This is the fourth story in our reporting series, “Year One: COVID-19’s Death Toll.” See all the stories and interactive features here.
The day after Christmas, Glenda Monzon, her husband Rey Monzon and their son discovered they had been exposed to COVID-19.
Glenda and her son tested positive, but her husband tested negative. Her son quarantined in his apartment in Ventura County, and Glenda quarantined downstairs in her house, trying to stay away from her husband and sanitize everything she touched. They told their daughter, who had been staying with them, but had been away for the holidays, to stay away.
But it became clear that something was wrong with Rey. He started developing backpains. Rey was tested again and again – each time his test came back negative.
After a few days, he went to the doctor. They tested him three times before one showed him positive for COVID.
On Jan. 7, Glenda’s son texted her in the morning to tell her he couldn’t breathe and drove himself to the emergency room. Thirty minutes later, Rey went upstairs and said he couldn’t breathe. She took him to the hospital.
Because Glenda was also positive, she couldn’t stay. For several days, she received updates from doctors about both her son and husband, who seemed to be going through the same treatment. Her son started to get better and would soon be released – though with oxygen – but Rey kept getting worse.
His kidneys were starting to fail, so doctors put him on dialysis and upped his medication. On Jan. 21, he was placed on a ventilator.
“They didn’t think he was going to make it,” Glenda said. Her sister picked up Glenda’s son, who was still on oxygen and couldn’t drive, to bring him home.
At 2:30 a.m. on Jan. 23, she got a call that they should go see Rey. Only two people would be allowed inside the hospital to see him – and it would still be through glass. She and her son had a half hour, while their daughter and other family members waited in the parking lot. They said goodbye over FaceTime.
He passed away soon after at Scripps Green Hospital.
“It can hit you and you don’t even know it,” Glenda said.
Rey was 63, but healthy. He had high blood pressure, but ran two miles every morning. He had been an advocate and leader in the Filipino community his whole life.
When he was a student at San Diego State University, he wrote his thesis and dissertation on Filipino college students and family relations. Monzon turned that into a career, working at San Diego State in research and data, but also helping to guide Filipino students as they made their way through school.
Filipinos were among the hardest-hit communities by COVID-19 in San Diego County — but that cost was largely hidden because the county reported cases and deaths among Filipinos within a broad category of Asian Americans, rather than breaking them out specifically. A Voice of San Diego analysis of death certificates of everyone who died from COVID-19 in the first year of the pandemic in San Diego County, though, shows the disparate impact the virus had on the region’s Filipino community.
Filipinos accounted for about 7 percent of the 4,000 COVID-19 deaths during the pandemic’s first year, while they make up roughly 6.5 percent of the county population. That made Filipinos the third largest nationality for pandemic deaths in the county during that time.
But that disparity still understates the toll the virus took on the Filipino community. Dr. Maria Rosario Araneta, a professor of family medicine and public health at UC San Diego School of Medicine, argued that looking at deaths per 100,000 people better reflects the effects the virus had on smaller populations, like Filipinos.
In that analysis, Filipinos had the second highest mortality rate in the county during the pandemic’s first year. The Filipino mortality rate was 120 deaths per 100,000 people. That’s lower than the Latino mortality rate of 170 per 100,000, but far higher than the White mortality rate of roughly 38 per 100,000. Looking at the death rate per 100,000, Araneta said, is a common way of looking at populations of different sizes to determine who is most at risk.
Filipinos faced a unique set of risks. Many Filipinos work in the health care sector or in other essential, high-risk employment, like in assisted living facilities. They also tend to live in multigenerational households, and suffer from certain health conditions that increase morbidity with COVID, like diabetes and hypertension. The majority of Filipinos who died, 92 percent, were immigrants, while only 8 percent were U.S.-born.
But because Filipino deaths and cases weren’t specifically tracked by the county – grouped instead with other Asian nationalities, which had lower numbers of cases and deaths – community advocates and researchers said that the community didn’t get the support and resources it needed.
A Unique Set of Risks
Filipinos make up nearly a fifth of registered nurses in California, according to a 2018 Board of Registered Nursing survey. Soon after the Philippines became a U.S. colony in 1898, the United States implemented American nursing programs there. In the 1960s, a change in U.S. immigration laws and a shortage of nurses resulted in many Filipino nurses coming to the United States to work.
Their prevalence in health care jobs – and the risk it put them at to contract COVID-19 – is clear.
According to the death certificates analyzed by VOSD in which occupation was reported, 14.6 percent of Filipinos who died were health care workers, while health care workers represented just 6.2 percent of non-Filipino pandemic deaths.
It’s even more stark among the working-age population. Among those 65 years old and younger, 20 percent of Filipinos who died were health care workers compared to 6 percent among non-Filipino deaths. Almost one-fourth of Filipino COVID deaths were people under 65.
This reflected a nationwide trend. A September 2020 report from National Nurses United, the country’s largest nursing union, found that even though Filipino nurses make up only 4 percent of the nursing population nationwide, nearly a third of nurses who have died from the coronavirus in the country are Filipino.
It is not clear why Filipino nurses and healthcare workers seemed to have been more impacted than healthcare workers of other ethnicities.
And while education level was a determinant for who lived and died from COVID throughout the county, Filipinos were an outlier, likely because of their prevalence in the health care industry. A college education didn’t offer protection from COVID deaths for many Filipinos. Although only 17 percent of people who died from COVID between March 2020 and March 2021 had a bachelor’s degree, among Filipinos who died from COVID in that time period, 34.5 percent had a bachelor’s degree.
In December, Gemma Rama-Banaag remembers coming home from work as Chief Nursing Officer at Paradise Valley Hospital with a terrible headache. She napped while her husband, Dr. Chester Banaag, made dinner. That happened several nights in a row before her youngest son called to say he and his girlfriend, who both work in hospitals, were showing symptoms of COVID-19. The family had been spending time together. All four tested positive.
“My first concern was my husband because he was the highest risk,” Rama-Banaag said.
Banaag retired from his dentistry practice in 2016, when he was 53 years old. He spent his years in retirement involved in community activities – from becoming the West Coast ambassador by the USA Pickleball Association and founding the first pickleball park in Chula Vista to participating in medical-dental missions to Tijuana to being an active youth mentor in his church community.
A few days later, they went to the hospital because Banaag was looking weak. His oxygen saturation was low, and he was placed in the ICU. A few days later Rama-Banaag took a turn for the worse, and was also admitted to the hospital for two nights.
By the time Rama-Banaag got home, the kids had recovered. Banaag also seemed to be doing better. But then suddenly, he had to be intubated a few days later.
Everything had been improving, except Banaag’s lungs, Rama-Banaag said. They knew his last chance would be an extracorporeal membrane oxygenation, and called around the state for an ECMO machine, which were in high demand during the 2020 holidays, when COVID cases surged statewide.
A childhood friend of Rama-Banaag’s was an ECMO nurse at St. John’s Well Child and Family Center in Los Angeles. The family flew him there, but the treatment didn’t work.
“By that time, we knew he wasn’t going to make it,” Rama-Banaag said. She was still weak from COVID, but stayed at a hotel close by, so she and her family could be with him.
On Jan. 1, 2021, Banaag died from COVID-19.
A report from the UC Davis Bulosan Center for Filipinx Studies found Filipinos were an at-risk group during the pandemic not only because of their exposure as health care workers, but also economic insecurity, pre-existing health conditions, a lack of health insurance and the fact that there are tens of thousands of undocumented Filipinos in California.
Rama-Banaag said Filipinos also have high rates of several health conditions that made it more likely to die from COVID. Her husband had hypertension, though it was well managed.
For example, one 2017 study found that Filipino Americans over 50 are at higher risk for diabetes – even if they’re not obese – when compared to their White counterparts. Another 2014 study found that hypertension among Filipino immigrants in the U.S. was disproportionately high when compared to other Asian groups and to Whites.
The Data Problem
Rey Monzon was someone who was constantly trying to bring data and research about the experiences of Filipinos to the forefront, said JoAnn Fields, a Filipino community advocate.
“Our community took a great loss when he passed,” Fields said. “Who was working under him? Who had his research? COVID-19 showed again how people tried to erase us.”
While the pandemic’s toll on other groups, like Latinos, has been widely reported, its impact on Filipinos wasn’t, because of the way deaths and cases were reported by public officials.
This mostly stemmed from the way data was collected and analyzed federally and at the state and county level.
Filipino advocates, medical professionals and political leaders have long been calling for data that breaks down the Asian racial and ethnic category into subgroups based on different nationalities.
“We were screaming, ‘disaggregate the data, disaggregate the data,’ after the first couple of months of the pandemic,”’ said Dr. GilAnthony Ungab, the CEO of the Southern California Center for Inclusion and Diversity. “Why didn’t they do it?”
San Diego Mayor Todd Gloria, then in the state Assembly, sent a letter to Gov. Gavin Newsom in August 2020, requesting that the California Department of Public Health report ethnicity by Asian subgroups “instead of using ‘Asian American’ as an overarching label.”
In a statement, county spokeswoman Sarah Sweeney said the county didn’t disaggregate the data because it uses categories set by the California Department of Public Health and the Centers for Disease Control and Prevention.
“These entities use this data to make funding and other prioritization decisions,” Sweeney wrote. “Additionally, the hospital systems statewide do not include these categories in the information reported to us. In essence the varied entities tracking and gathering this information all need to use the same standards and categories.”
A handful of other jurisdictions, though, chose to disaggregate their data, revealing disparities.
Santa Clara County disaggregated its Asian coronavirus cases into subgroups and found Filipinos and Vietnamese people were being disproportionately impacted by the virus. Though Filipino Americans make up 13 percent of the Asian American population in the county, they accounted for 21 percent of coronavirus cases between June 1 and Dec. 3 last year.
Hawaii has been disaggregating its data and found early on that the state’s Filipino community had the second worst disparity in the state, making up 16 percent of the population, but more than a fifth of confirmed coronavirus cases.
Voice of San Diego’s death certificate analysis showed Filipinos made up more than 60 percent of all Asian deaths in the first year of the pandemic.
But there have been other ways COVID data has been presented that has hidden the risk for some populations, said Araneta, the UC San Diego School of Medicine professor of family medicine and public health.
For example, COVID-19 case-fatality rates – the proportion of people with COVID-19 who die from COVID-19 – show Asians have been more likely to die from COVID once infected since the beginning of the pandemic.
In July 2020, the case-fatality rate among all San Diego COVID cases was 2 percent – meaning 2 percent of all San Diego COVID cases died. Among San Diego Asian COVID cases, though, that number rose to 5 percent. As of Nov. 24, 1.1 percent of all San Diego COVID cases died, but 2.1 percent of Asian San Diego COVID cases died.
“When we realized the case-fatality rate for Asians was so high, we were concerned that maybe they weren’t going to get tested because of the anti-Asian violence,” Araneta said.
But clear data on specific communities is vital, Araneta, Ungab and Fields all said, because it determined which populations got funding for outreach, education, research and other resources. As a result, organizations that specifically wanted to contact or research the Filipino community had less opportunity for county, state or other funding.
“Unless you could demonstrate, especially in grant applications, that your community was at risk, then the perception was that your community wasn’t in need,” Araneta said. “It made it hard to do basic interventions such as public health message.”
Funding could have been used to do more outreach, so Filipino health care workers living in multigenerational households could have safely isolated from the rest of their family, she said. There could have been efforts to look into whether there were reasons why Filipinos may not have been utilizing resources like the county hotel rooms that were offered.
“There’s been an urgency with COVID, but the importance and calls for disaggregation preceded the pandemic,” Araneta said. “California has the largest Asian American population in the country. It’s important and necessary to understand the differences in the prevalence of certain conditions and the treatment.”
Fields and Ungab started the San Diego Filipino COVID-19 Task Force shortly after the pandemic began in an effort to do outreach and education specific to the needs and risks of the community. But they said the effort has been completely unfunded.
“We do Zoom conferences,” Ungab said. “JoAnn has been begging people to let us use their Zoom.”
Sweeney said the county did give funds to groups that included the Filipino community in their outreach, the Union of Pan Asian Communities for outreach and education and Communities Fight COVID for contact tracing. UPAC received a $469,200 contract for Sept. 2020 to Dec. 2021 of millions that the county doled out during the pandemic for COVID-19-related health disparities and equity issues.
Fields said that wasn’t sufficient. UPAC is only one organization and serves all Asian communities. She thinks governments haven’t been concerned with helping the Filipino community.
“I know what’s possible if there is political will, but now it seems like no one is willing to move for us,” she said.
Correction: A previous version of this story said San Diego County does not report mortality rates in its demographic COVID death data. It does, but does not specifically isolate Filipinos in its demographic breakdowns.
This reporting project is made possible with support from the Fund for Investigative Journalism.