Language, Culture, and Health Disparities
Language and cultural health beliefs can negatively affect patients’ access and experience of health care and the likelihood that they will follow advice given by clinicians. This is most obvious when patients are recent immigrants, but more subtle effects can persist for generations among groups that retain their cultural identity and whose perceptions are influenced by the frequent experience of negative stereotyping and discrimination when they seek care. Their stories are shared with other members of the group, reinforcing negative expectations. As the United States experiences unprecedented rates of immigration from around the world, health care professionals must understand how language and culture affect communication in the context of patient care. Payers should keep this in mind when designing coverage policies and procedures, so we don’t inadvertently hinder access through failure to communicate and build trust.
We are a multilingual society. Language plays a fundamental role in culture and perpetuates group identity, including memories of centuries-old conflicts between ethnic groups in their countries of origin. New conflicts can arise when competing immigrant groups become neighbors. For example, in 1982, changes in state welfare and Medicaid rules caused a mass migration of Hmong immigrants from the Pacific Northwest to central California. The Hmong, farmers from the mountains of Laos and southern China displaced in the 1970s by the Vietnam War, arrived with farming as their only marketable skill. In Stockton, Merced, and the surrounding farm communities, the Hmong competed with Mexican migrant farmworkers for jobs. Violence resulted.[i]
Language shapes how we think. It channels our minds along well-worn pathways and affects how we respond as patients and health care professionals. A person’s heart language, the language in which they instinctively think and feel,[ii] is usually the first learned, though some individuals adapt to a second language and unconsciously think in it. Immigrants fluent in the official language of their country of origin may hear it through cultural filters influenced by historical conflicts. The Hmong, an independent people with a history of distrusting governments that persecuted them, needed translation into their own language. Speaking the same language does not necessarily mean we are communicating with mutual trust and understanding. Misunderstandings can have unintended consequences, such as failure to follow patient instructions.
Language shapes our perceptions of disease. In Nepal where I worked, the national language (Nepali) is Indo-European. Its structure and etymology are familiar to us, but culture and religion affect perceptions, language, and thought processes. In vernacular English, patients “own” their diseases. We catch colds. “I have diabetes” suggests that it is something I possess and can control. We coach students to say, “a person with diabetes,” someone who can learn to manage their condition, rather than “a diabetic patient” who is a passive participant. In Nepali, a disease is something that happens to you. The patient’s role is passive. This has practical implications.
Every language expresses some ideas very efficiently but has difficulty with others. If a person thinks in a language that cannot effectively express a concept, they can’t readily think it. When I was a child, my vocabulary did not include the word cellphone. Because of the absence of the concept in my language, I was incapable of noticing that I didn’t have one or insisting that I needed one. In Nepali, there is no direct way to ask, “How do you feel about that?” Bilingual Nepalis borrow the English word “feeling” when speaking their own language.
Indigenous medical and religious beliefs and practices compete with allopathic medicine. With awareness, treatment can be modified to accommodate many of them. Muslims celebrate Ramadan, a month-long fast during daylight hours, but patients that shouldn’t fast for medical reasons can ask their Imam for an alternative way to fulfill this religious duty.[iii] Some Christians also observe fast days. Orthodox Jews cannot eat certain foods during Passover. Depending on how this is interpreted, it can be a challenge for maintenance medications. I once had a patient on prophylactic cotrimoxazole suspension whose mother asked, “Is it kosher for Passover?” Teva, the manufacturer, couldn’t answer the question, though they are an Israeli company.
A British Rabbi who is also a pharmacist has provided an internet list of kosher medications and general rules.[iv] Patients can ask their Rabbi for an exception if needed.[v] Consumption of medications containing beef or pork derivatives can be a problem for individuals that observe these restrictions. Theories of disease in many parts of Asia suggest that a patient should consume (or avoid) certain foods, depending on the type of disease. My Nepali pharmacy staff made up “placebo” advice: don’t eat “hot” foods with this medication; don’t eat “cold” foods with that one. There was no scientific basis for this advice, but if it helped people take their prescriptions, I was fine with it.[vi]
When wars displace tribal people like the Hmong, they bring animistic religious practices to their new settings. Animism is a worldview in which spirits control much of life, and can cause medical problems. This sets up a conflict between patients and families and their health care providers. The doctors offer a scientific explanation, and the patients can see that they benefit from allopathic medical care, but that doesn’t change their belief in the underlying spiritual causes. When medical advice contradicts their understanding, they are unlikely to adhere. The patient will verbally agree with the clinician because they want to please, while they have no intention of actually doing what has been recommended.
Seeking medical care may be delayed while patients are treated by shamans or other folk healers, or they may continue to use traditional remedies, some of which are beneficial, others neutral, and some harmful or cause drug interactions. For some, the allopathic physician is the provider of last resort when others have failed. The result is a “collision of two cultures” described in depth with compassion and understanding in Anne Fadiman’s book, The Spirit Catches You and You Fall Down, the story of a Hmong family with a child with severe refractory seizures and their experiences with U. S. health care.[vii] Because of their history and culture, the Hmong do not like outsiders telling them what to do. They are unusually resistant, but others may have similar responses, if not as forcefully voiced. Many animists believe that if a person dies without the correct rituals, their spirit will cause trouble for surviving relatives.
Immigrants may be new to our thought patterns and the procedures they need to follow to access medical care, especially if they are from rural backgrounds like the Hmong. They lack cultural knowledge of our society, have limited (or no) computer skills, and may not know how to get help. Our complex health care system is difficult enough for those born here to navigate; it is even more perplexing to the growing number of recent immigrants needing to access care. Language and cultural beliefs can work against achieving desired clinical outcomes. In a world with perfect equity, every patient not fully fluent in English would have a culturally competent interpreter that speaks their native language. In practice, the interpreter may speak the national language that the patient doesn’t trust. Like history, language is written by the victors, and the losers are forced to speak it.
Communication is key to achieving good health outcomes. When unrecognized factors interfere, health professionals have difficulty understanding what is troubling the patient and communicating instructions clearly. Patients are less likely to adhere to treatments when not fully convinced of their effectiveness or the need for them. They may not follow recommendations they don’t fully understand or that conflict with traditional beliefs about illness. If providers and payers are aware of these dynamics, we will be better equipped to help them achieve the best possible outcomes of treatment. Payers spend a lot of time addressing geographical barriers to care. When we encounter linguistic minorities, we should make the same effort to help them access the care they need.
REFERENCES:
1. Wikipedia. History of the Hmong in Merced, California. This article describes the history and culture of the Hmong settlements in California. It illustrates the experience of a remote tribal group encountering our civilization for the first time. The Hmong did not ask to be here—they were casualties of a war they didn’t start, in which they sided with the U.S. against North Vietnam and the Pathet Lao. But they are tough resilient people and they learned to survive, though their middle aged and older generations just wanted to return home. https://en.wikipedia.org/wiki/History_of_the_Hmong_in_Merced,_California#:~:text=The%20Hmong%20began%20to%20settle,anti%2DCommunist%20United%20States%20side. Accessed 1/31/2024.
2. SIL. What is the “heart language” in multilingual communities? Available at https://www.sil.org/about/ multilingual-communities#:~:text=SIL%20has%20traditionally%20focused%20on,as%20for%20learning% 20new%20concepts. Accessed 12/20/23.
3. Grindrod K, Alsabbagh W. Managing medications during Ramadan fasting. Can Pharm J. 2017;150(3):146-149.
4. Rabbi A Adler, BPharm, MRPharms, in consultation with the food technologists of the KLBD. https://www.kosher.org.uk/sites/default/files/2023_medicines_v2.pdf. Accessed 1/31/24.
5. Alternatively, they can use the workaround Jews have employed for centuries. Forbidden items are sold to a gentile, with agreement to sell them back after Passover ends. According to Rabbi Adler, the patient can request that the owner allow them to continue taking the medication. People of many different ethnic groups employ similar strategies.
6. If we are tempted to judge these beliefs as non-scientific, we should remember the history of allopathic medicine has similar roots. Practices like bloodletting febrile patients with leeches were common into the 19th Century. The founding theories of Greek allopathic medicine, Hindu ayurvedic medicine, and Chinese traditional medicine are all based on correcting an imbalance of forces within the patient’s body.
7. Anne Fadiman. The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures. New York, Farrar, Strauss, and Giroux (1997). Available at Amazon. The author has spend many years learning to understand the Hmong, and she paints a colorful picture of their rich culture and proud heritage, as well as explaining why our health care system struggled to understand them.