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Worlds and Words Apart

Inadequate interpreter services for non-English-speaking patients has medical experts and civil rights advocates concerned.


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.

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