The life expectancy in South Dakota’s Oglala Lakota County, which includes the Native American reservation, is 66.8 years, while the life expectancy in wealthier regions of Colorado, which include Vail and Breckenridge, is 86 years.1 This 20-year difference is deeply unsettling and representative of deep-rooted issues of inaccessibility and inequality. Health is a basic human right for all. It is a resource which enables individuals to live productive and happy lives. And yet, research has shown huge health disparities.2 The uneven distribution of resources and care is directly related to the sociological conditions of racism, nationalism, and bias. In recent years, necessary increased attention has been paid to health inequities and disparities, especially in regard to race and wealth.3 Simultaneously, there has been dialogue on accent discrimination in health care.4 Most often, with the prevalence of organizations like Doctors Without Borders and the import and export of health professionals, this dialogue focuses on discrimination against nurses and doctors. But less has been done on reverse accent discrimination of the patient. Perception on the part of the healthcare provider is detrimental to the health of the patient. These ideological assumptions create and perpetuate health disparities. The inherent power dynamic of medicine--the knowledgeable doctor and layman patient--provides ample opportunity and space for even negligible prejudices to have drastic health effects. Healthcare providers’ perceptions of these underlying identities directly affect care. But, I argue, the health outcomes of those who are perceived as accented pay an undetected price in their health and well-being. Those who are perceived as accented, visually and aurally, are effectively silenced by the medical field. Through my work, I will explain how mainstream and marginalized identities receive different care. I will go into the baselessness of this bias and provide recommendations to counteract accent bias in healthcare.
The human body is a noisy and expressive thing. A rumbling stomach is a sign that we are hungry, while a burp implies that we are satisfied. Cracking your knuckles might be innocuous, while cracking your back could be relieving or even painful. A regular check up with a doctor will contain a number of aural tests such as a stethoscope to the heart to test for heart murmurs or other abnormalities. They will listen to lungs for the sound of liquid or ask patients to cough to check for hernias. Sound is an important diagnostic tool. As Shannon Mattern notes in an article on auscultation, “the human body is a resonance chamber whose particular sonic qualities can reveal its condition of well-being.”5 The way a body sounds can indicate how healthy it is. The ancient Greeks would press their ears to the chest of an individual to listen to his lungs, a technique which prevailed for centuries, while Leonard Auenbrugger pioneered tapping the thorax with the finger, called percussion, to listen for changes in density and thus air-filled, solid, and fluid filled body parts.6-7 But I would argue that the inseparable intersection of sound and health really came to fruition with the creation of the stethoscope in 1816 by René Laënnec. Laënnec was a French physician working in the early 19th century. While he was examining a particularly corpulent women, the inconvenience and modesty of the time made it unsuitable for him to press his ear to her chest as would have been the usual practice. So, instead, he rolled up paper to make a narrow tube and listened through the other end. He described the experience here:
“I then tightly rolled a sheet of paper, one end of which I placed over the precordium (chest) and my ear to the other. I was surprised and elated to be able to hear the beating of her heart with far greater clearness than I ever had with direct application of my ear. I immediately saw that this might become an indispensable method for studying, not only the beating of the heart, but all movements able of producing sound in the chest cavity.”8
Many advancements have been made to the elementary stethoscope Laënnec invented. But more important was his invention of the connection between the sounds of the body and its health leading to research delving into the specific sound of health and deviations of health.9 He created auscultation as a technique that necessitated an instrument. The integration of listening to the body and medicine have since become so intertwined that the stethoscope has become the de facto symbol of medicine. And in many ways, that has been good. Internal organs like the heart, lungs, and bowels can be heard without much intrusion or time investment. With minimal invasion, a trained doctor can tease out minor and serious health issues. The stethoscope amplifies the sounds of the internal body.
The process of listening is most effective when it is isolated from the other sensations.10 Discomfort on the part of the patient or physician in position will distract their ability to listen only to the stethoscope. Doctors shifted from listening to the patient to listening to their apparatus. “Mediate auscultation,” as Jonathan Sterne observes in his book on auscultation and the stethoscope, “was an artifact of a new approach to reason and the senses, in which listening moved away from the ideal of spoken exchanges between doctor and patient into the quiet, rhythmic, sonorous clarity of rationality.”11 Doctors shifted from listening to the vocalization of the patient to listening to the body and, through this act of listening to the body and not the patient, the stethoscope effectively pits the patient’s body against itself.12
When Laënnec invented the stethoscope, he not only found an instrument to listen but also provided an opportunity for physical distance between the patient and the doctor.13 The stethoscope creates a “private auditory space.”14 “The technique requires doctor and patient to get close to one another, but also ensures a degree of physical separation and diagnostic detachment.”15 Doctors were moving away from a preoccupation with the interpretation of symptoms as related by patients. They were instead becoming increasingly concerned with anatomy and pathology.”16
Laënnec said that a disease should be assessed through the rational consideration of empirically valid signs. Patients may lie but the sounds of the body could not. The doctor could listen and form an ‘objective’ opinion separated from the possible deceit of the patient.17 Therefore, the stethoscope pits the subject against itself. This can be seen in Egophony, which is when the patient is asked to say the letter “e” while the doctor listens to the lungs with a stethoscope. Clear lungs will sound like “ee,” while lungs that are filled with fluid or have a tumor will sound more like “ay.” The “e” sound is transmuted to an “a” sound through the body.”18 What the patient says and what the doctor hears are in contrast. And in this contrast, the doctor relies on what they hear more than what the patient says.
One patient in Tom Rice’s book, Hearing and the Hospital: Sound, Listening, Knowledge and Experience, said “they’re just part of what they [the doctors] do in here, which is basically turn you inside out.’”19 The stethoscope blurs the line between public and private by putting the inner life of the patient on display. The inner folds of the human body are broadcasted as sound, publicizing the private life, and thus removing boundaries.20 The patient’s self and subjectivity are seen as inconvenient and untrustworthy obstacles to be overcome by the stethoscope.
Michel Foucault in his book, The Birth of the Clinic: An Archaeology of Medical Perception, coined the term “medical gaze.”21 According to Foucault, the medical gaze is comprised of a “sensorial triangulation” of hearing, touch, and sight.22 The medical gaze touches, listens, and sees. So, by listening to the body the doctors are also exerting power over the patient. Understanding this concept becomes integral to understanding the inherent power dynamic in health. Foucault argues that hospitals, like prisons, are institutions of surveillance and control.23 Even though there is a dimension of healing, the reliance on and gratitude to doctors for health can further exacerbate feelings of obligation which hinder patient autonomy. Rice speaks to this in regard to patients consenting to being displayed and physically listened to by medical students. The patient’s debt from care means that even willing participation can really only be viewed as “quasi-voluntary.”24
The medical reliance on the Foucauldian gaze of seeing and listening to the body leads to a segmentation and dehumanizing of patients. It leads to thinking of patients as just bodies. By viewing patients anatomically, the emotional and intimate aspects of human existence are lost. One medical student said:
“’Sometimes I become really conscious that all we do is reduce people to two heart sounds and a murmur.’ He pointed out that just as the stethoscope was in essence a small amplifier, it had the effect of amplifying the heart sounds in such a way that they came to drown out other considerations, eventually eclipsing ‘the patient’ altogether.”25
The gaze becomes anatomical. But medical professionals are not just listening to heartbeats, but the health of a patient, family member, or their own heart. And the sound of something healthy or nonnormative can be a question of life and death. It establishes sound as a source of medical data and places a physical distance between the doctor and patient, especially in regard to training and authority.26-27 It creates a power dynamic between a patient and his or her doctor where the doctor is a trained expert at listening, while the patient cannot hear that sort of intimate knowledge about their inner body. This cements the power dynamic of the expert. The stethoscope is a symbol of power and in Rice’s book, medical students speak to the sense of elation and almost superiority they feel with a stethoscope draped across their shoulders, even when they have not yet mastered how to use one.28 It is a performance of authority complete with props.
This acceptance of doctor driven data over patient’s accounts is expressed in one anecdote where a patient had been complaining of chest pain for several months. However, despite her confidence that something was wrong, and since the doctors could not find anything with which to diagnose her, there was effectively nothing wrong with her. Finally, a doctor detected an aortic aneurysm. The doctor offered for to let the patient hear for herself what was wrong as the evidence of what the patient felt the whole time but did not really exist until it was ‘discovered’ by the doctor.29
With the creation and implementation of the stethoscope came the use of instruments to “mediate” the physician’s attention to audible movements inside the body to the effect that a doctor must rely on an instrument at the consequence of not listening to a patient. This shift in listening may seem innocuous or even beneficial, but its effect can be incredibly disastrous, particularly for accented bodies.30 It creates a sense of wariness of patients’ accounts in lieu of what the doctor perceives and creates distance between patient and physician. This distance is particularly detrimental to those who are perceived as accented who are already made silent and invisible in healthcare.
The importance of sound in medicine, and considering the patient’s feelings as less important than what the doctor hears, therefore, establishes the move into a study of accented patients in the medical field. And because all accents are not created equal, there are power dynamics therein. Patsy Rodenburg, a renowned voice teacher, coined this prejudice “vocal imperialism.” Her exposure to acting has created an awareness of people’s aural preferences. She rails against the shockingly pervasive underlying belief that there is “one right voice.” The “white, well-educated, middle to upper class, Christian, heterosexual, able-bodied and most likely male”31 has benefited from centuries of maintaining their way of speaking as correct and deeming all other forms as wrong. She correctly opines that English has been “enriched”32 by different groups. The fact is, just like racial judgments drawn from perceiving skin color, vocal imperialism is founded on nothing and yet accepted as the truth. “The biology, mechanics and hydraulics of the human voice are the same everywhere,” but the moment someone speaks, they are judged. 33 Assumptions are made about “intelligence, our background, class, race, our education, abilities and ultimately our power,”34 even though the voice is not a passport revealing the resume of the speaker. As listeners, we act like we can place the speaker and judge their worthiness. The speaker, not surprisingly, is incredibly aware of how they are perceived. The internal dissonance alone is enough to damage one’s self-image. “Whenever I work in the American South,” Rodenberg notes, “I get telephone calls from businessmen and women who 'want to sound more northern' and not so rural. They believe they will earn more respect with a quick change of vocal identity.” Rodenburg’s wide-ranging examples from Businessmen in Birmingham to Japanese film directors to Canadian actors suggest that no one with a perceived accent feels not judged. She continues, “We are instantly known to others by our voice and dialect, and we are actually censored from having the right to speak certain things. You may not believe it is true but there is such a thing as 'vocal imperialism'.” 35 It is not only wrong and problematic, but also criminal to determine a voice is not good enough.
English speakers perceived as accented receive differential treatment. Amy Tan in her essay, “Mother Tongue” touches on these themes of perception and bias. The way she speaks with her mother is their “language of intimacy,” but their conversations have been described by friends as “broken” or “fractured.” This unfairly implies that her mother’s voice needs to be changed and fixed. But beyond surface level ideas, the consequences of this thinking can be dangerous. With a view of “limited English” comes the belief that the speaker is “limited,” as in the “English reflects the quality of what [they] have to say.” If people hear an accent and use it as evidence of the speaker’s incapability, the speaker is made lesser than and voiceless. Tan tells a story of her mother going to the hospital excerpted here:
“My mother had gone to the hospital for an appointment, to find out about a benign brain tumor a CAT scan had revealed a month ago. She said she had spoken very good English, her best English, no mistakes. Still, she said, the hospital did not apologize when they said they had lost the CAT scan and she had come for nothing. She said they did not seem to have any sympathy when she told them she was anxious to know the exact diagnosis, since her husband and son had both died of brain tumors. She said they would not give her any more information until the next time, and she would have to make another appointment for that. So, she said she would not leave until the doctor called her daughter. She wouldn’t budge. And when the doctor finally called her daughter, me, who spoke in perfect English — lo and behold — we had assurances the CAT scan would be found, promises that a conference call on Monday would be held, and apologies for any suffering my mother had gone through for a most regrettable mistake.”
The right accent becomes directly synonymous with respect and attention. If the mother had not been persistent, she would have been made voiceless by the medical system purely due to her accent influencing healthcare workers’ perception of her as unworthy.
The perception of accent and difference leads to detrimentally different healthcare and health outcomes. One study conducted at the University of Nova Scotia collected qualitative data from 32 immigrant women from Asia, Africa, Latin America, the Middle east, and Europe. The findings revealed that markers of accent and difference such as skin color, aural sound, and weight, led to “unfavorable interpersonal dynamics. Fundamental causes of diseases and clinical discourses are embedded in ethno-cultural realities of gender, ethno-racial identity, English communication styles and immigration related economic downturns.”36 That is to say, perceptions of accent and health professionals’ personal views on immigration are compounded to create underwhelming and insufficient health resources for the women.
Two other studies conducted in Canada by two researchers in 2008 and 2009 looked at immigrants’ experiences with mental and maternal health, respectively. In both studies, the women reported poor healthcare experiences. While income and employment were determinants of health, a higher percentage of immigrant women in the study had professional degrees and many were economically well off. However, despite their socioeconomic status, the study found that the visually accented women’s health experiences were negatively affected by discrimination and racism. The author of these studies notes:
“Primary healthcare services in Canada are considered Eurocentric and exclusive to many visible minority women (and men) since they rarely accommodate immigrants’ culturally and linguistically underpinned health and social needs…The cultural and linguistic backgrounds of immigrant women and their healthcare providers sometimes led to difficulties in diagnosis and treatment. Many diagnostic tools and therapeutic approaches are based on research driven by and embedded in Western cultural values and norms…Participants in this study welcomed the idea of having a healthcare system with providers with similar cultural and linguistic backgrounds. They believed that this may free them from the need to justify their values and behaviours.”37
The health care system relies on Western approaches to medicine, and thus, subverts potential cultural and linguistic needs of the women. This interpretation led to discomfort and frustration among health professionals and the silencing of the patients.
With miscomprehension, comes apathy. A recently completed doctoral thesis by Brian Ray Snider looks at the varying prognosis of 110 participants and drew comparisons between the prognosis and the perception of racial identity. “The results suggest,” Snider writes, “that the subjects actually displayed a reverse bias in that they viewed the client who spoke non-standard American English as having a significantly better prognosis, and the client who spoke standard American English as in more urgent need of mental health treatment.”38 As the health professionals struggled to sympathize and empathize with their patients, they undermined their health needs and made them nonexistent in the system.
So, what is the solution? First and foremost, a counterintuitive shift in thinking is necessary in order for us to understand the predicament of the person who is rendered as an unspeaking thing to be made sense of. Thomas Nagels’ “What Is It Like to Be a Bat?” provides a good framework for such a revolutionary new way of thought. Nagel asks, “What Is It Like to Be a Bat?” and decides that when something alien is encountered, we can only imagine from our own experiences. We are “restricted to the resources” of our own minds which are inherently inadequate.39 Upon reflection, we realize that there are aspects of being a bat which cannot and will never be comprehended. The facts are too alien from our own experience to be fathomable. But “we can be compelled to recognize the existence of such facts without being able to state or comprehend them.”40 If “consciousness is what makes the mind-body problem really intractable” and consciousness takes two forms: subjective and objective. This perception is forever intertwined with the body. 41 Medical professionals, therefore, must recognize the facts of their own perceptions and must try to take up the point of view and experience of their patient. And, with this adoption of another experience, the view left behind remains unreduced. And if “the more different from oneself the other experiencer is, the less success one can expect with this enterprise,” then the health professional must see the limitation of their imagining and do extra work to make space for the voices of the accented. 42 However much we want to emphathize with others, our physiology, ideology, and culture limit us. We are perceived by the limitations of our bodies and limited by the way we are perceived. Medical training should include implicit bias and judgement training to integrate the awareness into care.
Much like the stethoscope, which shifted the attention of doctors from listening to their patients to listening to the bodies of their patients, language as it pertains to health and the way an individual’s health is categorized has been used historically to usurp the patient’s voice. For linguistic dominance to end in health, the field should be opened to a population more representative of the patient population. With multiculturality comes the expectation to ask more questions and listen more. All this is to facilitate healthcare accessibility. “When a person walks into a physician’s office, the physician becomes one of the players in the story.”43 This gives power to a physician to disenfranchise or believe and contextualize the patient’s illness. As health professionals struggle to sympathize and empathize with their patients, they undermine their health needs and silence them, making them nonexistent in the healthcare system.
Bibliography
Gu, Yulong, and Amee P. Shah. “A Systematic Review of Interventions to Address Accent-Related Communication Problems in Healthcare.” The Ochsner Journal 19, no. 4 (2019): 378–96. https://doi.org/10.31486/toj.19.0028.
Mattern, Shannon. “Urban Auscultation; or, Perceiving the Action of the Heart.” Places Journal, April 28, 2020. https://placesjournal.org/article/urban-auscultation-or-perceiving-the-action-of-the-heart/.
Nagel, Thomas. “What Is It Like to Be a Bat?” The Philosophical Review 83, no. 4 (October 1974): 435–50. https://doi.org/10.2307/2183914.
Orgera, Kendal, Olivia Pham Published: Mar 04, and 2020. “Disparities in Health and Health Care: Five Key Questions and Answers.” KFF (blog), March 4, 2020. https://www.kff.org/disparities-policy/issue-brief/disparities-in-health-and-health-care-five-key-questions-and-answers/.
Queen, Jack. “Study: Eagle County Has Third-Highest Life Expectancy in Nation; Summit First.” Accessed May 11, 2020. https://www.vaildaily.com/news/summit-county-has-the-highest-life-expectancy-in-the-nation-according-to-new-study/.
Reitmanova, Sylvia, and Diana L. Gustafson. “Health and Social Inequities of Visible Minority Immigrant Women in St. John’s: A Critical Population Health Perspective.” In Canadian Perspectives on Immigration in Small Cities, edited by Glenda Tibe Bonifacio and Julie L. Drolet, 173–94. International Perspectives on Migration. Cham: Springer International Publishing, 2017. https://doi.org/10.1007/978-3-319-40424-0_9.
“Sounds of the Body | Encyclopedia.Com.” Accessed May 11, 2020. https://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/sounds-body.