Building the Language Wall in Healthcare

If you do not know how to speak English in the United States, you are as good as dead — at least that is the case in healthcare. The COVID-19 pandemic has magnified this tragic trend.

A limited English proficient (LEP) woman entered a hospital with coronavirus in March and the staff mistakenly placed her with non-coronavirus patients. Due to her cough and fever, a doctor transferred her into a coronavirus unit, cautioning other physicians: “Good luck. She speaks Hungarian.” The medical resident treating her noted that no one wanted to arrange an interpreter to record her medical history. The resident proceeded to call the interpreter service as his N95 mask muffled his voice and his helmet blocked his ears. After spending five minutes yelling “Hungarian!” on the phone to get the appropriate interpreter, the service representative still thought he said “Spanish.” She died the following night.

Deficiencies in providing quality translating and interpreting services in healthcare have left LEP patients with worse outcomes: longer hospitalizations, more readmissions, and more medical errors. Yet the Trump administration reduced free access to language services and thereby explicitly undermined civil rights laws. The Civil Rights Act of 1964 established LEP individuals’ right to receive free language assistance. In 2010, the Affordable Care Act (ACA) clarified that language assistance must be meaningful—a standard evaluated by timeliness, accuracy, and efficacy. The Centers for Medicare and Medicaid Services (CMS) was authorized to assure these rights in 2014. Too bad they were all talk and no action.

CMS teased that by 2016, LEP patients would receive information about language services and have access to qualified interpreters. But that year, nearly a third of U.S. hospitals still failed to offer interpreters. Without normalizing the use of language services in patient treatment, physicians risk n

eglecting their patients. Clinicians mistakenly accept nods and smiles as the equivalent of health literacy, when patients actually nod in fear of burdening their physician. They do not know they have the right to communicate with their health providers, no matter their English fluency. I did not even know this myself.

I am a Vietnamese American immigrant. Yet until I took a science law class during my freshman year of college, I did not know that my grandpa deserved to hear his paralysis diagnosis in Vietnamese. Does this mean I did not have to play doctor, interpreter, and the bearer of bad news for my family members? It only took 15 years in the states and a fortune in tuition to figure out the answer: No.

But the availability of medical interpreters and funding is deficient. Even when facilities provide language assistance, the shortage of professional interpreters delays procedural practices. However, medical facilities’ non-compliance is not completely intentional. The government mandates language access for LEP individuals, but provides the minimum in resources. Only 3% of medical facilities receive reimbursements from the government or Medicaid systems for language services they provide. Thus, hospitals treat language services as another item on the budget. In an attempt to reduce expenditures, healthcare facilities rely on untrained family members and bilingual staff to bridge the communication gap, resulting in the improper use of medications, incomplete medical histories, and poor adherence to post-operation instructions.

The health system has failed to acknowledge the severity of the language barrier as a challenge to quality health care. Thus, the integrity of healthcare for LEP individuals has been deteriorating for decades, and the pandemic has exposed this inequity. The Hungarian woman may have died even if she spoke English, but her experience exemplifies how LEP patients suffer from poor quality of care. Healthcare workers have adapted to the pressure with a utilitarian approach whereby the patients presenting minimal challenges to care are the ones who receive the best care. No one expects fluent English speakers to comprehend the extent of COVID-19, so how are LEP individuals expected to without language assistance?

Even though COVID-19 collapsed America’s healthcare system, Donald Trump decided to exacerbate the condition for marginalized communities. He justifies his xenophobia because of “high costs.” In reality, when hospitals consistently use language services, they offset interpreting expenditures with the money they save from fewer hospital readmissions.

It is futile to expect change from a government that continues to systematically oppress its people. Clinicians, take it upon yourself to normalize informing patients of language services and using those services. Check in with the patient and interpreter to ensure vital information is absorbed. If you cannot communicate with your patient, then you cannot provide care.

Community-based organizations are also critical in connecting LEP patients to physicians by reducing fear of health institutions and standardizing language and cultural competency. If the health sector does not meet the needs of the expanding demographic landscape, ten percent of our American population is as good as dead.

Works Cited

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To Improve Access to CMS Federally Conducted Activities by Persons with Limited English Proficiency [Brochure]. Baltimore, Maryland: Author. Retrieved September 23, 2020, from https://www.cms.gov/About-CMS/Agency-Information/OEOCRInfo/Downloads/StrategicLanguageAccessPlan.pdf

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Professional Interpreters in the Hospital Decreases Readmission Rates and Estimated

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More than Genetics: Social Determinants of Health

Hypothetically, let’s claim that not all patients receiving health care are treated equally. I know, as a pre-health student, this claim is outrageous because the medical field must be full of the perfection, rainbows, and butterflies I imagined when I first wanted to become a physician. How is it conceivable that the infant mortality rate of Native American and Alaskan Natives is 60% higher than that of the white population? Or that African American men are 30% more likely than white American men to die prematurely from cardiovascular disease? Even that minority women are less likely to avoid seeing a doctor due to cost? As much as I hate to pop the bubble that is our fantasies about medicine, racial and ethnic disparities are very real problems that the healthcare industry faces and that must be addressed to achieve equitable treatment.

According to the CDC, a large aspect of health is accredited to social determinants, which are the economic and social conditions that influence the health of communities and people. Examples of social determinants include early childhood development, quality of education, job security, food security, access and quality of health services, adequate housing, social support, language and literacy, incarceration, access to technology, and many more. Many of these factors have inherent racial implications through the history of structural and institutionalized racism within the United States; one such example of historical influence were the Jim Crow laws from the early 19th century that established barriers toward job security, housing, and equitable education. What this means is that many of the statistical disparities we see are not necessarily genetically tied to different races, but rather are the cumulative effects of sociopolitical inequalities.

Even more concerning are the racial and ethnic health disparities that relate to the psychological stressors of experiencing racial discrimination. Namely, ‘mixed race’ children with a Black mother and a White father have higher rates of low birth weight than children with a White mother and a Black father (Tashiro, 2020). This outcome is attributed to the psychosocial stressors of racism that Black mothers experience and pass down through epigenetics, the study of changes in gene expression through environmental exposures. There are numerous ways in which racial/ethnic minorities experience racism--these include systemic and institutionalized racism as well as direct, face-to-face discrimination such as racial slurs, unfair treatment, and violence. Exposure to racial discrimination has been proven to be associated with poor physical health, substance abuse, and mental illness (Tashiro, 2020), and there are a variety of health issues related to direct experiences with racism. Some of these include elevated blood pressure, abdominal obesity, breast cancer, heart disease, premature death, increased anxiety and depressive symptoms, and elevated stress hormones in teenagers (Tashiro, 2020). It is also important to note that although there is no biological basis for race, the impacts of racism in healthcare are apparent and serve to emphasize the importance of continuing to acknowledge and mitigate health inequities. Without these conversations, how do we ethically contribute to and work towards a system that disproportionately disadvantages entire communities?

Ultimately, as many of us continue on in our education in health care, it is important that we address the social factors that have led to the inequities we see in the medical field today. As much as O-Chem and genetics are valuable knowledge for pre-health students to master, we can’t leave behind the important social factors that shape how patients experience and perceive health.

As much as I would love to stay in the bubble of my childhood fantasies about medicine, the reality of these ingrained problems serves as a reminder to all of us of the work that needs be done to create a system of accessible and quality health care for all people regardless of their race, ethnicity, or socioeconomic status.

References:

Crowley, Ryan. “Racial and Ethnic Disparities in Health Care.” Racial and Ethnic Disparities in

Health Care, Updated 2010, American College of Physicians, 2010,

www.acponline.org/acp_policy/policies/racial_ethnic_disparities_2010.pdf.

“Frequently Asked Questions.” Centers for Disease Control and Prevention, Centers for Disease

Control and Prevention, 19 Dec. 2019, www.cdc.gov/nchhstp/socialdeterminants/faq.html.

Sciences, National Academies of, et al. “The State of Health Disparities in the United States.”

Communities in Action: Pathways to Health Equity., U.S. National Library of Medicine,

11 Jan. 2017, www.ncbi.nlm.nih.gov/books/NBK425844/.

Tashiro, Cathy J. “Race, Racism, Ancestry and Health: Implications for Mixed Race People.”

Global "Mixed Race" Studies. 15 Sept. 2020.

The Keyless Car Dilemma of In Vitro Gametogenesis: What good is a car without keys?

The first time I witnessed someone using a “keyless” car, I was astonished. They could simply walk up to their car, open the door, press a button, and the car would start. When I tried to recreate this magic for myself, I quickly realized that I couldn’t even get into the car, let alone take it for a joyride. I was so amazed by this new technology that I didn’t stop to realize that it only worked for the person who had the key, even if said key was nowhere in sight.

When it comes to medical innovations, the confusion that I experienced around the keyless car is a sentiment commonly felt by much of the technology’s target population. So much effort is put into the research and design process that by the time we get to the implementation phase the idea has been stripped and rebuilt so many times that we forget to ensure that it can be used by the very people we claimed to be designing it for.

While this is common in almost every arena, my current focus is on the newly developed technique of in vitro gametogenesis (IVG). The basic idea of IVG is to recreate the process of gametogenesis outside of the human body. Normally the body creates either specialized egg or sperm cells, and during reproduction, the sperm fertilizes the egg that will eventually become the embryo. This technology is still in the research and design phase, but that is precisely why it’s so important to have this conversation now. IVG is currently being discussed as a revolutionary possibility for cisgender same-sex couples[1], but I worry that in reality, it may never serve this target audience in the way that it is currently projected to.

Navigating fertility as a queer person often involves a series of hoops to jump through, and unfortunately, this issue can be exacerbated by the very innovations that we thought would help. Imagine that someone buys you a new car (IVG technology), but they never give you the key (a straightforward path to said technology that doesn’t involve peeling back layers upon layers of bureaucratic red tape). There is no point in having a car without the key, so you call the dealership (insurance company) and explain your situation. They tell you that you are in luck because they help people with key replacements all the time. The only caveat is that they require you to confirm loss of the key (infertility) by searching for it (trying to conceive naturally) for a period of time before they will be able to help you. You explain that you never had the key in the first place (could not physiologically conceive a child naturally), but they insist that this is simply their policy for new vehicles (innovative technologies).

From an ethical standpoint, is it enough to develop the new technology and stop there? Is it enough to innovate with hopes of helping specific communities if we never make sure that said innovations get to them? My stance is simple: No. Innovation is an important step, but it isn’t the final one. Just because we build it does not mean that the people who need it most will be able to use it. It is our moral responsibility to do everything in our power to alleviate the barriers to our technology, not to stack them higher. I’m hopeful that IVG will be what breaks the current pattern and that it will one day deliver on its promises to the queer community.

In short, if you give someone a car, make sure you give them the key too.

[1] Spar, D. L. (2020, August 12). The Poly-Parent Households Are Coming. Retrieved September 12, 2020, from https://www.nytimes.com/2020/08/12/opinion/ivg-reproductive-technology.html