshadows public awareness regarding this culture of violence [15].

Despite abundant evidence of the adverse effects of violence on mental and physical health [16, 17], there is limited research examining the impact of racialized state violence on the health of South Asians [18]. There is an urgent need for dedicated research with disaggregated data to highlight potential relationships between violence and the health of South Asians in the USA. Thus, the purpose of this paper is to summarize and synthesize existing peer-reviewed and gray literature on the prevalence and types of state and interpersonal violence experienced by South Asians in the USA and the resulting health impacts. We propose a conceptual framework to describe the pathways that connect racialized state violence to health outcomes (see Fig. 1).

Fig. 1
figure 1

Conceptual framework describing the types of racialized state violence that impact the health of South Asians in the USA

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Racialized State Violence

Violence spurred by political xenophobic rhetoric—the perpetuation of fears based on racist stereotypes for political advantage—has been of particular significance for South Asians in the USA since September 11, 2001. Here, we focus on political hate rhetoric from public officials as an aspect of domestic state violence—with its authority to not only shape laws and policies but also impact public perceptions and actions, and influence law and immigration enforcement, with their significant power over the daily lives of immigrant communities.

Political xenophobic rhetoric directed against Muslim, Sikh, and South Asian groups, already present before September 11, has continued to steadily rise in the following two decades [19, 20], with a marked increase in the 12 months after the 2016 presidential election [20]; it is also consistently and overwhelmingly motivated by anti-Muslim sentiment [13, 19, 20]. The majority of this hate rhetoric plays out on the national stage, rather than at the state or local level, with a common theme: the xenophobic stereotype of “the foreigner” [19]. In the last 20 years, this hate rhetoric has found legal form in a slew of anti-Muslim and anti-immigrant laws targeting and criminalizing South Asians and others racialized as “Muslim” or “Brown,” based on religion, race, ethnicity, and national origin. It has also emboldened law and immigration agencies to act with impunity in enforcing racist laws and policies such as the USA PATRIOT Act, Muslim Travel Bans, Public Charge Rule, and other policies and practices based on racial profiling, such as “Stop and Frisk” and racially targeted immigration enforcement raids and deportation.

The hate impetus of political xenophobic rhetoric can also be traced directly to violence at collective and interpersonal levels—one in five hate incidents in 2016–2017 referenced the administration of former president Donald Trump [20]. Of note, hate incidents, including hate speech, that do not legally qualify as hate crimes are not reported by federal agencies and are being tracked only by advocacy organizations. Similarly, data on South Asians and others racialized as “Muslim” targeted by discriminatory laws and policies are also unavailable, both due to opacity of the programs and a lack of data disaggregation. Compounded with eroded community trust of law enforcement due to racial targeting, there is chronic underreporting of hate incidents in these communities [19]. This hate impetus also exacerbates violence experienced at the individual level, intensifying marginalization, alienation, and disenfranchisement from civic and political participation, and facilitates xenophobia-driven cultural phenomena such as the model minority myth [21].

Racialized Policing, Surveillance, and Immigration Enforcement

The South Asian community has experienced heightened racialized profiling since September 11, 2001, with the introduction of “terrorism-watch” lists and “no-fly” lists [22]. Particularly, New York City became one of the epicenters of racialized and religious profiling, especially after the passage of the USA PATRIOT Act. This law widened the government’s ability to spy on US citizens and allowed law enforcement to utilize methods of secret surveillance, providing access to personal information such as Internet and phone records, obtain search warrants without prior notice, wiretap residences, and trace phone calls [23, 24]. Closely following this law was the development of the National Security Entry-Exit Registration System (NSEERS) in 2002. NSEERS established a Muslim registry, mandating men aged 16 years and over from Muslim-majority countries register with local immigration offices, subsequently allowing the government easier access for surveillance [25]. By 2003, over 80,000 men were registered, resulting in 13,000 deportations. However, none of these individuals were linked to terrorism-related convictions [26].

While the New York City Police Department’s “Stop and Frisk” policy existed prior to September 11, 2001, its use against the South Asian community increased drastically in conjunction with the implementation of the USA PATRIOT Act, NSEERS, and other so-called counter-terrorism efforts. “Stop and Frisk” policies allowed law enforcement to stop people based on racial profiling and question and search them without demonstrable due cause [27]. These routine processes by law enforcement could then initiate detention and deportation procedures. According to a report published by a coalition of South Asian American organizations, 73% of South Asians reported being questioned about their national origin and 66% about their religious affiliations [28]. Additionally, South Asians who were questioned by government officials could be pressured to spy on fellow community members. As a result of the fears of being racially targeted, many South Asians altered their behavior and social interactions in an attempt to avoid additional investigations [28]. The consequences of these policies have also resulted in many South Asians developing a distrust in government and its ability to protect them in times of need [28].

Institutional Racism

The political and social culture of violence against South Asians and others racialized as “Muslim” and “Brown” has created a permissive environment for discrimination outside the governance apparatus in institutions such as employment, housing, healthcare, and education. Fear of racialized policing, surveillance, and immigration enforcement can deter South Asians from any recourse against unfair treatment. Institutional discrimination is common among Asian Americans, with those identified as “Brown Asians” experiencing it at even higher rates than other Asian subgroups [29,30,31]. Nationally, almost half of South Asians reported experiencing discrimination in institutional settings (46% vs. 22% among whites) [29]. Asian Americans are the largest foreign-born immigrant group and can have a precarious status in the labor market (e.g., being undocumented or having citizenship status linked to employment), and consequently may be particularly vulnerable to being treated unfairly in the workplace [32]. About a third of South Asians reported experiencing workplace discrimination in being hired, pay, promotions, and termination [29, 31]. Housing discrimination in rentals and purchases, and in entering specific neighborhoods, is experienced by almost a quarter of South Asians [29, 31], which may partially have its roots in the legacy of racial residential segregation in the USA. Healthcare discrimination is another significant issue among South Asians. Almost a fifth of South Asians reported experiencing unfair treatment when going to a doctor or health clinic, with some saying they avoided the doctor or healthcare due to concerns of receiving unfair treatment [29].

Hate Violence and Discrimination

The culture of violence perpetuated by political xenophobic rhetoric and compounded by institutional racism also permits racially motivated hate violence and discrimination at collective and interpersonal levels. In the immediate aftermath of September 11, advocacy groups tracked sharp increases in hate incidents targeting Muslims, Sikhs, Arabs, and South Asians in the USA [33]. In the first year of the Trump administration, 302 incidents of hate violence and hate speech against South Asians and others racialized as “Muslim” and “Brown” were documented, which was more than 45% higher than the year leading up to the 2016 election cycle; at least 80% of these were motivated by anti-Muslim sentiment [19]. Notably, one in every five perpetrators of these incidents referenced former President Trump, a Trump administration policy, or a Trump campaign slogan, suggesting a link between hate against communities perceived as “Muslim” and rhetoric or policies used by the Trump administration [20].

While hate violence primarily focuses on physical and verbal assault, discrimination more broadly refers to unfair treatment of individuals based in whole or part on race, ethnicity, skin color, religion, national origin, and other identities. These include experiences anchored in false stereotypes of “terrorist” or “perpetual foreigner,” as evidenced by higher rates of racial slurs (36% among South Asians vs. 23% among whites) and harassment (22% among South Asians vs. 16% among whites) [29]. Qualitative research conducted among middle- and upper-class Asian Indians found one’s appearance, accent, speech, attire, and behaviors could contribute to perceptions of difference [34]. For South Asian youth, bullying in school settings often intersects with racism and xenophobia [35].

Microaggressions refer to the everyday slights that may seem inconsequential when considered individually but accumulate when they occur repetitively over time [36]. Common examples cited by Asian Americans include people acting as if they do not or cannot speak English, being called names or insults, being threatened or harassed, people assuming that they are dishonest, and people acting as if they are afraid of them [31]. For South Asians, themes include assumptions of sameness (e.g., all South Asians are the same), assumptions of terrorism (e.g., suspicion, scrutiny), exoticization (e.g., appearance, attire), assumptions of inferiority (e.g., in occupation, housing), and microinvalidations [37] leading to experiences such as “being searched while traveling” and being told to “go back to your country” [34]. Nationally, almost half of South Asians reported experiencing microaggressions (45% vs. 19% among whites) [29].

Internalized Racism

The experience of Asian American immigrants has been described as “unassimilable foreigners” [38]. Even though multiple generations of Asian Americans, including South Asians, have lived in the USA since the 1700s, membership to the “American” identity has not been automatic. The xenophobic narrative of othering that casts “Brown Asians” as “foreign,” “outsider,” and “terrorist” exposes South Asians to persistent anti-immigrant and racist hostilities. Battling persistent racial stereotypes and schemas promotes the internalization of the dominant racial ideology, leading to detrimental health consequences [39].

Invisibility of anti-Asian racism is inextricably connected to the “model minority” stereotype. The term was coined in 1966 to describe the apparent socioeconomic success of Japanese Americans, despite being a marginalized minority group, and later evolved to include all Asian Americans [40, 41]. “Model minority” implies that Asian Americans are academically, economically, and socially successful due to perceived cultural values that emphasize hard work, perseverance, and belief in the American meritocracy [40,41,42]. This overly positive caricaturizing of Asian Americans conceals the diversity of Asian American experiences and erases differences in socioeconomic status and outcomes. It also creates a fear of failing to meet the model minority stereotype and heightens individual responsibility. Furthermore, it forces an inappropriate comparison to other racial and ethnic groups and creates a wedge that negatively impacts inter-racial solidarity [21]. “Racial triangulation” explains that Asian Americans “have been racialized relative to and through interaction with [White and Black people],” and positions Asian Americans against other racial groups by systems that maintain white privilege and power [43]. Model minority stereotypes are the manifestation of racial triangulation based in white supremacy today, which maintains structures of racialization and racially charged hate and violence.

Health Implications

Violence across all levels may impact mental and physical health. Direct pathways linking violence to health outcomes may include physical injuries and death, psychological stress and trauma, anticipatory stress and increased vigilance, and changes in health behaviors. Indirect pathways may include community disruption, criminalization, neglect, abuse and poor conditions, economic strain, and reduced access to and utilization of health and social services.

Laws and policies, such as the Public Charge Rule that poses a barrier for documented immigrants who depend on government assistance from obtaining permanent residency, can increase hesitancy to utilize healthcare, including skipping preventive care and delaying seeking medical care until absolutely necessary, for fear of being targeted for detention and deportation [44,45,46]. Similarly, the Muslim Travel Bans, restricting immigration from Muslim-majority countries, increased emergency department visits and missed primary care appointments among Muslims from these countries living in the USA [47]. Additionally, racialized enforcement of laws and policies contribute to worse health outcomes: people living in neighborhoods with frequent use of “Stop and Frisk” racial profiling were subject to higher rates of psychological distress, diabetes, and high blood pressure [48]. Racialized policing and surveillance can heighten anxiety and decrease health-seeking behaviors of residents in targeted neighborhoods by impeding their ability to safely partake in activities in public spaces, such as exercise in public spaces [49, 50]. Negative experiences with law enforcement can also lead to distrust of other institutions, such as hospitals, further contributing to healthcare underutilization [51].

Hate incidents can serve as messages to targeted communities of their outgroup identity, which can decrease feelings of safety or security [52]. Hate speech and violence can take place online or offline, with online hate rhetoric begetting offline violence [53]. Compared to other types of violence, there is more evidence for racially motivated discrimination, including against Muslims[54] and Asian Americans [55]. For South Asians in the USA, a small set of studies has confirmed the association between discrimination and mental health, including stress, anxiety, and depressive symptoms [56,57,58,59]; self-reported health [60, 61]; and health behaviors, specifically dietary intake [62] but not yet for other physical health outcomes [61, 63].

Internalization of the model minority stereotype has further led to inaccurate and unrealistic expectations and pressures that are a source of significant stress, which contributes to decreased help-seeking behaviors among Asian Americans due to embarrassment or shame of not living up to the stereotype [64, 65]. Studies among Asian American college students show that endorsements of the model minority stereotype is associated with psychological distress [21, 42, 66] and lower academic performance [66, 67].

The impact of cultural assimilation among immigrants and health outcomes is conflicting. Some research suggests that the initial health advantage of recent immigrants erodes over time due to the adoption of western dietary habits and sedentary lifestyles; however, some contrasting evidence suggests health outcomes improve due to better healthcare utilization and increased English language proficiency with immigrants’ increased length of stay [68,69,70]: however, heterogeneity of the assimilation process may help explain these contradictory findings. Asian American immigrants who reported being fully bicultural or integrated have better self-reported physical and mental health than those who reported being alienated from their culture group [71,72,73]. Limited studies among South Asian Americans also show that those using acculturation strategies of assimilation and integration are associated with improved cardiometabolic profile when compared to those using a separation strategy [74, 75]. More recently, it has been suggested this health advantages also erode due to being racialized within the USA, calling for more research the role of racists laws and policies and their enforcement [76].

Conclusions

Racialized state violence has existed ever since South Asian immigrants first arrived in the USA in the 1700s, reached new levels following September 11, 2001, and continues to spike during economic and political turmoil. Xenophobic rhetoric from public officials has shaped how laws and policies, and their racially targeted enforcement, disproportionately harm Muslim and “Brown” communities, including South Asians, and engender a cascade of hate and violence institutionally, collectively, interpersonally, and internally. However, the model minority myth and the persistent lack of disaggregated data on Asian Americans perpetuate exclusion of access to funding and resources to examine the health status of Asian American subgroups, including South Asians. Evidence to date suggests that these experiences of hate and violence have significant impacts on the physical and mental health, health behaviors, and healthcare utilization of South Asians in the USA via multiple mechanisms. These include direct experiences of physical injury and stress, psychological harms and trauma, and social and economic stressors; however, more research to empirically document these linkages is urgently needed. This framework indicates the need for more research on the health implications of racialized state violence and all inter-related levels of violence. It will also be important to consider intersections with other marginalized identities such as religion, gender, sexual orientation, class, and caste. Additionally, it can inform how healthcare and public health professionals understand the experiences of South Asians in the USA to build trust with individuals and communities they serve, and to advocate for change in domains linked to health, including the criminal legal and immigration enforcement systems. Ultimately, this framework illuminates critical systemic drivers of hate violence, and the need for change at the highest levels of governance to mitigate and resist it, including through improvements to political participation and inclusion, and equitable allocation of social and economic resources, to improve the health of South Asians in the USA.