When Language Becomes a Barrier to Health Care

“I told her that I had been waiting since 4:00 p.m.,” Adela, who emigrated from Mexico and worked cleaning homes, told me later. Without translation services, she struggled to understand the provider’s explanations about her chronic pain condition and the treatment options available to her.

Adela’s experience illustrates a pervasive but often invisible form of health care exclusion: the systematic under-resourcing of language interpretation services that leaves non-English speaking immigrants navigating complex medical systems without adequate support. My decade of research on Maryland’s Eastern Shore also reveals that language barriers intersect with racial discrimination in ways that create dramatically unequal hierarchies of care for different immigrant communities.

The cost of exclusion

Despite Maryland’s progressive state and local policies, the lack of public resources for immigrants has strained the ability of state and local governments to respond to the growing demands of a population that is largely uninsured.

Since 2000, the number of immigrants to Maryland’s rural Eastern Shore has risen rapidly, making the region’s seafood, livestock and agricultural industries attractive to temporary and more permanent migrant workers from Latin America and Haiti. From 2010 to 2019, Migration has been the primary source of the area’s population growth, between 2010 to 2019 the foreign-born population across all nine counties on the Eastern Shore increased by 90%.

The challenge goes beyond the simple availability of translation resources. As Demaris, an older woman who had been a patient at the local health center for years, explained: “The clinic only has one Spanish translator. That translator has to work between dental as well as medical.” This single interpreter serves hundreds of Spanish-speaking patients across multiple departments, creating impossible bottlenecks that leave people waiting for hours or receiving care without proper language support.

The human cost of these language barriers extends far beyond individual health outcomes. When immigrants can’t access preventive care due to language barriers, they’re more likely to end up in emergency departments with acute conditions. This creates higher costs for both individuals and health care systems.

The exclusion also undermines trust between immigrant communities and health care providers, making people less likely to seek care even when interpretation services are available. The experience of being misunderstood, dismissed or inadequately served creates lasting trauma that affects entire families and communities.

For the industries and rural communities that depend on immigrant labor, the failure to provide linguistically accessible health care represents a profound contradiction. These communities benefit economically from immigrant labor while systematically excluding immigrants from basic services.

When translation becomes mistranslation

Even when interpreters are available, language barriers intersect with class and racial biases in troubling ways. Several community members complained of interpreters who “deliberately mistranslated information because they looked down on poor immigrants.”

One family member described witnessing a clinical encounter between her aunt and a translator: “I am listening to the translator and the provider, and there was so much lost I was just shocked. I could not believe what he did not translate.”

These instances reveal how language interpretation isn’t simply a technical service—it’s a relationship of power that can either facilitate or obstruct health care access. When interpreters bring their own biases about class, education or immigration status into medical encounters, they can become barriers rather than bridges to care.

The inadequacy of professional interpretation services places enormous burdens on immigrant families, particularly children who are pressed into service as translators for their parents’ medical care. Adela sometimes schedules afternoon appointments “so that she is able to bring her daughter after school to help with translation.”

This practice, while common, creates multiple problems. Children may lack the vocabulary to translate complex medical terminology. They may be traumatized by learning about their parent’s serious health conditions. And parents may feel reluctant to discuss certain health issues in front of their children, leading to incomplete care.

David, an undocumented high school student whose parents work on local farms, described how his own bilingual abilities made him a resource for other immigrant families. “I see them sometimes crying because they do not understand, and I tell them to calm down because I experienced the same thing,” he told me. “When I can help, I do because others helped me when I first came, and I did not know anything.”

While David’s willingness to help reflects the mutual aid networks that sustain immigrant communities, it also highlights the failure of health care systems to provide adequate professional interpretation services.

Racialized hierarchies of care

The situation becomes even more dire when we move beyond the Spanish language.

While Spanish-speaking immigrants face significant barriers, they have at least some infrastructure to support them. Haitian immigrants often find themselves completely isolated from language-appropriate services.

Vivian, a program director at a social services agency, described how her organization had adapted over 20 years to serve Spanish-speaking immigrants: “Because we have had 20 years of large Latino influx, we have that capacity in different service agencies now. Almost everywhere, someone speaks enough Spanish to get to communicate fluently with somebody.”

But this capacity hadn’t extended to other groups like Haitian immigrants: “We try to help them as best as we can,” she says, “but when people do not feel like there is anybody that they can go to that they can trust, then I think that is when they are the most vulnerable.”

One Haitian Kreyòl-speaking community member expresses his frustration: “You know the main issue is that the Haitian community does not even have a Kreyòl translator. They have nothing.”

Compounding the issue is the region’s long and violent legacy of slavery, Jim Crow and anti-Black racism. As a result, this language hierarchy—where Spanish interpretation is inadequately provided and services for other languages like Haitian Kreyòl are nonexistent—reflects broader patterns of racialized exclusion in rural health care system that continues to be shaped by the history of racial capitalism.

The daily grind of systemic racism

These language barriers represent what my research participants—providers, immigrant communities and the rural poor—identified as a key mechanism through which systemic racism operates in rural health care. Another is the significant burden of bureaucracy and high costs plaguing U.S. health care that grinds away at people on a daily basis.

This “daily grind” of exclusion happens through seemingly neutral policies—like having only one interpreter for an entire health center, or scheduling interpreter services only during regular business hours—that systematically disadvantage non-English speakers. The cumulative effect is to make health care access so difficult that many immigrants simply avoid seeking care until they face medical emergencies.

Adela exemplified this pattern. When she needed dental care for a problem with her molar, she says she went to the FQHC dentist, “and then they sent me to another place where they asked me for identification, Social Security and my insurance.”

“If I didn’t have any of those things, what would I have done?” The combination of documentation requirements and language barriers created multiple obstacles that nearly prevented her from receiving care.

Rural context amplifies exclusion

Rural settings intensify these language-based exclusions in particular ways. The geographic isolation that characterizes rural health care means fewer options for finding culturally and linguistically appropriate care. Patients simply can’t go to a different provider if interpretation services are not available.

The resource constraints facing rural health care systems—including staffing shortages, financial pressures and limited specialist availability—make it easier to justify cutting “extra” services like interpretation. But language access isn’t extra—it’s fundamental to providing effective health care.

Historically, rural health care systems have served homogeneous patient populations, and as a result many lack experience developing culturally responsive services for diverse communities. The rapid demographic changes in rural areas have outpaced many systems’ ability to adapt their service delivery.

The federal requirement for equal access remains largely aspirational in many areas throughout the United States, where the combination of resource constraints and limited oversight allows discriminatory practices to persist.

Health care settings consistently fail to provide adequate language services. The enforcement mechanisms are weak, and providers often operate under the assumption that resource constraints excuse them from compliance.

Community innovations and workarounds

Faced with inadequate institutional support, immigrant communities develop creative solutions to language barriers. They create informal networks of community interpreters, share information about which providers are more accommodating, and develop systems for accessing care that work around institutional failures.

David’s role as an informal interpreter for other immigrant students reflects these community-generated solutions. While his help is invaluable, the fact that health care access depends on the generosity of teenagers highlights the inadequacy of formal systems.

Some health care providers also develop informal workarounds. Jennifer, a social worker, described going beyond her official duties to help clients: “There was an undocumented man, and I would talk to him in Spanish because you never know. I was able to get his paperwork worked out. I was not supposed to do that, but I was not giving him legal advice or anything. He just needed help.”

These adaptations demonstrate resilience, they also they highlight a troubling reality: health care access depends on the informal labor of teenagers and the goodwill of overextended providers.

Providers recognize that their temporary measures have become permanent features of the rural health infrastructure—what was meant as a stopgap has become the system itself. Band-Aid care allows the state to avoid its obligations by relegating care to the realm of humanitarian aid rather than the care that all people are entitled to.

The systemic changes required

Language barriers aren’t natural or inevitable—they’re the result of policy choices that systematically privilege English speakers and exclude everyone else. Addressing these barriers requires recognizing language access as a fundamental component of health care equity, not an “extra” service.

Rural health care systems need adequate funding to provide professional interpretation services in multiple languages, not just Spanish. They need to extend interpretation services beyond regular business hours to accommodate people’s work schedules. And they need to train staff to work effectively with interpreters and diverse communities.

But individual health care systems can’t solve this problem alone. It requires policy changes that provide dedicated funding for interpretation services, stronger enforcement of existing language access requirements, and recognition that linguistic diversity is a permanent feature of rural America rather than a temporary challenge.

Beyond individual solutions

At its core, the exclusion created by language barriers represents a failure of moral imagination in American health care. When Adela sits in a waiting room for hours without adequate interpretation, when Haitian immigrants can’t find anyone who speaks their language, when children are pressed into service as medical interpreters for their parents, we’re witnessing the consequences of a health care system that treats linguistic diversity as a problem rather than a resource.

These patterns aren’t unique to rural areas—they reflect broader failures of the U.S. health care system to serve diverse populations. Urban hospitals also struggle with inadequate interpretation services, and language barriers create exclusion across all health care settings. But rural contexts amplify these problems through geographic isolation, resource constraints and limited provider options.

Rural communities have an opportunity to lead by example. They can invest in interpretation services that recognize the dignity and humanity of all community members. They can develop culturally responsive health care systems that serve increasingly diverse populations effectively. And they can model what language justice looks like in practice.

But ultimately, this requires systemic change in how America funds and organizes health care. The alternative is to continue reproducing systems of exclusion that harm not just immigrants but entire communities. When significant portions of the population can’t access health care effectively, everyone’s health and safety are compromised.

The patterns documented here aren’t unique to rural areas—they reflect broader failures of the U.S. health care system to serve diverse populations. The question is whether America will continue reproducing systems of exclusion that harm entire communities or fundamentally reimagine how it organizes and funds health care to serve everyone effectively.

Thurka SangaramoorthyMore by this author →

Thurka Sangaramoorthy is professor of anthropology at American University. She is a cultural anthropologist with expertise in medical anthropology and epidemiology. Her research focuses on improving care for those living with HIV, developing more effective care systems for non-citizen immigrants, amplifying local community expertise as a transformative tool for enacting policies and practices that effectively address disparate environmental risks in communities of color, and advocating for social justice. Her writings on these topics appear in a wide range of scholarly and mainstream publications. She is also the author of Rapid Ethnographic Assessments: A Practical Approach and Toolkit for Collaborative Community Research (Routledge, 2020) and Treating AIDS: Politics of Difference, Paradox of Prevention (Rutgers University Press, 2014)