Worlds and Words Apart

Maria Francisco has sat in clinic waiting rooms all day and gone home without having seen a nurse or doctor. She has been given injections without explanation. She has, at times, simply pointed at what hurts, hoping her message got across.

Because the Los Angeles mother of three speaks only Kanjobal, an obscure form of Mayan unfamiliar outside her native Guatemala, neither she nor clinic personnel can make themselves understood. As a result, the 29-year-old has been forgoing medical care for recurrent headaches.

Though isolated, she is not alone.

No one tallies every patient’s race, ethnicity or language ability or even tracks how often those with limited English skills receive inadequate, if any, medical care, so there are no statistics to document the communication problem. But with 224 languages spoken in California--and 40% of Los Angeles County residents born in another country--those on the front lines of patient care do not doubt a communication gap exists.

“Regrettably, the problem is prevalent across the country,” says Thomas Perez, director of the Office for Civil Rights at the U.S. Department of Health and Human Services. The office fights discrimination in health and social services, and the workload is currently dominated by language cases.

When he asked his regional offices about their most pressing challenges, Perez says, “It didn’t matter if I was in Seattle, San Francisco, Atlanta or Chicago. I heard story after story of immigrants and others who couldn’t access critical services.”

He cited among the most egregious cases a South Carolina hospital’s practice of denying epidural anesthesia during childbirth to patients who couldn’t speak English. Doctors there said that if there were complications, the women wouldn’t be able to communicate. The policy has since been changed.

The cultural and linguistic divide also means that some foreign-language speakers cannot apply for health benefits. As a result, many turn to alternative medicine and home remedies, and “only when things reach an emergency” will they go to a hospital or clinic, said Karin Wang, staff attorney for the Asian Pacific American Legal Center in Los Angeles.

Once there, they’re likely to get lesser-quality care because they can’t make their needs known--and can’t give meaningful consent to treatment.

Elizabeth Anh-Dao Nyugen, a language consultant for Pacific Asian Language Services in Los Angeles, quoted one Vietnamese cancer patient as saying: “It seems as though I have a mouth but cannot talk; I have ears but cannot listen.”

More than just a guessing game, diagnosis becomes a physical ordeal.

“If the patient can’t describe their symptoms, then the doctor is going to be forced to use more complicated and invasive diagnostic tools,” said Julia Puebla Fortier, director of Resources for Cross Cultural Health Care in Silver Spring, Md.

If patients haven’t understood preoperative instructions, surgery is postponed. Meanwhile, doctors and those who pay for care--often state and federal programs--face higher costs generated by wrong diagnoses, ineffective prescriptions and mistakes.

Such problems could be avoided. After all, a law requiring interpreters has been on the books for decades.

Under the Civil Rights Act of 1964, any doctor, hospital or clinic seeing non-English-speaking patients through federal programs like Medicare, Medi-Cal or Healthy Families must provide interpreters.

On Aug. 30, the federal government reminded doctors and hospitals of their obligation to assist those with limited English proficiency. Providers who don’t comply risk losing federal funding.

In late September, Rancho Los Amigos National Rehabilitation Center in Downey agreed to provide free interpreters to patients with language barriers and to post signs in languages most often spoken in the region: Spanish, Chinese, Vietnamese, Korean and Armenian. The county-run facility expressed willingness to make changes after the Office for Civil Rights learned that a Vietnamese patient had been asked to furnish his own interpreter.

Despite the threat of federal intervention, some doctors balk at the financial burden.

The California Medical Assn. has complained that the cost of complying with the federal requirements, and similar requirements for Medi-Cal managed care providers, is onerous, especially for doctors in smaller practices. The organization, which represents 34,000 doctors, contends its members are not reimbursed enough to cover the cost of care plus language experts.

Perez says the federal government has “a lot of money potentially available” to states for interpreting services, but they must “step up to the plate.”

Greg Franklin, director of the state health department’s Office of Multicultural Health in Sacramento, said federal officials haven’t been clear about how to obtain Medicaid dollars for interpreter services. Furthermore, he said he’s not seen concrete evidence of a widespread problem in California.

His department has agreed to help the California Medical Assn. survey its doctors to “identify how pervasive this problem is--if it is a problem” and to identify solutions that would not worsen their administrative burden.

Degrees of Solutions

But amid the finger-pointing, progress is being made.

Many of the best programs have been established by institutions slapped with complaints.

The state of Washington acted after being hit with 16 civil rights complaints and several lawsuits over language assistance. The state and federal governments share the cost of furnishing interpreters and translated materials for medical, mental health, disability and social services.

Washington has since become a model state for interpretation, far exceeding federal guidelines.

But, lacking federal and state cooperation, there are other ways insurance companies, hospitals, offices and health-care workers can bridge the linguistic and cultural gap.

Ideally, of course, hospitals and doctor’s offices have bilingual doctors, nurses and receptionists.

When that’s not possible, some large hospitals and medical centers around Los Angeles, such as Cedars-Sinai, Childrens Hospital Los Angeles and UCLA, have created interpreting departments.

Kaiser Permanente, which serves 6.2 million California patients, a quarter of whom are Latino and 10% of whom are Asian, makes note of the language spoken by each of its Northern California patients. Every time those patients call for an appointment, they are asked whether they need an interpreter.

In the absence of full-time interpreters, hospitals often rely on language banks of employees paid extra for bilingual duty.

Others turn to community organizations like Pacific Asian Language Services, which provide interpreters for medical appointments.

In many cases, providers rely on telephone language lines, which offer dial-up interpreter services for a typical fee of $2 to $3 a minute.

Some hospitals are customizing their interpretation systems.

Santa Clara Valley Medical Center in San Jose relies on in-house interpreters who can work either through speakerphones placed in every examination room or face-to-face for speech pathology, neurology or physical therapy appointments.

The New York Task Force on Immigrant Health is conducting a pilot program at Gouverneur Hospital in New York City using a remote simultaneous medical system developed in California. Specially trained visually disabled individuals at a remote station interpret for doctors and patients wearing special wireless headsets.

Importance of Interpreters

Medical access for foreign speakers doesn’t simply involve hiring people who speak other languages; it means having interpreters who can deftly convey doctors’ and patients’ points of view while protecting confidentiality.

The interpreter becomes, in the best cases, part of the health-care team. Sometimes they go a step further, helping calm immigrant patient fears that once they get into the medical system, they may be deported.

The job can encompass outreach to neglected communities. The nonprofit Clinica Msr. Oscar Romero in Los Angeles, for example, has just begun offering interpretation for the 5,000-member Kanjobal-speaking community.

For Francisco, the Guatemala native who has suffered headaches for nearly two years, it has been a lifeline. Until she found the clinic, she often stayed home “because we know no one will understand us,” she said in a recent interview arranged by Idalia Xuncax, the clinic’s Kanjobal interpreter as well as a caseworker.

Although Francisco was told her headaches are probably stress-related, the diagnosis was more complicated for Juana Cano, 33, another Kanjobal speaker who had delayed seeking treatment.

With Xuncax’s encouragement, Cano allowed herself to be examined by a nurse, who discovered a growth on her back requiring an outside referral for more specialized medical care.

Xuncax will help Cano--who has three children under the age of 5--negotiate the paperwork and hospital visits. Without her interpreting and outreach skills, Cano could have gone undiagnosed.

Such examples demonstrate how interpreter services can help the medically disenfranchised. But inadequate interpretation can have dire consequences, as can reliance on ad hoc solutions, such as using children, other family members or, in some instances, hospital janitors to translate.

“Research has shown that untrained interpreters are extremely inaccurate, which means whatever the doctor says, the message gets edited, people put in their own ideas, they editorialize,” said Cindy Roat, co-chairwoman of the National Council on Interpretation in Health Care. She develops training programs for Pacific Interpreters and, separately, has been at the forefront of establishing interpreter testing and training standards.

“A lot of people who are not trained to interpret don’t know this medical terminology, so ‘glaucoma’ becomes ‘an eye infection,’ ” she says.

In addition, good interpretation requires knowledge of cultural backgrounds. Interpreters need to know, for example, that Chinese doctors often tell a patient to take a container of medicines all at once. When that patient is given a prescription by a Western-trained doctor, he or she must be warned not to take the entire bottle.

Interpreters can also help convey how different cultures handle pain.

Vietnamese women hardly make a sound in childbirth, yet Latino and Arab women “tend to be very florid in their expressions of pain,” says Jean Gilbert, a medical anthropologist and former director of cultural competence for Kaiser Permanente. “That creates issues on the wards because nurses may not understand people are in pain, and they’re not expressing it.”

As recognition of the communication gap grows, so too is the realization that interpreters play a crucial role in patient care.

Perez believes that attention to this role will make health-care providers realize that the short-term cost of adhering to the federal law is in their best interests financially.

“I firmly believe, putting aside the civil rights issue,” he says, “it’s the proverbial ‘pay me now or pay me later.’ ”

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Breaking Down the Language Barrier

Medical interpreters can bridge the communication gap between doctors and patients who speak different languages. Several organizations offer bilingual services on-site, while others can help patients find an appropriate clinic or hospital. Dial-up services can also link doctors and patients to professional interpreters. If all else fails, advocacy groups can help patients bring complaints when they’re denied good interpreters.

Resources for non-English-speaking patients:

* PALS (Pacific Asian Language Services) for Health in Los Angeles offers language help. Call (213) 553-1818 or, for multilingual voicemail, (800) 228-8886.

* L.A. Care Health Plan serves Medi-Cal managed-care recipients in L.A. County and can help them locate appropriate providers. Contact member services at (888) 452-2273.

* Clinica Msr. Oscar Romero in Los Angeles, serves Spanish- and English-speaking patients and offers Kanjobal interpretation to its patients. Contact Idalia Xuncax, (213) 989-7700, Ext. 345.

* Clinica Para Las Americas in Los Angeles offers Spanish interpretation services and document translation services for HIV and AIDS patients. Contact Carlos Hernandez at (213) 273-8708.

* California Primary Care Assn. operates a hotline for referrals to local clinics with language services. Call (888) 895-0808.

Resources for doctors and hospitals that need interpretation or translation services:

* Language Line Services: (800) 528-5888, option 3 for immediate service using a credit card; (800) 752-0093 to set up an account; https://www.LanguageLine.com.

* Online Interpreters: (800) 645-5005 for immediate service using a credit card; (800) 307-1001 to set up an account; https://www.onlineinterpreters.com.

* Pacific Interpreters: (800) 870-1069 to set up an account; https://www.pacificinterpreters.com.

* CyraCom International: (800) 713-4950 to set up an account or arrange credit-card payment for immediate service; https://www.cyracom.net.

* Tele-Interpreters: (888) 326-2686 or (877) 835-3468; https://www.Tele-Interpreters.com.

* San Diego Language Line, a program of Catholic Charities San Diego, provides interpretation and translation in 24 languages. (619) 287-9454.

For questions about rights to medical interpretation:

* Asian Pacific American Legal Center, Los Angeles: (213) 977-7500.

* National Health Law Program, Los Angeles: (310) 204-6010.

* California Pan-Ethnic Health Network, Oakland: (510) 832-1160.

To file a complaint about a doctor, hospital or clinic not providing interpreter services:

* The Office for Civil Rights of the U.S. Department of Health and Human Services, (800) 368-1019, which routes California callers to the Region IX office in San Francisco. The agency Web site (https://www.hhs.gov/ocr) also provides information on filing a complaint.