Language Barriers to Health Care in the United States

This perspective article was written and published back in 2006 by Glenn Flores, M.D. in the New England Journal of Medicine (N Engl J Med 2006; 355:229-231 - July 20, 2006) yet it remains dramatically and sadly true today, 6 years later.

A 12-year-old Latino boy arrived at a Boston emergency department with dizziness and a headache. The patient, whom I’ll call Raul, had limited proficiency in English; his mother spoke no English, and the attending physician spoke little Spanish. No medical interpreter was available, so Raul acted as his own interpreter. His mother described his symptoms:

“La semana pasada a el le dio mucho mareo y no tenía fiebre ni nada, y la familia por parte de papá todos padecen de diabetes.”(Last week, he had a lot of dizziness, and he didn’t have fever or anything, and his dad’s family all suffer from diabetes.)

“Uh hum,” replied the physician.

The mother went on. “A mí me da miedo porque el lo que estaba mareado, mareado, mareado y no tenía fiebre ni nada.” (I’m scared because he’s dizzy, dizzy, dizzy, and he didn’t have fever or anything.)

Turning to Raul, the physician asked, “OK, so she’s saying you look kind of yellow, is that what she’s saying?”

Raul interpreted for his mother: “Es que si me vi amarillo?” (Is it that I looked yellow?)

“Estaba como mareado, como pálido” (You were like dizzy, like pale), his mother replied.

Raul turned back to the doctor. “Like I was like paralyzed, something like that,” he said.

If Raul received inappropriate care owing to his misinterpretation, he would not be alone. One interpreter, mistranslating for a nurse practitioner, told the mother of a seven-year-old girl with otitis media to put (oral) amoxicillin “in the ears.” In another case, a Spanish-speaking woman told a resident that her two-year-old had “hit herself” when she fell off her tricycle; the resident misinterpreted two words, understood the fracture to have resulted from abuse, and contacted the Department of Social Services (DSS). DSS sent a worker who, without an interpreter present, had the mother sign over custody of her two children. Clearly, catastrophes can and do result from such miscommunication.

Some 49.6 million Americans (18.7 percent of U.S. residents) speak a language other than English at home; 22.3 million (8.4 percent) have limited English proficiency, speaking English less than “very well,” according to self-ratings. Between 1990 and 2000, the number of Americans who spoke a language other than English at home grew by 15.1 million (a 47 percent increase), and the number with limited English proficiency grew by 7.3 million (a 53 percent increase, see graph). Percentages of Americans Who Speak a Language Other Than English at Home or Who Have Limited English Proficiency.). The numbers are particularly high in some places: in 2000, 40 percent of Californians and 75 percent of Miami residents spoke a language other than English at home, and 20 percent of Californians and 47 percent of Miami residents had limited English proficiency.

Yet many patients who need medical interpreters have no access to them. According to one study, no interpreter was used in 46 percent of emergency department cases involving patients with limited English proficiency. Few clinicians receive training in working with interpreters; only 23 percent of U.S. teaching hospitals provide any such training, and most of these make it optional. Data collection on patients’ primary language and English proficiency is frequently inadequate or nonexistent. Although no federal statutes require the collection of such information, no statute prohibits it, either.

Language barriers can have deleterious effects. Patients who face such barriers are less likely than others to have a usual source of medical care; they receive preventive services at reduced rates; and they have an increased risk of nonadherence to medication. Among patients with psychiatric conditions, those who encounter language barriers are more likely than others to receive a diagnosis of severe psychopathology — but are also more likely to leave the hospital against medical advice. Among children with asthma, those who confront language barriers have an increased risk of intubation. Such patients are less likely than others to return for follow-up appointments after visits to the emergency room, and they have higher rates of hospitalization and drug complications. Greater resources are used in their care, but they have lower levels of patient satisfaction.

Inadequate communication can have tragic consequences: in one case, the misinterpretation of a single word led to a patient’s delayed care and preventable quadriplegia. A Spanish-speaking 18-year-old had stumbled into his girlfriend’s home, told her he was “intoxicado,” and collapsed. When the girlfriend and her mother repeated the term, the non–Spanish-speaking paramedics took it to mean “intoxicated”; the intended meaning was “nauseated.” After more than 36 hours in the hospital being worked up for a drug overdose, the comatose patient was reevaluated and given a diagnosis of intracerebellar hematoma with brain-stem compression and a subdural hematoma secondary to a ruptured artery. (The hospital ended up paying a $71 million malpractice settlement.)

In 1998, the Office for Civil Rights of the Department of Health and Human Services issued a memorandum regarding the prohibition, under Title VI of the Civil Rights Act of 1964, against discrimination on the basis of national origin — which affects persons with limited English proficiency. This memorandum states that the denial or delay of medical care because of language barriers constitutes discrimination and requires that recipients of Medicaid or Medicare funds provide adequate language assistance to patients with limited English proficiency. In 2000, a presidential executive order was issued on improving such persons’ access to services. Thirteen states currently provide third-party reimbursement (through Medicaid and the State Children’s Health Insurance Program) for interpreter services. Unfortunately, most of the states containing the largest numbers of patients with limited English proficiency have not followed suit, sometimes citing concerns about costs. Although the Office for Civil Rights issued guidelines in 2003 that seem to allow health care facilities to opt out of providing language services if their costs are too burdensome, Title VI provides no such exemption.

Ad hoc interpreters, including family members, friends, untrained members of the support staff, and strangers found in waiting rooms or on the street, are commonly used in clinical encounters. But such interpreters are considerably more likely than professional interpreters to commit errors that may have adverse clinical consequences. Ad hoc interpreters are also unlikely to have had training in medical terminology and confidentiality; their priorities sometimes conflict with those of patients; and their presence may inhibit discussions regarding sensitive issues such as domestic violence, substance abuse, psychiatric illness, and sexually transmitted diseases. It is especially risky to have children interpret, since they are unlikely to have a full command of two languages or of medical terminology; they frequently make errors of clinical consequence; and they are particularly likely to avoid sensitive issues. Given the documented risks associated with the use of ad hoc interpreters, it is of concern that the 2003 guidance from the Office for Civil Rights states that such use “may be appropriate.”

Later this year, the California legislature will consider a bill prohibiting state-funded organizations from using children younger than 15 years of age as medical interpreters. Leland Yee, the California speaker pro tempore, proposed the bill, prompted by his experiences interpreting for his mother and, later, as a child psychologist. The bill requires organizations receiving state funding to establish a procedure for “providing competent interpretation services that does not involve the use of children.”

Although this legislation may emerge as a state model, as an unfunded mandate, it will have limited power to improve care. Perhaps the time has come for payers to be required to reimburse providers for interpreter services. The provision of adequate language services results in optimal communication, patient satisfaction, outcomes, resource use, and patient safety. A 2002 report from the Office of Management and Budget estimated that it would cost, on average, only $4.04 (0.5 percent) more per physician visit to provide all U.S. patients who have limited English proficiency with appropriate language services for emergency-department, inpatient, outpatient, and dental visits. This seems like a small price to pay to ensure safe, high-quality health care for 49.6 million Americans.

SOURCE INFORMATION

Dr. Flores is director of the Center for the Advancement of Underserved Children and a professor of pediatrics, epidemiology, and health policy at the Medical College of Wisconsin and the Children’s Research Institute of the Children’s Hospital of Wisconsin, Milwaukee.

Glenn Flores, M.D.- New England Journal of Medicine 2006; 355:229-231 July 20, 2006 - original article: http://www.nejm.org/doi/full/10.1056/NEJMp058316

Translation Tools Could Save Less-Used Languages

Tom Simonite - Wednesday, June 6, 2012, Technology Review (published by MIT)

Languages that aren’t used online risk being left behind. New translation technology from Google and Microsoft could help them catch up.

Sometimes you may feel like there’s nothing worth reading on the Web, but at least there’s plenty of material you can read and understand. Millions of people around the world, in contrast, speak languages that are still barely represented online, despite widespread Internet access and improving translation technology.

Web giants Microsoft and Google are trying to change that with new translation technology aimed at languages that are being left behind—or perhaps even being actively killed off—by the Web. Although both companies have worked on translation technology for years, they have, until now, focused on such major languages of international trade as English, Spanish, and Chinese.

Microsoft and Google’s existing translation tools, which are free, are a triumph of big data. Instead of learning as a human translator would, by studying the rules of different languages, a translation tool’s algorithms learn how to translate one language into another by statistically comparing thousands or millions of online documents that have been translated by humans.

The two companies have both departed from that formula slightly to serve less popular languages. Google was able to recently launch experimental “alpha” support for a collection of five Indian languages (Bengali, Gujarati, Kannada, Tamil, and Telugu) by giving its software some direct lessons in grammar, while Microsoft has released a service that allows a community to build a translation system for its own language by supplying its own source material.

Google first realized it needed to give its system a grammar lesson when trying to polish its Japanese translations, says Ashish Venugopal, a research scientist working on Google’s translation software. “We were producing sentences with the verb in the middle, but in Japanese, it needs to go at the end,” Venugopal says. The problem stemmed from the system being largely blind to grammar. The fix that the Google team came up with—adding some understanding of grammar—enabled the launch of the five Indic languages, all used by millions on the subcontinent but largely missing from the Web.

Google’s system was trained in grammar by giving it a large collection of sentences in which the grammatical parts had been labeled—more instruction than Google’s translation algorithms typically receive.

Venugopal says that, so far, the system can’t handle the underserved languages as well as Google’s existing translation technology can handle more established languages, such as French and German. But, he says, offering any support at all is important for languages that are relatively rare online. “It’s an important part of our mission to make those other languages available on the Web,” he says. “We don’t want people to have to decide whether to publish their blog in their own language or in English. We want to help the world read your blog.”

Microsoft is also interested in helping languages not in common use online, to prevent those languages from being sidelined and falling from use, says Kristin Tolle, a director at Microsoft Research. Her team recently launched a website that helps anyone to create their own translation software, called Translation Hub. It is intended for communities that wish to ensure their language is used online.

Using Translation Hub involves creating an account and then uploading source materials in the two languages to be translated between. Microsoft’s machine-learning algorithms use that material and can then attempt to translate any text written in the new language. Microsoft piloted that technology in collaboration with leaders of Fresno, California’s large Hmong community, for whose language a machine translation system does not exist.

“Allowing anyone to create their own translation model can help communities save their languages,” says Kristin Tolle, a director at Microsoft Research. Machine translation systems have been developed for roughly 100 of the world’s 7,000 languages, says Tolle.

“There is a lot of truth to what Microsoft is saying,” says Greg Anderson, director of nonprofit Living Tongues, which documents, researches, and tries to support disappearing languages. “Today’s playing field involves a digital online presence whether you are community or a company—if you don’t have a Web presence, you don’t exist, on some level.” Anderson says that sidelined languages making a comeback are usually those from communities that have embraced online life using their language.

Margaret Noori, a lecturer at University of Michigan who works to preserve the Anishinaabemowin or Ojibwe, a native American language, agrees, but adds that preserving a language involves more than the Web. “There is a reason to be online in today’s world, but it absolutely must be balanced by songs sung only aloud and ceremonies never recorded.”

Microsoft’s Translation Hub is also aimed at enabling the translation of specialist technical terms or jargon, which general purpose online translation tools do not handle well. Nonprofits could, for example, use it to translate materials on agricultural techniques, says Tolle, and the technology can also be useful to companies that wish to speed up translation of instruction manuals or other material.

“Companies often want to have their data available to them privately and retain their data—not to provide it to someone else that will train a translation system,” she says. Volvo and Mercedes have expressed an interest in testing Microsoft’s Translation Hub, says Tolle.

Tom Simonite - Wednesday, June 6, 2012,
Source:  Technology Review (published by MIT)