Lack of Language

Communication Challenges to Health in Rural America

My hometown of Harrisonburg, Virginia is a hub for the world’s nationalities and ethnicities in the heart of the rural Shenandoah Valley. In our public school system, 53 birth countries and 57 foreign languages are represented (Harrisonburg City Public Schools, 2017). From my experiences with first- and second-generation immigrants, I’ve learned how vital language is in everyday life. Fundamental activities like running errands and ordering at restaurants require communication that I would not give a second thought. However, for those that lack English fluency, these can create difficult and anxiety-provoking situations. Furthermore, when the non-native English speaker becomes a patient, these language barriers become especially challenging.

Keezletown Road runs just behind my neighborhood, connecting hundreds of acres of farmland in Harrisonburg and its surrounding area. (Photo by Holly Bill)

There are a multitude of factors that impede effective communication regarding healthcare. Individuals that are not fluent in English may have difficulty grasping the complicated syntax used to convey serious medical information, even if they are knowledgeable about health-related concepts. These subsequent language barriers are heightened in rural areas, causing their extension into spheres outside of direct physician-patient interactions. 

Language in the Rural

According to the U.S. Department of Health, limited English proficiency can prevent access to health care services, clearly indicating language as a social determinant of health (Healthy People 2030, n.d.). This is generally tied to health literacy, defined as “the degree to which patients understand basic health information,” which has lower rates in rural areas (Rural Health Information Hub, 2022). However, after reflecting upon this definition and its use of the word “understand,” I feel as though there is a distinction between language and health literacy as social determinants of health. An immigrant patient may have a strong perception of their health based on information they received in their first language. However, the patient may struggle with language barriers if they reside in an area that lacks access to interpreters, like in rural communities (Rural Health Information Hub, 2022). This can result in poor health outcomes, such as improper medication use or health screening misunderstandings. While closely related to health literacy, language differences result in more of a fundamental miscommunication barrier, especially in rural areas where there are limited resources to overcome the challenges they create. 

Silver Lake Mill, a farm located just west of Harrisonburg in the rural town of Dayton, VA. (Photo by Holly Bill)

Taking the case of Harrisonburg in particular, those in my town fall victim to the underlying language divide, despite the area’s diversity. There is a shortage of interpreters and multilingual physicians, and offering translated medical documents is not common practice (Kraska, 2016, 18). This reminded me of the Nature article’s meat-packing vignette in the rural San Joaquin Valley. Despite the poultry plant’s employees speaking strictly Spanish, Hmong, and Punjabi, all of the signs in the building about coronavirus safety and statistics were in English (Maxmen, 2021, 680). The lack of accessible COVID-19 information for the workers posed a serious health hazard. Even in rural communities where those fluent in English are the minority, language barriers to health persist. 

“Hard copies of consent forms, aftercare instructions, any of those
things, all of the brochures…I just don’t think they’re out there in all the possible languages that they can just pick up.”

Danielle, a Harrisonburg-based Spanish interpreter in reference to the lack of written medical information in more than one language (Kraska, 2016, 19-20).

A Barrier Beyond Healthcare

Communication differences can also play a role in scenarios tangentially related to healthcare access, such as those within the legal system. Rural areas have been hit particularly hard by the drug epidemic and have high rates of substance use disorders (Dickman et al., 2017, 1434). My mother is a psychiatrist at a state hospital, and she deals with the repercussions of  these crises not only on her ward but also in court. She speaks about the hardships faced by non-native English speakers because they have difficulty understanding the jargon of judicial proceedings. Without confidence in their English proficiency, these individuals are often frightened to stand trial. 

Medical-legal partnerships are valuable for residents of rural communities concerning issues like family law and insurance benefits, and these improve health outcomes (Rural Health Information Hub, 2022). However, if a patient doesn’t speak fluent English and lacks an interpreter, they cannot advocate for themselves in the midst of legal scenarios. 

We discussed the importance of addressing the underlying social determinants of health in confronting rural healthcare inequalities, and legal assistance is an example that does so beneficially. Yet, my mother’s experiences with many immigrants show that the efficacy of these solutions is limited. Individuals that do not speak the same language as the professionals offering assistance cannot reap the full benefits of these interventions. 

Modes of Action

After relating what we’ve learned in class regarding social determinants of health to the experiences of immigrants in my hometown, I have found that language significantly influences health outcomes. The barriers that arise from language differences are especially prevalent in rural areas and are so foundational to everyday life that they expand into realms outside of health. Thus, efforts to address these barriers are essential for tackling health disparities. These could include increased educational initiatives for both English learners (to increase their understanding of medical language) and providers (to train them to work with patients that are not fluent English speakers). Additionally, perhaps investing in translation technology and hiring more multilingual medical staff and interpreters would prove beneficial. 

“You shall love every foreigner as yourself.”

A Bible verse displayed outside of a refugee church in San Joaquin Valley, CA (Maxmen, 2021, 677).

Harrisonburg calls itself “the Friendly City” because of our supportive, welcoming nature to people from across the world. I am proud to be from such a diverse town, but I know work is necessary to ensure that every resident, especially those suffering from language barriers, can live a healthy life.  


Dickman, S. L., Himmelstein, D. U., & Woolhandler, S. (2017, April 8). Inequality and the health-care system in the USA. Lancet, 389(10077), 1431-1441.

Harrisonburg City Public Schools. (2017, September 10). Enrollment of English Learners – September 29, 2017. Harrisonburg City Public Schools Enrollment Statistics. Retrieved February 30, 2023, from

Healthy People 2030. (n.d.). Social Determinants of Health. Office of Disease Prevention and Health Promotion. Retrieved February 15, 2023, from

Kraska, S. J. (2016, May). Examination of the effects of language and cultural barriers on Spanish-speaking patients in health settings as observed by medical Spanish interpreters. Senior Honors Projects, 185, 1-44.

Maxmen, A. (2021, April 29). Inequality’s Deadly Toll. Nature, 592, 674-680.

Public School Review. (2023). Harrisonburg High School (2023 Ranking) – Harrisonburg, VA. Public School Review. Retrieved February 15, 2023, from

Rural Health Information Hub. (2022, June 6). Social Determinants of Health for Rural People Overview. Rural Health Information Hub. Retrieved February 16, 2023, from

Brick by Brick

America is the land of the free and home of the brave. It is the land of opportunity where so many have come to try to live their own American dream and make it big. However, this country is in no way perfect and has a handful of glaring flaws, one of the biggest and most significant being the healthcare system. Still, throughout the nation’s history, we have shown the ability to recognize our flaws, address them, and turn out better in the end. The healthcare system is broken, but not beyond repair. The key is finding exactly where and why it is broken and then repairing it piece by piece, brick by brick.

Trials and Failures

America is the world’s largest economy by nominal GDP and spends more on health care than any other country. Despite this fact, the US scores surprisingly poorly on a variety of key health measures, such as life expectancy, preventable hospitable admissions, suicide, maternal mortality, and obesity rate4. In this country, it is mostly pay to win, but many are still paying a lot just to continue to get the short end of the stick. 

Certain efforts are geared towards improving the current system, but many of them do not address any of the root causes of these current issues. In fact, the majority of the investments in the healthcare system simply perpetuate and intensify the system’s flaws. For one, there is an extreme overemphasis on procedures and drugs4. While these options should generally be seen as secondary, tertiary, or last resort alternatives, they make up a sizable chunk of primary treatment decisions. These options can be helpful and beneficial, but they are often burdensome on the body and usually come with a collection of side effects making them less than ideal.  Focusing on drugs and procedures has also led to a high emphasis on technology and specialty care4. Innovation in these fields can be very exciting and life changing for many people, but it also diminishes the attention towards promoting basic health practices such as nutrition, exercise, mental health, and primary care in general. This is extremely problematic as ignoring these components of people’s lives is often what leads to the more serious health issues. 

Building From the Ground Up

Since there are so many problems that can be prevented, addressed, and treated on the primary care level, there needs to be more emphasis on its importance. Due to social media and pop culture, people often get lost in the alure and flare of the operating room, dramatic technological innovation, and breakthroughs in medical research. Shows like Grey’s Anatomy or ER demonstrate the adrenaline, excitement, and miraculous effects of surgery and medical innovation, and these values and perspectives seep into the viewers mind, distorting the image of the real healthcare system in its entirety. Each of these components holds intrinsic value but can overshadow the power and impact of incremental primary care2

“Governments everywhere tend to drastically undervalue incrementalism and overvalue heroism.”

Atul Gawande from the New Yorker2

I have seen this firsthand when my own little sister’s life was saved because of the attention, care, and intuition of her primary care physician, Dr. Nicholas Kyriazi. My older sister, myself, and my younger brother all had the same doctor, so our family had a good, long-standing relationship with him. One day, during a routine check-up, he was listening to my little sister’s heart and noticed the rhythm was slightly off. He notified my mom that he had identified a heart arrythmia and advised that she follow up with a cardiologist to confirm and seek proper treatment. Through a variety of tests and scans, the cardiologist confirmed what Dr. Kyriazi had detected with his stethoscope. The cardiologist found a small hole in my sister’s heart which was the source of the arrythmia. However, since it had been caught so early on, there was plenty of time to address the issue and ensure the best treatment be put in place. At 5 years old, my little sister had successful open-heart surgery to repair the hole in her heart, and she is now a fully healthy and happy 15-year-old having no issues since. The surgeon directly resolved the issue in the end, but Dr. Kyriazi identified the problem and gave our family plenty of time to find the best solution. He is a hero.

Giving Care to Those Who Need It Most

“Until today, I didn’t know what a leaf looked like.”

4 year old child after receiving glasses for the first time at RAM3

My sister needed a hero, and there are plenty more out there who need a hero just as much if not more than she did. A multitude of those in need are suffering from more than just medical issues. One of these groups includes middle-aged, non-Hispanic white people, especially those without a college degree. Throughout the past few decades, this group in particular has experienced a spike in mortality, identified by a Princeton University study1. These so-called “deaths of despair” include “white, working-class people ages 45 to 54 were drinking themselves to death with alcohol, accidentally overdosing on opioids and other drugs, and killing themselves, often by shooting or hanging1.” These source from four main indicators which include feelings of hopelessness, having low self-esteem, feeling unloved, and worrying frequently. Both the deaths and the associated indicators are evidence of the social determinants of health. 

Source: Science News

There have been efforts to address these issues and kickstart some reparations to this broken system. Organizations such as Remote Area Medical have made an incredible impact in these rural communities of Appalachia. They travel and set up large medical clinics in rural areas where they provide free medical, vision, and dental treatment to people who generally do not have financial or geographical access to healthcare3. They provide relatively simple care, but the effects of what they do change the lives of so many underserved individuals. Organizations like RAM and individuals like Dr. Kyriazi represent the small yet powerful solutions to our broken system. Recognize them, celebrate them, and emphasize their power and importance. 


1Bower, Bruce. “’Deaths of Despair’ Are Rising. It’s Time to Define Despair.” Science News, 2 Nov. 2020, 

2Gawande, Atul. “The Heroism of Incremental Care.” The New Yorker, 16 Jan. 2017, 

3Reichart, Jeff and Farihah Zaman, directors. Remote Area Medical. Candescent Films, 2013. 

4Robert H. Shmerling, MD. “Is Our Healthcare System Broken?” Harvard Health, 13 July 2021, 

5Tikkanen, Roosa, and Melinda K Abrams. “U.S. Health Care from a Global Perspective, 2019: Higher Spending, Worse Outcomes?” U.S. Health Care from a Global Perspective, 2019 | Commonwealth Fund, 30 Jan. 2020,