Improving Language Access: A Personal and National Agenda

Over the past several decades, the United States has made unprecedented advances in medicine and technology. At the same time, America’s ever-increasing diversity has enriched our nation culturally, linguistically, and economically. However, not all Americans are benefiting equally from improvements in health and health care, and in some cases, diversity has translated into health disparities.

Health literacy – the ability of an individual to access, understand, and use health-related information and services to make appropriate decisions – is fundamental to our individual and national health. Yet, more than 90 million Americans have difficulty understanding basic health information.¹ Language barriers add another layer of complexity.² Culturally and linguistically diverse groups typically experience less adequate access to care, lower quality of care, and poorer health status and outcomes.^3–5

I grew up a poor Latino street kid in New York City. I was often hungry and was homeless for the first time when I was 6 years old. I know what it is like to be on the fringes of society, to be someone whom people were willing to forget and leave alone. My parents were good people, but they struggled with serious substance abuse problems. My grandmother – my abuelita – helped raise my brothers and sister and me. Although she was poor and uneducated, she was one of the strongest people I have ever known. She lived on the margins of society for many years, as did the whole family, yet she lived with a great deal of dignity as the matriarch of our family.

I was often called on to translate for my grandmother at the doctor’s office. I felt honored to do so, but I knew it was too much responsibility to interpret words and symptoms that I did not understand. What I know now that I could not have understood then is that Abuelita’s own dignity would prevent her from speaking openly about her symptoms in front of me—her young grandson. I know that my experience as a child interpreter was not unique then and is not unique now.

We were very fortunate to eventually find a doctor in our neighborhood who spoke our language and understood our culture. However, before we became Dr. Richard Izquierdo’s patients, we struggled to understand what we needed to do to prevent diseases or to recover from illness or injuries.

When I was 17 years old, I dropped out of high school and soon after joined the U.S. Army, becoming a Special Forces weapons specialist and medic. I served in Vietnam, and when I returned home to New York City, I started college thanks to an open-enrollment program that Bronx Community College offered for Vietnam veterans. In the years that followed, I have had the privilege to serve as a registered nurse, physician’s assistant, trauma surgeon, CEO of a hospital system, and public health official. Throughout those experiences, I continued to see that language and cultural differences sometimes become barriers to quality care. Often there was a wall between health professionals and the people we were trying to serve. It was a wall of confusion and misunderstanding. Unfortunately, it was sometimes made worse by our inability to recognize that patients did not always understand the care instructions or other information that we were trying to communicate. I also saw the cycle repeated that my family and I had experienced. Every day, my colleagues and I saw patients who hid their confusion from us because they were too ashamed or intimidated to ask for help. What I learned and what I tried to teach my students, interns, and residents is that we as health professionals need to offer information even if our patients do not ask us the questions.

Still today, communication and cultural barriers between patients and health professionals lead to decreased use of preventive services and higher rates of hospitalization and drug complications. When understanding of health and medical information is incomplete, patients often do not access or even know how to access appropriate follow-up care so that they can recover from illnesses and injuries that lead them to emergency care settings.^3,5

Given the existing population growth trends and pervasive health disparities in our nation, we must increase our determination to serve diverse populations by disseminating the best available health information in ways that Americans can understand and use to be healthy and safe.^4,5 For example, we must redouble our efforts to increase the capacity of our health care workforce to provide culturally and linguistically appropriate care to our patients. The good news is that there are tools available to help health care organizations implement language access services.⁵

I commend the Journal of General Internal Medicine, Hablamos Juntos, and the Robert Wood Johnson Foundation for developing this supplemental issue. Together, we must elevate and energize the national dialogue about how to remove all barriers to quality care, and we must highlight promising research and strategies to improve the health of all populations.

To put a new twist on something that a great man – Dr. Martin Luther King, Jr. – once said: the inseparable twin of racial injustice is health injustice. We all know that is true. We must continue to work together to foster a world in which all people can live long, healthy lives—no matter their cultural home, the color of their skin, or the languages that they speak.

I am grateful to the editors of this supplement for providing me with an opportunity to share my experiences, concerns, and hopes about this topic. I stand ready to work together to remove barriers to improve the health and well-being of our great nation today, and for all future generations.