Blog Health Care Health Equity

Linguistic diversity and disparate health outcomes

Written by John Baugh, PhD, MA, Margaret Bush Wilson Professor in Arts & Sciences; Zishan Hirani, MD, MS, professor in the Department of Obstetrics and Gynecology at the University of Texas Rio Grande Valley School of Medicine ; and Will Ross, MD, MPH, professor in the Department of Medicine at Washington University School of Medicine

Effective communication between patients and health care providers may depend upon (dis)similarities in their linguistic and cultural backgrounds. Conversation is central to nearly every human endeavor, yet few people have a full appreciation of the complex intricacies associated with linguistic behavior, or potential sources of miscommunication when people from different linguistic backgrounds speak with one another. Some of the most basic and central tenets of linguistic science are taken for granted by nearly every normal speaker because their use of language in day-to-day life is ubiquitous.

For example, every normal child learns their first language without the aid of formal instruction, and they have no memory of the enormity of this magnificent accomplishment. This is a universal fact pertaining to all normally developing children anywhere on earth, regardless of the society into which they are born. The United States is particularly interesting from the standpoint of its linguistic evolution, and the emergence of English as the dominant national language. Moreover, the linguistic composition of the United States is constantly undergoing change due to a wide range of national and international influences.

Before turning to the specific relationship between linguistic diversity and its relevance to differential health outcomes for patients with dissimilar language backgrounds, it is important to appreciate some of the unique historical circumstances that have influenced the growth and evolution of linguistic diversity in America. Long before Europeans ever set foot on the land that now occupies the continental United States, hundreds of mutually unintelligible indigenous languages flourished from coast to coast.

Does the linguistic background of any given patient have anything to do with the level of access, quality of care, and/or effectiveness of the medical treatment they receive?

Centuries of linguistic isolation among Native Americans who lived in different regions resulted in the emergence of diverse languages. After exploration and subsequent colonial claims on the land by various European rulers, ensuing settlers did more than bring their languages with them as new arrivals, they also had superior weaponry that allowed them to expand upon their occupation while diminishing the populations and languages that had existed prior to their arrival.

Unlike Europe, which was settled at a time when feudal lords traced their linguistic ancestry back to Latin in many instances, America’s linguistic legacy is comparatively young, and has been strongly influenced by the coincidence of rapid advances in technology that have directly influenced our collective national linguistic development.

In its youth the American nation witnessed an uncontrolled linguistic experiment where people from Europe migrated to these lands of their own volition, while Africans were sold into slavery against their free will. Native Americans were constantly being displaced, and native speakers of Irish, Scots, Welch, French, Spanish, German, Polish, and Italian, and many other languages, came to the fledgling United States, often without papers (i.e. W.O.P.), creating a linguistic stew that existed nowhere else on earth. The emergence of English as the dominant language was cast from the outset due to British rule over the original colonies, as well as the eventual need to declare the independence of our new nation in a language that would be readily comprehended by the King of England.

The practice of medicine throughout this period, as throughout human history, was evolving; periodic advances in technology created new medical tools, and medical procedures were gradually being refined. However, those procedures were fairly primitive, particularly when compared to modern medical practices. However, physicians – then, as now – often found themselves serving patients with whom they did not always share a common language, or dialect. Medical professionals know well that many of their patients who do not have any medical training cannot be expected to know or understand technical medical jargon, and one of the hallmarks of the field of medicine as a whole has been the recognition and desire to enhance and improve communication between patients and medical practitioners whenever possible.

Our shared interest in this topic grows from a combination of facts and observations that led us to raise the following question; does the linguistic background of any given patient have anything to do with the level of access, quality of care, and/or effectiveness of the medical treatment they receive? In an effort to broach this admittedly complex question we began to ponder potential comparison between some of the procedures that had been developed in studies of housing discrimination, where it was shown that speakers of nonstandard English were routinely discouraged or dismissed by prospective landlords who devalued their speech. Some unscrupulous employers were also found to be guilty of linguistic profiling, by discouraging women and minorities from pursuing certain occupations in favor of men who were native speakers of mainstream Standard American English. We wondered if it might be possible that some medical professionals could also, perhaps inadvertently, demonstrate forms of linguistic bias that would impact medical treatment or patient outcomes. In the healthcare setting, racial discrimination does not require personal contact between physician/medical staff and patients. People are often able to discriminate before there is a face-to-face interaction between African-American patients and medical professionals whenever telephone conversations precede personal interactions.

The initial experiments that we conducted were formulated with the knowledge that some groups, including many members of minority groups, suffer from health disparities. African Americans, specifically, have worse outcomes in a wide range of fields including cancer screening and management; cardiovascular disease; HIV infection; child and adult immunization. It is important to note that health outcomes alone are not sufficient to understand the severity of health disparities; we need to understand the importance of access to care. African Americans are not simply struggling with health outcomes but in accessing healthcare in general. As a result, people who receive poor access to care have increased rates of hospitalizations for preventable and chronic diseases.

Thus far our work on this topic has been preliminary, and also quite promising when compared to discriminatory outcomes in housing or employment. For example, we have noticed that those seeking medical appointments for potentially life threatening ailments tend to be treated equally by medical professionals regardless of their language background. However, there are some circumstances, often existing in lower income communities, where the volume of requests for medical appointments or advice is overwhelming, and might result in delayed replies, thereby slowing potentially urgent medical diagnoses and treatment of life threatening diseases.

While our research on this topic is ongoing, and the findings in hand thus far are not definitive, we are encouraged by a clear trend where the vast majority of medical practitioners do not engage in linguistic profiling; that is, they do their best to serve everyone who calls upon them for medical advice or treatment, and they do so with considerable consistency regardless of the language background of the prospective patient. We have just begun to consider some of the added burdens that may fall upon medical professionals in circumstances where language barriers are insurmountable in a timely manner. For example, there are growing numbers of Spanish speakers in the St. Louis region, and prospects for immediate translation is quite high for patients who speak Spanish. However, an elderly Hmong speaker in need of medical treatment anywhere in the United States will, in all likelihood, have considerable difficulty locating a translator who can assist them, to say little of the many cultural barriers that could impact treatment.

Of greatest significance to our findings thus far is the remarkable spirit of goodwill that exists among medical professionals who share the ethos of doing the very best they can to insure that anyone seeking their assistance or care will receive the best available treatment.

Our best assessment of the role that language barriers play regarding the perpetuation of health disparities suggests that some indirect correlations may exist, but they are not the product of willful linguistic prejudice; rather, they are the consequences of occasionally unpredictable circumstances where prospective patients and medical professionals do not share sufficiently similar linguistic experiences, nor do they have immediate or adequate access to reliable linguistic interpreters. One final caution worthy of attention takes place on some occasions where patients and medical providers speak the same language, but they do not share the same cultural background. Under these circumstances potential miscommunication may not only occur, it may go undetected.

Effective cross-cultural communication has always stressed the importance of the principles of adapting language and health materials that reflect the patient’s level of health literacy, as well as adhering to the DHHS standards of culturally and linguistically appropriate services in healthcare. However, linguistic concordance is rarely considered an essential component of effective communication between patients and medical professionals when the patient and medical professional share the same language but different dialects. This intra-English linguistic discordance can exacerbate the patient’s distrust of the medical establishment, can reinforce both explicit and unconscious bias in the medical provider, and can perpetuate health disparities. It is certainly conceivable that patient’s well-documented preference for medical professionals with racial/ethnic concordance may actually belie a greater desire for linguistic concordance. It is an area ripe for investigation.

Effective communication can never be taken for granted under any circumstances, but medical communication is especially important and is most likely to be successful when patients and medical professionals are native speakers of the same language. Prospects for miscommunication may increase when patients and medical professionals speak different dialects of the same language, and communication has the greatest potential to break down whenever different languages are used, especially in the absence of adequate interpretation.

Of greatest significance to our findings thus far is the remarkable spirit of goodwill that exists among medical professionals who share the ethos of doing the very best they can to insure that anyone seeking their assistance or care will receive the best available treatment. We have not yet encountered any medical providers who are dismissive of prospective patients based on their linguistic backgrounds, and we hope our efforts may help identify new policies or procedures that will enhance communication, and ultimately reduce health disparities, that may correspond the linguistic differences between medical professionals and their patients.