The Right to Narrate: Reflections on Language, Race, and Migration

No name is yours until you speak it; somebody returns your call and suddenly, the circuit of signs, gestures, gesticulations is established and you enter the territory of the right to narrate. You are part of a dialogue that may not, at first, be heard or heralded—you may be ignored—but your personhood cannot be denied.

Homi K. Bhabha, The Location of Culture. p. XXV

Who has the right to narrate? The question demands that we examine mainstream discourses in medicine that claim to place a patient’s narrative at the heart of clinical care. I work at a hospital in a large, linguistically diverse city where almost one quarter of my patients prefer to communicate in languages other than English. Like many hospitals, interpretation services are available, but underused. A patient may be admitted and discharged without ever speaking to a clinician in their preferred language. We attribute this practice to “language barriers” and by doing so naturalize linguistic inequities in our institutions.

We do this, in part, because of an impoverished understanding of spoken language in medicine. Language discordance between a patient and clinician is viewed as primarily a technical problem requiring a technical solution,¹ such as the use of interpretation. However, language intersects with race and migration in complex ways that shape the care received by language minority communities. When we frame language discordance as a technical problem, we absolve speakers of the dominant language of their responsibility for communication, obscure the role of institutions in constructing language barriers, and overlook the relationship between English language dominance and White supremacy. However, if we view linguistic inequities as structural, we expand the scope of our analysis and the spectrum of possible responses.

The Limits of “Limited English Proficiency”

A person is commonly said to have “limited English proficiency” if they self-report speaking English less than “very well.” This definition is drawn from the US Census and is frequently used in the medical literature. It creates a binary that is well-suited to research: a person either is English proficient or has limited English proficiency. But language proficiency is not binary; it is contingent on context. Language is also relational, and so when the term “limited English proficiency” is applied to a patient, it identifies them as the site of deficiency and as the subject of analysis,² and not the institutions that structure communication, or the speakers of the dominant language whose approaches to listening must also be examined.³

Importantly, the construct of “English language proficiency” itself is contested in other disciplines, where scholars point to its deficit framing and note that the “linguistic practices of racialized populations are systematically stigmatized regardless of the extent to which these practices might seem to correspond to standardized norms”.² We must then carefully consider what we are measuring when we study those “with” limited English proficiency and the claims we can make about the causes of inequitable health outcomes. Thus, the term “language discordance” may better describe the situation where patient and clinician speak different languages, as speakers and listeners share in responsibility for dialogue.

What Is a Language Barrier?

If language is seen as the method by which a message is conveyed by one person to another, then language barriers obstruct the movement of that message. This framing makes “language barriers” seem natural, neutral, and immutable. However, language barriers do not simply appear—they are constructed and are, at their core, discriminatory structures. There is no barrier if a physician speaks the patient’s language, and there is evidence for improved patient outcomes when both parties are language-concordant.⁴ Yet, the linguistic diversity of populations may not be reflected in those who gain entry into medical school.

Partnering with interpreters improves quality of care and mitigates barriers to communication,⁵ but almost one-third of US hospitals do not offer interpretation services.⁶ The absence of interpretation is not due to the absence of data documenting its benefits. Rather, governments and health systems choose not to invest in interpretation infrastructure despite its established benefits. The French sociologist, Pierre Bourdieu, observed that “speech always owes a major part of its value to the value of the person who utters it”.³ By not offering interpretation, institutions signal the value they accord to non-English speakers. It becomes clear then that the “patient narrative” can be venerated or suppressed depending on the speaker.

Language barriers are further reinforced by the dominance of English in health care institutions, including medical education. As a consequence of British colonialism, English is the language of instruction in many medical schools around the world. It is also the dominant language of academic work in many disciplines,³ including medicine. Thus, we become habituated to the use of English as the standard within our institutions and the use of non-English languages is viewed as a deviation.

Language, Migration, and Race

A foundational ideology of “nations of immigrants,” like Canada and the United States, is that immigrants assimilate into the dominant culture and speak the dominant language.³ The subordination of non-English languages is central to the maintenance of White supremacy. From this perspective, to not acquire English fluency is seen as a choice and individuals who lack fluency assume “personal responsibility” for the consequences of poor communication.³ Heller and McElhinny argue, “if monolingualism is an important dimension of the functioning of the nation, then it becomes important to reward monolingual performances, and to control, suppress, or sanction multilingual ones....¹” When health care institutions choose not to offer multilingual services, they reward English speakers and sanction those from language minority communities. In this way, institutions function to maintain the dominance of English and linguistic injustice becomes embedded in their structure.

Moreover, language is embodied by speakers and perceptions of a person’s language use are inseparable from the ways in which they are racialized and the effects of racism.² Languages themselves are placed in hierarchies that position “European languages as superior to non-European languages”.² And so, a White French-speaking patient may be seen, heard, and cared for in materially different ways from one who is not White (or one who speaks a non-European language). Similarly, an English speaker with a familiar or high prestige accent may be viewed as more “proficient” than someone with an unfamiliar or low prestige accent, and perceptions of accents are themselves shaped by race. In medicine, a patient or clinician’s accent may influence assessment of their intelligibility and competence.

And so, while linguistic diversity is celebrated, the borders around language are often heavily policed for racialized speakers of non-English languages, particularly in the face of increasing nativism. For instance, racialized US citizens have been apprehended by Customs and Border Protection for the act of speaking Spanish in public.⁷ Some hospitals have instituted “English only” policies ostensibly for patient safety, but in several instances, workers have been disciplined for speaking non-English languages during their break time.³ Thus, we must be clear that “debates about linguistic diversity are rarely concerned with purely linguistic matters, but are about speakers”,³ and that wider debates about the language practices of racialized populations do not stop at the walls of health care institutions. The structures that construct and constrain a patient’s “right to narrate” extend beyond binary considerations of English language proficiency to race, migration status, and other factors.

Toward a Right to Narrate

The project to redress racism in health care is incomplete without attending to linguistic inequities. This moment requires us to expand our analysis of language to examine how physicians and institutions act as listeners. It demands that we consider how “language barriers” are constructed so that we can determine how they might be dismantled. It necessitates theory and research that explores the complex relationships between language, racism, and nativism in medicine. And so, we must re-imagine our institutions and practice so that we might enter into dialogue with those we care for.

Author Contribution

Gobi Jeyaratnam MPH, Malika Sharma MD MEd.

Declarations

Conflict of Interest

None.