This editorial appears in the November 2024 issue of the American Journal of Bioethics
Seeing language barriers as a significant threat to the health of patients calls for a response from health-care institutions and providers at all levels. Failing to respond allows an arbitrary social circumstance to deny full opportunity for a healthy life to particular persons. That’s a paradigmatic instance of injustice and inequity.
Chipman, Meagher, and Barwise have provided a strong and compelling case for taking language barriers more seriously in public health and health care. They seek to reframe language considerations as a social determinant of health (SDOH). They issue a call to action to public health officials, researchers, and bioethicists. Their argument will be easily understood and likely accepted by their intended audience and by healthcare providers. This audience lives within a framework or world of rationality and solidarity that is in many ways foreign to the larger encompassing political world. The latter world can be characterized by its emphasis on division and the opposition to populations perceived as “other.” Overlooking the tension between these two worlds may pose considerable peril.
The world of rationality and solidarity is characterized by values such as those from the APHA Public Health Code of Ethics that should govern obligations toward people with Limited English Proficiency (LEP) and gaps in our health-care system: interdependence and solidarity, inclusivity and engagement, health justice and equity that Chipman and colleagues highlight. These public health values have substantial overlap with the kinds of values that characterize our nonprofit health-care organizations as welcoming/caring institutions that aim at efficient treatment of illness and promote the health of the community. Such values undergird the premise that patients and their communities are both better off if the members of the community understand how to prevent illness and are willing to present for care in a timely manner when sick. Solidarity is merely recognition that our health is related to the health of our neighbors, and the health system that we all depend upon will serve everyone better if access is readily available and effectively utilized. These ideals tend to be better recognized during a public health emergency such as the COVID-19 pandemic when the interrelated state of everyone’s health is more apparent.
In the world of rationality and solidarity public health and health-care institutions are seen as a sphere that has a defined and respected mission, i.e., the health of patients and communities. The mission is important enough that it should not be unnecessarily compromised by extraneous ends. This has sometimes been recognized in public policy regarding immigration enforcement. For instance, during the Obama administration, the Department of Homeland Security designated hospitals and healthcare facilities as “sensitive locations” that should be zones free of routine immigration enforcement actions. This is directly relevant to Chipman and colleagues’ work because they note that being an immigrant is largely, albeit not entirely, co-extensive with limited English proficiency.
Of course, the problem is that this rational world that Chipman and colleagues presuppose, the world of healing, is embedded in the larger world in which actions and attitudes toward immigrants are driven by ideological and political agendas and racial animus. The volatility of this world, the world of division, is especially well-known to health-care professionals who serve immigrant communities. During the Trump administration (2016-20), the political rhetoric and various policies caused a “chilling effect” on many immigrant patients’ willingness to seek care. Many health-care facilities implemented policies to foster the protection of immigrant patients within their facilities. While the Biden administration significantly ameliorated these concerns by reiterating that hospitals are “protected areas,” invasive and disturbing actions involving health-care facilities have continued at the state level. For instance, the states of Florida and Texas compel hospitals to ask the immigration status of patients at admission. This kind of mandate discourages utilization and undermines the values and identity of our healing institutions and professions.
How Shall the World of Healing Respond to Incursions?
Chipman and colleagues understand that using the terminology of social determinants of health for a language preference other than English could be stigmatizing. That is, it makes limited English proficiency a health vulnerability of particular patient populations. While we want to avoid these stigmatizing implications, the authors rightly point out the simple truth that having limited English proficiency in a health system and nation that predominantly uses English results in inequities. This conclusion is viewed differently in the different worlds.
In the world of healing, the implication of any inequity is that resources should be deployed to ameliorate it. Strategies to provide adequate language services in the clinical setting and to provide health information and education in the community should be deployed, tested, and refined. This is an area of research whose findings should drive resource allocation. Conversely, in the world of division, these needs are costs that burden the health system and the citizenry and are exactly the kind of resource utilization that laws like those in Florida and Texas seek to quantify as a prelude to elimination.
The collision of these two worlds is usually an unhappy one for the world of healing. The mission of promoting efficient care that fosters the health of the public is easily undermined by measures that scare away sick persons. And resistance is difficult because financial reimbursement such as Medicaid is tied to compliance.
How does this collision end? It feels naïve to simply continue to enumerate the needs of stigmatized populations such as immigrants and other non-English speakers. We risk contributing to the negative stereotype of a group of people who are a burden on the system and our nation rather than the contributors and essential workers they typically are. As addressing their health needs does require illuminating the social conditions that are barriers to health, our response cannot be simply to table research and discussion of the role of language and language services. So, the only other option would seem to be to push back on the world of division. Two options come to mind.
First, healthcare organizations can band together to develop legislative proposals that safeguard health-care institutions from the incursions of the world of division. Their status as sensitive locations and protected areas should not be left to the guidance of changing presidential administrations. One such effort was the “Protecting Sensitive Locations Act” that was introduced in the past. However, such a bill should also include provisions to prevent states from compelling hospitals and clinics to gather sensitive, non-essential health information directly from patients. Given the difficulties of passing legislation regarding these populations, this will be an uphill battle. But it is worth undertaking the effort as an ongoing agenda item of the advocacy arms of professional societies and health systems in order to preserve the integrity of the world of healing.
Second, we—the healing professions and bioethicists—must become more actively engaged in recasting the understanding of health as a shared and interrelated good. For far too long, we have accepted the discussion of health care as an individual benefit. We have sometimes fed into this framework by arguing that health care is a human right which accepts the framework that it is primarily about the individual. We must begin to educate and insist upon the idea that our health statuses are interconnected because disease is related to our environments, circumstances, and communities, i.e., socially determined, and excluding anyone from access to the health care system undermines the efficient, mission-driven functions of that system. This is, of course, an enormously heavy lift and will need to take place over a long period of time. However, it is our failure to undertake this effort that has landed us in the present situation of watching the values and identity of healing institutions and professions being eroded. Reversing this tide requires a sustained, ongoing effort. We must make a beginning.