by Vincent LaBarca, DNP, NP-C
Back in 2017, before Americans were considered a biohazard due to the country’s poor handling of COVID-19, I was bumming around Central Europe. Tracing the Danube, I was in Budapest, chowing down on bowls of goulash in between gulps of crisp pilsner.
The night before taking a train to Slovenia, my stomach started feeling some kind of way.
I evaluated my symptoms as I would any patient’s. Probably just indigestion or constipation from the goulash, I thought. But as the night grew longer, my list of differentials grew shorter.
Rather than boarding the train the next morning, I crawled into a cab with a fistful of Hungarian forints. The day unfurled like some sort of Kafkaesque fugue, and I found myself in a military hospital along the outskirts of Budapest. I shared a room with two Hungarian men whose names I never learned because they spoke not a lick of English. Next to my bed was a door to an outdoor patio where nurses, polite enough to make sure the door was closed, took smoke breaks. In my abdomen was a tube that, according to the surgeon, was needed to collect the “pus and poop” from my ruptured appendix.
As beautiful and profound as his description of my insides was, it exhausted his English vocabulary.
I spent five nights in the hospital. I was peeved, and not just because I had to miss the final leg of my trip. As a non-native Hungarian speaker, I felt unheard and isolated, and I lacked an understanding of Hungarian cultural norms about health and illness. And—worst of all—because no interpreter was offered and no staff member spoke fluent English, I had no way to communicate. I became the object of what French philosopher Michel Foucault dubbed “the clinical gaze.”
It’s through this gaze that clinicians deconstruct patient identity. Patients enter a hospital as individuals with a diversity of interests, stories, and experiences. The gaze reduces them to a room number, replacing their identity with a diagnosis. They are then at the mercy of the facility. We structure their time, plan their meals, and restrict their movement. We compel them to relinquish control, and in return, we agree to heal them to the best of our ability.
Being subjected to Foucault’s gaze is a frightening, surreal experience, and the ordeal left me wondering: is that what my non-English speaking patients feel like?
There are roughly 25 million people in the US with limited English proficiency (LEP); that is, they speak English less than “very well.” LEP is independently associated with worse health outcomes, and patients with LEP face specific health disparities because of their limited familiarity with English. These disparities are difficult to justify, given that language has no inherent value and one’s ability to speak a certain language is morally irrelevant.
Poor outcomes in patients with LEP are well-documented: they defer care more often; are at higher risk of leaving the hospital against medical advice; are less likely to have a primary care provider; receive fewer preventative services; and, within the context of inpatient appendicitis treatment, are often discharged without definitive management and have a longer length of stay.
The Civil Rights Act of 1964 mandates that hospitals and providers receiving federal funds offer “meaningful access” to interpreter services. This mandate is weakly enforced, partly owing to a shortage of medical interpreters. In 2015, California, for example, had less than 800 certified medical interpreters to assist the state’s 1.7 million people with LEP.
Even when an interpreter is available, physicians and other health care workers often look to family members or untrained staff to interpret. My paltry high school Spanish may be good enough in an emergency with a Spanish-speaking patient, but explaining a complex diagnosis, discussing treatment options, and planning follow-up require considerably more training and expertise. If a patient speaks Mandarin, American Sign Language, or Mixtec, I’m basically useless.
Of the many injustices exposed by COVID–19, language inequity has received comparatively little scrutiny, both by news outlets and researchers (barring a few exceptions). The lack of coverage is surprising given the pandemic’s disproportionate toll on non-English speaking patients, particularly those from Latinx communities. The oversight is even more egregious because, in some hospitals, nearly half of patients with LEP do not interact with an interpreter.
There are, of course, structural and institutional barriers to redressing how we treat patients with LEP. Medical interpreters are underpaid and overworked, and they report feeling “disposable” in the eyes of their clinical colleagues. Tuition assistance and reimbursement, increased diversity of languages offered by interpreter services, unionization, and robust enforcement of Title VI are a good start.
And while hospital administrators, insurers, lawmakers, and outside groups are undoubtedly needed to achieve system-level change, the decision to request interpreter services is ultimately left to individual providers.
Providers weigh the perceived value of communicating with non-English speaking patients against the inconveniences of working in the modern hospital. The decision to forgo an interpreter is often justified by citing time constraints and concerns about delaying patient care. While valid, these justifications do not outweigh our moral and legal obligations to patients with LEP. We would not tolerate the abandonment of informed consent for English-speaking patients, but that is exactly what happens to non-English speaking patients when we fail to meet their language needs.
What, then, to make of providers who choose to rely on their own dubious language credentials when treating non-English speaking patients despite knowing the consequences?
I suspect this cognitive dissonance is a byproduct of ethnocentrism and linguistic prejudice mixed with bureaucratic red tape. But I also find it indicative of medicine’s reluctance to grapple with Foucault’s gaze.
Clinicians are taught and incentivized to decontextualize patients by viewing them within a biomedical framework. Our narrow conception of health and disease leaves little room for the less tangible aspects of patient care. Whatever doesn’t help us achieve our primary directive—keeping patients alive or at least from getting worse—is immaterial.
The threat to one’s sense of self is acute in the presence of illness. This threat is heightened when patients become what philosopher Kay Toombs calls the “body-as-object,” reminiscent of the medical gaze. When directed at patients with LEP, the gaze turns into x-ray vision. Without the capability to express their fears, worries, and preferences, these patients rightly feel disrespected, afraid, and frustrated.
As clinicians, we must not limit ourselves to institutional responses to a phenomenological problem. In its simplest form, medicine is an interpersonal relationship between the patient and the provider, and we cannot be a full, committed partner if we disregard the patient’s experience.
If we are serious about equity and justice in a post-COVID world, we must take steps to preserve our patients’ sense of identity. Doing so requires concrete reform, such as expanding interpreter services. It also depends on a personal commitment on behalf of providers, a commitment to those marginalized by political and economic forces. This dedication requires more than treating an individual no matter their background; it presupposes solidarity and identification with the other.
It’s no easy task, but like a bowl of authentic Hungarian goulash, it’s well worth the effort.