Money, Culture Push Many to Back-Room Health Care

As long as he lives, Salvador Martinez will blame himself for the death of his son, Christopher.

The 13-month-old boy died in April 1998 of dehydration after he was treated for the flu at what authorities described as a sham clinic in Santa Ana where a phony doctor advised withholding food and water.

“Every day I ask myself, ‘Of all the clinics and doctors I could’ve taken him to, why did I take him there?’ ” Martinez said. “Why, God, did I take him there?”

Such tragedies--and haunting regrets--are all too predictable, a result of many immigrant Latino families’ isolation from mainstream medical care.

A knot of economic, political and cultural forces trap many immigrants into seeking relief from unlicensed medical providers. They frequently are given bad, sometimes fatal, medical advice as well as dangerous drugs, banned or restricted in the United States, that are smuggled in from Mexico.

Controlling the problem, experts say, will require more than just cracking down on the smugglers and suppliers of illegal drugs. Instead, doctors, hospitals and policymakers must find ways to overcome the suspicions of immigrants who either reject the U.S. system of health care or conclude that it has rejected them.

Many immigrants wonder why U.S. doctors don’t see the value of injections that, to them, seem so rapid and powerful. And why don’t doctors here know about the ailments soothed by folk healers back home--problems like empacho, an intestinal problem attributed to food stuck in the body, or susto, a terrible disease-inducing fright?

“Medicine from Mexico cures faster and is more potent,” said Edmundo Hernandez, a Los Angeles swap meet shopkeeper voicing a common view. “Visits to the doctor here are very expensive and in the end the treatments don’t work. They are a fraud.”

To dismiss or ignore the widespread practices and beliefs among the state’s fastest-growing immigrant population--more than 4 million foreign-born Latinos--is neither humane nor sound disease control policy, experts say. It engenders a perilous alienation.

“If a patient comes from Mexico and says her son has empacho, and the doctor says there’s no such thing . . . the patient is not going to say, ‘Oh foolish me, I am so dumb,’ ” said Jean Gilbert, director of cultural competence for Kaiser Permanente in California. “What she’s going to say is, ‘This doctor doesn’t know about empacho. How good a doctor can he be?’ ”

Showing Patients Respect

What is needed is to treat immigrants where they live, within their means, respecting their culture and using their language, experts say.

“Fundamentally, I think people in health care have to get out of their offices and get down to these communities . . . and ask them what their needs are and how they can help,” said Judith Barker, a medical anthropologist at UC San Francisco.

Dr. Francisco A. Jimenez, whose motto is “Have stethoscope, will travel,” couldn’t agree more. Not content to wait for patients to come to his office, he treats patients where they shop--at Anaheim’s huge indoor swap meet, amid row upon row of other entrepreneurs hawking everything from baby clothes to jewelry.

“I go the extra mile to prevent them from going to these back-door situations. They need to know that they really don’t have to go there . . . there are bona fide physicians willing to see them.”

Individual efforts and the ingenuity of physicians like Jimenez are tiny steps in comparison to the gaping need. For the vast majority of Latino immigrants, poverty and a dread of deportation remain enormous barriers to mainstream care.

Cultural and linguistic snafus only make matters worse. Less than 5% of doctors in California are Latino, relatively few physicians speak good Spanish, and qualified medical interpreters are critically lacking in hospitals and clinics.

“The need is humongous--beyond words--and what is being done about it is very little,” said Stanford University Medical Center’s head interpreter, Linda Haffner, who has seen children under 12 years old drafted to explain surgical consent forms to their parents.

Beyond language barriers, many immigrants, accustomed to ready access and trusting relationships with folk healers and pharmacists back home, are left bewildered by the U.S. medical bureaucracy and the clinical detachment common among physicians here.

So pronounced is the overall estrangement from mainstream care among immigrants that when a family member falls ill, the response often is a frenzied stab at the most familiar and accessible option for treatment--but not necessarily the safest one.

“You get desperate when your child is sick,” said Martinez, Christopher’s father. “Desperation makes one do stupid things.”

Without insurance and cash to pay for medical care upfront, many families do without. For fear of jeopardizing their own--or their families’--immigration status, many do not apply for government assistance even when they are eligible.

Nearly 40% of California Latinos under age 65 lack health insurance, and 57% of noncitizen Latinos overwhelmingly work in low-wage jobs that offer no coverage, according to the UCLA Center for Health Policy Research.

Los Angeles County has 2.8 million uninsured non-elderly residents, more than two-thirds of whom are Latino. In Orange County, Latinos account for more than half the about 502,000 uninsured.

California has two major programs designed to help the uninsured, but hundreds of thousands of residents, many of them Latino, have not signed up even though they qualify.

As of last year, more than 778,000 California children were eligible for but not enrolled in Medi-Cal, the state’s insurance program for the poor, according to UCLA estimates. Tens of thousands of others aren’t signing up for coverage under the Healthy Families program for the working poor, although enrollment has improved since the hefty and confusing application packet was recently streamlined. These programs primarily are open only to U.S. citizens and legal residents, but many immigrant children qualify.

Still, many Latino immigrants, even those here legally, are leery of any contact with “the system.” Often, they come from families of mixed immigration status--with documented and undocumented members--and do not want to invite scrutiny or incur dreaded “public charges” that will count against them.

“There are people who . . . break their arms and can’t go get care,” said Dr. Fernando Mendoza, pediatrics chief at the Stanford University School of Medicine.

Martinez, reflecting on his son’s death, explained: “If you can’t afford . . . to go to a doctor or a hospital, you do the best you can. . . . You just want to get [your child] well.”

Even immigrants who know where to get legal and affordable medical care sometimes are stymied by the cost of prescription drugs. So they head for the border to buy cheaper versions in Tijuana, or they try some other trusted remedy closer at hand.

Many immigrants simply drive to swap meets. At a recent Costa Mesa swap meet, merchants in at least three stalls sold medications, including drugs that are either banned or have never been approved for use in the United States, such as the painkiller Neo-Melubrina and the arthritis drug Artridol.

The illicit drugs were kept hidden, stored in plastic bins or inside vans.

One merchant, in her early 20s, was busy dispensing Artridol to a woman with bone pain. Another man sold jars of a veterinary rheumatism ointment that he admitted was intended for livestock.

When a customer showed him pills that had been prescribed by a doctor, he dismissed them with an impatient flip of the hand. “American doctors don’t know what they’re doing,” he said.

Reformers say that bringing immigrant patients out of the swap meets and into the mainstream requires more aggressive outreach in immigrant neighborhoods, using well-established local organizations such as schools, churches and nonprofit groups; making use of Spanish-language media and elaborate community grapevines to spread good information and counter misinformation; and improving transportation and access to affordable clinics.

Until recently, the state has had trouble mustering the political will and money to follow through with these strategies.

Free or low-cost community clinics may be uninsured immigrants’ best hope in Southern California. But health care advocates say they are not a panacea.

Los Angeles County, where the health department is struggling to recover from a fiscal near-collapse several years ago, has built a public-private network of more than 150 primary care clinics and doctors’ offices offering free services to those who qualify.

Long Bus Rides and Long Waits

Some are swamped, but others remain underused. One complaint is that they often are geographically remote--three or four bus transfers away for mothers with children in tow--and the waits are too long for appointments. More often, immigrants do not know they exist.

Ramona Guerrero, a Los Angeles in-home aide whose husband works in a furniture factory, was one of several Mexican immigrants who said they had paid hundreds of dollars in hard-earned cash to neighborhood clinics with large Latino clienteles, unaware that free care was offered anywhere in the region.

Guerrero paid more than $400 in small installments to a doctor who gave her three weeks worth of injections for her chronic headaches. That seemed to help for a while, but when the headaches came back she sought help from “a naturalist” whose fees were far lower. The naturalist put her on a diet of orange juice and grilled onions.

Guerrero lives within several miles of at least two community clinics--a bus ride away--in central Los Angeles.

In Orange County, with 32 cities and half a million uninsured people, there isn’t even one community clinic per city. More than inconvenient, the journeys to health care appointments can be daunting.

“You have to cross seven gang [territory] lines to get from the Boys and Girls Club [in Santa Ana] to the Santa Ana clinic,” said Children’s Hospital of Orange County clinic coordinator Marilyn Mills. Parents would “like a clinic in their own community.”

Wherever they live, many immigrants feel unwelcome in the health care system or publicly funded programs, said David Hayes Bautista, director of the Center for the Study of Latino Health at UCLA.

“A lot of people are just horrendously confused” by the political zigzags of the 1990s--a decade that included crackdowns on illegal immigrants and wavering signals on whether undocumented women were eligible for prenatal care, Bautista said.

Other, sometimes more subtle, cultural forces are at work, prompting immigrants to question this country’s foreign ways and return to what is familiar.

The tens of thousands of Latino immigrants who make medical visits to Tijuana each month are enticed by more than the great buys and selection in the city’s pharmacies. They are lured by a system they consider more friendly and navigable, where druggists readily diagnose and dispense, where access to healers is easy and where everyone speaks their language.

“As soon as I come in my [Mexican doctor] asks me, ‘What’s up with you? How do you feel?’ ” said Maria Aguayo, who has health insurance through her job in Los Angeles, but still seeks care from a neurologist in Tijuana. “I’ve been with other doctors [here] and they only ask, ‘What do you have?’ and that’s it.”

For immigrants in the United States, just making themselves understood can be a struggle.

The law requires that translation services be available in most medical facilities that receive federal money or provide acute care in California. But practically nobody checks, and critics say translation is not high on hospitals’ list of priorities.

From the patient’s end, not being understood--or worse, being rebuffed or ignored--can be a permanent turnoff to U.S. medical care.

“As soon as they [receptionists] see that you have trouble speaking English, they tell you to go sit down and wait,” said Los Angeles shopkeeper Hernandez, who now relies on doctors in Tijuana and vitamin shots from swap meet vendors here. “They have very little kindness towards you. It’s like they talk better to their dog.”

The problem extends well beyond language. Health plans, hospitals and physicians increasingly recognize the compelling need for greater cultural literacy and sensitivity in medicine. “Cultural competence” has become the topic du jour at medical conferences, employee training sessions and academic lectures, particularly in California.

Recognizing the growing size of the Latino market, several big players in medicine are investing in the notion that such skills can be taught. Kaiser Permanente, the state’s largest HMO, has published several manuals on cultural competence, including a slick 50-page booklet on Latinos that details everything from their prevailing beliefs about cancer to their high susceptibility to diabetes.

It’s not pure altruism. The Latino population in California tends to be both younger and healthier than other residents--despite limited access to care. This “Latino paradox” is attractive to managed care organizations seeking low-cost members.

Physicians who treat large numbers of Latino immigrants bristle at stereotypes and what they consider cynical motivations, but they see a real advantage in recognizing--and flagging--common cultural patterns.

For example, they cite immigrants’ tendency to link illnesses to emotions--such as fright--and the importance of religion and relatives in health care.

Perhaps the most important pattern to understand, doctors say, is Latino immigrants’ tendency to seek treatment from a range of sources, from high-tech to spiritual, from legitimate to harmful.

Seeking Care From a Variety of Sources

Just as many Americans who are dissatisfied with the health care system are increasingly experimenting with alternatives, many immigrant mothers try to fill the gaps in their family’s health care by combining remedies from the old and new worlds. They mix and match folk cures with a doctor’s orders. They will take their children to sobadoras, similar to masseuses, for empacho, but go to doctors for immunizations.

“Doctors here don’t believe in empacho. They probably weren’t taught that. They learned by the book,” said Guerrero, 35, who grew up in a family that made use of teas and herbs for such conditions. “These remedies worked for my parents and grandparents, but [American doctors] want to use medicines that are chemicals.”

Most folk remedies are relatively harmless, say doctors who treat large numbers of immigrants.

Some, however, are worrisome, such as ointments or powders containing lead or mercury and the sometimes indiscriminate use of multiple medications. More troublesome, doctors say, is a passion for quick, dramatic fixes in the form of injections, often without questioning the contents.

Margarita Aguilar, 36, says she prefers sobadoras for certain ailments because they are more knowledgeable and sympathetic. They know what to do, not just for empacho, but for another frightening condition in which the soft spot of a baby’s head sinks in and the jaw starts making a cracking sound. Sobadoras massage the head and jaw, putting their thumb inside the mouth to push on the palate. Sometimes, they will hold a child upside down so the soft spot “pops out,” Aguilar said.

Doctors call the head condition sunken or fallen fontanel and say it can come from dehydration. To the extent that going to a sobadora delays or prevents parents from getting the child proper fluids, it can be dangerous, they say.

Still, doctors with large numbers of immigrant patients say they engage their patients in discussing the hows and whys of their illnesses, trying to listen without judgment to gain their confidence and find out what other treatments they are seeking.

“If you tend to mock that, your relationship is over,” said Dr. Roberto Chiprut, a Century City internist and gastroenterologist.

Arthur Kleinman, an authority on cultural sensitivity in medicine at Harvard University, said: “It’s OK for doctors to disagree with patients. You do it in a respectful way. It would be unethical to hear something you thought was dangerous and not raise an objection. . . . The problem is, most physicians don’t know how to bring it up.”

Doctors have an important advantage though: Once immigrant Latinos trust a physician, he or she often has the status of a venerated family member.

“I’ve had patients come in with ballots and ask me how they should vote . . . that’s how much they rely on me,” said Dr. Aliza Lifshitz, an internist at Cedars-Sinai Medical Center.

In return for such loyalty, immigrants expect compassion from their doctors. Said Chiprut: “If we could bring back the humanistic parts of medicine, that would be a big improvement.” Sometimes, he is rushed, too, but “it takes exactly 30 seconds to show care, to show warmth to patients. Those things are crucial to [health] care, but we sometimes forget it.”

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About This Series After two Orange County infants died following treatment and injections of medication received in back-room clinics serving Latinos, The Times assembled a team of reporters here and in Mexico to investigate this underground medical phenomenon. The team spent three months following the trail of dangerous medications from Mexico through the border and into Southern California.

SUNDAY

The back rooms of some markets, dress shops and swap meets peddle drugs that are banned or tightly restricted in the United States because of severe side effects that can kill. These drugs are smuggled in from Mexico, where looser drug laws allow multinational drug companies to sell them much more freely.

MONDAY

Millions of prescription drugs are pouring into the United States from border towns, virtually unchecked by customs inspectors more intent on stopping contraband such as cocaine.

TODAY

Economic, political and cultural forces push many immigrants to seek help from unlicensed medical providers using illegal or unproven drugs. These immigrants either reject the U.S. system of health care or conclude that it has rejected them.

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The entire series is available on the Times Web site: www.latimes.com/mexdrugs

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Times staff writers Joseph Trevino, Tracy Weber, H.G. Reza and David Reyes contributed to this report.

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AGUSTIN GURZA: The columnist says Mexico’s non-regulation of drugs is a symptom of its corruption. B1