Map of life expectancy at birth from Global Education Project.

Tuesday, August 09, 2005

Civil Rights

The disgraceful, heart rending events described below are not an anomaly. I only noticed the connection in hindsight -- I didn't have a plan -- but I have devoted much of my work since completing my degree to understanding what happens when people who are not fluent in English encounter the U.S. medical institution. Actually my work is considerably broader than that -- having almost no shared language is really just a heightened case, an extra complication, but medical communication is always a problem.

The law, for what it's worth, is clear. The Office of Civil Rights of the U.S. Department of Health and Human Services has long interpreted Title VI of the Civil Rights Act of 1995 as requiring all institutions that receive federal funding -- which includes essentially every hospital, nursing home, community health center in the United States -- to provide full access and equal services to people with limited English speaking ability. However, there is no proactive enforcement of what is, undisputably, the law of the land. People can complain, they can sue, and if they prevail, the outcome will be a resolution agreement: the institution will not admit that they ever did it, but they'll promise not to do it again. Then they'll do it again.

Hospitals, such as the one in question, have policies requiring that people be given interpreters when they need them. They have, as in this case, interpreter services. The problem is, nobody bothers to tell the doctors. As too many doctors aren't particularly interested in communicating with their patients anyway, they aren't going to go out of their way. There are plenty who are responsible about this, but plenty more who aren't.

I tape recorded a pediatric visit, with a very sick child, which was interpreted by the toddler's 11-year-old sister. The doctor apparently did not recognize that she was actually supposed to communicate with the mother, through the sister, so she treated her interlocutor like an 11-year-old: a pest whose questions were intrusive and annoying, who didn't need to know anything. And of course, the little girl was an incompetent translator. The doctor never found out that the family was living in a shelter because the father of the children was hunting for them to kill them all, among other facts that may have been relevant to the child's condition. Her medication instructions and other key information were incorrectly translated. Etc.

My colleague interviewed a Spanish speaking man who underwent a triple bypass operation at a hospital just down the street from the one where I had such a great time. The doctors would come on morning rounds, stand at the foot of his bed and talk about him in a language he didn't understand. In the afternoon, when his daughter got off work, she would call his doctor, then call him to convey her understanding of his condition.

I had a medical student who was doing a rotation in the emergency department at the same hospital stay with me for a month. It is the law in Massachusetts that emergency departments must provide interpreters. I asked the student about this and he said he'd never heard of it. "They usually have a family member who can translate. We had a guy come in last night who'd had a heart attack, and his son translated for him."

I tape recorded and analyzed 13 pediatric outpatient visits featuring interpretation. The interpretation was uniformly terrible because the interpreters weren't trained, weren't professional, and either didn't know what they were doing or grossly misbehaved. Having family members interpret is unethical and as far as I'm concerned, it constitutes medical malpractice res ipsa loquitur. Think about it: aren't your conversations with your doctor supposed to be condfidential? Do you necessarily want your mother, or your cousin, or your 12 year old daughter there while you discuss your cancer, or your drinking, or your gonorrhea, or for that matter, your worries about your relatives? And what do they know about medical terminology or the very complex art of mapping meaning from one language to another?

I could go on. I should go on. I have ranted about this until I depleted the oxygen supply again and again. Hospital executives, department heads, plain old doctors just don't get it. They don't beleve it. They have a policy. The housekeeping staff is always around to translate. The people want their family members to translate, so what can we do? So what if there isn't always an intepreter, we can still diagnose and treat.

Wrong, wrong, wrong, and wrong. You're hurting people. You're killing people. You're violating people's human rights. It's long past time to get serious about this. If you don't care, or you don't think you have to, or you think you've already done it, you're incompetent and unethical and you aren't doing your job.

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