"Devil, devil," the man muttered.
Sabyasachi Kar, a doctor at Washington Adventist Hospital in Takoma Park, shook his head in bewilderment. He was examining a Spanish-speaking patient with the help of a colleague who barely spoke the language, and he was getting nowhere.
"It was frustrating. I couldn't do my job," Kar recalled. Only the next day, when he returned with a bilingual colleague, did Kar learn the man had been saying he felt "debil," or weak.
As immigrant communities swell around the country, hospitals, clinics and health-care providers are increasingly confronted with language and cultural challenges that can discourage people from seeking care and lead to calamitous errors in diagnoses and treatment regimens.
In the Washington area, a sharp rise of the foreign-born population in the past two decades has been met by a patchwork response in the medical field. Many area hospitals have taken steps such as installing phones to connect patients and staff members to interpreters, hiring interpreters or training employees to do the job, and recruiting bilingual staff. But some large physician practices and small primary and specialty care services have not added language or cultural services.
"All providers in this area should . . . have a mechanism to deal with language barriers," said Isabel van Isschot, director of interpretation services at La Clinica del Pueblo in Washington, which supplies interpreters to health facilities. When patients don't have access to an interpreter, she said, "I think that's a form of discrimination."
Need An Interpreter?
Consider your options:
- Most area hospitals, medical centers and local government health services have in-house interpreters and/or use a local interpretation agency or telephone service. Call ahead to verify the availability of an interpreter. (Spanish-speakers who call typically are transferred to a Spanish-speaking operator.)
- Most independent primary-and specialty-care providers do not have staff interpreters but may use phone interpretation services, such as Language Line.
- Some organizations and programs supply free assistance. In the District, La Clinica del Pueblo, 202-462-4788, will arrange for interpreters in various languages to accompany patients to appointments. In Montgomery County, Asian-language speakers can call the Asian American Health Initiative, 301-760-4993.
- Patients have the right to an interpreter under federal law. Complaints about violations may be made to the Office for Civil Rights at the Department of Health and Human Services.
Hospitals and doctors, however, are wary of the cost of interpretation services, which can run up to $190 an hour; they say the government, not them, should pay these costs.
"Appropriate funding for these services is needed so that patients don't lose access to care," said Joseph M. Heyman, chair of the board of trustees of the American Medical Association, which has asserted in policy statements that "physicians cannot be expected to provide and fund . . . translation services for their patients."
A 45-year-old federal civil rights law requires hospitals and doctors who accept federal funds to offer language services. Some federal funding for interpretation services is available through Medicaid and the Children's Health Insurance Program, state-run programs that serve the poor and children, respectively. But to obtain the money, states have to pitch in some of their own. The District and Virginia have done so; Maryland has not.
California alone has put the funding burden on private insurers for patients who have that coverage. Some other states are considering similar legislation, but the issue is not a political priority in the Washington area, advocates say, even though about 20 percent of residents in the region are foreign-born, according to the Urban Institute, a nonpartisan think tank. Some 110 languages are spoken here, an analysis of 2000 Census data by the U.S. English Foundation found, making the Washington area the sixth most linguistically diverse urban area in the United States.
Though many immigrants speak enough English to get by in their workplace, that may not be sufficient in the doctor's office, where medical jargon and emotional reactions can cloud their ability to communicate.
Norma Chinchilla, 26, a Honduran immigrant living in Silver Spring, has been in the United States for four years but has not learned English. Last year, she ran smack into the language barrier while trying to make an appointment over the phone for her 2-year-old son. When she reached an English-only operator at Children's National Medical Center, the few English words she knew seemed to vaporize as the impatience on the other end of the line grew. She hung up, defeated and without an appointment.
"It has been very hard to get medical care for my son without speaking English," Chinchilla said.
Paula Darte, public relations director for the center, says it does have a language services office. "It's troubling that this person didn't get through the right channels, because there's usually someone around who speaks Spanish," she said.
Patients with limited or no English who do manage to obtain care can still fall prey to miscommunication. In a 2006 study published in the New England Journal of Medicine, Glenn Flores, now a professor of pediatrics at the University of Texas Southwestern Medical Center at Dallas, detailed several such cases. In one, a mother misunderstood instructions and put oral antibiotics in a child's ears. In another, a doctor not fluent in Spanish interpreted "she hit herself" as "I hit her," resulting in a mother's losing custody of her children.
Some interpreters say medical staff sometimes are unsympathetic to immigrants' needs. "There is a lot of prejudice and animosity," said Rosemary Rodriguez, an interpreter in Richmond. "Nurses say to me, 'Why don't they learn English?' or 'I know she speaks English.' "
To address the language barrier, many area hospitals have installed an array of options. Adventist HealthCare, the parent of Washington Adventist Hospital, has provided medical interpretation and cultural competency training to 150 of its bilingual nurses, janitors, technicians and other staff members.
Kar, the physician who once found it frustrating trying to communicate with Spanish-speakers, says he can now call in a trained bilingual colleague for assistance. And if he has a patient who speaks a rare language, such as Bulgarian, he uses a special phone to reach professional interpreters.
Howard University Hospital has two full-time Spanish interpreters; one full-time Amharic, Tigrinya and French interpreter for the Ethiopian, Eritrean and French West African communities; and one full-time Chinese interpreter.
They also interpret cultural differences. Azeb Abraham, Howard's Amharic, Tigrinya and French interpreter, says some Ethiopian and Eritrean women feel uncomfortable undressed in the presence of male doctors, so she helps the doctors figure out how to examine the women in a way that does not offend them.
Inova Fairfax Hospital in Falls Church has several full-time interpreters and 700 staff members trained to interpret on the fly in some 35 languages.
Alicia Ellis, one of Inova Fairfax's full-time medical interpreters, recently got a call for help with a pregnant Nicaraguan woman complaining of vaginal bleeding.
Ellis hurried into a labor and delivery ward to find Juana Varela, 36, lying on her back, her ample belly protruding between the top and bottom of her hospital gown. Ellis explained she was there to interpret for Colleen Pineda, the nurse who would perform the preliminary examination. Ellis began to speak for Varela: "I woke up in the morning with pain and bleeding, and now I'm worried this birth won't be normal."
"When did the pain begin?" Pineda asked in English. Ellis repeated the question to Varela in Spanish, her eyes cast down to deflect attention from herself and create a seamless link between doctor and patient.
Other health-care organizations have been slower to invest in interpretation services. George Washington University Medical Faculty Associates, a practice that sees about 4,600 patients per day (more than five times the number treated at Inova Fairfax), has no full-time staff interpreters but a few bilingual staff members. According to the group's chief executive, Stephen Badger, "The cost of interpreters is expensive and usually is greater than the payment we receive [from Medicaid] for the health care actually provided."
Montgomery County provides professional medical interpreters to clinics at no cost, according to Sonia Mora, manager of the Latino Health Initiative at the county's Department of Health and Human Services.
Mora says that there is still a tremendous need in immigrant communities that is not being met and that providers who do have capacity have a huge burden thrust on them. But, she says, she has seen language services improve significantly in the last five years. "Now we're starting to see that it's going to save us money, because people are going to be healthier," she said.