Olin College of Engineering
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Role of Language in Identity and in Healthcare
Interactions of Haitian Immigrants
Jacqueline Baca
Franklin W. Olin College of Engineering, [email protected]
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Baca, Jacqueline, "Role of Language in Identity and in Healthcare Interactions of Haitian Immigrants" (2012). 2012 AHS Capstone
Projects. Paper 25.
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Role of Language in
Identity and in Healthcare
Interactions of Haitian
Immigrants
Jacqueline Baca
12/12/2012
Baca 1
Introduction
The Greater Boston area hosts the third largest populations of Haitian immigrants in the
United States (BRA , 2009). As people who self-identify as Haitian make up approximately three
percent of the city’s population (US Census, 2010), health personnel working in Boston can
expect to regularly encounter Haitian patients - some of whom will be limited in their English
proficiency. Providing effective, patient-centered medical care to this population requires an
understanding of cultural and linguistic factors.
For Haitians, languages have a complex historical and social significance, as Haiti has a
legacy of social stratification enforced by language, with the elite using French to the detriment
of the vast majority of the Haitians who are monolingual Haitian Creole (henceforth referred to
as Creole) speakers. The resulting perceptions surrounding language use persist among Haitians
residing in the United States. As these immigrants acculturate to the United States, English
comes to have an increasing role in their communication, even when among Haitians. Some
Haitian adults are wary of youth acculturation, which, due to race attitudes in the United States,
tends to be with African Americans. These adults invoke language as a differentiator instead of a
means by which to blend in.
According to 2010 census data, forty-four percent of the Haitians living in Boston selfreported speaking English less than “very well.” All health care for this population, whether on
an individual or population level, will have to accommodate the language needs of this
population. For individual Haitians, these needs can be addressed either by the provision of a
medical interpreter or by the use of a Haitian and/or Creole-fluent provider. Each of these
methods has challenges in effective implementation, both logistically and culturally. At the
public health level, initiatives intended to affect the health of the Haitian-American population
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must be in an accessible language and be done in a culturally suitable manner to be successful.
This paper seeks to reveal the language attitudes of Haitians in the Boston area and the role of
language in the receipt of healthcare by these individuals, using information gathered in a small
series of informal interviews with Haitians and healthcare providers who work with Haitians,
with a review of relevant literature providing context for their observations. Table one introduces
the subjects of these informal interviews.
Table 1
Pseudonym
Occupation
Comments
Isabelle
Fully trilingual, has lived in
Haiti, Canada, and the US
Luc
Works with a non-profit for
women with reproductive
disorders
College student
Madeleine
College student
Nicole
Nurse Practitioner, Home
Health
Works in public health
Moved to US at 5 y/o, speaks
Creole and English
Born and raised in the US,
spent 3 years living in Haiti as
a teen.
Haitian , sees many Haitian
patients
Trilingual, raised in Haiti
Emergency department
physician
Not Haitian has treated
Haitians and worked in Haiti.
Marc
Jon
Haitian History, Focused on Language
The language attitudes of Haitians residing in the United States stem from the language
situation of Haiti. The current roles of French, Creole, and, increasingly, English in Haitian
culture have been determined by the history of Haiti, dating back to its colonization.
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In 1697, France assumed control of the portion of the island of Hispaniola that they called
Saint Domingue (now Haiti), from Spain. The Taino natives of the area were killed by
combination of enslavement by Europeans and exposure to disease (Fouron, 2010). Under the
French, a highly profitable plantation system developed utilizing slave labor. The slaves came to
Haiti speaking various West African languages. They all had exposure, in varying degrees, to
French via the landowners, overseers, and slaves working in houses. According to popular
linguistic theories, to communicate with each other, these slaves began to adopt a French-based
vocabulary with West African grammatical structure, which, over time, developed into Haitian
Creole (Zéphir, 2010).
A revolution that began in 1791 culminated with Haiti declaring its independence from
France in 1804, creating the world’s first free, black republic. In the period following
independence, Haiti was largely isolated, as its possible influence on slaves elsewhere was seen
by the US and Europe as dangerous (Fouron, 2010). When it recognized Haitian independence in
1825, France charged Haiti a reparation fee of 150 million francs for the property that was taken
from French citizens in the revolution. Haiti’s first national bank was established largely under
French and German control, with Haiti incurring significant debt to both countries (Fouron,
2010). As a result, the elite, banking class had contact with foreign nations and their languages
whereas the peasants remained largely isolated. Furthermore, internal economic stabilization and
growth were superseded by the need to fix the external financial affairs (Farmer, 2003). The
political situation during the nineteenth century remained unstable, with multiple violent
overthrows of government, many of which were aided by foreign powers supporting their
business interests (Fouron, 2010).
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The United States began military occupation of Haiti in 1915, under the pretext of
helping them to manage their volatile political situation (Fouron, 2010). A new national
constitution (drafted by Franklin Delano Roosevelt) was introduced in 1918. Among other
things, this constitution, which was approved by voters in a flawed election (Farmer, 2003),
allowed foreigners to own land in Haiti, a right prohibited under the previous constitution, and
established French as the official language. The former had the effect of allowing US citizens to
purchase land in Haiti and take advantage of cheap labor for business ventures. The latter
reinforced that all official transactions would be conducted in a language that only the most elite
five-percent of the country could understand.
For the remainder of the twentieth century following the US departure in 1934, the
country was governed by a string of dictators. Almost all the leaders during this time were
promoted by US and elite interests (Farmer, 2003). This included, notably François and JeanClaude Duvalier, a father and son dictator regime supported by the US under the pretext of
preventing communism in Haiti. Haitian emigration picked up speed under the Duvaliers, who
maintained paramilitary groups that terrorized the citizenry. These parties had interest in
maintaining a status quo and the French language became a tool for them to retain power.
Effectively, with the French as the official language in Haiti, monolingual Creole speakers could
not perform even the most mundane of government tasks without assistance.
Since the end Duvalier reign in 1986, there have been a multiple leaders in Haiti, some of
whom, such as Jean-Bertrand Aristide, were elected and come of whom took power through
force. The US sent troops to Haiti in 1994 to reinstate Aristide, who’d been ousted in a coup and
UN troops went to Haiti to maintain order when Aristide was ousted for a second time in 2004
(Fouron, 2010). The subsequent president, René Préval was able to serve his full term in the
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presidency and transfer power to Michel Martelly in 2011. Despite the political situation having
calmed down in Haiti, the country has struggled, especially since the Earthquake in 2010.
One token step for Haitian Creole in attaining official recognition occurred with the
Bernard Reform, of 1979, which stipulated that the first four years of classroom instruction in
government schools should occur in Creole, after which French could be introduced (Joseph,
2010). It makes sense for students to be taught in a language they understand, but many Creolespeaking families were (and some continue to be) skeptical of this reform, as they wanted their
children to have the option for social and educational mobility implied by knowledge of French.
Furthermore, over eighty-percent of education in Haiti is provided by private schools, where the
reform does not take effect. Regardless, for any educational reforms or initiatives to be
successful in Haiti, basic challenges, such as the cost of school fees relative to family income and
the lack of credentialed teachers must be addressed (Office of the Special Envoy). Educational
reform has been slow to implement with the result that students are neither being taught other
subjects (such as math) in Creole, nor are they actually learning French (Joseph, 2010).
Creole has been gaining ground in terms of its use in Haiti. It is now used in many
Catholic masses (Zéphir, 2010), a movement started by liberation theologists, such as Father
Jean-Bertrand Aristide (Farmer, 2003). Additionally, it is used increasingly in radio and
television media. Furthermore, it has been recognized as an official language alongside French
since the constitution of 1987 and is now used in many official proceedings, such as court trials
(Zéphir, 2010). To this day, however, much of the business in urban areas of Haiti continues to
be conducted in French, consistent with the language hierarchy that was established over the
preceding 300 years of Haitian History.
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Language use of Haitian immigrants – French, Creole, or English
Haitian immigrants in the United States communicate in French, Creole, and English,
depending on social circumstances and intent. While they use English when interacting with nonHaitians in the United States, many Haitians who were raised in Haiti prefer to speak French or
Creole when speaking with other Haitians. The choice between French and Creole has many of
the same social implications as it does in Haiti. Haitians who were raised in the United States and
who spoke English extensively from a young age often prefer to use English, even when among
Haitians. To some extent, this represents purposeful acculturation and an attempt to blend in.
Language is therefore sometimes also used as a tool of differentiation by those who fear the
station to which they are being pressured to acculturate. Due to the varied social pressures
determining the language choices of Haitian immigrants, language takes on significance beyond
practical communication.
Those who choose to signify that they are among other Haitians by not using English have the
choice between French and Creole. This choice is a delicate one. Luc would like to learn French
because he would someday like to travel to France and because he has heard that it can be used
to impress women – apparently that tactic worked in helping his biological father court his
mother. He hastens to add, “I would never speak French to my Ma if I knew it,” recognizing that
the pretension and distance of French could insult his Mother. Even as a non-French speaker who
grew up in the United States, where Creole and English predominate, Luc senses that French
must be used carefully, describing its use as potentially “snobby.”
While close friends and family generally use Creole when speaking to each other,
French is sometimes employed among acquaintances and strangers (Zéphir, 1997). The choice of
Baca 7
a Haitian to initiate a conversation in French serves two purposed: 1) the speaker is making a
statement about his or her social status and 2) the speaker is saying that he or she has taken the
measure of the other person and found him or her to be of a social standing that indicates that he
or she also speaks French (Zephir, 1997). If the listener does not, in fact, speak French, however,
the assumption that they should could result in embarrassment.
Though Isabelle is fluent in French, she uses Creole when speaking with other Haitians.
She would rather insult someone by refusing to acknowledge their class than embarrass someone
by making them admit to not knowing a language. On one occasion she persisted to respond in
Creole to a gentleman who was speaking to her in French. He questioned her on it, and she
responded, “How wonderful is it that you speak to me in one language, I answer in another, and
we both understand?” While Isabelle will speak French with friends from the Côte d’Ivoire, and
will even speak it with Haitians in Montreal, where French is the dominant local language, she
refuses to use it to reinforce class distinctions. By responding to a French conversation in Creole,
she was effectively rejecting the suggestion that either she or the person talking to her should
belong to a higher class than other Haitians. Her sarcastic response to his questioning emphasizes
her attitude on language, which is that any language is acceptable as long as it is being used as a
tool for communication and not as a means of social stratification.
English necessarily contributes to the language choices of Haitians in the United States.
English is, by necessity, language of communication with non-Haitians within the United States.
It is increasingly gaining use among Haitians as well, especially among young people. There is a
persistent idea that all Haitians speak creole, but families who speak only English at home now
comprise 18.5% of the Haitian households in Boston (US Census, 2010). Madeleine’s father
always speaks English with her and though her mother will use creole with her, her tendency
Baca 8
while young was to respond in English. Even youth who speak Creole with their parents at home
speak English at school and become accustomed to using English with their peers. As a child,
Luc often attended Catholic masses in Creole and was part of the church youth group. Though all
the students in the group were Haitian and could speak Creole, they chose to use English.
To some extent, the choice to use English represents an attempt to further acculturate to
the United States. Luc remembers stress among different Caribbean nationalities while he was
growing up in New York. “There’s division within the Caribbean itself. It’s so stupid. Like
Jamaicans and Haitians, DO NOT get along AT ALL, EVER.” When he was in elementary and
middle schools, he used to try to hide the fact that he was Haitian to avoid such playground
taunts, usually from other black students, as “Watch out! He’s going to use voodoo on you.” The
better and less accented they speak English, the easier it is for Haitian students to avoid being
singled out as Haitian.
While youth may wish to acculturate to the United States as much as possible, Haitian
adults are sometimes concerned about the position to which their children are adjusting. In
moving to the United States, many Haitians from the upper and middle classes find their social
status downgraded by virtue of both a change in relative wealth and racial stratification (Zéphir,
1997). Furthermore, some Haitians feel that by allowing their children to acculturate as African
Americans, they are encouraging delinquency (Cantave, 2010). For these Haitians, language
becomes a key differentiator between themselves and other Black Americans. Haitians use
Creole to maintain a strong sense of Haitian identity among their youth. Alternatively,
recognizing that French has a connotation of sophistication among white Americans, Haitians
use French to try to achieve higher social standing than other black people in the United States
(Zéphir, 1997). While negative attitudes of Haitians toward African-Americans are neither
Baca 9
universal nor necessarily majority opinions, they do help to explain the language use patterns
among Haitians.
Haitian Providers serving Haitians
The use of language concordant providers is one method by which Haitian patients who
have limited English proficiency can receive effective medical care. Even Haitians who speak
English well might feel more comfortable working with a Haitian provider. Unfortunately, the
limited availability of Haitian providers limits this approach. Furthermore, even Haitian
providers must recognize the importance of cultural sensitivity and patient centeredness to make
real improvements in the healthcare experience of Haitian patients.
Being a Haitian healthcare provider has advantages in establishing rapport with Haitian
patients. When Nicole notices a patient has a French name, she asks them if they are Haitian. “I
see the relief in their eyes when I say ‘Yes, I am Haitian too,’” she notes. Implicit in their relief
is the assumption that Nicole will understand their language and background. In her position
coordinating home care for patients, she sees many Haitians who, by virtue of their complex
health needs, have spent a lot of time navigating the United States healthcare system. She finds
that these people, even those who have a good command of English, are more apt to vent to her
than to English-speaking providers about their frustrations related to their treatment. She recalls
one caregiver of an elderly patient whom she realized was Haitian. Nicole began to speak to the
caregiver in Creole and soon the caregiver revealed that for months she had paid another person
from her own salary to stay with the man during the night, so that she could make sure he would
not be alone if he fell. Nicole feels that, had she not been Haitian, the caregiver would not have
told her this.
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There is evidence supporting Nicole’s observation that Haitian patients reveal more to her
than to their other providers. A study comparing the use of medical interpretation to the use of
language-concordant providers for Asian immigrants found that, while there was no reported
difference in patient satisfaction ratings, patients using interpreters were more likely to have
unasked questions, especially pertaining to mental health (Green, 2005). While this study did
not involve Haitians, it involves the same issue of language concordance in a different
population of immigrants, giving us insight into the analogous condition of Haitians. It
demonstrates that even when language is removed as a barrier to communicating questions,
patients are more likely to pose sensitive questions to a language-concordant provider than to a
non-concordant provider through a third party.
The increased comfort of patients with language-concordant providers suggests that more
effort should be made to increase rates of language-concordant care. One challenge in expanding
language-concordance is that there are more patients who could benefit from this approach than
providers to deliver it (Hacker, 2012). Luc described bringing Game Boy handheld electronic
games to combat the five- or six-hour wait at his Haitian pediatrician’s office as a child. “Either
there are no Haitian doctors in Brooklyn, or every Haitian needs to see this one doctor, and that,
in essence, screws us over in the end,” he noted. In Luc’s case the lack of Haitian providers
meant an excessive wait time to appointment time ratio, whereas in most cases this results in
patients settling for English-speaking providers.
While improved patient satisfaction or comfort is considered a significant outcome for
health quality researchers, to advocate that health institutions devote increased commitment to
language-concordant care, there should also be quantifiable evidence of improved provision of
care. One frustrating aspect of concordant care is that the chief benefit of language or ethnic
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concordance in studies has been an increase in patient satisfaction, with evidence for quantified
improvement in patient-centered communication or in outcomes being much more limited
(Cooper and Powe, 2004). With the caveat he was young and may not have fully understood the
interaction between his mother and his pediatrician, Luc’s experience demonstrates this
challenge. While he surmises that going to this pediatrician made his mother more comfortable
than going to an English-speaking one, Luc didn’t notice any appreciable significance in the
patient-provider informative interaction – “It was like immunizations, crack a couple of Haitian
jokes, then leave.” This is not to say that joking or mutual understanding is not important ideally, every patient should be able to connect to their physician on a human level - but to say
that language-concordant healthcare providers are not capitalizing on this personal connection to
help their patients to better understand their health conditions or to make them partners in their
own care.
It is similarly wrong to assume that a Haitian provider is qualified to make a deeper
connection with a Haitian patient, simply by virtue of being Haitian. Marc expressed concerns
that even Haitian providers might not be adequately trained in cultural sensitivity. A Haitian who
has United States practice credentials has achieved a social standing that may compromise his
ability to effectively communicate with his Haitian patients. Most of the Haitian clinician’s
education may have occurred in French and English. This might cause the clinician to use French
or English terms when addressing a patient in Creole. Because the majority of the conversation is
in Creole, the patient is more likely to be ashamed of not understanding the full conversation.
Isabelle noted that she felt that the use of French or French terms in healthcare interactions
would put up “an instant wall” between patient and provider. A physician who is not well versed
in the class dynamics and implications of language might not even realize the significance of
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their choice to use French. In this instance of quasi-concordance, the use of a medical interpreter,
who will employ a standardized Creole vocabulary for explanations, would likely benefit the
patient.
The use of medical interpreters
Many hospitals in Massachusetts either have on-site interpretation services available for
Haitian Creole or subscribe to a telephone interpretation service. These services can usually be
requested by a patient prior to the visit or can be arranged on provider request. In theory, a good
interpreter should eliminate language as a barrier to medical care. For medical interpretation to
work properly, the service must be employed when warranted. Furthermore, interpreters must be
both competent and ethical, to ensure conveyance of complete messages without editorializing.
The use of a medical interpreter must be initiated, and even when a provider takes it upon
herself to offer to call an interpreter, the patient may not accept the offer. Nicole recalled an
instance in which the Haitian wife of a patient told her, “you don’t have to speak Creole – I
speak English fine.” This woman had been in the United States a while, had, unfortunately, a lot
of experience with the healthcare system, and probably did speak English well. She apparently
felt that Nicole was trying to patronize her by speaking Creole with her, whereas Nicole just sees
Creole as a means of better connecting with her patients. While this conversation took place with
a language-concordant provider, it demonstrates how a patient, not wanting to be a burden, to be
catered to, or to be looked down upon for communicating in Creole might refuse an interpreter.
In denying need for a Creole interpreter, a patient can miss important information. Nicole
noticed this when providing follow-up care to a woman with poorly controlled hypertension,
despite pharmacological intervention and a discussion of lifestyle changes. During the meeting, it
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became clear that the woman had not clearly understood the physician’s directions. Nicole was
able to convince the woman that medical jargon is not an aspect of English that she hears in
everyday conversation and, as such, the need for an interpreter does not reflect poorly on her
grasp of English.
Much of the issue with accepting interpretation services seems to be one of pride. Isabelle
has started a nonprofit for women with reproductive issues. Through this organization, she
referred a woman with cervical cancer to a major teaching hospital. The center reported back to
Isabelle that the patient had denied knowledge of Creole and requested a French interpreter.
Isabelle knew this woman and knew that she did, in fact speak Creole and was not fluent in
French. This woman had been involved in an abusive relationship, was unemployed, and was
currently living in a shelter. In this situation, it would seem that she needed as many resources as
possible to help her with the medical problems she was facing. Dwelling in such a powerless
position in American society, she was trying to earn a bit of regard for herself by professing
knowledge of French. It is disheartening that relative prestige of French over Creole can cause
someone to jeopardize their ability to understand their medical care.
In some instances, a patient might either prefer to or, through lack of an available
interpreter, be forced to rely on a friend or family member for medical interpretation.
Madeleine’s sister often acts as her grandmother’s interpreter. Madeleine states that her sister is
comfortable in this role and hasn’t felt that she’s had any communication issues. A study in two
Boston pediatric emergency departments found, however, that the use of ad hoc interpreters in
lieu of trained medical interpreters is associated with almost double the rate of clinically
significant interpretation errors (Flores et al, 2012). In light of this, health care facilities should
Baca 14
make sure that relying on a family member to interpret is not the default plan for patients with
limited English proficiency, and that institutional policy discourages or prohibits this practice.
Even when using a trained interpreter, it is important to make sure that the patientprovider communication is intact. This is generally done using the teach-back method, in which
the provider either asks the patient to reiterate the instructions they have been given or in which
the provider recounts what they think the patient has told them. Jon uses this method extensively
in the emergency department. Not only does it ensure that he gets the history straight, but it also
demonstrates to the patient that he is listening and gives the patient a chance to add additional
information. Because he is generally meeting his patients for the first time, establishing trust with
his patients is harder for Jon than it may be for a primary care provider, and he sometimes feels
that patients are not telling him the full story related to their symptoms. The best he can do is to
make sure the mechanics of interpretation are sound and to persist in asking questions or
repeating questions until he is confident that he has “reconciled the record with what [he’s]
hearing.”
Isabelle worked with the department of Immigrants and Refugees of a teaching hospital
on its protocols for interpretation. During this time, she kept receiving complaints from Haitian
patients about one particular interpreter. He would speak French instead of Creole, even when
patients specifically told him to speak Creole. He always dressed in a suit jacket with leather
patches and a bow-tie, as though he was, according to Isabelle, “one click above.” She told
patients to gather specific instances for her to make a case for his dismissal. This was ultimately
unnecessary, as he was fired for telling a patient having an abortion, “I hope you rot in hell.”
This is an extreme example of a medical interpreter acting inappropriately, one which occurred a
number of years ago. Unfortunately, interpretation does bring a third party into the patient-
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provider trust dynamics. The presence of this third, potentially judgmental individual may
explain why mental health concerns are less likely to be disclosed in visits utilizing medical
interpretation than in visits with language-concordant providers (Green, 2005)
Public Health Initiatives
The aforementioned approaches concern patients on an individual level, but addressing
health disparities for Haitian immigrants also requires working with the population as a whole.
Information can be disseminated in oral form, through radio or television, and in print form. The
caveat in employing written materials is that the literacy rate is low. The United States State
Department estimates that the literacy rate in Haiti is approximately 52% (“Haiti” 2012). Much
of this literacy, especially among older Haitians, is in French, not Haitian Creole, but the
population most in need of health interventions tends to be Creole speaking. Though this practice
is becoming less common, Marc, who works on public health programs for the Haitian
community around Boston, notes that through the first half of the 1990’s many materials
intended for Haitian audiences were written in French or in Creole of unofficial orthography. He
attributes this to the presence on organizational boards of “illiterate intellectuals,” Haitians who
“can fully present to you any kind of conceptual piece or presentation in any of their languages,
including Creole,” but who are literate only in French and English. Now, professional
translations are overwhelmingly in proper Creole, but due to illiteracy, that still does not mean
the target people will be able to read them. Marc suggests that the largest role of written
materials today is in standardizing the vocabulary that health professionals and interpreters are
using to discuss complex issues, such as safe sex practices, with their patients. Over time,
however, he is optimistic that increasing numbers of Haitians will be literate in Creole,
increasing the utility of these publications to individuals.
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To have the greatest impact on the health of the community, interventions must be
assessed for efficacy. This holds both in the public health domain and in individual care – to
change medical interpretation protocol or shift to using more language-concordant providers,
quality research demonstrating the benefit of these measures to the care of Haitian patients must
be performed. Cultural and linguistic barriers complicate achieving meaningful research results
within this population. One difficulty results in trying to do comparative research across different
ethnicities. Marc is concerned that Haitians answering quality surveys will have a tendency to
rate the quality of care higher than other populations, based on comparisons to the health systems
in Haiti. One key challenge in this area of research is how to establish a common basis for
comparison between populations.
An additional concern lies in convincing Haitian patients, many of whom are working
multiple jobs and raising children, that participating in research is possible and worthwhile. Marc
suggested ensuring that studies both compensate patients for their time and ensure that logistical
needs, such as transportation and childcare, are not barriers to participation. In the Journal of
Multicultural Nursing and Health, Anne Norris describes the process used for developing a
qualitative study of an HIV prevention education intervention conducted with Haitian teenage
girls (Norris, 2005). She describes steps the researchers took to achieve participation, such as
having the principle investigator appear on a radio show, and steps the researchers took to make
sure that the parents and students were comfortable with informed consent and their rights as
research participants. She further describes a process of balancing the concerns of working with
the Institutional Review Board and with members of the Haitian community to determine
protocols and compensation that would recognize the importance of participation without being
exploitive. To better serve the Haitian population, Haitians must be included in studies, but to do
Baca 17
so may require extra effort on behalf of investigators to ensure that the study design works for
Haitian patients and produces meaningful results.
Conclusion
Language plays a significant role in the identities of Haitians living in the Boston area.
Healthcare providers can expect contact with this population on a daily basis. While language
and ethnic concordance between providers and patients may enhance the patient-provider
relationship, a mismatch between the number of Haitian clinicians and patients will likely
persist. To better serve the Haitian population, it is imperative that healthcare providers and
researchers understand the historical and ongoing complexity of language use to these patients.
Baca 18
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