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Language Still A Barrier
For Good Medical Care
Hilary Waldman, Hartford Courant
Vietnam
September 20, 2004
After years of torture in Vietnamese concentration camps following the fall of Saigon, Tan Le had plenty of reasons to be depressed.
By the time he finally fled his Southeast Asian homeland in 1993 and was resettled in Hartford, he was tired all the time. Walking from the couch to the kitchen of his small apartment left him so worn out he had to lie down.
Le sought help at a clinic in Hartford, but even when he was accompanied by someone who spoke Vietnamese, he could not articulate his distress.
Nobody was sure what was wrong with the middle-aged man, but depression seemed a likely suspect. He returned to the clinic repeatedly without getting the help he needed.
One day, Le Lien Smith, a Vietnamese community advocate, accompanied Le to the clinic. She has a degree in psychology and suspected that Le's malaise might not be in his head. She asked the doctor to test him for diabetes. The test showed Le's blood sugar was dangerously high.
"Before that, they never asked and he could not tell the doctor what was his problem," said Smith, interpreting for Le.
Although area hospitals contend that such language barriers are a thing of the past, advocates for immigrants and refugees in Connecticut maintain that a dearth of competent interpreters continues to threaten the health of non-English-speaking residents.
"This is a tragedy and we're getting old," said a frustrated Mary Scully, who as program director of Khmer Health Advocates has been fighting for better language services for 20 years. The organization coordinates health care for people who were tortured during the Khmer Rouge reign in Cambodia.
"We stop what we're doing all the time [to interpret for clients] because people are going to die," she said.
Scully and other advocates want state lawmakers to create a commission - of health care providers and community agencies that represent refugees and immigrants - to identify how to improve language services in hospitals and clinics.
"We should be talking to one another to develop access to care," Scully said. And, she said, hospitals should enlist the help of immigrant communities. "Right now, it's adversarial."
Immigrant groups from Vietnam, Cambodia, Laos, Bosnia, Albania, Africa, Poland and Spanish-speaking countries are among those calling for change.
The groups say they have bilingual staffs and connections to their communities and should be able to develop relationships with the hospitals to make interpreters more available. And, they say, the state and federal government should help pay for language services. At present, hospitals pay for it.
Janitors As Interpreters
To ensure that nobody goes without an interpreter, the immigrant groups are also calling for stricter enforcement of Title VI of the U.S. Civil Rights Act. The 1964 law directs hospitals to provide qualified language interpreters under the provision banning discrimination based on national origin.
Title VI was virtually invisible until the early 1980s when an exodus from Vietnam, Cambodia and Laos after the war there flooded the United States with the largest wave of refugees since early in the 20th century.
With the newcomers came horror stories of janitors serving as interpreters in hospital emergency rooms and grade-school children helping their mothers seek birth control.
Twenty years later, the headlines have disappeared. But, despite some progress, the problems have not.
Four years ago, then-President Clinton signed an executive order calling on federally funded agencies, including hospitals, to improve access to people with limited English proficiency. Since then, hospitals across Connecticut have increased their efforts to provide interpreter services.
Virtually every hospital now contracts with commercial telephone language services, which offer on-the-spot, over-the-phone interpreters in 150 languages around the clock.
Some also have compiled lists of bilingual staff members willing to serve as volunteer interpreters.
Windham Hospital has taken its commitment one step further by offering a medical translation course to its Spanish-speaking employees. The class meets twice a week in the evenings for about two months and most employees attend on their own time.
In addition to learning medical terms, participants discuss issues related to ethics and confidentiality. Once certified, employees are paid a stipend when they are called away from their regular jobs to serve as interpreters, said Marty Levine, Windham's vice president for human resources.
Juan Osuba, whose job is to wheel patients to and from X-ray rooms, said without the course he could not have been a competent interpreter. Although he grew up speaking Spanish with his Puerto Rican-born parents, he did not previously know the proper terms for lab tests or parts of the anatomy.
Letter Of Apology
Last year, a Laotian man living in Danbury filed a federal civil rights complaint claiming that he almost died because Yale-New Haven Hospital did not supply him with sufficient language services.
Shortly after the man underwent surgery to repair intestinal damage, a dietary aide mistakenly delivered a dinner tray to his room. Without an interpreter who spoke his language, the patient did not understand instructions not to eat after surgery.
With the tray in front of him, the man assumed he was expected to eat. The food caused a life-threatening reaction that sent him to the intensive care unit for several days. When he recovered, he filed a complaint with the Office of Civil Rights at the U.S. Department of Health and Human Services.
Three years later, as part of a settlement, he received a letter of apology from Yale-New Haven - in both Laotian and English. It was the first time the hospital had communicated with him in his own language.
Although administrative civil rights complaints are the only recourse for patients who feel they have been harmed by insufficient language services, they are almost never filed.
Since the Laotian man's problem in 2000, the hospital has taken numerous steps to address the needs of patients who do not speak English well.
Yale-New Haven Hospital has six full-time Spanish-speaking interpreters on its staff. At present, they are available only during business hours, but this fall the hospital hopes to expand the service to include Saturdays and nights.
The hospital also uses telephone language services and has contracts with local interpreters who can speak Portuguese, Mandarin, Turkish, Arabic, Croation, Russian and other frequently requested languages, said Jeannette Hodge, director of patient relations at Yale-New Haven.
In addition, all hospital employees are required to take a computer-generated course each year drilling them on when to call in an interpreter for a patient and how to find an interpreter for virtually any language.
Bridging The Cost Gap
While everyone agrees that health care providers should be more sensitive to patients who don't speak English, it is also clear that the task is not easy.
Yale-New Haven's annual budget for language services is about $400,000. Medicare and Medicaid, the government health insurance for elderly and low-income people, do not pay for interpreters.
Even the cost of providing phone interpreters is high.
With no paid interpreters on its staff, Bridgeport Hospital used 2,300 minutes - almost 40 hours - of phone interpreter services in June, the most recent month for which the bill was available. At a cost of $2 to $3 a minute, the hospital could spend about $70,000 a year on phone interpreters.
Despite a directive in Clinton's executive order that phone interpreters be used only as a last resort, telephone language lines seem to be the most practical way to offer services, said Lynn Charbonneau, director of patient relations at Bridgeport Hospital.
In June, the hospital provided phone interpreters to patients who spoke Spanish, Haitian, Czech, Albanian, French, Russian, Korean, Turkish and Ukrainian.
With so many languages in demand, Charbonneau and other hospital administrators said it would be impossible to have trained interpreters present all the time.
But Scully said that with a little bit of extra money, community groups could fill a large part of the void. She estimated that with $500,000, her organization and other community groups could provide interpreters and case workers to assist all of the estimated 9,000 Southeast Asians in Connecticut who do not speak English well.
"The key issue is community health workers who walk people through the system," Scully said. "To even say, `You have to have blood drawn; you can't eat for 12 hours before,'" would be more helpful than printed materials in Southeast Asian languages, she said, because many refugees were farmers who never learned to read.
Ruthie Mathews, who is in charge of interpreter services at St. Francis Hospital and Medical Center in Hartford, agreed that including community advocates could go a long way toward bridging the gap.
She also agreed that quickly diagnosing and treating patients such as Tan Le could save enough money to pay for comprehensive language services. Without proper treatment, non-English-speaking people can get sicker. For a diabetic patient, for example, the cost of bilingual health education is minuscule compared with the astronomical cost of a stay in the intensive care unit for a diabetic coma.
"It's good business to make patients understand what needs to be done," Mathews said.
To find out if better Spanish-English communication does improve health outcomes, the Connecticut Health Foundation recently gave St. Francis a grant to place an interpreter in the hospital's pediatric outpatient clinic.
The interpreter will be available 20 hours a week. At the end of three years, the health foundation will compare the health outcomes of patients who received interpreter services with those who did not to determine if better communication can eliminate some of the well-documented health disparities between white and minority patients.
While everyone acknowledges that comprehensive community-based interpreter services could be years away, Scully said an intermediate solution might include adding video links to phone interpreter services.
Tan Le said the Hartford Hospital outpatient clinic he visited had called a phone interpreter for him on several occasions. But he said he was frequently unable to understand the person speaking to him in Vietnamese at the other end of the line.
Scully said a video link would have helped the interpreter better read Le's body language or at least recognize that Le did not understand.
"We've got a saying in our office: If they're getting whirligigs in their eyes, you've got to start over," Scully said of interpreting. "On the telephone, you're not going to see those whirligigs."
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