Spanish in Health Care: Policy, Practice and Pedagogy in Latino Health (Routledge Studies in Hispanic and Lusophone Linguistics) [1 ed.] 113871366X, 9781138713666

Table of contents :
Cover
Half Title
Series
Title
Copyright
Dedication
Contents
List of figures
List of tables and text box
Acknowledgments
1 Language and Latino health: from social determinant to syndemic
Overview of the book
How language affects health
Language, Latinidad, and Latino health
Language and Latino health: from social determinant to syndemic
References
2 Language in health care policies
Health policy in the United States
Health care as right and as commodity
The role of the government
Who “deserves” subsidized care?
Language policy and planning in the United States
Key concepts in language policy and planning
Language policy and planning in the U.S.
Language policy in health care in the United States
Language policy in health care at the national level
Language policy in health care at the state level
Language in health care policy and ideologies of language
Language in health care policy and health policy
References
3 Language and cultural practices in health communication
Language and culture in health communication
Health behavior theory
Models of health behavior change
Language and culture in health behavior theory
Provider-patient communication
Health communication approaches to provider-patient interaction
Language and culture in provider-patient communication
Interpreter-mediated communication
Ethics and standards of practice in interpreting
Language and culture in ethical reflection on interpreting
Cultural values and beliefs
Critical perspective on cultural values and beliefs
References
4 Uncovering language and cultural practices in Latino health
Provider-patient communication in Latino health
Sociomedical studies of provider-patient communication
Discourse studies of provider-patient communication
Interpreter-mediated communication in Latino health
Sociomedical studies of interpreter-mediated communication
Discourse studies of interpreter-mediated communication
Mass communication in Latino health
Health literacy and Latino health
Health information seeking and Latino health
Communication ecologies in Latino health
References
5 Language pedagogy and Latino health
The making of medical Spanish
The historical roots of medical Spanish
The evolution of medical Spanish curricula
Languages for Specific Purposes
Shaping the LSP agenda
The expansion of the LSP agenda
Medical Spanish and LSP
The diversity of medical Spanish programs
Needs analysis in medical Spanish and pedagogical innovation
Medical Spanish and language assessment
Teaching Spanish for Latino Health
Health/communicative inequities in Spanish for Latino Health
Ethical Listening, testimonial justice and raciolinguistic perspectives in Spanish for Latino Health
Translanguaging and Spanish for Latino Health
References
Index

Citation preview

Spanish in Health Care

Spanish in Health Care fills an important gap by offering a panoramic overview of the research on Spanish in health settings that is emerging from a variety of disciplines. Synthesizing research from diverse disciplines such as sociolinguistics, discourse analysis, health services research, behavioral health research, health policy and administration, and social epidemiology, the volume offers a uniquely unified approach to the subject of Spanish in healthcare. This volume will be of interest to researchers in Spanish linguistics, sociolinguistics, health communication, and languages for specific purposes. Glenn A. Martínez is Professor of Hispanic Linguistics and Director of the Center for Languages, Literatures, and Cultures at The Ohio State University.

Routledge Studies in Hispanic and Lusophone Linguistics Series Editor: Dale A. Koike University of Texas at Austin

The Routledge Studies in Hispanic and Lusophone Linguistics series provides a showcase for the latest research on Spanish and Portuguese Linguistics. It publishes select research monographs on various topics in the field, reflecting strands of current interest. Titles in the series: Lusophone, Galician, and Hispanic Linguistics Bridging Frames and Traditions Edited by Gabriel Rei-Doval and Fernando Tejedo-Herrero Pragmatic Variation in Service Encounter Interactions across the Spanish-Speaking World Edited by J. César Félix-Brasdefer and María Elena Placencia Dialects from Tropical Islands Caribbean Spanish in the United States Edited by Wilfredo Valentín-Márquez & Melvin González-Rivera Interface-Driven Phenomena in Spanish Essays in Honor of Javier Gutiérrez-Rexach Edited by Melvin González-Rivera and Sandro Sessarego Spanish in the United States Attitudes and Variation Edited by Scott M. Alvord and Gregory L. Thompson Spanish in Health Care Policy, Practice and Pedagogy in Latino Health Glenn A. Martínez For more information about this series please visit: https://www.routledge.com/ Routledge-Studies-in-Hispanic-and-Lusophone-Linguistics/book-series/RSHLL

Spanish in Health Care Policy, Practice and Pedagogy in Latino Health Glenn A. Martínez Series Editor: Dale A. Koike Spanish List Advisor: Javier Muñoz-Basols

First published 2020 by Routledge 2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN and by Routledge 52 Vanderbilt Avenue, New York, NY 10017 Routledge is an imprint of the Taylor & Francis Group, an informa business © 2020 Glenn A. Martínez The right of Glenn A. Martínez to be identified as author of this work has been asserted by him in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data A catalog record for this book has been requested ISBN: 978-1-138-71366-6 (hbk) ISBN: 978-1-315-19837-8 (ebk) Typeset in Times New Roman by Apex CoVantage, LLC

To the memory of Agustín R. and Ofelia Martínez and to my students, past and present, who continue to teach me about the power in language to improve health.

Contents

List of figures List of tables and text box Acknowledgments

x xi xii

1

Language and Latino health: from social determinant to syndemic Overview of the book  3 How language affects health  5 Language, Latinidad, and Latino health  10 Language and Latino health: from social determinant to syndemic 18 References 27

2

Language in health care policies Health policy in the United States  34 Health care as right and as commodity  36 The role of the government  38 Who “deserves” subsidized care?  40 Language policy and planning in the United States  43 Key concepts in language policy and planning  43 Language policy and planning in the U.S.  45 Language policy in health care in the United States  47 Language policy in health care at the national level  47 Language policy in health care at the state level  56 Language in health care policy and ideologies of language  59 Language in health care policy and health policy  64 References 67

33

3

Language and cultural practices in health communication Language and culture in health communication  72 Health behavior theory  73

70

1

viii  Contents Models of health behavior change  73 Language and culture in health behavior theory  77 Provider-patient communication  79 Health communication approaches to provider-patient interaction 80 Language and culture in provider-patient communication  83 Interpreter-mediated communication  85 Ethics and standards of practice in interpreting  85 Language and culture in ethical reflection on interpreting  90 Cultural values and beliefs  92 Critical perspective on cultural values and beliefs  94 References  96 4

Uncovering language and cultural practices in Latino health Provider-patient communication in Latino health  102 Sociomedical studies of provider-patient communication  102 Discourse studies of provider-patient communication  107 Interpreter-mediated communication in Latino health  112 Sociomedical studies of interpreter-mediated communication 112 Discourse studies of interpreter-mediated communication  119 Mass communication in Latino health  127 Health literacy and Latino health  128 Health information seeking and Latino health  134 Communication ecologies in Latino health  137 References 147

5

Language pedagogy and Latino health The making of medical Spanish  159 The historical roots of medical Spanish  159 The evolution of medical Spanish curricula  162 Languages for Specific Purposes  168 Shaping the LSP agenda  169 The expansion of the LSP agenda  170 Medical Spanish and LSP  172 The diversity of medical Spanish programs  173 Needs analysis in medical Spanish and pedagogical innovation 174 Medical Spanish and language assessment  178 Teaching Spanish for Latino Health  185

99

156

Contents  ix Health/communicative inequities in Spanish for Latino Health  185 Ethical Listening, testimonial justice and raciolinguistic perspectives in Spanish for Latino Health 187 Translanguaging and Spanish for Latino Health  192 References 200 Index

206

Figures

1.1 Social determinants of health 1.2 A Syndemic model of substance abuse, intimate partner violence, HIV infection and mental health conditions 4.1 Makeshift plumbing system at a colonia residence in Mission, Texas 4.2 Family home in a colonia in Mission, Texas 4.3 Stray dog in a colonia in Mission, Texas 5.1 Thematic clusters in a unit on tuberculosis 5.2 Picture of translated sign taken by student

19 26 144 145 146 188 197

Tables

2.1 The National Standards for Culturally and Linguistically Appropriate Services 2001 2.2 New and Revised Joint Commission Language Access Accreditation Standards 2.3 The Enhanced National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care, 2013 3.1 Code of ethics for interpreters in health care 3.2 National Standards of Practice for Interpreters in Health Care 3.3 Latino cultural values 3.4 Common folk illnesses and treatments 4.1 Types of medical interpreters 4.2 Cultural adaptation of text messages 5.1 Dialogue for addressing emotional needs in patient care 5.2 Advising speech acts in Spanish 5.3 Components of communicative competence

49 54 57 86 87 93 94 115 135 162 177 183

Text box 5.1 Sample item from the CCLA-S Exam

183

Acknowledgments

Portions of Chapter 5 were previously published as “Public Health and the ­Politics of Spanish in Early Twentieth Century Texas” in Jose Del Valle, ed. (2013). A Political History of Spanish: The Making of a Language. Cambridge: ­Cambridge University Press, pp.  293–304. Reproduced with permission of ­Cambridge ­University Press through PLSclear. I thank Cynthia Gonzalez, Aaron Salinas, Karmín San Martín, Alejandro Rodriguez, and Palmira Cepeda for sharing their stories and giving permission to publish them. I thank Tatiana D. Friedman for her help in editing the final manuscript. Finally, I thank Dale Koike, series editor, for her encouragement throughout this project.

1 Language and Latino health From social determinant to syndemic

My name is Maribel Garza. I have three children: one boy and two girls. My youngest daughter is Malena. She is twelve years old, and this is our story. Malena has always been a darling young person. As a baby, her beaming brown eyes and her crooked smile could light up any room. I would dress her up in cute dresses and put matching bows in her hair to complement her natural disposition. Every time I walked down the street or entered a store, people would stop me and ask to give the child “un cariño.” While Malena was always outwardly pleasant, she was a bit introverted, I admit. I will never forget Malena’s seventh birthday. It was that day that my life changed forever. It was around 2 a.m. when I heard a howling screech coming from the girls’ room. I jumped out of bed petrified and ran as fast as I could to their room. Malena was standing on her bed, crying hysterically – ¡quítamelos, quítamelos! Malena’s sister and I ran up to her and grabbed hold of her stiff arms – ¡quítamelos, quítamelos! ¡Los bichos – quítamelos! Seeing nothing on her arms, I  immediately ripped the sheets off the bed and found nothing. ¡Quítamelos, quítamelos! Malena continued to cry. I remember picking her up and bringing her with me to my room. Sitting in bed, I rocked her, sung her a lullaby, and prayed that God would give her peace. I was terrified. The next day I  took Malena to the doctor. After a battery of tests and three appointments later, I was told that Malena had schizophrenia, severe autism, epilepsy and developmental delay. It was a life shattering experience. I never imagined myself on such a steep uphill climb. I’m a single mom and it’s so hard for me to keep a job and provide for all of the medical needs of my daughter. I enrolled in night classes at cosmetology school and put a small beauty salon in my house. I don’t make a lot of money, but at least I can be home with Malena. Malena is on medication for the hallucinations and spends most of her time at home – in her room, wandering the halls, and talking to herself. It’s just hard – it’s hard to talk to her. I wish I could do more for her. It’s just hard – it’s hard to deal with this system in the U.S. I don’t speak English very well.

2  Language and Latino health I have trouble talking to my daughter’s teachers. We have meetings to discuss Malena’s academic needs. They tell me they are going to do everything in their power to help her, but they never keep their promises. I feel ignored most of the time. School is really just day care. My daughter is twelve years old and can’t read; she doesn’t know how to add or subtract; she rarely speaks in complete sentences. It’s frustrating. I feel like I don’t have a voice – like I’m almost invisible. And school is just the beginning. I feel just as helpless with the doctors. The nurses and receptionists are just plain rude. I feel as if they are mad at me because I don’t speak English, and they scold me for arriving late to my appointments. Oftentimes, I have appointments with several doctors on the same day. If one doctor is late, I will be late to all my other appointments. It’s also hard for me to follow all the doctors’ instructions. My daughter’s neurologist, for example, ordered one-on-one help for Malena at school. I had to fight with the school to get it, and to this day it hasn’t happened. The people at the pharmacy are very helpful. Malena takes six different medications every day. The pharmacists give me medicine bottles with different colored lids to help me keep everything straight. Every day is a battle  – a struggle to help my child. I  think if I  spoke English, the doctors, nurses, receptionists and teachers would take me more seriously. I’m taking English classes to learn English – one day I will be able to help my child more, one day when I know English. Story by Cynthia M. Gonzalez (Used with permission)

I begin with this story because it is illustrative of the multiple and intersectional impacts of language on the health and well-being of Latino populations in the United States. While this story presents only one perspective of a larger narrative – that of a struggling caregiver – it sheds light on the entanglements of language, health care and health that are the focus of this book. Maribel’s struggles with language are far-reaching and diverse. They affect her ability to negotiate optimal outcomes with her child’s teachers and they impact her interactions in health care settings. When looking at Maribel’s struggles, we might be tempted to focus on the adverse outcomes that the language barrier is producing in her child. Malena cannot read; she cannot add and subtract. Malena’s medical condition is not improving – instead it’s deteriorating. Following doctors’ recommendations is a challenge and keeping up with the hectic pace of multiple treatments is difficult. Yet,  the  impact  of  Maribel’s  struggles far surpass the poor outcomes of her child’s care and takes a toll on Maribel herself. She feels invisible, unheard. She is frustrated by the neglect of officials entrusted as partners in her child’s welfare – teachers, school administrators, doctors, and nurses. She is caught in the crosscurrents of multi-morbid chronic care treatment and the wider economic demands and social expectations imposed upon her. She feels guilty because her

Language and Latino health  3 ability to arrive at appointments on time and to follow doctor’s orders are oftentimes beyond her reach. Added to the poor outcomes of her child’s care are these more self-debilitating outcomes in Maribel herself. Maribel’s feelings of guilt and impotence, moreover, cannot be bracketed off from the overarching experience and burden of illness. Each instance of micro-aggression experienced in the doctor’s office, each promise made and not kept by school officials feeds right back into the overwhelming burden she deals with day in and day out and adds to the frustration of seeing little progress in her daughter’s treatment. In spite of it all, however, Maribel is resilient. Maribel looks out on the horizon and sees just beyond it to that “one day” – that one day when she will be able to help her child more, that one day when she knows English.

Overview of the book Maribel’s resilience, her faith in that “one day,” is the impetus of this book. Perhaps she is overly optimistic about the influence of knowing English. Perhaps simply knowing English would not fundamentally change her plight. But this book looks beyond her faith in English to her deep-seated desire to improve the health outcomes and the well-being of her child. The foundation of Maribel’s resilience is found at its core in this overriding desire – in her desire that “one day” she will be able to help her child more. It is this desire that leads me to ask: What role do language professionals – Spanish teachers, English teachers, interpreter trainers, and language researchers – play in getting to that “one day” that drives Maribel’s resilience? What perspectives do language professionals bring to the broader discussions about Latino health and well-being and the elimination of health disparities in Latino populations? Language, and the literacies that it generates and sustains, have long been recognized as critical factors in addressing health disparities in Latino populations in the United States. Language educators, sociolinguists, and literacy researchers, however, have not played a central role in assessing the causes of and developing interventions to address these disparities. The missing voices of language specialists in research on language access in health care have led to an undertheorized approach to the numerous linguistic and sociocultural challenges that affect Spanish speakers in the U.S. health delivery system. Spanish in Health Care: Policy, Practice and Pedagogy in Latino Health is written to provide scholars and students in Spanish linguistics, sociolinguistics, and applied linguistics a broad perspective of the linguistic challenges faced by Spanish speakers in the health delivery system, to familiarize them with the established and emerging literature in the field, and to point them to particularly pressing areas of future sociolinguistic and applied linguistic research. In this chapter, I will consider the role of language in Latino health. I will first consider the relationship between language and health. As sociocultural perspectives have been introduced both in the study of health care and the study of language, the two areas have converged in ways that reveal previously unseen spaces of overlap, synergy, and reciprocity. I will explore these spaces in depth

4  Language and Latino health offering a model for the analysis of language and health on two separate planes: the communicative plane and the ideological plane. With this model in mind, I  will then explore the emergence of latinidad and describe its role in current formulations of Latino health. I will review various epidemiological studies that explore the relationship between language and health in Latino populations. Finally, I will show how the findings of these studies have been assessed under two distinct interpretive frameworks: the social determinant perspective and the syndemic perspective. The social determinant perspective considers language and language-related phenomena to be causal factors in health disparities. Language is viewed as a distal factor in the chain of causality that leads to poor health outcomes. The syndemic perspective, on the other hand, does not discount the role of language as a causal factor but rather emphasizes the ways in which language both generates poor health outcomes and fundamentally shapes the experience of those outcomes. Chapter 2 draws on the theoretical framework of syndemics to describe language policies in health care that affect Spanish speakers in the U.S. After a brief consideration of the major questions that have emerged in health policy, I will discuss the historical background of U.S. language policy and how this background has shaped language policy in health care at the national and state levels over the past two decades. I assess these policy interventions on ideological grounds in order to demonstrate the intimate relationship between language policy and health policy. I wrap up the discussion by underscoring the multiple ways in which language in health care policy affects the lives of Spanish speakers. In Chapter 3, I begin an extended discussion of the language and cultural practices in health care that interact with the policy environment discussed in Chapter 2. In this chapter, I argue for the need for a practice perspective in the study of communication in Spanish in health care contexts. A focus on language and cultural practice, as opposed to a focus on language and culture, helps us move away from the notion that language and culture are preexisting bodies of knowledge and skills that are brought to the health care encounter and to move towards a notion of language and culture as co-constructed in health care encounters themselves. In applying this notion to health communication, I  review various theoretical frameworks including health behavior theory, provider-patient communication, interpreter-mediated communication, and cultural values and beliefs. I  further explore the limitations of these theories in accounting for a practice perspective on language and culture. Chapter  4 takes up the practice perspective described in the previous chapter and reviews studies of provider-patient communication, interpreter-mediated communication, and health literacy and health information seeking in Spanishspeaking communities. In synthesizing the research, I explore the multiple tensions that have arisen in the literature and their relationship to existing policy. I conclude the chapter by arguing for a communication ecology approach to Spanish in health care that can inform policy and account for the multiple language and cultural practices enacted by Spanish speakers in health care settings.

Language and Latino health 5 In Chapter 5, I move away from a focus on practice to consider the pedagogical implications of communication research with Spanish speakers to the teaching and learning of Medical Spanish. I review the development of Medical Spanish beginning as early as the 1930s. I describe the role of Languages for Specific Purposes in shaping Medical Spanish in the present, and I argue for a more nuanced approach to the teaching of Medical Spanish that I call Spanish for Latino Health. Spanish for Latino Health is conceived of as an expansive agenda for Medical Spanish that broadens the focus of instruction to include engagement with health/ communicative inequities, ethical listening, and translanguaging. The three strands of Spanish in health care described in this book  – policy, practice, and pedagogy – are meant to contribute to a more complete understanding of communication in Latino health and to provide substantive information for researchers and teachers who are just entering the field of Spanish for health care. At the beginning of each chapter, I include vignettes that bring out issues of culture, identity, and language in health care contexts in order to engage the reader with the real-world issues that undergird the theoretical perspectives outlined in the book. These stories are culled from years of teaching Spanish to students – both heritage and second language learners – aspiring to enter the health professions. I am grateful to Cynthia Gonzalez, Aaron Salinas, Karmín San Martín, Alex Rodriguez, and Palmira Cepeda for granting me permission to use their powerful stories. I hope it will be evident to the reader how much I have learned from these stories and that they will serve not only as a solid basis for the discussions pursued in each chapter but also as a pattern of learning through teaching that must remain the cornerstone of language teaching for social justice.

How language affects health To speak of the relationship between language and health is to cover an enormous conceptual stretch. A novice might approach the topic wondering how the specific set of lexical items and grammatical rules a person uses to communicate impinges on the presence of diseased states in that individual. However, such an approach would miss much of the larger conceptualization of both language and health. The World Health Organization (WHO), as early as 1946, adopted a view of health that eschewed the notion that health is simply the absence of disease. According to the WHO, “health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO, 1946). By this definition, the question of the relationship between language and health requires attention not only to disease states but also to the myriad factors affecting complete physical, mental, and social well-being. In the same vein, a view of language as a specific set of lexical items and grammatical rules used to communicate misses the mark of our current conceptualization of language. While Ferdinand de Saussure defined language as “a social property of the faculty of speech and a collection of necessary conventions that have been adopted by a social body to permit individuals to exercise that faculty” (de Saussure, 1987, p. 9), he was quick to distinguish this abstracted notion of “language” from “speech” which he characterized

6  Language and Latino health as “many-sided and heterogenous” and as belonging both to the individual and society. Sausure bracketed off speech from his consideration because he found that in speech there was no unity to be discovered. This same division was held well into the twentieth century and became a foundational tenet of at least one variety of linguistic science. Under this conceptualization, it might be plausible to understand the relationship between language and health as something entirely different from the relationship between health and speech effectively extirpating from the purview of linguistics the whole question of language use or speech in healthcare contexts. Yet, linguistics has not shied away from the consideration of language in use. In fact, a whole field of linguistics, namely sociolinguistics, has emerged that is dedicated principally to understanding how language is used in social contexts for social purposes. Dell Hymes referred to this approach as a “socially constituted linguistics” in which all questions about language are to some extent embedded in social analysis (Hymes, 1997). These pioneering ideas, in conjunction with those proposed by a long line of other scholars, have considerably expanded our notion of what language is and what it means to study it. From the tradition of sociolinguistic scholarship, myriad perspectives on language have emerged including the study of language variation, language stylization, language attitudes and ideologies, language maintenance and shift, and the list goes on and on. What is clear from the legacy of sociolinguistics is that the relationship between language and health – both broadly conceived – is a rich, complex, and multifaceted area of linguistic inquiry. The relationship between language and health can be viewed from at least two distinct standpoints. First, we can think of language as a determinant of access to care. Language is the vehicle through which patients and providers give and receive information. In the absence of a shared communicative system, access to care will be limited. Limited access prevents patients from expressing symptoms, side effects and other essential information for providers to deliver treatment. At the same time, limited access curtails the patient’s ability to obtain information that is critical for understanding their condition, its symptoms, its treatment, and risk factors that can aggravate it. Limited access to information is perhaps the most obvious adverse effect of language barriers, and it is a significant factor in the relationship between language and health. In Latino populations, the negative impacts of limited access to information have led to tragic consequences. The story of Gricelda Zamora is one such tragedy. Gricelda was a 13-year old from Yuma, Arizona who, like many children whose parents speak limited English, served as her family’s interpreter. When Gricelda developed severe abdominal pain, her parents rushed her to the hospital. Unfortunately, Gricelda was too sick to interpret for herself, and the hospital did not provide an interpreter. A night of observation passed. Without the aid of an interpreter, her Spanish-speaking parents were told to bring her back immediately if her symptoms worsened or otherwise to follow up with her doctor in three days. The parents, however, understood from the conversation that they should wait three days to see the doctor. After two days, with Gricelda’s condition deteriorating, they felt they could no

Language and Latino health  7 longer wait and rushed her back to the emergency room. Doctors there discovered that she had a ruptured appendix. She was airlifted to a nearby medical center in Phoenix. She died a few hours later (Chen, Youdelman & Brooks, 2007, p. 362). Flores (2006) pointed out another tragic case in which information barriers led to deleterious and avoidable effects. A Spanish-speaking woman brought her two-year old daughter to the emergency room after the child fell off her tricycle. The woman confidently informed the resident that the child had “hit herself.” The resident on call listened to the woman’s explanation and understood that she had hit the child. He proceeded to notify the Department of Social Services, and they immediately sent a case worker to investigate the case. Without an interpreter present, the case worker had the mother sign over custody of her two children (p. 229). Stories such as these have led policy makers to understand the need to eliminate language barriers in health care. The obvious solution in cases such as these is the use of trained, professional interpreter staff members to bridge the information gap between patients and providers. The field of medical interpreting has grown substantially since the 1990s and today constitutes a vital service for Spanishspeaking patients in the U.S. health delivery system. The medical interpreting profession has developed standards of practice and ethical guidelines to ensure the quality of interpreted medical encounters (Bancroft et al., 2016). The provision of professional interpretation services in the care of non-English speaking patients has rapidly become the standard of care (OMH, 2001; Joint Commission, 2010; OMH, 2013). The use of bilingual health personnel, on the other hand, offers an additional solution. The research on the health benefits of language concordant care have been significant drivers on this front. Recent efforts are moving towards a standardized process of training, validating, and using bilingual health professionals (Tang et al., 2011; Ortega, 2018). We will discuss the pedagogical dimensions of Spanish in health care in greater depth in Chapter 5. Notwithstanding the advances realized in closing the information gap between English-speaking providers and their Spanish-speaking patients, there are other ways in which language intervenes in health and health care. While language obviously serves a communicative function that is essential in health care encounters, it also serves other functions that sociolinguists have strived to enumerate. Language serves as a bond between its speakers, endearing them to each other (Heath, 1983), and it also serves as a form of symbolic capital establishing and perpetuating social hierarchies (Bourdieu, 1991). Similarly, people fashion their identities through language – stylizing themselves and sometimes crossing, i.e., using the language variety that belongs to another group (Rampton, 2018). These insights into the identity function of language suggest that language differences are never neutral but rather always charged with deep-seated, heartfelt meaning. In her classic work Borderlands/La Frontera, feminist scholar-activist Gloria Anzaldúa underscores this point. “So, if you really want to hurt me,” she writes, “talk badly about my language. Ethnic identity is twin skin to linguistic identity – I am my language. Until I can take pride in my language, I cannot take pride in myself” (Anzaldúa, 1999, p. 81). Language is deeply personal. In her poem “You

8  Language and Latino health know how to say arroz con pollo but not what you are,” poet Melissa LozadaOliva explores what it means to claim Spanish as her own. She writes: If you ask if I am fluent in Spanish I will tell you. . . . My Spanish is understanding that there are stories that will always be out my reach, there are people who will never fit together the way that I want them to, there are some letters that will always stay silent, there are some words that will always escape me. (Lozada-Oliva, 2017) For Lozada-Oliva, language is fundamental not only to her identity but also to her personhood. Her Spanish is who she is. This identity function of language, embedded as it is in a whole array of social hierarchies, racial and ethnic prejudices, and sociocultural expectations, also impinges on the relationship of language and health. If the communicative function of language limits access to health care, the identity function of language limits and strains acceptance in health care. It is not enough to just have access to information. There is also a need to feel accepted and welcomed in the health care encounter. Lack of acceptance leads to mistrust between patients and providers and has the potential to override any gains realized through access. Lack of acceptance, moreover, shapes dispositions both on the provider and the patient side. Perhaps a patient’s lack of compliance or leaving the hospital against medical advice (Desai, Torres-Rivera & Backes, 2016) is nothing more than a symptom of a lack of trust. Perhaps a doctor’s overutilization of costly tests and increased worries about medical malpractice lawsuits in treating limited English proficient patients stems from a lack of acceptance (Chen, Fang & Rizzo, 2011). The use of interpreters, however, does little to mitigate the barriers of acceptance occasioned by language barriers. Telephonic interpreter Nataly Kelly, for example, describes how her mediation skills, even while effective in closing the access gap, were useless in bridging the gap of acceptance. She writes: On the flip side, I’ve witnessed – by phone – some behavior by providers that is offensive or rude. I’ve interpreted for patients who ask, “Why is the doctor speaking so slowly to me? Does he think I’m stupid?” I’ve also interpreted the words, “Please tell the nurse not to yell at me. I  don’t have a hearing problem – I just don’t speak English.” Recently I heard a physician say, in all seriousness, “Next time you come, you speak inglés, understand?” as if mastery of a new language would magically occur by the follow-up appointment. (Kelly, 2008, p. 1704) Kelly’s observations suggest that something more than interpreters is needed to address this dimension of the language barrier. Some have argued that training health care providers on how to work with an interpreter is needed (Diamond & Jacobs, 2010). Others have contended that successfully confronting these issues requires training in cultural competence (Watt, Abbott  & Reath, 2016). While

Language and Latino health  9 both may be partially on point, it is important to realize that language acceptance is part of a much larger habitus in which health care is couched. Habitus is a concept developed by Pierre Bourdieu as part of a much more complex theory of practice (Bourdieu, 2002). He speaks of the habitus as “systems of durable, transposable dispositions” that are deployed in “regulated and regular” form without being “the product of the orchestrating action of a conductor” (Bourdieu, 1990, p.  53). Habitus thus refers to values, attitudes, ideologies, and actions that are adopted unconsciously as part of membership in a particular field. With respect to language, we might conceive of a series of dispositions about the normal, normative language to be spoken in public space. Those dispositions are challenged when a doctor must dial a phone and connect to an interpreter in order to converse with a patient. The dissonance caused by the challenging of these dispositions then results in the type of encounter chronicled by Kelly. Seth Holmes (2013), in his ethnography of Oaxacan migrant farmworkers, argues that cultural competency training models often fail to adequately frame the problem of the larger habitus. He contends that most cultural competency training programs focus on lists of stereotypical cultural traits and thus implicitly present culture as the problem. Instead, he argues, following Jonathan Metzl, that medical educators should focus on social analysis and structural competency rather than on cultural competency (p. 153). Tervalon and Murray-García (1998), on the other hand, proposed the notion of cultural humility as an alternative to cultural competency that would address the larger habitus of health care. Cultural humility proves to be a more powerful concept than cultural competence inasmuch as it attempts to reframe competence in terms of dispositions rather than in terms of knowledge or skills. Cultural humility is approaching other cultures with a pervasive desire to learn; it is listening attentively; it is not assuming a shared perspective. Cultural competence is something you achieve once and for all, but cultural humility is something you do over and over again. Cultural humility is founded on three principles: lifelong learning, power imbalances, and institutional accountability. The practice of cultural humility is characterized by a persistent disposition to learn. It is characterized by a recognition of power asymmetries that occur in provider-patient relationships. And finally, it is characterized by institutions that hold themselves accountable for generating these durable dispositions. Tervalon and Murray-García provide an example of the differences between cultural competence and cultural humility. They recall a Latina female Spanish-speaking patient who is complaining of excruciating pain after a surgical procedure. The patient is seen by an English-speaking doctor in the presence of a Latina nurse. The doctor is concerned about the patient’s pain. The nurse, however, replies that Latinas generally exaggerate their pain and that she is probably fine with the current level of pain medication. In this case, the nurse is presenting herself as culturally competent, but not as culturally humble. She is not disposed to learn from the patient, but rather assumes the patient is exaggerating. She is oblivious to the power imbalances that are present in the situation and fails to recognize that her representation of herself as a cultural expert undermines the patient’s legitimate request for additional pain medication. Finally, the institution is not accountable

10  Language and Latino health for the actions. The doctor simply agreed with the nurse without any further probing or exploration. Having established a framework for understanding the relationship between language, health, and health care, we will now turn to an examination of Latino health in particular. We will explore the unifying threads that tie Latino health together and consider the place of latinidad as a centering idea in the umbrella concept of Latino health.

Language, Latinidad, and Latino health The notion of Latinos as a single homogenous group emerged in the 1970s from a constellation of forces that were both imposed upon and emerged out of diverse communities. Politicians coveted what appeared to be a growing voting bloc and activists sought to gain civil rights victories by forming pan-ethnic coalitions. Beginning in the 1970s and into the 1980s, the U.S. Census Bureau introduced the pan-ethnic census category of “Hispanic” and media outlets began to emerge that would unify Latino communities through a common language – Spanish (Mora, 2014). These efforts of constructing a catch-all category that would place Spanish speakers and descendants of Spanish-speaking people under a single umbrella quickly spread to health research and health policy making. By the early 1990s, the focus on Latinos as a relevant grouping for public health analysis and intervention was well underway. In 1994, Marilyn AguirreMolina edited a groundbreaking volume Latino Health in the U.S.A: A Growing Challenge followed by Health Issues in the Latino Community in 2001 and Latina Health in the United States: A Public Health Reader in 2003. These early works brought into focus the work of multiple health researchers over several decades. As the editors note in the first chapter of the second volume in the trilogy: “the challenge before us is to consider the health of Latinos within the context of the demographic and social transformations that have begun and that will continue over the next several decades in the United States. Such a contextual analysis,” they continue, “can serve to inform policy as well as empower Latinos as the strengths and potential of this community are identified” (Falcón, Aguirre-Molina & Molina, 2001, p. 3). Even while the authors stress the demographic and social transformations affecting the Latino population – for example, the inclusion of emerging subgroups from Central America, the Caribbean, and South America – they continued to postulate Latinos as a single community undergoing internal transformations. A single-population optic, they proffered, would be the vehicle for favorable policy making from above and for ethnic empowerment from below. Latino health can be understood as the combination of public health and health services research focusing on people of Latino descent. The large umbrella term provides the strategic advantages of numbers and growth that have the potential of garnering the attention of policy makers and funders while at the same time providing a mechanism for population-internal consciousness-raising, advocacy, and empowerment. As a field, however, Latino health has paid less attention to

Language and Latino health  11 the internal dynamics of latinidad that undergird and sustain a sense of pan-ethnic identification within the population itself. It has also only recently begun to bring into focus the “racializing” and “othering” processes that constitute Latinos as a population “at risk.” Both of these considerations are essential to our understanding of Latino health. The consciousness-raising, advocacy, and empowerment envisioned by Latino health scholars is properly rooted in conceptions of latinidad. The potential for meaningful policy development, on the other hand, must attend not only to in-group characteristics but also to the portrayal and apprehension of these characteristics by out-groups. In what follows, we will consider these two facets of latinidad in order to lay the groundwork for a consideration of the relationship between language and Latino health. Jillian Baez (2007) argues for three different ways in which the concept of latinidad has been theorized. She argues for a political latinidad, a commodified latinidad, and a lived latinidad. Political latinidad is what she calls a strategic political alliance in which intragroup Latinos band together in order to achieve strategic objectives. She draws on the early work of Felix Padilla (1985) on intragroup Latino relations among Mexicans and Puerto Ricans in Chicago and his notion of a “Latino ethnic consciousness” to establish this theoretical orientation. Commodified latinidad is a second theorization that views the construction of a homogenous conceptualization of latinidad as rooted in market interests. Drawing on Arlene Dávila’s work on the construction of the “Hispanic market” (2001), she argues that the theoretical orientation of commodified latinidad essentially co-opts ethnic identification and erases cultural specificity and nuance. Commodified latinidad, according to Dávila (2000), equates language with Latino representativity and subsumes other cultural particularities. Finally, Baez identifies a third theorization that she calls lived latinidad. She draws on Mérida Rúa’s ethnographic work (2001) on the ways that ordinary people live into latinidad through daily negotiations of identity. Rúa sets out to show how latinidad is what Frances Aparicio called “an oppositional yet contested and multiply inflected marker of identity” (1999, p. 3). Rúa’s work uncovers “the agency of individuals in claiming transculturalized spaces such as PortoMex and MexiRicans, while recognizing the multiple tensions located in asserting such an identity for the individual” (2001, p.  123). She argues that people live into latinidad by negotiating and contesting essentializing practices through the deployment of multiple speech patterns, “crossing” over from one group to the other and “passing” as a member of one group rather than the other. People live into latinidad by engaging in transculturalized practices that draw flexibly from different social spaces. Lived latinidad, then, begins with “ordinary exchanges between Latinos of diverse ethnoracial backgrounds” (2001, p. 129). Each of these theorizations informs our understanding of the role of latinidad in the embodiment of health care and health disparities in Latino communities. The theoretical orientation of political latinidad opens a first window into the intersection of latinidad and Latino health. Political latinidad, in fact, has been a salient force in activism around health equity and social justice in Latino populations. The unlawful firing of Magdalena García, a lab technician at Rush

12  Language and Latino health Presbyterian St. Luke’s hospital in Chicago, is a case in point. Victoria Pérez, a colleague of García’s, recalls: like other Latinos, she [Magdalena] was constantly pulled away from her job to translate. That’s how she began to see patient abuses. Many people didn’t know what was being done to them. They were just expected to sign the consent forms. The hospital administrators began to suspect that Magdalena was advising patients about their rights and didn’t like it. She was eventually fired because the hospital believed she could no longer be trusted. (Pérez, 2011, p. 118) García filed a lawsuit against the hospital under Title VII of the Civil Rights Act of 1964 arguing that her discharge was prompted in retaliation for her advocacy of Latino rights and assistance to other Latinos. The case was heard in U.S. District Court in 1978. The plaintiffs, moreover, defined Latino as any Spanish-surnamed person or individual of Hispanic ancestry residing in the city of Chicago. The formation of a political latinidad in this case brought attention to the mistreatment of all Latinos in the health system in Chicago at the time and accused it of systematic discrimination against its own employees who identified with this group. Commodified latinidad, on the other hand, interfaces with Latino health in a different way. If political latinidad has served as a driver of activism and advocacy in opposition to mainstream health services, commodified latinidad has provided a vehicle to bring latinidad into the mainstream. Researchers studying health outcomes in Latino populations have long confronted what seems to be a paradox – while Latino populations demonstrate lower socioeconomic status and less access to health care, their health outcomes appear to be better than those with higher socioeconomic status and greater access. This finding has come to be known as the Latino epidemiological paradox. In 2007, the New York Times published a vivid portrayal of the paradox highlighting the longer-than-expected life span of Latino immigrants: “If medical researchers were to pick someone who might defy national life expectancy statistics,” the author writes, “few would pick Irma Lara” (Kolata, 2007). The author of the piece goes on to describe Mrs. Lara as a 75-year old widow who emigrated to Texas from Mexico, had seven children, and lived on the meager salary of cotton compress company worker. Mrs. Lara, according to the article, is still poor, living on only $600 per month. Even so, Mrs. Lara’s life expectancy is thought to be greater than a similarly situated non-Hispanic white or African American female. Numerous hypotheses have been proffered to account for this paradox. The salmon-bias hypothesis, for example, posits that immigrants tend to return to their countries of origin to die, therefore disappearing from the mortality statistics and creating an illusion of greater longevity. Another hypothesis, known as the healthy migrant effect, posits that the mortality statistics are skewed because only the healthiest people choose to migrate. Unhealthy people choose to remain in the country of origin, thus introducing a selection bias in the population. Studies have found, however, that these hypotheses do not fully explain the mortality statistics. Life expectancy is not the only indicator that

Language and Latino health  13 has puzzled researchers. Birthweight is also a health statistic that has confounded researchers. Latina women tend to have better than expected delivery outcomes as revealed by birthweight statistics. In 2017, the national average of low birthweight deliveries as a percent of all births stood at 8.3%. While African American women accounted for the highest low birthweight deliveries at 13.6%, Hispanic women accounted for only 7.4% – a figure that is much closer to the 7.0% rate of nonHispanic whites than to African Americans (CDC, 2018). Alyshia Galvez (2011) conducted an ethnographic study of Mexican immigrant women in New York City to uncover the potential factors that contribute to the lower than expected low birthweight statistics. Her findings reveal that cultural approaches to prenatal care may be a contributing factor to the low birthweight phenomenon among Mexican immigrants. She argues that many women bring with them traditional prenatal care practices from previous deliveries in Mexico and that these practices might produce a health protective effect. In fact, Galvez’s findings echo a theme that has been resounding in scholarly approaches to the paradox for some time. Researchers have hypothesized that perhaps the cultural practices of immigrants – devotion to family, a collectivist orientation, cultivation of spirituality – provide health protective benefits that neutralize the benefits that accrue to nonimmigrant via socioeconomic indicators. This focus on “culture as cure” (cf. Santiago-Irrizary, 2001) has led some researchers to view the discussion of the Latino epidemiological paradox as an element of the commodified discourse surrounding latinidad. “The popular usage of the Latino paradox,” Arlene Dávila argues, “renders Latinos as the only group whose health is seemingly buffered by their culture” (2008, p. 2). Dávila suggests that the Latino paradox converges on a larger discourse, what she calls “Latino spin,” that reconstitutes Latinos as a marketable segment of the population. The theoretical orientation of commodified latinidad, then, provides another window into how latinidad intersects with Latino health. The theoretical orientation of lived latinidad opens a third window on the intersection of latinidad and Latino health. This orientation brings into focus the perspective of Latinos as they engage with the health system. Lived latinidad provides a framework for understanding the complex negotiations that take place as Latinos interact with a dominant culture health system and with each other in that context. As David Hayes-Bautista argues: when a pregnant Latina avoids going out during a full moon, gives up the pleasures of gum chewing, wears a red thread around her abdomen, and yet wants to see her sonogram and practice Lamaze techniques, she embodies the continuity and change that characterize Latino culture. (2008, p. 6) Engagement with the health system provokes a flexibility and a hybridity in which disparate cultural forms and practices are negotiated and combined in different ways. In one sense, then, latinidad comes to be expressed through these varied combinations. In another sense, however, expressions of latinidad in health care encounters can be assessed through the identities and identifications of

14  Language and Latino health different Latino subgroups in clinical encounters. David Hayes-Bautista and Roberto Chiprut demonstrate the lived experience of pan-ethnic identities and identifications in health care settings in their book The Art of Healing Latinos: Firsthand accounts from physicians and other health advocates. In this book, the editors collect testimonial accounts of Latino health care providers who reflect on their encounters with Latino patients. The testimonial genre offers unique insights into the perspectives of health care providers from multiple backgrounds highlighting the ways that they identify with the culture of their patients. Cuban-born physician Felipe Santana, for example, describes his connection with Mexican immigrant patients in a community mental health clinic in southern California. He writes: In the second week at Clínicas, the experience of American professional life fell away, and I returned to my roots. Everything became clear to me. Everything made sense. I  was present with my patients. I  began to utilize the appropriate cultural tools. I did not need to begin by asking questions. I did not need to be systematic. I was able to learn what I needed through a conversation, during which almost all the information was revealed without my prompting. This method, developed through my experience, was both profound and simple. (Santana, 2008, p. 26) Lived latinidad is thus manifested through these wider pan-ethnic cultural identifications. Another way in which lived latinidad is evinced is through advocacy for Latino patients. América Bracho, a Venezuelan health promoter and director of Latino Health Access in Orange County, California – an award-winning diabetes education program – recalls her advocacy efforts when she was informed that one of her diabetes participants had suddenly gone blind. “In talking with her health provider,” Bracho writes, I discovered that diabetics weren’t receiving eye examinations annually because the clinic simply didn’t believe the patients could manage the treatment of these sorts of complications. I  felt frustrated. This condescending attitude correlated with so many others I  had witnessed in which patients have not been informed of their problems because it was assumed that they were incapable of being part of the solution. And when the patients are lowincome Latinos, the attitudes are even worse. (Bracho, 2008, p. 77) Bracho goes on to describe how she immediately included a module on eye care in her diabetes education curriculum. These examples underscore the role that latinidad can play in health care encounters as a transcultural negotiation both between the home culture and biomedical culture as well as between pan-ethnic providers and patients. These three theoretical orientations to latinidad – political latinidad, commodified latinidad, and lived latinidad – speak to the in-group characteristics that shape

Language and Latino health  15 the experience of health care for Latino populations. But out-group characteristics also play a role in shaping this experience. The “racialization” and “othering” processes that affect Latinos are deep and have been far-reaching. The racialization of Mexicans is a well-documented process that goes back to the initial contacts between Anglos and Mexicans in the nineteenth century (cf. De León, 1983). At the dawn of the twentieth century, propelled by the mass movement of people from Mexico to the U.S. southwest fleeing the violence of the Mexican Revolution, the racialization processes intensified. Carey McWilliams describes an emerging discourse around the so-called “Mexican problem” between 1920 and 1930 (1968, p. 206). Discourse about the Mexican problem focused on the threat of Mexicans to the social fabric of the United States through high rates of delinquency, unsanitary living conditions, illiteracy, and infectious disease. The presence of Mexicans in the United States was thus portrayed as a public health threat. Chicago physician Benjamin Goldberg expressed the view of Mexicans as a public health threat concisely in his 1929 article in the American Journal of Public Health: The Mexican of tomorrow will bring to our towns and cities dangers which will strain the resources of the local and national public health agencies to the utmost. We have discussed the subject of tuberculosis in primitive races merely to bring out the ravages among the Mexicans as they go through the process of urbanization. We have tried to indicate that in this process the Mexican will not be like the Indian, for he will not suffer alone; he will be infected and in turn will broadcast tuberculosis in the community. (Goldberg, 1929, p. 278) The public health response to the perceived threat posed by the presence of Mexicans was to be found in population control measures through either deportation or fertility control. In what follows, we will discuss each of these mechanisms separately; however, it is worth noting at the outset that the mechanisms were open to broad interpretations that quickly spread from a singular focus on Mexicans to a wider focus on Latinos. Deportation and deportability have been key concepts in the production of Mexicans and other Latinos as undesirable and unfit members of the polity. Deportation highlights the power of the state to exert control over its boundaries by forcibly removing and effectively erasing those that it deems undesirable or threatening. It is a powerful mechanism of population control that has been wielded against Latino populations, communities, and families for decades. In the 1930s, for example, the U.S. government unleashed this mechanism in an unprecedented way. Between 1929 and 1936, anywhere from 400,000 to 2,000,000 Mexicans were forcibly removed from the country in response to the concomitant forces of anti-Mexican hysteria and the Great Depression. It is estimated that up to 60% of those forcibly removed were birthright citizens of the United States (Balderrama & Rodríguez, 2006). People of Mexican origin were stripped from their families and their possessions, loaded up on trains and sent to a country that

16  Language and Latino health they did not know. The public health system was an integral part of the effort to identify, locate, and deport Mexicans. In Los Angeles, for example, the responsibility for identifying candidates for repatriation was located in the Deportation Section of the Los Angeles County Department of Charities – the entity responsible for all public medical facilities in the county. The mission of the deportation section was “to identify and then deport any undocumented Mexican receiving county-sponsored medical aid” (Molina, 2006, p. 136). According to Molina, this single deportation section was responsible for deporting over thirteen thousand Mexicans between 1931 and 1933. But the role of public health in carrying out deportation was not limited to the implementation of the mass repatriation of Mexicans in the 1930s. On the contrary, public health’s role in deportation has been codified in immigration law, making medical diagnosis a singularly potent criterion for deportability. The Immigration Act of 1891 defines the condition of “likely to become a public charge” (LPC) as grounds for deportation. “Any alien who becomes a public charge within one year after his arrival in the United States from causes existing prior to his landing therein shall be deemed to have come in violation of law and shall be returned as foresaid” (cited in Molina, 2014, p. 92). By 1917, the LPC grounds had been extended from 1 year to 5 years. LPC, then, became permanent grounds for deportation and was utilized to target undesirable immigrants. As Molina notes: The strategy was foolproof. Migrant laborers’ poor working and living conditions made them more vulnerable to disease, and the high population of single, male migrant workers and workers separated from their families increased the likelihood of the presence of sexually transmitted diseases in particular. Hence, Mexicans were always suspended in the state of deportability. (Molina, 2014, p. 109) Deportability, as a mechanism of population control, has been accompanied by another mechanism – fertility control. The concerns over Mexican immigration emerging in the 1920s continued unabated throughout the twentieth century. As Alexandra Stern has shown in her book Eugenic Nation: Faults and frontiers of better breeding in modern America, immigration concerns had long been tied to eugenic views on population control. Coined by Sir Francis Galton, the term eugenics refers to what Davenport called in 1911 the “science of the improvement of the human race by better breeding” (cited in Stern, 2016, p.  11). The eugenic underbelly of anti-immigrant sentiment was manifested more fully in the 1960s when anti-immigrant sentiment converged with growing concerns around the impact of overpopulation on the planet and on humanity itself. Stanford University professor Paul Ehrlich published his book The Population Bomb in 1968 warning of mass starvation and major societal upheaval if population growth was not curtailed. His work, although severely criticized for its alarmist tone, sparked a move towards zero population growth (a situation in which the natality rate was equal to the mortality rate). The convergence of these two discourses brought into focus not just the “illegal” presence of Mexicans in the United States but also

Language and Latino health  17 their higher-than-average fertility rate. Fertility control thus came to be a sinister cousin of deportation and deportability. Leo Chavez sums up the concern over Mexican fertility in the U.S.: “in the final analysis, the discourse surrounding Latina fertility and reproduction is actually about more than reproduction. It is also about reinforcing a characterization of whites as the legitimate Americans who are being supplanted demographically by less-legitimate Latinos” (2008, p. 110). The same concerns that motivated deportation were also the driving force of fertility control. Coercive sterilization was the method of choice to enact fertility control. In her book Fertile Matters: The politics of Mexican-origin women’s reproduction, Elena Gutiérrez documents the pattern of coercive sterilization that emerged in Los Angeles during the mid-twentieth century leading up to the landmark case Madrigal vs. Quiligan. The Madrigal case was a complaint by ten women who had been sterilized without proper consent at the Los Angeles County Medical Center. The complaint alleged that Mexican women were sterilized at higher rates than non-Mexican women and that they were coerced into consent by multiple means, such as being told that their babies would die if they failed to consent, having pain medication withheld, or simply being told “sign here.” The impact of sterilization on the lives of the plaintiffs was profound. It thrust some women into severe depression, led to marital strife and even drove some women to want to commit suicide. While the court case ultimately did not lead to a legal victory, it did prompt policy changes such as a mandate to provide informed consent forms in Spanish and a mandatory 72-hour waiting period in cases of informed consent for tubal ligations (Gutierrez, 2008). Coercive sterilization was not only exacted on Mexican women but was also a common practice in Puerto Rico beginning in the late 1930s until well into the 1970s. In the Puerto Rican case, the motive for coercive sterilization was the soaring unemployment rate on the island as a consequence of industrialization. The U.S. government implemented a series of campaigns promoting the ideal family size as an imperative of modernization. And while the kinds of abuses documented in California were not present in Puerto Rico, the common theme among sterilized Puerto Rican women was that they thought it was a reversible procedure. Coercive sterilization quickly become a hot-button political issue tied to the larger issue of the political status of the island. These concerns spread to mainland Puerto Rican advocacy groups such as the Young Lords. As Laura Briggs notes: “mainland-born youth in their late teens and early twenties were inspired by mainland racial justice movements, the legacy of Albizu, and the insular independence movement. They adopted the pro-natalist, anti-sterilization rhetoric” (2002, p. 152). Deportation and fertility control were thus tied together as twin engines that fueled the policy response to what Leo Chavez has called the discourse of “Latino threat.” In doing so, they also blurred and erased the cultural nuances of the different Latino origin subgroups and strengthened the representation of Latinos as a single homogenous and undesirable group. By placing Latinos within a “Latino threat” narrative “the objects of this discourse are represented as the Other and

18  Language and Latino health as a ‘threat’ and ‘danger’ to the nation through such simple binaries of citizen/ foreigner, real Americans/Mexicans or real Americans/Hispanics, natives/enemies, us/them, and legitimate/illegal” (Chavez, 2008, p. 41). This dimension of racialization and othering is a powerful force in Latino health. Recent research has sought to explore the impact of othering on health by proposing that the processes whereby immigrants and their descendants ‘become American’ involve more than behavioral norm-swapping, as simple conceptualization and interpretations of acculturation would lead us to believe. Rather, these processes entail learning and interpreting the racial dynamics of the U.S. and finding one’s location within it. (Viruell-Fuentes, 2007, p. 1533) When I talk about Latino health, then, I am not referring simply to public health and health services research that focuses on Latino populations. On the contrary, Latino health brings into focus not only the internal dynamics of intra-ethnic identification and identity within the health care context but also the effect of larger racialization and othering processes that affect Latinos as a collective whole. In what follows, we will explore the intersection of this specific understanding of Latino health with the use of Spanish in health care settings.

Language and Latino health: from social determinant to syndemic The empirical study of the impact of Spanish language preference and use in Latino populations has evolved considerably over the past two decades. In this section, we will consider the major thrust and evolution of this empirical research, identify gaps, and propose alternative theoretical insights that may provide new understandings of the place of Spanish in Latino health. Early studies focused on Spanish language preference as a stable dichotomous (Spanish vs. English) or trichotomous (Spanish vs. Spanish/English vs. English) variable that sheds light on patterns of disease distribution or access to care. Rooted in social epidemiology, a subfield of epidemiology that seeks to uncover the influence of social circumstances on health, these studies viewed Spanish language preference, use and/or proficiency as a social determinant of health. Social determinants of health can be viewed as causes of illness or wellness. For example, we have typically understood causes such as a diet high in saturated fat and salt as a risk factor of the ultimate outcome, i.e., heart attack. Social determinants take a step back and consider the reasons why some people are more likely than others to consume this type of high-risk diet. As Michael Marmot has noted: “it is not an accident that people consume diets high in saturated fat and salt. It represents the nature of the food supply, culture, affordability, and availability, among other influences” (Marmot, 2006, p. 3). These more distal influences then are viewed as social determinants of health. Figure  1.1 visually represents the concept of social determinants of health.

Language and Latino health  19

Figure 1.1 Social determinants of health. The model links social structure to health and disease via material, psychosocial and behavioral pathways. Genetic, early life and cultural factors are futher important influences on population health. Source: Brunner & Marmot 2006, p. 9; Reproduced with permission from Oxford University Press through PLSclear

This visual representation highlights a uni-directional influence wherein social structure (in the upper left-hand corner) impacts well-being, morbidity, and mortality (in the lower right-hand corner). The pathways of influence can be either material (as seen in the direct line going from social structure to well-being, morbidity, and mortality) or they can be mediating influences in the form of early life experiences, genetic disposition, or cultural factors (which all mediate some part of the model). In the center of the diagram, furthermore, we see a complex chain of causation that takes us from social structure through either work experience or the social environment. These two factors in turn may influence both health behaviors and psychological factors. Psychological factors have a direct impact on the brain and both the brain and psychological factors may influence health behaviors (as noted in the dual-headed arrows). Finally, factors in the brain and in health behaviors influence pathological changes which then ultimately lead to well-being, morbidity or mortality. Studies of Latino health that consider language as a social determinant of health can be sorted into those that look at language preference, use, or proficiency of the patient as a factor influencing health outcomes, and those that look at the impact of language concordance between provider and patient. Studies focusing on

20  Language and Latino health language preference, use, or proficiency have identified outcome factors related to both access to care and specific health outcomes. These studies provide conclusive evidence that Spanish-language preference, use, and proficiency are associated with limited access to health service and with less than optimal health outcomes. Studies have examined the impact of Spanish language preference, use, or proficiency on access to health services. Access-oriented studies have focused on cancer screening, on receipt of recommended care, and on health literacy. Jacobs et al. (2005), for example, found that women who only spoke a language other than English had a lower likelihood of cancer screening than women who spoke English. Cheng, Chen, and Cunningham (2007), on the other hand, focused on patient receipt of eligible health care services by Latino and white patients using data from the Medical Expenditure Panel Survey of 2003. They compared white patients with Latino patients who spoke English at home, Latino patients who did not speak English at home but were comfortable speaking English, and Latinos who did not speak English at home and were not comfortable speaking English. While 53.6% of Latinos who spoke English at home received all eligible health care services, only 35% of Latinos who did not speak English at home and were not comfortable speaking English received these services. Jacobson, Hund, and Soto Mas (2016) focused on health literacy as a measure of access. The Institute of Medicine defines health literacy as the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions (IOM, 2004). The authors found that English proficiency was the strongest predictor of health literacy. Outcome-oriented studies point to disparities in the results of care and have focused on vaccination, participation in health-promoting lifestyle activities, length of hospital stays, and informed consent. A study of influenza vaccination among Latino seniors in the southeast of the U.S., for example, found that Spanishpreferring and linguistically isolated seniors were far more likely to have lower rates of vaccination than non-Hispanic whites (Haviland et  al., 2011). Another outcome-oriented study focused on participation in health-promoting lifestyle activities among Spanish-speaking Latinos in Nebraska and Iowa- including healthy eating, participation in physical activity, stress management, and spiritual growth behaviors. Latinos were grouped in three language-based strata: 1) those who spoke Spanish only, 2) those who spoke Spanish more than English, and 3) those who spoke both languages equally. The findings revealed that those who spoke Spanish only were least likely to participate in health-promoting lifestyle activities, followed by those who spoke Spanish more than English. Those who spoke both languages equally were the most likely to participate in these activities. The authors thus concluded that English language proficiency and use increases participation in health-promoting lifestyle behaviors (Hulme et al., 2003). Hospitalbased studies have also focused on outcomes. For example, a study of length of hospital stays compared limited English proficient (LEP) patients with English proficient (EP) patients and found that LEP patients stay in the hospital 6% longer than EP patients (John-Baptiste, 2004). Another hospital-based study examined the documentation of informed consent for common invasive procedures among

Language and Latino health  21 LEP and EP patients. This study found that EP patients were three times more likely than LEP patients to have full informed consent documentation in the medical record (Schenker et al., 2007). Studies of language concordance seek to elucidate the effects of receiving care from a Spanish-speaking provider. Language concordant care occurs when a Spanish-speaking patient is seen by a provider who also speaks Spanish. Language discordant care occurs when a Spanish-speaking patient is seen by a provider who does not speak Spanish. Language concordance studies with Latino populations have focused on specific health outcomes, on the quality of care, and on intersubjective processes in the health care encounter. Outcomes-oriented studies have focused on the influence of language concordance on glycemic control among Spanish-speaking patients with diabetes. Spanish-speaking patients with diabetes who receive language discordant care are almost twice as likely to have poor glycemic control in comparison to Englishspeaking patients, while those who receive language concordant care are more similar to English-speaking patients (Fernandez et al., 2011). A follow-up study was conducted to confirm these findings and further underscore the impact of language concordance on diabetes management. The study set out to determine the impact on glycemic and cholesterol (LDL) control when a Spanish-speaking patient with diabetes switched from a language discordant physician to a language concordant physician. Among patients who switched physicians, there was a 10% increase in glycemic control and a 15% increase in LDL control (Parker et al., 2017). Other outcomes-oriented studies have focused on the role of language concordance in promoting medication adherence. A study examining adherence of Spanish-speaking patients to cardiovascular disease medication found that patients with language concordant physicians were 6% more likely than patients with language discordant physicians to adhere to their medication regimen (Traylor et al., 2010). Another study on medication adherence evaluated the effect of language concordant prescription medication instructions. This study demonstrated that patients who received language concordant instructions demonstrated greater understanding of their medication and its dosing (Bailey et  al., 2012). These outcome-oriented studies demonstrate that language concordant care has clinically relevant implications for Spanish-speaking patients. Language concordance studies have also focused on quality of health care investigating measures such as patient satisfaction, timeliness of care, and hospital discharge processes. A  study of foreign-born, limited–English-proficient Latino patients drawn from the Latino Health Survey indicated that these patients were more likely to self-report clinical experiences as confusing, frustrating, and of poor quality. The study set out to determine if patients receiving language concordant care were more or less likely to self-report these experiences. The findings revealed that patients with language concordant physicians were less likely to report confusion, frustration or poor quality in comparison to patients with language discordant physicians. The authors conclude that while English language proficiency is important in receiving quality care, the fact that the patient and the doctor speak the same language seems to be a more important determinant of

22  Language and Latino health quality care (González, Vega & Tarraf, 2010). Another study indicated that while language concordance in general drives patient satisfaction, patients were more satisfied when their providers spoke Spanish fluently (Eskes et al., 2013). Finally, language concordance studies have measured intersubjective processes such as agreement with physician recommendations, number of questions asked, trust and rapport, and perceptions of discrimination. These intersubjectiveoriented studies also point to the advantages of language concordant care. A study that examined physician-patient agreement about physician recommendations for health behaviors found that patients with language concordant physicians were more likely to agree with their physician’s recommendations about exercising than those with language discordant physicians (Clark, Sleath & Rubin, 2004). Another study examined the influence of language concordance on interpersonal care as a function of communication, decision-making, and interpersonal style. Patients with language concordant physicians, in comparison to patients with language discordant physicians, were less likely to perceive lack of clarity in physician communication and more likely to indicate that the doctor elicited concerns and explained results. Patients with language concordant physicians were also more likely to indicate that decisions were made together in comparison to patients with language discordant physicians (Detz et al., 2014). Patients’ improved perceptions of interpersonal care with language concordant physicians has also been shown to impact the number of questions that patients tend to ask. Language concordant care increases the number of patient-asked questions during a visit (Jaramillo et  al., 2016). This outcome of language concordant care reflects a broader impact in the trust and rapport established between Spanishspeaking patients and their language concordant physicians. A study of clinical interactions among patients with diabetes, for example, found that patients with language discordant physicians were significantly more likely to lack confidence and trust in their physician and to feel treated poorly and disrespected by physicians in comparison to patients with language concordant physicians (Schenker et al., 2010). A study on the effects of language concordance and interpreter use on the therapeutic alliance in behavioral health found that patients felt that language concordant encounters were more efficient, more effective, more confidential, and easier for the establishment of trust and rapport. Patients in the study who had language concordant providers also indicated that they were more willing to disclose sensitive information when interacting with a language concordant provider as opposed to when they were interacting through an interpreter (Villalobos et al., 2016). Together these studies establish language as a social determinant of health. They show that Spanish-language preference, use, and proficiency have a measurable impact on access to services and on health outcomes. Further, they suggest that the presence of language concordant providers improves health outcomes, quality of care, and intersubjective processes. Recent research, however, has begun to push the boundaries of these associations. For example, researchers are beginning to question how Spanish-language preference, use, and proficiency interact with other known social determinants of health. They are also questioning

Language and Latino health  23 the influence of intersubjective processes beyond the language concordant health care encounter. Studies that seek to shed light on the interactions between language and other social determinants are beginning to uncover heretofore unnoticed connections. For example, researchers are beginning to look at mediating factors that might affect the relationship between language and health, including racial identification (Cuevas, Dawson & Williams, 2016) and place of origin (Abraido-Lanza, 2015). As Abraido-Lanza points out: “Latino groups differ in sociopolitical histories and reasons for migrating to the United States. Moreover, the context of reception in the United States differs for the various groups and at different points as a result of economic conditions, labor shortages, and the political climate” (Abraido-Lanza, 2015, p. 567). These differential contexts can shape the ways that language interacts with health. Economic conditions, labor shortages, and the political climate can significantly reduce the frequency of contact between Spanish speakers and health and social service agencies. Other studies are zeroing in on “post-migration perceived social mobility” as a factor that interacts with language. These studies focus on the perception of upward or downward mobility as a function of migration. An examination of data drawn from the National Latino and Asian American Study found that major depressive events were positively correlated with perceptions of post-migration downward mobility (Alcántara, Chen & Alegría, 2014). Together these studies appear to suggest that social determinants, including language, may be relative to the contexts in which they emerge and may be dependent upon previous experiences. As Hsieh (2017) has pointed out: language discordance is situated in the complex tension of political power and linguistic legitimacy . . . an under-theorized and under-synthesized area of research on LEP patients is the various factors that may serve as mediating and moderating factors for language discordant patients’ experiences in health care settings. (p. 3) In addition to questions about the interactions and situatedness of language and other social determinants, researchers are also beginning to focus on issues of intersubjectivity beyond the clinical encounter. How do wider intersubjective processes influence health outcomes and health care access? A study of health beliefs, health promotion practices, past health care experiences, and transition to a new society and health care system among 20 Latina women in Utah found that women expressed feelings of aloneness in seeking health care. The women in this study recalled that, in their home countries, illness was handled in a more social way. One of the women in the study confided: “I feel that I could not defend myself in this country” (Sanchez-Birkhead et  al., 2011, p.  1170). A  study of language barriers among Latina mothers in Detroit and Baltimore revealed similar findings. Mothers described managing language barriers as a “battle” and expressed a preference for bilingual providers, negative bias towards interpreters, getting by with limited language skills, fear of being a burden, and stigma and discrimination

24  Language and Latino health (Steinberg et al., 2016). A review of coping strategies among Latino caregivers of children with chronic illnesses found that language, cultural dissimilarities, differences in health beliefs, and feeling disrespected were common challenges. Sources of support among lower income recent immigrants with limited English proficiency were principally from the family. Feelings of isolation, furthermore, were more pronounced and emerged from having a significantly smaller social network (Desai, Torres-Rivera & Backes, 2016). Viruell-Fuentes and Schultz (2009) probed the issue of social ties further in their study of first- and second-generation Mexican women in Detroit. They argue that networks are less culturally determined and more responsive to the contexts in which they emerge. For example, they demonstrate that first-generation women found a great deal of support in family members upon arrival but that this support withered away as family members faced their own challenges. Second-generation women, on the other hand, emphasized the racialized context of social ties and the importance of identity supports that would foster a positive ethnic identity. First- and second-generation women thus faced different challenges in establishing and maintaining social ties. First-generation women experienced eroding support from family members and increasing isolation. Second-generation women experienced “othering” processes and identity erosion in a racialized context. Together these studies underscore the impact of wider intersubjective processes on health outcomes and health care access. Feelings of aloneness and isolation, lack of social support, struggles for access, and othering all place Latinas/os at risk of diminishing emotional health. These new directions in research on language as a social determinant of health suggest the need for a different “idiom of social justice mobilization” when discussing the relationship of Spanish to Latino health (Willen, Abadía-Barrera & Davidovitch, 2017). Studies on the interactions of language and other social determinants suggest that the effects of Spanish-language preference, use, and proficiency are situated and contextual. Studies on the wider intersubjective processes affecting Spanish speakers suggest that language barriers interact with emotionally debilitating experiences both within the health care setting and beyond it. What these approaches have in common is their insistence on viewing language as couched in a larger set of processes that impact health outcomes and health care access. The social determinant model, however, has difficulty capturing the embeddedness and intersectionality of language with other social determinants, wider intersubjective processes and, many times, multi-morbid physical and mental health conditions. The unidirectional nature of the model and its bias towards causation as opposed to interaction leads us to question its ability to adequately capture the multilayered and complex relationship between Spanish and Latino health. Syndemic theory is an alternative way to conceptualize the relationship between Spanish and Latino health. Syndemic is an idiom of social justice mobilization for health that values the complexity of interacting social factors and that looks beyond disease causation to focus instead on the varying experiences of living with disease. Rooted in medical anthropology, syndemic theory arose out of concerns around medical comorbidities and the social factors that interact

Language and Latino health  25 with comorbid conditions. Merrill Singer coined the term syndemic as a blend of the words “synergy” and “epidemic” to express the dominant focus of the approach on synergies in disease states. The concept emerged from Singer’s work among HIV-AIDS patients in Connecticut. He found that most HIV-AIDS interventions were designed primarily with middle-class, white, homosexual men in mind. These interventions were of little use in his work where he encountered HIV-AIDS patients who not only did not match the demographic bias, but also who were experiencing other conditions together with HIV-AIDS, namely substance abuse and violence. He thus set out to explore the experience of living with AIDS in conjunction with substance abuse and violence and characterized his work as focusing on the SAVA (Substance Abuse, Violence, AIDS) syndemic. He defines the term syndemic as “the concentration and deleterious interaction of two or more diseases or other health conditions in a population, especially as a consequence of social inequity and the unjust exercise of power” (Singer, 2009, p. xv). More than a model or a theory, syndemic can be described as a sensibility; a sensibility that expands, enriches, and reframes our understanding of complex situations of health adversity (Willen, Abadía-Barrera  & Davidovitch, 2017). Viewing health adversity with a syndemic sensibility allows us to: 1) Recognize how upstream factors create and perpetuate structural vulnerabilities that contribute to syndemic emergence and excacerbation; 2) to understand and describe how certain individuals, families, and communities but not others are consigned to harmful environments of syndemic vulnerability with concrete effects, and 3) to intervene more effectively both upstream in the domains of civil society, law, policy, and public health practice and downstream at the point of clinical contact. (Willen, Abadía-Barrera & Davidovitch, 2017, p. 968) In this way, a syndemic sensibility moves us away from a focus on causation and invites us to focus instead on interaction. Figure 1.2, describing a syndemic model of substance abuse, intimate partner violence, HIV infection, and mental health conditions among Latinos, visually represents the distinctive features of the syndemic perspective. In Figure  1.2, the cross-shaped figure represents the syndemic interaction of the four identified health conditions. The circles represent upstream social factors that influence the four-pronged syndemic interaction including individual factors, cultural factors, relationship factors and socio-environmental factors. These factors not only interact with the comorbid conditions identified in the syndemic, but they also interact with each other as represented in the dual-headed arrows linking each circle. The syndemic perspective has been profitably applied to Latino health. Emily Mendenhall (2012) describes the VIDDA syndemic affecting Mexican immigrant women in Chicago. The VIDDA syndemic analyzes the interactions between violence, immigration/isolation, depression, diabetes, and abuse. Her analysis of

26  Language and Latino health

Individual Factors •

Intrinsic: Self-esteem, selfefficacy, self-reliance

•

Extrinsic: Income, education, employment, lack of health insurance

Substance Abuse

Relationship Factors • • • •

Relationship conflict Family conflict Communication Connection to community organizations/institutions

Cultural Factors • • • • •

Acculturation Hispanic stress Familism Traditional gender norms Religion

Intimate Partner Violence

HIV Infection

Syndemic

Mental Health Conditions

Socio-Environmental Factors • • • • •

Access to culturally sensitive services Discrimination Laws regarding legal status Poverty Structural unemployment and underemployment

Figure 1.2 A Syndemic model of substance abuse, intimate partner violence, HIV infection and mental health conditions among Hispanics. Source: González-Guarda et. al. 2011, p. 368; Reproduced with permission of John Wiley and Sons, Ltd by PLSclear

the syndemic draws on the life stories of women whose biographies personify the complex interactions and interrelatedness of experiences such as childhood trauma, struggles for social integration, sexual coercion and violence, family stress, depression, and the everyday stresses of managing diabetes. She demonstrates how structural factors such as food deserts, unsafe neighborhoods, and discrimination interact with sociocultural factors such as acculturation and gender roles, which in turn interact with individual factors such as childhood experiences and coping mechanisms and with relationship factors such as family conflict and social support in order to create an excess burden of diabetes, depression, immigration, violence, and abuse. Sarah Bronwen Horton (2016) describes a syndemic of heat stroke and kidney disease among farmworkers in California’s Central Valley abetted by structural factors such lack of labor protections for agricultural workers and undocumented status. González-Guarda, Florom-Smith and Thomas (2011), González-Guarda et al. (2016) describes a syndemic of substance abuse,

Language and Latino health  27 intimate partner violence, HIV, and mental health among Latino men. They argue that cultural factors such as immigration-related stress and adherence to cultural values such as familismo, machismo, and marianismo, and the influence of religion may all serve to link syndemic conditions. While these factors may contribute to an excessive burden of disease in some cases, in other cases cultural factors may also be health protective. For example, the cultural value of familismo can be an important protective factor when families accept and support children identifying with a minority sexual orientation. The application of a syndemic sensibility has the potential of considerably advancing our understanding of the relationship of Spanish and Latino health. It invites us to contextualize Spanish-language preference, use, and proficiency in ways that previous studies have overlooked. Further, it invites us to adopt a more granular perspective on language concordant encounters. A  syndemic sensibility in the study of Spanish and Latino health, moreover, can open up new lines of research. For instance, how do life-course events and experiences shape and contribute to syndemic production? What role do childhood or recent immigrant experiences of linguistic othering play in the burden of disease within Latino populations? Questions such as these will open our research purview to language experiences that are currently invisible to us. And this brings us full circle to Maribel Garza. Her story is one of multiple conditions, all interacting with each other and increasing the burden of disease, changing the experience of disease. I think we owe it to Maribel Garza to expand our questioning and to strive to truly understand her plight. Only in this way can we begin to lighten her load and get to that “one day” that drives her.

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30  Language and Latino health Hulme, Polly, Noble Walker, Susan, Effle, Kathy, et al. (2003). Health-promoting lifestyle behaviors of Spanish-speaking hispanic adults. Journal of Transcultural Nursing 14: 244–254. Hymes, Dell. (1997). The scope of sociolinguistics. In Nikolas Coupland & Adam Jaworski, eds. Sociolinguistics: A Reader and Coursebook. New York: Palgrave Macmillan, pp. 12–22. Institute of Medicine. (2004). Health Literacy: A Prescription to End Confusion. Washington, DC: National Academies Press. Jacobs, Elizabeth, Karavolos, Kelly, Rathouz, Paul, Ferris, Timothy  & Powell, Lynda. (2005). Limited English proficiency and breast and cervical cancer screening in a multiethnic population. American Journal of Public Health 95: 1410–1416. Jacobson, Holly, Hund, Lauren & Soto Mas, Francisco. (2016). Predictors of English health literacy among U.S. hispanic immigrants: The importance of language, bilingualism and sociolinguistic environment. Literacy and Numeracy Studies 24: 43–65. Jaramillo, Joshua, Snyder, Elizabeth, Dunlap, Jonathan, et al. (2016). The hispanic clinic for pediatric surgery: A model to improve parent-provider communication for hispanic pediatric surgery patients. Journal of Pediatric Surgery 51: 670–674. John-Baptiste, Ava, Naglie, Gary, Tomlinson, George, et al. (2004). The effect of English language proficiency on length of stay and in-hospital mortality. Journal of General Internal Medicine 19: 221–228. Joint Commission. (2010). Advancing Effective Communication, Cultural Competence and Patient- and Family-Centered Care: A Roadmap for Hospitals. Oak Terrace, IL: The Joint Commission. Kelly, Natalie. (2008). The voice on the other end of the phone. Health Affairs 27: 1701–1706. Kolata, Gina. (2007). Data on Hispanic immigrants presents puzzle on aging. New York Times. Retrieved 3 December  2018 from: https://www.nytimes.com/2007/01/03/ science/03ageside.html. Lozada-Oliva, Melissa. (2017). Peluda. Minneapolis: Button Poetry. Marmot, Michael. (2006). Introduction. In Michael Marmot  & Richard Wilkinson, eds. Social Determinants of Health. 2nd Edition. Oxford: Oxford University Press, pp. 1–5. McWilliams, Carey. (1968[1948]). North from Mexico: The Spanish-Speaking People of the United States. New York: Greenwood Press. Mendenhall, Emily. (2012). Syndemic Suffering: Social Distress, Depression, and Diabetes Among Mexican Immigrant Women. New York: Routledge. Molina, Natalia. (2006). Fit to Be Citizens? Public Health and Race in Los Angeles, 1879– 1939. Berkeley: University of California Press. Molina, Natalia. (2014). How Race Is Made in America: Immigration, Citizenship, and the Historical Power of Racial Scripts. Berkeley: University of California Press. Mora, Cristina. (2014). Making Hispanics: How Activists, Bureaucrats and Media Constructed a New America. Chicago: University of Chicago Press. Office of Minority Health. (2001). National Standards for Culturally and Linguistically Appropriate Services in Health Care. Washington, DC: U.S. Department of Health and Human Services. Office of Minority Health. (2013). National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care: A Blueprint for Advancing and Sustaining CLAS Policy and Practice. Washington, DC: U.S. Department of Health and Human Services.

Language and Latino health  31 Ortega, Pilar. (2018). Spanish language concordance in U.S. medical care: A multifaceted challenge and call to action. Academic Medicine 93: 1276–1280. Padilla, Felix. (1985). Latino Ethnic Consciousness: The Case of Mexican Americans and Puerto Ricans in Chicago. Notre Dame: University of Notre Dame Press. Parker, Melissa, Fernandez, Alicia, Moffet, Howard, et al. (2017). Association of patientphysician language concordance and glycemic control for limited English proficiency Latinos with type 2 diabetes. Journal of the American Medical Association 177: 380–387. Pérez, Victoria. (2011). Defending my people and my culture. In L. Ramírez, ed. Chicanas of 18th Street: Narratives of a Movement from Latino Chicago. Urbana: University of Illinois Press. Rampton, Ben. (2018). Crossing: Language and Ethnicity among Adolescents. New York: Routledge. Rúa, Mérida. (2001). Colao subjectivities: Porto-Mex and MexiRicans perspectives on language and identity. CENTRO Journal 13: 117–133. Sanchez-Birkhead, Ana, Kennedy, Holly, Callister, Lynn  & Miyamoto, Teresa. (2011). Navigating a new health culture: Experiences of immigrant hispanic women. Journal of Immigrant and Minority Health 13: 1168–1174. Santana, Felipe. (2008). Dolor de cabeza: Headache–depression or martyrdom? In D. Hayes-Bautista  & R. Chiprut, eds. The Art of Healing Latinos. Los Angeles: UCLA Chicano Studies Research Center Press, pp. 24–36. Santiago-Irrizary, Vilma. (2001). Medicalizing Ethnicity: The Construction of Latino Identity in a Psychiatric Setting. Ithaca: Cornell University Press. Schenker, Yael, Karter, Andrew, Schillinger, Dean, et  al. (2010). The impact of limited English proficiency and physician language concordance on reports of clinical interactions among patients with diabetes: The DISTANCE study. Patient Education and Counseling 81: 222–228. Schenker, Yael, Wang, Frances, Selig, Sarah, Ng, Rita & Fernandez, Alicia. (2007). The impact of language barriers on documentation of informed consent at a hospital with onsite interpreter services. Journal of General Internal Medicine 22: 294–299. Singer, Merrill. (2009). Introduction to Syndemics: A Critical Systems Approach to Public and Community Health. San Francisco: Jossey-Bass. Steinberg, Emma, Valenzuea-Araujo, Doris, Zickafoose, Joseph, et  al. (2016). The ­“battle” of managing language barriers in health care. Clinical Pediatrics 55: 1318–1327. Stern, Alexandra. (2016). Eugenic Nation: Faults and Frontiers of Better Breeding in Modern America. 2nd Edition. Berkeley: University of California Press. Tang, Gayle, Lanza, Oscar, Rodríguez, Fátima & Chang, Annie. (2011). The Kaiser Permanente clinician cultural and linguistic assessment initiative: Research and development in patient-provider language concordance. American Journal of Public Health 101: 205–208. Tervalon, M. & Murray-García, J. (1998). Cultural humility versus cultural competence: A critical distinction in physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved 9: 117–125. Traylor, Ana, Schmittdiel, Julie, Uratsu, Connie, Mangione, Carol & Subramanian, Usha. (2010). Adherence to cardiovascular diseases medications: Does patient-provider race/ ethnicity and language concordance matter? Journal of General Internal Medicine 25: 1172–1177.

32  Language and Latino health Villalobos, Bianca, Bridges, Ana, Anastasia, Elizabeth, et al. (2016). Effects of language concordance and interpreter use on therapeutic alliance in Spanish-speaking integrated behavioral health care patients. Psychological Services 13: 49–59. Viruell-Fuentes, Edna. (2007). Beyond acculturation: Immigration, discrimination, and health research among Mexicans in the United States. Social Science & Medicine 65: 1524–1535. Viruell-Fuentes, Edna  & Schultz, Amy. (2009). Toward a dynamic conceptualization of social ties and context: Implications for understanding immigrant and Latino health. American Journal of Public Health 99: 2167–2175. Watt, Kelly, Abbott, Penny & Reath, Jenny. (2016). Developing cultural competence in general practitioners: An integrative review of the literature. BMC Family Practice 17: 158. Willen, Sarah, Abadía-Barrera, Cesar  & Davidovitch, Nadav. (2017). Syndemic vulnerability and the right to health. Lancet 389: 964–977. World Health Organization. (1946). Preamble to the Constitution of WHO as Adopted by the International Health Conference, New York, 19 June–22 July; signed on 22 July 1946 by the representatives of 61 States (Official Records of WHO, no. 2, p. 100) and entered into force on 7 April 1948.

2 Language in health care policies

Miguel was born in Reynosa, Mexico. Miguel was the oldest of four boys. Miguel’s mother Rosa recalls that she rarely saw a doctor during her pregnancy with Miguel. There really was no extra income to spend on doctor’s visits. Miguel was born premature at a gestational age of 33 weeks; he weighed two kilograms at birth. His health problems were constant. He spent a month in the Neonatal Intensive Care Unit in a Mexican hospital until finally he was discharged. When Miguel reached seven months, Rosa and her husband decided to move to the U.S. in search of better medical treatment and ultimately a “shot at life” for Miguel. Rosa recalls the family’s plight immediately after making their way to the U.S. They had difficulty finding a steady job. They struggled to find a place to live. For about 3 months, they bounced around from town to town in the Rio Grande Valley. After several months living in the U.S., Miguel had his first seizure while Rosa was feeding him. Rosa immediately called the ambulance and Miguel was taken to the local Children’s Hospital. This was the first of a series of endless hospital visits for Miguel. After multiple hospital stays, doctor’s visits, and tests, Miguel was diagnosed with epilepsy. Rosa recalls seeing specialists for Miguel and feeling helpless as she was not able to understand them, nor were they able to communicate with her. The inability to communicate with doctors left Rosa feeling as if she was in the dark. She had never heard the word epilepsy before and had no idea how to help Miguel through his seizures. Even so, Miguel was taking up to six different kinds of medications. Rosa did not understand what all the medications were for, nor did she know what to do in case of violent and prolonged convulsive seizures. But Rosa faithfully administered the medication that Miguel was given in the hope that somehow it would help. After several months of seeing no change, the family began to think that the doctors really didn’t want to cure Miguel. They began to think that it was really all just a business. Rosa would go to the doctor. She did her part. But she felt like the doctors didn’t really take the time to explain her child’s condition to her. Part of the reason she sometimes decided to stay away from the doctors

34  Language in health care policies was that she couldn’t understand them, much less trust them. What if they found out that she didn’t have papers? What if they deemed her child as undeserving of treatment? Rosa recalls a time when she was at the doctor’s office and an ICE (Immigration and Customs Enforcement) agent walked in. She remembers seeing the ICE agent lower his sunglasses looking at Miguel peacefully playing with the pieces of a jigsaw puzzle on floor. She panicked. She got out of her chair, collected her belongings, picked Miguel up from the floor and walked out of the office. The receptionist at the doctor’s office called several hours later to ask what the problem was. Rosa just didn’t want to go back to that office. Rosa recalls that during her first year of living in the U.S., she called the ambulance more than ten times due to seizures that lasted over five minutes. After three years of living in the U.S., Miguel had a seizure that lasted for more than thirty minutes. He was taken to the hospital for what had seemingly become a routine visit. On that fateful night, Miguel passed away. Doctors say that Miguel’s passing was due to a lack of oxygen in the brain caused by the seizures. Rosa says that she never thought that trying to give her children a better life would cost her son Miguel’s life. Story by Aaron Salinas (Used with permission)

Rosa’s story is a fitting one to begin this chapter on language in health care policies (LHP). Her story highlights the ways that policies are entangled in health care access and health outcomes. Rosa’s story points to the cracks in the health delivery system as well as to the complex intersections between health policy and immigration policy. It gives us a glimpse of the human side of health policy. In this chapter, we will endeavor to review LHP from a broad perspective that recognizes the location of this policy within a larger body of health and immigration policy while also striving to keep a focus on its human side – its enactment and entanglement in the lives of Spanish speakers like Rosa. Health policy can be defined as the aggregate of public policies that have an impact on people’s health. Health policy, therefore, can encompass multiple types of policies – from labor policy to immigration policy to tax policy – and can be carried out in the public domain by elected and appointed officials or in the private domain by executives and boards of trustees. Health policy shapes the arrangement of providers in the health care workforce, establishes the scope of activity of health care organizations, and provides mechanisms for the financing of health care services.

Health policy in the United States Health policy aims to impact access to health care, health care costs, and health care quality. Access, cost, and quality are interrelated aims that affect each other

Language in health care policies  35 synergistically. Elevated health care costs can prohibit access to care. Inadequate access to care can affect quality, and quality can, in turn, determine cost. A striking example of this synergy is found in the Institute of Medicine’s (now the National Academy of Medicine) 2009 report America’s Uninsured Crisis. In this report, the authors contend that higher rates of uninsurance within a community can have spillover effects that also affect the insured. When community uninsurance is great, the supply of health care providers and services is diminished, leading to a scenario where lack of access to care simultaneously lowers quality and elevates costs (IOM, 2009, pp. 7–11). Health policy, therefore, seeks to affect access, cost, and quality and appropriately balance their synergistic effects. Managed care is an example of a health policy that seeks to lower health care costs. Managed care organizations “provide a broad range of services, generally emphasizing primary and preventive care” (Shi & Singh, 2008, p. 204). Managed care organizations control costs by hiring their own health care professionals to provide routine services and by entering into agreements with specialty providers to provide other services at a discounted rate. They also control cost by monitoring and controlling utilization of services. The establishment of public health care insurance programs such as Medicare and Medicaid are an example of health policies aimed at increasing access to health care. Medicare was established as an amendment to the Social Security Act that would provide health care coverage to anyone who qualifies for social security benefits. Medicare is a federal health insurance program that provides coverage to individuals who have exited the workforce, are age 65 or older, and who are no longer eligible for employer-sponsored health insurance coverage. It is often referred to as an “entitlement program” because individual workers pay Medicare taxes throughout their working lives and thus are entitled to the benefits of the program upon retirement (Barr, 2011, p. 132). Medicaid was also established as  an amendment to the Social Security Act, but its structure was wholly different from that of Medicare. Medicare was conceived as a universal health care coverage program for the elderly. Medicaid, on the other hand, was conceived as a limited program for certain subgroups of poor people. Medicare was set up as a federally administered program providing direct benefits to enrollees. Medicaid was set up as a state administered program under broad federal guidelines with varying degrees of federal financial support based on the economic condition of the state (Barr, 2011, pp. 166–167). Medicaid is thus often referred to as a “means-tested” program because eligibility is based on meeting a set of criteria determined on a state-by-state basis. So, in sum, while Medicare aimed to increase access for the elderly who have exited the workforce, Medicaid sought to increase access for the poor who do not have access to mainstream employer-sponsored health care programs. Health policies aimed at improving the quality of care include a variety of both public and private measures. State and national licensing procedures for health care facilities and professionals, for example, are publicly based quality-oriented policies. State governments, through their appointed departments of health, typically oversee the licensure of facilities. Statewide boards, whose members are

36  Language in health care policies appointed by elected officials, oversee the licensure of health professionals including physicians, nurses, and social workers. Voluntary accreditation of health care facilities, on the other hand, are examples of privately based quality-oriented policies. “Accreditation,” according to Shi and Singh (2008), “is a private mechanism designed to assure that accredited health care facilities meet certain basic standards” (p. 320). In these ways, policy measures are meant to impact the cost, access, and quality dimensions of health care. In this chapter, we will consider language policies in health care as one dimension of the larger arena of health policy. In line with my previous observations about the wide breadth of health policy and its entanglement with other areas of public policy, I propose that language policy in health care is a subset of health policy. As such, any treatment of the subject of language policy in health care must strive to locate language policy within the overarching goals of health policy described earlier: cost, access, and quality. In addition, language policy in health care is situated in the larger contexts of health policy. Health policy is an inherently political process and thus involves a whole host of questions and concerns that interface with the provision of health care. Questions such as: Is access to care a fundamental human right or is it a market commodity? Should the government play a role in the availability of health care, and if so, what level of involvement should the government assert? What conditions constitute health care consumers as deserving of publicly funded or subsidized care? The answers to these questions will invariably shape the direction of health policy and set the tenor of health policy debates. At the same time, these same underlying contexts come into play in the development and implementation of language policy in health care. So, we will begin our consideration of language policy in healthcare by introducing some of the key debates and tensions that have characterized health policy in the U.S. more generally. Health care as right and as commodity The first question we need to address has to do with the nature of health and health care either as a fundamental human right or as a market commodity. Although the World Health Organization has maintained since its founding over 70 years ago that “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition” (WHO, 2006, p. 1), the question has continued to animate discussions of health policy and health care reform to the present day. In a 2017 opinion piece in The National Review, conservative commentator Ben Shapiro brazenly declared that “morally, you have no right to demand medical care of me . . . medical care is a service and a good provided by a third party” (Shapiro, 2017). The polarization of the left-leaning position held by the WHO and the right-leaning position held by Shapiro reveals that the underlying tension has to do with a question of individual liberties. The WHO’s position perceives the right to health care from the perspective of the user of health services whereas Shapiro’s position perceives the choice of health care from the

Language in health care policies  37 perspective of the provider of services. The tension is thus rooted in opposing theories of just social arrangements. The libertarian view of justice, admirably espoused by Robert Nozick in his book Anarchy, State, and Utopia, views individual liberty as the foundational principle of just social arrangements. The principle of individual liberty places restrictions on entitlements because one person’s entitlement is always another person’s obligation. Under this principle, entitlements are viewed as holdings that are acquired or transferred through just means. So, in the case of health care, a doctor may acquire her skills justly through years of education and training and may transfer her skills justly through the provision of health care services for a fee. A health care user may benefit from these skills based on just payment for services rendered. An entitlement to health care outside of the payment for services rendered would be considered an unjust entitlement. Nozick sums up the position succinctly when he writes: The major objection to speaking of everyone’s having a right to various things such as equality of opportunity, life, and so on, and enforcing this right, is that these “rights” require a substructure of things and materials and actions; and people may have rights and entitlements over these. No one has a right to something whose realization requires certain uses of things and activities that other people have rights and entitlements over. (Nozick, 1974, p. 238) The libertarian view, therefore, assigns health care a status equivalent to that of any other marketable service and fails to assign it any special importance. The egalitarian view of justice diverges from the libertarian view in that it views certain goods and services, for example, health care and education, as fundamental services that are required to ensure fairness. John Rawls, in his book A Theory of Justice, argues that any just social arrangement will ensure the best possible outcome for the least well off. Just social arrangements emerge from a social contract whose parties are theoretically under a veil of ignorance at the time of entering into the contract. The veil of ignorance ensures that no party will ever know what position he or she will attain after the execution of the contract. For that reason, all parties will ensure the best position for the least well off. But what are the constituent features of the “best position”? What do people need to have to enjoy the best possible position? Egalitarian theories of justice view opportunity as the linchpin of a just social arrangement – a just social arrangement is one in which fundamental opportunities are available to all even if some are more successful than others in taking advantage of those opportunities (Rawls, 1999, pp. 3–46). An egalitarian view of justice thus assigns a special importance to health care that is not available under the libertarian view. Meeting the health needs of a population through adequate and appropriate health care provides for the normal functioning of people and thus constitutes the grounding of their opportunity. If some people suffer from less than normal functioning, we can expect their access

38  Language in health care policies to opportunities to be diminished. There is a fundamental unfairness about comparing the efforts of the hungry and the ill to those of the well fed and the healthy. Daniels (2008) argues that in order to preserve normal functioning and thus ensure equal opportunity, a just social arrangement should be committed to meeting, at minimum, the following health needs of all its members: 1) adequate nutrition, 2) sanitary, safe, unpolluted living and working conditions, 3) exercise, rest, and such important lifestyle features as avoiding substance abuse and practicing safe sex, 4) preventive, curative, rehabilitative, and compensatory personal medical services and devices, 5) nonmedical personal and social support services, and 6) an appropriate distribution of other social determinants of health (pp. 42–43). An inventory such as this would ensure that all people will have access to equal opportunity and thus that all are free to compete in a fair market. However, at the same time that this arrangement guarantees equal opportunity it also infringes on the liberties of numerous others including farmers (who must ensure adequate provisions for nutrition), landlords and employers (who must ensure sanitary, safe, and unpolluted living and working conditions), public health workers (who must endeavor to create conditions for healthy lifestyles), and health care providers (who must provide for the preventive, curative, rehabilitative, and compensatory care needed regardless of ability to pay). The social contract, in other words, demands that certain rights and liberties should be ceded for the benefit of a fair and just social arrangement. The role of the government The theories of just social arrangements that undergird perspectives on health as a fundamental right or a market commodity also inform the role of the government in ensuring adequate provision of health care to its citizens. The primary mechanism for ensuring adequate provision of health care is insurance. Insurance is, in essence, an arrangement that allows for the prepayment of certain essential goods and services prior to the point at which those goods and services are needed. Automobile insurance, for example, allows drivers to prepay potential losses resulting from an accident. Life insurance allows the living to prepay into a fund that will be disbursed to that person’s beneficiaries upon their death. Health care insurance is meant to follow the same logic. While we are healthy, we pay into a health insurance policy that will cover expenditures when we are sick. In the case of health care, however, the prepayment logic is complicated because sickness is not a one-time event like a car accident or death. Instead, health care is utilized at different points in our lives for different purposes. As noted by Daniels, sometimes the care we need is preventive, curative, rehabilitative or compensatory. Oftentimes, the cost of these different types of services exceeds the amount of money paid into a health insurance policy in the form of premiums. Therefore, to ensure the health of the population, it is necessary to draw on other sources of revenue to meet the overall lifetime health needs of individuals above and beyond the prepayments made by that individual. In the U.S., this excess has typically been met through employer-sponsored health insurance. As a benefit of employment, employers pay into a health insurance

Language in health care policies  39 policy for their employees and thus offset the cost of the lifetime health needs of employees – and sometimes their families. Employer-sponsored health insurance, however, is limited to those who actively participate in the workforce. The very poor and unemployed and those who have retired from the workforce are left out. Government programs, such as Medicaid and Medicare (discussed earlier), are meant to fill these gaps produced by employer-sponsored health insurance. In sum, then, the U.S. health insurance arrangement can be viewed as a system of shared contributions for the prepayment of services. Service providers are, for the most part, private agents free to charge whatever the market will bear for their services. However, there are some exceptions. Service providers who work for the Department of Veterans Affairs and those who provide public health services and services to inmates may be public employees. Insurance companies are also largely private and able to charge premiums based on numerous factors including the size of the companies they provide insurance for and the relative risk assigned to the workforce. The Patient Protection and Affordable Health Care Act (ACA) of 2010, which we will discuss later in this chapter, however, has placed a series of limitations on these private insurance companies including a ban on excluding enrollees from coverage based on preexisting conditions and a requirement to cover the children of eligible enrollees up until the age of 26. The U.S. is rather anomalous among the developed nations of the world in its particular approach to health insurance. Most developed nations provide some measure of government-sponsored health insurance in order to cover the prepayment of services. T.R. Reid, in his book The Healing of America, describes four different models of health insurance deployed by countries around the world: the Bismark model, the Beveridge model, the National Health Insurance model, and the “Out-of-Pocket” model. The Bismark model, named after the Prussian chancellor Otto von Bismark, uses private health care providers and insurance companies to provide health care coverage. Health insurance plans are funded through payroll taxes charged to both the employer and the employee. The fundamental difference between the Bismark model and the current model in the U.S. is that under the Bismark model, insurance companies are established as not-for-profit entities. The Bismark model can be found in Germany, Japan, France, and in some countries in Latin America. The Beveridge model differs from the Bismark model in that it cuts insurance companies out of the equation. The government collects health insurance taxes and establishes and funds health services organizations to provide medical treatment. Reid likens medical services under the Beveridge model to other public services such as the fire department or the public library. In the Beveridge model, hospitals are government agencies and health care providers are government employees. The Beveridge model can be found in the United Kingdom, Spain, and Italy. The National Health Insurance model preserves the private standing of hospitals and health care providers, but health insurance companies are government-run. Every citizen pays into the government-run insurance program and this program in turn pays the medical bills submitted by private health care providers. The National Health Insurance model is found in Canada. The final model described by Reid – the model adopted by around 80% of the world’s countries – is what he calls the

40  Language in health care policies “Out-of-Pocket” model. In this model, there is no government-sponsored health care insurance system and individuals are expected to pay for medical expenses out of pocket (Reid, 2009, pp.  16–21). Each of these arrangements specifies a unique role for the government in the provision and financing of health care. The Out-of-Pocket model liberates the government from any responsibility. Under the Bismark model, the government’s role is relatively loose providing simple oversight and regulatory power over independent charitable insurance companies. Under the National Health Insurance model, the government exerts greater control by running the insurance system but allowing health care providers to operate privately. The Beveridge model cedes the greatest control to the government by making hospitals and health care providers a part of the government. Who “deserves” subsidized care? The extent and the means of government contributions to prepayment of health care services raises other questions about who “deserves” such benefits. I have been using the word “citizen” to describe the beneficiaries of government-sponsored health care prepayment, and citizenship is indeed a criterion of many programs. However, in addition to citizens, taxpayers who contribute to the health insurance system, whether citizens or not, should properly have access to its benefits. The view of health care as a fundamental human right, on the other hand, would argue that every human being is deserving of health care benefits as an extension of the importance of the services to their normal functioning. But in addition to citizenship or taxpayer status, other factors also determine who deserves care and when they deserve it. Gravity of illness, the extent to which a condition impedes normal functioning, and the relative cost of treatment are all potential determinants of who gets care and when. In fact, one of the most common objections to government-sponsored health insurance systems in the U.S. has been the fear that “socialized medicine” will produce a rationing of services. Yet health services are routinely rationed both in the U.S. and abroad. Triage systems in hospital emergency rooms, for example, are a type of rationing. Triage allows health care providers to assess the most urgent cases and to treat those cases first. The more acute and life-threatening cases are treated first, and the less acute cases are treated later. Government-sponsored health insurance has a tendency to expand this phenomenon beyond the emergency room, resulting in prolonged waiting periods to receive needed but non-urgent care. The question of deservingness, therefore, is a major driver of health policy. The health delivery system in the U.S. does not fit neatly into any of the models described earlier but instead consists of a relatively loose arrangement of pieces of each of them. We have already discussed the centrality of employer-sponsored private health insurance and the public health insurance options for those who are not in the workforce. The health delivery system in the U.S., however, is still a bit more complex. While provisions are made for the very poor through the Medicaid program and for the elderly through the Medicare program, there is still a significant group of people who do not receive health insurance benefits from their

Language in health care policies  41 employer – the uninsured – and others for whom the employee share of the premium is too high – the underinsured (Allison, 2017). In the U.S. health delivery system, therefore, there is an array of programs collectively known as the “safety net” that are meant to catch those who fall through the cracks, so to speak, of ordinary health insurance arrangements. Medicaid, and the Children’s Health Insurance Program or CHIP, are important parts of the safety net. But the safety net also includes Federally Qualified Health Centers (FQHCs) – community-based clinics that operate on a sliding scale fee basis receiving a portion of operating funds from fees collected and another portion from federal block grants. FQHCs are seen as community-driven organizations that can uniquely respond to health threats and issues. One of the requirements of an FQHC is that clinic patients have a role on the governing board (Shi & Singh, 2008). In addition to FQHCs, the Emergency Medical Treatment and Active Labor Act (EMTALA) requires that all hospital emergency rooms provide life-stabilizing services to any person who presents with illness regardless of ability to pay. Hospitals may bill for the services after they are rendered, but they may not withhold life-saving treatment based on the ability to pay (Shi  & Singh, 2008). This law inevitably results in large unreimbursed costs to hospitals. The Hill-Burton program provides funding to hospitals in the form of assistance for capital projects, for example, buildings and large equipment purchases in recognition of revenue losses due to EMTALA (Barr, 2011, p.  89). In addition, disproportionate share funding is available for hospitals whose roster of Medicaid-eligible patients is higher than normal (Shi & Singh, 2008). Disproportionate share funding is needed for hospitals to recuperate the cost of providing services because Medicaid reimbursements tend to be lower than the actual cost of services. Access to safety net services by immigrants has been a lightning rod for health policy stretching back to at least the 1990s. California’s Proposition 187, also known as the Save Our State initiative, was endorsed by then-Governor Pete Wilson and approved by voters in 1994. The measure was designed to deny access to all public benefits and services, including public education and health care safety net services, for the state’s undocumented population. As noted by Illingworth and Parmet, “although the act was quickly halted by a federal court that found that it violated federal law, it left a lasting impact on U.S. health policy” (2017, p. 75). The failed Proposition 187 in California was but a foreshadowing of the immigrant restrictions to services that would be encoded in the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996. While PRWORA is best known for its reform of federal welfare programs, the greatest cost savings in the law came not from moving people off the welfare rolls and into gainful employment but in restricting access to public benefits by both documented and undocumented immigrants. Legal residents of the United States were barred from accessing public health care services for a period of five years. As Illingworth and Parmet put it: “Congress thus codified nativists’ views that immigrants are not worthy of public benefits. To the extent that social solidarity is embedded in laws providing support to those who need health care, PRWORA exclaimed, it doesn’t extend to immigrants” (2017, p.  76). More recently, the Patient Protection and

42  Language in health care policies Affordable Care Act (ACA) of 2010 has further bolstered the doctrine encoded in PRWORA by explicitly excluding undocumented immigrants from obtaining coverage options through the ACA. In September 2009, President Barack Obama addressed a joint session of Congress to discuss the ACA. Obama stated that the new law would not provide coverage to the undocumented. South Carolina Congressman Joe Wilson broke with all norms of decorum by shouting “you lie” in the middle of Obama’s speech (Lubin, 2014). This was only the beginning of a lasting anti-immigrant rhetoric that would later infect the debate on health insurance reform. California Congressman Dana Rohrabacher remarked: “this bill cuts healthcare for our seniors by hundreds of billions of dollars while providing subsidized health care of illegal immigrants” (Lubin, 2014). Explicit provisions denying health care services to immigrants have been coupled with less apparent but equally noxious policies that differentially position immigrants as deserving and undeserving with the health care safety net. Sarah Horton (2004) explored the differential positioning of Cuban refugees and Mexican immigrants in a New Mexico hospital. She argued that hospital policies projected a differential cultural citizenship upon Cuban refugees and Mexican immigrants “preparing the former to be active citizens and discouraging the latter from pressing demands on American civil institutions” (p. 472). She detailed the hospital policy that in 1999 began to charge an upfront fee of $50 for an initial visit and $30 for a follow-up visit for those patients who were not able to verify legal status in the country. Hospital administrators in her study conceded that the policy on the uninsured was in reality a policy targeting the undocumented. In addition to gatekeeping measures, the hospital in Horton’s study also engaged in the practice of medical deportation. Medical deportation allows for a hospital to return a patient to their country of origin to receive oftentimes expensive follow-up care. Horton details the story of Maribel Miramontes Loya, a 16-yearold Mexican in the United States on a tourist visa. Maribel was admitted to the hospital in New Mexico to address problems with a metal shunt that had been placed in the back of her head to drain fluids from the brain. Maribel was in the hospital for three weeks and underwent three unsuccessful surgical procedures to replace the shunt. Maribel was pregnant at the time of hospitalization and doctors performed a C-section to deliver the baby two months prematurely. After this, Maribel fell into a coma. The hospital proposed a medical transfer to a nursing facility in Chihuahua, Mexico after a week in coma. Maribel’s parents objected to the decision, but the hospital insisted that the best care for Maribel was to be found in Mexico. The Mexican Consulate intervened in the matter and the plane that was transporting Maribel to Chihuahua turned around in mid-air to return Maribel to the hospital in New Mexico. Notwithstanding the failed attempt at medical deportation in Maribel’s case, the practice is becoming more common for immigrants who enter the U.S. health delivery system. Jacinto Rodríguez Cruz and José Rodríguez Saldaña were involved in a car accident in Iowa and suffered traumatic brain injury. Even though the two men were insured, because they were undocumented, they did not qualify for long-term care benefits under Medicaid. Iowa Methodist Hospital found a rehabilitation clinic in Veracruz, Mexico that

Language in health care policies  43 would take the two men and proceeded to deport them. The men were released to the care of their families within a month of their arrival in Veracruz. The families sued Iowa Methodist for “false imprisonment” but eventually lost the case on appeal. The court found that the family did not sufficiently protest the transfer at the time it took place (Illingworth & Parmet, 2017, pp. 86–87). Deservingness of safety net health services is thus constructed through explicit exclusions as found in Proposition 187, PROWRA, the ACA, and through implicit exclusions such as limitations on charity care and the practice of medical deportation. Others have argued that the construction of deservingness can also be self-imposed. Becker (2004), for example, argued that discrimination, costs, and substandard services lead many Latinos to delay care and avoid seeking treatment. The growing anti-immigrant sentiment in public discourse and policy, moreover, has been found to have had a “chilling effect” (Viladrich, 2012) that generates avoidance of health services and internalized feelings of undeservedness. Illegality itself becomes embodied both epidemiologically and experientially among the undocumented, leading to significant long-term effects for physical health, mental health, and cognitive development (Willen, 2012). As Almeida et al. (2016) have argued: “Anti-immigrant policies stigmatize both foreign and U.S.-born Latinos by creating a hostile societal environment which affects their experiences of discrimination” (p.  897). Anderson (2014) studied the chilling effect of Arizona’s SB 1070 (the Support our Law Enforcement and Safe Neighborhoods Act) and found that the passage of the law was correlated with poorer self-reported health among Latinos. Gurrola (2018) examined the impact anti-immigrant sentiment in California and found that Latinos experienced increased discrimination for being uninsured and speaking Spanish. Vargas, Sanchez, and Juárez (2017) found similar results after investigating self-reported physical and mental health in states with unfavorable anti-immigration laws. The answers to questions having to do with the value ascribed to health and health care, the role of government in ensuring access to care, and the deservingness of those receiving health care benefits have given a particular shape to health policy debates in the U.S. And it is within this context that language policy in health care has emerged. In what remains of this chapter, we will explore the development of language policy in health care and its unique place in health policy more generally.

Language policy and planning in the United States Key concepts in language policy and planning The discipline of language policy and language planning emerged in response to the challenges of decolonization in the twentieth century. Language planners and policy makers considered the multiple implications of establishing autochthonous languages in the place of colonial languages in newly independent nations in Africa and other continents with a significant colonial presence (Rubin & Jernudd, 1971). Since its inception, language policy and planning has emerged as a

44  Language in health care policies coherent branch of sociolinguistics that considers the place of intentional efforts to control both the role of language in constituting and altering social structures and the role of social structures in constituting and altering language practices. Language policy refers to the rules, norms, myths, proclamations, and prejudices that modify and modulate language practices (Spolsky, 2004). Language policies can thus be official and explicit pronouncements such as the identification of an official language within a polity. But language policy can also consist of unofficial and implicit attitudes, opinions, and ideologies that define or otherwise constrain language use. Shohamy (2006) expands the scope of language policy significantly by recasting our understanding of language as personal, open, free, dynamic, creative, and constantly evolving that “has become a tool for the manipulation of people and their behaviors, as it is used for a variety of political agendas in the battle of power, representation, and voice” (p. 22). Language planning, on the other hand, can be viewed as the implementation of policy. Language planning is the intentional process of identifying ideal patterns of language practices and of proposing language policies to ensure the greatest possible conformity to those patterns. Language planning has typically been viewed as a constellation of different types of activities. Corpus planning is the identification of words and grammatical forms that are representative of ideal language practices. Lexicographers and grammarians typically engage in corpus planning. Status planning is the identification of languages or varieties of a language that are considered representative of ideal language practices. Status planning is often carried out by curriculum developers and extended by teachers in schooling. Acquisition planning is the identification of strategies and methods to ensure that ideal language practices are acquired by selected populations. Prestige planning attempts to elevate the prestige of a language and improve its image abroad. Prestige planning is typically carried out by official language academies or institutes. The work of the Instituto Cervantes, the Goethe Institute, the Confucius Institute or the French Alliance would fall under the heading of prestige planning (Ager, 2001). Language policy and planning research has focused on multiple domains. While initial work in language policy and planning focused on the arrangement of languages at the scale of the nation state, more recent work has strived to explore the role of policy and planning in other domains. Language policy in educational settings, at national, regional or local levels, has been a major area of inquiry (Tollefson, 2002; Gándara  & Hopkins, 2010). These studies have looked at language policies in schools and assessed the impact of these policies in creating barriers for some students and privilege for others. They have looked at language policies at the state level considering the impact of statewide initiatives such as the Seal of Biliteracy (Davin & Heineke, 2017), and they have assessed national level policies such as No Child Left Behind (Valenzuela, 2005). Language policy and planning research has also been carried out in religious domains. For example, the relationship between the missionary agency, the Summer Institute of Linguistics, and the state in shaping indigenous communities in

Language in health care policies  45 Latin America has been studied (Hartch, 2006; Barros, 1995). Shohamy (2006) connected an already blossoming literature on linguistic landscape and language in the public sphere to language policy and planning concerns. Finally, recent studies have shifted the attention of policy and planning to the family and household level (Velázquez, 2018). The study of language policy and planning has grown substantively over the years. Spolsky (2004, 2009) views language policy as the constellation of language management (efforts to change language behavior), language practices (unregulated patterns in choosing a language or variety), and language ideology or beliefs. Schiffman (1996), on the other hand, understands language policy from the perspective of what he calls “linguistic culture.” Linguistic culture, for Schiffman, refers to ideas, values, beliefs, attitudes, prejudices, myths, religious structures, and other cultural baggage that people bring to their dealings with language. McCarty (2014) argues for a more ethnographic approach to language policy that focuses on the language interaction, negotiation, and production in the context of relations of power. Johnson (2013) takes a more eclectic approach, combining elements from all these approaches arguing that the study of language policy involves attention to official regulations, unofficial or covert mechanisms, policy processes, and policy texts and discourses. Language policy and planning has thus generated a broad array of orientations. Language policy and planning in the U.S. Now that we have reviewed some of the key concepts surrounding language policy and planning generally, we can look more closely at language policy in the U.S. Does the U.S. have a language policy? If what is meant by that question is whether the U.S. has an official language and laws, regulations, and statutes protecting and promoting that language, the answer would be no. If the question refers to efforts, both covert and overt, to manipulate the language practices and ideologies of those within its polity, however, the answer is a resounding yes. The underlying theme in U.S. language policy has been the issue of language rights. In his book, The American Bilingual Tradition, Heinz Kloss distinguished between promotion-oriented rights and tolerance-oriented language rights. Promotion-oriented rights “regulate how public institutions may use and cultivate the languages and cultures of minorities” (1988, p.  20) and tolerance-oriented rights refer to the rights of individuals to “cultivate their language in a private sphere, namely, in the family and in private organizations” (1988, p. 20). Tolerance-oriented rights have been a mainstay in U.S. political thought. Promotion-oriented rights, on the other hand, have been tenuous to say the least. The framers of the U.S. Constitution intentionally left the pronouncement of an official national language for the new republic unspoken. The commitment to individual liberty was likely a driving force in this decision. In her book, An American Language: The History of Spanish in the United States, Rosina Lozano demonstrates how this commitment to individual liberty would prove difficult to sustain in a representative

46  Language in health care policies democracy. She tells the story of José M. Gallegos, the first New Mexican territorial representative elected to Congress in 1853. Gallegos, like the vast majority of his constituents, spoke only Spanish. His participation in Congress was mediated by translators such as Georgia Representative Alexander Stevens. When he won reelection in 1856, his bilingual opponent, Miguel Otero, appealed the results of the election. A hearing was conducted in which Otero made his own case and Gallegos relied on his friend Stevens to translate and read his remarks. Otero was seated and Gallegos was stripped of his lawfully appointed duties (Lozano, 2018, pp. 21–22). Gallegos confronted the conundrum that many of his fellow “treaty citizens” (Mexicans who became U.S. citizens by virtue of the Treaty of Guadalupe Hidalgo) faced. While he had the individual liberty to cultivate his own language in his family and his community, the lack of English would yield political disenfranchisement. This story strikes at the heart of one of the most enduring questions of U.S. language policy: How can the lawful exercise of one individual liberty be reconciled with other rights? The Bill of Rights contains at least two fundamental rights that pertain to language: the First Amendment, freedom of speech, and the Sixth Amendment, the rights of the accused. The First Amendment states that Congress shall make no law abridging the freedom of speech. While freedom of speech has mostly been understood to mean the content of speech and not the language through which that speech is enunciated, there is a legal argument to be made that establishes language rights under the freedom of speech clause (Del Valle, 2003), even though it has not been explicitly invoked in cases involving language rights. The Sixth Amendment states that the accused shall enjoy the right to be informed of the nature and cause of the accusation. The rights of the accused clause has been successfully invoked in cases of language rights and led to the creation of the Federal Court Interpreters Act of 1978 which requires the presence of certified interpreters in all proceedings against non-English speaking persons in federal court. Outside of the Bill of Rights, the Equal Protection and Due Process clause of the Fourteenth Amendment has also been invoked to safeguard language rights in the United States (Del Valle, 2003, pp. 23–30). The best-known case of the application of the Fourteenth Amendment to language rights is Meyer v. Nebraska. In 1919, in the wake of World War I  and growing anti-German sentiment in the U.S., the Nebraska legislature enacted a law concerning the teaching of foreign languages in the state of Nebraska known as the Siman Act. The law stated that “no person, individually or as a teacher, shall, in any private, denominational, parochial or public school, teach any subject to any person in any language other than the English language” and it prohibited the instruction of a foreign language as a subject itself until after successful completion of the eighth grade. Robert Meyer, an instructor at Zion Parochial School, was charged with violating the Siman Act for allowing his student to read the Bible in German in the classroom. He was tried, convicted and ordered to pay a fine. The case was appealed to the Nebraska State Supreme Court, and the conviction was upheld. Further appeal to the U.S. Supreme Court led to the decision in Meyer v. Nebraska concluding that

Language in health care policies  47 the law prohibiting the teaching of subjects in a language other than English was a violation of the Due Process clause of the Constitution (Capozzola, 2008). “The legislature,” the majority opinion declared, “has attempted materially to interfere with the calling of modern language teachers, with the opportunities of pupils to acquire knowledge, and with the power of parents to control the education of their own” (cited in Cooper, 2016). Notwithstanding the place of constitutional arguments in advocacy of language rights within American jurisprudence, the majority of cases involving language rights in the U.S. have been argued on the basis of civil rights (Spolsky, 2004). A prime example of this preference for language rights as civil rights can be seen in the landmark case Lau v. Nichols. The Lau case consisted of a complaint by the parents of Kinney Kinmon Lau, an elementary school student of Chinese origin in the San Francisco Unified School District. Chinese students at the time were integrated into mainstream English-speaking classrooms and offered no support to help them learn English. The complaint held that because there was no provision for the learning of English, Kinney’s right of access to education had been violated by the district. While the district provided a desk for the student, by failing to provide English language instruction, they were effectively denying the student “meaningful” access to education. The District Court found in favor of the defendant arguing that because the policy of integrating students was uniform there was no basis for a claim of violation of rights. The Court of Appeals for the Ninth Circuit upheld the lower court’s decision. Both courts viewed the case primarily through the prism of Equal Protection holding that there can be no individual discrimination when the policy applied equally to all students. The U.S. Supreme Court, however, reached a different conclusion. In their opinion, the case was a violation of civil rights because even though the policy was applied equally to all students, that same policy had a disparate impact on a particular class of students. “We do not reach the Equal Protection Clause argument which has been advanced,” the High Court argued, “but rely solely on [Title VI] of the Civil Rights Acts of 1964 . . . to reverse the Court of Appeals” (Cooper, 2016). Title VI of the Civil Rights Act of 1964 prohibits discrimination based on a set of protected classes. The protected classes include race, age, sex, religion, and national origin. The Lau decision was important because it established the precedent that even though language itself is not a protected category, language can be viewed as a proxy for the protected class of national origin (Moran, 2009). Viewing language as a proxy for national origin effectively shifted language rights and cemented their place in civil rights jurisprudence.

Language policy in health care in the United States Language policy in health care at the national level The Lau decision had an enormous impact in the educational domain leading to the passage of the Equal Educational Opportunity Act in 1974. At the Federal level,

48  Language in health care policies however, it would take several years for the impact of the Lau decision to reach other domains outside of education. On August 11, 2000, twenty-six years after the landmark Lau decision, President Bill Clinton signed Executive Order 13166 titled: “Improving Access to Services for Persons with Limited English Proficiency.” Steeped in the language of the Civil Rights Act of 1964 and the Lau opinion, the order read as follows: By the authority vested in me as President by the Constitution and the laws of the United States of America, and to improve access to federally conducted and federally assisted programs and activities for persons who, as a result of national origin, are limited in their English proficiency (LEP), it is hereby ordered. The order required all federal agencies providing services to the public and nonfederal agencies receiving federal money for service programs to create plans for ensuring “meaningful” access to services for people with limited English proficiency. While the order did not single out health care organizations in any way, the impact of the new rule on health care was substantive given the large federal investment in health care. Health care organizations receiving reimbursements from Medicare, Medicaid or any other federal program were required to comply with the new order. This caused quite a bit of consternation in the medical community, so much so that the American Medical Association wrote a letter to thenSecretary of Health and Human Services, Tommy Thompson, arguing that the provision of language access services was too expensive to be implemented and requesting that the order be rescinded. Rescinding the requirement would require rescinding the entire Civil Rights Act, however, since EO 13166 was rooted in civil rights legislation. In order to address the opposition, the Office of Minority Health within the Department of Health and Human Services issued the National Standards for Culturally and Linguistically Appropriate Services in 2001, also known as the CLAS Standards. The CLAS Standards were meant to assuage the health care community’s vehement opposition and to provide guidance on how health care organizations might best meet the requirements of the new Executive Order. The standards were proposed “as a means to correct inequities that currently exist in the provision of health services and to make these services more responsive to the individual needs of all patients/consumers” (OMH, 2001, p. 3). The final report of the CLAS project listed 14 standards organized under three main subheadings: culturally competent care, language access services, and organizational supports for cultural competence. The standards were also classified as mandates (understood as current Federal requirements for all recipients of Federal dollars), guidelines (activities recommended by OMH for adoption as mandates by Federal, State, and national accrediting agencies), and recommendations (activities suggested by OMH for voluntary adoption by health care organizations). The standards are listed in Table 2.1:

Table 2.1 The National Standards for Culturally and Linguistically Appropriate Services 2001 Number Standard theme Standard type

Standard

1

Culturally competent care

Guideline

2

Culturally competent care

Guideline

3

Culturally competent care

Guideline

4

Language access services

Mandate

5

Language access services

Mandate

6

Language access services

Mandate

7

Language access services

Mandate

Health care organizations should ensure that patients/consumers receive from all staff members effective, understandable, and respectful care that is provided in a manner comparable with their cultural health beliefs and practices and preferred language. Health care organizations should implement strategies to recruit, retain, and promote at all levels of the organization a diverse staff and leadership that are representative of the demographic characteristics of the service area. Health care organizations should ensure that staff at all levels and across all disciplines receive ongoing education and training in culturally and linguistically appropriate service delivery. Health care organizations must offer and provide language assistance services, including bilingual staff and interpreter services, at no cost to each patient/consumer with limited English proficiency at all points of contact, in a timely manner during all hours of operation. Health care organizations must provide to patients/consumers in their preferred language both verbal offers and written notices informing them of their right to receive language assistance services. Health care organizations must assure the competence of language assistance provided to limited English proficient patients/consumers by interpreters and bilingual staff. Family and friends should not be used to provide interpretation services (except on request by the patient/consumer). Health care organizations must make available easily understood patientrelated materials and post signage in the languages of the commonly encountered groups and/or groups represented in the service area. (Continued)

Table 2.1 (Continued) Number Standard theme Standard type 8

Organizational supports

9

Organizational supports

10

Organizational supports

11

Organizational supports

12

Organizational supports

13

Organizational supports

14

Organizational supports

Guideline

Standard

Health care organizations should develop, implement, and promote a written strategic plan that outlines clear goals, policies, operational plans, and management accountability/oversight mechanisms to provide culturally and linguistically appropriate services. Guideline Health care organizations should conduct initial and ongoing organizational selfassessments of CLAS–related activities and are encouraged to integrate cultural and linguistic competence-related measures into their internal audits, performance improvement programs, patient satisfaction assessments, and outcomes-based evaluations. Guideline Health care organizations should ensure that data on the individual patient’s/ consumer’s race, ethnicity, and spoken and written language are collected in health records, integrated into the organization’s management information systems, and periodically updated. Guideline Health care organizations should maintain a current demographic, cultural, and epidemiological profile of the community as well as a needs assessment to accurately plan for and implement services that respond to the cultural and linguistic characteristics of the service area. Guideline Health care organizations should develop participatory, collaborative partnerships with communities and utilize a variety of formal and informal mechanisms to facilitate community and patient/ consumer involvement in designing and implementing CLAS–related activities. Guideline Health care organizations should ensure that conflict and grievance resolution processes are culturally and linguistically sensitive and capable of identifying, preventing, and resolving cross-cultural conflicts or complaints by patients/consumers. Recommendation Health care organizations are encouraged to regularly make available to the public information about their progress and successful innovations in implementing CLAS standards and to provide public notice in their communities about the validity of this information.

Language in health care policies  51 Fears of excessive costs associated with the implementation of Executive Order 13166 were somewhat allayed with the publication of the CLAS Standards. The standards were fairly broad and consisted mostly of guidelines directed principally at accrediting agencies. The presence of Standards 4–7, listed as mandates that required provision of language services in all points of contact and at all times at no cost to the patient (Standard 4), assurance of competency of all personnel providing language services (Standard 6), and availability of easily understood patient-related materials (Standard 7), continued to cause consternation though. Further efforts were made to ease these concerns. In 2007, for example, the Alliance of Community Health Plans, with support from the Merck Company Foundation, released a report entitled: “Making the business case for culturally and linguistically appropriate services in health care: Case studies from the field.” The report highlighted 13 exemplary organizations whose implementation of CLAS standards positively impacted their financial bottom line. The report found, for example, that organizations that made efforts to implement CLAS standards increased their market share among limited English proficient patients. It also found that reductions in outsourcing language interpretation services yielded subsequent overall savings. Finally, it showed that CLAS standards reduced communication delays between patients and providers and appreciably shortened hospital stays leading to significant cost reductions (ACHP, 2007). Notwithstanding the positive business case associated with the implementation of CLAS standards, health care administrators worried that increasing numbers of different language groups would eventually exacerbate the organization’s ability to provide services. It might be possible to implement the full set of CLAS standards for a limited number of languages, but the worry was that there would come a point when the number of languages spoken in the service area could overwhelm the organization’s capacity. In response to these worries, the Civil Rights Division of the U.S. Department of Justice issued federal guidance regarding the extent of an organization’s responsibility in meeting language access requirements. The guidance proposed a “four factor analysis” that would assist organizations in determining the extent to which they were responsible for providing language access services: Recipients of federal financial assistance have an obligation to reduce language barriers that can preclude meaningful access by LEP persons to important benefits, rights, programs, information and services. . . . The starting point is an individual assessment that balances the following four factors: (1) the number or proportion of LEP persons eligible to be served or likely to be encountered by the program or grantee/recipient, (2) the frequency with which LEP individuals come into contact with the program, (3) the nature and importance of the program, activity, or service provided by the program to people’s lives; and (4) the resources available to the grantee/ recipient and costs. (Civil Rights Division, 2005) The four-factor analysis effectively created an uneven distribution of the burden of CLAS compliance and, thus, led to differential patterns of implementation. Safety net providers, for example, by virtue of the greater likelihood of encountering

52  Language in health care policies LEP persons, assumed greater responsibility in the provision of language access services. Urgent care facilities and hospital emergency departments, moreover, were also excessively burdened given the importance of the service they provide to people’s lives. Organizations in densely populated urban areas with larger budgets and greater margins also shouldered a greater responsibility for language access. In sum, then, the CLAS standards succeeded in bringing unprecedented awareness of language access and cultural competency issues to the health care field. It was less successful, however, in ensuring universal implementation. Instead, it unevenly distributed compliance responsibility throughout the health delivery system. In 2010, Congress passed the ACA and President Barack H. Obama signed the bill into law. Section 1557 of the ACA requires the provision of meaningful access for individuals with limited English proficiency. It reaffirmed the language access mandates in EO 13166 and in the CLAS Standards. However, while EO 13166 covered only those providers who received federal funding, Section 1557 of the ACA expanded the number of organizations and providers who were required to comply with language access mandates to include “the Health Insurance Marketplaces and issuers that participate in those Marketplaces” (USDHHS, n.d.). As discussed earlier, the ACA sought to increase the number of covered individuals by making private health insurance accessible to individuals through the establishment of Marketplaces where individuals could pool together to purchase health insurance plans at a reduced rate. Federal subsidies and tax credits were introduced to offset the costs of these plans to low-income individuals. Section 1557 of the ACA made explicit that participation in Marketplace programs constituted federal assistance and thus required compliance with language access mandates. The section explicitly identified the language access provisions that providers are required to make: 1) Covered entities are required to post a notice of individuals’ rights providing information about communication assistance for individuals with limited English proficiency, among other information. 2) In each state, covered entities are required to post taglines in the top 15 languages spoken by individuals with limited English proficiency in that state that indicate the availability of language assistance. 3) Covered entities are prohibited from using low-quality video remote interpreting services or relying on unqualified staff, translators when providing language assistance services. 4) Covered entities are encouraged to develop and implement a language access plan to ensure they are prepared to take reasonable steps to provide meaningful access to each individual that may require assistance. (USDHHS, n.d.) In 2009, the Joint Commission for the Accreditation of Health Care Organizations, referred to simply as the Joint Commission, took up many of the principles expressed in the CLAS standards and re-formulated them as accreditation standards. The Joint Commission was founded in 1951 as a nonprofit agency to provide voluntary accreditation services to hospitals and other health care

Language in health care policies  53 organizations and programs. Joint Commission accreditation serves as assurance to the public that hospitals and health care organizations are operating based on acceptable standards of safety and quality. Joint Commission accreditation requirements cover issues such as appropriate vaccination of health care professionals, appropriate sterilization of medical instruments, and appropriate policies and procedures for patient complaints and grievances among many other issues. Even though accreditation is a voluntary process, hospitals and health organizations have been compelled to seek it. In 1965, Joint Commission accreditation became a requirement that hospitals needed to meet in order to be eligible to participate in Medicare. Today, accreditation remains a requirement of Medicare participation and the Centers for Medicare and Medicaid Services oversees all organizations that are authorized to accredit health organizations including the Joint Commission. The Joint Commission’s involvement with language policy began in 2003 when a gap analysis was conducted to identify the differences between existing accreditation standards and the National CLAS Standards. After this analysis and a series of independent studies, the Joint Commission’s Standards and Survey Procedures Committee presented new and revised standards for patient-centered communication. The new and revised standards were added in the categories of 1) Human Resources (HR), 2) Provision of Care, Treatment, and Services (PC), 3) Record of Care, Treatment and Services (RC), and 4) Rights and Responsibilities of the Individual (RI) in the Comprehensive Accreditation Manual for Hospitals (Joint Commission, 2010). The new and revised standards are listed in Table 2.2. The Joint Commission standards inserted many of the principles from the CLAS Standards into existing accreditation requirements. For example, the mandate in CLAS Standard 7 to ensure the qualifications of personnel providing language services was inserted into Joint Commission Standard HR.01.02.01 through a note that made explicit that the human resource requirement also applies to those providing language services. The mandate in CLAS Standard 4, on the other hand, was incorporated into Joint Commission accreditation standards by adding an element of performance and a corresponding note to Standard RI.01.01.03. Joint Commission Standard PC.02.01.21 incorporates elements from CLAS Standard 7 with regard to the availability of easily understood patient-related materials. The Joint Commission standards were released on a trial basis beginning in 2010 together with a monograph titled Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals. The purpose of the monograph was to “inspire hospitals to integrate concepts from the communication, cultural competence, and patient- and familycentered care fields into their organizations” (2010, p. 3). In 2011, the Joint Commission released an R3 Report summarizing the revised standards and informing the public of the new standards. “Joint Commission surveyors,” the report noted, “began evaluating compliance with the patient-centered communication standards on January 1, 2011.” Findings, however, did not begin to affect accreditation decisions until 2013. The inclusion of CLAS principles into Joint Commission accreditation requirements, therefore, created a more stringent regulatory

Table 2.2  New and Revised Joint Commission Language Access Accreditation Standards Number

Description

Elements of performance

Notes

HR.01.02.01

The hospital defines staff qualifications.

EP 1: The hospital defines staff qualifications specific to their job responsibilities.

PC.02.01.21

The hospital effectively communicates with patients when providing care, treatment, and services.

EP 1: The hospital identifies the patient’s oral and written communication needs including the patients preferred language for discussing health care.

Qualifications for language interpreters and translators may be met through language proficiency assessment, education, training, and experience. The use of qualified interpreters and translators is supported by the Americans with Disabilities Act, Section 504 of the Rehabilitation of 1973 and Title VI of the Civil Rights Act of 1964. Examples of communication needs include the need for personal devices such as hearing aids or glasses, language interpreters, communication boards, and translated or plain language materials.

RC.02.01.01

The medical record contains information that reflects the patient’s care, treatment, and services.

EP 2: The hospital communicates with the patient during the provision of care, treatment, and services in a manner that meets the patient’s oral and written communication needs. EP 1: The medical record contains the following demographic information: 1) the patient’s name, address, date of birth, and the name of any legally authorized representative, 2) the patient’s sex, 3) the legal status of any patient receiving behavioral health care services, and 4) the patient’s communication needs including preferred language for discussing health care.

If the patient is a minor, is incapacitated or has a designated advocate, the communication needs of the parent or legal guardian, surrogate decision-maker, or legally authorized representative are documented in the medical record.

Number

RI.01.01.01

RI.01.01.03

Description

The hospital respects, protects, and promotes patient rights.

The hospital respects the patient’s right to receive information in a manner he or she understands.

Elements of performance EP 28: The medical record contains the patient’s race and ethnicity. EP 28: The hospital allows a family member, friend or other individual to be present with the patient for emotional support during the course of stay.

EP 29: The hospital prohibits discrimination based on age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, and gender identity or expression EP 2: The hospital provides language interpreting and translation services.

EP 3: The hospital provides information to the patient who has vision, speech, hearing or cognitive impairments in a manner that meets the patient’s needs.

Notes

The hospital allows for the presence of a support individual of the patient’s choice, unless the individual’s presence infringes on others’ rights, safety or is medically or therapeutically contraindicated. The individual may or may not be the patient’s surrogate decision- maker or legally authorized representative.

Language interpreting options may include hospital-employed language interpreters, contract interpreting services, or trained bilingual staff. These options may be provided in person or via telephone or video. The hospital determines which translated documents and languages are needed based on its patient population.

56  Language in health care policies environment for language access policy in health care, correcting somewhat for the uneven burden of compliance generated by the Division of Civil Rights’ fourfactor analysis described earlier. The inclusion of CLAS principles within enforceable Joint Commission accreditation standards in 2013 was a significant milestone for language policy in health care. In that same year, the Office of Minority Health renewed its commitment to language access by releasing the Enhanced National CLAS Standards. The enhancement project was taken up in 2010 for the purpose of ensuring that the standards developed in 2000 reflected the growth of the fields of cultural and linguistic competency and were consistent with new national policies and legislation such as the ACA. The Enhanced CLAS standards differed from the original standards in a number of ways. First, a Principal Standard was added that expressed the overall goal of CLAS. The OMH argued that “if the other 14 standards are adopted, implemented and maintained, then the Principal Standard will be achieved” (OMH, 2013, pp. 11–12). Second, the distinction between guidelines, mandates, and recommendations was eliminated ensuring that all 14 standards were viewed as equally important. Finally, the Enhanced CLAS standards emphasized the importance of organizational governance and leadership. “Organizational governance and leadership,” the report affirms, “are key to ensuring the successful implementation and maintenance of CLAS” (p.  12). The Enhanced CLAS Standards are listed in Table 2.3. Together EO 13166, the National CLAS Standards of 2001, Section 1557 of the ACA, the Joint Commission accreditation standards, and the Enhanced CLAS Standards of 2013 form the basis of LHP at the national level. As discussed at the beginning of this chapter, however, health policy in the United States follows a distributed model in which policy making is shared between the federal and state level policy makers. For example, although Medicaid is a federal program, it is administered at the state level. LHP, therefore, has not only been the prerogative of the federal government but has also occurred at the state level. In what follows, I will provide a brief survey of language policy measures that have been enacted at the state level. Language policy in health care at the state level Every state in the U.S. has some type of language access law. Youdelman (2008) collected an inventory of state level language access laws and found that while every state has at least two laws on the books, 22 states have more than 20 laws on the books and four states (Washington, New Jersey, Illinois, and California) have more than 75 laws on the books. Some states have developed comprehensive laws that mirror Title VI regulations. California’s Government Code Sections 11135 and 11139, for example, prohibit discrimination among state agencies that provide services to the public. The Dymally-Alatorre Bilingual Services Act, furthermore, requires that state agencies providing services to non-English speakers employ sufficient numbers of qualified bilingual personnel to ensure language access. The Act also requires that materials provided in English explaining services be made

Table 2.3 The Enhanced National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care, 2013 Principal Standard

Governance, Leadership, and Workforce

Communication and Language Assistance

Engagement, Continuous Improvement and Accountability

1 Provide effective, equitable, understandable and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs. 2 Advance and sustain organizational governance and leadership that promotes CLAS and health equity through policy, practices, and allocated resources 3 Recruit, promote, and support a culturally and linguistically diverse governance, leadership, and workforce that are responsive to the population in the service area 4 Educate and train governance, leadership, and workforce in culturally and linguistically appropriate policies and practices on an ongoing basis. 5 Offer language assistance to individuals who have limited English proficiency and/or other communication needs, at no cost to them, to facilitate timely access to all health care and services 6 Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing 7 Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided 8 Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area 9 Establish culturally and linguistically appropriate goals, policies, and management accountability, and infuse them throughout the organization’s planning and operations 10 Conduct ongoing assessments of the organization’s CLASrelated activities and integrate CLAS-related measures into measurement and continuous quality improvement activities 11 Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health equity and outcomes and to inform service delivery 12 Conduct regular assessments of community health assets and needs and use the results to plan and implement services that respond to the cultural and linguistic diversity of populations in the service area 13 Partner with the community to design, implement, and evaluate policies, practices and services to ensure cultural and linguistic appropriateness 14 Create conflict and grievance resolution processes that are culturally and linguistically appropriate to identify, prevent and resolve conflicts or complaints 15 Communicate the organization’s progress in implementing and sustaining CLAS to all stakeholders, constituents, and the general public

58  Language in health care policies available in any non-English language spoken by any group that represents at least 5% of the service user population. Few states, however, have laws as comprehensive as California’s. States such as New Jersey, Washington, and California have adopted laws that require the inclusion of cultural competency and language access in medical education and in continuing education for health professionals. In Ohio, similar efforts are underway to compel state licensing boards to require cultural competency instruction or continuing education as a condition for the renewal of state licenses for dentists, pharmacists, physicians, nurses, optometrists, psychologists, and social workers (S.B. 16). In addition to the licensing of individual providers, states have also included language access requirements for the licensure of health care facilities. Hospitals in Rhode Island, for example, must provide qualified interpreters or bilingual clinicians to all non-English speaking patients as a condition of their license to operate in the state. State-level language policy has also sought to ensure language access for special populations including children, the elderly, and pregnant women. Women’s Right to Know legislation, for example, requires that information about adoption, fetal pain associated with abortion, and the psychological impact of abortion be made available in any non-English language spoken by more than 2% of the state’s population. In Illinois, patients with mental illnesses also receive special accommodations. The Illinois Mental Health Hispanic Interpreter Act states that: Every State-operated mental health and development disability facility where at least 1% of the total annual admissions for inpatient or outpatient care consists of recipients of Hispanic descent shall provide a qualified interpreter when such recipient lacks proficiency in the English language to such an extent that communication with facility staff for purposes of receiving care or treatment is prevented. Many states have made compliance with these special population requirements a precondition of Medicaid payments (Youdelman, 2008, p. 428). Finally, there are examples of state level language policies that seek to ensure the qualification of those who provide language access services. Typically, state level policies ensure the qualification of health care professionals through a process of licensure. Licensure confers legal authority to practice through a stateappointed board that sets and enforces the qualifications needed to practice within the borders of the state. Physicians, nurses, and social workers require state level licenses to legally practice their profession. Health care interpreters, however, are not required to have a license to practice. State laws do not, at present, require health care interpreters to demonstrate qualification as a condition of practice. Legally, anyone can provide health care interpreting services; however, states have developed mechanisms to distinguish one interpreter from another. The process of certification provides a mechanism for interpreters to demonstrate their qualifications through an objective assessment of their credentials and skills. Only one state (Washington State) has developed a statewide certification program for

Language in health care policies  59 health care interpreters. Interpreters and bilingual staff who work directly for the State of Washington Department of Social and Health Services as well as contractors who provide services to DSHS clients are required to obtain professional language certification. The certification process involves an assessment of proficiency in English and the second language together with assessment of interpreting skills. DSHS certification is available in Spanish, Cantonese, Mandarin, Korean, Russian, and Vietnamese. Other states have depended on national health care interpreter certification bodies (the Commission for the Certification of Healthcare Interpreters and the National Board for the Certification of Medical Interpreters) to allow health care interpreters to distinguish themselves. In the State of Texas, for example, the Texas Association of Healthcare Interpreters and Translators (TAHIT) successfully advocated for a state law that would require the State’s Department of Health and Human Services to establish an advisory committee on qualification for health care translators and interpreters (Diaz, 2010). The bill was signed into law in 2009. The Advisory Committee is charged with “increasing the quality of and access to health care by improving the quality of communication between health care providers and consumers with limited English proficiency (LEP) and consumers who are deaf or hard of hearing” (TDHHS, 2016, p. 2). The committee recommended a statewide requirement that all individuals in the state of Texas who provide interpreting services as part of their professional duties in a health care setting should demonstrate qualifications through national certification or through successful completion of training that covers interpreting skills, ethics, standards of practice, roles of health care interpreters, cultural awareness, legislation, and regulations and general medical knowledge (HHS, 2016, pp. 4–5). State level language policies in health care thus reinforce federal level policies in some cases and complement them in others. Title VI look-alike laws and laws aiming to promote language access for special populations, for example, reinforce federal level policies already in place. Laws requiring cultural competency and the qualification of professionals who provide language assistance services, on the other hand, reinforce federal level policy by providing more specificity on the implementation of federal language in healthcare policy.

Language in health care policy and ideologies of language As we saw in the previous section, language policy in healthcare has evolved considerably over the past two decades. In assessing this evolution, we must consider not only the policy measures themselves but also the ideological framework in which these policies are articulated and implemented. In language policy research, the ideological framework has been conceptualized in different ways. Schiffman, as mentioned earlier, considers the ideological framework to be part of a larger linguistic culture. Spolsky, on the other hand, views the ideological framework of language policy as “a speech community’s consensus on what value to apply to each of the language variables or named language varieties that make up its repertoire” (2004, p. 14). Richard Ruiz, in his seminal paper “Orientations

60  Language in health care policies in language planning”, argued that the ideological framework of language policy consists of the specific normative orientation toward language that it displays. A language orientation, according to Ruiz, “refers to a complex of dispositions toward language and its role, and toward languages and their role in society” (1988, p. 4). More recently, Ruiz has clarified what is meant by orientation. A language orientation, he argues, is a normative framework that gives order to phenomena. By normative orientation, he means an organizing frame that shapes and informs language interventions (Ruiz, 2010). Ruiz identifies three orientations that have dominated U.S. policymaking: language-as-problem, language-as-right, and language-as-resource. The language-as-problem orientation is the “orientation that language is a social problem to be identified operationally and resolved through treatments” (Ruiz, 1988, p. 10). This orientation, according to Ruiz, often results in the social and cultural subordination of minority language communities. The language-as-right orientation is one that affirms the freedom to use a minority language and that protects from discrimination on the basis of its use (p. 11). This orientation, through its reliance on legal discourse, tends to create tensions and animosities between minority and majority language groups. The languageas-resource orientation, finally, “would tend to regard language minority communities as important sources for expertise. Not only could language competent community members be used to train others; the whole community itself could afford multilingual opportunities” (p. 17). The distinction between language-asright and language-as-resource has recently been clarified by Ruiz. In proposing the orientation of language-as-resource, he does not mean to subordinate language rights. Instead, he views language as a resource as a necessary precondition for language rights: Unless one sees a language as a good thing in itself, it is impossible to affirm anyone’s right to it. To say that one has a right to one’s mother tongue – to say access to one’s mother tongue is a linguistic human right – is to say, first, that the mother tongue is good thing in itself. (2010, p. 165) Ruiz’s insights bring up important questions about LHP in the U.S. To what extent does the language rights qua civil rights framework within which LHP is articulated draw upon and sustain language-as-problem and language-as-resource orientations? In the introduction of the final report on the National Standards for Culturally and Linguistically Appropriate Services, the authors state that: “interpretation for a non-English speaking patient/consumer is as important a diagnostic tool, or more so, than any blood test or x-ray” (OMH, 2001, p. 68). At the same time, the authors of the report point out a disparity in the availability of language services. They write: the provision of medical interpretation services in the United States is marked by contrasts: highly trained and well-paid professional interpreters deliver

Language in health care policies  61 services in some communities, whereas other institutions use housekeeping staff who barely understand English or call ethnic restaurants for free, ad hoc, ‘interpretation’. (OMH, 2001, p. 73) The recognition of language as an important diagnostic tool together with the identification of the disparities in the utilization of the tool constitute the foundational linguistic practice that is targeted for modification in U.S. LHP. In response to the unveiling of the CLAS standards during the public comment period, the American Academy of Pediatrics observed: “The Academy has concerns regarding the availability of education, training, qualified personnel, adequate reimbursement, evaluation mechanisms, and other resources required to implement and comply with standards” (OMH, 2001, p. 31). In response to these comments, the Office of Minority Health argued that the cost of not providing adequate language services was greater than the investment needed to implement them. “Lack of language services cost the organization time and resources during the patient’s visit” (AIR, 2005, p. 31). Such costs include unnecessary medical tests, late diagnoses and undetected medical problems. Beyond these costs, however, there is also a symbolic cost to not providing language services. In an American Institutes for Research report commissioned by the Office of Minority Health in 2005 entitled A Patient-Centered Guide to Implementing Language Access Services, the authors argue: “posting meaningful signage and otherwise helping patients to find their way within a healthcare organization demonstrates consumer friendliness and helps LEP patients and their families feel more comfortable in a stressful situation” (AIR, 2005, p.  115). The authors of the report go on to point out that the provision of language services helps patients become informed and efficient consumers. Proactively notifying LEP patients of available language assistance services not only helps patients better utilize your organization’s services but also helps them learn to be more informed consumers of health care as they are able to more efficiently move through your organization and the healthcare system in general. (AIR, 2005, p. 133) By making the business case for CLAS, the Office of Minority Health implicitly framed CLAS policy within a language-as-problem orientation. Language differences constitute a social problem that increases the cost of health care through deficiencies in the utilization of the system including unnecessary tests, medical errors, and other inefficiencies. But the presentation of a business case is not the only way that the Office of Minority Health framed CLAS policy within a language-as-problem orientation. The CLAS standards adopt what Bauman and Briggs (2003) have identified as an autonomous view of language, i.e., the view, emerging at the dawn of modernity in the seventeenth century, that language is a neutral vehicle for the precise

62  Language in health care policies and objective transmission or telementation of ideas. The autonomous view of language espoused in policy interacts with ideologies of the privileged place of English (cf. Santa Ana, 2002) by deterritorializing Spanish and creating an aura of high specialization in the provision of language services. This aura is evident primarily in ideas about surveillance and control of communication in languages other than English. The authors of the American Institutes for Research report, for example, state: the hospital had to trust that the patients were receiving correct and accurate information about discharge and post-discharge instructions. Plus, the hospital had no control over the quality or content of the instructions that patients received. . . . Any adverse effects of incorrect or inaccurate information could result in ineffective care that would be at least partially the hospital’s liability. (AIR, 2005, p. 52) This example sheds light on the rationale for Standard 6 of the CLAS standards that requires health care organizations to ensure the competence of individuals providing language services. The linguistic surveillance promoted in Standard 6 applies to both interpreters and to bilingual health professionals who interact directly with patients in their own language. The CLAS report states: bilingual clinicians and other staff who communicate directly with patients/ consumers in their preferred language must demonstrate a command of both English and the target language that includes knowledge and facility with the terms and concepts relevant to the type of encounter. Ideally this should be verified by formal testing. (OMH, 2001, p. 12) The autonomous view of language espoused by the CLAS standards through concerns over liability thus forms a new regime of linguistic surveillance that is dependent upon formal language testing. This new regime, furthermore, views with suspicion any provider who learned the language as a second or heritage language while privileging those who were trained as health professionals in a foreign country. “Bilingual individuals,” argue the authors of the CLAS report, unless they were trained as health professionals in another country, generally have only conversational skills in the target language and medical terminology would need to be specifically acquired through a course of study. In addition, a bilingual individual may not have had formal training in medical interpreting skills and may risk making mistakes. (OMH, 2001, p. 75) Under this new regime, the proficiency of language learners – those who “may have learned the language conversationally at home, in high school or in college”

Language in health care policies  63 (p. 75) – is always already viewed as suspect and in need of assessment while foreign trained professionals are simply assumed to be proficient. The CLAS report, furthermore, casts doubt on programs designed to develop language skills for health care purposes. Nevertheless, language training programs for medical/social service staff are proliferating. Given the potential for errors, health care organizations should not offer or suggest these courses as sufficient to communicate with LEP patients/consumers in clinical encounters. It can only be misleading to market 8-hour courses in ‘survival Spanish’ to clinicians or health care administrators. Still, many medical schools offer or encourage students to take semester long or shorter courses in ‘medical Spanish’. (OMH, 2001, p. 76) King de Ramírez and Martínez (2018) demonstrate how this policy orientation has led bilingual health providers to shy away from using their language skills on the job. One of the nurses in the study expressed her frustration by asking: “what’s the point of having two languages if you can’t use them” (p. 311). The regime of linguistic surveillance deterritorializes Spanish by displacing its legitimate acquisition in the United States (Szurmuk & Irwin, 2009). The autonomous view of language and the regime of linguistic surveillance that it generates frames the policy within a language-as-problem orientation by elevating the legitimate use of the language to the highest degree of specialization and thereby minimizing the contributions of domestic speakers of the language. With regard to the production of written materials in language other than English for use in health care organizations, the CLAS report asserts: organizations should develop policies and procedures to ensure the development of quality non-English signage and patient-related materials that are appropriate for their target audiences. At a minimum, the translation process should include translation by a trained individual, back translation and/or review by target audience groups, and periodic updates. (OMH, 2001, p. 13) Review of written materials by target audiences is also stressed in the American Institutes for Research report: “including the patient community in developing the materials can help ensure that the materials are accurate and useful” (AIR, 2005, p. 113). The inclusion of patient communities in the preparation of written materials appears to be grounded in the view that minority language communities may not possess high levels of literacy in their minority languages. The CLAS report states: a healthcare organization can help to ensure that its LEP patients/consumers have equal access to its services by including in its language assistance program translated materials that are written in commonly encountered

64  Language in health care policies non-English languages and that are consistent with the culture and literacy levels of target language groups. (OMH, 2001, p. 78) The American Institutes for Research report, on the other hand, emphasizes that “uniformity between written materials and oral communication is important. Vocabulary in written materials should match vocabulary used by staff and interpreters whenever possible” (AIR, 2005, p.  95). The language-as-problem orientation is also evident in the policy’s approach to written language. In its presumptions about levels of literacy present in the community, it subordinates written language to oral language thus reducing literacy to orality and fracturing the literacy practices actually used in and by the community. Vélez-Ibáñez and Greenberg (2005) characterize fractured literacies as an interruption of the extended development of Spanish literacy. The ideologies of language present in CLAS policy texts inform and give shape to the interventions that it recommends. The autonomous view of language, on the one hand, generates a regime of linguistic surveillance that delegitimizes the language spoken by second language and heritage language learners. The presumptions about literacy levels in the community, on the other hand, fracture the literacy practices and traditions present in the community and elevate instead practices and traditions that are based on orality. These ideologies bolster the language-as-problem orientation that underpin LHP in the U.S. A  language-as-resource orientation, on the other hand, would draw on community resources to affirm and protect the language rights of minority language speakers in the health delivery system. This would include encouraging second and heritage language learners to develop linguistic resources and practices that would promote language access. It would also encourage health care organizations to develop an understanding of the literacy practices that exist in the community and to develop written materials that are consistent with those practices instead of developing written materials that match oral language practices used in the clinical setting.

Language in health care policy and health policy At the outset of this chapter I made the claim that language in health care policy is a subset of health policy. In doing so, I sought to underscore the fact that LHP takes as its fundamental goals issues related to health care cost, access, and quality and that it is rooted and substantiated in the same guiding questions that drive health policy as a whole. These questions include: 1) Is access to care a fundamental human right or is it a market commodity? 2) Should the government play a role in the availability of health care, and if so, what level of involvement should the government assert? And 3) What conditions constitute health care consumers as deserving of publicly funded or subsidized care? In this concluding section of the chapter, I will consider how the guiding questions that animate health policy also animate LHP.

Language in health care policies  65 LHP addresses the issue of access to care through the perspective of fairness. Should the language that you speak determine whether or not you receive timely and adequate care? Should the language that you speak determine the level of pain you bear after surgery? Should the language that you speak determine whether you live or die? Questions such as these presuppose a veil of ignorance and encourage the respondent to think about what it would be like if the language that they spoke had such consequential impacts on their lives and their bodies. Under a veil of ignorance, we would want to make sure that the least advantaged position is in the best position possible because we have no way of knowing that we will not end up in that position. A recent public service announcement seeking to gain support for language in health care policies made this point vividly (Fluency, 2010). The scene begins with a young, blonde haired and blue eyed, English-speaking mother checking the temperature of her crying infant. The camera zooms in on a thermometer reading of 105 degrees. The scene cuts out and the distraught mother again appears entering through a door with a sign that reads “24 HORO – URGA PRIZORGO.” She approaches a receptionist interrupting a conversation with another patient. “Excuse me, sir,” she says, and goes on to explain the emergency to the receptionist: “she’s been crying non-stop, she has a temperature of 105. I don’t know what to do.” The receptionist, visibly irritated by the intrusion, slowly repeats “vi paroles versant.” “I don’t understand what you’re saying. What are you saying?” the young mother responds. A by-stander in the waiting room is called upon by the receptionist. He walks up to the counter and slowly says “do you have” and points to a blank form. “Please, please, just feel her head, feel her head.” The by-stander responds incomprehensibly and the scene ends with the mother running behind the counter saying “just someone let me in to see the doctor. Can anyone understand what I’m saying? Please, someone help me.” The scene cuts out and a voice over says: “eight percent of U.S. citizens speak limited English. For these 25 million Americans, professional interpreters can mean the difference between life and death.” The PSA attempts to place the viewer in the position of a minority language speaker and to simulate what it would feel like to be in a situation of dire emergency with no one who understands their language. LHP, therefore, seeks to ensure a just social arrangement by ensuring fair access to care for all regardless of the language that is spoken. LHP also intersects with questions about the role of government in ensuring access to health care by sharing in the prepayment of services. As mentioned earlier, a central rationale for LHP encoded in EO 13166 is that health care organizations receiving federal funding must provide meaningful access to their services for people with limited English proficiency. State level LHP also connects language access to the receipt of public funds. Underlying this rationale is the conviction that health care services prepayed with public funds should be available to all regardless of the language they speak. While on the surface LHP appears to be an unfunded mandate, it is actually more of a condition for accessing publicly funded health care prepayments. Finally, LHP touches on questions to do with the conditions that constitute consumers as deserving of publicly funded or subsidized services. While English

66  Language in health care policies Only ideologies buttress a perception that only those who speak English should have access to public services, LHP undercuts this assumption. In a study of health care professionals’ perceptions of LHP in the Rio Grande Valley of Texas, I found that many professionals felt that anyone receiving health care services in the U.S. has a responsibility to learn English. “You’re in America, you need to speak English” commented a bilingual therapist (Martinez, 2009, p. 264). An Englishspeaking nurse proposed the following analogy: “I don’t know Spanish. I go to Mexico and I don’t expect those people in stores to speak English to me” (p. 264). A monolingual physician of Latino descent stated the case more forcefully saying: “This is the U.S.! Patients seeking care should learn English or provide for their own interpreters – especially if Medicare or Medicaid is footing the bill. We live a few miles from the border. That is where the line was drawn. Anyone seeking medical care needs to remember that” (p. 265). In constructing English language proficiency as a requisite for deservingness, these professionals minimized the moral obligation of providing language assistance services to speakers of Spanish. LHP, however, turns these arguments on their head by emphasizing that it is precisely those who receive public assistance who are the most deserving of language assistance services. The tension between LHP and other language policies, such as English Only laws, demonstrates the unique position of LHP as fundamentally health policy rather than fundamentally language policy. Youdelman sums up the tension as follows: although there are more than 1,000 laws requiring language services, thirty states have enacted English-only laws that declare English to be the official or common language of the state and require all state activities to take place in English. However, since federal law preempts conflicting state law, states’ English-only laws cannot override Title VI. Indeed, eight of the state laws have explicit exceptions to allow compliance with federal law. (2008, p. 429) In this chapter we have explored the policies that direct the use of Spanish in health care settings and the regulatory environment that these policies have established. In doing so, we have explored the interconnectedness of language policy in health care to broader health policy concerns in the areas of access, cost, and quality. Even as language in health care policy is shaped by a larger health policy context, it is also affected by other policies including labor policy and immigration policy. At the same time, language policy in health care is sustained by ideologies of language that impact its deployment in Spanish-speaking populations. After reviewing these tenets of language policy in health care, we have come to a broader understanding of Rosa’s plight as she faced significant health threats in an inhospitable policy climate. Language policy in health care, we have come to understand, has significant impacts in the lives of speakers. In the next two chapters, we will expand our consideration of Spanish in health care by focusing on the language and cultural practices that occur within these regulatory environments.

Language in health care policies  67

References Ager, Dennis. (2001). Motivation in Language Planning and Language Policy. Clevedon: Multilingual Matters. Alliance of Community Health Plans Foundation. (2007). Making the Business Case for Culturally and Linguistically Appropriate Services in Health Care: Case Studies from the Field. Retrieved 9 January  2019 from: https://minorityhealth.hhs.gov/Assets/pdf/ Checked/CLAS.pdf. Allison, Juliann. (2017). Barriers to Latino warehouse workers’ health care: Survey results from Inland Southern California and policy implications. Journal of Poverty 21: 389–410. Almeida, Joanna, Biello, Katie, Pedraza, Francisco, Wintner, Suzanne & Viruell-Fuentes, Edna. (2016). The association between anti-immigrant policies and perceived discrimination among Latinos in the U.S.: A  multi-level analysis. SSM-Population Health 2: 897–903. American Institutes for Research. (2005). A Patient-Centered Guide to Implementing Language Access Services in Healthcare Organizations. Washington, DC: US Department of Health and Human Services. Anderson, Kathryn. (2014). Racially charged legislation and Latino health disparities: The case of Arizona’s SB 1070. Sociological Spectrum 34: 526–548. Barr, Donald. (2011). Introduction to U.S. Health Policy: The Organization, Financing, and Delivery of Health Care in America. 3rd Edition. Baltimore: Johns Hopkins University Press. Barros, Maria C. (1995). The missionary presence in literacy campaigns in the indigenous languages of Latin America. International Journal of Educational Development 15: 277–287. Bauman, Richard & Briggs, Charles. (2003). Voices of Modernity: Language Ideologies and the Politics of Inequality. Cambridge: Cambridge University Press. Becker, Gay. (2004). Deadly inequality in the health care safety net: Uninsured ethnic minorities struggle to live with life-threatening illnesses. Medical Anthropology Quarterly 18: 258–275. Civil Rights Division. (2005). Limited English Proficiency: What Federal Agencies and Federally Assisted Programs Should Know About Providing Services to LEP Individuals. Washington: U.S. Department of Justice. Capozzola, Christopher. (2008). Uncle Sam Wants You: World War I and the Making of the Modern American Citizen. Oxford: Oxford University Press. Cooper, Phillip. (2016). Civil Rights in Public Service. New York: Routledge. Daniels, Norman. (2008). Just Health: Meeting Health Needs Fairly. Cambridge: Cambridge University Press. Davin, Kristin & Heineke, Amy. (2017). The seal of biliteracy: Variations in policy and outcomes. Foreign Language Annals 50: 486–499. Del Valle, Sandra. (2003). Language rights and the law in the United States: Finding our voices. Clevedon: Multilingual Matters. Diaz, Esther. (2010). Case Study on Healthcare Interpreter Legislation in Texas. Austin: Texas Association of Healthcare Interpreters and Translators. Fluency [Gofluently]. (2010, 13 September). Interpreters Save Lives [Video File]. Retrieved 15 December  2019 from: https://www.youtube.com/watch?time_continue= 1&v=PJnZYCsXDQ8& feature=emb_logo. Gándara, Patricia & Hopkins, Megan, eds. (2010). Forbidden Language: English Learners and Restrictive Language Policies. New York: Teachers College Press.

68  Language in health care policies Gurrola, Maria & Ayón, Cecilia. (2018). Immigration policies and social determinants of health: Is immigrants’ health at risk? Race and Social Problems 10: 209–220. Hartch, Todd. (2006). Missionaries of the State: The Summer Institute of Linguistics, State Formation and Indigenous Mexico, 1935–1985. Tuscaloosa: University of Alabama Press. Horton, Sarah. (2004). Different subjects: The health care system’s participation in the differential construction of cultural citizenship of Cuban refugees and Mexican immigrants. Medical Anthropology Quarterly 18: 472–489. Horton, Sarah. (2016). They Leave Their Kidneys in the Fields: Illness, Injury and Illegality Among U.S. Farmworkers. Berkeley: University of California Press. Illingworth, Patricia  & Parmet, Wendy. (2017). The Health of Newcomers: Immigration, Health Policy and the Case for Global Solidarity. New York: New York University Press. Institute of Medicine. (2009). America’s Uninsured Crisis: Consequences for Health and Health Care. Washington, DC: National Academies Press. Johnson, David Cassels. (2013). Language Policy. New York: Palgrave Macmillan. The Joint Commission. (2010). Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals. Oakbrook Terrace, IL: The Joint Commission. King de Ramírez, Carmen & Martínez, Glenn. (2018). Nurses’ perspectives on language standardization in health care: The silencing of bilingual health providers. Heritage Language Journal 15: 297–318. Kloss, Heinz. (1988). The American Bilingual Tradition. McHenry, IL: Delta Systems and Center for Applied Linguistics. Lozano, Rosina. (2018). An American Language: The History of Spanish in the United States. Berkeley: University of California Press. Lubin, Judy. (2014). Inclusion and exclusion of Latinos in the affordable care act: Challenges and opportunities for achieving health equity. Harvard Journal of Hispanic Policy 26: 21–41. Martinez, Glenn. (2009). Language in healthcare policy and planning along the U.S.Mexico border. In Manel Lacorte & Jennifer Leeman, eds. Español en Estados Unidos y otros contextos de contacto: Sociolingüística, ideología y pedagogía. Madrid: Iberoamericana, pp. 255–269. McCarty, Teresa. (2014). Ethnography and Language Policy. New York: Routledge. Moran, Rachel. (2009). The untold story of Lau v. Nichols. In M. Lacorte & J. Leeman, eds. Spanish in the United States and Other Contact Environments: Sociolinguistics, Ideology and Pedagogy. Madrid: Iberoamericana, pp. 277–302. Nozick, Robert. (1974). Anarchy, State and Utopia. New York: Basic Books. Office of Minority Health. (2001). National Standards for Culturally and Linguistically Appropriate Services in Health Care: Final Report. Washington, DC: US Department of Health and Human Services. Office of Minority Health. (2013). National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care: A Blueprint for Advancing and Sustaining CLAS Policy and Practice. Washington, DC: US Department of Health and Human Services. Rawls, John. (1999). A Theory of Justice. Revised Edition. Cambridge: The Belknap Press of Harvard University Press. Reid, T.R. (2009). The Healing of America: A Global Quest for Better, Cheaper and Fairer Health Care. New York: Penguin Press. Rubin, Joan & Jernudd, Bjorn. (1971). Can Languages Be Planned? Honolulu: The University Press of Hawaii.

Language in health care policies  69 Ruiz, Richard. (1988). Orientations in language planning. In Sandra McKay & Sau-ling Cynthia Wong, eds. Language Diversity: Problem or Resource? Boston: Heinle. Ruiz, Richard. (2010). Reorienting language as resource. In John Petrovic, ed. International Perspectives on Bilingual Education. Charlotte: Information Age. Santa Ana, Otto. (2002). Brown Tide Rising: Metaphors of Latinos in Contemporary American Discourse. Austin: University of Texas Press. Schiffman, Harold. (1996). Linguistic Culture and Language Policy. New York: Routledge. Shapiro, Ben. (2017). Health care is a commodity, not a right. The National Review. Retrieved 22 December  2018 from: https://www.nationalreview.com/2017/01/healthcare-markets-government-commodity-human-right/. Shi, Leiyu  & Singh, Douglas. (2008). Delivering Health Care in America: A Systems Approach. Boston: Jones and Bartlett Publishers. Shohamy, Elana. (2006). Language Policy: Hidden Agendas and New Approaches. New York: Routledge. Spolsky, Bernard. (2004). Language Policy. Cambridge: Cambridge University Press. Spolsky, Bernard. (2009). Language Management. Cambridge: Cambridge University Press. Szurmuk, Monica & Irwin, Robert McKee. (2009). Diccionario de estudios culturales latinoamericanos. Mexico: Siglo XXI. Texas Department of Health and Human Services. (2016). Advisory Committee on Qualifications for Health Care Translators and Interpreters 2016 Report. Retrieved 19 January  2019 from: https://hhs.texas.gov/sites/default/files/documents/laws-regulations/rep orts-presentations/hb233-qhcti-adv-comm-report.pdf. Tollefson, James, ed. (2002). Language Policies in Education: Critical Issues. Mahwah, NJ: Lawrence Erlbaum Associates. United States Department of Health and Human Services. (n.d.). Section 1557: Ensuring meaningful access for individuals with limited English proficiency. Patient Protection and Affordable Act. Retrieved 9 January 2019 from: https://www.hhs.gov/sites/default/ files/1557-fs-lep-508.pdf. Valenzuela, Angela, ed. (2005). Leaving Children Behind: How Texas-Style Accountability Fails Latino Youth. Albany: SUNY Press. Vargas, Edward, Sanchez, Gabriel & Juárez, Melina. (2017). Fear by association: Perceptions of anti-immigrant policy and health outcomes. Journal of Health Politics, Policy and Law 42: 459–483. Velázquez, María Isabel. (2018). Household Perspectives on Minority Language Maintenance and Loss: Language in the Small Spaces. Clevedon: Multilingual Matters. Vélez-Ibáñez, Carlos & Greenberg, Joseph. (2005). Formation and transformation in funds of knowledge. In Norma González, Luis Moll & Cathy Amanti, eds. Funds of Knowledge: Theorizing Practices in Households, Communities and Classrooms. Mahwah, NJ: Lawrence Erlbaum Associates, pp. 47–70. Viladrich, Anahí. (2012). Beyond welfare reform: Reframing undocumented immigrants’ entitlement to health care in the United States, a critical review. Social Science and Medicine 74: 822–829. Willen, Sarah. (2012). Migration, “illegality,” and health: Mapping embodied vulnerability and debating health-related deservingness. Social Science and Medicine 74: 805–811. World Health Organization. (2006). Constitution of the World Health Organization. Retrieved 22 December  2018 from: https://www.who.int/governance/eb/who_ constitution_en.pdf. Youdelman, Mara. (2008). The medical tongue: U.S. laws and policies on language access. Health Affairs 27: 424–433.

3 Language and cultural practices in health communication

Tania is from Tampico, Mexico. She lives in McAllen Texas together with her husband and her two grown children. During her first pregnancy, at the age of 24, Tania was diagnosed with diabetes and high blood pressure. She controlled the diabetes with a strict diet and after her son was born everything went back to normal. At the age of 41, however, the disease came back. Her reaction was one of fear and anxiety. Diabetes ran in her family, so she knew what it was all about. Tania never thought it would happen to her. A year later she had complications and that’s when she started treatment. It made her angry. She could no longer eat the foods she enjoyed so much. She’s been on insulin for six years. She injects insulin twice a day, takes medication, and has a strict diet. Fortunately, the only consequences of the disease so far have been pain in her hands and feet. It’s hard to be on such a strict diet. The food the doctor recommends is rather bland. It’s also hard to have to eat every three to four hours as the doctor recommends. Every night she remembers what she ate and if she didn’t follow the doctor’s recommendations, she is overcome by feelings of both guilt and shame. Whenever she goes to the doctor, the nurses and the doctor criticize and scold her. She doesn’t feel supported. She feels disciplined and threatened. She feels that there is a lack of psychological support to help her get through all the different stages of the disease. Her greatest fear is to wind up on dialysis or to lose a limb. Even though she lives in the U.S., she sees her doctor in Mexico. She says that the relationship with the doctor is the most important one besides one’s family. She crosses the border to see her doctor every three months and maintains communication with his office through email and text messages. She worries that she might wind up in the hospital on the U.S. side and not be able to communicate. She is comforted by the fact that her two boys speak English and she is confident that they will help her if the need arises. Story by Karmín San Martín (Used with permission)

Language in health communication  71 I begin this chapter with Tania’s story because it demonstrates how practices of language and culture are imbricated in Latino health. I have deliberately chosen to refer to practices of language and culture rather than simply language and culture. Tania’s experience of language and health shape her practices. She prefers to see her doctor in Mexico rather than see one in the United States. At the same time, however, she is cognizant of the limitations that this practice implies and thus depends on her children to mediate for her should she ever find herself in a situation where she was not able to communicate with health care providers. The notion of language and cultural practices has come into applied linguistic thinking, according to Pennycook (2010), via theorists such as Ludwig Wittgenstein and Pierre Bourdieu. Practice allows us to move away from an over-voluntaristic micro perspective that prizes individual rational action and choice while also avoiding an over-deterministic macro perspective that focuses on the sociocultural, political, and economic forces that shape human choices and decision-making. Instead, the notion of practice occupies an intermediate, meso level locus of analysis that recognizes both individual choice and structural determinants in interaction within bundles of activities that are at once engaged in voluntarily at the micro level and shaped by macro level forces. Bourdieu’s notion of habitus, defined in Chapter 1, is central to this line of thinking. The idea of language and cultural practices can be viewed as a starting point to understand the material and political consequences of language use. By identifying language and cultural practice as the starting point, I am seeking to move beyond mechanistic views of language and culture as social determinants of health. I understand language not as a structure accessed through cognition but rather, to borrow Pennycook’s turn of phrase, as “a product of the deeply social and cultural activities in which people engage” (2010, p. 1). I understand culture in a similar vein, as an emergent property of interactions, rather than a preexisting set of beliefs, values, and orientations that precede any given encounter. “A focus on language practices,” argues Pennycook, “moves the focus from language as an autonomous system that pre-exists its use, and competence as an internal capacity that accounts for language production towards an understanding of language as a product of the embodied social practices it brings about” (2010, p. 9). When I refer to language and cultural practices, then, I am de-emphasizing the materials, perspectives, and values that are brought to the encounter precisely in order to highlight the ways that these same aspects are produced within the encounter. This view of language has significant implications for the understanding of both language barriers in health care and Latino health. Where do language barriers exist? From where do they emerge? These questions inevitably must be addressed in any consideration of Spanish in health care. In this chapter, my aim will be to explore the role that language and cultural practices play in Latino health and to further our understanding of how language barriers that impact Latino health emerge. I will begin by considering the ways that language and culture have traditionally been approached in health communication. I will then present some alternative approaches that transcend notions of language and culture as static entities and that bring practices into view.

72  Language in health communication

Language and culture in health communication Health communication has been defined in numerous ways. The Centers for Disease Control and Prevention, for example, defines health communication as “the study and use of communication strategies to inform and influence individual and community decisions that enhance health” (CDC, 2019). This definition presupposes that the enhancement of health is within the locus of control of individual and/or community decisions. It also assumes that decisions are fundamentally shaped by the input of information and that they are subject to influence through communication strategies. In a sense, then, we might say that informing and influencing are the two central functions of health communication. Even so, it is important to recognize that informing and influence can take place at different scales of social interaction. For example, information and influence could emerge from a private conversation with a physician or through an advertising campaign targeted to an entire demographic group. Secondly, it is also important to recognize that the transmission of new information always depends on the presence of old information, so we cannot assume that all information transfers to the same extent and in the same fashion. A  simple statement such as “HPV vaccination during adolescence prevents the transmission of human papilloma virus during sexual intercourse and thus reduces the incidence of cervical cancer” can be understood in very different ways depending on the previous information that the listener possesses. For example, not every listener will understand that the vaccine does not presuppose that the adolescent is sexually active. Not every listener will understand the relationship between a virus and the development of cervical cancer either. So, health communication is not only shaped by the scale at which it occurs, but it also depends on the background knowledge of the receiver of the message. Renata Schiavo (2014) has proposed a more nuanced definition that covers these various facets. She writes: Health communication is a multifaceted and multidisciplinary field of research, theory, and practice. It is concerned with reaching different populations and groups to exchange health-related information, ideas and methods in order to influence, engage, empower, and support individuals, communities, health care professionals, patients, policymakers, organizations, special groups and the public, so that they will champion, introduce, adopt or sustain a health or social behavior, practice, or policy that will ultimately improve individual, community, and public health outcomes. (Schiavo, 2014, p. 9) Schiavo’s definition addresses the issues of scales and background knowledge mentioned earlier quite directly. She emphasizes the different populations and groups that are reached by health communication interventions, and she points out that the target of health communication interventions extends beyond individuals and communities to health care professionals, policymakers, organizations, and the like. Her approach to the causal relationship between decision-making and

Language in health communication  73 health outcomes is also a bit more nuanced since she specifies that championing, introducing, adopting, and sustaining health or social behavior, practice or policy may not immediately change health outcomes even if that is the ultimate goal. Finally, Schiavo’s definition significantly expands the informing and influencing functions of health communication proposed by the CDC by signaling instead the exchange of health-related information, ideas, and methods for the purpose of influencing, engaging, empowering, and supporting. Schiavo’s broad definition helps us to understand the multiple theoretical strands that weave together the tapestry of health communication. Sociological concepts, for example, elucidate the observed differences between populations and groups. Psychological concepts, on the other hand, clarify the mechanisms responsible for influence, engagement, empowerment, and support. Discourse and conversation analysis provide a basis for understanding the exchange of information, ideas, and methods, and cultural studies contribute to our understanding of the core values that shape a population or group’s particular understanding of information, ideas, and methods and the resources that are available for championing, introducing, adopting, and sustaining health or social behaviors. In what follows, we will consider how language and cultural practices have been included or excluded in these various theoretical strands that constitute health communication.

Health behavior theory Health behavior theories emerging out of psychology have been extremely important in health communication research and practice. Health behavior theories strive to understand the cognitive and emotional factors that drive health and risk behaviors. Health behavior theories are thus explanations of behaviors based on a set of theoretical constructs. A construct is a key concept that serves as a component of a theory (Pasick et al., 2009). Why do people choose to stop smoking? Why did they choose to start in the first place? What factors contribute to the decision to stop smoking and which factors correlate most positively with success? These are the kinds of questions that health behavior theories ask. Health behavior theories seek to identify the factors that influence behavior and also specify how these factors work together to produce behavioral change. Smoking has been a major subject in health behavior theorizing, but other health behaviors such as cancer screening, type 2 diabetes self-management, weight loss, and substance abuse have also been productive areas for the development of health behavior theory. Models of health behavior change The health belief model (HBM) is an extremely influential theory that has been used to undergird countless health communication interventions. The major proposition of the HBM is that behavior change is more likely when the perceived threat of the behavior is high (Champion & Skinner, 2008). The perceived threat of a given behavior, for example smoking, emerges from a variety of constructs. First, we need to consider individual perceptions. Does the person view the

74  Language in health communication consequences of smoking  – emphysema, bronchitis, and lung cancer  – as relatively more or less severe? This is called perceived severity. A second, and equally important, facet of individual perceptions is perceived susceptibility. Does the person view the consequences of smoking as something that could happen to her? Oftentimes, smokers recognize the severity of the consequences of tobacco use but feel that since their grandfather smoked until he was 90 years old, that individual’s susceptibility is relatively low. The HBM proposes that both perceived severity and perceived susceptibility must be high in order for an individual to perceive the behavior as risky enough to change. The model recognizes that individual perceptions are shaped by numerous modifying factors. An 18-year-old smoker, for example, is less likely to view their own susceptibility to cancer as high as a 50-year-old smoker. Modifying factors include age, sex, ethnicity, personality, socioeconomic factors, background knowledge, and the like. In addition to these modifying factors, cues to action may also influence an individual’s perceived threat. In many Latin American and European countries, for example, in addition to containing warning messages about the adverse consequences of smoking, packages of cigarettes are required to show graphic images of these consequences on the lungs, throat, and mouth as a cue to action that will influence and elevate the individual smoker’s perceived severity and susceptibility. But even when the perceived threat is high, an individual may choose not to change the behavior. The HBM proposes that an elevated perception of threat is not, in itself, sufficient to change behavior. An individual must also perceive benefits of changing the behavior that outweigh any perceived barriers. A person might say: “I understand that smoking bad, but it’s just too difficult to quit.” In this case, the difficulty of quitting (perceived barrier) reduces the likelihood that the person will quit. Another person might say: “I’ve been smoking since I  was twelve, so I  figure any damage that was going to happen has already happened.” In this case, the perception of low benefits associated with smoking cessation reduces the likelihood that the person will quit. Health communication makes use of the HBM by understanding the need to appropriately target messages that will both elevate the perceived susceptibility and severity while at the same time increase the perceived benefits and decrease the perceived barriers. While the HBM proposes that the perception of threat is the prime motivator of behavior change, the theory of reasoned action and the theory of planned behavior (TRA/TPB), developed by Martin Fishbein and Icek Ajzen, argued that perception by itself was not sufficient to account for behavior change. Instead, they argued that the key to behavior change is intention to change (Montaño & Kasprzyk, 2008). Behavioral intention is driven by attitudes, norms, and control. Attitudes towards behavior change in the HBM are viewed primarily in terms of the combination of perceived susceptibility and severity. An attitude towards quitting smoking would be shaped by whether or not the smoker sees himself developing lung cancer and the severity he assigns to that condition. In the TRA/TPB model, attitudes are looked at differently. It is not the attitude towards the outcome that is important but rather it is the attitude towards the behavior that drives change. Consider, for example, colorectal cancer screening. While men typically

Language in health communication  75 have positive attitudes towards the outcome of prostate cancer screening, i.e., early detection and cure, they may not have equally positive attitudes about the behavior of screening itself which might include a digital rectal examination in addition to a battery of blood tests. In the TRA/TPB model, then, attitudes are fundamentally reoriented towards the behavior rather than the outcome. In the HBM, cues to action tend to focus solely on the outcome. Recall the pictures included on cigarette packages in Latin America and Europe that depict diseased organs. The TRA/TPB also stresses the importance of norms in behavior change. The HBM model, with its focus on perceived threats, benefits, and barriers does not explicitly account for the decisive role of peer pressure and peer support in behavior change. Subjective norms in the TRA/TPB refer to the opinions and perceptions of people who are close to or influence an individual. If a person perceives that the people who are important to them will be supportive of a behavior, they will be more likely to engage in change. If, on the other hand, they perceive that they will be ridiculed by those who are important to them, their intention to change may decrease. Let’s return to the example of prostate cancer screening. The negative attitude towards the behavior of a digital rectal examination may be heightened by the subjective norms surrounding masculinity. A person may, for example, feel that he will be ridiculed by his friends for the behavior and this, in turn, may influence his intention. Up to this point, I have been discussing the TRA and the TPB as a single theory. The theories, however, were developed independently. The TRA was developed first and focused on the importance of attitudes and norms in behavioral intent. The TPB was developed later and added to the model the construct of control. Behavioral control refers to the facilitators and inhibitors of a particular behavior (similar to the constructs of perceived benefits and barriers in the HBM) which may also contribute to the intention to change. The TRA/TPB posits that perceived behavioral control is combined with selfefficacy, i.e., a person’s perception of ability to perform the behavior. The inclusion of Albert Bandura’s construct of self-efficacy is an important addition to the model given the fact that the existence of facilitators may be of little consequence if a person has no confidence in their ability to perform the behavior. Overall, the TRA/TPB provides a portrait of the multiple factors that shape a person’s intention to change. When comparing the TRA/TPB to the HBM, we can think of the TRA/TPB as the process that takes place in between the perception of threat and engagement in behavioral change, i.e., the development of intention to change. James Prochaska and Carlo Di Clemente developed the Transtheoretical Model (TTM) that provided additional insights into our understanding of health behavior change. If the TRA/TPB proposed an intermediary step between the perception of threat and behavioral change proposed by the HBM model, the TTM expanded our understanding of change itself. In the TTM, behavioral change is not viewed as a single, discrete action but instead as a process that includes multiple stages. Health promotion and education programs are notorious for achieving limited success. There is always a group of participants that simply does not respond to the intervention. How do we explain this failure? For some time, the focus had been on the individual resistant to change. Health promoters and educators would

76  Language in health communication simply throw up their hands and say, “these folks just aren’t ready to change.” The TTM, however, turns the table on this predicament and proposes that maybe it’s not the individual who is not ready for the program but the program that is not ready for the individual (Prochaska, Redding & Evers, 2008). In making this bold claim, the TTM underscores that change is a process and that there are various stages in the process. Regardless of a person’s perception of a threat (HBM) and intention to change (TRA/TPB), people find themselves in different places when it comes to actually engaging in behavior change. The TTM identifies five stages of change: pre-contemplation, contemplation, preparation, action, and maintenance. Each stage indicates a level of intention. The pre-contemplation stage is when a person is uninformed or misinformed about the risks associated with a given behavior. The contemplation stage is when a person perceives the risk and begins to think about the possibility of change. The cues to action of the HBM, for example, may help to move an individual from pre-contemplation to contemplation. The preparation stage is when a person begins to make minor modifications in advance of a behavior change. The action stage is when a person actually engages in the behavior change itself and the maintenance stage is when the person actively engages in avoiding a relapse. The TTM’s proposal of stages of change helps health promoters and educators target their interventions to the various levels of readiness to change of their participants. For example, an intervention targeting smokers in the pre-contemplation stage might emphasize the health consequences of tobacco use while an intervention targeting smokers in the maintenance stage might be more likely to emphasize triggers for relapse and strategies to avoid or limit the impact of those triggers. In addition to proposing stages of change, the TTM also identifies processes of change. Processes of change are the activities that people engage in, consciously or unconsciously, as they progress through the stages. The following processes have been identified: 1 2 3 4

Consciousness raising: the process by which people increase awareness about the causes, consequences, and cures of a particular behavior. Self-reevaluation: the process by which a person evaluates herself in light of the changed behavior. Self-liberation: the process by which a person makes a firm commitment to the change. Helping relationships: the process through which the person builds a network of caring and supportive relationships that affirm the person’s commitment to change.

These processes of change align with many of the factors identified in the TRA/ TPB. For example, the process of establishing healthy relationships aligns with the TRA/TPB insight on the influence of subjective norms. Self-reevaluation aligns with the TRA/TPB focus on the role of attitudes in generating an intention to change. At the same time, the TTM processes of change also align with many of the foundational constructs of the HBM. The process of consciousness raising, for example, aligns with the perceived susceptibility and severity of a behavior,

Language in health communication  77 and the self-liberation process aligns with the perceived benefits and barriers to behavior change. Language and culture in health behavior theory The three models of health behavior change all share an emphasis on the individual while de-emphasizing many of the social and cultural conditioning factors that make individual behavior change possible (Brewer & Rimer, 2008). Dutta (2008) points out the inherent dangers of this undue emphasis on individual cognition in health behavior change. The HBM, according to Dutta, “does not accommodate the communicative practices in alternative discursive spaces where a systematic evaluation of the target behavior does not precede health practices” (p. 23). Dutta thus brings into view the practice orientation invoked at the beginning of this chapter. Health behaviors are not universally preceded by a rational calculus of susceptibility, severity, benefits, and barriers. On the contrary, health behaviors are bundled activities that include various kinds of reasoning, relationships, and resources. These activities, moreover, are always embedded in social and cultural contexts. The various constructs involved in each theory – perceived susceptibility, perceived benefit, subjective norms, self-efficacy, and intention – are heavily influenced by social and cultural factors. Rena Pasick and her colleagues, for example, explored the role of sociocultural influences in the application of behavior theory to mammography utilization among Latina and Filipina women (Pasick et al., 2009). They found that social context significantly shaped the meaning of the constructs of perceived benefit, perceived susceptibility, self-efficacy, intention, and subjective norms. The influence of social context on health behavior emerged within three domains: relational culture, social capital, and transculturation and transmigration. The domain of relational culture relates to the interconnectedness and interdependence that emerges in communities where Latina and Filipina women live. The authors found that these connections and relationships were highly valued and that they significantly mediated interactions within and outside the community. Relational culture affects constructs such as intention and subjective norms from the TRA/TPB. For example, while the TRA/TPB defines behavioral intention as a plan to attain a specific behavioral goal, Pasik and colleagues note that the strength of relational culture can often motivate behaviors in the absence of intentions. In other words, people engage in a behavioral change not because they are individually motivated but because the relationship with the person asking them to adopt the change is extremely important to them. Pasik and colleagues provide the example of a Filipino patient with diabetes who was told by the doctor that he needed to have his foot amputated. The patient resisted the doctor’s advice, not because he questioned it but because that kind of personal information “must come from someone the patient knows and trusts and must be delivered in a more caring and subtle way” (p. 24S). The context of relational culture also affects the construct of subjective norms. The construct of subjective norms in the TRA/TPB emphasizes beliefs about what others think of a given behavior. In

78  Language in health communication relational culture, however, it is not so much what those who are important to you think about the behavior, but rather it is the relationship itself that is important. For example, someone trying to quit smoking may not be concerned about what people who are important to him think about him quitting smoking, but he might be concerned instead about the impact of not smoking on the relationship itself. Will those people still want to be around him? Will they be offended when he refuses their offer of a cigarette? These are dimensions of subjective norms that the construct, in its present form, does not account for. A second domain of social context identified by Pasik and colleagues is social capital. The authors define social capital as “the benefits and challenges that accrue from participation in social networks and groups” (p. 25S). An informant in their study described social capital as follows: “When you go to Miami and you go into a Cuban neighborhood . . . you think you are in Puerto Rico or Cuba. So there is a welcoming climate that’s very important . . . you have some social capital so you can help yourself” (p. 25S). This view of social capital challenges the theoretical construct of self-efficacy inasmuch as it highlights the importance of the surrounding environment in terms of the capacity a person believes they have to successfully achieve a behavior. The women in Pasik et al.’s study “defined selfefficacy in terms of caring, support, relationships and family . . . in terms of the connections with others that enable them to take care of those most important to them” (p. 28S). The TRA/TPB proposes control as one of three contributing factors that account for behavioral intention. The construct of control, furthermore, is defined as the combination of external facilitators and inhibitors and self-efficacy where self-efficacy is limited to the person’s belief in their own ability and skill set to perform the behavior. Pasik and colleagues, however, show that in the context of social capital the meaning of self-efficacy may be too narrow because it assumes that self-efficacy is transferrable across social contexts. A behavior that a person could easily perform in a Spanish-speaking neighborhood in Miami might be more difficult in an English-speaking neighborhood in Georgia. In this way, the concept of social capital expands our understanding of self-efficacy and helps us view the complex and situated nature of a person’s perception of their ability to perform a behavior. In addition to relational culture and social capital, Pasik and colleagues also identify transculturation and transmigration as a significant domain of social context that challenges our understanding of key constructs in health behavior theory. Transculturation is a concept that contrasts with the notion of acculturation which has been so pervasive in public health literature. Cuban anthropologist Fernando Ortiz first described transculturation in 1939 as a complex, dynamic, and bi- or multidirectional process that spans distinct phases of social and cultural change from de-culturation through neo-culturation (Ortiz, 2002). Similarly, Pasik and colleagues describe transculturation as a multiplicity of cultural transformations “that occur when people from different cultural contexts meet through colonialism, imperialism and migration” (p. 26S). Transmigration, on the other hand, is viewed as a parallel process to transculturation that describes “migrants’ maintenance of connections between country of origin and destination country and

Language in health communication  79 the mutual influences of the social structures and commitments in both places” (p.  26S). Transculturation and transmigration call into question the application of behavioral theory constructs such as perceived benefit and perceived susceptibility. The meaning of health, risk, and illness, for example, cannot be teased apart from experiences of discrimination, othering, unfamiliarity, fear, and mistrust. The benefits of a given health behavior, for example, could be perceived as less likely given these transcultural experiences. Likewise, susceptibility may be viewed differently. As Pasik and colleagues note: “fundamental understandings of life and health based on generations of deeply held religious and spiritual beliefs can conflict with physiological explanations used by Western medicine” (p. 28S). Transmigration phenomena, including ongoing connections with the place of origin and the use of unlicensed health practitioners such as curanderos (Clark et al., 2010), sustain the tensions between these perspectives. These tensions do not emerge solely from the practices and perspectives of immigrant communities themselves but instead are bolstered by the discourse present in Western medicine. Holliday (2008), for example, uses a critical medical anthropological approach to examine biomedical labeling trends associated with botánicas and unlicensed medical professionals. She argues that while “complementary” and “alternative” medicine has been gaining traction in health care research, the labeling of Latino health beliefs rarely falls under this rubric. Instead, Latino health practices continue to be referred to as “traditional” practices and “folk” beliefs. She argues that “by using the terms ‘complementary’ and ‘alternative’ instead of ‘folk’ and ‘traditional,’ Latino/a ideologies are validated as modern through the invocation of contemporarily accredited label” (p. 410). A view of health behavior theory from the perspective of language and cultural practices proposes that key constructs are emergent rather than prefabricated; that more than being brought to the change, they are built, negotiated, and reconstituted within the process of change itself. Relational culture, social capital, and transculturation and transmigration are all actualized through language and cultural practices – bundles of activities involving both linguistic resources and cultural perspectives. And it is through these practices that people perceive risk, develop intentions to change behavior, and progress through stages of change. In what follows, we will discuss health communication perspectives on interpersonal dimensions of patient-provider interactions. In this discussion we will attempt to draw out how language and cultural practices intervene in the building, negotiation, and reconstitution of key constructs such as perceived risk, behavioral intention, and progress in behavioral change.

Provider-patient communication Provider-patient interaction has been an important area of research in health communication. Talk in medical encounters is of paramount importance because it is through talk that providers obtain access to symptoms, exposures, and lifestyle factors that aid in formulating a diagnosis and a treatment plan. The medical interview is the primary mechanism through which these interactions take place. The

80  Language in health communication medical interview is a mode of speaking that positions providers and patients unequally from the very beginning and that leads the doctor sequentially and in linear fashion from a chief complaint to a prognosis (or forecast). Following Waitzkin (1991), we can map out the structure of the medical interview as follows: Chief Complaint → Present Illness → Past History → Family History → Social History → Systems Review → Physical Examination → Other ­Investigations → Diagnosis → Treatment Plan → Prognosis The chief complaint is the initial response to a question such as: What brings you in today? Once the patient has indicated the reason for seeing a provider, the provider may probe deeper into the conditions surrounding the complaint including pain and other symptoms. This is the present illness segment of the interview. The mnemonic LIQOR-AAA is commonly used to explore pain symptoms associated with a chief complaint. The mnemonic indicates the major questions around pain that include: Location (Where does it hurt?), Intensity (How bad is the pain?), Quality (What kind of pain is it?), Origin (Where does it start?), Radiation (Does it spread to other parts of the body?) and Associated factors (Does anything else hurt?), Alleviating factors (Does anything make it better?), and Aggravating factors (Does anything make it worse?). After assessing the physical characteristics of the complaint, the provider will seek to understand the history of when the pain or symptoms started and what was going on in a person’s life at that time. Family history is also important for some hereditary conditions, so the provider may ask if there is any precedent of illness in the family. Other conditions are the result of lifestyle factors, and the provider may explore specific behaviors including smoking, drinking, and sexual activity. The systems review is meant to capture information left out of the history of present illness. The provider may ask questions relating to the organ system in question. As Waitzkin points out: “under the gastrointestinal system, the doctor would ask questions about symptoms or prior conditions of the esophagus, stomach, duodenum, small intestine, large intestine, rectum, liver and pancreas” (p.  30). The physical examination consists of the laying on of hands where the provider conducts a review of the patient’s body through the senses of touch, sight, and sound. Other investigations such as x-ray imaging and bloodwork may follow. At this point, the provider applies clinical reasoning to arrive at a diagnosis, uses the standard of care to determine the best treatment, and presents the findings to the patient. The presentation of the findings, furthermore, is typically associated with a prognosis indicating the outlook towards cure. Health communication approaches to provider-patient interaction The medical interview is a technology of what Foucault has called the “medical gaze” (Foucault, 1973). The medical gaze is the clinical process through which a patient’s body is separated from the person and segmented into discrete units of analysis, such as organ systems. As a technology of the medical gaze, the

Language in health communication  81 medical interview can be understood through Althusser’s concept of interpellation. Interpellation is the process of hailing a person into a unique subject position or role (Althusser, 2001). Beginning from the chief complaint – what brings you in today? – the patient is hailed into a specific subject position or role, and this role shapes the entire interaction. Talcott Parsons (1999) explored the subject positions created in the medical encounter. The “sick role,” according to Parsons, imbues the subject with four main features. He explains, for example, the sick person is exempted from certain social obligations, such as going to work or to school. At the same time, the sick person is also exempted from responsibility for his own state. We normally do not blame a sick person for being sick. A third characteristic of the sick role, Parsons explains, is that the state of illness is viewed as time bound. “No one is given the privilege of being sick any longer than necessary but only so long as ‘he can’t help it’ ” (p. 104). Finally, the sick role situates a person as in need of help. A sick person recognizes the need for medical attention and thus is expected to cooperate with medical personnel to achieve a return to the non-sick role. Parsons’ notion of the sick role cedes most control to the medical provider, leaving the person in the sick role to control only their own compliance with provider orders. Roter and Hall (2006), however, point out that the distribution of control in the provider-patient encounter need not be static. Control is shared in different ways between providers and patients and each configuration establishes a specific role. Roter and Hall thus seek to move past an overarching conceptualization of a sick role and to define other types of roles in provider-patient interactions. They identify four role patterns between providers and patients based on the level of control exerted by each participant. Paternalism is the role pattern assumed in Parsons’ model where the sick person has low control and the medical provider has high control. The sick person, in a state of vulnerability and dependency, cedes control to the provider to exert his or her specialized knowledge. Consumerism, on the other hand, is a role pattern in which the sick person has high control and the provider has low control. The consumerist role pattern applies marketplace principles to the health care encounter and identifies the patient as the customer and the provider as the seller. In this role pattern, “the customer is always right” and the customer is expected to negotiate for the “best deal.” The advent of directto-consumer advertising (DTCA) of prescription medications within the past two decades has contributed enormously to a shift towards consumerism in providerpatient interactions. DTCA is meant to persuade patients to opt for a particular medication and to pressure their providers to prescribe that medication as can be seen in the ubiquitous phrase in all DTC advertisements: “ask your doctor if this medication is right for you.” According to Roter and Hall, however, redefinition of the doctor-patient relationship as a consumer-provider exchange is more than a matter of simple semantics, for it refocuses the traditional perspective and thereby changes the very nature of the social relationship between the medical professional and the lay world. (p. 31)

82  Language in health communication Mutuality is the role pattern in which both provider and patient exert high control each in their own appropriate lanes. According to Roter and Hall, this is the ideal role pattern. In mutuality “each of the participants brings strengths and resources to the relationship as well as a commitment to work through disagreements in a mutually respectful manner” (p. 35). Mutuality, therefore, can be characterized as a “two-way process” in which patients disclose their problem with openness and providers work with patients to determine the optimal course of action. A final role pattern identified by Roter and Hall is what they call default. This is a pattern in which both provider and patient exert low control. “Default,” explain Roter and Hall, “can be characterized by unclear or contested common goals and an uncertain physician role” (p. 37). The role patterns identified by Roter and Hall suggest that provider-patient interaction is not statically confined in concrete roles but instead that it is by its very nature dynamic. Role patterns in provider-patient interaction are artifacts of discourse. Elliot Mishler (1984) introduced the concept of “voice” to account for this relationship between discourse and role patterns in the medical interview. He argues that interactions in the medical setting are sites of convergence and competence between two distinct voices: the “voice of medicine” and the “voice of the lifeworld.” The voice of medicine, for Mishler, represents “the technical-scientific assumptions of medicine” while the voice of the lifeworld represents “the natural attitude of everyday life” (p. 14). These voices come into contact in the clinical encounter as patient and provider interact. Take for example the following exchange: Doctor: Patient: Doctor: Patient:

How long have you been drinking? Since I’ve been married. How long is that? Four years (Gwyn, 2002, p. 71).

In this brief exchange, the doctor formulates the question in the voice of medicine – how long have you been drinking? – but the patient responds in the voice of the lifeworld – since I’ve been married. The doctor then exerts the voice of medicine again in order to elicit a response that provides a specific time frame – four years – and one that is divorced from the patient’s lifeworld. The dialectic of voices in the medical encounter is further elaborated in Ainsworth-Vaughn’s (1998) study of provider-patient interactions. Speech activities, she argues, are used purposefully in the medical encounter to claim power. Speech activities that patients use to claim power include controlling the topic, co-constructing diagnoses, and proposing treatments. “Speech activities and social identities,” Ainsworth-Vaughn concludes, “are rich, complex resources for both patients and physicians, as they cooperatively construct talk (a joint effort) and claim power for themselves (an individual effort)” (p. 180). Cordella (2004) expands Mishler’s concept of voice and Ainsworth-Vaughn’s notion of power claims by identifying multiple voices taken up by both doctors and patients in medical interactions. She proposes that doctors speak with at least three discursively differentiated voices: 1) the doctor voice, 2) the educator voice, and 3) the fellow human voice. These

Language in health communication  83 voices, according to Cordella, correspond to the different functional goals of the medical encounter. The doctor voice aligns the provider’s function of gathering information about the patient’s health. The educator voice serves the provider in educating the patient to adhere to medical advice and recommendations, and the fellow human voice affords the provider the ability to offer support and show empathy. These different voices weave together to construct provider discourse in the medical encounter (pp. 58–59). The patient, on the other hand, also takes up multiple voices in the course of the medical encounter. Cordella distinguishes four different voices: 1) the health-related storytelling voice, 2) the voice of competence, 3) the voice of social communicator and 4) the voice of initiator (p. 60). The health-related storytelling voice gives patients a means to express their current health condition (p. 153). The voice of competence reveals the patient’s previous experience and familiarity with medical procedures (p. 157). The voice of social communicator affords patients the opportunity to raise issues related to their social identities and experiences (p. 165). Finally, the initiator voice is an information-seeking disposition that triggers the educator voice of the provider. The patient acknowledges lack of knowledge or understanding and bids for the provider’s expertise (p. 171). Provider and patient voices interact in the encounter in numerous dynamic ways. Cordella understands that the medical encounter initiates with a power asymmetry where the provider, by virtue of knowledge, training, and institutional backing, exerts greater power; and the patient, by virtue of being an outsider to the institution and the uptake of Parsons’ sick role, exerts less power. However, as Cordella rightly notes, these power asymmetries are not static but rather are dynamic and respond to the deployment of different voices. For example, the deployment of the patient’s voice of competence serves to elevate their power status by expanding the patient’s base of knowledge and experience. The provider’s use of the fellow human voice, similarly, has a leveling effect where the provider can relate to the patient outside of the inherently asymmetric power structure. The deployment of multiple voices in the medical encounter, therefore, not only defines emergent patient and provider roles but also modulates the distribution of power within the encounter. Language and culture in provider-patient communication The perspective of language and cultural practices raises important questions and provides unique insights into the roles, role patterns, and voices that emerge in medical encounters. A practice perspective assumes that these elements of the medical encounter are constructed rather than pre-fabricated. It also assumes that the construction of roles and role patterns is enacted through multiple competing voices within the encounter. Voices are used to express power claims that fundamentally change role patterns as observed in Ainswoth-Vaughn’s work. At the same time, Cordella’s work teaches us that voices are not automatically deployed. Rather, the deployment of one voice in the patient can trigger a different voice in the provider as can be seen in her observation that the patient’s initiator voice triggers the doctor’s educator voice. This animation of

84  Language in health communication the doctor’s educator voice through the patient’s initiator voice undergirds the establishment of a particular role pattern – paternalism. Likewise, the patient’s deployment of speech activities such as topic control and the co-construction of the diagnosis, as shown by Ainsworth-Vaughn, generates the role pattern of consumerism. Notice, however, that the voices and role patterns always serve a specific agenda – a larger social action constituted by a bundle of social activities. Rodney Jones (2013) observes this aspect of provider-patient interaction insightfully. He writes: The important thing about voices is that they constitute not just ways of talking but ways of getting things done. Voices represent agendas, so that the doctor’s way of speaking and of controlling what the patient is able to say both reflects what he or she is trying to do and actually contributes to the agenda. Furthermore, it is through appropriating the ‘voice of medicine’ to accomplish these ‘doctorly actions’ that the doctor enacts his or her identity as a doctor and imputes to the patient the identity of a patient. Voices create social positions (perspectives) from which people are invited (summoned) to speak, listen, act, read and write, think, feel, believe and value in certain characteristic, historically recognizable ways. (p. 21) While Jones’s example focuses on the doctor side, the same may be said of the patient side. The patient also has an agenda and the voices employed by the patient create a specific social position that invites the doctor to respond in a particular way. The perspective of language and cultural practice helps us to understand the specific relationship between the therapeutic relationship and the language used. Philosopher John L. Austin famously asked how we do things with words. The question assumes that language  – sounds, grammatical forms and meanings  – brings about certain effects in the world. The linear view from language to action suggests that in order to change action all we have to do is change the language. A practice perspective, on the other hand, asks not how to do things with words but rather “how it is that the things we do with words produce language” (Pennycook, 2010, p. 17). This perspective assumes a symbiotic and synergistic relationship between language and action rather than a linear one. From a practice perspective, then, it is rather simplistic to think that changing language will always result in a changed therapeutic relationship. Instead, a changed therapeutic relationship may also generate changed language. The two elements work together symbiotically, synergistically, and not necessarily through causation. The practice perspective highlights this aspect of provider-patient communication because it recognizes that language is but a piece of a bundle of activities that make up social activities. The perspective also allows us to consider the impact of additional voices in the provider-patient interaction and it is to this aspect of health communication that we now turn.

Language in health communication  85

Interpreter-mediated communication The study of Spanish in health care in the United States must necessarily give attention not only to direct verbal interactions between providers and patients but also to interactions that are mediated through a third party. As Angelelli (2014) notes, an interpreted communicative event (ICE) is qualitatively different from and more complex than a monolingual interaction even when it occurs between members of different social groups. Angelelli explains: interpreters facilitate specialized, dynamic, multifaceted interactions. They comprehend and produce language of various degrees of complexity, alternating between target and source languages, for rural and urban speakers whose levels of education range from second grade to graduate school, and in speech communities to which they do not necessarily belong. (p. 5) This complexity may dramatically shape the nature and the outcome of the interaction. What is the role of the interpreter in the ICE? How are the voices of providers and patients preserved in the ICE? And, when is the interpreter justified in intervening or inserting him- or herself in the ICE? Questions such as these have preoccupied both practicing interpreters and communication theorists alike. Ethics and standards of practice in interpreting In 2002, the California Health Interpreting Association (CHIA) released The California Standards for Healthcare Interpreters (CHIA, 2002). The document represented the first concerted and collective effort to “standardize healthcare interpreting practices by providing a set of ethical principles, interpreting protocols and guidance on roles particular to the specialty of healthcare interpreting” (p. 8). The concepts and principles developed through CHIAs initial efforts were taken up two years later by the National Council on Interpreting in Health Care (NCIHC) and in 2004 the NCIHC released A National Code of Ethics for Interpreters in Health Care (NCIHC, 2004). Both the CHIA document and the NCIHC code stressed the neutral role of the interpreter and the commitment to accurate and faithful interpretation. Table 3.1 lists the NCIHC ethical principles. While the code covers a wide swath of behaviors, it appears to place a premium on neutrality in the interpreted encounter. Ethical principles related to impartiality, role boundaries, and accuracy buttress the ideal of the interpreter’s invisibility in the ICE (Venuti, 1995). The extremely wordy description of the principle of advocacy, on the other hand, displays the committee’s trepidation in encouraging the interpreter to move outside the lane of invisibility. The code of ethics can be likened to the bar that a tightrope walker uses to ensure balance while enacting the daring feat. The code of ethics then serves the interpreter as a picture of what professional interpreting looks like, but it does not provide guidance on how that

86  Language in health communication Table 3.1  Code of ethics for interpreters in health care Ethical Principle

Definition

Confidentiality

The interpreter treats as confidential, within the treating team, all information learned in the performance of their professional duties, while observing relevant requirements regarding disclosure. The interpreter strives to render the message accurately, conveying the content and spirit of the original message, taking into consideration its cultural context. The interpreter strives to maintain impartiality and refrains from counseling, advising or projecting personal biases or beliefs. The interpreter maintains the boundaries of the professional role, refraining from personal involvement. The interpreter continuously strives to develop awareness of his/her own and other (including biomedical) cultures encountered in the performance of their professional duties. The interpreter treats all parties with respect. When the patient’s health, well-being, or dignity is at risk, the interpreter may be justified in acting as an advocate. Advocacy is understood as an action taken on behalf of an individual that goes beyond facilitating communication, with the intention of supporting good health outcomes. Advocacy must only be undertaken after careful and thoughtful analysis of the situation and if other less intrusive actions have not resolved the problem. The interpreter strives to continually further his/her knowledge and skills. The interpreter must at all times act in a professional and ethical manner.

Accuracy Impartiality Role Boundaries Cultural Awareness Respect Advocacy

Professional Development Professionalism

Source: Adapted from NCIHC, 2004

picture can actually be realized. In recognition of this gap, the NCIHC released its National Standards of Practice for Interpreters in Health Care (NCIHC, 2005) in 2005. If the code of ethics were the what of professional interpreting practice, the standards of practice were the how. As Bancroft et al. (2015) explain: standards of practice are more detailed than ethics. They tend to offer more concrete strategies that help you understand what to do to support your ethical duties. If ethical principles are the arrow on your compass, standards of practice are the steps you take to move in the right direction. (p. 395) The National Standards of Practice have become the authoritative source for interpreter training in the United States and beyond. Table 3.2 lists the standards of practice:

Table 3.2 National Standards of Practice for Interpreters in Health Care Ethical principle Objective Accuracy

To enable other parties to know precisely what each speaker has said.

Standard Description number 1

2 3 4 5 6

Confidentiality

Impartiality

Respect

To honor the private and personal nature of the health care interaction and maintain trust among all parties.

To eliminate the effect of interpreter bias or preference.

To acknowledge the inherent dignity of all parties in the interpreted encounter.

7

8 9 10

11

12 13

Cultural awareness

To facilitate communication across cultural differences.

14

The interpreter renders all messages accurately and completely, without adding, omitting or substituting. The interpreter replicates the register, style, and tone of the speaker. The interpreter advises parties that everything said will be interpreted. The interpreter manages the flow of communication. The interpreter corrects errors in interpretation. The interpreter maintains transparency. The interpreter maintains confidentiality and does not disclose information outside the treating team, except with the patient’s consent or if required by law. The interpreter protects written patient information in his or her possession. The interpreter does not allow personal judgments or cultural values to influence objectivity. The interpreter discloses potential conflicts of interest, withdrawing from assignments if necessary. The interpreter uses professional, culturally appropriate ways of showing respect. The interpreter promotes direct communication among all parties in the encounter. The interpreter promotes patient autonomy. The interpreter strives to understand the cultures associated with the languages he or she interprets, including biomedical culture. (Continued)

Table 3.2 (Continued) Ethical principle Objective

Standard Description number 15

Role boundaries

To clarify the scope and limits of the interpreting role, in order to avoid conflicts of interest.

16

17

18

Professionalism

To uphold the public’s trust in the interpreting profession.

19

20 21 22

23 24 25 26

Professional development

To attain the highest possible level of competence and service.

27

28

The interpreter alerts all parties to any significant cultural misunderstanding that arises. The interpreter limits personal involvement with all parties during the interpreting assignment. The interpreter limits his or her professional activity to interpreting within an encounter. The interpreter with an additional role adheres to all interpreting standards of practice while interpreting. The interpreter is honest and ethical in all business practices. The interpreter is prepared for all assignments. The interpreter discloses skill limitations with respect to particular assignments. The interpreter avoids sight translation,1 especially of complex or critical documents, if he or she lacks sight translation skills. The interpreter is accountable for professional performance. The interpreter advocates for working conditions that support quality interpreting. The interpreter shows respect for professionals with whom he or she works. The interpreter acts in a manner befitting the dignity of the profession and appropriate to the setting. The interpreter continues to develop language and cultural knowledge and interpreting skills. The interpreter seeks feedback to improve his or her performance.

Language in health communication  89 Ethical principle Objective

Standard Description number 29 30

Advocacy

To prevent harm to parties that the interpreter serves.

31 32

The interpreter supports the professional development of fellow interpreters. The interpreter participates in organizations and activities that contribute to the development of the profession. The interpreter may speak out to protect an individual from serious harm. The interpreter may advocate on behalf of a party or group to correct mistreatment or abuse.

Source: Adapted from NCIHC, 2005

The standards of practice are meant to prescribe the behavior of interpreters in ICEs. For example, interpreters are often trained to create a mental script for introducing themselves. Within this script, the interpreter includes many of the elements indicated by the standards. The interpreter may say: “Hi. My name is X. I will be your interpreter today. I will interpret everything that is said in the room (standard 3) and everything said will remain confidential (standard 7). Please remember to speak directly to the patient (standard 12), and when I raise my hand, please stop so that I can interpret (standard 4).” The standards prescribe additional behaviors such as interpreting in the first person, i.e., reserving “I” and “you” for the interlocutors and referring to oneself as “the interpreter” (standard 6), refraining from giving advice or providing support and directing patients to appropriate resources within the institution instead (standards 13 and 17), and avoiding sharing or eliciting personal information with patients (standard 16). Together these behaviors support the nine ethical principles put forward in the Code of Ethics. The code of ethics and standards of practice have a dual purpose: First, they seek to ensure the truth and accuracy of all interpreted utterances, and second, they are an assurance to other participants in the conversation that their words are being conveyed as they intended (Inghilleri, 2011, p. 26). As established by the NCIHC, the code of ethics “creates consistency and lessens arbitrariness in our choices when confronted with difficult dilemmas” (NCIHC, 2004, p. 6). Ethics and standards of practice are rooted in a cluster of core values. The NCIHC identifies three core values: beneficence, fidelity, and respect. Beneficence conveys the primary obligation to the health and well-being of the patient. Non-malfeasance is a related value that conveys the avoidance of harm. The core values of beneficence and non-malfeasance are shared with other health professionals. Fidelity refers to faithfulness to the original. “In adhering to the essential function of their role,” explains the NCIHC, “interpreters make what amounts to a vow to remain faithful to the original message as they convert utterances from one language into another without adding to, omitting from, or distorting the original message”

90  Language in health communication (pp. 8–9). This core value of fidelity, however, is nuanced by the third core value of respect for the importance of culture and cultural differences. Adherence to the vow of fidelity requires that interpreters know not only words but also the cultural contexts, propositions, and values that shape their meaning. “Without understanding that the cultural frame of the speaker is an integral part of the meaning system of that speaker,” the NCIHC explains, “an interpreter may focus only on the surface meaning of words and miss the essential message that the speaker is trying to convey” (p. 9). These core values permeate the entire code of ethics and can be observed in each of the nine ethical principles established in the code and operationalized in the standards of practice. Language and culture in ethical reflection on interpreting Inghilleri (2011) points out that interpreter codes of ethics are grounded in a deontological approach to ethics. The core values, ethical principles and standards of practice together constitute a set of guardrails that prescribe the particular way interpreters should approach their job. The interpreter is compelled by a sense of duty to practice within these guardrails. As Inghilleri explains: the deontological view imagines a process in which a rational individual puts him or herself in the position of another and reaches a moral judgment that would hold for or be applicable to all across time and space . . . individuals behave morally responsibly when acting out of a sense of duty to these principles rather than responding to personal emotions or a concern for the consequences of their behavior or otherwise. (p. 27) The guardrails that are the focus of duty, however, convey a limited understanding of language and culture. As Wilce (2009) reminds us: “Translation involves more than a simple transfer of information across languages; it is also a question of power” (p. 208). Interpreting always involves a tension between difference and sameness and this tension plays into the reproduction of social inequality. The interpreter code of ethics grounds duty in a commitment to sameness – whether that be direct linguistic sameness or indirect cultural sameness. At the same time, it assumes that interpreted interactions always take place in contexts devoid of power differentials. As Inghilleri notes: Interpreter codes of ethics champion the impartial interpretation of utterances because it presumes to offer the same rights to all parties, regardless of their relational status or power within the interaction. It also allows interpreters who act impartially to remain morally blameless, without responsibility for the outcome of the interaction regardless of whether it results in an individual being wrongly imprisoned or set free, deported or granted asylum, tortured or even killed. (pp. 49–50)

Language in health communication  91 The conflicts and tensions emerging from the preservation of sameness coupled with an unjust end result challenges the interpreter to reassess the limits of duty. Is the primary duty to the message or to message bearer? The conflict is rooted in the very same core values that animate the code of ethics. The core values of beneficence and non-malfeasance, for example, often come into direct conflict with the value of fidelity. These challenges have been observed by interpreters themselves as they attempt to carry out ethical principles in their work. Angelelli (2006) points out that interpreters often feel as if doctors and other institutional representatives have expectations of them that interfere with their ethical duties. Interpreters in her study also indicated that ethical duties can interfere with culturally appropriate behavior. For example, one of her participants stated: “At the clinic where I work the clients are migrant workers and they tend to come over and bring you a basket of fruit, this or that, which they have just picked from the field, and for us to decline is an insult” (p. 187). The perspective of language and cultural practice sheds new light on the tensions that emerge in ethical practice in interpreting. As we have noted earlier in this chapter, the perspective of language and cultural practice rejects the idea that language and culture exist outside of interaction but rather suggests that language and culture emerge out of the bundle of social activities in which people engage. The core values of fidelity and respect, on the other hand, assume that language and culture precede any given encounter. From the perspective of language and cultural practice, therefore, it is impossible for the interpreter to perform dutifully because the object of the duty does not exist until interaction has already taken place. This perspective begs for an alternative ethical approach. Discourse ethics, grounded in the work of Jurgen Habermas, is one possible alternative. Discourse ethics rejects the notion that ethical subjectivity consists of an encounter between an individual and a duty. Instead, discourse ethics suggests that ethical subjectivity begins in the encounter with the other. Ethics is fundamentally and inherently intersubjective. Discourse ethics, therefore, grounds ethical action not in adherence to duty but rather in relations of mutual recognition (Inghilleri, 2011). It is not an imperative towards duty that incites ethical behavior, but it is the recognition of the other that “disturbs, upsets, and overwhelms the self-relation of the self with a moral obligation to respond” (Cohen, 2006, p. xxx). In Otherwise than Being, Emmanuel Levinas (1998) draws a distinction between what is said (le Dit) and the act of saying (le Dire). The content of discourse (le Dit) is not ethical but the act of saying (le Dire) most certainly is. Deontological approaches to interpreter ethics ground ethical behavior in what is said but discourse ethics grounds it in the saying. Interpreters, as Inghilleri points out, are “active players in dialogic communication” and by virtue of this participation they shape “the social and political relationships that obtain amongst all parties involved in the dialogue” (p. 33). This alternative ethical approach accounts for the tensions between beneficence and fidelity mentioned earlier and also addresses many of the ethical conundrums that interpreters have recognized.

92  Language in health communication Cultural values and beliefs The distinctive cultural values of Spanish-speaking communities have been an important area of focus in health communication research. Chicano psychologist Amado Padilla introduced an important set of cultural values in his early work on acculturation (Padilla, 1980; Keefe  & Padilla, 1987). The initial set of cultural values identified by Padilla was later expanded by health researchers such as Gerardo Marín and Barbara Van Oss Marín (Chong, 2002). Cultural values can be understood as norms, attitudes, and perspectives that shape perspectives and condition responses in an interaction. Chong identifies three overarching value sets, including group and family orientation, harmonious relationships, and respect. Within these overarching value sets, she identifies nine specific values listed in Table 3.3. Cultural values turn up in interaction patterns through colloquial expressions, dichos (sayings), and through nonverbal behaviors. The value of religiosity, for example, is evident in colloquial expressions such as si Dios quiere, con el favor de Dios or que será será. Respect is demonstrated through the use of formal forms of address including the use of usted and the use of the titles don or doña. The value of distance and power turns up through the use of professional titles such as doctor, profesor, licenciado or ingeniero. Personalismo is enacted through demonstrations of interest in a person’s life outside of the professional relationship including an interest in the person’s family and in rituals such as greeting a person with a handshake. Dichos such as de tal palo tal astilla, el que no agarra consejo no llega a viejo, and dime con quien andas y te diré quien eres reflect a collectivist orientation. In addition to these direct manifestations of cultural values in discourse, these values also shape larger interaction patterns. Chong points out that interaction patterns are often characterized by a delay of direct questioning, a preponderance of indirect responses to questions, and adoption of a passive role that distances the speaker from a specific problem. De la Torre and Estrada (2015) underscore that cultural values “affect the provider-patient relationship and help determine whether a patient stays in treatment or follows prescribed regimens” (p. 47). In addition to cultural values, cultural beliefs regarding health and illness also influence provider-patient interactions. De la Torre and Estrada explain that these beliefs “shape how a person communicates individual health problems, perceives and interprets symptoms, chooses when and where to go for care, decides how long to stay in care, and evaluates the care received” (p. 47). Arthur Kleinman describes cultural beliefs in terms of what he calls “explanatory models.” For Kleinman, explanatory models are “responses to urgent life circumstances” that convey the “notions that patients, families and practitioners have about a specific illness episode” (1988, p. 121). The import of explanatory models lies in the fact that, according to Kleinman, they are “anchored in strong emotions, feelings that are difficult to express openly and that strongly color one person’s reaction to another’s explanatory model” (p. 122). Cultural beliefs and explanatory models among Spanish-speaking patients have often centered on a set of folk illnesses such as empacho, susto, mal de ojo, and mollera caída. Table 3.4 lists some of

Table 3.3 Latino cultural values Value set

Cultural value

Definition

Exemplary behavior

Group and family orientation

Collectivism

Latinos prefer the company of others over being alone; relationships provide a sense of satisfaction, security, belonging. The family (both nuclear and extended) is of the utmost importance. Individual success is subordinated to the success of the family.

Taking friends and/ or relatives to the provider’s office.

Familismo

Marianismo

Machismo

Harmonious relationships

Personalismo

Simpatía

Time Orientation Respect

Respeto

Distance and Power

Religiosity

Source: Adapted from Chong, 2002

Women’s roles are patterned on the ideal of the Virgin Mary. Women earn social respect through the devotion to their children and their husband. Women are to be respected and revered by their children. Men are given ultimate authority in the household and thus are to be respected. They are responsible for the sustenance and well-being of the family. The quality of relating to others on a personal level and showing interest in the individual as a person. The ability to cultivate harmonious relationships that demonstrate an attitude of caring and compassion. Time commitments are less important than personal relationships. A sense of admiration attributed to a person based on qualities such as honesty, integrity, and courage. A respect for social hierarchies. Professionals are worthy of deference given their social position and they are not to be questioned or challenged. A profound reverence for God and other powerful forces. People are to resign themselves to God’s will.

Failing to reveal the existence of dysfunctional relations among family members to maintain the integrity of the family’s secrets. Taking responsibility for the health of all family members.

Refusing a digital rectal examination.

Expressing interest in overcoming a health problem despite all odds. Bringing homemade food or a present for the provider on a subsequent visit. Being late and explaining that the parking lot was full. Standing up until being asked to sit down when the provider is a female. Accepting the clinician’s knowledgeable recommendations.

Explaining that God has kept a family member in good health.

94  Language in health communication Table 3.4  Common folk illnesses and treatments Illness

Definition

Treatment

Empacho

Swollen belly resulting from massage by a sobadora or from undigested food. Susto or fright caused by seeing a ghost or being awakened suddenly; more serious than susto. Often mistranslated as “the evil eye” this is “illness caused by staring.” Results when infants or children receive more attention than usual; can result in restlessness, vomiting or fever.

Drinking herbal teas such as yerba buena (peppermint) or manzanilla (chamomile). Retrieving one’s soul, limpia, or house blessing.

Espanto

Mal de ojo

Rubbing an egg over the child as prayers are recited using a special charm or amulet.

Source: Adapted from De la Torre & Estrada, 2015, p. 134

these illnesses together with their definition and treatments. Mollera caída provides a particularly vivid illustration of competing explanatory models. Mollera caída or “sunken fontanelle” refers to an obvious curving in of the “soft spot” on an infant’s head. In Latino explanatory models, mollera caída “can be caused by abruptly removing the breast, bottle or pacifier from a baby’s mouth, by bouncing or tossing a child, by a fall, and/or by moving someone around a lot” (Patcher et al., 2016, p. 1069). Alternatively, biomedical explanatory models identify dehydration as the cause of mollera caída. Critical perspective on cultural values and beliefs The treatment of cultural values and beliefs as a discrete set of orientations, ideas, and explanatory models, however, readily contributes to the formation of stereotypes. Such stereotypes, as seen in our treatment of cultural competence and cultural humility in Chapter 1, can lead to unfair and unequal treatment in health care settings. The field of health communication has developed a variety of models and approaches that refocus culture and thus move away from stereotypical representations. Mohan Dutta, for example, proposes a “culture-centered approach” to health communication. This approach starts from the premise that communicating about health “involves the negotiation of shared meanings embedded in socially constructed identities, relationships, social norms and structures” (2008, p. 55). Active participation in the negotiation of meanings, for Dutta, is essentially cultural. Cultural values and beliefs are emergent in the process of negotiating meaning, not external baggage that precedes and interferes with communication. As Dutta-Bergman puts it: The culture-centered approach to health communication emphasizes dialogue and mutual understanding, locating agency for examining health practices

Language in health communication  95 in the culture being studied, not in the researcher and the institutional practices that inform his/her research practice. Cultural context is located at the center of the culture-centered approach, emphasizing meanings that are coconstructed by the researcher and the cultural participants. (cited in Dutta, 2008, p. 56) The culture-centered approach, then, treats cultural values and beliefs not as irritants to communication but instead as the expression of agency that animates voice, dialogue, and mutual understanding within the context of mediating social structure. Shim (2010) expands this practice view of culture in health communication by postulating the notion of cultural health capital (CHC). Shim conceives of CHC as “socially transmitted and differentially distributed skills and resources that are critical to the ability to effectively engage and communicate with clinical providers” (p. 2). Skills and resources that make up CHC include language practices, proactive attitudes towards the accumulation of knowledge, ability to understand and use biomedical information, and instrumental approaches to treatment and disease management. Grounded in Bourdieu’s theory of cultural capital, CHC becomes an asset in establishing and maintaining distinction within the health field. The proactive patient who consults WebMD or MedlinePlus before an office visit, writes down key questions about the symptoms and potential diagnosis, and interacts with the physician using the lexicon of medicine achieves for him or herself a level of distinction in the encounter. This distinction not only projects a level of sophistication but also accrues certain privileges such as the ability to provide alternate diagnoses, to suggest different treatment plans, and to ask for a second opinion. CHC, according to Shim, “develops in and through the repeated enactment of health-related practices, such as consuming biomedical knowledge, exercising calculative and future-oriented approaches to decisionmaking, and engaging in self-surveillance and risk-reduction practices” (p.  3). CHC is thus embedded in “durable social processes that produce inequality” (p. 3). Notice, for example, that while the proactive patient who consults recognized sources such as WebMD and MedlinePlus accrues privilege, the similarly proactive patient who consults unrecognized sources such as a curandero or a spiritual healer does not accrue privilege but instead accrues suspicion and mistrust. For this reason, Shim insists that CHC is deeply relational; “it refers to the power of dominant social groups not only to shape institutional arrangements, but also to define the kinds of activities, resources and behaviors that carry value in those contexts” (p. 3). Shim’s conceptualization of CHC sheds further light on cultural values and beliefs. While they are expressions of agency that animate voice, dialogue, and mutual understanding, they are also fitted into structures of inequality that marginalize these very same voices. As Dutta observes, “in the culture-centered approach, the emphasis is not on creating skills, so that community members can be empowered . . . rather, the emphasis is on understanding existing forms of participation in communities which have been traditionally treated as devoid of agency” (p. 58). In this chapter, we have considered the theoretical substrate that undergirds research in health communication. We have focused on health behavior theory,

96  Language in health communication provider-patient communication, interpreted communication, and cultural values and beliefs. In each of these reviews, we have discussed the role of language and culture in each theoretical paradigm. Additionally, we have considered the ways that a perspective of language and cultural practice challenges and extends these theories. In the next chapter, we will review how these theories have been applied to health communication with Spanish speakers in order to draw a portrait of language and cultural practices in Latino health.

Note 1 Sight translation is one of the three modes of interpreting, together with consecutive interpreting and simultaneous interpreting. In consecutive interpreting, the interpreter mediates after each conversational turn. In simultaneous interpreting, the interpreter speaks at the same time as the interlocutor. In sight translation, the interpreter reads a text written in one language aloud in the other language.

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Language in health communication  97 Cohen, Richard. (2006). Introduction. In E. Levinas, ed. Humanism of the Other. Urbana: University of Illinois Press. Cordella, Marisa. (2004). The Dynamic Consultation: A Discourse Analytical Study of Doctor-Patient Communication. Amsterdam: John Benjamins Publishing Company. De la Torre, Adela & Estrada, Antonio. (2015). Mexicans Americans and Health: ¡Sana! ¡Sana! 2nd Edition. Tucson: University of Arizona Press. Dutta, Mohan. (2008). Communicating Health: A Culture-Centered Approach. Malden, MA: Polity Press. Foucault, Michel. (1973). The Birth of the Clinic. New York: Pantheon Books. Gwyn, Richard. (2002). Communicating Health and Illness. Thousand Oaks, CA: Sage Publications. Holliday, Karen. (2008). “Folk” or “traditional” versus “complementary” and “alternative” medicine: Constructing Latino/a health and illness through biomedical labeling. Latino Studies 6: 398–417. Inghilleri, Moira. (2011). Interpreting Justice: Ethics, Politics and Language. New York: Routledge. Jones, Rodney. (2013). Health and Risk Communication: An Applied Linguistic Perspective. New York: Routledge. Keefe, Susan & Padilla, Amado. (1987). Chicano Ethnicity. Albuquerque: University of New Mexico Press. Kleinman, Arthur. (1988). The Illness Narratives: Suffering, Health and the Human Condition. New York: Basic Books. Levinas, Emmanuel. (1998). Otherwise than Being or Beyond Essence. A. Lingis, trans. Pittsburgh: Duquesne University Press. Mishler, Elliot. (1984). The Discourse of Medicine: Dialectics of the Medical Interview. Norwood, NJ: Albex Publishing Corporation. Montaño, Daniel  & Kasprzyk, Dannuta. (2008). Theory of reasoned action, theory of planned behavior, and the integrated behavioral model. In K. Glanz, B. Rimer  & K. Viswanath, eds. Health Behavior and Health Education: Theory, Research and Practice. San Francisco: Jossey-Bass, pp. 67–96. National Council on Interpreting in Health Care. (2004). A National Code of Ethics for Interpreters in Health Care. Retrieved 25 June 2019 from: https://www.ncihc.org/assets/ documents/publications/NCIHC%20National%20Code%20of%20Ethics.pdf. National Council on Interpreting in Health Care. (2005). National Standards of Practice for Interpreters in Health Care. Retrieved 25 June 2019 from: https://www.ncihc.org/ assets/documents/publications/NCIHC%20National%20Standards%20of%20Prac tice.pdf. Ortiz, Fernando. (2002). Contrapunteo cubano de tabaco y el azúcar. Madrid: Cátedra. Padilla, Amado. (1980). Acculturation: Theory, Models and Some New Findings. Boulder: Westview Press. Parsons, Talcott. (1999). Illness and the role of the physician. In B. Turner, ed. The Talcott Parsons Reader. Malden, MA: Blackwell Publishers, pp. 101–108. Pasick, Rena, Burke, Nancy, Barker, Judith, et al. (2009). Behavioral theory in a diverse society: Like a compass on mars. Health Education and Behavior 36: 11S–35S. Patcher, Lee, Weller, Susan, Baer, Roberta, et al. (2016). Culture and dehydration: A comparative study of Caída de la mollera (fallen fontanel) in three Latino populations. Journal of Immigrant and Minority Health 18: 1066–1075. Pennycook, Alastair. (2010). Language as a Local Practice. New York: Routledge. Prochaska, James, Redding, Colleen & Evers, Kerry. (2008). The transtheoretical model and stages of change. In K. Glanz, B. Rimer  & K. Viswanath, eds. Health Behavior

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4 Uncovering language and cultural practices in Latino health

My name is Camila Avila. I am 62 years old, I was born in Mercedes, Texas, and I  have type 2 diabetes. I  remember the first day my mother dropped me off at Lincoln Elementary. I was six years old. We weren’t allowed to speak Spanish at that school. If we needed to go to the restroom, we were told to use a hand gesture consisting of raising two fingers with our thumb extended. I tried not to go to the restroom. At the age of 13, I began working during the summers on the migrant circuit with my family in Minnesota. The fields became my life. Migrant labor was an important part of my life. When I was first diagnosed with diabetes, I remember that I was working at a cucumber farm in ­Michigan. There were 11 of us in the family and each one of us had a specific chore to get ready for the workday. We would wake up at 4 am. My husband would cook our lunch meal and I would make the tortillas. The kids were older by that time and they would pack the lunch boxes – utensils, plates, water, and everything else we would need on the field. I think working in the fields helped me because we did a lot of exercise. We weren’t just sitting around, you know. I think working in the fields has helped me to control my diabetes. I think diabetes runs in the family. It’s in our blood, but it is also in our traditions. I like to eat a lot of fish. When we were in Minnesota we lived in a migrant camp near the Red River and we would go to the river to fish. This was another tradition that I think helped me to control my diabetes. In the cities and towns where we would go to work it was rare to find anyone who spoke Spanish. We would use a lot of hand gestures, and we depended on one another to help us communicate at gas stations, with our landlords, and in the doctor’s office. Those of us who didn’t know any English and who couldn’t communicate with the doctors and nurses would have to take one of our children with us to help us communicate. They may not have been great with English, but they did what they could. I am so proud of my migrant heritage. It’s hard work, but I’ve always liked it. We see a lot of different places. On our way to the fields, we would stop and see the sights. I  have been to Canada, to Mount

100  Uncovering language and cultural practices Rushmore, to Philadelphia, and to our nation’s capital. If there was something I  could change in my life, it would be that I  should know more English. Since I didn’t really go to school, I still have trouble communicating in English. Story by H. Alejandro Rodriguez (Used with permission)

Language and cultural practices are imbricated into larger patterns of living. These patterns of living, moreover, are always local and situated. Even though Camila Avila ends her story lamenting her inability to speak English, that inability is situated in a larger narrative that begins with language discrimination at school. Camila recounts how she felt silenced in school even to the point of not being allowed to voice her need to go to the restroom. The voice that was muffled at school, however, flourished on the fields. Camila speaks of her pride in being a migrant worker and she underscores how her life as a migrant gave her so much. Life on the fields brought her family closer together, it took her all over the country, and it positioned her to successfully manage her diabetes by staying active and eating healthy foods. In this chapter we will consider how local language and cultural practices are embedded in interactions with health care providers in Latino health. We will focus on provider-patient interactions, interpreter-mediated interactions, and interactions with the wider sphere of health information. Through these multiple engagements of language and cultural practice, we will reach for a more comprehensive understanding of how situated practices shape the experience of Spanish speakers within the U.S. health delivery system, their relationships and relatedness to health care providers, and their engagement with health information. Studies of language and cultural practices in health among Spanish speakers have been carried out within two major research paradigms in the wider field of health communication: the sociomedical studies approach and the discourse studies approach (Roberts, 1999). The sociomedical studies approach seeks to uncover perceptions and outcomes associated with health communication processes. These studies rely on surveys, questionnaires, and interviews that capture the impressions and perspectives of patients and providers after an encounter has taken place. The discourse studies approach, on the other hand, seeks to observe discourse processes as they actually take place in the encounter and to characterize the specific discourse features that shape the health communication process. Discourse studies thus rely on recorded conversations between patients and health care providers and utilize discourse analytic tools to uncover salient conversational features. Within discourse studies, moreover, two distinct approaches have emerged. Conversation analysis (CA) is an approach that focuses exclusively on the interaction itself without regard to extraneous social, cultural, and political factors that may contribute to the interaction. “One of the hallmarks of conversation analysis,” explains Stivers (2007), “is that in analyzing any bit of social

Uncovering language and cultural practices  101 interaction, analysts must validate their understanding of participants’ social actions through an examination of interactants’ responses” (p.  14). Within the interaction, CA researchers focus on the sequence of interaction as a reflection of power dynamics and other social factors, but they rarely go beyond these conversational internal features. Stivers continues: “very few conversation analytic studies have attempted to connect interactional practices to large-scale exogenous issues, whether they are relational, socioeconomic, demographic, or public health issues” (p. 15). Discourse analysis (DA), and particularly critical discourse analysis, on the other hand, relates the features of the interaction analysis to wider social and political forces. Within the DA approach, power dynamics are not revealed exclusively through elements that are present in the interaction but may also turn up through elements that are absent from the discourse. Norman Fairclough, in his influential book Language and Power (1989), proposed a foundational distinction between power in discourse and power behind discourse. Power in discourse occurs when the discourse itself is the field in which power is exerted. The exertion of power in a judge’s discourse while emitting a sentence on a person convicted of a crime would be an example of power in discourse. But power in discourse is not the only, or even the primary, way that power is exerted through language. Fairclough suggests that power behind discourse “shifts the focus to how orders of discourse, as dimensions of the social orders of social institutions or societies, are themselves shaped and constituted by relations of power” (p. 43). Power behind discourse, then, consists of those invisible but influential exertions of power that, while not visible in the interaction itself, have an enormous impact on its shape and on its outcomes. DA approaches to health communication thus strive to relate sociomedical data to discourse in both explicit and implicit ways. Researchers have used these different approaches to explore a variety of perspectives on health communication involving Spanish speakers. Interpersonal communication between providers and patients has been explored from sociomedical, conversation analytic, and critical discourse analytic perspectives. These studies have focused on issues related both to discourse mechanisms and to communication outcomes. A second strand of research focuses on interpersonal communication when an interpreter is present. Studies on interpreter-mediated communication have focused on discourse features of interpreted encounters including communication strategies and interpreter errors as well as on the discourse features associated with different interpreter roles. Studies have also drawn attention to the different types of interpreters, the utilization of interpreters, and health outcomes associated with interpreters. A third strand of research shifts the focus from interpersonal communication to mass communication. This research takes up issues related to health literacy in Spanish-speaking populations focusing on the determinants of health literacy and the processes of cultural adaptation of health-related materials. It also brings into focus issues related to health information seeking in Spanish-speaking communities. Information-seeking studies focus on sources of information and on the role of relationships in the transmission of information. Emerging from this focus on health literacy and health information seeking, researchers have begun to construct a more ecological view of language

102  Uncovering language and cultural practices and cultural practices in Latino health. This view brings into focus issues related to information surrogacy and the key role of allied health providers such as promotoras de salud. It argues that health literacy and health information seeking may be better characterized as collective skills and collaborative processes in Spanish-speaking communities that traverse traditional binaries such as individual/community, monolingual/bilingual, and English/Spanish. In what follows, we will review each of these research strands in order to piece together a comprehensive view of language and cultural practices in Latino health.

Provider-patient communication in Latino health Sociomedical studies of provider-patient communication Sociomedical studies of provider-patient interaction have focused on patient satisfaction with communication, patient activation and shared decision-making, and barriers to disclosure of medical information. Studies focusing on satisfaction with communication have turned up something of a conundrum. While Spanish-speaking patients clearly face greater communication challenges in their interactions with providers, they are more likely than English speakers to rate that communication as good or very good. This paradoxical finding is evident in data from the 2015 National Healthcare Quality and Disparities Report which showed that 84.9% of respondents who spoke Spanish in the home most often reported to have always had good communication with doctors in the hospital. Only 81% of respondents who spoke English in the home most often reported to have always had good communication with doctors (AHRQ, 2019). The trend in these national data is borne out in the conflicting findings of more localized studies. Morales et al. (1999), for example, found that Spanish-speaking Latinos were more dissatisfied with doctor communication than English-speaking Latinos. Satisfaction with communication was determined based on five domains: listening, answering questions, explaining prescriptions, explaining treatment, and providing reassurance and support. Morales and colleagues found that Spanish-speaking respondents were far less likely than English-speaking respondents to rate the communication of providers highly in these five domains. Tandon, Parillo and Keefer (2005) studied Latina mothers’ perception of patient-centeredness in prenatal care. Their findings coincide with those of Morales and colleagues. They found that Latina women were less likely than non-Latina women to perceive that doctors and nurses treated them with respect and more likely to experience language and communication problems during their visit. On the other hand, Wallace et al. (2007) conducted a study on satisfaction with communication by Latinos and non-Latinos in Tennessee that turned up opposing findings. Their data show that Spanish-speaking patients were more likely to report that providers always listened to them, explained things so that they understood, showed respect for what they had to say, and spent enough time with them. The study did show, however, that Spanish speakers were less likely to indicate that their provider always gave them control over treatment options. So, while some localized studies show

Uncovering language and cultural practices  103 that Spanish speakers rate communication lower than English speakers, other studies show that they rate communication higher than English speakers. Sheppard et  al. (2008) focus their attention not on satisfaction with communication but instead on satisfaction with health care relationships. This change of focus allowed them to move beyond the conundrum and to explore different factors that might contribute to communication challenges. They define positive health care relationships as those in which there is a high level of trust in the provider and in which the patient did not report experiences of discrimination. Perez, Sribney and Rodríguez (2009), moreover, took a magnifying glass to the issue of perceived discrimination among Latinos in the metropolitan Detroit area. They found that U.S.–born Latinos were twice as likely as foreign-born Latinos to have experienced discrimination and that the experience of discrimination was significantly associated with worse provider-patient communication. Connors (2019) sheds further light on the issue of discrimination in her study of parents of children admitted to the emergency room. She shows that Spanish-speaking mothers feel targeted in the emergency room for being Latina and for speaking Spanish. She argues, furthermore, that this discrimination leads to lower acuity scores1 and thus much longer wait times. “A  patient’s educational, cultural and linguistic background,” she writes, not only influences his or her ability to effectively communicate and the length of time of triage, but also how he or she is assessed by the nurse. Patients may be reluctant to admit that they do not speak English in triage because of the stigma associated with being an immigrant or fear of being labeled as less educated. (p. 38) Latina mothers in this study were thus acutely aware of the discrimination and took steps to avert it. Beach et al. (2010) conducted a study that compared patientprovider communication between Latino and non-Latino patients with HIV. They found that visits with Latino patients were less patient-centered and included less psychosocial talk. Even so, they found that Latino patients were three times more likely to give higher ratings for provider communication than non-Latinos. The authors conclude: “The fact that Hispanic patients rated their visits more positively than whites raises the possibility that these racial/ethnic differences in patient-provider interactions may reflect differences in patient preferences and communication styles” (p. 686). This study sheds light on the conundrum by suggesting that satisfaction with communication may not mean the same thing to Latino and non-Latino patients. Discrimination, for example, may be viewed as separate from communication even though its impact on communication is undeniable. The focus on health care relationships, which includes communication, trust, and discrimination, may therefore present a more complete picture of overall satisfaction with communication between providers and patients. The focus on health care relationships has brought up questions about patient activation and shared decision-making in provider-patient encounters. Patient

104  Uncovering language and cultural practices activation has been defined as a patient’s ability and willingness to manage their health and health care (Alegría et al., 2009). Shared decision-making, on the other hand, represents a step beyond activation that involves “bidirectional information flow” between the clinician and the patient. The clinician is responsible for providing information about the disease and treatment options, and the patient is responsible for providing information about their values relevant to the treatment and risk factors (Schrager et al., 2017). Studies on patient activation have found significant differences in patient activation between U.S.–born and foreign-born Latinos. Tracking with this finding, studies have also demonstrated that bilingual Latinos are more likely than Spanish-speaking Latinos to have higher activation as assessed by the Patient Activation Measure (Alegría et al., 2009). The Patient Activation Measure is a questionnaire that solicits agreement or disagreement with a series of statements about the patient’s role in health care and the relationship with the provider. Example questions include: 1 2

When all is said and done, I am the person who is responsible for managing my health condition. Taking an active role in my own health care is the most important factor in determining my health and ability to function (Alegría et  al., 2009, p. S535).

Patient activation thus measures the sense of collaboration and mutual involvement that emerges out of clinical interactions and provides a mechanism to improve the quality of care. Interventions to increase patient activation among Spanish speakers have also been tested (Maranda et al., 2014). The intervention described by Maranda and colleagues, piloted among Spanish speakers in New York City, helped patients identify medical decisions and provided a five-step process for developing, identifying, and prioritizing questions. The intervention was most successful among Spanish speakers who needed encouragement to ask question or who lacked skills to pose questions. The authors conclude, however, that “Spanish-speakers are a diverse population. Some individuals are already activated and skilled in asking questions . . . [the intervention] is best targeted at Spanish-speakers who lack question formulating skills or those who are reluctant to ask questions” (p.  601). Patient activation studies have thus found that Spanish-speaking patients may have a greater likelihood of disengaging in the health care encounter as compared to English-speaking patients. Studies of shared decision-making provide some clues as to why this may be the case. A study of decision-making participation, satisfaction, and regret among Latina and nonLatina women with ductal carcinoma in situ (DCIS), a noninvasive form of breast cancer, found that Spanish-speaking Latinas had the highest preference for involvement in decision-making but had the lowest actual involvement. In addition, Spanish-speaking Latinas were most likely to defer their final treatment to the provider. Spanish-speaking women were also less satisfied with the decisionmaking process and expressed more treatment regret (López et  al., 2014). The authors hypothesize that while language barriers are a primary cause for the lack

Uncovering language and cultural practices  105 of decision-making partnership building among Spanish-speaking women with DCIS, other cultural factors may also be at play. They write: for Spanish-speaking Latinas, cultural values that govern social interactions and relationships with individuals perceived to be in positions of power, may influence their expectations of the patient-physician relationship and level of involvement in decision-making. Spanish-speaking Latinas may expect more direct guidance from their physicians during decision-making or may feel uncomfortable questioning their physicians. (p. 87) A systematic review of shared decision-making in cancer care among racial and ethnic minorities also found that cultural values and norms play a significant role in building a decision-making partnership. The authors identify acculturation, social support, communication, and cultural congruence as four pillars of shared decision-making. Decision-making partnerships, they argue, appear to be available only to the highly acculturated, to rely on strong networks of social support, to be grounded in effective provider communication, and to depend on culturally congruent care. Cultural values and norms are essential to each of these pillars. The authors found, for example, that low-acculturated patients tended to be least satisfied with their decision-making role and outcome. They found that strong social support among minority patients included not only spouses and family but also included friends, community members, and members of a shared faith community. They found that lack of provider skill in cross-cultural communication and lack of provider knowledge of culture and history led to unmet communication needs. And finally, they found that a culturally congruent approach to care led to improved communication, less use of costly services, and better health outcomes (Mead et al., 2013). Studies on patient activation and shared decisionmaking thus highlight the cultural underpinnings of health care relationships that situate and shape provider-patient interaction. Studies of patient disclosure of medical information have further explored the cultural underpinnings of health care relationships seeking to identify the factors that mediate between cultural values, provider-patient interaction and health outcomes. Disclosure of mental health symptoms has been a keen area of interest. Researchers have examined the association between acculturation and pediatric mental health disclosure among Latino parents and health care providers and have found that parents living in the U.S. for less than 5 years were less likely to discuss their child’s psychosocial problems, stress in their own lives with their child, and their child’s problems at school when compared with parents living in the U.S. for 10 years or more. Spanish-speaking parents with English-speaking children, moreover, were the most likely to avoid disclosure of psychosocial issues in this study (Cook, 2014). Disclosure has also been explored among Latinos who use complementary and alternative medicine together with medical care. A  study of Spanish-speaking patients in community health centers in Southern California showed that while 90% of the patients surveyed reported using herbal

106  Uncovering language and cultural practices supplements only 25% ever disclosed this utilization to providers. Among those who did disclose their use of herbal remedies, only 31% reported receiving a positive response from health care providers (Malika, Desai & Belliard, 2017). While acculturation measures are associated with nondisclosure, they do not in themselves explain why Spanish-speaking patients fail to disclose important medical information. Julliard and colleagues conducted a qualitative exploration of the factors that contribute to Latina patients’ nondisclosure of medical information (Julliard et al., 2008). Patients in this study placed great value on qualities such as compassion, caring, human interest, and kindness. They were most likely to disclose medical information when these qualities were present and least likely to do so when they were absent. These qualities were operationalized by participants in the study in two ways: 1) by a provider’s willingness to listen and 2) by their own sense of being heard. One of the participants bluntly stated: “they never ask you more than your symptoms, and when I want to share more, they cut me off” (p. 545). Provider impatience and frustration was also flagged as a key factor in disclosure. Another participant in the study shared: “I couldn’t understand what he told me. He had a really difficult accent, and he got upset because of that” (p. 545). Mediating factors between cultural values, provider-patient communication, and health outcomes have been explored to account for nondisclosure. A study of Latino patients with comorbid end stage renal disease and depression found that these patients were less likely to be engaged in the conversation, to ask for clarification, and to be forthcoming with the physician (Gonzalez et al., 2013). Depressive symptoms, furthermore, have been linked to cultural values through the impact of loneliness. Monica Gallegos (2013) explores the convergence of loneliness and cultural values on health outcomes including overall health, depression, and engagement in protective health behaviors. She hypothesizes that the link between cultural values and loneliness may contribute to a fuller understanding of the Latino health paradox (discussed in Chapter 1). Building on a significant thrust in the literature connecting loneliness to physiological decline, Gallegos hypothesizes that the link between loneliness and depression is mediated among Latinos by cultural values such as familismo, marianismo and machismo, and religiosity. While she did not find a significant mediating effect of marianismo and machismo, she did find that both familismo and spiritual well-being showed a significant indirect effect on depression through loneliness. Familismo, Gallegos explains, is a resilient cultural value that persists in spite of acculturative influence on other aspects of Latino culture. Familismo involves expectations that one will take care of one’s family, that decisions should be made in consideration of family members, and that older family members will be cared for by younger family members. These expectations generate a sense of closeness both psychosocially and geographically and provide a sense of social support. When familismo is absent loneliness sets in. Religiosity and spiritual well-being have been operationalized using proxies such as attendance at religious services and the importance of prayer to their own health and the health of family members. Loneliness was found to be higher when spiritual well-being was lower. Gallegos’ findings suggest that the indirect effect of spiritual well-being through loneliness

Uncovering language and cultural practices  107 on depression was greater for Latinos than for non-Latinos. Gallegos concludes: “overall, results support the assertion that loneliness and Latino cultural values, especially spiritual well-being, play a considerable role in explaining the Latino health paradox. Specifically, loneliness appears to be a key mediator in the relationship between Latino cultural values and health” (p. 107). Studies on disclosure in provider-patient interaction provide a richer understanding of the influence of cultural values and beliefs and their connection to other mediating factors such as depression and loneliness as they shape provider-patient interaction. Sociomedical studies of provider-patient interaction tease out a tension in the way Spanish-speaking patients report on communication and the way they experience it. While numerous studies show that Spanish speakers evaluate communication positively, other studies demonstrate that they feel disrespected, discriminated, and have less trust in their providers. Patient activation studies, for example, have found that Spanish-speaking patients tend to be more disengaged than English-speaking patients. Studies on shared decision-making, moreover, have found that even though Spanish speakers have a high preference for establishing decision-making partnerships, they are the most likely to be dissatisfied with the decision-making process and the most likely to express treatment regret. In light of this tension, researchers have turned their attention away from elements of interaction and have focused instead on elements of relationships. Relationships are extended intersubjective engagements that include both active interactions and passive perceptions. Researchers have defined health care relationships as rooted in a high level of trust and low perception of discrimination. Both trust and discrimination are viewed through the prism of cultural values. People bring different expectations to an intersubjective engagement and they evaluate the engagement in terms of these expectations. A patient may defer to the authority of the doctor and perceive the communication as adequate or good because it meets their expectation. Cultural values and beliefs, therefore, play an important role in shaping provider-patient interactions. Studies have demonstrated, for example, that disclosure of medical information depends primarily on the qualities that patients perceive in their providers. Cultural values and beliefs, however, also play a role in shaping other mediating factors that impinge on provider-patient interaction. For example, studies have shown that depression and loneliness are significantly mediated by the lack of strong family support systems and spiritual well-being. Discourse studies of provider-patient communication Discourse studies of provider-patient communication open a different window into these communication processes by focusing on intersubjective practices and discursive mechanisms that are involved in health care relationships. Researchers studying provider-patient communication have explored intersubjective practices using the concept of homophily. Homophily is the “preference of individuals to choose others who are similar to themselves as partners” (Mascia et  al., 2015, p. 2). Hompohily can be the result of individual choice or it can be induced by

108  Uncovering language and cultural practices social structures. As an intersubjective practice, homophily highlights the way in which the self and the other actively participate in social positioning in the process of linguistic exchange. Bucholtz and Hall (2004) suggest that intersubjectivity is produced through tactics of adequation, authentication, and authorization. Adequation refers to the mutual recognition of sameness in the process of social identification. Authentication, on the other hand, refers to the “processes by which authenticity is claimed, imposed or perceived” (p.  498) in social identification. Authorization, finally, refers to the legitimization of social identities in the interaction. Intersubjectivity emerges then from the confluence of mutual recognition, of transparency and of legitimacy in social encounters. The tactics of intersubjectivity, as Bucholtz and Hall recognize, are largely discursive. It is through discourse that we establish recognition and transparency, and it is through discourse that we confer legitimacy. Discourse studies of provider-patient communication open a window into this nuanced functioning of language. Margarita Alegría and colleagues studied the discourse of mental health intake visits seeking to determine the role of ethnic concordance for continuance of care (Alegría et al., 2013). They studied 93 intake visits focusing on ethnic concordance between provider and patient. The distribution of visits by ethnic dyad was: 34 white concordant dyads, 24 Latino concordant dyads, and 35 mixed dyads. They found that ethnic discordant interactions were viewed by patients as less satisfactory and were characterized by less participatory decision-making and higher rates of miscommunication. Latino dyads, on the other hand, demonstrated wholly different characteristics. In these dyads, clinicians tended to actively engage patients and were more likely to ask about shared understanding while were more verbally dominant and less likely to make attempts to clarify understanding between themselves and the clinicians. The positive communication attributes emerging from Latino dyads, however, were not replicated when a mixed dyad encounter was conducted in Spanish. As Alegría and colleagues note: “six Spanish-speaking mixed ethnicity dyads differed from the Latino dyads on key markers including verbal dominance, patient-centeredness, and working alliance. Language concordance alone cannot explain our findings” (p. 195). While this study may suggest that shared ethnicity activates an element of intersubjectivity to the encounter that language alone cannot trigger, it may also suggest that intersubjective linguistic and cultural resources are taken up differently in Latino and in mixed dyads. Marrs Fuchsel (2018) explores how Latino mental health professionals facilitated a Spanish-language empowerment and educational curriculum for immigrant Latina women. The results of her study show that the effectiveness of the facilitators was rooted not in their ability to speak the language but in their disposition and their self-­ disclosure. “Group members reported that the sharing of experiences and stories among group peers and learning about the facilitator’s experiences helped them to examine their own situation” (p.  42). Too often language concordance research enshrines language itself as the precursor to positive interactions. But if we view language not as the precursor of positive interactions but

Uncovering language and cultural practices  109 as  created within  positive interactions, we begin to see how these facilitators’ disposition and willingness to share their stories creates the language concordance that makes positive interactions possible. The self-disclosure of the mental health professionals described in Marrs Fuschel’s study thus represents a disposition that is laminated over language. We can also see these cultural values inscribed into language resources themselves. Lucy Candib (2006), for example, suggests that the response “sí, doctora” has multiple intersubjective meanings that far surpass mere agreement. She writes: “Sí, doctora” could mean “Yes, I agree with your plan and I will do what you recommend.” This interpretation views these words as hoped-for agreement on common ground. Too often we take this meaning to be correct and go no further. Often, however, “Sí, doctora” means “I have heard what you are saying but I don’t really want to do that; I also don’t want to be rude and disagree with you openly.” Left unexplored, “sí, doctora: with this meaning leads to deep miscommunication. (p. 460) Candib’s insight into the simple phrase “sí, doctora” demonstrates how language resources are intertwined with cultural values and expectations. Erzinger (1991) argues for an operationalization of cultural values through linguistic resources. She argues that cultural values such as respeto, personalismo, and simpatía are more than simple stereotyped preferences but instead are “features of communication that accompany the words of speakers” (p. 92). Drawing on Deborah Tannen’s metaphor, she argues that these cultural values are more than frosting on a cake, they are baked into the cake itself (see also Cordella, 2004). She concludes that while the need for Spanish-speaking health personnel is compelling, the acquisition of medical Spanish by itself offers limited redress. In conjunction with the articulation of understandable questions, the doctor’s conversational manner must reflect an ability to listen, understand, and encourage the patient’s responses in Spanish. (p. 107) Erzinger’s early insights resulted in a clarion call for researchers to look more deeply and intently for tangible manifestations of cultural values within discourse itself. Dalia Magaña explores discourse strategies used by Spanish-speaking providers to convey a sense of homophily. She explores the use of small talk (Magaña, 2014) as well as the use of colloquial expressions and code switching (Magaña, 2013). Small talk, as Magaña points out, is one mechanism that allows providers to engage with what Mishler called the “voice of the lifeworld.” Coinciding with Cordella, moreover, she views small talk as a discursive embodiment of the

110  Uncovering language and cultural practices cultural value of simpatía. In Magaña’s data, small talk helps foster an interpersonal relationship between provider and patient. It emerges in discourse through anecdotes, recounts, brief personal exchanges, and gossip. Small talk is culturally informed discourse that takes up knowledge of the patient’s cultural norms and recasts them in ways that promote mutual recognition of sameness, transparency, and legitimization. In Magaña’s data, providers deploy cultural knowledge in the use of humor, self-disclosure, offers of personal advice, and compliments. Magaña concludes: “through the doctor’s small talk, we are witnessing a local adaptation of a professional genre in service of a particular community, which serves as an explicit example of how to achieve transcultural competence” (p.  94). Magaña (2013) shows that the same tactics of intersubjectivity employed in small talk permeate the entire provider-patient encounter, and she identifies specific linguistic resources that achieve this purpose. For example, she demonstrates how the use of colloquial expressions such as a lo bestia (exaggerated), tristón (very sad), chupe (drinking  alcohol), and  chela (beer) are deployed in interaction to engender a sense of closeness. At times, the provider brings up these expressions without prompting as in the following exchange: 1  2  3  4 

Doctor:   Patient:   Doctor:   Patient:  

¿Tequila, ron, whiskey? No, nada de eso. ¿Puras chelas? [Laughs] Pura cerveza (Magaña, 2013, p. 135)

At other times, the doctor seizes upon a colloquial expression that the patient uses and reinserts it into his own discourse as a sign of understanding and legitimization. The following exchange demonstrates how the doctor seizes the expression “’ta duro.”   1    2    3    4 

Doctor:   ¿Eres casado? Patient:   No Doctor:   ¿Has sido casado? Patient:   En un tiempo, pero nomás un año duré, a la señora le gustaba andar con   5      muchos hombres   6  Doctor:   Mientras sean 2 o 3 está bien, pero muchos no, ¿verdad?   7  Patient:   [Laughs], ’ta duro pa’ encontrar mujeres horita, ¿’edá?   8  Doctor:   ’ta duro   9  Patient:   No sabes en qué te vas a meter 10  Doctor:   Ándale (Magaña, 2013, p. 132) Another linguistic resource that the doctor in Magaña’s data seizes upon is code switching. When patients brought up a word in English, the doctor would not provide the equivalent word in Spanish but rather would follow through using the same code-switched word. For example, the following excerpt demonstrates the use of the code-switched word “gallbladder.” The doctor could have responded

Uncovering language and cultural practices  111 by giving the Spanish medical term “vesícula” but instead followed through using the same code-switched form: 1  2  3  4 

Doctor:   En el setenta y cuatro le quitaron la – Patient:   La gallbladder Doctor:   La gallbladder Patient:    Sí, y luego empecé con pancreas attacks, malos y estuve aquí. Una de las 5        veces me dijeron que estaba muy mal y me metieron al hospital, un 6        doctor, Fulano (Magaña, 2013, p. 162) Magaña’s data demonstrate how cultural values are operationalized in discourse through small talk and how linguistic resources are taken up in the deployment of tactics of intersubjectivity. Caroline Vickers and colleagues explore similar phenomena in interactions between Spanish-speaking patients and English-dominant health care providers. Vickers and Goble (2011), for example, examined the use of English discourse markers in Spanish interactions. Discourse markers fulfill a range of functions including responses such as “yeah,” “uh-huh”; negative responses such as “oh geez,” “shoot”; attention markers such as “then,” “now, let’s see”; and attention markers of disagreement such as “well,” “but” and “I mean.” The authors found that English-dominant medical providers used English discourse markers more frequently and with a broader range of functions than Spanish-dominant providers. For example, negative response discourse markers accounted for 18% of the total discourse markers used by the English-dominant provider. The following excerpt demonstrates the use of a negative response discourse marker in English: 1  2  3  4  5 

Arturo:   y se me pone hinchado el pie Doctor:   ah, oh geez Arturo:   y tengo miedo que Doctor:   y tiene razón. ¿cuándo empezó? Arturo:   Me la descubrí el sábado (Vickers & Goble, 2011, pp. 553–554)

The preponderance of these types of discourse markers, Vickers and Goble contend, reinforce the dominant role of English in society at large. “The prevalence of these EDMs (English discourse markers), therefore, may have had the effect of distancing the EDMPs (English-dominant medical providers) from their monolingual Spanish-speaking patients” (p. 561). Vickers, Deckert, and Goble (2014) advance this argument further by focusing on stancetaking in Spanish-language medical consultations. Jaffe defines stancetaking as “taking up a position with respect to the form or the content of one’s utterance” (p. 3) and considers it a fundamental property of communication (Jaffe, 2009). Vickers, Deckert, and Goble distinguish two different types of stance in the medical consultation: administrative stance and authoritative stance. Administrative stance is related to aspects of clinic bureaucracy apart from interaction with the patient. Authoritative stance is

112  Uncovering language and cultural practices related to evaluations of the patient within the interaction. The former aligns the provider with the institution and the later places the provider in a position of authority over the patient. The authors show that providers often code-switch to English in these stancetaking moves. They argue, moreover, that it “indexes English as normative and Spanish, the language the patients use, as marked within these consultations, creating further distance between the provider and the monolingual Spanish-speaking patient” (p.  707). Vickers and colleagues show that the distancing effects in Spanish language medical consultations is not only mediated by code switching, but that other discourse features also enact the authoritative stance. Vickers and Goble (2014), for example, focus on prosody and politeness features in discourse that reveal authoritative stancetaking. Providers, they argue, often silence patients as they give directions using forms such as “yo quiero,” using unnecessary repetitions, and usurping the patient’s autonomy by including themselves in the action (“lo que vamos a hacer es . . .”). These discursive features are coupled with a “patterned use of command intonation” in Spanish that indexes and constitutes “an authoritarian communicative style” (p. 216). These data together confirm Erzinger’s caution and Alegría’s insight that language alone is insufficient to develop the intersubjective relationships that health and healing require. A  single phenomenon such as code switching can at once serve to establish mutual recognition, transparency, and legitimization as seen in Magaña’s work, but at the same time can serve to distance and delegitimize as seen in the work of Vickers and colleagues. The perspective of language and cultural practices introduced in Chapter 3 proves especially helpful in assessing this tension. We will always limit our perspective if we understand language as the antecedent to provider-patient encounters. Language is not the antecedent but rather is the result of these encounters. I would, in fact, be comfortable in asserting that even though both the providers in Magaña’s and Vickers’ studies provided services in Spanish, they were actually speaking very different languages. In other words, they were each drawing on some of the same linguistic resources but engaging in very different practices  – different bundles of social activity  – with widely divergent results.

Interpreter-mediated communication in Latino health Sociomedical studies of interpreter-mediated communication Sociomedical studies of interpreter-mediated communication have focused on issues of interpreter utilization and the variety of interpreters used. Utilization studies seek to measure the extent to which interpreters are used and to identify the factors associated with utilization or non-utilization. Ramirez, Engel, and Tang (2008) conducted a clinical review of papers dealing with the utilization of interpreters in emergency rooms. They found that even while professional interpreters have been shown to improve patient satisfaction, decrease miscommunication and medical errors, and improve access, there is a clear under-utilization of

Uncovering language and cultural practices  113 interpreters in emergency rooms. Ginde, Clark, and Camargo (2009) studied the utilization of medical interpreters in Massachusetts after the passage of a state law that mandated competent interpreter services in the delivery of certain acute health care services. They surveyed 530 emergency room patients in a Boston hospital and found that 60 were in need of language services. Their findings showed that of these 60 patients in need of language access services, only 15% received hospital interpreter services, 11% received no services and the rest received services directly from the provider (30%), from family and friends (30%), or from other hospital staff (14%). The authors conclude that even one year after the passage of state legislation, the utilization of interpreters was inadequate. Other researchers have looked at how cancer physicians utilize interpreters. Rose et  al. (2010) report on a survey of 348 oncologists in southern California. They found that 75% of physicians surveyed reported using untrained interpreters to communicate with patients with limited English proficiency. In addition, only one third of the physicians surveyed reported good availability of interpreting services when needed. Rose and colleagues’ research also brings up important differences in physician practice settings. They found that physicians in solo and single-specialty small group practice were less likely to report using trained interpreters and were more likely to report difficulty in accessing services when needed as compared to physicians in larger practices. Gadon, Balch and Jacobs (2007) focused specifically on the way that private practice physicians approach the provision of language access services. The study revealed that private practice physicians often used family and friends as interpreters. While physicians agreed that language barriers negatively affect the quality and safety of patient care, they expressed concerns about the cost, accessibility, and convenience of using professional interpreters. Kuo et  al. (2007) studied the provision of language services to families with limited English proficiency in pediatric encounters. A  nationwide survey was conducted representing over 1,000 pediatricians. The survey showed that bilingual family members and staff were most commonly used as interpreters in pediatric encounters with families with limited English proficiency. Approximately 40% of the respondents indicated using professional interpreters. The use of professional interpreters was most frequent in states that provide reimbursement for language services and least frequent in smaller and rural practices and in states with higher proportions of limited English proficient individuals. The inadequate utilization of interpreters can be explained by the shortage of interpreters. A 2015 report from the Leonard D. Schaeffer Center for Health Policy and Economics at the University of Southern California found that there were only 738 certified medical interpreters in the state serving a population of 6.8 million Californians with limited proficiency in English (Gonzales, 2015). In addition to the shortage of interpreters, there is also a lack of training for providers on when to call an interpreter and how to work with the interpreter (Kale & Syed, 2010). Such training would include issues such as the physical location of the interpreter, how to interact with the patient in the presence of the interpreter, and how to regulate discourse in an interpreted interaction (Diamond  & Jacobs, 2010; Jacobs,

114  Uncovering language and cultural practices 2010). Finally, researchers have shown that interpreter utilization varies depending on the type of clinical communication event. Lee and colleagues explore the results of the implementation of a bedside interpreter phone system to improve health care quality. While the system did improve the odds of obtaining adequate informed consent (Lee et al., 2017), it did not consistently improve discharge preparedness (Lee et al., 2018). The authors note that clinicians preferred in-person interpreters for complex discharge instructions and that patients preferred to rely on family in all matters related to discharge. They conclude: “the interpreterphone intervention was well received for many types of clinical communication. However, it was less well received for discharge communication and did not substantially alter healthcare team preferences and practices regarding interpretation at discharge for patients with LEP” (2018, p. 29). Researchers studying interpreter-mediated communication from a sociomedically informed approach have also strived to identify and classify the different types of interpreters that mediate health care interactions between providers, patients, and their family members. Early approaches to this question tended to dichotomize interpreters into binary groups such as trained vs. untrained and professional vs. ad hoc (Hsieh, 2006). While these dichotomies are partially illustrative of differences between interpreters, they do not capture the full range of differences that can, and often do, influence mediation practices. Elaine Hsieh (2006) proposes a five-fold characterization of interpreters in health care settings in order to account for the range of positions, expectations, and skills that interpreters bring to their mediation practices. She identifies the following groups: chance interpreters, untrained interpreters, bilingual health care providers, on-site interpreters, and telephone interpreters. Table 4.1 provides an overview of these different types of interpreters. Hsieh’s classification helps us to understand significant differences between each type of interpreter and to move beyond simple binaries that often cloud or erase these differences. She points out, for example, that untrained interpreters may engage in the practice of mediation only occasionally or incidentally, or they may engage in the practice as part of their job. Trained interpreters also reveal important differences. For example, while on-site interpreters are trained to conduct interpreting in the first person, i.e., the first (I/yo) and second (you/tú or usted) person pronouns are reserved for the interlocutors and the interpreter uses the third person (the interpreter/el or la intérprete), telephone interpreters are required to interpret in the third person, i.e., the interpreter refers to the interlocutors as (he or she/él or ella). Hsieh concludes that “by recognizing different types of medical interpreters, researchers can avoid the simplistic view of seeing medical interpreters as a generic group” and that by recognizing that interpreter-mediated communications in health care settings are dynamic situations and that all participants can influence the outcomes of the communication, researchers can start to investigate the interrelationships among all of the participants and thus develop different strategies that will improve the quality of bilingual health communication. (p. 184)

Uncovering language and cultural practices  115 Table 4.1  Types of medical interpreters Type of interpreter

Definition

Examples

Chance interpreter

Interpreters who do not have formal training in interpreting and do interpreting on an ad hoc basis. Bilinguals who are hired as interpreters or who are expected to provide interpreting services but who have not received formal training. Health care providers who learn the patients’ native language as their second or heritage language.

Typically family and friends but could also be bystanders who happen to be bilingual. Nurses, technicians, receptionists, and other bilinguals hired to interpret on the basis of bilingual ability.

Untrained interpreters

Bilingual health care providers

On-site interpreters

Individuals specifically trained for medical interpretation and experienced in the health care setting.

Telephone interpreters

Individuals trained to provide remote interpreting services via the telephone not necessarily specialized in medical interpretation and may or may not have experience in a health care setting.

Physicians, nurses, dietitians, or social workers who study the language formally or informally for use in their job. Typically trained through a 40-hour training program, knowledgeable about ethics and standards of practice, and engaged in the profession. Typically trained through a 40-hour training program or on-the-job training. Typically cover a variety of interpreting assignments including medical encounters, 911 calls, and insurance claims.

Source: Adapted from Hsieh, 2006

Interpreters who fulfill a dual role as both health care providers and interpreters have been the focus of additional research. Moreno, Otero-Sabogal, and Newman (2007), for example, conducted a study to assess the linguistic competence of dual-role staff interpreters in an integrated health care system in Northern California. The researchers recruited 840 dual-role staff interpreters to take a linguistic competency assessment that measured language comprehension, completeness, and vocabulary in both English and Spanish. The assessment yielded three different levels of competence: not pass, pass at a basic level, and pass at a medical interpreter level. The results of the assessment showed that 2% of the dual-role interpreters did not pass, 21% passed at the basic level, and 77% passed at the medical interpreter level. While the majority of dual-role staff interpreters demonstrated sufficient levels of language proficiency, the researchers underscore that 1 in 5 interpreters had insufficient bilingual skills to serve as interpreters. Other researchers have shown that dual-role interpreters may lack not only linguistic proficiency but also knowledge of appropriate standards of practice in medical

116  Uncovering language and cultural practices interpreting. Ramírez (2008), for example, conducted a study of bilingual medical assistants in community health centers in the Rio Grande Valley of Texas. Her findings revealed that even though these allied health professionals were hired because of their bilingual skills, many of them lacked knowledge of medical and health care bureaucracy terminology in Spanish. She notes, for example, that words such as “appointment,” “vitals,” and “chart” were often expressed only in English. She also shows that bilingual medical assistants tended to summarize, generalize, and omit information during interpreted encounters. She illustrates this with the following exchange:   1 Doctor:   2   3 MA:   4 Patient:   5   6 MA:   7 Doctor:   8 MA:   9 Patient: 10 11 MA: 12 13 Doctor: 14 15 MA: 16 17 Patient: 18 MA: 19 Doctor: 20 21 MA: 22 23 Patient: 24 25 MA: 26 Doctor:

Morning! What’s the reason for her visit? She hasn’t been here before, right? ¿Cuál es la razón de su visita? Fíjese que se me duerme la mano izquierda de una fecha pa’cá y me da miedo. She says her left hand is numb and she’s scared. What other symptoms does she have? Dice que ¿qué mas siente? Pos también siento que me hace falta mucho el aire pa’ respirar a veces. Me siento como borracha y siento una presión en el pecho muy fuerte. She says she cannot breathe, and she also feels dizzy. Oh! And her chest hurts sometimes. Ok. I will check her heart with my stethoscope to see if I can hear any problems with her heart. Dice que le checará el corazón pa’ ver si tiene un problema con el aparato pa’ oír. Ok. Está bien. ¿me subo a la cama pa’ que me cheque? Sí She has a heart murmur. Does she know this? Since when has she had these symptoms? ¿Ya sabía que tenía usted un problema en el corazón? ¿Cuánto tiempo tiene sintiéndose así? Pos, ya tengo años con esto se me va y ya luego vuelve de repente otra vez. She says it’s been years already. Does she suffer from any blood pressure problems?

Uncovering language and cultural practices  117 27 28 29 30

MA: Patient: MA: Doctor:

31 32 33 34 35 36 37 38 MA: 39 40 41 Patient:

¿Usted tiene problemas con su presión? Sí, tengo alta presión. She says she has high blood pressure. Well, let her know that this could be a cause for her symptoms besides the heart murmur that she has. What I’m going to do right now is prescribe her medicine for her high blood pressure so that she can get rid of some symptoms, but she needs to have an electrocardiogram so that I can know how her arteries are doing. Once we receive the results from the test, she has to come back so that we can see what has to be done in this case. Give her a referral for the cardiologist, please. And I’ll see her when the results get to our clinic. Dice el doctor que le va a dar medicina para la presión pa’ ver si se le quitan eso que trae y que la va a mandar hacerse un examen para el corazón. Cuando lleguen los resultados va a tener que venir pa’ tras. No, pos ’ta bien eso, pa’ ver porque me da esto a mí. (Ramírez, 2008, pp. 33–35)

In this interaction we can see how the lack of specific medical terminology in Spanish leads the medical assistant to generalize the message rendered. For example, while the doctor indicates that he will examine the patient with the stethoscope (line 13), the medical assistant renders the message in Spanish as “el aparato pa’ oír” (lines 15 and 16), and when he indicates that the patient has heart murmur (line 19) the medical assistant conveys the more general “un problema con el corazón” (line 21). Similarly, the doctor orders an electrocardiogram (line 33), but the medical assistant only conveys that the patient needs “un examen para el corazón” (lines 39 and 40). In addition to these changes, the medical assistant omits information that the patient specifically wants to convey. For example, “me siento como borracha” in line 10 is left uninterpreted as is “y ya luego de repente vuelve otra vez” in lines 23 and 24. Elderkin-Thompson, Silver, and Waitzkin (2001) conducted a similar study of nurses who serve as dual-role interpreters. Their findings revealed miscommunication problems similar to those reported by Ramírez. Unlike the medical assistants in Ramírez’s study, however, the nurses in Elderkin-Thompson’s study tended to slant interpretations to make them more congruent with clinical expectations and to do so in ways that reflected unfavorably on patients and undermined their credibility. Finally, researchers have turned their attention to family members who act as interpreters. Childhood interpreting is frowned upon from a policy standpoint,

118  Uncovering language and cultural practices but even so, the evidence that it continues to take place is incontrovertible. Scholars in psychology and education studies, moreover, have discussed the cognitive and developmental advantages of childhood interpreting (Valdés, 2003; Orellana, 2009; López & Vaid, 2018). In the area of health research, scholars are also beginning to recognize the important contribution of childhood interpreting to the informal economy of health care. Green et al. (2005), for example, argue that we need to move beyond the conceptualization of childhood interpreting as simply inappropriate and inadequate interpreting and recognize instead that “there will always be some situations in which young people from linguistic minority communities will be contributing to the work of accessing health care” (p. 2108). The authors also point out that childhood interpreters mediate multiple interactions from interpreting in a doctor’s office to explaining a medical bill to making a follow-up appointment. Along these same lines, Vikki Katz (2014) argues for the need to look at childhood interpreting in health care from an ecological perspective. “By brokering,” writes Katz, “children of immigrants provide a service for their parents” (p. 209). This contribution, moreover, has implications for the social, moral, and educational trajectories of children as they not only link their families to needed resources but also expose the shortcomings of health care institutions. Too often health care professionals and policy makers engage in finger wagging and tend to shame immigrant families for using their children to mediate interactions in a complex health delivery system, considering it almost a form of child abuse. Far less often do these moralistic sentiments point the finger at the health care institutions that are causing the shortcoming or recognize the family dynamics at play in the practice. California Assemblyman Leland Lee authored a proposed bill in California that would ban any person under the age of 15 from providing interpreter services. “Information is translated inaccurately,” he argued, “the child themselves may not have the full grasp of the English language and therefore may not fully the information that has been shared with them. This is not good clinical practice” (Jauregui, 2006). In an NPR story covering the proposed legislation, a Spanish-speaking mother of a childhood interpreter, Susana Ramírez, offers a different assessment: “yo pienso que no está bien porque sí se necesita que les traduzcan. Muchas de las veces hay personas que dicen que saben traducir pero no te dicen todo lo que te están diciendo, te dicen por partes” [I don’t think it’s right because we do need them to translate. A  lot of people say they can translate but they don’t say everything. They say things in bits and pieces] (Jauregui, 2006). This back-and-forth reveals the shortcomings of a moralistic approach to childhood interpreting and the need to view it in its wider social context. An ecological perspective, like the one advocated by Katz, allows us to consider the agency of children and their families even as they engage with structural power. Sociomedically oriented studies of interpreter-mediated communication reveal a complex web of factors that contribute to the utilization of interpreters and the multiple obligations and demands of different types of interpreters. These two facets of medical interpreting in the U.S. are connected inasmuch as the utilization

Uncovering language and cultural practices  119 of interpreters often pits one type of interpreter against others. The fundamental problem, however, may lie in the chronic shortage of interpreters. The shortage of professional interpreters, as James Dwyer (2001) explains, is a community problem that requires a community, strengths-based solution (Delgado-Romero et  al., 2018). Dwyer explains that because the shortage of interpreters “affects members of linguistic communities and the hospital that serves them, it is an occasion for the hospital staff to work with these community members to address the problem” (p. 35). A strengths-based solution requires a broad ecological perspective that recognizes the multiple types of interpreters and language brokers that exist and that identifies the positive contributions of each. There is no silver bullet solution to the problem of language barriers; instead an all-of-the-above solution is required. Pitting professional interpreters against nonprofessional interpreters, bilingual providers against interpreters, and children against their families exacerbates already profound problems of both language access and language acceptance (Martínez, 2010). Understanding the interrelationship between these different agents of language access, on the other hand, will give us the ability to recognize the different ways in which each of these agents bridge the gap and contribute to the establishment of an overarching framework for good health outcomes for Spanish-speaking patients. Discourse studies of interpreter-mediated communication Discourse-oriented studies on interpreter-mediated communication have focused on interpreter errors and on the discursive construction of the interpreter’s role in the triadic encounter (Pöchhacker  & Schlesinger, 2005). Studies on interpreter errors concentrate on the frequency and categories of errors as well as on discursive elements left out of interpreter-mediated encounters. Flores et al. (2003) set out to describe the frequency, categories, and potential clinical consequences of errors in medical interpreting. The study looked at interpreter-mediated pediatric encounters in an outpatient clinic in Massachusetts over a 7-month period. The encounters were analyzed and five major types of errors emerged: omission, addition, substitution, editorialization, and false fluency. Omission referred to instances when the interpreter failed to convey a word or phrase uttered by the interlocutors. Addition referred to instances when the interpreter added a word or phrase to the interpretation of an interlocutor’s utterance. Substitution referred to instances when the interpreter substituted a word or phrase uttered by the interlocutor with a word or phrase with a different meaning. Editorialization referred to instances when the interpreter inserted his/her own views into the conversation. False fluency referred to instances when the interpreter used an incorrect word or phrase in rendering a message from one language to another. The authors provide the following example to illustrate the errors: 1 2

Pediatrician:   So probably the rash is from the Augmentin. Interpreter:   Probablemente, es de la medicina, por eso va a cambiarla. Y ahora ella

120  Uncovering language and cultural practices 3 4 5

Pediatrician:

6 7

Interpreter:

8

puede comenzar a tomar otra medicina, por dos días. What else did you want me to tell her? Ten days on the new medicine. Don’t give the old medicine anymore. Plenty to drink. Treat the fever. Okay. Dice que no toma la medicina, la otra medicina y . . . es importante que ella bebe bastante, y ¿tiene Tylenol?

In this example, we see clear cases of omission, editorialization, and addition in lines 2–3. The doctor hypothesizes that the rash is from the medication Augmentin. The interpreter fails to state the precise medication, “Augmentin,” and editorializes that the medication will be changed while adding that the new medication should be given for two days. In lines 7–8, we also see omission of the specific instructions about the new medication – to take it for ten days – as well as substitution when instead of conveying the doctor’s order to treat the fever, the interpreter asks if the parent has Tylenol. Flores and colleagues found that omissions were the most common error type (52%), followed by false fluency (16%), substitution (13%), editorialization (10%), and addition (8%). The authors also evaluated the errors to determine whether or not they could have clinical consequences. They found that errors with potential clinical consequences made up 53% of all errors committed by professional interpreters and 77% of errors committed by ad hoc interpreters. Pope et al. (2016) conducted a similar study to review errors in interpreted pediatric visits between adolescents, parents, interpreters, and pediatricians. The study reviewed 20 routine visits in Latino-serving clinics in Oklahoma and South Carolina. The authors used all of the error categories identified by Flores and colleagues, but they expanded the category of addition to include adding clarification, adding question, and adding information. They also added other inaccuracies such as medical terminology, explanation, cultural interpreting, and conversation overlap. Consistent with Flores and colleagues’ findings, the authors found that omission was the most common error, followed by editorialization, medical terminology errors, explanation errors, and false fluency. The tetradic (four part) interaction in Pope et al.’s study seemed to be especially conducive to interpretation errors. They found a tendency for providers to ally with teens by interacting solely in English and leaving the interpreter to editorialize in sidebar conversations and a tendency of the parent to ally with the interpreter leading to explanation errors. Aranguri, Davidson and Ramirez (2006) conducted a detailed sociolinguistic analysis of 13 interpreted interactions in California. Their analysis turned up a pattern consistent with that of Flores et al. (2003) and Pope et al. (2016). They found that interpreters tended to reduce speech through outright omission, content revision, and content reduction. Questions asked by patients, for example, were often answered by the interpreter and not passed along to the doctor. Small talk was also lost in the interaction. They conclude that “the presence of a third person in the interview adds a level of coldness to the relationship between

Uncovering language and cultural practices  121 patient and physician” (p. 627) adding that the discourse often becomes less personal and restricted solely to the facts. Aranguri and colleagues, therefore, demonstrate that interpreter errors do not just alter the content of messages but that they also alter the form of the message. Other studies have taken up this focus on the impact of errors on the pragmalinguistic shape of interpreted utterances in the medical encounter. Albl-Mikasa et al. (2015) generalize that phatic tokens and hedges tend to be inconsistently rendered by interpreters. Phatic tokens are rapport-building devices while hedges serve to soften the power differential between provider and patient. The authors suggest that these devices may be lost in interpreted renditions because medical interpreters do not understand their functional significance in building a therapeutic alliance. Allison (2016) confirmed this hypothesis in her study of the use of pragmalinguistic devices for the establishment of rapport in interpretermediated interactions at a family medicine clinic serving Spanish-speaking patients in central Texas. She identifies seven rapport-building devices including: affiliative humor, mitigation of directives, inclusive pronouns for solidarity, ritual greeting and leave-taking, words of empathy, compliments, and apologies. Her findings reveal that while providers use these devices to build rapport, interpreters may omit these devices due to perceived time constraints or to the view that politeness strategies are less important than the directives themselves. Examples of omission of pragmalinguistic devices include omission of inclusive pronouns (Doctor: so just what we’ll do is try to avoid eating a lot of bread. Interpreter: Lo que debe hacer es evitar comer mucho pan), omission of mitigation of directives (Doctor: if you can go ahead and lay down here. Interpreter: Acuéstese primero), omission of apologies (Doctor: Oh, I’m sorry. Has baby been moving good for ya? Interpreter: ¿Está moviendo bien el bebé?), and omission of words of empathy (Doctor: Unfortunately, those are all things that are happening because of your pregnancy. Interpreter: Todo eso es a causa del embarazo). Discourse-oriented studies on interpreter-mediated communication have also brought into focus the discursive constructions of the interpreter’s role in mediated interactions. In her important book Medical Interpreting and Cross-Cultural Communication, Claudia Angelelli explains: The role of interpreters in a bilingual encounter can take different forms. For example, interpreters may help minority-language speakers explore possibilities, thereby channeling opportunities for them. This brokering may be achieved by being attentive to the social reality of the speakers. Alternatively, interpreters may focus on the message only, disregarding how it is socially constructed by each of the parties involved in the conversation. Another possibility is that interpreters may align with the speaker of the societal language, conveying information to the less-dominant speakers without helping them gain access to it. (2004, p. 7) Hsieh (2014) notes the overwhelming trend within health care interpreting research to push through the artificially imposed limitations of the conduit model,

122  Uncovering language and cultural practices i.e., what Angelelli refers to as a “focus on the message only.” She identifies four strands of this overarching trend: 1) the recognition of interpreters as active participants in mediated communication, 2) the coordinated nature of the mediated communicative event, 3) the complex clinical demands that emerge in interpretermediated communication, and 4) the impact of contextual factors such as the specific medical specialty where interpreting occurs and the type of medical interpreter mediating communication. Dysart-Gale (2007) argues that interpreter roles are rooted in the specific way that we conceptualize or model communication. She offers two contrasting communication models: the transmission model and the semiotic model. The transmission model views communication as “the one-to-one transfer of information from a sender to a receiver, passing through a channel” (p. 240). The semiotic model, on the other hand, views communication as a process of co-construction and evolution of meaning in interaction. “When applied to interpreter practice,” Dysart-Gale explains, “the semiotic model of communication suggests answers to the questions regarding the expanded roles of interpreting practice (culture broker, patient advocate, and clarifier), specifically, when to move into these expanded roles and how to evaluate one’s performance in them” (p. 241). The communication models identified by Dysart-Gale are but shadows of longstanding ideologies of language that have driven the politics of inequality from the dawn of modernity into the present (Bauman & Briggs, 2003). The transmission model separates language from its speakers and thus makes it amenable to processes of engineering and re-engineering. These processes of language engineering take the form of “metadiscursive regimes” that categorize and classify languages based on power structures that are independent of language and that reflect the cultural, political, and economic interests of one group of speakers in relation to others. The semiotic model, on the other hand, places the speaker first and recognizes that it is speakers who make languages and not languages that make speakers. This ideological tension strikes at the heart of the language and cultural practice perspective that we explored in Chapter 3. Unlike Dysart-Gale, however, who views these communication models as moderators of interpreting practice, I would argue that these models are in fact constitutive of interpreting practice. They constitute practice not only through their codification in interpreter training and their embodiment in professional interpreters, but also in the expectations that emerge around their work. Hsieh and Kramer (2012) describe how the ideologies that undergird the transmission model are embodied in a utilitarian view of the interpreter’s role. “By this we mean that interpreters are conceptualized as instruments in the process, providing utility without influencing the content or dynamics of provider-patient interaction” (p. 158). They argue that this utilitarian approach positions the interpreter in ways that silence the voices of patients and interpreters, that objectify interpreters’ emotional work, and that exploit patients’ needs. They propose an alternative conceptualization of the interpreter as a smart technology. They explain: “whereas a hammer does not have control over its use or develop new skills over time, an intelligent program accommodates and

Uncovering language and cultural practices  123 learns from its users’ needs but also sets a clear parameter about its functionality” (p. 161). The smart technology metaphor reveals the insight that interpreting practice is shaped primarily through collaboration. Baraldi (2009) classifies the discursive properties that emerge in interpreting practice as it is superintended by different language ideologies. He argues that in the transmission model of communication and its ideology of language as a bounded and preexisting entity outside of its speakers, the discursive property that emerges is “dyadic separation.” He offers various examples of dyadic separation including the choice of doctors or patients to make the interpreter the primary interlocutor. This is discursively enacted when the doctor or patient push each other out to the third person and use the second person to address the interpreter directly. Dyadic separation also occurs when the interpreter answers a question on behalf of another participant. Finally, dyadic separation is evident when the interpreter provides direct instruction to one of the participants. The semiotic model of communication, on the other hand, engenders the discursive property of “dialogic transformative mediation.” Dialogic transformative mediation, according to Baraldi, fairly distributes active participation in the interaction and shows sensitivity for the other participants’ interests or needs. Dialogic transformative mediation is discursively enacted through strategies such as checking participants’ perceptions and feelings, actively listening to all parties, and appreciating each participants’ self-expression (p. 122). In doing so, mediators actively intervene in the interaction by generating opportunities to talk, inducing interlocutors to engage with issues, and reinforcing roles and identities. Raymond (2014) identifies “epistemic brokering” as one way in which dialogic transformative mediation is enacted in interpreter-mediated communication. He argues that interpreters reframe the transfer and reception of messages on a turn-by-turn basis. “By reframing the presentation and receipt of knowledge for both doctors and patients,” Raymond explains, “interpretersas-epistemic-brokers take into account not only that some content is transferred from one interactant to another but also the sequentially conditioned discursive means through which that transfer is achieved” (p. 430). He provides numerous examples of epistemic brokering from interpreted interactions. 1  Doctor: Her levels of methylmalonic acid have gone down from eighteen hundred 2  down to an- two hun’red an thirty six 3  Interpreter: ‘Tonces los niveles de metilmalónico le llama? Los ha bajado de dieci- de 4  mil ochocientos a doscientos treinta The addition of the phrase “le llama?” in line 3 signals to the patient that the term is a technical one that may not be understood. As Raymond explains: “the interpreter, through his translation, interactionally reshapes the presentation of this knowledge to a less-presupposing format that no longer holds Mom accountable

124  Uncovering language and cultural practices for recognizing the referent in question” (p. 433). He demonstrates a similar epistemic brokering moment in the following example: 1  Dietitian: Then you’d have to use, either jus’ give a very small amount or uhm, use 2  the low protein macaroni, er, the low protein cheese. And so it doesn’t 3  have that much in it. 4  Interpreter: Hacen macarone especial con menos queso, o con queso que no tiene tanta 5  proteína. También hacen otro tipo de macarone con queso que tiene menos 6   proteína In this example, the interpreter reframes the dietitian presentation of “low protein macaroni” as a product that the patient would already know about. While the dietitian references “the” low protein macaroni, the interpreter renders “hacen macarone especial.” Interpreter roles, therefore, are best understood as constellations of discourse practices, rooted in language ideologies, that position the interpreter in relation to other participants. Davidson (2000, 2001) provided groundbreaking insights into the role of the interpreter in health care showing that interpreters, far from being neutral conduits, are active participants in the process of diagnosis, rendering them as co-diagnosticians. Interpreters in Davidson’s study would initiate consultations on behalf of the physician in the role of co-interviewer, they would fail to pass on questions to the doctor, and they would fail to fully disclose patient’s complaints. Davidson concludes: “the construction of the interpreter as a simple instrument of semantic conveyance is only possible when those who hire and use interpreters imagine that it is possible for interpretation to be the task of merely echoing content faithfully” (2000, p. 401). Leanza, Boivin, and Rosenberg (2010) conducted a study comparing family member and trained interpreters that looked specifically at lifeworld interruptions. Lifeworld interruptions were instances where the voice of the lifeworld was blocked or ignored by the physician, the interpreter, or the patient. They found that physicians interrupted the voice of the lifeworld significantly more often in the presence of a trained interpreter than in the presence of a family member interpreter. Trained interpreters and family member interpreters also interrupted the voice of the lifeworld, but they did so for different reasons. While family members interrupted so that they could control the agenda, trained interpreters interrupted to meet biomedical goals on behalf of the physician. The pattern of lifeworld interruptions demonstrated by trained interpreters reveal the alignment of interpreters with institutions as shown in Davidson’s study. Hsieh (2007) explores in greater depth the strategies that interpreters utilize in taking on a co-diagnostician role. She identifies five strategies: assuming the provider’s role, editorializing information for medical emphasis, initiating information seeking for health information, participating in the diagnostic task, and volunteering medically

Uncovering language and cultural practices  125 relevant information to the patient. Interpreters in Hsieh’s study assumed the provider’s role by initiating information re-seeking on behalf of the provider without the provider having asked for it. They often editorialized information by ignoring or downplaying the provider’s actual communicative goal and focused instead on medical information exclusively. They initiated bids for information from patients based on their own personal judgement about medically necessary information. They collaborated with providers to investigate information, examine physical symptoms, and identify specific illness. Finally, they felt that their experience and cultural background gave them institutional standing to make medical recommendations when the provider failed to do so for lack of time, cultural differences or simple neglect. Hudelson (2005) conducted interviews with interpreters to obtain their perspective on the co-diagnostician role. She found that interpreters often recognize a mutual lack of awareness on the part of both the provider and the patient and thus feel compelled to bridge this gap. She writes: although patient/provider differences in terms of social and cultural background, education and experience create the potential for misunderstanding, it is the lack of awareness of these differences and their potential effect on clinical communication that is at the root of the problems described. (p. 315) Notwithstanding the co-diagnostician role that interpreters often assume, Hsieh (2010) shows that providers often monitor interpreter performance using creative surveillance strategies such as comparing differences in utterance length, listening for keywords, and observing nonverbal behavior and emotional tones. She also shows that providers maintain control, power, and authority through their access to institutional resources. These studies reveal the portrait of the interpreter who exerts executive actions in the mediated encounter under competing and often conflicting expectations and demands. As discursively constituted positionings, interpreter roles are not static and fixed but rather are shifting throughout the encounter. Rather than identify a single role in the interpreted encounter, we must think instead about how different roles are negotiated on a turn-by-turn basis (Raymond, 2014). White and Laws (2009) studied the phenomenon of role exchange in interpreter-mediated encounters between Spanish-speaking patients and providers at a pediatric outpatient clinic in New England. They identified three specific turn-related role exchange behaviors: assuming the provider’s role, taking the patient’s role, and engaging in other non-interpretive tasks. Assuming the provider’s role included discursive actions such as asking questions, providing health education, editing information for relevant content, and altering the provider’s recommendations. Taking the patient’s role consisted of the discursive action of speaking on behalf of the mother, and engaging in other non-interpretive roles included discursive actions such as socializing with the mother or child and educating the provider. White and Laws transcribed 13 encounters; six included a “chance interpreter” (5 dual-role interpreters and 1 family member interpreter) and seven included a “paid interpreter.”

126  Uncovering language and cultural practices They documented each instance of role exchange behavior and found that chance interpreters produced 55% of the role exchange instances, while paid interpreters produced 45%. Another study of dual-role interpreters in health care institutions on the U.S.–Mexico border found that role exchange was motivated by a combination of institutional and individual factors (Martinez, 2009). The patient advocate role assumed by dual-role interpreters interviewed in this study reflected a unique repertoire of sociolinguistic identities shaped by institutional factors such as lack of compensation, lack of training, and lack of quality control. These institutional factors thus frame the interpreting act as an individual act of caring. At the same time, however, dual-role interpreters express their perception that providing interpreting services is somehow expected of them, even though it is not explicitly stated in their job descriptions. The ambiguity would seem to be resolved through an identification of interpreting services as part of the more global practice of patient care. Individual factors such as sociolinguistic history and prior professional experience in a Spanish-speaking institutional setting, on the other hand, appeared to frame the act of interpreting as an act of professional competency. The resistance to a conduit role, among dual-role interpreters in this study, may in fact reflect the interpreter’s desire to act in a way that is consistent with professional duties and that draws on their professional knowledge and skill set. In other words, acting as a simple conduit and interpreting without any intervention would constitute a minimization of the interpreter’s professional contribution in the clinical encounter. In the same way that dual-role interpreters are prompted in role-exchange activity by multiple institutional, moral, and professional factors, professional interpreters also engage in role exchange in purposeful ways. A study of hospital-based interpreters in genetic counseling sessions, for example, showed how interpreters draw on linguistic tools in order to empathize with Spanishspeaking families (Gutierrez et  al., 2019). The interpreters in this study used a variety of empathic linguistic resources to contextualize the results of genomic sequencing tests, to provide encouragement to families, to check comprehension, to create endearment, and to soften the message. The following example reveals the strategy of using diminutives to achieve endearment: 1  Clinician: His body processes a little different, so it would be good to let the doctors 2  know this information. 3  Interpreter: El cuerpecito de él procesa ese medicamento de una forma diferente así es 4  que sería muy bueno si ustedes le dejaran saber que tiene ese problema. (p. 898) Interpreters in this study also used linguistic resources to encourage parents faced with difficult choices: 1  Clinician: We can actually provide you with a handout. 2  Interpreter: Nosotros podemos darle información escrita, no se preocupe. (pp. 897–898)

Uncovering language and cultural practices  127 The addition of “no se preocupe” offers encouragement to the parents that was not explicitly stated by the clinician. The authors conclude: “our results illustrate how interpreters use their knowledge of the cultural aspects of clinical communication to act as bicultural resources for both families and clinicians to overcome sociolinguistic barriers” (p. 898). Discourse studies on interpreting both support and challenge established standards of practice and ethics in the field. Studies of errors have shown that inaccuracies in interpreting are pervasive, that they may have clinical consequences, and that they impact essential pragmalinguistic features of the discourse that help to build rapport between providers and patients. Studies on the role of the interpreter, however, point to the language ideologies that undergird standards and ethics and demonstrate how these ideologies shape interpreter practice in meaningful ways. These studies challenge standards and ethics by demonstrating the multiple pressures that interpreters experience within institutional contexts to take on the role of co-interviewer and co-diagnostician. They also point to the ways in which interpreters make moral decisions that defy ethics even while they support patient outcomes. Dual role interpreters, for example, envision interpreting as part of their global professional duty to patient care and thus engage more readily in advocacy for patients. Professional interpreters, on the other hand, use linguistic tools in order to add empathic content to utterances that did not originally contain them. The growing recognition of the limitations of the conduit role and the fault lines inherent in the transmission model of communication are leading researchers and practitioners to question the rigidity of the standards and code of ethics and to rethink ethical professional practice in terms that are more sensitive to the interactional and collaborative nature of the interpreted conversational event.

Mass communication in Latino health Language and cultural practices have observable impacts on Latino health in interpersonal communication, whether that communication occurs directly between providers and patients or whether it is mediated through an interpreter. Even so, these practices also have appreciable effects outside of the interpersonal encounters that take place in the consultation rooms of hospitals and clinics. Language and cultural practices permeate the circulation of health-related messages in fields that are far removed from the hospital and the clinic. Mass communication approaches to health communication seek to uncover the ways in which health behaviors and practices become entextualized in health messages addressed to a mass audience and how individual receptors of these messages recontextualize them into their own behaviors and practices. Rodney Jones argues that entextualization “involves the various mechanisms through with actions are turned into discourse” (2013, p. 29). Entextualization, argues Jones, technologizes social practices and identities, making them more authoritative and less open to question and challenge. It also fossilizes those social practices and identities within specific language and cultural practices. Entextualized health behaviors and practices are not culturally and linguistically neutral

128  Uncovering language and cultural practices but instead are embedded in language and cultural practices. Recontextualization, Jones argues, refers to the often strategic ways these technologized practices and identities are appropriated into specific sites of engagement to take specific actions such as deciding a course of medical treatment, taking time off to be with a sick relative, regulating what one’s children eat, or negotiating sexual contact. (p. 29) Recontextualization, then, includes the uptake of entextualized health behaviors and practices in different spheres of language and cultural practice. Mass communication studies of Latino health have sought to describe these processes of entextualization and recontextualization from at least three different perspectives. The first perspective, health literacy, focuses on individual skills and strategies involved in accessing health information and the ways in which information can be adapted and tailored to individuals with differing levels of health literacy. The second perspective, health information seeking, focuses on the motivations and sources of health information that are accessible to individuals. The third perspective, communication ecology, seeks to understand the collaborative mechanisms that make access to health information possible even in the absence of adequate health literacy and appropriate health information seeking behaviors. Health literacy and Latino health In 2004, the Institute of Medicine published a groundbreaking report describing the mounting evidence base for the role of information access, understanding, and utilization in determining health outcomes. The report, Health Literacy: A Prescription to end confusion, argues that the rapid pace of change in medicine requires access to complex information through multiple channels. Even so, millions of Americans cannot understand or act upon this information. The gap in consumer understanding and utilization of health information owes its existence to what the committee called “health literacy” (HL). In that report, they adopted the following definition of HL: “the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions” (2004, p.  32). HL, the authors contend, emerges from interactions and influences ranging from society and culture, the education system, and the health delivery system. The level of HL that a consumer possesses, furthermore, has appreciable impacts on both the quality and the cost of care. Low HL can lead to failure to adhere to critical medication regimens, failure to adequately participate in essential screenings, and failure to fully understand risk factors. These failures, in turn, lead to ineffective treatments, delayed diagnoses, and premature death. The IOM Committee’s conceptualization of HL restricts it to the individual’s capacity to obtain, process, and understand basic health information. Zarcadoolas, Pleasant, and Greer (2006), however, present an alternative definition that

Uncovering language and cultural practices  129 accounts for the wider social and textual contexts of “basic health information.” Health information, they understand, does not exist in a vacuum but instead is shaped and contextualized by a variety of other kinds of information. In order to capture this insight, they define HL as “the wide range of skills and competencies that people develop over their lifetimes to seek out, comprehend, evaluate and use health information and concepts to make informed choices, reduce health risks, and increase quality of life” (p. 55). This definition understands health information as accessible through a “wide range of skills and competencies” that develop and change over the course of the lifespan. From this definition, the authors develop a multidimensional model of HL that proposes four distinct domains of skills and competencies: fundamental literacy, scientific literacy, civic literacy, and cultural literacy. Fundamental literacy includes traditional notions of the ability to read and write and to work with numbers. The authors propose that fundamental literacy is a bedrock component of HL given the central role of reading, writing, and numeracy in health care interactions. Scientific literacy, on the other hand, refers to the ability to engage the discourses of science and technology including an “awareness of the process of science” (p. 56). Central to this awareness is the ability to adequately process scientific uncertainty and to understand its place in medical diagnosis and treatment. Civic literacy refers to an awareness of public issues and the ability to engage in critical dialogue about those issues. Finally, cultural literacy “refers to abilities to recognize, understand, and use the collective beliefs, customs, worldview and social identity of diverse individuals to interpret and act on information” (p. 57). Zarcadoolas and colleagues’ alternative definition of HL and its related multidimensional model of health literacy skills and competencies represented a critical step forward in the conceptualization of HL. The definitions of HL adopted by the IOM Committee and Zarcadoolas and colleagues, however, share a narrow focus on the health care consumer. HL, according to these definitions, consists of individual capacities, skills, and competencies for obtaining, processing, evaluating, and understanding health information and of individual choices made on the basis of those capacities. In a 2010 perspective piece in The New England Journal of Medicine, Harvard School of Public Health Professor Rima Rudd challenged the IOM committee’s narrow focus on the individual health care consumer. “Although health care professionals can do little to directly improve literacy skills of the public,” Rudd concedes, “they can reexamine their own activities, assumptions and environments to remove literacy-related barriers” (2010, p. 2284). Rudd’s observations underscore the social nature of literacy events. Her identification of health care providers’ contributions to HL barriers underscores the socially constructed nature of the literacy environments that surround patients as they access health care and the associated assumptions that these environments make about the literacies of health care consumers. We might even say that these assumptions discipline health care consumers into adopting a specific type of literacy practice in order to become full participants in their own care. This insight helped to bring HL into the orbit of more contemporary views of literacy and literacies (commonly referred to as “The New Literacy Studies”) that understand literacy not as an autonomous skill that prepares an individual to

130  Uncovering language and cultural practices engage in a potentially infinite number of different scenarios but instead as situated practices that reflect ideologically motivated preferences and that determine inclusion and exclusion. This perspective has been developed in the works of anthropologists such as Brian Street and Jenny Cook-Gumperz, linguists such as Shirley Brice Heath and James Paul Gee, and education theorists such as Bill Cope and Mary Kalantzis. David Barton sums up the approach as follows: Ultimately literacy reflects inequalities in society: inequalities of power, inequalities in the distribution of wealth, and inequalities in access to education. These inequalities exist both within countries and between countries. Literacy can only be understood in the context of these social relations. Literacy education will always be ineffective unless these other issues are addressed alongside questions of literacy. To the extent that it is meaningful, the eradication of literacy is possible, but only if it is preceded by the eradication of poverty. (1994, p. 218) Applied to HL, the perspective of New Literacy Studies opens up the ideological dimensions of the wide range of skills and competencies needed to seek out, comprehend, evaluate, and use health information. James Paul Gee (1996) discusses the “aspirin bottle problem” as a particularly salient issue for literacy studies. An analysis of the multiple meanings and the heteroglossic voices present in a simple warning label on an aspirin bottle, Gee argues, reveals that texts are the social and historical inventions of various groups of people. One always and only learns to interpret texts of a certain type in certain ways through having access to, and ample experience in, social settings where texts of that type are read in those ways. One is socialized or enculturated into a certain social practice. (pp. 44–45) The measurement of HL has typically been achieved through instruments that assess an individual’s knowledge of words and collocations used in the health care field. While most tools measure general health care knowledge, researchers are now beginning to recognize the importance of measuring disease-specific health literacy (Echeverri, Anderson & Nápoles, 2018). Stonbraker, Schnall and Larson (2015) conducted an integrative review of the literature and found 19 different instruments that have been used to measure HL among Spanish speakers. Their findings revealed that tools varied widely in what they measured – from reading comprehension, numeracy, and listening comprehension to confidence and responsibility in message processing and the ability to use information in a health care context. Three important tools are the Spanish version of the Test of Functional Health Literacy in Adults (TOFHLA-S), the Short Assessment of Health Literacy for Spanish-speaking Adults (SAHLSA), and the Single Item Literacy Screener (SILS). The TOFHLA-S aims to assess Spanish-speaking patients’ ability to read

Uncovering language and cultural practices  131 health-related materials. The instrument consists of a 67-item multiple choice test that assesses reading comprehension (50 questions) and numeracy (17 questions). TOFHLA-S is a translation of the English version. The following is an example reading comprehension item from the English version of the TOFHLA: The x-ray will __________________ a b c d

from 1 to 3 _____________ to do.

take   view   talk   look  

a  beds b  brains c  hours d  diets (IOM, 2004)

The TOFHLA has been shown to be a valid and reliable indicator of patient ability to read health-related materials both in English and in Spanish (Parker et  al., 1995). The results of the TOFHLA instrument classify respondents in one of three categories: adequate functional HL, marginal functional HL, and inadequate functional HL. SAHLSA is a word recognition instrument developed as an easy to use HL test for Spanish-speaking adults. SAHLSA is a Spanish language adaptation of the English Rapid Estimate of Adult Literacy in Medicine (REALM). It consists of a 50-item tool that assesses recognition of medical vocabulary through association with a related word. The respondent is presented with a word such as depresión and is presented with three options such as apetito, sentimientos, and no sé. The respondent is then asked to choose the option that is best associated with the word presented. In this example, the correct response would be sentimientos. If the respondent scores between 0 and 37 on the instrument, the respondent is deemed to have inadequate HL. Finally, the SILS is designed to assess one component of HL  – reading ability. The SILS is a one question assessment of HL that consists of the question: “How often do you need to have someone to help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?” The respondent may choose from among five possible responses: 1-Never, 2-Rarely, 3-Sometimes, 4-Often and 5-Always. A score greater than 2 is considered an indicator of adequate HL (Morris et al., 2006). While these measures do not capture the full scope of HL, they do measure at least one component – reading comprehension, recognition of medical vocabulary, and reading ability – and thus serve as indicators of potentially inadequate HL. Inadequate HL, as determined by measures such as TOFHLA, SAHLSA, and SILS, have yielded important insights into its potential impact on health-related outcomes. Edward et  al. (2018), for example, determined that inadequate HL was associated with insurance status and access to care. Calvo (2016), on the other hand, found that HL affected perceptions of quality of care as measured on the 2007 Pew Hispanic Center and Robert Wood Johnson Hispanic Healthcare Survey. In response to the question: “Overall, how would you rate the quality of medical care you have received in the past 12 months?” Calvo shows that immigrants with higher levels of HL were more likely to give a positive

132  Uncovering language and cultural practices response to this question. Another study assessed perceptions of quality of pediatric ambulatory services among low-income Latina mothers. Mothers with low HL were the most likely to perceive low-quality care (Fry-Bowers, 2013). HL has also been shown to impact health behaviors. In a study of physical activity self-efficacy among sedentary Latinas at risk for chronic illness, Dominick et al. (2013) found that women with higher HL scores responded more positively to a physical activity intervention than women with lower HL scores. Armin et al. (2014) studied breast self-examination behaviors among Latinas in a federally qualified health center in Massachusetts. They found that women with adequate HL were more likely to practice breast self-examination as part of routine breast cancer screening in comparison with women with inadequate HL. Coffman, Norton, and Beene (2012) found that among Latino adults at risk for type 2 diabetes those with low HL were least likely to recognize and respond to symptoms of the disease. Together these studies demonstrate the profound influence that HL has on Latino health. In addition to the numerous studies that link HL to health outcomes in Latino communities, researchers have also turned their attention to the determinants of HL. HL, for example, may be tied to acculturation among Latino immigrants. Acculturation, while generally understood as encompassing a variety of beliefs and practices is typically measured through questions relating to language proficiency and language use. A study of the association between HL and acculturation among Latinos in Cincinnati, for example, used a bi-dimensional acculturation subscale that measures both English and Spanish language ability (Rojas-Guyler et al., 2013). Other studies have relied on the Short Acculturation Scale for Hispanics that assesses the predominant language or languages read and spoken, the languages usually spoken at home, the languages usually used for thinking, and the languages spoken with friends (Boyas, 2013; Perez, 2015). Using language proficiency and use as a proxy for acculturation, these studies coincide in their identification of acculturation as significantly associated with HL. Other studies have confirmed that limited English proficiency is linked to low HL among different immigrant populations (Sentell & Braun, 2012). Language proficiency in these studies is not measured explicitly but rather is self-reported. Jacobson, Hund, and Soto Mas (2016), however, sought to assess the impact of explicitly measured English language proficiency on HL. Their findings revealed that higher levels of English language proficiency were associated with higher levels of HL. Other studies have shown that English proficiency clusters with other determinants of HL such as living in poverty, lack of consistent health insurance, and years of education (Becerra, Arias & Becerra, 2017; Van Servellen, 2003). The study of determinants of HL have expanded the perspective to consider not only the individual patient characteristics that are associated with HL but also the influence of a caregiver’s HL. In a study of elderly Latinos in Texas, Garcia et  al. (2013) examined the relationship between the HL of patients and their caregivers. The findings revealed that a plurality of elderly patients with low HL had caregivers with adequate HL but that nearly a third of the elderly patients in the study had

Uncovering language and cultural practices  133 caregivers with inadequate HL. The pairing of low HL patients and caregivers, they argue, may negatively affect the health outcomes of their older patient, regardless of the patient’s own health literacy level, as caregivers perform tasks that have a direct effect on the patient’s health status, such as dispensing medications and assisting the patient in following physician instructions. (p. 267) Jacobson, Hund, and Soto Mas (2016) argue that “geography and sociolinguistic environment must also be integrated into research on health literacy” (p. 59). By this, they signal the multiple determinants of HL which are not limited to an individual’s ability to speak English, years of schooling, and socioeconomic position, but that also include social networks, interaction patterns, and levels of bilingualism. They conclude: language diversity is facilitated by globalization, immigration, and displacement of people. Language use is a contextual factor that may influence health care and health outcomes, and assessing L1 and L2 proficiency should become the norm in health literacy studies with language minorities. Health literacy research must further explore the role of bilingualism in health literacy among Hispanics and clarify the factors that must be considered when measuring health literacy in this group. (p. 61) Interventions to address low HL in the context of Latino health have been multifaceted. Interventions have sought to incorporate HL content in institutional contexts, develop innovative curricula, and culturally adapt existing interventions. The integration of HL in adult education and the expansion of general educational opportunities have been key areas of HL intervention (Soto Mas, Jacobson & Olivares, 2017; Soto Mas & Jacobson, 2019). Tapping other institutions in Latino communities such as faith-based organizations, moreover, has been shown to be an effective way to increase HL and to address cultural stigma around mental health (Caplan & Cordero, 2015). Innovative curricula have included the development of consumer health courses based on popular music, culture, and culturally attuned scenarios (El-Khayad, 2017), depression literacy interventions based on a fotonovela that portrays a soap opera story conveying educational messages (Cabassa, Molina  & Baron, 2012), and curation of health information available across the internet within a single Latino-focused portal (Ramirez et al., 2016). Cultural adaptation of existing HL interventions has been an intense focus of research. Ramos and Alegría (2014), for example, describe the adaptation process for a telephone cognitive-behavioral depression intervention to be used among Latinos in low-resource settings. The intervention includes psychoeducation about depression and its treatment, promotion of behavioral activation,

134  Uncovering language and cultural practices challenging negative thoughts and stigmas, and giving participants an opportunity to develop a self-care plan. To increase access, processing, and use of the health information contained in the intervention, the authors applied a series of adaptations. In order to make the educational materials more accessible to participants, the authors incorporated dichos and proverbs into the clinician manual. Proverbs such as Es mejor prevenir que lamentar and No dejes para mañana lo que puedes hacer hoy were examples of linguistic modifications that enhanced accessibility to the content. Cultural values such as collectivism and familismo were also operationalized in sayings such as poniendo de su parte (p. 297). Cameron et al. (2017) present the adaptation of healthy diet text message intervention. They adapted an existing mHealth program called HealthyYouTXT, developed by the National Cancer Institute to send text messages to participants that provided advice, nonjudgmental support, and positive feedback on healthy eating to Spanishspeaking participants. The process of adaptation included both translation and trans-creation (Solomon et al., 2005) of messages. Messages were first translated into Spanish and backtranslated into English to ensure accuracy. After translation occurred, messages were adapted to the medium of text messaging including reducing the size of the message to 160 characters, finding alternative words in Spanish that did not include Spanish-based characters such as ¿, ¡, í, ñ, á, and use of Pan-American Spanish words as opposed to dialectal variants (for example, the use of the word frijoles as opposed to habichuelas or albulias). After adapting the messages to the medium, the authors then set out to adapt the messages to the culture. Cultural adaptation consisted of the inclusion of popular food items such as avocados, jicama, and cilantro and inclusion of cultural values. Some examples of culturally adapted messages can be seen in Table 4.2. These examples highlight the trans-creation process that results from a multistep approach of translation and cultural adaptation. HL influences Latino health in profound ways that reveal structural inequalities and cultural conflict. HL studies demonstrate how health disparities and health inequities track along with language barriers, socioeconomic marginalization, and cultural subordination. They also reveal that inadequate HL influences perceptions of care, participation in critical screening and other preventive health measures, and symptom recognition. Effective interventions that address HL have sought to embed it in existing adult education, expand general educational opportunities, develop innovative curricula that speaks directly to Spanish-speaking populations, and adapt existing materials into Spanish through translation and trans-creation. Health information seeking and Latino health Health information seeking behaviors have been explored in tandem with HL in Latino health. Health information seeking is the active and intentional effort to obtain specific information about health. Health information seeking includes any non-routine media use or interpersonal conversation about a specific health topic and thus includes behaviors such as viewing a special program

Uncovering language and cultural practices  135 Table 4.2  Cultural adaptation of text messages Original text message

Adapted text message

Cultural values incorporated

Cutting out all treats can feel like punishment. Take charge by selecting when and if you have treats. It’s your choice!

Dejar de comer sus antojitos es un buen sacrificio para el bienestar de su familia. Limite cuando y cuantos antojitos come. Es su decisión! Para que sus hijos se sientan incluidos en sus decisiones, invítelos a planear o preparar alimentos. Intente actividades apropiadas para sus hijos. Es la temporada del elote! Comalos de manera saludable y deliciosa. Evite grasas y solo use limon y chile en lugar de mayonesa y mantequilla.

This message incorporates the value of familismo by stressing the importance of healthy eating for family well-being.

When kids have a part in planning of putting together meals, health eating becomes “theirs.” Find ageappropriate ways to get them involved. It’s corn season! Take those kernels off the cob & try out this yummy side dish: [Link]

This message incorporates the value of familismo by providing a clearer focus on personal actions one can take to promote children’s participation in meal preparation. This message incorporates traditional foods by providing a healthier alternative for a popular recipe for corn on the cob with mayonnaise and ground peppers.

Source: Adapted from Cameron et al., 2017

about a health-related treatment, using a search engine to find information about a particular health topic on the internet, and/or posing specific healthrelated questions to a friend, family member or medical practitioner outside the normal flow of conversation. (Niederdeppe et al., 2007, p. 155) Health information seeking is in some ways similar to HL in its attempt to characterize access to information but differs inasmuch as its emphasis is on the process of obtaining information rather than on the process of comprehension and utilization of health information. Health information seeking research in Latino health has focused on patterns of health information seeking behaviors in Spanishspeaking communities, on the sources of health information available to Spanish speakers, and on relative levels of trust in various sources of information. Patterns of health information seeking behaviors in Latino populations have been found to differ from those of other racial and ethnic groups. In a comparative study using data from the 2007 USA Health Tracking Household survey, for example, Rooks et al. (2012) found that while African Americans did not differ from Whites in their health information seeking behaviors, Latinos were significantly less likely than Whites to seek health information and when they did seek it, they were less likely to use it when speaking with their doctors. Vanderpool et  al. (2009) looked at cancer information seeking behaviors among Spanish

136  Uncovering language and cultural practices speakers in a sample derived from the 2005 Health Information National Trends Survey. Their findings are consistent with those of Rooks in that over 80% of the respondents reported never having looked for cancer information. In comparing their findings to English-speaking Latinos, furthermore, they found that Spanish speakers who sought information indicated that the search took a lot of effort, that the information found was hard to understand, and that the process was frustrating. These findings suggest that language preference is an important component of health information seeking. Shin and Maupome (2017) argue that language preferences in health information seeking can be tied to levels of acculturation. Based on 13 linguistic, psychological, and behavioral indicators they stratified a sample of 332 Mexican immigrants into four acculturation groups: 1) less acculturated, 2) moderately acculturated, 3) highly acculturated, and 4) selectively acculturated. The less acculturated group preferred Spanish in all domains, identified as Mexicans, and indicated loyalty to Mexican family values. The moderately acculturated group preferred Spanish or bilingual interactions in all domains, identified as Mexicans or Americans, and indicated loyalty to Mexican family values. The highly acculturated group preferred bilingual interactions in all domains except media. In the media domain, they preferred English. This group identified as bicultural and indicated little loyalty to Mexican family values. The selectively acculturated group preferred bilingual interactions in all domains, identified as bicultural and indicated loyalty to Mexican family values. The authors found significant differences in the language preferences of each of these groups when seeking health information. Less acculturated and selectively acculturated individuals sought health information in Spanish whereas highly acculturated individuals preferred English. Selectively acculturated individuals preferred bilingual health information. In addition to the preferred language of health information, researchers have also looked at preferred sources of health information. Several studies have examined the utilization of electronic media in comparison with traditional print media. A study of the preferred medium for receiving information about Affordable Care Act insurance among Latinos in North Carolina found that even though there was a willingness to try electronic media, there was a clear preference for traditional print media when it came to receiving health information (Arcury et  al., 2017). Another study focusing on the Latino farmworker population in the state revealed numerous challenges to electronic media. Even though cell phone and smartphone ownership was high, most farmworkers preferred talk and text functions over other mobile functions, and many failed to maintain consistent phone numbers. Participants in this study also voiced a preference for traditional print media (Sandberg et al., 2016). While print media remains the preferred method of communication, content analyses of Spanish-language newspapers have found that these newspapers publish a high number of health-related stories focusing on information about diseases, symptoms, and treatments. Even so, “they fail to adequately provide news and analysis of political, socioeconomic, and public policy developments related to health care” (Vargas & de Pyssler, 1999, p. 202). Vargas and de Plysser, further, argue that Spanish language newspaper media thus serves a

Uncovering language and cultural practices  137 function of social control. Clinical information, they contend, “diverts attention away from the socioeconomic and political structures shaping the overall dismal health status of the Latino population” (p. 203). Content analyses of health coverage on Spanish-language television has found similar results (Katz, Ang & Suro, 2012). Studies that have looked at trust in health information sources, however, have found that Spanish speakers tend to have greater trust in health messages received from radio in comparison to other media sources such as newspapers, magazines, and the internet (Viswanath & Anderson, 2011). Clayman et al. (2010) arrived at a similar conclusion based on their analysis of data from the 2005 Health Information National Trends Survey. They found that Latinos who were comfortable speaking English indicated higher trust in information from newspapers, magazines, and the internet. These Latinos also reported greater exposure to each of these media outlets than Spanish-speaking Latinos. They conclude that health information available primarily through these media outlets may be inaccessible for Spanish speakers due to language ability, lower trust, and relative low utilization. By far the most important source of health information for Spanish speakers seems to be interpersonal interactions with health professionals and community leaders (Arcury, 2017). Oftentimes mass media outlets serve as a bridge to interpersonal health seeking behaviors. Ramirez et al. (2017) found that callers to a Spanish-language radio health program frequently asked questions for others. Information surrogacy thus constitutes an important source of health information in Spanish-speaking communities and we will consider this phenomenon in more detail in the next section. Communication ecologies in Latino health The predominant focus on individual health literacy and health information seeking behaviors elides significant language and cultural practices in the approaches that Spanish speakers take to obtaining health information. As Ramirez and colleagues’ study showed, information surrogacy is an important piece of the health information seeking practices of Spanish speakers. In their analysis of a Spanishlanguage talk radio show, they found that Spanish speakers were very much willing to seek out health information on behalf of friends and family members. This practice of information surrogacy, they argue, leverages natural familial social networks and spreads information in ways that an individual focus cannot adequately capture. Katz, Ang and Suro (2012) have proposed the useful concept of “communication ecology” to understand the ways that health information spreads in Spanish-speaking communities. They define communication ecology as “the array of interpersonal, mediated, and organizational communication options available to an individual to achieve everyday goals” (p. 438). Communication ecologies thus focus on the cumulative effects of multiple sources of health communication connections including family, friends, radio, television, the internet, newspapers, magazines, churches, and community organizations on health information access, understanding, and use. In looking at these multiple sources of health information, the authors found that while informal health communication

138  Uncovering language and cultural practices connections did not compensate for lack of access to formal connections, greater diversity of health communication connections was related to improved health care access and favorable health outcomes. Communication ecologies, however, must be viewed within a wider perspective of language ecologies. Einar Haugen defined language ecology as “the study of interactions between any given language and its environment” (1972, p. 325). He further specified that the true environment of a language “is the society that uses it as one of its codes” (p. 325). Language ecology, therefore, was for Haugen governed by the learners, users, and transmitters of language in any given society. Haugen’s early formulation of language ecology has been criticized because it overdetermines the relative power of learners, users, and transmitters in the shaping of the ecological environment. Calvet (2006), for example, observes that ecologies are shaped just as much by learners as by non-learners, by users as by nonusers, and by transmitters as by non-transmitters. For Calvet, language ecology emerges not simply from language practices (what people say) but also from language representations adopted by users and nonusers alike (how people view what is said). Because of this, Calvet prefers to think of ecolinguistic systems rather than ecologies of language and argues that these systems represent a synergy of language and environment that generates multiplicity, interbreeding, variation, competitions, and convergence. A key component of Calvet’s approach to ecolinguistic systems is his gravitational model which seeks to account for macro-sociolinguistic relations between different languages. Simply put, the gravitational model posits that some languages have greater weight in terms of social prestige, information density, and presence on the linguistic landscape. He distinguishes different weights in the constellation of languages that include a hyper-central language, i.e., English; super-central languages such as Spanish, French, and Portuguese; and a range of languages central to a limited geographic region. Calvet’s theory of ecolinguistic systems sheds additional light on the communication ecologies proposed by Katz, Ramirez, and others. Within a communication ecology, information exchange takes place in different languages with different levels of prestige. The gravitational pull of the language in which the information is transmitted will have an effect on the message. The message is not severable from the messenger and the language in which the message is conveyed will leave its imprint on the message itself. This generalization tracks with Katz, Ang, and Suro’s observation that informal communication connections do not compensate for the lack of interactions with health care professionals. Further, it sheds light on their finding that more diversified communication connections are related to greater health care access and more favorable health outcomes. Diversified communication connections reinforce messages and bend them in localized and situated shapes that may not be present in every instance of message transmission. For example, the same information about type 2 diabetes may be communicated through different communication connections such as doctors, dietitians, magazines, friends, and family members. While the message is constant the particular shape may differ. The doctor may focus more on the medications and health care routines needed for optimal control, the dietitian may focus instead on

Uncovering language and cultural practices  139 healthy eating habits, and family and friends may discuss how these eating habits can be integrated into traditional foods. These content foci are accompanied, furthermore, by different interaction patterns and different languages which also bend the message in particular ways. Promotoras de Salud or community health workers have emerged as critical actors within the language and communication ecologies that impact health information seeking and utilization in Spanish-speaking populations. Promotoras have been defined as “trusted and respected community members who provide informal, community-based health related services and who establish vital links between health professionals and persons in the community. They act to increase the accessibility, acceptability, and appropriateness of available health services” (cited in Ford et al., 1998). Promotoras de salud, moreover, are fitted within a historic role of cultural health figures in Spanish-speaking communities. Parteras, médicos, and curanderos are all precursors or cultural kin to the present day promotora de salud. Characteristic of these cultural health figures is the coalescence of traditional health practices, spirituality, and biomedicine in the delivery of care via an actor trained via informal apprenticeships. Jesusita Aragón, a well-known partera from Las Vegas, New Mexico whose contribution to the health of her community was memorialized in Fran Leeper Buss’ biography La Partera: The Story of Midwife, demonstrates how cultural health figures coalesce traditional health practice, spirituality, and biomedicine. In an interview conducted with Jesusita for the film Médicas y Médicos: A Healing Tradition in the Southwest produced by Medicinas del Bosque in collaboration with the University of New Mexico’s Center for Regional Studies, Aragón recalls: Mi abuela fue partera por muchos años, y yo fui partera por muchos años también. Mi abuelita me enseñó. Yo aprendí todo de ella. Médica, partera y todo lo aprendí de mi abuelita. Porque de muy chiquita mi abuelita me enseñó y a mi me gustó y siempre lo hice con mucho gusto con toda la gente. No importara quien viniera a mi casa o fueran por mí, yo iba contenta y servía con toda voluntad y todo gusto y siempre Dios me ayudó. Jesusita’s story includes numerous encounters with biomedicine and tells of the emergence of a unique collaboration between the partera and the health delivery system in rural New Mexico. Fran Leeper Buss narrates Jesusita’s characterization of this collaboration: Today I still deliver babies. The ladies come to me when they think they’re pregnant. They go to public health too, for the tests. When she first comes I check to see if the baby’s in good position. I check with my hands, by the way they feel. (Buss, 2000, p. 68) Jesusita’s story thus demonstrates the coalescence of biomedicine, traditional healing practices, and spirituality in community health delivery Spanish-speaking communities. This same coalescence of biomedicine, traditional healing practices,

140  Uncovering language and cultural practices and spirituality is evident in the contemporary promotora de salud who serves to link Spanish-speaking communities to health services and to provide access to health information and knowledge in some of the nation’s most vulnerable neighborhoods. In the Robert Wood Johnson Foundation short film Health Angels: Help for society’s most vulnerable people, Aurelio Martínez summarizes the work of the promotora as follows: The promotoras are literally the angels of services providers because they go into the colonias and are seen as angels. Every time you go back in providing that case management, you’ll hear these women say ‘mi angelita, mi angelita.’ My angel is here. Ford et  al. (1998) describe promotoras as “boundary spanners” both in public health and in communication. As public health boundary spanners, they characterize promotoras as health educators, health care referral sources, social support providers, and health practice role models. As communication boundary spanners, on the other hand, they argue that promotoras serve as opinion leaders (exerting influence in their communities of practice), as gatekeepers (controlling the flow of information between the community and the health system), as bridges (linking members of the community with health service providers), and as liaisons (serving as drivers of organization and mobilization on behalf of the community). In these multiple roles as boundary spanners, promotoras have contributed substantially to the improvement of health in Spanish-speaking communities. Elder et al. (2005), for example, assessed the impact of promotoras on a nutrition education intervention for Latina women on the California-Mexico border. They used a randomized controlled trial design to compare the efficacy of three nutrition education conditions: an off-the-shelf Spanish language nutrition education curriculum, a culturally tailored nutrition education curriculum, and a culturally tailored curriculum with the assistance of a promotora. The findings revealed that women exposed to the culturally tailored curriculum with assistance of a promotora achieved significantly lower caloric intake and lower total fat, saturated fat  and  carbohydrate intake. The authors suggest that the superiority of the promotora model may be due to the “personal touch” of the promotora as well as the assistance given in actually interacting with the educational materials. Larkey (2006) explored the role of promotoras in improving cancer prevention and screening behaviors among low-income Latina women. Promotoras implemented a 12-week cancer prevention education intervention with 366 women in the Phoenix area. Pre- and post-intervention measures were collected. The findings revealed that participants increased fruit and vegetable intake, engaged in more physical activity, and increased utilization of key cancer screening measures such as Pap smears, mammograms, and fecal occult blood tests after completing the course. Lujan, Ostwald and Ortiz (2007) reported on a promotora-led diabetes self-management intervention and found that Promotoras, with their unique firsthand knowledge of the Mexican American culture and command of the language, delivered diabetes self-management

Uncovering language and cultural practices  141 education in a culturally sensitive manner by speaking Spanish at an appropriate level, using relevant food items, recommending feasible physical activities, and acknowledging and integrating the Mexican American beliefs of divine fatalism and familialism into relevant interactions to improve health. (pp. 66–67) Ingram et al. (2007) documented a 1% reduction in HbA1C levels among Spanishspeaking farmworkers with high-risk of diabetes complications through a promotora-led intervention. Ryabov and Richardson (2011) found that monthly visits by promotoras were similarly effective in lowering patients’ A1C and in raising their diabetes knowledge, self-efficacy, and self-management. Heisler et al. (2009) queried participants in a promotora-led intervention and found that promotoras provided clear and detailed information on diabetes and diabetes care, sustained and nonjudgmental assistance to increase motivation and confidence, and social and peer support that enabled patients to better manage their diabetes. The consistent positive findings of promotora-led interventions has led researchers to explore the mechanisms that contribute to their effectiveness. Deitrick et al. (2010) reported on the essential role of language in the influence exerted by promotoras. In their study of the essential components of the promotora role that make diabetes education programs successful, Dietrick and colleagues argue that Spanish was a key factor in connecting promotoras and patients in productive intersubjective bonds. “Not only was speaking in Spanish important” they write, “but the reading level of written materials was also a consideration to ensure understanding by patients with varying Spanish reading levels” (p. 392). They also comment on the use of colloquialisms in Spanish as a means of creating and sustaining productive intersubjective bonds. Together these studies point to the essential role of language practices in the efficacy of promotora-led interventions. Even so, detailed analysis of promotora discourse continues to constitute a serious gap in our understanding of the promotora’s influence. Promotora discourse can profitably be assessed within a larger perspective of language and cultural practices fitted within a communication ecology. I used a language and cultural practice perspective to analyze the discourse of eight promotoras from the Cameron Park colonia in Cameron County, Texas (Martinez, 2016). In this study, I sought to identify the language practices employed by promotoras in their bridging efforts and to uncover how these practices are situated in the spatial context of colonias along the U.S.–Mexico border. This dual aim allowed me to analyze promotora discourse attending to both the micro level features of promotora discourse illustrative of translanguaging as well as to the macro level features that tease out the role of the political economy in local language practice. The discourse of promotoras is embedded in a multifaceted and complex language and communication ecology that brings together many linguistic repertoires and reflects varying levels of multicompetence. Following García and Wei (2014), I view this complex ecology from a translanguaging perspective that posits not a bifurcated and segmented ecology that neatly separates English speakers from Spanish speakers and monolinguals from bilinguals, but rather that posits a fluid and dynamic environment in which individuals engage in multiple discursive practices in order to make sense of the complex ecology in which they are

142  Uncovering language and cultural practices situated. Promotora discourse is characterized by multiple features of translanguaging practice. Code switching was common in promotora discourse. Examples of code switching emerging from promotora discourse include: 1 2 3

Y luego la que yo recruit ha sido promotora por muchos años De hacer ejercicios, ahh, it’s my favorite Por dos o tres yo pagué y hacía car wash para pagar y ellos me ayudaban y mis hijas me decían: estás bien negra ya de tanto car wash

But translanguaging practices extended beyond the facile binary of English/ Spanish in promotora discourse. Another aspect of translingual practice in promotora discourse was the consistent uptake of technical health-related language in their discourse. Promotoras seamlessly slipped technical medical terminology into their discourse that at once legitimized their role as health authorities but that also embedded health information within the community context. The presence of this technical terminology in promotora discourse irrevocably shaped community discourse and linked it to the discourse of health professionals. For as Bahktin has noted: “the word does not forget its path of transfer and cannot completely free itself from the power of those concrete contexts into which it has entered . . . the word enters our context from another context, permeated with the intentions of other speakers” (cited in Holborow, 2015, p. 124). Examples of technical discourse present in the discourse of promotoras include: 4 5 6 7

apenas ayer le dieron ganas de hacerse el papanicolau comer pan integral, leche con bajas grasas, porciones Y he mantenido mi colesterol porque tengo 6 hijos y quiero conocer a mis nietos cuando me los den Y me preguntaron de la papiloma humano es que mejor que no tengan relaciones y respeten a las mujeres

Technical words about biology, nutrition, medical procedures and medical specialties were inserted into the discourse community and created greater access to health information for those who interact with the promotoras. But the translingual practices of promotoras, while inserting technical words into the discourse of the community, also legitimizes colloquial health-related language. One of the promotoras in my study exemplified this fluid interchange between technical and colloquial language. “Cambios físicos, cambios en la cocina, cambios en nuestros cuerpos, arreglarnos más, vernos más guapas, sale todo eso en lo que hablamos. Hablamos de todo.” Colloquial words and collocations were present throughout the promotora discourse and often linked up to technical words. In discussing physical activity routines, for example, one of the promotoras stated: 8

Sí porque no te sientes cansada y te sientes más livianita antes de una hora de ejercicio siempre me iba a caminar

Uncovering language and cultural practices  143 Other examples of colloquial language inserted within discourse about health include:   9 Así dejas de estar flojiando 10 Mucho cambio, gente que no tomaban agua, como aquí el señor presente, no toma agua. Les ayudamos a tomar agua porque el agua es vida 11 Pero sí me gusta brincar la cuerda y limpiar mi solar y barrer, me salgo afuera. No soy de las que me gusta estar sentada nomás. This translingual practice of using colloquial expressions in health-related discourse legitimized the sociocultural context in which the expressions normally appeared. So, the access created by the seeping of technical words into the community through promotora discourse was matched by the legitimization engendered by the inclusion of colloquial words and collocations in health-related discourse. The discourse of promotoras, however, was also shaped by the space in which it occurred – in the colonia. The U.S. Department of Housing and Urban Development defines a colonia as a “rural community within the U.S.-Mexico border region that lacks adequate water, sewer, or decent housing or a combination of all three” (HUD, 2015). In South Texas, colonias are most often rural, unincorporated areas under the jurisdiction of the county. They generally consist of inappropriately subdivided land with housing made of salvaged materials, although trailer homes are often present in many colonias. I follow Dolhinow (2010) in her interpretation of the colonia as a result of “neoliberal housing at its best” (p. 47). Colonias emerged in the context of the conclusion of the Bracero program in 1964 and the passage of the Immigration Reform and Control Act (IRCA) in 1986. The Bracero program created a steady stream of migrant agricultural workers who for years worked on fields and resided in tenements provided by landowners. IRCA created a path to legalization for many of these workers and also afforded them the opportunity to reunite with their families on the U.S. side of the border. The Bracero program and IRCA were followed by the Border Industrialization Program and the North American Free Trade Agreement which led to greater concentrations of the working poor on both sides of the U.S.–Mexico border. In the absence of government-sponsored affordable housing for these new families, the neoliberal model of privatization generated an opportunity for land developers to step in. According to Dolhinow: Many colonias developed in a milieu of neoliberal retrenchment of the state and privatization of social services in the 1980s and 1990s. Yet these neoliberal cutbacks exist within a discriminatory housing market, especially on the border, and the inadequate and stigmatized public housing that does exist simply cannot house the growing population of Mexican working poor. It was in this particular convergence of limited housing, ethnic discrimination, neoliberal policy, and the prevalence of Mexican culture that colonias developed. (p. 49)

144  Uncovering language and cultural practices

Figure 4.1  Makeshift plumbing system at a colonia residence in Mission, Texas

Colonias often emerge on unusable farmland that is subdivided in multiple lots and sold using a deed-for-contract mechanism. Lots are sold to Mexican workers for a low down payment  – often whatever they have in their pocket  – and low monthly payments. At the time of purchase, land developers would generally promise that improvements such as sewage, water, and electricity were forthcoming. The subdivided land is normally conveyed through multiple owners leaving the land buyer in a state of perpetual debt and making the original seller virtually undetectable. At the same time, however, the colonia provides a sense of ownership and investment to Mexican working poor that could not exist in public housing. Dolhinow showed that the colonia residents in her study expressed a great deal of satisfaction and pride in their colonia dwellings and that they would be unlikely to leave. The neoliberal project of colonia production thus created a sense of personal responsibility and entrepreneurship that permeated social life within the colonia. In my analysis of promotora discourse, I  found that promotoras drew heavily on the entrepreneurial spirit generated within the neoliberal colonias. Entrepreneurship and personal responsibility were framed within the promotora’s ability to bring people together and to generate cohesion within the colonia. The promotora’s individual work was seen as a gravitational force that brings the

Uncovering language and cultural practices  145

Figure 4.2  Family home in a colonia in Mission, Texas

community together. One of the participants stated this succinctly when she commented: “Y muchas corren la voz para que las amigas vayan a las juntas y esas amigas les dicen a otras y vamos acarreando a mucha gente.” The promotora’s entrepreneurial spirit was also unleashed in her desire to help. For example, one of the participants recalled the following: 12 Hubo una actividad y yo fui a hablar con la mamá y muy pobre la niña y no tenía calcetín ni zapatos así que yo le di y fui a hablar con la mamá The promotora also utilized human capital at her disposal to generate a sense of community within the colonia. Speaking about her efforts to help the youth, another participant stated: 13 Hay un grupo de muchachos que les decimos los mariguanos, y ahí vienen los mariguanos. Son muchachos que tienen sentimientos y yo me arrimé y les dije hagan su equipo, yo tengo el mío (con mis hijos) y nos juntamos los domingos. Y me dicen ¿De verás señora? Sí. Y me da mucho gusto.

146  Uncovering language and cultural practices The cohesion that emerges from the promotora’s work within the community converges on a drive towards mobilization for the community’s benefit. In discussing the problem of neighborhood dogs and the dangers that it poses to community members, one of the participants recalled: 14 Y fui y encontré donde recogen a los perros. Hablé con el mero de los perros que tenía mucho trabajando ahí y me dijo que una ley así que diga que van a levantar perros con o sin dueño no ha existido. Simplemente se les notifican que está un perro suelto y vienen por él Aside from seeking out assistance from local institutions as in the previous example, promotoras also serve as a means to bring local institutions into the colonias. 15 También tuvimos una junta aquí y vinieron los de protección de perros y nos dijieron que no se pueden estar amarrados

Figure 4.3  Stray dog in a colonia in Mission, Texas

Uncovering language and cultural practices  147 Promotora discourse, therefore, draws on the neoliberal framework that shapes discourse in the colonias. The entrepreneurial and self-reliant orientation emerging from the neoliberal framework shapes the way that promotoras describe their own role in generating cohesiveness in the colonia and in mobilizing external resources to respond to internal problems. Mass communication perspectives on Latino health have shown how local language and cultural practices influence health outside of the clinical encounter. These perspectives bring into focus the skills and capacities that individuals bring to encounters with health information, the behaviors adopted in seeking health information, and the fluidity of health information as it is weaved into language and cultural practices. Health literacy, health information seeking, and communication ecologies in Latino health unsettle the idealization of a generic health consumer who is nothing more than a passive recipient of health information and instead ground health communication in local language and cultural practices that bend health messages along unexpected contours. In this chapter we have focused on the description of language and cultural practices in health care from the perspective of provider-patient communication, interpretermediated communication and mass communication. We have distinguished between sociomedical studies, discourse studies, health literacy studies, and health information seeking studies in order to ensure comparable data for generalization and in order to cull evidence in a way that contributes to a wider theoretical basis for analyzing Spanish in health care. In sum, our conclusions have led us to an appreciation of an ecological perspective that can adequately support multiple communication practices while ensuring access, controlling cost, and improving quality.

Note 1 Patient acuity refers to the severity of illness. Acuity scores are used to determine the number of patients who can be seen at any given time relative to the nurses on staff. A lower acuity score thus results in longer wait times in hospital emergency rooms.

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5 Language pedagogy and Latino health

Javier Mauricio Cepeda es mi padre y tiene 52 años de edad. Mi padre es todo para mí porque por él soy lo que soy ahora. Es nacido en Mainero, Tamaulipas e inmigró a los Estados Unidos cuando sólo era un adolescente para poder ayudar a su padre ya que a los trece años él había perdido a su madre. En el verano del 2011, a la semana de regresar de Villagrán, Tamaulipas a Sebastian, Texas por las vacaciones, mi padre se quejaba de un dolor de cabeza. Mi padre es una persona bien socarrón que su respuesta siempre es no antes de que le preguntes algo. A él no le gusta que alguien le diga qué tiene que hacer o no hacer. Él nos decía – “al rato se me quita este dolor, ya me tomé una pastilla” – para que ya no lo molestáramos. Mi papá no quería ir al hospital después de tantas veces que le decíamos que lo lleváramos. La barrera de la información era también a causa de que mi papá no quisiera ir al hospital. No sabía la ayuda que le podían dar y decía – “yo estoy bien. ¿Qué me puede hacer el doctor? Y también no tengo dinero para andar pagando doctores.” Se quejaba pero nunca nos dejaba que lo viéramos haciendo gestos de dolor. Hasta que mi hermana Marisol dijo – “¡basta ya! Yo te voy a llevar al hospital.” Mi hermana Marisol fue por nosotros a Sebastian y fuimos a Valley Baptist Medical Center en Harlingen, Texas. Mi papá Javier, mamá Francisca, hermana Marisol y yo íbamos temerosos por lo que los doctores nos dijeran. Esa media hora de camino de la casa al hospital fue el más lento de nuestras vidas, rezando todo el camino a nuestro Señor para que mi papito no tuviera nada grave. Le pedí a la Virgen de Guadalupe – “Virgencita, Madre mía, te ruego y te imploro que por tu divina misericordia no desampares a mi papi en estos momentos.” Y ese agosto 9 del 2011, sin saber, era el día que iba cambiar nuestras vidas. Marisol entró al cuatro de emergencias con mi papá porque él no sabe el hablar inglés – no se le requiere en sus trabajos de labor – y ella era su traductora. Marisol me mandó un mensaje diciéndome – “No te asustes, pero calma a mamá. Ella también está enferma del corazón.” Cuando apenas leí eso ya sabía que papá tenía algo grave. Seguí leyendo y más adelante decía – “apá tiene sangre en el cerebro. Dile a mamá pero tranquilícela. Y dile que apá

Language pedagogy and Latino health  157 va a salir bien.” Mis ojos se pusieron llorosos y le tuve que decir a mi mamá que su otra mitad, el hombre con el que ha estado casada por 31 años, tenía sangre en el cerebro. Cerebral hematoma es el término médico de lo que mi padre padecía. Eso causaba que mi padre durmiera en casa casi todo el día y noche y que le diera muy fuertes dolores de cabeza. Después lo movieron a la unidad de cuidados intensivos donde el largo proceso de lágrimas, tristeza, oración y fe comenzó. Mi padre no quería ir al hospital porque no sabía mucho inglés fuera de “good morning” o “thank you” solamente. Mis hermanas y yo éramos sus traductoras. Mi madre se quedaba con mi padre día y noche y nosotras nos tomábamos turnos para que ella descansara también. Era muy duro porque cuando las enfermeras y doctores venían a llevarse a mi padre a ir a hacer exámenes era en la madrugada y mi madre tenía que comunicarse por señas con ellos. Nada más dejaban que una persona se quedara adentro de la unidad de cuidados intensivos y pues mi mamá no sabe inglés. Aparte de la barrera del idioma, el personal médico era bueno. Después de la primera operación que mi padre tuvo, él salió bien. Pero a los dos días, no quiso volver en sí. Los doctores no supieron por qué, así que tuvieron que operarlo otra vez porque según todavía tenía sangre. Después de la segunda operación todo marchaba bien, pero resultó que tenía una infección y tuvieron que operarlo por tercera vez. Había días que mi padre amanecía bien pero otros no. En unos días perdía el movimiento en la parte izquierda de su cuerpo y en otros días la parte derecha. Los doctores nada más nos decían que el caso de mi padre era raro y único, que eso nunca había pasado. Los doctores no se explicaban lo que mi padre tenía porque le preguntaban si se había golpeado la cabeza y mi padre respondía que no. Después los doctores nos preguntaban a nosotras y les decíamos lo mismo, que mi padre no se había golpeado la cabeza. Ellos no entendían porque mi papá tenía sangre en el cerebro sin haberse dado un golpe. Si ellos no sabían, menos nosotras, pues mi padre no nos decía nada. Tuvo tratamiento para recuperar la fuerza de músculo que estaba perdiendo. Le daban tratamiento de habla porque había días que no se le entendía lo que decía. En otoño de 2011 yo no regresé a la escuela porque me quedé en casa de mis padres para poder ayudar a mi mamá en cuidar a mi padre en el hospital. No me lo pidieron. De hecho, mi mamá se preocupaba que iba a faltar un semestre, pero le dije – “lo que importa ahora es papi y ya a la escuela después que se recupere yo regresaré.” En el trascurso de los seis meses mi padre se estaba mejorando. Días antes del Día de Acción de Gracias nos pudimos llevar a mi padre a la casa. Su recuperación de esas tres operaciones fueron un largo proceso pero finalmente se recuperó. Entonces estaba determinada a continuar mis estudios por él. Regresé a la universidad en primavera del 2012. Mi papá siempre me dice – “la educación es la única herencia que te voy a dejar el día que

158  Language pedagogy and Latino health yo no esté aquí.” Esas palabras se me han grabado en mi para que yo siga adelante en mis estudios. Mi padre aconseja a futuros proveedores de salud que aprendan variedad de idiomas para ayudar a esa gente que no entiende, que informen a la comunidad que hay mucha ayuda y que traten a sus pacientes con calidad y amor.1 Story by Palmira Cepeda (Used with permission) Palmira Cepeda shared this story with a class that I taught at The University of Texas Pan American in the spring of 2012. The class, entitled Sociolinguistics and Latino Health, was part of a Medical Spanish program that sought to develop a broad perspective on the intersection of health and language and cultural practices for Spanish speakers who desired to enter the health professions. The emotions that Palmira brought to her story were raw at the time but gave her a perspective that was unmatched among her classmates. Palmira’s description of the ways that language was involved in her father’s plight struck me as particularly insightful. While the presence of language barriers deterred her father from seeking medical treatment immediately and while Palmira and Marisol’s bilingualism also served an instrumental function, the involvement of language in Palmira’s story runs much deeper. Even as it separated the family from needed care, language brought the family together in meaningful ways. Marisol’s words – ¡basta ya!, calma a Mamá, and tranquilícela – animate a deep sense of family commitment and allegiance. Palmira’s words – Virgencita, Madre mía, te ruego y te imploro que por tu divina misericordia no desampares a mi papi en estos momentos – ground the experience in her faith. The dual involvement of language in Palmira’s story reminded me of the opposing views of language adopted by language teachers described by the Modern Language Association’s Ad Hoc Committee on Foreign Languages. The authors of the report stated: Divergent views concerning language and its many functions are reflected in differing approaches to the study of language. At one end, language is considered to be principally instrumental, a skill to use for communicating thought and information. At the opposite end, language is understood as an essential element of a human being’s thought processes, perceptions, and selfexpressions; and as such it is considered to be at the core of translingual and transcultural competence. While we use language to communicate our needs to others, language simultaneously reveals us to others and to ourselves. Language is a complex multifunctional phenomenon that links an individual to other individuals, to communities, and to national cultures. (MLA, 2007) The tension between an instrumental and a constitutive view of language, as described by the authors of the MLA report, has been a mainstay in language teaching for the health professions generally and the teaching of Spanish for Latino health more specifically. In this chapter, we will explore this tension in greater depth as it has manifested itself in language pedagogy for health care. We

Language pedagogy and Latino health  159 will begin by assessing the emergence of Medical Spanish and how its conception was shaped by an instrumental view of language. We will then examine the intersection between Medical Spanish and Languages for Specific Purposes with an eye towards understanding some of the recent transformations in the teaching of Medical Spanish. After reviewing some of the major areas of concern in the teaching of Medical Spanish, we will sketch out some general principles for a forward-looking approach to teaching Spanish for Latino health.

The making of medical Spanish Concern over the health status of Spanish-speaking populations in the United States began as early as the 1920s. Much of the research at the time sought to identify a genetic basis for the higher than normal mortality and morbidity rates encountered in Spanish-speaking communities in the U.S. (Stern, 2005). The public policy response to health disparities in Spanish-speaking populations, as discussed in Chapter 1, often focused on the tightening of surveillance at ports of entry along the U.S.–Mexico border and on mass deportations of Mexicans motivated by public health concerns (Molina, 2006; Mckiernan-González, 2012). The end of the Great Depression, the New Deal, and the rise of Mexican American political organizations, however, put an end to these draconian policies and ushered in a new response to health disparities in Spanish-speaking populations (Sánchez, 1993). The new response was rooted in an ideology of language that at once preserved the elevated status of English and justified an instrumental role for Spanish in U.S. society (Martínez, 2013). The historical roots of medical Spanish In 1929, a group of seven established Mexican American organizations convened in Corpus Christi, Texas to establish the League of United Latin American Citizens (LULAC). For the first time, Mexican Americans were organizing and mobilizing political forces to create a national organization that would advocate for equal access and opportunity. From the outset, the goal of LULAC was “the complete assimilation of Mexicans and their acceptance as equal citizens by Anglo society” (Gonzalez, 2000, p. 103). In aspiring to equality in mainstream Anglo society, Lulacers worked diligently and committed themselves unabashedly to shed the scourge of racial animus against Mexicans through the acceptance and adoption of a thoroughly American cultural identity. Some Lulacers believed that a complete assimilation into the American social mainstream must be accomplished and that Mexican Americans should ‘encourage the conglomeration and blending of races at the expense of distinction. Do as the Gringos do if at all possible. Talk the English language in your homes’. (Márquez, 1993, p. 23) Lulacers felt that if they continued to act like Mexicans, they would continue to be treated like Mexicans. They felt that in order to demand a change from Anglo society,

160  Language pedagogy and Latino health they should meet them halfway. But even though Lulacers adopted English as the official language of the organization and limited membership to United States citizens, they did not advocate a complete abandonment of Spanish. As Mario García (1989) points out, “Spanish symbolized more than culture for Lulacers; it served as a practical tool . . . LULAC could not enforce its own rule that English be used as the organization’s official language” (p. 44). While the official policy was never changed, Lulacers in councils with Spanish-dominant members routinely conducted official League business in Spanish. Furthermore, Lulacers in all councils used Spanish regularly as a way to inform their communities of activities and services sponsored by the League. The use of Spanish as a bridge to the community would turn out to be one of the defining features of LULAC’s strategy to deal with growing health disparities in Mexican communities throughout Texas. The Movimiento Pro Salud was an attempt to respond to health disparities in Mexican communities through collaborations and partnerships with local and state public health organizations. As part of the Movimiento, Lulacers formed committees and sponsored health fairs in cities and towns throughout the state. Health fairs were weeklong events that brought in guest speakers from state and local public health organizations and that touched on a variety of topics in the prevention of disease and the protection of health. In partnership with the Texas Tuberculosis Association, for example, Lulacers in San Antonio sponsored the First Latin American Health Week in 1934. The agenda for the meeting included sessions on “Health from the religious point of view,” “Health and the home,” “Health and the community,” “Tuberculosis day,” “Disease prevention day,” “Health in the schools,” and “General health and clean-up day.” The Movimiento Pro Salud was also active in helping organizations raise funds for the benefit of health promotion activities. Alonso Perales, a San Antonio attorney who was influential within LULAC, served as a key promoter in San Antonio for the sale of National Tuberculosis Association Christmas Seals. Lulacers also lobbied the county division of the Texas Tuberculosis Association to pursue activities that were inclusive of Mexican communities. Finally, they lobbied municipal government to develop and enforce policies and ordinances that would promote the health of Mexicans in the city. The Movimiento Pro Salud soon extended beyond LULAC and came to be led by public health workers affiliated with state and national associations. The foremost proponent of the Movimiento Pro Salud in Texas was Ruben C. Ortega. An ordained Methodist minister educated at Wesleyan College in San Luis Potosí, Mexico, Ortega immigrated to El Paso, Texas to escape the violence of the Mexican Revolution. While serving as an instructor at the theological school of the Methodist Church in El Paso, Ortega observed firsthand the unmet health needs of large numbers of Mexicans throughout the state. In 1918, he began working as a health educator in Mexican communities along the border. By 1920, he had secured a position on the staff of the Texas Anti-Tuberculosis Association. In 1941, he was named Director of Latin American Health Education of the Association. By 1947, he was named Secretary of the Texas Tuberculosis Association and served as a translator for its parent organization, the National Tuberculosis Association. During his 30-year career in public health, Ortega developed a unique approach to health education. Ortega insisted that health messages must

Language pedagogy and Latino health  161 be transmitted in Spanish in a way that people can understand. His commitment to culturally attuned health education led him to considerably diversify his didactic repertoire. In the 1930s, Ortega began publishing the Boletín Pro Salud, a Spanish language periodical dedicated to issues of health and hygiene. In 1939, he wrote the screenplay and was cast in the lead role of the Edgar Ulmer film A Cloud in the Sky. Secondary sources suggest that Ortega also completed a Spanish language novel entitled Bienvenida al Sanatorio, an instructional piece designed to dispel fears of sanatoria treatment among Mexicans. Ortega’s health education strategy was almost as varied as his didactic repertoire. During the 1930s and 1940s, Ortega regularly traveled across Texas giving public lectures and hosting film screenings to crowds as large as 600 people. Ortega also talked to school children and conducted door-to-door house calls to meet individually with families. Finally, Ortega visited high schools and colleges around the state and met with Spanish students in order to engage future generations in health promotion work. Ortega believed in the power of education to reduce the burden of disease among Mexicans. He believed that accurate information transmitted in a way that is understandable would lead to changed behaviors among the Mexicans of Texas. Yet, his concern for accurate and culturally attuned health education was balanced by his equally insistent demand for justice and equity in the distribution of health services. Ortega fought vigorously to increase access to hospital care and medical technologies for Mexican victims of tuberculosis. He also criticized discriminatory treatment upon and after admission to the hospital which included linguistic isolation. Madsen (1964), for example, noted that in south Texas “hospitals would enforce strict rules prohibiting Latin nurses from speaking Spanish on the premises” (pp. 93–94). Ortega’s approach to the tuberculosis epidemic was radically different from the approach previously taken. Whereas prior to the incursion of the Movimiento Pro Salud, deportation and exclusion were the primary means of tuberculosis control, the Movimiento identified language and culture as sites where disease prevention and control could take place. This use of language constituted an instrumentalization of Spanish that at once legitimized the subordinated language and redeemed the pathologized body of the Spanish speaker. The use of Spanish in public places, the printing of Spanish pamphlets and posters, the production of Spanish language films, and awareness building among students of Spanish were celebrated by mainstream English-speaking society because of their ultimate benefit to the health and well-being of all. By instrumentalization I mean that Spanish acquired a practical and legitimate purpose that was seen to benefit society as a whole. The use of Spanish, rather than an aberrant and unwanted interruption in the march towards modernity, had, through the work of Ortega, become a tool that helped to achieve the modernist project. Ortega himself displayed his allegiance to the creed of modernity in his 1941 address. He stated, We, as the servants of the Biblical parable, have been sent out in the highways, streets, and public places to invite the people to enjoy the banquet that the scientists had prepared for suffering humanity. We have even at times forced them to come. (p. 2)

162  Language pedagogy and Latino health The evolution of medical Spanish curricula By the 1970s, the instrumentalization of Spanish rooted in the work of the Movimiento Pro Salud began taking hold at the college level and ushered in the development of courses and materials for the teaching of Spanish to health professionals. In 1972, Julia Tabery, Marion Webb, and Beatriz Vasquez Mueller published a textbook in mimeograph form entitled Communicating in Spanish for Medical Personnel. The book was issued in published form in 1975. In their remarks to the student, Tabery and colleagues spell out their approach to teaching Spanish for medical personnel: “the Spanish structures given are the easiest correct ones for the speaker of English to learn and are selected to teach you to communicate at a basic level” (1975, p. ix). They sum up the ultimate objective of the text as the ability “to communicate with any Spanish-speaking person concerning his basic needs and wants” (1975, p. ix). The book is organized in 41 lessons, each dedicated to an aspect of hospital care. General instruction on the human body, numbers, and hospital policies and protocols is followed by more specific instruction dealing with patient care, maternity, surgery, emergency care, major illnesses, and other ancillary health services. Each lesson is built around a dialogue that exemplifies key features in hospital-based discourse. The opening dialogue for Lesson 20 entitled “Care of the Patient: Emotional Needs” begins as follows:

Table 5.1 Dialogue for addressing emotional needs in patient care New material

Materia nueva

Hospital Patient Are you Yes, I’m comfortable. comfortable? Why are you Because I’m afraid of worried? the operation. I have pain. I’m afraid of the pain

Hospital Patient ¿Está usted Sí, estoy cómodo/a, cómodo/a? gracias. ¿Por qué está usted Porque tengo miedo de la preocupado/a? operación. Porque tengo dolor. Porque tengo miedo del dolor. Porque tengo problemas. Porque no tengo dinero.

Why are you upset?

I have problems Because I don’t have money. Because I don’t have work Because I don’t have family here. Because I have problems. Because I have family problems. Because I have problems at work Because my son takes drugs.

Porque no tengo trabajo. Porque no tengo familia aquí. ¿Por qué está usted Porque tengo problemas. mortificado/a? Porque tengo problemas en la familia. Porque tengo problemas en el trabajo. Porque mi hijo toma drogas.

Language pedagogy and Latino health 163 New material

Materia nueva Because my son is in jail. Because my husband has left me. Because my husband is an alcoholic.

Porque mi hijo está en la cárcel Porque mi esposo me ha abandonado. Porque mi esposo es alcohólico

Source: Adapted from Tabery, Webb & Meuller, 1975, pp. 214–215

The underlined segments in the dialogue represent new structures and were meant to be drilled in order to achieve mastery. The objective was to equip students with basic structures in Spanish to appropriately assess a patient’s emotional needs and to provide the student with potential responses. The project was met with skepticism at the time of its publication. In a summary piece analyzing the mimeographed version of the text published in the journal Hispania, Richard Teschner wondered: “One might question whether fluency could be achieved in thirteen lessons or whether a phrasebook can cover all sickroom situations” (Teschner, 1973, p. 24). Notwithstanding Teschner’s view that the book is not instrumental enough, I would argue that the book set a tone in the teaching of Medical Spanish that over-instrumentalizes the language. The focus on specific forms such as ¿Está usted . . . and ¿Por qué está usted . . . crowds out the impact of the striking predicates included in the dialogue: tengo problemas, no tengo dinero, tengo problemas en el trabajo, mi hijo está en la cárcel, mi esposo me ha abandonado, mi esposo es alcohólico. While the pedagogical material presented equips the student to elicit the information, it provides no instruction on how to interact with the responses. The over-instrumentalization that appears to have been emerging from this early textbook project privileged the informationseeking aspect of language at the expense of intersubjective tactics needed to adequately respond to the information obtained. Despite early criticism of Medical Spanish materials, the development of Medical Spanish programs and textbooks continued unabated through the 1980s and 1990s. In the 1980s, Joanna Ríos developed and implemented an intensive 4-day continuing education course for physicians and other health personnel. The accompanying manual to the Ríos program was not published until 2004 however. It appeared as McGraw Hill’s Complete Medical Spanish. The manual was purported to facilitate “quick learning” of “key Spanish words and phrases.” The quick and simple approach advertised on the book’s cover is elaborated in the authors’ introduction. “You will find that by remembering just a handful of very basic structures, combined with some of the many cognates that exist in the medical field, you will surprise yourself with your ability converse satisfactorily. Above all, keep in mind: do not translate literally and keep it simple” (Ríos & Torres, 2004, p. xii). Unlike the Tabery, Webb, and Mueller textbook, which was structured thematically around hospital-based scenarios, the Ríos textbook follows a traditional format organized around language functions and forms such

164  Language pedagogy and Latino health as greetings, numbers, irregular verbs, possessive adjectives, reflexive verbs, etc. Grammar explanations and exercises consisting of cloze passages, sentence transformations, and form production are followed by dialogues that allow students to observe the grammatical forms in context. The following dialogue appears in the chapter covering reflexive verbs and deals with breast self-examination. Enfermera: ¿Usted se examina los senos en casa cada mes? Paciente: Pues, fíjese que no. ¿Necesito yo examinarme? No sé cómo hacerlo. ¿Puede usted explicarme cómo examinarlos? Enfermera: Claro que sí. Hay tres pasos muy fáciles. Primero, examínese los senos al bañarse. Es más fácil sentir las bolitas o bultos con la piel mojada. Después de bañarse, mírese en un espejo y examínese los senos otra vez. Después, acuéstese y ponga la mano izquierda, para tocarse el seno derecho. Use las yemas de los dedos para buscar bolitas o bultos. Mueva las yemas de los dedos alrededor del seno. Luego, use la mano derecha para examinarse el seno izquierdo . . . así. Luego apriétese los pezones, suavemente, para ver si hay una secreción o desecho. Paciente: ¿Cada cuando debo examinarme los pechos? Enfermera: Debe examinarse después de su regla, no antes. Paciente: ¿Y si ya no baja la regla por cambio de vida . . .? Enfermera: Si ha tenido la histerectomía o está en la menopausia, debe hacerlo el primero de cada mes. Paciente: Y si encuentro algo, ¿qué hago? Enfermera: Llámenos para hacer una consulta. Su doctora va a examinarle más detalladamente. Paciente: Gracias, señorita. Creo que entiendo ahora. Voy a comenzar a examinarme cada mes. Muchas gracias y hasta pronto. Enfermera: Por nada, señora, cuídese mucho y que le vaya muy bien. (Ríos & Torres, 2004, pp. 223–224) While the dialogue illustrates the grammatical form in multiple contexts within a real-life scenario, it also over-instrumentalizes by drawing a narrow focus on the form. As with Tabery’s dialogue, there is little room in this dialogue to explore the cultural subtext that shapes the use of grammatical forms. For example, the concept of fatalism which is commonly invoked in discussions of cancer screening and prevention is strikingly absent from this dialogue. While sociocultural information is present in the book, it tends to be isolated in footnotes and in the final chapter of the book (Hardin, 2012, p. 706). In 1990, Teresa González-Lee and Harold Simon published a new book on medical Spanish that made a significant effort to include a richer cultural component within language instruction for healthcare professionals. The textbook titled Medical Spanish: Interviewing the Latino Patient endeavored to develop oral proficiency within a rich context of intercultural issues. The text introduces basic vocabulary and grammatical structures while familiarizing the reader with

Language pedagogy and Latino health  165 cultural issues in healthcare such as folk health beliefs, the ethical dimensions of intercultural communication, and Latino perceptions of mental health. Even so, the text maintains the mantra of a quick and simple approach. “Pre-clinical students,” the authors remark, “have achieved proficiency in Medical Spanish after one year or less of classroom, language laboratory, and clinical instruction” (1990, p. ix). The book is structured around the discursive genre of the medical interview. It opens with a review of medical terminology focusing on anatomy, symptoms, and diseases. It then covers interviewing techniques and the different parts of the medical interview. It concludes with a chapter on intercultural communication dealing with cultural aspects of health and medicine and the intersection between culture, communication, and ethics. This book represented a giant leap forward in the teaching of Medical Spanish inasmuch as it included a rich cultural focus that drew student attention to cultural beliefs and perspectives and to multiple dialectal and sociolectal variants used by Spanish speakers. While the textbook made use of dialogues and role play activities, it expanded these activities to include case studies that would allow students to reflect critically on the totality of the language examples presented. The following case study from the text stands out: Un paciente latino ingresa en la sala de emergencia de un hospital por la noche. Viene con los síntomas de la enfermedad de Hodgkin, en estado muy avanzado ya. La familia lo acompaña y trata de hacer todas las decisiones por él. Confrontados con la forma de consentimiento para internarlo al hospital, no desean que el paciente se entere de la gravedad de su enfermedad e impiden que el paciente lo firme. El personal médico de emergencia se frustra, porque se encuentran en conflicto con un sistema cultural muy diferente. Sus limitaciones son de origen lingüístico y cultural, porque no conocen la lengua española y los valores culturales. Tampoco hay intérpretes en el turno de noche, agravando la falta de comunicación. (González-Lee & Simon, 1990, pp. 176–177) The case study is followed by questions for critical appraisal of the situation including: What cultural barriers are present in the consent process? What is the cause of cultural conflict between the Latino patient and the medical personnel in the hospital? The use of case studies and the creation of opportunities for critical reflection was a significant advance in the teaching of Medical Spanish that had not been common in earlier textbooks. Notwithstanding the innovative contributions of the text, its reception at the time also came under fire. A review of the textbook in 1991 criticized the text due to the extent of “Anglicisms and other semantic encroachments” and because of its presentation of Latino cultural beliefs as “primitive” (Iglesias, 1991, p. 165). Hardin (2012), on the other hand, noted that the text “omits grammar, requiring students to learn basic language rules from other sources” (p. 704). In 1998, Robert O. Chase and Clarisa Medina de Chase published a new Medical Spanish textbook titled An Introduction to Spanish for Health Care Workers:

166  Language pedagogy and Latino health Communication and Culture. Similar to the González-Lee and Simon book, this text elevated cultural knowledge and understanding in the development of proficiency in Spanish. As noted in subsequent reviews of the book, it broke away from previous books in its adoption of theoretically informed communicative language teaching techniques (Marcé, 2010). In the introduction to the book, the authors argue: “the crucial precepts of the book are context and communication. Vocabulary is organized by specific medical themes” (Chase & Medina de Chase, 2003, p. xxii). This contextual approach is evident in the organization of the text. The book consists of 12 chapters covering both the immediate and the more distant context of medical encounters. For example, it contains chapters dealing with greetings and introductions, assessing the chief complaint, the physical exam, and medical history taking which are situated in the immediate context of the provider-patient interaction. It also contains chapters dealing with intermediary contexts of interaction that include the receptionist, the family, the pharmacy and hospitalizations, dentistry, and mental health. Finally, it covers cultural topics such as maternity, food and nutrition, and safer sex. Cultural notes are sprinkled throughout the text dealing with specific cultural values such as confianza, cultural beliefs such as nervios, and cultural practices such as the preference for starchy vegetables in Spanish-speaking communities. The authors make clear from the outset that the book is not intended to replace the use of medical interpreters. “Health care providers who want to learn Spanish in order to communicate directly with their patients, to perform specific assessments or procedures in Spanish, or to express empathy by crossing the border of language will find a rich foundation of knowledge and experience in this book” (p. xxi). The authors thus approach the teaching of Medical Spanish from a more nuanced perspective than previous textbook authors. Rather than promising quick and effective results, they stress that a course in Medical Spanish is a beginning rather than an end and that the achievement of fluency in Medical Spanish will require continued practice, further coursework, and immersion in a Spanish-speaking community or country. The authors conclude their introduction with a short vignette that captures their ultimate objective in writing the book. They write: Barbara, an emergency room nurse enrolled in a medical Spanish class, was brave enough to speak in Spanish to a frequent patient who had never admitted to understanding any English. The patient responded to Barbara’s simple Spanish in broken English. The kindness and determination of the nurse instilled in the patient the courage to use the smattering of English she had learned. More than laughter and words, they shared empathy and understanding. (p. xxiii) Chase and Medina de Chase thus focus more on a relational objective than a linguistic objective in the teaching of Medical Spanish. This focus significantly broadened the perspective of Medical Spanish pedagogy beyond language

Language pedagogy and Latino health  167 acquisition objectives and created an opening for a more nuanced view of language that surpassed the naïve instrumentalism that pervaded earlier textbooks. The ¡A Su Salud! program, developed in the University of North Carolina at Chapel Hill’s School of Medicine, was published in 2005. ¡A Su Salud! is a complete program including an instructional, dramatized telenovela on DVD and a comprehensive workbook. The program was innovative in its targeting of intermediate level learners and its integrative approach that included grammar, vocabulary, and culture. It emphasized the teaching of language in context and a unique focus on the Spanish spoken in the United States. In their note to students, for example, the authors warn that “geographic origin, educational level, social class, age, time in the United States, and living conditions are some of the many factors that can influence the type of Spanish you’ll hear” (2004, p. 1). The book also integrates cultural knowledge with communicative practices in novel ways. In a note to students, the authors of the workbook state: “language and culture are interconnected, not independent of one another. Meaning and understanding are derived from many sources, such as existing beliefs and practices, and knowledge of these factors is imperative if you truly wish to communicate effectively” (2004, p. 79). Following this statement, the authors go on to introduce folk beliefs in medicine and to explain the various ways in which these beliefs shape communication. They urge the student “to ask your patients and clients what they believe caused the illness and what they believe will cure it. As you suggest your own theory and prescribe treatment,” they continue, “ask if they are taking other medications or teas or if they are being treated by a family member, curandero, espiritista or other type of traditional healer” (2004, p. 79). In her review of the book, Pilar Marcé writes that “by integrating Spanish language instruction in the context of public health care and Hispanic immigrant culture, this course makes learning Spanish meaningful and useful to the student” (2007, p.  498). Hardin (2012) coincided with Marcé in her assessment of the integration of vocabulary into the DVD materials but lamented the “significant amount of explanation and commentary in English” (p. 702) as well as the inattention to pragmatic concepts that are critical in medical communication. Karol Hardin (2012) conducted a groundbreaking review of 18 Medical Spanish textbooks published between 1990 and 2012 (the review includes the books by Ríos and Torres, González-Lee and Simon, Chase and Medina de Chase, and ¡A Su Salud! described in the previous paragraphs). Her review analyzes seven factors in each textbook including: 1) targeted level of proficiency, 2) vocabulary, 3) oral and aural activities, 4) grammatical concepts, 5) cultural beliefs and sociolinguistic information, 6) pragmatic concepts, and 7) real-world situations. Her findings reveal several shared characteristics between the textbooks. She argues, for example, that the textbooks seem to share an emphasis on beginning Spanish including basic grammatical concepts and vocabulary. Additionally, she finds that vocabulary is typically presented in dictionary or reference book format lacking any significant meaningful communicative or practical activities. Finally, she observes that cultural concepts are typically presented in a decontextualized fashion that obviates more basic cultural notions relating to medicine. She cautions

168  Language pedagogy and Latino health that the corpus of instructional materials available may engender “the false belief that beginning textbooks assure students enough proficiency to adequately communicate and that learners will no longer need to use interpreters” (2012, p. 709). She concludes by offering seven recommendations that should guide the creation of new textbooks and teaching materials going forward. First, she contends that the targeted level of proficiency should reach at least the intermediate level. Second, she recommends organizing vocabulary around relevant medical themes and presenting it in contextual questions, answers, and dialogues rather than in isolated lists. Third, she advocates for more oral communicative activities. She reasons that while traditional Spanish instruction privileges reading and writing, given the goal of moving students into the study of linguistics, literature, and cultural studies, Medical Spanish instruction should privilege oral communication since students who use Spanish in health care contexts will need to talk and listen more than they need to read and write. Fourth, she advocates presenting grammar as recycled concepts and providing meaningful opportunities for students to interact with the grammatical forms. Fifth, she contends that cultural and sociolinguistic information should be presented at each level of instruction and should be related to a wider set of cultural values and beliefs. Sixth, she emphasizes the need for injecting pragmatic information into the curriculum through the presentation of information about politeness, professionalism, levels of directness and formality, and mitigation strategies. Finally, she advocates for the use of authentic situations including the use of simulated role-play activities. Hardin’s article presented the state of Medical Spanish pedagogy with a level of clarity that had not been perceived before. It also set the stage for a more collaborative and evidencebased approach to curriculum development moving forward. At the same time, her insights began to bring Medical Spanish into conversation with the wider field of Languages for Specific Purposes.

Languages for Specific Purposes Language for Specific Purposes (LSP) emerged in the 1960s as a subfield within the teaching of English. English for Specific Purposes (ESP) was primarily a needs-focused approach to the teaching of English. Hutchinson and Waters (1987) captured the ESP approach in their well-known phrase: “tell me what you need English for and I will tell you the English you need” (p. 8). The first theoretical articulation of ESP/LSP was profferred by Halliday, McIntosh, and Strevens in their 1964 monograph The Linguistic Sciences and Language Teaching. In this seminal work, Halliday and his colleagues argued for the need to establish an adequate descriptive empirical basis for the teaching of languages. The basis they identify, which later developed into an independent theory of language known as systemic functional linguistics, describes language not as a system of rules (following the dominant structuralist paradigm of their day), but rather as a resource for meaning making. The empirical basis for language teaching, in other words, ought to be oriented “to speakers’ meaning potential (what they can mean) rather than neurologically based constraints on what they can say” (Halliday & Martin,

Language pedagogy and Latino health  169 1993, p.  22). The theoretical principles and practical applications of the ESP approach were later adopted within the wider field of language teaching giving rise to LSP. Shaping the LSP agenda According to Grosse and Voght (1990), the increasing popularity of LSP in language teaching can be explained by three separate emerging desires in the field. First, there was a desire to promote language teaching to groups of students with diverse interests. In other words, LSP helped to diversify the pool of language learners. Second, there was a desire to expand the curriculum beyond the traditional focus on literature. Scholars with interests in linguistics and cultural studies, for example, saw a need to prepare students to do more with language than read the major works in the language’s literary cannon. As Long (2017) notes: In LSP courses and programs, the categories of texts and situations being analyzed have expanded beyond literature, increasing sources of cultural information and paving the way for the critical tools of textual and discourse analysis to be applied to influential contemporary texts and discourses generated by a broad array of private, governmental, and non-governmental institutions that seek to direct global views and practices. (p. 3) And thirdly, there was a desire to inject humanities perspectives into disciplines that lay outside of the liberal arts. Scholars were keen on infusing humanistic perspectives in professional fields that had long divorced themselves from the foundational disciplines of a classical liberal arts education. Long (2017) again notes: “LSP courses and programs offer students applied knowledge and skills related to professional domains while at the same time helping them to develop the critical thinking skills and deep cultural knowledge that are at the heart of the traditional humanities education in language and literature” (p.  3). In line with these emerging desires, Doyle (2012) conceives of LSP within a tripartite curricular structure consisting of 1) the integration of professional knowledge, 2) the use of the language in the professional domain, and 3) knowledge of the culture of target language speakers. The wider view of LSP advocated by Doyle can be seen in the various accents present in the definitions of LSP formulated by different scholars. Hyland, for example, defined LSP as “a distinctive approach to language education based on identification of the specific language features, discourse practices and communicative skills of target groups and on teaching practices that recognize the particular subject matter needs and expertise of learners” (cited in Brown & Thompson, 2018, pp. 100–101). Arnó-Macía, on the other hand, suggested that LSP focuses on “the learner’s need to participate effectively in the target academic or professional community” (cited in Brown & Thompson, 2018, pp. 100–101). Finally, Lafford contended that LSP serves “to prepare language students for the practical application of their L2 in professional environments”

170  Language pedagogy and Latino health (cited in Brown & Thompson, 2018, pp. 100–101). These definitions all share a focus on student needs. Hyland circumscribes those needs to “specific language features, discourse practices and communicative skills” while Arnó-Macía and Lafford adopt a more encompassing approach to needs rooted in concepts such as “effective participation” and “practical application.” The variety of emphases and accents in the definition of LSP has caused some scholars to speak about an “LSP agenda” rather than simply LSP in order to stress the healthy variation in the field and to highlight its evolving nature. Gollin-Kies, Hall and Moore (2015), for example, write: The LSP agenda is to characterize the ways in which language is used in specific contexts by specific groups for specific purposes, to explore the extent to which language use in such contexts is stable, to examine the role of language in establishing, maintaining and developing group values and self-identification, and to identify and evaluate the means by which people can become proficient in using language in specific contexts for their own specific purposes, and can graduate to membership of their target group or groups. (pp. 17–18) By proposing a wider LSP agenda, Gollin-Kies and colleagues signal the growing potential of the field while consolidating the various accents found in previous definitions. The expansion of LSP to Spanish occurred initially in the field of business with the impetus of the U.S. Department of Education’s Title VI Centers for International Business and Education. Some of the earliest collected volumes on Spanish for Specific Purposes (SSP) were exclusively or primarily devoted to the teaching of Spanish for business contexts (Voght, 1984; Fryer & Guntermann, 1998). In the 2000s, however, building on a solid foundation of theoretical and practical insights, SSP began to consolidate other professional fields that had been emerging independently for some time. As Carol Klee observes: “in the U.S., the development of courses in Spanish for the Professions resulted in part from the desire to diversify the curriculum and attract more students to the study of language as well as the push to internationalize the curriculum” (2015, p. 187). In addition to these internal factors, however, demographic changes in the U.S. fueled by the settlement of Spanish-speaking communities in all 50 states and the pressures placed on immigrant-serving organizations served as an external factor that bolstered SSP. These external factors led practitioners to embrace an expansion of SSP to include health care, social work, education, and law – all under the rubric of the LSP agenda. The expansion of the LSP agenda The inclusion of Medical Spanish within the LSP agenda exposed it to a series of theoretical and practical interrogations that had not been fully addressed in the past, and it connected Medical Spanish to practices and approaches that were

Language pedagogy and Latino health  171 already commonplace in LSP. As it came into greater dialogue with LSP, Medical Spanish was exposed to a more nuanced and theoretically informed view of language itself. The view of language adopted by LSP, rooted in the linguistic theories of the British linguist M. A. K. Halliday and the Russian linguistic Valentin Voloshinov, contends that meaning making is the object of analysis in linguistics and that the making of meaning involves the synergistic interaction of both words and contexts. Bennett (2003) explains that for Voloshinov: the proper concern of linguistics should be to establish a typology of speech genres which would explain the peculiar mode of the refraction of signification of reality they effect with reference to the social conditions of socioverbal interaction, themselves contextualized within the framework of the wider social and political relationships which underlie and produce them. (p. 66) The emphasis on context, including register and genre, in LSP’s view of language has made a significant impact on the understanding of how Spanish is used in health care settings. LSP also offered Medical Spanish a different view of purpose in language teaching and learning. While the audio-lingual method approached the teaching of language from the perspective of rote memorization, the communicative method abandoned this approach and focused instead on teaching students to negotiate meaning in the new language through a variety of language functions. LSP coincides with the communicative method insofar as it focuses on the negotiation meaning, but it differs because the functions targeted are not decided on by the teacher or the curriculum but rather by the students themselves. Finally, LSP offered a nuanced view of specificity in language teaching. In particular, it perceives a gradation from more to less specificity in language teaching. Johns (2006) signals the more specific end of the spectrum when she states: “central to LSP pedagogy must be the determination of the unique characteristics of each teaching/learning situation, and the exploitation of these characteristics for development of syllabuses, of classroom activities, and of evaluation and assessment” (p. 684). At the other end of the spectrum, we find LSP courses designed for broad fields such as business, the health professions, human services, etc. Brown and Thompson (2018) point out the shortcomings of these more wideangled approaches to LSP. They consider the fact that the teaching of Spanish for Business typically focuses on import/export processes and procedures, customs forms and interactions, preparation of contracts, taxation, and supply chain management. They point out, however, that in the globalized economy many of these processes are typically carried out in English, the lingua franca of the business world. In developing specificity in this way, they argue, Spanish for Business may be obviating one of the most significant areas where Spanish is presently used in commercial contexts, such as marketing and customer service to Spanish-speaking populations in the United States. The unique and nuanced view of language, purpose, and specificity in LSP has engendered foundational practices and approaches. The most important of these is the practice of needs analysis. Needs analysis is the

172  Language pedagogy and Latino health process of discovery of the specific language needs of students. Fundamentally, it consists of describing various facets of language and learners in order to ensure a responsive curriculum. Language description consists of a micro-analysis of language use in a specific discourse, rhetorical analysis of texts associated with the discourse, and analysis of professional registers. Learner description consists of an assessment of the existing levels of proficiency of students, identification of specific skills to be developed, evaluation of degree of professional knowledge, student motivation, and student learning styles. In addition to the description of language and learners, needs analysis may also explore existing curricular materials and the availability and characteristics of available teachers (Basturkmen, 2006). In addition to practices such as needs analysis, LSP also advocates for unique approaches to issues of disciplinarity and interdisciplinarity. As LSP has carved out a space for itself in between a purely instrumental approach to language and a more constitutive approach typical of that found in language departments, it has defined itself as a kind of interdiscipline that merges the specific bodies of knowledge of a professional field with the perspectives of language and culture that are brought to light in the academic disciplines of languages and literatures. In doing so, it harmonizes profession-specific knowledge with more global sociolinguistic and cultural perspectives. Michael Doyle’s now classic textbook for Business Spanish, Exito Comercial, begins with a quote from a Latin American economist that says: “si los bienes no cruzan las fronteras, los soldados las cruzarán.” This quote summarizes Doyle’s approach to teaching the particularities of Business Spanish within the context of the wider discipline of Spanish. Teaching business professionals to interact productively across national borders will promote world peace. In this way, Doyle brings the interests and desires of the wider field of Spanish into harmony with the particular task of teaching Business Spanish. LSP thus strives to situate its pedagogical practice within larger disciplinary interests and desires that reside outside of the professional domain and that reflect the humanities traditions in which language study is embedded. These uniquely LSP perspectives, practices, and approaches have had a singular impact on Medical Spanish from the late 1990s well into the new millennium. In the next section, I will describe how these LSP perspectives, practices, and approaches have been integrated into Medical Spanish.

Medical Spanish and LSP The convergence of the LSP agenda on Medical Spanish has shaped both curricular contents and teaching methodologies. At the same time, it has engendered thorny questions that remain to be satisfactorily answered. The unanswered questions have emerged in part from the diverse contexts in which Medical Spanish has been deployed – from undergraduate education, to professional schools, to residency programs, to continuing medical education. What is the appropriate learning outcome of Medical Spanish instruction? What level of proficiency is required to provide health services in Spanish? Prior to delving into the specific innovations in Medical Spanish that have emerged from its interaction with the

Language pedagogy and Latino health  173 wider LSP agenda, however, it would be useful to consider the diverse array of educational contexts in which Medical Spanish has been embedded. The diversity of medical Spanish programs Hardin and Hardin (2013) conducted a literature review of articles describing Medical Spanish programs between 1977 and 2012. The 25-year search turned up articles that reported on the process or outcomes for 23 Medical Spanish programs. Of these programs, six were undergraduate programs housed in language departments and schools of nursing, nine were graduate level programs housed in schools of medicine, pharmacy, nursing, and physician assistant studies, five were residency programs housed in hospitals or schools of medicine, and three were continuing medical education programs housed in hospitals, schools of medicine, and area health education centers. While the analysis of the articles found that there was little uniformity between the programs and that the results reported for each program were not fully comparable, it put a spotlight on the diversity of programs across educational contexts and the tendency of programs to concentrate at the post-graduate level. A follow up article (Hardin, 2015) expanded the list of programs to include eight undergraduate programs, 17 health-related graduate programs, and seven residency programs. These data confirm the distribution previously adduced with the vast majority of programs existing at the post-graduate level. A national survey of Medical Spanish curricula at medical schools in the U.S. (Morales et  al., 2015) provided further information on the nature of postgraduate level programs. The authors found that 66% medical schools surveyed offered a Medical Spanish curriculum, while 32% of those that did not offer the curriculum planned to do so within two years. Schools that offered a Medical Spanish program were located throughout the country and there was no association between the prevalence of Spanish speakers in the state or region where a medical school was located and the existence of Medical Spanish curricula. The most common reasons that medical schools reported for developing Medical Spanish curricula were 1) the growing Spanish-speaking patient population and 2) student interest. While the majority of schools employed faculty members to deliver the Medical Spanish curriculum, some schools used medical students with advanced proficiency and other schools hired an outside firm to deliver instruction. A  little over half of the schools surveyed indicated that course credit was awarded for completing the curriculum, while the remaining schools offered other kinds of credit, such as a notation on the student’s transcript or inclusion of program completion in the dean’s letter of recommendation for residency programs. Together, these articles point to a wide diversity in the objectives and implementation of Medical Spanish programs. They also coincide on the need to develop evidence-based best practices for Medical Spanish programs that will deliver a uniform curriculum in a more standardized way in order to ensure comparable outcomes among health professionals. Recent efforts are addressing these needs including the creation of a U.S. Medical Spanish Taskforce consisting of medical educators, bilingual health care providers, language educators, and language

174  Language pedagogy and Latino health access professionals. The Task Force has set out to develop core Medical Spanish learner competencies and an associated core curriculum, to standardize learning objectives and student performance expectations, and to assess Medical Spanish learner skills through observed structural clinical encounters (Ortega et al., 2019). The diverse educational contexts in which Medical Spanish instruction occurs has generated concern over the continuity of curricula across the health care education pipeline. Programs in post-graduate schools have struggled to identify students with adequate base language proficiency to successfully complete the programs (Morales et al., 2015; Chaterjee et al., 2015; Frasier et al., 2005; Valdini et al., 2009). Programs in undergraduate language departments, on the other hand, are generally limited in terms of the health care contexts to which their students can be exposed. The articulation of Medical Spanish programs between undergraduate education, professional training, and lifelong learning is indeed a pressing need in the field. Karol Hardin envisions what an articulated program might look like: At the undergraduate level, instructors should focus on achieving the highest level of oral and aural proficiency possible; ideally, offering community service-learning opportunities for intermediate and advanced students. They can emphasize crosscultural awareness through role play and discuss cultural scenarios that build a background understanding.  .  .  . Graduate schools in health fields can then build on this awareness and skill level to tailor courses to their more specialized needs. Finally, better post-graduate and CME programs should be offered to increase the proficiency base for current nonbilingual practitioners and to complement the work of interpreters. Curricula for Spanish for medicine must be focused, ongoing and collaborative. (2015, p. 654) Hardin thus envisions a robust partnership that will avoid the current trend where programs at different levels operate independently of one another and move towards a longintudinal pathway where students are continuously exposed to meaningful opportunities to use the language in scenarios that are consistent with their professional preparation. Needs analysis in medical Spanish and pedagogical innovation Needs analysis is a cornerstone principle of LSP which has been gaining ground in the development of the Medical Spanish curriculum. Lear (2005) presented a formal needs analysis of Spanish for working medical professionals based on interviews with English-speaking health professionals working with Spanishspeaking patients at four public perinatal clinics in the U.S. midwest. All participants had previous experience with Spanish through formal instruction at the high school level, continuing education classes, travel abroad or various combinations of these. Her findings revealed that participants were most interested in developing adequate reception skills. All of the participants were more satisfied with their speaking abilities than they were with their listening skills. They were particularly

Language pedagogy and Latino health  175 concerned with their ability to listen appropriately in telephone conversations with Spanish-speaking patients. In addition, they were concerned with developing strategies to create with the language rather than depending on fixed scripts. A similar finding was uncovered in Bloom’s needs analysis of undergraduate students in a nursing program (Bloom, Timmerman & Sands, 2006; Bloom, 2004). Her findings indicated that students were more interested in developing strategies for circumlocution around medical concepts instead of developing specific medical terminology in Spanish. She also points out that students were interested in developing strategies to compensate for misunderstanding in oral interaction with Spanish-speaking patients. In light of these identified needs, Bloom points out that learners must deal with an inherent tension in learning Medical Spanish that pits the goal of linguistic perfection, so often coveted in the foreign language classroom, against the real and pervasive need for effective communication. The needs analysis approach adopted from LSP infused Medical Spanish with new perspectives that would shape both teaching methods and curricular content. Hardin and Hardin (2013) argue that Medical Spanish curricula should “prepare students for substantive patient communication” (p. 310) through the use of doctor-patient role play and simulated patient exams rather than writing Spanish essays on diseases. They argue that a focus on substantive patient communication will address these needs in ways that more traditional literacy-focused instruction does not. The focus on substantive patient communication has carved out a space for multiple innovations in teaching methods in Medical Spanish. Alstaedter (2017), for example, argues that Medical Spanish courses should take a “communication oriented, learner centered approach that goes beyond teaching of specialized vocabulary and expressions and instead engages students in moving more seamlessly among the three communicative modes (interpersonal, interpretive and presentational)” (p. 52). Role play and simulation have been key elements that have emerged in this approach (Garavalia et al., 2017; BenavidesVaello, Stevens & Vines, 2014; Copeland et al., 2011; Reuland et al., 2008). The use of role play and simulation in the Medical Spanish classroom can serve both interpretive and productive ends. Role play and simulation can range from more controlled to less controlled. More controlled role play consists of students reading through and acting out clinical scenarios following a script based on authentic conversation. These more controlled approaches offer students an opportunity to verbalize key linguistic forms and to imagine themselves as part of a clinical conversation. Moving along the cline from more controlled to less controlled, the use of digital voice boards can offer the student an opportunity to create their own response to a specific question or observation in the context of a clinical encounter. Martínez, Menon, and Szalacha (2019) report on the use of a digital voice board to develop conversational skills for nurses to appropriately respond to brief prompts that might occur in a diabetes counseling session. The following is an example of the prompt used and student responses: 1 2

Prompt: Cada vez que me toca ir con el doctor me da mucha vergüenza porque no logro cuidarme bien.

176  Language pedagogy and Latino health 3 4 5

Student: Gracias a usted por hablar de sus sentimientos difíciles. Es importante saber que no está solo en sus sentimientos. Mucha gente que tiene algun tipo de enfermedad siente frustración también.

The prompt illustrated here offers the student an opportunity to display empathy by externalizing the patient’s frustrations when going to the doctor. In the student’s response there is a clear identification of the frustration and a series of statements that acknowledge and respond to it. This type of role play and simulation offers the student greater opportunities to create with the language. Finally, observed structured clinical evaluations (OSCEs) have been used to provide the least controlled environment. In an OSCE, the student is paired with a standardized patient, typically a trained actor, who is given a minimal script. The script will contain information about the chief complaint, information on the history of the disease, demographic and family information, as well as cultural and linguistic cues to insert in the conversation. The student, on the other hand, receives a brief summary of the patient’s condition, a review of the patient’s previous interactions with the clinic, e.g., whether it is an initial or a follow-up visit, and a series of lab results and other biometric information. OSCEs typically take place in a laboratory setting with a room that looks like a typical exam room. The room is equipped with cameras and microphones for recording the interaction as well as a two-way mirror that allows instructors to observe the interaction in real time. Benavides-Vaello, Stevens, and Vines (2014) conducted a qualitative interpretive descriptive study to assess perceptions of the use of simulation in a Spanish for Healthcare Professions course by 28 students from a variety of disciplines including nursing, pharmacy, medicine, and speech and hearing sciences. While the students found the experience to be nerve wracking and anxiety provoking, they also recognized its value as a real-world experience. The experience, moreover, increased confidence among students. The authors report that confidence “was related to a student’s ability to recognize his or her limitations and to the ability to speak Spanish, even if limited, with patients” (p. e173). Copeland et al. (2011) similarly report on the use of simulation in a Medical Spanish course in a surgical clerkship. Students in the course were divided into three groups based on their previous exposure to Spanish. Group 1 had minimal knowledge of Spanish, Group 2 had two or more years of college level Spanish, and Group 3 were fluent and/or native speakers. The study showed that all groups benefited from simulations but that students in Group 2 showed the greatest gains in terms of the benefit of the exercise and its usefulness in communicating with Spanish-speaking patients. Curricular content has also been impacted by the convergence of Medical Spanish on the LSP agenda. As early as 1991, Keith Mason argued for an approach to Medical Spanish that would move away from the elementary level courses that were common at the time and that instead would introduce Medical Spanish at the advanced level targeted specifically to Spanish majors. Mason reasoned that such an approach could “bring students to a level of functional proficiency

Language pedagogy and Latino health  177 that is both needed and desired” (1991, p. 452) and that it would also open the curriculum to new and different content including “complex issues such as sociolinguistics, culture, dialectal variation, and ethical factors as well as emotional and psychological needs for communicating effectively” (p. 452). Mason’s call was an early indication of convergence between Medical Spanish and the LSP agenda. As Medical Spanish continued to move into the orbit of the LSP agenda, however, more specific recommendations began to emerge. Belpoliti and Pérez (2016), for example, report on instruction for advice giving in Medical Spanish. Direct advising speech acts can occur in imperative, performative or declarative constructions. Conventionally indirect advising speech acts can occur in formulaic questions, conditional structures or impersonal expressions. Finally, indirect advising speech acts can occur as general statements or as personal examples. Table 5.2 demonstrates examples of each type of advising speech act. The authors demonstrate how these advising speech acts can be taught in the Medical Spanish classroom. They first present the different types of advising speech acts through contextualized examples from movies, TV advertisements, and segments of interviews with native speakers. Exposure to advising speech acts was then followed by analysis and classification. After students had demonstrated mastery of the linguistic forms, the authors incorporated the speech acts into a variety of role plays and simulations. “Students had to recommend the same course of action (reduce sugar intake) to patients of diverse ages and were expected to select the appropriate forms of address in each case” (p. 138). Finally, the students were placed in a service learning experience where they “assisted nonSpanish speaking health professionals in communicating the results of glucose, blood pressure, cholesterol screenings, etc. to Hispanic clients; they also offered advice on prevention strategies while reviewing education pamphlets provided by different organizations” (pp.  138–139). Belpoliti and Pérez thus provide a comprehensive example of how pragmatic content can be incorporated into an

Table 5.2  Advising speech acts in Spanish Type of advising speech act

Linguistic construction

Example

Direct

Imperative Performative

Haz x/No hagas x Sugiero que/Recomiendo que/Aconsejo que Debes/Necesitas/Tienes que ¿Qué tal si . . .?/¿Por qué no . . .?

Conventionally indirect Indirect

Declarative Formulaic questions Conditional structures Impersonal expressions General statements Personal example

Source: Adapted from Belpoliti & Pérez, 2016, p. 130

Yo en tu lugar . . . /Yo que tú Es importante que tú Hacer ejercicio ayuda a bajar de peso Estoy caminando todos los días una hora para bajar de peso

178  Language pedagogy and Latino health undergraduate Medical Spanish curriculum (Hardin, 2012). Lusk et  al. (2014) describe a clinical social work course taught fully in Spanish and demonstrate how this course allowed them to introduce additional new content into the Medical Spanish curriculum. They report specifically on the incorporation of dichos and refranes as a way of “conveying folk wisdom and connecting a present clinical situation with a long-standing cultural tradition of oral history” (p.  447). They also describe the discursive genre of testimonio and describe its use in mental health evaluation and intervention. “The testimonio or life story,” they argue, “can be a particularly effective way of giving voice and meaning to a deeply felt personal experience” (p. 447). Hardin (2017) argues that pragmatic and sociolinguistic information can be meaningfully taught in the Medical Spanish curriculum through the use of authentic dialogue. She demonstrates how video recordings of clinical encounters between Ecuadorian doctors and patients were successfully used for teaching pragmatic concepts, negotiation of meaning, and culturally implied information. The videos alert students to the different voices (the Doctor voice, the Educator voice, and the Fellow Human voice) that the doctor employs in engaging the patient, to the variety of dialectal variants and colloquial expressions used in the encounter, to the linguistic embodiment of cultural perspectives, and to the shaping influence of social, political, and economic contexts in clinical conversations. The introduction of pragmatic and sociolinguistic content in the Medical Spanish curriculum more fully prepares students for “substantive patient communication” (Hardin & Hardin, 2013). Medical Spanish and language assessment Notwithstanding the impact that the LSP agenda has had on Medical Spanish in terms of teaching methodology and curricular content, significant questions remain unanswered. The issue of specific learner outcomes enrolled in Medical Spanish courses continues to be a hot-button issue for a number of reasons. While it is known that language concordant care results in improved patient satisfaction and health outcomes, there is uncertainty as to the degree of language proficiency needed to achieve the benefits associated with language concordant care. In fact, concern over adverse effects of partial language concordance abounds. As Diamond and Jacobs (2009) note: “in the case of language, a little proficiency can be a dangerous thing” (p. s190). The major concern is that health care providers will rely on inadequate second language skills, forego the use of professional interpreters and thus unwittingly reduce meaningful access to care while increasing health disparities. Diamond and Reuland (2009) expressed the concern specifically: “physicians with low levels of general Spanish proficiency who develop medical Spanish skills are unlikely to be able to engage in health communication that requires linguistic nuance, such as clarifying understanding or engaging in shared decision-making” (p. 427). The potential for reducing access and increasing disparities becomes even more alarming when we consider that the characterization of language proficiency in health care settings has been nebulous, and that the measures of proficiency have been largely subjective rather than objective.

Language pedagogy and Latino health  179 While subjective measures of proficiency are generally viewed with suspicion by applied linguists, self-rating of language skills has been the norm in health care for some time. Research on the correlation of self-rating with other measures of patient satisfaction, in fact, has shown that when physicians self-rate their language ability as high, patients tend to highly rate the physician’s elicitation of and responsiveness to problems and concerns (Fernandez et al., 2004). The value of self-assessment, however, has been linked to the specific characterization of language skills. The characterization of language proficiency using nebulous terms such as “fluent,” “bilingual,” or “survival skills” has been shown to impact selfrating of proficiency. Diamond et al. (2012), for example, reported on the impact of a change in the characterization of language proficiency in a multispecialty health care organization in northern California. The authors describe the results of a change in language proficiency characterization from a non-validated and undefined three-category tool to a tool based on the Interagency Language Roundtable (ILR) scale and adapted specifically for physicians. The non-validated tool consisted of three categories to describe language proficiency: 1) basic, 2) medical/conversational, and 3) fluent. Definitions of each category were not provided. The ILR-based tool, on the other hand, consisted of five categories with in-depth descriptions that included both general and physician-specific characterizations of language abilities. The levels identified were: 1) poor, 2) fair, 3) good, 4) very good, and 5) excellent. Each level was described using both general and health care specific terms. For example, “poor” was described as “satisfies elementary needs and minimum courtesy requirements. Able to understand and respond to a 2- to 3-word entry-level question. May require slow speech and repetition to understand. Unable to understand or communicate most health care concepts” (p. 560). “Excellent” was described as “speaks proficiently, equivalent to that of an educated native speaker, and is skilled at incorporating appropriate medical terminology and concepts into communication. Has complete fluency in the language such that speech in all levels is fully accepted by educated native speakers in all its features, including breadth of vocabulary and idioms, colloquialisms, and pertinent cultural references” (p. 560). When physicians were presented with the new tool, 75% of them decided to update their language proficiency self-rating. The category on the non-validated tool that was most likely to be revised was the “medical/conversational category” and physicians who spoke two or more nonEnglish languages were more likely to lower their self-reported proficiency rating as compared to the non-validated tool, especially when one of those languages was Spanish. Even while the modification of language proficiency characterization has been shown to improve self-reported proficiency ratings, the desire to move from subjective forms of assessment to more objective forms remains. Objective assessment of English language proficiency for health care personnel wishing to practice in an English-speaking country have been the norm for years (McNamara, Knoch & Fan, 2019). Advocates of language credentialing in health care argue that a similar process should be implemented for professionals who desire to provide direct care to patients in a language other than English. O’Rourke and Gruener (2014) make

180  Language pedagogy and Latino health the point forcefully when they write: “our desire to help patients by speaking Spanish could be harming them through our unwitting language errors” (p. 531). McNamara, Knoch, and Fan (2019) argue that all language tests are subject to two different kinds of evaluation: justice and fairness. “This distinction,” they write, is intended to help us understand that even a test that was as fair as it could be made to be, carefully designed, validated, its areas of weakness identified and remedied as far as was humanly possible, might still involve issues of justice in the very fact that it is used at all, for example, as serving a misguided or discriminatory policy. (p. 19) Justice criteria thus refer to external factors such as the social and policy environment from which the mandate for the test emerges. Fairness criteria, on the other hand, refer to the internal factors such as the validity and reliability of the test itself. The argument for objective assessment of proficiency in languages other than English in health care is rooted in considerations of justice. Objective assessment of Spanish language proficiency, advocates argue, will provide an empirical basis upon which to infer probable success in effectively communicating with Spanish-speaking patients. These inferences, moreover, will protect patients, enhance safety, and reduce medical error. But a focus on criteria of justice does not categorically favor the implementation of language credentialing exams in health care. Justice considerations also require that we give attention to the impact of credentialing exams on the ecology of language in health care organizations. King de Ramírez and Martínez (2018), for example, reported on Latina nurses in a Phoenix area hospital that had implemented a language credentialing program. Their conclusions point to an unintended consequence of making these heritage language professionals feel inferior about their language skills and to fear the consequences of illicitly using their language to help patients. O’Rourke and Gruener (2014) describe the implementation of a language credentialing policy at a hospital in Chicago. They describe the changing ecology as follows: We saw the true power of the certification as we witnessed a transformation in the culture of our medical center to one with a heightened commitment to providing language concordant care to patients with limited English proficiency. Staff now challenge Spanish-speaking providers who do not display certification identification tags. Likewise, staff who previously relied on ad hoc interpreters have become strong proponents of staff and phone interpreters. (p. 532) While O’Rourke and Gruener spin the change as positive, I am reluctant to concur. I wonder, for example, who those staff members are who are challenging providers and who the providers are who are being challenged. Is there a bias against heritage language professionals? Does the credentialing system reflect another

Language pedagogy and Latino health  181 mechanism to reproduce the inequalities and prejudices that exist in society at large? While O’Rourke and Gruener do not provide answers to these questions, the fact that they can be justifiably raised points to the reality that the justice of a language test does not exist in a vacuum, but rather interacts with social and political considerations. In addition to considerations of justice, language credentialing in health care can also be evaluated through a focus on fairness. Is the instrument or test used to make inferences about a candidate’s performance to adequately provide services in Spanish fair to its users? The fairness of a language test is often assessed by considering its validity. In general, the concept of validity is used to assess whether a test actually measures what it intends to measure. Language testing scholars recognize several facets of validity. Face validity refers to the acceptability of the test to those involved in its development and use. Content validity probes a little deeper asking the extent to which the test content is relevant to the inferences made about the potential future performance. Construct validity questions whether the test instrument itself actually measures the underlying ability or trait desired. Consequential validity focuses on the consequences of a test. For example, does the introduction of the test change the way that people are prepared to take the test? If so, this could threaten the validity of the inferences made based on the results (McNamara, 2000, pp. 50–54). Finally, cultural validity “positions cultural and linguistic diversity as integral to test design” (Schissel, 2019, p. 144). Cultural validity seeks to uncover biases in the test emerging from the intersectional minoritized status of a segment of test takers. Language credentialing in health care raises numerous questions with regard to validity. To what extent are existing proficiency tests valid predictors of success in providing patient care in the language tested? The ILR scale, mentioned earlier, for example, was developed with foreign service officers in mind. Thus, the highest level on the scale describes the “excellent” speaker as one who “has complete fluency in the language such that speech in all levels is fully accepted by educated native speakers in all its features” (Diamond et al., 2012, p. 560). While this criterion may be valid for foreign service officers who are constantly interacting with educated native speakers in order to fulfill their job functions, it may be less valid for health care professionals who are interacting with speakers who do not fit that description. Proficiency rating scales such as the American Council on the Teaching of Foreign Languages (ACTFL) Oral Proficiency Scale typically stratify ratings based on ability to complete a given function in the language. A superior speaker on the ACTFL scale, for example, is described as able to discuss their interests and special fields of competence, explain complex matters in detail, and provide lengthy and coherent narrations all with ease, fluency, and accuracy. They present their opinions on a number of issues of interest to them, such as social and political issues and provide structured arguments to support these opinions. They are able to construct and develop hypotheses to explore alternative possibilities. (ACTFL, 2012)

182  Language pedagogy and Latino health An intermediate high speaker on the same scale “can narrate and describe in all major time frames using connected discourse of paragraph length, but not all the time” (ACTFL, 2012). The scale is thus designed to mirror the process of language acquisition following a specific syllabus where mastery of narration and description precedes mastery of hypothetical discourse. Applying a scale such as this to health care can present threats to content validity. Isaacs et  al. (2011) conducted a study of nurses who provide services to linguistic minority patients in a second language and found that the most difficult tasks dealt not with hypothetical discourse but rather with emotional aspects of caregiving and conveying health-specific information. To the extent that these are the most difficult speech tasks for nurses, they should be represented at the higher end of the proficiency scale. Finally, cultural validity may be threatened to the extent that existing scales are applied to Latino health professionals who identify as heritage language speakers. Valdés (1989) pointed out the biases against Latino students inherent in the oral proficiency movement. She asks: “Will a Chicano student, for example, who uses the pluperfect subjunctive rather than the conditional perfect in contrary to fact conditions be rated down in comparison with his less fluent but more ‘accurate’ non-native peer?” (p. 400). The application of existing proficiency measures to health care contexts thus presents validity threats at a number of different levels. The issues related to fairness in language credentialing in health care have been addressed in the field through the development of context-specific assessments. Tang et al. (2011) describe the development of the Kaiser Permanente Clinician Cultural and Linguistic Assessment (CCLA). The CCLA was designed to measure “communicative competence” in a health care setting. The authors define communicative competence as follows: “the ability to meaningfully and accurately understand and produce the target language in a medical setting in a culturally appropriate way” (p.  205). Inspired by the framework developed years earlier by Michael Canale and Merrill Swain, the authors define various components of communicative competence that the test is designed to measure. These components are summarized in Table 5.3. In addition to the objective components of communicative competence described in Table  5.3, the CCLA also assesses subjective measures including ­fluency – “the ease with which a candidate can produce native-like target ­language, including the degree of hesitation, the clarity of speech sounds, and the appropriate use of rhythm, stress and intonation” (p.  206); pronunciation – “the degree of target language phonology, accent and related comprehensibility” (p.  206); customer service – “the ability to make medical issues and concepts accessible to the patient” (p. 206); and cultural proficiency – “the ability to recognize and respect the patients’ expressed beliefs. It also includes comprehension of idiomatic and colloquial speech” (p. 206). The exam consists of four sections covering sociocultural competence, symptoms, diagnoses and treatment, explaining medical information, and taking a medical history (NCITRP, 2012). Text Box 5.1 illustrates a sample question from the CCLA exam.

Language pedagogy and Latino health  183 Table 5.3  Components of communicative competence Communicative competence component

Description

Grammatical competence

If a doctor can use grammar to construct meaning, then the individual has a degree of grammatical competence. If a doctor can use language effectively in a logical and connected way to persuade or explain, he or she is demonstrating discourse competence. If a doctor can adjust his or her style of speaking according to the age, gender, or educational status of a patient and use culturally appropriate language, then he or she can be said to possess sociolinguistic competence. If a doctor describes a procedure but does not have the terminology in Spanish, he or she can be said to be using strategic competence.

Discourse competence Sociolinguistic competence

Strategic competence

Source: Adapted from Tang et al., 2011, p. 206

Text Box. 5.1  Sample item from the CCLA-S Exam (Adapted from NCITRP, 2012, p. 24) Direcciones: Su paciente es un hombre de 27 (veinte y siete) años, a quien han atendido por lesiones recibidas en un accidente automovilístico y ha venido para una cita de seguimiento. Su esposa fue herida seriamente en el mismo accidente. Después de escuchar los comentarios de su paciente, vamos a pedirle que le comunique cierta información importante. Ahora escuche a su paciente: Doctor, hoy vine porque me duele el pecho y no puedo moverme bien. También vengo porque las pastillas que me dio no sirven y el dolor me está matando. Y aparte, quería preguntarle por mi querida esposa. ¿Usted cree que va a salir de esta? Estoy mortificadísimo y rezándole a Dios que no se la lleve. Ahora comuníquele lo siguiente directamente a su paciente: 1

Assure him that his wife is2 stable and that she is responding nicely to the surgery she had to repair her broken arm.

184  Language pedagogy and Latino health 2

Ask him if his sprained ankle is causing him pain and tell him to only engage in activity as tolerated. 3 Ask him if the swelling has subsided and if he has been running a fever. 4 Tell him that, after examination, you believe his fractures have begun to mend and that with some time his abrasions will also heal. 5 Tell him you a giving him new prescriptions for a muscle relaxant, and something to relieve the pain. 6 Tell him that if these drugs don’t take care of the pain in his leg, to call the office.

The rating of the exam is conducted independently by two qualified and trained raters. Upon completion of the independent rating, the raters identify differences in the assessment of each scoring unit and come to a consensus. The CCLA stratifies candidates in three bands classified as low-proficiency, medium-proficiency, and high-proficiency. Both criterion and content validity were assessed in the development of the test. Criterion validity was assessed by comparing the mean number of objective errors in each proficiency band. Content validity, on the other hand, was established using a diverse group of constituents including physicians, linguists, health care interpreters, health administrators, and legal representatives (Tang et  al., 2011, p.  207). It is worth pointing out, however, that one important stakeholder left out of the content validation process are Spanish-speaking patients themselves. How would a patient perspective contribute to the content validity of the instrument? Studies to determine the cultural and consequential validity of the CCLA, to my knowledge, have not yet appeared. Even so, there is a need to understand whether biases emerge in the rating of candidate produced utterances. For example, how are stigmatized linguistic forms assessed in the rating of specific scoring units? In Text Box 5.1 the word “swelling” is identified as a scoring unit. Do raters treat the use of the Spanish words inflamación and hinchazón in the same way? What considerations are taken into account in the consensus-building efforts of raters? There is also a need to evaluate the consequences of the implementation of the test. Are certain physicians systematically excluded from credentialing based on biases in the test? Does the test shape behaviors in any specifiable way? These are questions that remain unanswered in the validation of a health care specific test like the CCLA. In this section, we have reviewed some of the major contributions that the LSP agenda has made to Medical Spanish teaching. We considered the influence of LSP in enhancing the teaching methodologies of Medical Spanish to include role-playing, patient care simulation, and community service learning. We further considered the influence of LSP in generating new curricular content such as a focus on pragmatic features of the language including advice giving and the use

Language pedagogy and Latino health  185 of dichos, refranes, and testimonios. Finally, we considered an area of potential influence for LSP which has not yet come to fruition: the assessment and credentialing of Spanish for use in health care settings. We analyzed the many problems in relation to the justice and fairness of using already-existing proficiency measures to indicate competency in Medical Spanish and we presented a health care specific exam pointing out both the strengths and weaknesses in its validation. In what follows, we will close the chapter by drawing on the LSP agenda to question the specificity of Medical Spanish. Are we really teaching Spanish for medical purposes in any context or are we, instead, attempting to teach Spanish for medical purposes in the specific context of the U.S. Latino population? If the answer is the latter, how does that shape our approach to teaching? In short, what would the teaching of Spanish for Latino Health look like and how would it differ from the teaching of Medical Spanish that currently exists?

Teaching Spanish for Latino Health Practitioners who commit to teaching Medical Spanish and students who enroll in such classes share an underlying concern to address health inequities. Teachers and students sense the ways in which language contributes to inequities and they take intentional steps to remedy those inequities by expanding access and improving communication for Spanish speakers. Throughout this book, I have sought to describe the multiple ways in which language impacts and interacts with health. Language, in policy and in practice, is intimately involved in health and health care experiences. This involvement occurs on at least three different planes related to 1) knowledge of health and risk, 2) relationships with health care providers, and 3) resiliency generated through family and community allegiances. Medical Spanish, as currently conceived however, addresses primarily the first plane while the remaining two tend to be left unattended. By shifting the approach from Medical Spanish to Spanish for Latino Health, I am seeking to broaden the pedagogical objectives of Medical Spanish teaching to encompass these other crucial areas of language involvement in health care. I will first describe three theoretical insights  – health/communicative inequities, ethical listening, and translanguaging – and then proceed to explain how these insights can be profitably applied to the teaching and learning of Spanish for Latino Health. Health/communicative inequities in Spanish for Latino Health Health inequities and communicative inequities are seen to be distinct but related aspects of inequality. The general perception has been that communicative inequity, for example limited English proficiency, is a precursor or determinant of health inequity. It is the lack of language access that generates an inequity that otherwise would not exist, or at least not to the same extent or with the same consequence. Other options for understanding the relationship between communicative inequity and health inequity exist, however. The syndemic approach, for example, holds that comorbidity is more than a simple stacking of infirmities

186  Language pedagogy and Latino health one atop the other. Rather, the syndemic approach holds that diseases and the structural conditions that determine them all interrelate and affect one another in dynamic ways (see Chapter  1 for a more in-depth discussion). Briggs and Mantini-Briggs (2016) adopt the syndemic approach as they relate communicative inequity to health inequity. They introduce a new term coined “health/communicative inequality” that understands the relationship between the two as mutually reinforcing. “We go beyond simply looking at both communicative inequities and health inequities,” they explain, “to analyze how they emerge simultaneously, one powerfully shaping the other and often exacerbating its effects” (p. 2). By linking health and communicative inequities in this way, they lead us away from the concept of causation (communicative inequities cause health inequities) and draw us toward the insight of co-production. “Health/communicative inequities are coproduced in clinical encounters, epidemiological investigations, media coverage and the development of health policies” (p. 2). This insight has deep implications for the teaching of Spanish for Latino Health. Hardin (2015) argues that Medical Spanish curriculum should include discussions of traditional medicine, etiologies, and explanatory models of illness, sociolinguistic and politeness norms in health situations, and health-related cultural values and beliefs (p. 656). Diamond and Jacobs (2009), moreover, contend that information on the contribution of language barriers to health disparities is essential and should include a review of the growing literature as well as descriptions of salient cases (p. s190). These recommendations certainly contribute to a broader understanding of health/communicative inequities, but they fall short of engendering the critical perspective that is needed to engage a broadly syndemic understanding of the intersection of Spanish and Latino Health. Instead, they could be presented through the lenses of critical epidemiology and Latin American Social Medicine (Briggs  & Mantini-Briggs, 2016) in order to highlight the ways that these topics may in themselves be imbricated in larger patterns of health/ communicative inequities. Krieger (2011), for example, notes that the scientific registers used to describe health disparities and inequities are often implicated in the very structures of knowledge control that generate and sustain disparities. Latin American Social Medicine further contributes to this line of thought by recognizing the reduction of “a multiplicity of subjectivities and forms of knowledge to the singularity of the scientific rationality of professionals, thereby overlooking the subjectivities of patients, their relatives and others, and their contributions to knowledge” (Briggs & Mantini-Briggs, 2016, p. 228). In teaching Spanish for Latino Health we must strive to expose students to these multiple subjectivities and forms of knowledge in order for them to recognize, address, and remedy health/communicative inequities. While consideration of cultural perspectives of disease, in-depth analysis of scientific literature, and critical appraisal of detail-rich case studies can help to make these multiple subjectivities visible to students, the development of medical terminology in Spanish can also provide an opening to introduce concepts of health/communicative inequities. I  advocate an approach to the development of medical terminology in Spanish that is grounded in Systemic Functional Linguistics and guided by a

Language pedagogy and Latino health  187 genre-based instructional approach (Colombi, 2009). SFL, as discussed earlier, holds that linguistic structure is a consequence of language use. Genre-based approaches, on the other hand, hold that for students to apprehend and acquire specific linguistic structures, they must be made active participants in the contexts of their use. Exposure to medical terminology may be achieved through a linear sequence of texts unified by a single medical theme but extending over a variety of genres. The genres represented within the sequence of texts are spread out along the continua of oral/written, personal/impersonal, and concrete/abstract language. An example from a lesson on tuberculosis in Figure 5.1 illustrates the progression of discourse that exposes students to a single medical topic over a variety of genres along these different continua. Instruction through a multi-generic thematic unit is designed to expose students to the different ways in which illness and injury are articulated in Spanish discourse and representative of different health/communicative subjectivities. The initial text draws on routine experience and colloquial language to describe the specific health issue. The intermediate text represents a more scientific approach to the issue that is still accessible to a lay audience. The most advanced text draws on more abstract discourse to discuss scientific aspects of the issue. Exposure to these different genres allows students to perceive the health issue from multiple perspectives and to develop a wide variety of linguistic resources to use when talking about the health issue in Spanish. Ethical Listening, testimonial justice and raciolinguistic perspectives in Spanish for Latino Health Anna Brady, a medical student at the Lerner College of Medicine, wrote a reflection piece on her experiences caring for Spanish-speaking patients on rounds in the Cleveland Clinic. She concludes her reflection: “Spanish is a language; medical Spanish is not. Medicine has its own language, its own words, and its own ideas. Yes, I speak Spanish, but to ensure that my patients understand me, and I them, takes time and effort in any language” (2010, p. 128). Brady’s reflection not only underscores the import of health/communicative inequities in our understanding of Spanish for Latino Health, but it also points to a second critical insight. Spanish for Latino Health is not simply about transferring medical words, ideas, and recommendations from English into Spanish; it is rather a process through which relationships are made and nurtured, through which inequities are addressed and remedied, and through which justice is sought and applied. As Brady says: “it takes time and effort.” Time and effort in language study is normally taken to mean the individual exertion made to reach perfection and mastery; the exertion to speak flawlessly and to erase the perception of non-nativeness. This bias towards speaking, towards the learner’s performance, in language teaching is part of a larger logocentric system of culture (Fiumara, 1990) in which speaking, enunciating, and articulating are the primary means of displaying rationality and in which listening, acknowledging, and assenting are always secondary. This system of culture has certainly infected both theories of language acquisition and

Figure 5.1  Thematic clusters in a unit on tuberculosis

Language pedagogy and Latino health  189 models of language teaching. From behaviorist theories to mentalist theories, language acquisition is described primarily in terms of what a learner does and is able to do in the process of acquiring a language. The incontrovertible evidence for language acquisition is production in speech. Vivian Cook, for example, lamented that “listening does not even figure as a topic in most introductions to L2 learning” (1996, p. 77). Listening in language acquisition is often reduced to “input” and as such prioritizes the individualistic notion of comprehension over and above the intersubjective notion of listening. Cook lists the processes involved in listening as access to words, parsing, and memory processes and cognition (pp. 77–78) – all focusing on the comprehension of input and not on the establishment of relationships. As comprehensible input, the language material listened to becomes a model that can later be applied in an output. In this way, then, when listening is treated as input, it becomes subservient to output. Even sociocultural approaches to language acquisition, which stress the shared and collaborative nature of learning, wind up giving an undue priority to the individualistic notions of speaking and comprehension. The zone of proximal development (Vygotsky, 2012) is what the learner can achieve with the help of another. The presence of the other, however, always centers on the performance of the learner. Language teaching methodologies, then, tend to follow in the same footsteps of the logocentric system of culture grounding instructional technique and pedagogical objectives in comprehension and speech production rather than in intersubjective listening. Ramirez (1995) draws out the helpful distinction between transactional and interactional interpersonal communication. Transactional communication refers to situations where one interlocutor is trying to get something from another. Interactional communication, on the other hand, focuses on the establishment and maintenance of interpersonal relationships. Listening in the language curriculum, unfortunately, has been more focused on the transactional than on the interactional. The impact of the logocentric preference in language learning and teaching is significant indeed. As Fiumara put it: “when western knowledge tries to frame the entire world and its history by making use of the power that basically emanates from the voice of our rationality then, perhaps, an excessively logocentric culture emerges in which there is no longer any room for listening” (p. 19). In order to address the health/communicative inequities that engulf Spanish speakers in the U.S., teachers and learners of Spanish for Latino Health must overcome this preference for comprehension/speaking and give due attention to listening. Listening is a fundamental part of the relationship building and nurturing role that is essential in speaking Spanish in health care. As Hans Georg Gadamer writes: “anyone who listens is fundamentally open. Without this kind of openness to one another there is no genuine human relationship. Belonging together always also means being able to listen to one another” (cited in Fiumara, 1990, p. 8). This type of listening involves not mere comprehension of words and sentences, but instead demands a level of deep understanding that engages the thoughts, experiences, and expectations of the other. This type of listening is lacking in current approaches to the teaching of Spanish for Latino Health and is sorely needed for it to fulfill its core objective. Listening for relationships, listening as a path to

190  Language pedagogy and Latino health openness, is primarily an ethical act. When listening to others we are presented with a matrix of choices. We can choose to listen selectively – to hear only what we want to hear. We can choose not to listen – even while hearing we suppress any meaningful interaction with what is heard. We can choose to listen together – drawing on the act of hearing as a communal practice that knits us together as a community. These choices construct and constitute us as ethical listening subjects (Beard, 2009). Once constituted as an ethical listening subject, we are then in a position to draw on the listening faculty to promote ethical social relationships and to pursue testimonial justice. Miranda Fricker (2007) defines testimonial justice as doing right by someone in their capacity as a knower. Testimonial justice is acknowledging the right of a person to know while believing and treasuring the knowledge that they convey without prejudice and free of stereotypes. An ethical approach to listening in the service of testimonial justice helps us to uncover and contextualize raciolinguistic hierarchies that envelop communication in Spanish in health care contexts. The raciolinguistic perspective refers to a co-naturalization of language and race that “involves accounting for the modes of perception though which bodies are parsed in relation to racial categories and communicative forms . . . construed in relation to named language varieties” (Rosa, 2019, p.  7). A  move towards placing an emphasis on listening in Spanish for Latino Health, then, requires that we elevate the ethical dimensions of listening, bring in to focus the testimony, the stories, the evidence, the feelings of those with whom we engage in Spanish, and contextualize both the heard and the spoken within the array of raciolinguistic hierarchies that situate Spanish speakers in the U.S. It is not just about understanding the surface level words and sentences articulated, but instead it is about understanding and empathizing with the full experience being conveyed through those words. In fact, listening for relationships is primarily a way of being humble, a form of cultural humility (see Chapter 1). It is a way of suspending our preconception and our prejudices in order to see from the perspective of the other. And in this sense, it is one of the most important skills to cultivate in Spanish for Latino Health. Role play and simulation (Hardin, 2015; Ortega et al., 2019) are surely effective means to enhance listening skills in Spanish for clinical conversations. However, to cultivate ethical listening, testimonial justice, and engagement with raciolinguistic hierarchies, I think we need to expose students to additional experiences that will provide opportunities for nuanced observation and self-reflection. Martínez and San Martín (2018), for example, draw on a digital narrative project to provide an opportunity for Medical Spanish students to engage with testimonies of health inequity in their communities. The project required that students collect, analyze, and interpret a lived experience of language barriers in health care. The students were asked to identify a person who had suffered an illness or injury in the United States and who did not speak English well. After identifying their subject and obtaining consent, students conducted a formal interview in which they collected information about the person’s biography, the illness, the treatment, the effects and the physical and emotional impact of not speaking English. Based on this information, students were then required to write a two-page synthesis of the

Language pedagogy and Latino health  191 illness narrative. The synthesis consisted of 1) biographical data, 2) identification and explanation of the illness, 3) experiences in the health delivery system, 4) impact of those experiences, and 5) a critical assessment or evaluation of the story from the student’s point of view. Upon completion and revision of the synthesis, students then proceeded to collect photos, music, video, and the recorded narration of their synthesis in order to create a digital story. The stories that the students created reflected a serious and solemn process of ethical listening. Students understood the primary goal of the digital story to be to recognize and honor the courage and endurance of their interviewee and thus they were committed, above all, to ensuring that they conveyed the full meaning of the interviewee’s experience. The stories also reflected a desire to promote testimonial justice. Students understood that, in many cases, the digital story was the only means through which the voices of those who had been silenced by not knowing English could be heard. Finally, the stories provided an opportunity for reflection based on a raciolinguistic perspective. In their narratives, students astutely recognized how language and race were co-naturalized through multiple processes of discrimination, subordination, and erasure. At times, these moments of insight led to critical reappraisal of their own thinking. The following comment reflects this reappraisal: During the class we talked about compliance to doctor’s orders. I’ll be honest. I used to always blame the patient for not adhering to doctor’s orders. But, is it always the patient’s fault? I see how hard my mother tries to adhere to the doctor’s orders in order to help my sister. But, as is often the case with non-English speakers, she is unable to receive the respect necessary to carry out the orders. (Martínez & San Martín, 2018, p. 121) At other times, these moments of insight led students to identify specific health/ communicative inequities in the health delivery system. The following comment reflects this kind of identification: Con aproximadamente un 93% de la población latina e hispanohablante, es realmente una lástima que en El Valle haya tanta necesidad de doctores capacitados no sólo en medicina sino en lenguaje y cultura para darles a los pacientes un cuidad de calidad. (Martínez & San Martín, 2018, p. 121) Digital storytelling and the recovery of community-based testimonies is one way to promote ethical listening, testimonial justice, and raciolinguistic awareness in the Spanish for Latino Health classroom. Other strategies have proven equally effective. One of the texts that I  require in my Spanish for Health Care course at The Ohio State University is Danielle Ofri’s powerful memoir Medicine in Translation: Journeys with my Patients. In this book, Ofri chronicles her experiences caring for a multilingual patient population at Bellevue Hospital in New York City. Her memoirs chronicle moments of misunderstanding, frustration,

192  Language pedagogy and Latino health and most importantly, of deep love for her patients. These moments of Ofri’s life are situated within a larger story of language learning including brief courses in New York City, prying telephone conversations with interpreters, and a oneyear immersion experience in Costa Rica. Ofri shows how her language learning fundamentally changes her both as a doctor and as a human being as she begins to relate in different ways to her patients. The use of this text in the classroom exposes students to a unique perspective on using Spanish in health care settings, but more importantly it encourages them to reflect on their own language learning experiences. One of the assignments that I typically ask students to complete in connection with this reading is to narrate their own experiences of learning and using Spanish in a health care setting. The stories that students tell always fascinate me. The following quote exemplifies some of the discoveries that students make as they reflect on their own experience: I was shadowing a physician assistant who worked in orthopedics and was surprised to learn that an interpreter would be joining us for several of the appointments. One couple, who only spoke Spanish, had combined appointments with the PA because they both needed knee replacements. I stood in the corner and tried to unobtrusively observe. As the PA was talking, the wife looked over at me and asked, “¿Ella es estudiante?” Even though the wife directed the question to the interpreter, my one meager semester of Spanish had taught me enough to respond. “Sí,” I said. Suddenly both the husband and wife had huge smiles and began talking excitedly. I have no idea what they said, but they seemed very happy. After the appointment, the interpreter came and thanked me for speaking Spanish to them. I was completely amazed that one tiny word could have such an impact. Providing students structured opportunities for reflection affords them a space to talk about their own experiences as a language learner and to reconsider and reframe the relationships that they have built through Spanish. The student’s knee jerk reaction to blurt out “sí” had a profound impact on her experience and this activity gave her an opportunity to articulate it. She concludes her reflection as follows: “I hope that someday I will be able to repay the many people, patients, and teachers who contributed to my understanding of Spanish and encouraged me to keep learning by gently correcting and being patient with my mistakes. I hope to show future patients that I value their history and language.” In my experience, the use of reflection is another strategy that develops ethical listening, testimonial justice and raciolinguistic awareness in the Spanish for Latino Health classroom. Translanguaging and Spanish for Latino Health Translanguaging is a third theoretical insight that informs the teaching of Spanish for Latino Health. García and Wei (2014) define translanguaging as follows: Translanguaging refers to the act of languaging between systems that have been described as separate, and beyond them. As such, translanguaging is

Language pedagogy and Latino health  193 transformative and creates change in interactive cognitive and social structures that in turn affect our continuous languaging becoming. Finally, in its transdisciplinarity, translanguaging enables us as speakers to go beyond traditional academic disciplines and conventional structures, in order to gain new understandings of human relations and generate more just social structures, capable of liberating the voices of the oppressed. (p. 42) Translanguaging, therefore, is as much about speaking as it is about listening. Sayer (2013) reminds us that “a translanguaging lens is less focused on language per se, and more concerned with examining how bilinguals make sense of things through language” (p. 84). In this way, then, translanguaging is not only about drawing freely on all linguistic resources at one’s disposal but also about tolerating ambiguity and working towards new understandings of human relations and relationality. It is about challenging borders and boundaries that separate one named language variety from another – whether that be English and Spanish, Standard Spanish and Vernacular Spanish, etc. – as producers of language. But traversing the borders and spanning the boundaries of named languages, in totality, requires more than simply the productive act. It also requires the receptive act. How do we welcome the border crosser and boundary spanner? Do we extend a helping hand or do we reinforce boundaries? In this way, translanguaging practices contribute to the development of new understandings of human relations. Creese and Blackledge (2015) perceptively note that “translanguaging in the classroom can engage learners through identity investment, transforming relations of power” (p. 33). The tolerance of ambiguity engendered through the transformation of relations of power is essential in the listening for relationships goal of Spanish for Latino Health. Students of Spanish for Latino Health need to be prepared to be challenged in their understanding of cultural values, linguistic expression, and structural determinants of health/communicative inequities. The practice of translanguaging offers precisely these opportunities. It challenges our preconceived notions of linguistic and identity boundedness and stasis and allows us to recognize the fluid and mobile nature of meaning and the languages that contain and convey them. Rachel Bloom-Pojar (2018) proposes a rhetorical account of translanguaging in order to make sense of identity investments and transforming relations of power in a Medical Spanish international service-learning experience in a medical mission to the Dominican Republic. The rhetorical approach that she adopts affords her the ability to analyze translanguaging phenomena from a collectivist perspective. She assesses interactions between Spanish L2 (second language) learner health professions students, local Dominican ayudantes provided by the nonprofit organization sponsoring the trip, and rural Dominican patients. She notes: by drawing on each group member’s linguistic resources, a collective approach to rhetoric can be even more powerful and effective for the varied linguistic and cultural needs of specific audiences. By coming together, individuals can

194  Language pedagogy and Latino health translanguage in innovative ways that may provide new insights into solving problems and pursuing shared goals. (p. 22) The study thus highlights the rhetorical negotiation of different Spanishes on the field and documents the transformative power of these negotiations. The transformation engendered by translanguaging practices can be seen in Andrew’s assessment of helping patients fill out an intake survey. He observes: In a clinical setting in which we’ve been in this program, I mean there’s kind of a whole ‘nother vocabulary there to learn with the medical Spanish, and so, and that’s maybe some stuff that the campesinos don’t know that vocab, and so having to explain stuff like that to them is difficult. . . . I think a lot of it is kind of reading facial expressions and body language and if you can sense they don’t get it, asking, like, ‘did you understand all that?’ and then trying to . . . to put it in, I don’t know, more laymen’s terms, so to speak. (p. 67) Andrew signals here a transformation not only of his view of Spanish and medical Spanish but also of the import of those views in real and consequential relationships. Bloom-Pojar argues that experiences such as those described by Andrew can be assessed in three different ways. First, experiences of translanguaging in the clinic challenged and inverted language ideologies (see also Martinez & Schwartz, 2012). Learners found themselves questioning “standard” and “correct” forms of language that had been stressed in Spanish language classrooms in the U.S. Ayudantes, on the other hand, relished their brokering roles that extended well beyond what Roman Jakobson once called interlinguistic translation. Second, experiences of translanguaging engendered a deep awareness of translation spaces as learners, ayudantes, and patients negotiated meaning around communication, both written and oral. Translation spaces are less about interlinguistic equivalence and more about building and sustaining mutual understanding. Translation spaces force the interlocutor to analyze “the listener’s verbal and nonverbal expressions to recognize when they have found common ground to understand the topic at hand” (Bloom-Pojar, 2018, pp. 61–62). The challenging of language ideologies and the cultivation of translation spaces through translanguaging, moreover, created a context for relationship building. Translanguaging is not simply a communicative tool, but instead is a framework for further association, collaboration, and collective identity. María, one of the ayudantes in Bloom-Pojar’s study, succinctly describes the generative power of translanguaging: “En la mañana trabajamos y en la tarde siempre no(s) podemos(s) compartir todo(s) junto(s) dominicano(s) y americano(s)  .  .  . jugamos mucho y siempre vamos a los río(s). Que muy ­divertido . . . cocinamo(s) junto(s); comimo(s) junto(s)” (p. 90). The “parallel monolingualism” (Heller, 1999) that is elevated and cultivated in the L2 classroom reflects systems of communication unto which speakers are to succumb in exchange for being fully understood. In doing so, we give up

Language pedagogy and Latino health  195 the abundance that is ours in the range of linguistic resources that we possess. McKnight and Block (2010) describe in detail the limiting effects of systems, not only in communication, but in our community lives more generally. Systems are rational organizations of elements designed to deliver a specific good or commodity. As McKnight and Block point out, moreover, systems always say to us: you are inadequate, incompetent, problematic, or broken. We will fix you. Go back to sleep. It is, in the final analysis, our inadequacy, incompetence, problems, and brokenness that require system intervention in the first place. They contrast system-thinking with what they call associational life. “Associational Life,” they write, “begins with a group of people who are drawn together for some reason, and that reason is what makes it work” (Kindle Location, 1233). Associational life is the practice of coming together voluntarily to achieve a collective end. As people engage in associational life, they become more connected, more accountable to one another, and their gifts, rather than their deficits, are emphasized. If parallel monolingualism encases speakers in systems, translanguaging opens them up to associational life. By inserting translanguaging practices and sensibilities into Spanish for Latino Health, we are not only disciplining students in the practice of drawing on all their linguistic resources, but we are also inviting them into associational life with their future patients. The study abroad and community service-learning approaches that have been identified as best practices in Medical Spanish teaching (Hardin, 2015; Abbott & Martínez, 2018; Sánchez-López, 2014; Lowther-Pereira, 2018; Lear, 2012) have been shown to be excellent spaces in which to engage students in translanguaging practices (Bloom-Pojar, 2018; Martinez & Schwartz, 2012). Engagement of translanguaging practices in the classroom, however, has not yet received the attention it deserves. Bloom (2004) described the effects of translanguaging practices in the classroom to build and enhance meaning negotiation skills. She writes: Many language teachers and researchers might criticize even the strategic use of the L1 in the language classroom, stating that the students and the teacher should be maximizing the use of the L2 in order to increase both input and output in the L2. However, students used the L1 strategically to both communicate and clarify the use of the L2. The students did not rely entirely on the L1 when they were communicating; rather they used it as a tool in communication. (p. 216) Bloom’s use of translanguaging supported her classroom goals of developing communication strategies that would allow her students to better communicate in Spanish. At the same time, however, her use of translanguaging also contributed to the making of a collaborative classroom. Bloom describes the collaboration as follows: “In our class, I needed to rely on the students to bring their nursing expertise to the classroom and to assist me through my ZPD in general nursing knowledge. I was the language expert in the classroom, but the students were the nursing experts” (p. 65). The interdependency in the collaborative classroom gave

196  Language pedagogy and Latino health specific purpose to the translanguaging environment that was emerging. Even so, the translanguaging environment that Bloom was constructing for her collaborative classroom did not emerge without tension. Bloom recalls that two students felt that they were being singled out for speaking English. They added that it felt like they were being humiliated for speaking English. The episode caused Bloom quite a bit of consternation and she took appropriate steps to correct the misunderstanding. Bloom reports on the final email she received from the student in relation to the episode. The student wrote: “I hope you don’t have any hard feelings about my email. . . . This semester is the end of a 5-year long ordeal of ups and downs, so I apologize for being a little on the bitter side. Class was great yesterday” (pp. 103–104). This episode demonstrates the ways that ideologies of language seep into the translanguaging environment generating misunderstanding. Even so, the introduction of translanguaging in the Spanish classroom can provide a rich learning experience leading to more “abundant” communities of learners (McKnight & Block, 2010). In addition to generating a communicationoriented approach to L1/L2 use in the classroom, a translanguaging environment can also be constructed by providing opportunities for critical reflection of translation spaces (Bloom-Pojar, 2018). Martínez (2014), for example, reports on a photovoice project developed in the context of a Medical Spanish classroom. Photovoice is a participatory action research method that enables people to document, reflect upon, and communicate community needs through the techniques of documentary photography and critical dialogue (Findholt, 2011, Wang, 1997). Wang summarizes the method as follows: “From the people, their visions and their words, we can begin to assess real local needs, in the hope that the divergent perspectives of health professional sand laypeople will converge to exert a more effective impact on a community’s well-being” (Wang, 1997, p.  385). In this project, students went out into their communities to document the presence of English and Spanish documents, posters, and other written materials in health care facilities. After collecting the photos, students were asked to choose their three favorite photos and to explain where the photo was taken, why they chose to take that photo, and how the photo made them feel. Figure 5.2 demonstrates one student’s photo. In describing why she took the photo, the student commented that she decided to take it because it was placed at the entrance door of the clinic. She viewed the sign as a gatekeeper of sorts. In her reflection on how the sign made her feel, she wrote: La foto revela que están más interesados si la persona puede pagar o si tienen seguro médico como el Medicaid, y si tienen Medicaid que tenga la prueba porque como dice el anuncio: ‘No es la responsabilidad de nosotros obtener la prueba de seguro,’ da la impresión que no quieren ayudar a la gente o dar servicios médicos en mi opinión. Once students completed the assignment, they were asked to present their photos to one another and expand on their feelings. The discussion led to critical revelations about how decisions about what to translate are made and how those translations communicate a broader social message to patients. These revelations,

Language pedagogy and Latino health  197

Figure 5.2  Picture of translated sign taken by student Source: Photo by Crystal M. López

moreover, were often connected to personal experiences. One student involved in the discussion commented: Hay muchas personas que hablan español y cuando me toca ir con mi papá y mi mamá y vamos a la clínica y se quedan viendo el letrero y me dicen ¿qué

198  Language pedagogy and Latino health quiere decir allí? Y pues les tengo que decir y entonces, pues, es donde se ve la necesidad que ellos necesitan, o sea, la información en español para que puedan entender lo que hay en la clínica. The connection made to previous experiences, moreover, led the group to arrive at profound generalizations. “Cosas de gran importancia no las tenían en español, nada más las cosas básicas,” one student commented. Another student commented: “creo que deberían poner más atención los hospitales, concentrarse más, para poder ayudar a las personas porque a veces para los hospitales ellos pueden ver que es dinero pero en sí es vida, el bienestar para todos.” By critically interrogating translation spaces, then, students gain an opportunity to see the importance of translanguaging practices. Spanish for Latino Health expands current conceptualizations of Medical Spanish by adding dimensions of health/communicative inequities, ethical listening, and translanguaging to the content and the method of teaching and learning. Health/communicative inequities focus student attention on localized policies and practices that simultaneously generate inequities in both health outcomes and health communication. Ethical listening, on the other hand, encourages students to engage with patients humbly and on their own terms while also providing an analytic lens through which to appraise raciolinguistic hierarchies. Translanguaging, finally, provides students an overarching approach to the cultivation of relationships by leveraging all of their linguistic resources. These three areas, all highly interwoven, have the potential of specifying the teaching of Spanish for health professionals in ways that are consistent with the social justice commitments that many teachers and students bring with them to the Medical Spanish classroom. In this chapter, we have explored the historical origins of Medical Spanish and its development in the U.S. through detailed examination of a variety of textbooks and curricular materials. We have considered how the LSP agenda has led to new developments in the teaching of Medical Spanish, and we have proposed a further specification of Medical Spanish, Spanish for Latino Health, that can address some of the major issues facing Spanish speakers in the U.S. health delivery system. Palmira’s story, recounted at the beginning of this chapter, highlights the complex involvement of language in health and health care. The major theoretical insights proposed as central to the project of teaching Spanish for Latino Health provide instructors and curriculum designers mechanisms to ensure that Spanish language teaching is always connected to the wider entanglements of Spanish in health care in the United States.

Notes 1 Javier Mauricio Cepeda is my father and he is 52 years old. My father means everything to me. It is because of him that I am what I am today. He was born in Mainero, Tamaulipas and he immigrated to the United States when he was a teenager in order to help his father. His mother passed away when he was only two years old. In the summer of 2011, a week after we returned from Villagrán, Tamaulipas to Sebastian, Texas for our vacation, my father began complaining about a headache. My dad is a very stubborn

Language pedagogy and Latino health  199 man. He answers even before a question is asked. He doesn’t like to be told what to do. He would say: “it’ll go away. I already took a pill.” It seemed like he said this simply to get us to stop bothering him. My dad refused to go to the hospital even though we kept insisting. The language barrier was one of the reasons my dad avoided the hospital. He felt that they wouldn’t help him anyway and he would say – “I’m fine. What’s the doctor going to do anyway? I don’t have money to be paying doctors.” He would complain but he never let us see him when he writhed in pain. Then my sister Marisol said: “enough is enough; I am taking you to the hospital.” My sister picked us up in Sebastian and we went to Valley Baptist Medical Center in Harlingen, Texas. My father Javier, my mother Francisca, my sister Marisol and I were fretting during the entire trip. We feared the worst. That half hour trip from our house to the hospital felt like the longest trip of our lives. I prayed the whole way that my dad’s problem would not be that severe. I asked the Virgin of Guadalupe: “Virgencita, Madre mía, te ruego y te imploro que por tu divina ayuda no desampares a mi papi en estos momentos.” That day, August  9, 2012, was the day that would change our lives forever. Marisol went with my dad into the emergency room because he doesn’t speak English – it’s not like he needs it working on the farms – and she was his interpreter. Marisol sent me a text message telling me: “Don’t be afraid but make sure not to upset mom; she also has a heart condition.” As soon as I  read this I  knew that something was seriously wrong. I kept reading. Marisol wrote: “dad has bleeding in his brain. Tell mom but make sure that she doesn’t get upset. Tell her that dad will be fine.” My eyes watered and I had to tell my mom that the man she had been married to for 31 years was bleeding in his brain. “Cerebral hematoma,” that’s what the doctor’s called it. This made my dad sleep all the time and caused severe headaches. Later they moved him to the intensive care unit and there a long process of tears, sadness, prayer, and faith began. My dad did not want to go to the hospital because he didn’t know any English other than “good morning” and “thank you.” My sisters and I were his translators. My mom would stay with him day and night. My sister and I would take turns staying so that she could go home and rest. It was hard. It was hard because when the doctors and nurses would come to take my father for tests it was in the middle of the night and my mom had to communicate with them through gestures. They would only allow one person in the room at a time and my mom didn’t know English. The language barrier notwithstanding, the medical personnel was good. After my father’s first surgery, he was recovering well. But a few days later, he passed out and would not wake up. The doctors didn’t know why so they operated on him again because he continued to bleed. After the second surgery things appeared to be stable but it turned out that he had an infection so they operated on him a third time. Some days my dad would be fine; other days, not so much. Some days he would lose control of the left side of his body; other days he would lose control of the right side. The doctors would tell us that my father’s condition was rare – that it was something they had never seen. They were at a loss to explain my dad’s condition. They kept asking if he had hit his head, and my dad kept responding that he had not. Then the doctors asked us, and we said the same thing: he had not hit his head. They couldn’t understand what may have caused the bleeding. If they didn’t know, we didn’t know either; my dad never told us anything. He was placed in rehabilitation to recover the muscle strength that he had lost while in the hospital. He received speech therapy because some days we just couldn’t understand what he was saying. In the autumn of 2011 I didn’t go back to school. I stayed in my parent’s home to help my mom take care of my father in the hospital. They didn’t ask me to do it. In fact, my mom was worried that I was going to fall behind a semester. I told her: “the most important thing for me right now is my dad. I will go back to school once he gets better.” Over the next six months my father began a slow process of recovery. Just days before Thanksgiving we were told that we could finally take him home. It was a long haul, but ultimately he recovered. I returned to the university in Spring 2012. My dad always told me: “your education is the only inheritance that I will leave

200  Language pedagogy and Latino health you when I am no longer here.” Those words were inscribed in me and motivated me to finish my degree. My dad has the following advice for future health care providers: learn a variety of languages so that you can help people who don’t understand, let the community know that you are there to help and treat all your patients with love and compassion. 2 The underlined portions refer to scoring units.

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Index

Abraido-Lanza, Ana 23 acceptance in health care, identity and 7 – 8 access to health care, language and 6 – 7 accreditation 36 acquisition planning 44 action stage of TTM 76 addition errors 119 adequation 108 Advancing Effective Communication, Cultural Competence, and Patient-and Family-Centered Care: A Roadmap for Hospitals (Joint Commission) 53 advising speech acts 177 Affordable Care Act (ACA) 41 – 42, 43, 52 Aguirre-Molina, Marilyn 10 Ainsworth-Vaughn, Nancy 82, 83, 84 Ajzen, Icek 74 Albl-Mikasa, Michaela 121 Alegría, Margarita 108, 133 – 134 Alliance of Community Health Plans 51 Allison, Abigail 121 Almeida, Joanna 43 Alstaedter, Laura 175 Althusser, Louis 81 American Academy of Pediatrics 61 American Bilingual Tradition, The (Kloss) 45 American Council on the Teaching of Foreign Languages (ACTFL) Oral Proficiency Scale 181 – 182 American Institutes for Research (AIR) 61 – 62, 63 – 64 American Journal of Public Health 15 American Language: The History of Spanish in the United States, An (Lozano) 45 – 46 America’s Uninsured Crisis (Institute of Medicine) 35 Anarchy, State, and Utopia (Nozick) 37

Anderson, Kathryn 43 Ang, Alfonso 137 Angelelli, Claudia 85, 91, 121 Anzaldúa, Gloria 7 Aparicio, Frances 11 Aragón, Jesusita 139 – 140 Aranguri, Cesar 120 – 121 Armin, Julie 132 Art of Healing Latinos: Firsthand accounts from physicians and other health advocates, The (Hayes-Bautista and Chiprut) 14 associational life 195 ¡A Su Salud! program, University of North Carolina 167 Austin, John L. 84 authentication 108 authorization 108 Avila, Camila 99 – 100 Baez, Jillian 11 Balch, George 113 Bancroft, Marjory 86 Bandura, Albert 75 Baraldi, Claudio 123 Barton, David 130 Bauman, Richard 61 – 62 Beach, Mary 103 Becker, Gay 43 Beene, Lara 132 Belpoliti, Flavia 177 – 178 Benavides-Vaello, Sandra 176 Bennett, Tony 171 Beveridge model 39 Bienvenida al Sanatorio (Ortega) 161 bilingual health care providers 115 Bismark, Otto von 39 Bismark model 39 Blackledge, Adrian 193

Index  207 Block, Peter 195 Bloom, Melanie 175, 195 – 196 Bloom-Pojar, Rachel 193 – 194 Boivin, Isabelle 124 Boletín Pro Salud (Ortega) 161 Borderlands/La Frontera (Anzaldúa) 7 botánicas 79 Bourdieu, Pierre 9, 71 Bracero program 143 Bracho, América 14 Brady, Anna 187 Briggs, Charles 61 – 62, 186 Briggs, Laura 17 Bronwen Horton, Sarah 26 Brown, Alan 171 Bucholtz, Mary 108 Buss, Fran Leeper 139 California Health Interpreting Association (CHIA) 85 California Standards for Healthcare Interpreters, The (CHIA) 85 Calvet, Louis Jean 138 Calvo, Rocío 131 – 132 Camargo, Carlos 113 Cameron, Linda 134 Canale, Michael 182 Candib, Lucy 109 CDC see Centers for Disease Control and Prevention (CDC) Centers for Disease Control and Prevention (CDC) 72 Centers for Medicare and Medicaid Services 53 Cepeda, Javier Mauricio 156 – 158 Cepeda, Palmira 156 – 158 chance interpreter 115 Chase, Robert O. 165 – 166 Chavez, Leo 17 Chen, Alex 20 Cheng, Eric 20 Children’s Health Insurance Program (CHIP) 41 Chiprut, Roberto 14 Chong, Nilda 92 civic literacy 129 Clark, Sunday 113 CLAS Standards (National Standards for Culturally and Linguistically Appropriate Services) 48 – 52; Enhanced CLAS Standards, 2013 56, 57; final report on 60 – 61; Joint Commission standards and 53 – 56; language-asproblem orientation with 60 – 63

Clinician Cultural and Linguistic Assessment (CCLA) 182 – 184 Clinton, Bill 48 Cloud in the Sky, A (film) 161 Coffman, Maren 132 colloquial expression use 110 – 111 colonia 143 – 147 commodified latinidad 11, 12 – 13 Communicating in Spanish for Medical Personnel (Tabery, Webb, and Mueller) 162 – 163 communication ecologies in Latino health 137 – 147 communicative competence, components of 182 – 183 communicative inequities in Spanish for Latino Health 185 – 187 Comprehensive Accreditation Manual for Hospitals (Joint Commission) 53 Confucius Institute 44 Connors, Kaleigh 103 consciousness raising process of change 76 consumerism role in provider-patient interactions 81 contemplation stage of TTM 76 conversation analysis (CA) 100 – 101 Cook, Vivian 189 Cook-Gumperz, Jenny 130 Cope, Bill 130 Copeland, Hannah 176 Cordella, Marisa 82 – 83 corpus planning 44 Creese, Angela 193 Cruz, Jacinto Rodríguez 42 – 43 cultural beliefs 92, 94 cultural competency 9 – 10 cultural health capital (CHC) 95 cultural humility 9 cultural literacy 129 cultural practice: critical perspective on 94 – 96; health behavior theory and 77 – 79; health communication research and 92 – 94; interpreter codes of ethics and 90 – 91; language in health communication and 71, 72 – 73 cultural validity 181 – 182 cultural values 92, 93 Cunningham, William 20 curanderos 79 Daniels, Norman 38 Davidson, Brad 120 – 121, 124 Dávila, Arlene 11, 13 Deckert, Sharon 111 – 112

208  Index Deitrick, Lynn 141 De la Torre, Adela 92 Department of Health and Human Services 48 Department of Veterans Affairs 39 deportation, public health system and 15 – 18 de Saussure, Ferdinand 5 – 6 Diamond, Lisa 178, 179, 186 Di Clemente, Carlo 75 direct-to-consumer advertising (DTCA) 81 – 82 discourse analysis (DA) 101 discourse ethics 91 discourse-oriented studies 100 – 101; of interpreter-mediated communication in Latino health 119 – 127; of providerpatient communication in Latino health 107 – 112 doctor voice 82, 83 Dolhinow, Rebecca 143 Dominick, Gregory 132 Doyle, Michael 169, 172 Dutta, Mohan 77, 94 – 95 Dwyer, James 119 Dymally-Alatorre Bilingual Services Act 56, 58 Dysart-Gale, Deborah 122 editorialization errors 119 educator voice 82, 83 Edward, Jean 131 Ehrlich, Paul 16 Elder, John 140 Elderkin-Thompson, Virginia 117 Emergency Medical Treatment and Active Labor Act (EMTALA) 41 Engel, Kirsten 112 – 113 English for Specific Purposes (ESP) 168 Enhanced CLAS Standards, 2013 56, 57 entextualization 127 – 128 entitlement program 35 epistemic brokering 123 Erzinger, Sharry 109 Estrada, Antonio 92 ethical listening in Spanish for Latino Health 187 – 192 Eugenic Nation: Faults and frontiers of better breeding in modern America (Stern) 16 eugenics 16 Exito Comercial (Doyle) 172 Fairclough, Norman 101 false fluency errors 119

Fan, Jason 180 Federally Qualified Health Centers (FQHCs) 41 fellow human voice 82, 83 Fertile Matters: The politics of Mexicanorigin women’s reproduction (Gutiérrez) 17 First Latin American Health Week 160 Fishbein, Martin 74 Flores, Glenn 7, 119 – 120 Florom-Smith, Aubrey 26 – 27 Ford, Leigh 140 Foucault, Michel 80 Fourteenth Amendment, Equal Protection and Due Process clause 46 French Alliance 44 Fricker, Miranda 190 Fuchsel, Marrs 108 – 109 Gadamer, Hans Georg 189 Gadon, Margaret 113 Gallegos, José M. 46 Gallegos, Monica 106 – 107 Galton, Francis 16 Galvez, Alyshia 13 Garcia, Cesar 132 – 133 García, Magdalena 11 – 12 García, Mario 160 García, Ofelia 141, 192 – 193 Garza, Cynthia 1 – 2 Garza, Maribel 1 – 2, 27 Gee, James Paul 130 Ginde, Adit 113 Goble, Ryan 111 – 112 Goethe Institute 44 Goldberg, Benjamin 15 Gollin-Kies, Sandra 170 González-Guarda, Rosa Maria 26 – 27 González-Lee, Teresa 164 – 165 Green, Judith 118 Greenberg, Joseph 64 Greer, David 128 – 129 Grosse, Christine 169 Gruener, Gregory 179 – 181 Gurrola, Maria 43 Gutiérrez, Elena 17 Habermas, Jurgen 91 habitus 9 Hall, David 170 Hall, Judith 81 – 82 Hall, Kira 108 Halliday, M. A. K. 171 Hardin, Karol 165, 167 – 168, 173, 174, 175, 178, 186

Index  209 Hardin, Mike 173, 175 Haugen, Einar 138 Hayes-Bautista, David 13, 14 Healing of America, The (Reid) 39 health, WHO definition of 5 Health Angels: Help for society’s most vulnerable people (film) 140 health behavior theory: health belief model (HBM) 73 – 74; language and culture in 77 – 79; language in health communication and 73 – 79; relational culture domain and 77 – 78; social capital domain and 78; theory of reasoned action/theory of planned behavior (TRA/TPB) and 74 – 75; transculturation/transmigration domain and 78 – 79; Transtheoretical Model (TTM) 75 – 76 health belief model (HBM) 73 – 74 health care: acceptance in, identity and 7 – 8; access to, language and 6 – 7; as commodity 37 – 38; cultural competency and 9 – 10; insurance and 38 – 40; as right 36 – 37 health communication: CDC definition of 72; culture-centered approach to 94 – 96; language and cultural practice in 71, 72 – 73; provider-patient communication and 80 – 83; Schiavo definition of 72 – 73 health/communicative inequities in Spanish for Latino Health 185 – 187 health information seeking: defined 134; Latino health and 134 – 137 health literacy (HL): acculturation and 132; defined 20, 128 – 129; Latino health and 128 – 134, 135 Health Literacy: A Prescription to end confusion (IOM) 128 health policy: defined 34; improving quality of care 35 – 36; increasing access to health care 35; language in health care and 64 – 66; in United States 34 – 43 (see also United States health policy) health-related storytelling voice 83 HealthyYouTXT 134 Heath, Shirley Brice 130 Heisler, Michele 141 helping relationships process of change 76 Hill-Burton program 41 Holliday, Karen 79 Holmes, Seth 9 homophily 107 – 108 Horton, Sarah 42 Hsieh, Elaine 23, 114, 121 – 122, 124 – 125 Hudelson, Patricia 125

Hund, Lauren 20, 132, 133 Hutchinson, Tom 168 Hymes, Dell 6 identity function of language, Latino health and 7 – 8 ideologies of language, language in health care policies and 59 – 64 Illingworth, Patricia 41 Illinois Mental Health Hispanic Interpreter Act 58 Inghilleri, Moira 90 Ingram, Maia 141 Institute of Medicine (IOM) 20, 128 Instituto Cervantes 44 interactional communication 189 Interagency Language Roundtable (ILR) scale 179 interpellation 81 interpreted communicative event (ICE) 85, 89 interpreter-mediated communication 85 – 96; cultural values/beliefs and 92 – 94; culture-centered approach to 94 – 96; discourse-oriented studies of, in Latino health 119 – 127; ethics and standards of practice in 85 – 90; language and culture in ethical reflection on 90 – 91; National Standards of Practice 86 – 89; overview of 85; sociomedical studies of, in Latino health 112 – 119 interpreters 114 – 119 Introduction to Spanish for Health Care Workers: Communication and Culture, An (Chase and Medina de Chase) 165 – 167 IOM see Institute of Medicine (IOM) Isaacs, Talia 182 Jacobs, Elizabeth 20, 113, 178, 186 Jacobson, Holly 20, 132, 133 Jakobson, Roman 194 Johns, Ann 171 Johnson, David Cassels 45 Joint Commission for the Accreditation of Health Care Organizations 52 – 56 Jones, Rodney 84, 127 – 128 Juárez, Melina 43 Julliard, Kell 106 Kaiser Permanente Clinician Cultural and Linguistic Assessment (CCLA) 182 – 184 Kalantzis, Mary 130 Katz, Vikki 118, 137

210  Index Keefer, Maureen 102 Kelly, Nataly 8 King de Ramírez, Carmen 63, 180 Klee, Carol 170 Kleinman, Arthur 92 Kloss, Heinz 45 Knoch, Ute 180 Kramer, E. 122 – 123 Krieger, Nancy 186 Kuo, Dennis 113 language; see also individual headings: and cultural practices in Latino health care providers 99 – 147; de Saussure definition of 5 – 6; in health care policies 33 – 66; in health communication 70 – 96; identity function of, Latino health and 7 – 8; Latino health and 1 – 27; teaching for Latino health care 156 – 198 language acquisition, listening in 187, 189 Language and Power (Fairclough) 101 language-as-problem orientation 60 language-as-resource orientation 60 language-as-right orientation 60 language ecology, defined 138 Language for Specific Purposes (LSP) 168 – 172; see also Medical Spanish; agenda 169 – 170; definitions of 169 – 170; expansion of 170 – 172; Medical Spanish and 172 – 185; overview of 168 – 169 language ideologies 59 – 64 language in health care policies (LHP) 33 – 66; see also United States health policy; United States language policy and planning; health policy and 64 – 66; health policy in United States 34 – 43; ideologies of language and 59 – 64; key concepts in 43 – 45; language policy/ planning in United States 43 – 47; Miguel and Rosa’s story 33 – 34; at national level 47 – 56; at state level 56 – 59 language in health communication 70 – 96; cultural practice and 71, 72 – 73, 83 – 84; health behavior theories and 73 – 79; health belief model and 73 – 74; interpreter codes of ethics and 90 – 91; interpreter-mediated communication and 85 – 96; overview of 71; providerpatient communication and 79 – 84; Tania’s story 70; theory of reasoned action/planned behavior and 74 – 75; Transtheoretical Model and 75 – 76

language planning 44 language policy and planning 43 – 47; key concepts in 43 – 45; scope of 44; study of 45; in United States 45 – 47 language teaching for Latino health care 156 – 198; see also Language for Specific Purposes (LSP); Medical Spanish; Spanish for Latino Health; Language for Specific Purposes (LSP) and 168 – 172; Medical Spanish, making of 159 – 168; overview of 158 – 159; Palmira’s story 156 – 158; Spanish for Latino Health and 185 – 198 La Partera: The Story of Midwife (Buss) 139 Lara, Irma 12 Larkey, Linda 140 Larson, Elaine 130 Latina Health in the United States: A Public Health Reader (AguirreMolina) 10 latinidad: commodified 11, 12 – 13; conceptions of 11; in-group characteristics of 11 – 15; Latino health and 10 – 18; lived 11, 13 – 14; out-group characteristics of 15; political 11 – 12 Latino health; see also language teaching for Latino health care; Latino health care providers, language and cultural practices in: communication ecologies in 137 – 147; components of, term 10; cultural practices in, language and 70 – 96 (see also language in health communication); health information seeking and 134 – 137; health literacy and 128 – 134, 135; language role in (see Latino health, language and); language teaching for 156 – 198; latinidad and 10 – 18; mass communication in 127 – 147 Latino health, language and 1 – 27; see also language in health communication; latinidad; Latino health care providers, language and cultural practices in; access to care and 6 – 7; cultural competency and 9 – 10; deportation and 15 – 17; Garza, Cynthia’s story of 1 – 2; identity function of language and 7 – 8; latinidad and 10 – 18; overview of 3 – 5; relationship between 5 – 10; social determinant perspective 18 – 24; syndemic perspective 24 – 27; Zamora, Gricelda’s story of 6 – 7

Index  211 Latino health care providers, language and cultural practices in 99 – 147; see also interpreter-mediated communication; provider-patient communication; Avila’s story 99 – 100; interpreter-mediated communication 112 – 127; mass communication 127 – 147 (see also Latino health); overview of 100 – 102; providerpatient communication 102 – 112 Latino Health in the U.S.A: A Growing Challenge (Aguirre-Molina) 10 Lau, Kinney Kinmon 47 Lau v. Nichols 47 – 48 Laws, Barton 125 – 126 League of United Latin American Citizens (LULAC) 159 – 160 Leanza, Yvan 124 Lear, Darcy 174 Lee, Jonathan 114 Lee, Leland 118 Levinas, Emmanuel 91 “likely to become a public charge” (LPC) 16 linguistic culture 45 Linguistic Sciences and Language Teaching, The (Halliday, McIntosh, and Strevens) 168 – 169 LIQOR-AAA mnemonic 80 lived latinidad 11, 13 – 14 Long, Mary 169 Loya, Maribel Miramontes 42 Lozada-Oliva, Melissa 7 – 8 Lozano, Rosina 45 – 46 LSP see Language for Specific Purposes (LSP) Lujan, Josefina 140 – 141 Madrigal vs. Quiligan 17 Madsen, William 161 Magaña, Dalia 109 – 111 maintenance stage of TTM 76 managed care 35 Mantini-Briggs, Clara 186 Maranda, Michael 104 Marcé, Pilar 167 Marín, Gerardo 92 Marmot, Michael 18 Martínez, Glenn 63, 175 – 176, 180, 190 – 191, 196 Mason, Keith 176 – 177 mass communication in Latino health 127 – 147 Maupome, Gerardo 136 McCarty, Teresa 45

McGraw Hill’s Complete Medical Spanish (Ríos) 163 – 164 McKnight, John 195 McNamara, Tim 180 McWilliams, Carey 15 means-tested program 35 Medicaid 35, 39, 41 Medical Interpreting and Cross-Cultural Communication (Angelelli) 121 medical interpreting field 7 medical interview 79 – 80 Medical Spanish 159 – 168; cultural validity and 181 – 182; curricula, evolution of 162 – 168; diversity of 173 – 174; historical roots of 159 – 161; language assessment and 178 – 185; and LSP 172 – 185; needs analysis in, teaching innovation and 174 – 178; overview of 159; proficiency measures in 178 – 180; role play/simulation in, classroom 175 – 176 Medical Spanish: Interviewing the Latino Patient (González-Lee and Simon) 164 – 165 Medicare 35, 39 Medicine in Translation: Journeys with my Patients (Ofri) 191 – 192 Medina de Chase, Clarisa 165 – 166 MedlinePlus 95 Mendenhall, Emily 25 – 26 Menon, Usha 175 – 176 Merck Company Foundation 51 Metzl, Jonathan 9 Mexican problem 15 – 16 Meyer, Robert 46 Meyer v. Nebraska 46 – 47 Mishler, Elliot 82 Modern Language Association 158 Molina, Natalia 16 Moore, Stephen 170 Morales, Leo 102 Moreno, Maria 115 Movimiento Pro Salud 160 – 161, 162 Mueller, Beatriz Vasquez 162 Murray-García, J. 9 mutuality role in provider-patient interactions 82 National Code of Ethics for Interpreters in Health Care, A (NCIHC) 85, 86 National Council on Interpreting in Health Care (NCIHC) 85 – 86, 89 – 90 National Healthcare Quality and Disparities Report, 2015 102

212  Index National Health Insurance model 39 national level language policies in health care 47 – 56 National Review, The 36 National Standards for Culturally and Linguistically Appropriate Services (CLAS Standards) 48 – 52; Enhanced CLAS Standards, 2013 56, 57; final report on 60 – 61; Joint Commission standards and 53 – 56; language-asproblem orientation with 60 – 63 National Standards of Practice for Interpreters in Health Care (NCIHC) 86 National Tuberculosis Association 160 NCIHC see National Council on Interpreting in Health Care (NCIHC) New Literacy Studies 129 – 130 Newman, Jeffrey 115 No Child Left Behind 44 Norton, Cynthia 132 Nozick, Robert 37 Obama, Barack H. 42, 52 observed structured clinical evaluations (OSCEs) 176 Ofri, Danielle 191 – 192 omission errors 119 on-site interpreter 115 O’Rourke, Katherine 179 – 181 Ortega, Ruben C. 160 – 161 Ortiz, Fernando 78 Ortiz, Melchor 140 – 141 Oss Marín, Barbara Van 92 Ostwald, Sharon 140 – 141 Otero, Miguel 46 Otero-Sabogal, Regina 115 othering 15, 24 Otherwise than Being (Levinas) 91 outcome-oriented studies 20 – 22 Out-of-Pocket model 39 – 40 Padilla, Amado 92 Padilla, Felix 11 parallel monolingualism 194 – 195 Parillo, Kathleen 102 Parmet, Wendy 41 Parsons, Talcott 81 Pasick, Rena 77 – 79 paternalism role in provider-patient interactions 81 patient activation 103 – 104 Patient Activation Measure 104 Patient-Centered Guide to Implementing Language Access Services, A (AIR) 61

patient disclosure of medical information studies 105 – 106 Patient Protection and Affordable Care Act (ACA) 41 – 42, 43, 52 Pennycook, Alastair 71 Perales, Alonso 160 Perez, Debra 103 Pérez, María 177 – 178 Pérez, Victoria 12 Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) 41 – 42, 43 Pleasant, Andrew 128 – 129 political latinidad 11 – 12 Pope, Charlene 120 Population Bomb, The (Ehrlich) 16 power behind discourse 101 power in discourse 101 pre-contemplation stage of TTM 76 preparation stage of TTM 76 prestige planning 44 processes of change, TTM 76 Prochaska, James 75 proficiency measures in Medical Spanish 178 – 180 promotion-oriented rights 45 promotoras de salud 139 – 143, 145 – 147 provider-patient communication 79 – 84; discourse studies of, in Latino health 107 – 112; health communication approaches to 80 – 83; language and culture in 83 – 84; medical interview 79 – 80; role patterns in 81 – 83; sociomedical studies of, in Latino health 102 – 107; voice of medicine and 82 – 83 racialization 15 raciolinguistic perspectives in Spanish for Latino Health 190 – 192, 198 Ramirez, Arnulfo 189 Ramirez, Dorian 112 – 113 Ramirez, Robert 120 – 121 Ramírez, Saray 116 – 117 Ramírez, Susana 118, 137 Ramos, Zorangeli 133 – 134 Rawls, John 37 Raymond, Chase 123 – 124 recontextualization 128 Reid, T. R. 39 relational culture domain 77 – 78 Reuland, Daniel 178 Richardson, Chad 141 Ríos, Joanna 163 – 164 Rodriguez, H. Alejandro 99 – 100

Index  213 Rodríguez, Michael 103 Rohrabacher, Dana 42 role patterns in provider-patient communication 81 – 83 Rooks, Ronica 135 Rose, Danielle 113 Rosenberg, Ellen 124 Roter, Debra 81 – 82 Rúa, Mérida 11 Rudd, Rima 129 Ruiz, Richard 59 – 60 Ryabov, Igor 141 safety net services 41 – 43 Saldaña, José Rodríguez 42 – 43 Salinas, Aaron 33 – 34 Sanchez, Gabriel 43 San Martín, Karmín 70, 190 – 191 Santana, Felipe 14 Save Our State initiative, California 41 Sayer, Peter 193 Schiavo, Renata 72 – 73 Schiffman, Harold 45 Schnall, Rebecca 130 Schultz, Amy 24 Seal of Biliteracy 44 self-liberation process of change 76 self-reevaluation process of change 76 Shapiro, Ben 36 – 37 shared decision-making 103, 104, 105 Sheppard, Vanessa 103 Shi, Leiyu 36 Shim, Janet 95 Shin, Young Ju 136 Shohamy, Elana 44 Short Acculturation Scale for Hispanics 132 Short Assessment of Health Literacy for Spanish-speaking Adults (SAHLSA) 130, 131 sick role 81 Silver, Roxane 117 Siman Act, Nebraska 46 Simon, Harold 164 – 165 Singer, Merrill 25 Singh, Douglas 36 Single Item Literacy Screener (SILS) 130, 131 small talk 109 – 110 social capital domain 78 social determinant perspective of Latino health 18 – 24 socially constituted linguistics 6 sociolinguistics 6

sociomedical studies 100, 107; of interpreter-mediated communication in Latino health 112 – 119; of providerpatient communication in Latino health 102 – 107 Soto Mas, Francisco 20, 132, 133 Spanish for Latino Health 185 – 198; ethical listening in 187 – 192; health/ communicative inequities in 185 – 187; raciolinguistic perspectives in 190 – 192, 198; teaching overview 185; testimonial justice in 190 – 191; translanguaging and 192 – 198 Spanish for Specific Purposes (SSP) 170 Spolsky, Bernard 45, 59 Sribney, William 103 state level language policies in health care 56 – 59 status planning 44 sterilization, public health system and 17 – 18 Stern, Alexandra 16 Stevens, Alexander 46 Stevens, Kevin 176 Stivers, Tanya 100 – 101 Stonbraker, Samantha 130 Street, Brian 130 subsidized care 40 – 43 substitution errors 119 Summer Institute of Linguistics 44 Suro, Roberto 137 Swain, Merrill 182 syndemic perspective of Latino health 24 – 27 Systemic Functional Linguistics (SFL) 186 – 187 Szalacha, Laura 175 – 176 Tabery, Julia 162 Tandon, Darius 102 Tang, Gayle 182 Tang, Tricia 112 – 113 Tannen, Deborah 109 teaching Spanish for Latino Health see Spanish for Latino Health telephone interpreter 115 Tervalon, M. 9 Teschner, Richard 163 testimonial justice in Spanish for Latino Health 190 – 191 Test of Functional Health Literacy in Adults (TOFHLA-S) 130 – 131 Texas Anti-Tuberculosis Association 160 Texas Association of Healthcare Interpreters and Translators (TAHIT) 59

214  Index Texas Tuberculosis Association 160 textbooks, Medical Spanish 162 – 168 theoretical constructs, defined 73 Theory of Justice, A (Rawls) 37 theory of reasoned action/theory of planned behavior (TRA/TPB) 74 – 75; relational culture and 77 – 78; social capital and 78 Thomas, Tainayah 26 – 27 Thompson, Greg 171 Thompson, Tommy 48 tolerance-oriented language rights 45 transactional communication 189 transculturation/transmigration domain 78 – 79 translanguaging: associational life and 195; defined 192 – 193; parallel monolingualism and 194 – 195; rhetorical account of 193 – 194; Spanish for Latino Health and 192 – 198; translation spaces and 194 Transtheoretical Model (TTM) 75 – 76 TTM see Transtheoretical Model (TTM) Ulmer, Edgar 161 United States health policy 34 – 43; government role in 38 – 40; health care as right and commodity 36 – 38; subsidized care and 40 – 43 United States language policy and planning 43 – 47; described 45 – 47; key concepts 43 – 45 untrained interpreter 115

Valdés, Guadalupe 182 Vanderpool, Robin 135 – 136 Vargas, Edward 43 Vélez-Ibáñez, Carlos 64 Vickers, Caroline 111 – 112 VIDDA syndemic 25 – 26 Vines, Mary 176 Viruell-Fuentes, Edna 24 Voght, Geoffrey 169 voice: of competence 83; of initiator 83; of medicine 82 – 83; of social communicator 83 Voloshinov, Valentin 171 Waitzkin, Howard 80, 117 Wallace, Lorraine 102 Waters, Alan 168 Webb, Marion 162 WebMD 95 Wei, Li 141, 192 – 193 White, Kari 125 – 126 WHO see World Health Organization (WHO) Wilce, James 90 Wilson, Joe 42 Wilson, Pete 41 Wittgenstein, Ludwig 71 World Health Organization (WHO) 5; health care and 36 – 37 Youdelman, Mara 56, 66 Zamora, Gricelda 6 – 7 Zarcadoolas, Cristina 128 – 129