Alicia Fernandez

Eliseo Perez-Stable

HB Shin

IG Ellen

Somnath Saha

English

PubMed

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Reducing Language Barriers and Racial/Ethnic Disparities
in Health Care: An Investment in Our Future
Somnath Saha, MD, MPH1,2, Alicia Fernandez, MD3, and Eliseo Perez-Stable, MD3
1Section of General Internal Medicine, Portland VA Medical Center (P3MED), Portland, OR, USA; 2Division of General Internal Medicine &
Geriatrics, Oregon Health & Science University, Portland, OR, USA; 3Department of Medicine, University of California San Francisco, San
Francisco, CA, USA.
KEY WORDS: language; ethnic groups; delivery of health care.
J Gen Intern Med 22(Suppl 2):371–2
DOI: 10.1007/s11606-007-0372-4
© Society of General Internal Medicine 2007
I n 2003, the Institute of Medicine issued a groundbreakingreport that shone a spotlight on the problem of racial and
ethnic disparities in health care in the United States.1 It is now
well recognized that minority Americans tend to receive less
care, and lower-quality care, than the majority (white) popula-
tion. The reasons behind this phenomenon are complex and
opaque. There is no single explanation, and in many cases, we
do not have an explanation. However, for millions of minority
Americans, most of them foreign-born, one explanation is
readily apparent: they do not speak, read, or write English,
and health care in this country, with few exceptions, is
delivered in English.
Two articles in this JGIM Supplement attest to the role of
language barriers in explaining racial/ethnic disparities in
health care. Cheng and colleagues examined the use of
basic, evidence-based health care services for prevention and
chronic disease management among Latinos and whites
in the United States.2 They found that whites were more
likely than Latinos as a whole to receive all recommended
services for which they were eligible. However, when grouped
by language use, Latinos who spoke English at home were
not significantly less likely than whites to receive recom-
mended services, whereas those who spoke Spanish at home
were, even after accounting for education, insurance cover-
age, usual source of care, and a host of other potential
explanatory factors. Thus, the bulk of the racial/ethnic
disparity between whites and Latinos, in this case, is
actually a “language” disparity, between English-speakers
and Spanish-speakers.
The study by Sentell et al. produced similar findings.3 They
examined access to mental health care in California, the state
with the highest proportion of limited English-proficient (LEP)
persons in the country.4 They found that among individuals
stating a need for mental health services, Latinos were less
likely than whites to have received them. However, English-
speaking Latinos were similar to whites in their access to
mental health care, whereas non-English-speaking Latinos
had a markedly lower likelihood of receiving services (even
when they had mental health insurance coverage). Again, the
disparity here is not so much a racial/ethnic one per se, as one
related to English proficiency.
The findings of these studies indicate not only that language
plays a large role in explaining racial/ethnic disparities, but
that comparing groups by race/ethnicity alone may substan-
tially underestimate the degree of inequity between the haves
and the have-nots. For instance, in the study by Sentell et al.,
Latinos as a whole were about one-third less likely to receive
needed mental health services when compared to the overall
California population (28% vs 45%). But Latinos who spoke no
English were 85% less likely to receive services compared to
the general, English-speaking population (8% vs 51%).3
In the same vein, examining groups by English proficiency
can reveal “hidden” disparities. Sentell and colleagues found
that Asians (whom we often do not think of as a disadvantaged
group) did not have significantly lower access to mental health
care than whites, after accounting for other factors. However,
splitting the Asian population, into those who spoke English
and those who did not, revealed stark disparities. Non-
English-speaking Asians were substantially less likely than
the general, English-speaking population to receive needed
services (11% vs 51%).3 Clearly, focusing on Latinos and
Asians as racial/ethnic groups, without attention to sub-
groups defined by English proficiency, carries the potential of
overlooking large inequities in health care.
It must be acknowledged that the inequities experienced by
LEP Americans may not be caused solely by language barriers.
In the study by Cheng et al., Latinos who spoke Spanish at
home were less likely than whites to receive recommended
care. However, this disparity was evident when comparing
whites to both LEP Latinos and to those who spoke Spanish at
home but were also comfortable conversing in English2; i.e.,
Spanish-speaking patients received fewer services, even when
they could speak to their doctors in English. This finding
suggests that factors other than language itself may play a role
in the disparities observed across language groups. It is likely
that language use in this instance serves as a partial proxy for
acculturation, the degree to which people from other countries
and cultures have adopted the norms of the majority popula-
tion. Those who have not assimilated as fully to the dominant
American culture may, for numerous reasons, experience
lower levels of access, utilization, and quality of care.
Whatever the underlying reasons, non-English-speaking
Americans are clearly a disadvantaged population when it
comes to health care. Whereas numerous studies have shown
that English-speaking racial and ethnic minority populations—
particularly African Americans—suffer inequities,1 LEP minor-
ities are among the groups we treat most unfairly. This has
direct relevance to health policy. If we want to remedy racial
and ethnic disparities in health care, attending to language
371
barriers is basically “low-hanging fruit.” It targets a well-
documented source of disparities and a population experiencing
dramatic inequities.
To play devil’s advocate for a moment, we might ask why we
should even care about disadvantages experienced by LEP
populations (a question we believe exists in the minds of many
people in this country, even if they do not voice it explicitly). The
vast majority of Americans believe that English should be the
official language of the United States.5 Racial and ethnic groups
cannot change their status as minorities, but LEP Americans,
by becoming English-proficient, can. So should the health care
system change to accommodate LEP patients, or should LEP
learn English to use the patients system health care effectively?
Such English-only rhetoric can be, superficially, quite
convincing. But scratch the surface, and the arguments begin
to fall apart. The non-English-speaking population of the
United States has grown substantially over time.4 Although
we seem loathe to admit it, we depend heavily on immigrant
labor.6 And, whereas we expect immigrants to learn English,
we do not have a coordinated system for making that happen.
Likewise, whereas we say that we want them to integrate into
our society, and assimilate into the mainstream U.S. culture,
we also tend not to want them moving into our communities.7
As our former Surgeon General, Richard Carmona, attests in
his foreword to this Supplement, we push LEP immigrants to
the fringes of our society.8 The net effect is that many
immigrant groups form communities of their own, in which
they are able to go about their daily lives in their native
languages...until they get sick.
There are many reasons—ethical, legal, and practical—that
it is incumbent on us to better serve the health needs of LEP
populations. We are a nation founded on the tenets of equality,
justice, and unity. It goes against our founding principles to
tolerate the inequities that the studies in this Supplement, and
many others, reveal. Moreover, it goes against our laws. As
Chen et al.9 have reiterated, not attending to language barriers
amounts to discrimination on the basis of nationality, a
violation of our cherished Civil Rights Act. Finally, it is in our
best interest to adequately care for LEP populations and other
minority groups, to protect the diversity that is one of our
greatest economic and cultural assets. This country was built
by immigrants (voluntary and forced); its foundation is made of
a concrete formed by the mixing of diverse values and cultures.
In today’s global economy, our multicultural and multilingual
environment is more important than ever, providing an
advantage shared by few other nations. It would be foolish
not to nurture this advantage by providing good health care
across cultures and languages.
Achieving this goal, however, is easier said than done. The
studies in this Supplement provide hopeful advances, but we
still have much to learn about how to best address language
barriers. As Partida10 points out, we will need coordinated,
systemic efforts to conduct the research and develop the
solutions needed to transform our English-language health
care system into one that is fully accessible to LEP Americans.
The foreign-born population of the United States is expected to
grow for decades to come,11 and accordingly, our population
will remain multilingual for the foreseeable future. Transform-
ing our health care system to deliver care effectively across
language barriers is an essential investment in that future.
Acknowledgments: Dr. Saha is supported by an Advanced
Research Career Development award from the Department of
Veterans Affairs, Health Services Research & Development Service,
and by a Generalist Physician Faculty Scholars award from the
Robert Wood Johnson Foundation. The opinions expressed in this
editorial are those of the authors and not necessarily those of the
Department of Veterans Affairs or the Robert Wood Johnson
Foundation.
Corresponding Author: Somnath Saha, MD, MPH; Section of
General Internal Medicine, Portland VA Medical Center (P3MED),
3710 SW U.S. Veterans Hospital Rd., Portland, OR 97239, USA (e-
mail: sahas@ohsu.edu).
REFERENCES
1. Smedley BD, Stith AY, Nelson AR, eds. Unequal Treatment: Confront-
ing Racial and Ethnic Disparities in Health Care. Washington, DC:
National Academies Press, 2003.
2. Cheng EM, Chen A, Cunningham W. Primary language and receipt of
recommended health care among Hispanics in the United States. J Gen
Intern Med. 2007 (in press) DOI 10.1007/s11606-007-0346-6.
3. Sentell T, Shumway M, Snowden L. Access to mental health treatment
by English language proficiency and race/ethnicity. J Gen Intern Med.
2007 (in press) DOI 10.1007/s11606-007-0345-7.
4. Shin HB, Bruno R. Language Use and English Speaking Ability: 2000.
Census 2000 Brief. Washington, DC: U.S. Census Bureau; October
2003.
5. Rasmussen Reports. 85% support English as official language of U.S.
Available at: http://www.rasmussenreports.com/public_content/politics/
85_support_english_as_official_language_of_u_s. Accessed September 3,
2007.
6. Sum A, Harrington P, Khatiwada I. New foreign immigrants and the
labor market in the U.S.: the unprecedented effects of new foreign
immigration on the growth of the nation’s labor force and its employed
population, 2000 to 2004. Boston, MA: Center for Labor Market Studies,
Northeastern University; January 2005. Available at: http://www.aypf.
org/publications/U.S.Immigrationpaperjanuary2005.pdf. Accessed
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7. Ellen IG. Sharing America’s Neighborhoods: The Prospects for Stable
Racial Integration. Cambridge, MA: Harvard University Press, 2000.
8. Carmona RH. Improving language access: a personal and national
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0376-0.
9. Chen AH, Youdelman MK, Brooks J. Legal framework for language
access: Title VI and beyond. J Gen Intern Med. 2007 (in press) DOI
10.1007/s11606-007-0366-2.
10. Partida Y. Addressing language barriers: building response capacity for
a changing nation. J Gen Intern Med. 2007 (in press) DOI 10.1007/
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11. U.S. Census Bureau. National Population Projections. I. Summary files:
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Accessed September 3, 2007.
372 Saha et al.: Language and Healthcare Disparities JGIM


Reducing Language Barriers and Racial/Ethnic Disparities in Health Care: An Investment in Our Future

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Reducing Language Barriers and Racial/Ethnic Disparities in Health Care: An Investment in Our Future

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