Map of life expectancy at birth from Global Education Project.

Friday, November 10, 2006

More from Clark Kent

Okay, I said I would talk more about what I do for a living. Now that we have that little election thing out of the way, I'll continue with the series.

At the APHA meeting, I was on a panel on Latino access to health care, sponsored by the Latino caucus. It was a great pleasure for me to be a part of a panel that really came together coherently around some important issues.

Tilly Gurman from Johns Hopkins found that Latina mothers giving birth at a certain hospital experienced major failures of communication with their doctors, including not understanding lab tests and discharge instructions, and only half of providers felt truly competent to serve Latinas. Nevertheless, the women consistently expressed a high degree of satisfaction with their care. I was nodding my head as she spoke because we consistently find the same thing -- we observe really atrocious processes of care, but Latina mothers give the clinic outstanding marks on patient satisfaction surveys.

There are a combination of reasons: a cultural norm of appreciating that people at least appear to be making an effort and not offering criticism unless you are asked repeatedly; favorable comparison of facilities and resources in the U.S. with those of the poor countries from which many of these women come; respect for authority; and of course, not necessarily realizing that there has been a failure of communication. (As Rummy says, there are the known unknowns and the unknown unknowns.)

Antonio Estrada spoke about barriers to care among HIV+ Latinos in the Mexican border region. While there were various problems, about 8% of the respondents indicated that difficulty crossing the border and the presence of the border patrol specifically were an obstacle. These are individuals who for one reason or another spend time on both sides. This is a reminder that for the population of the region, the border is an artificial construct. Mexicans of that region did not cross the border, it crossed them, when the U.S. seized the territory by force in 1848. To this day, members of extended families live on both sides. The Hispanic population of the Southwest does not consist, for the most part, of immigrants, but of people who found themselves in an Anglo dominated country while staying right where they were.

Mara Youdelman of the National Health Law Program discussed promising practices for providing language access in health care settings. For people who are interested in their excellent work on this subject, you can find out all about it here.

Vilma Enriquez-Haass discussed her dissertation research, based on an analysis of a survey of Latino day laborers. (This is a subject I wrote about a while back when I covered for Jordan Barab at Confined Space. I wish I'd had Vilma's findings available then.) Day laborers, who assemble to find work at places such as Home Depot parking lots, often do construction and landscaping work, but they don't have the benefit of worker's compensation and health insurance. Men who are injured on the job may get acute care, but no follow-up or rehab, and certainly not any short-term disability. In other words, if they can't work because they are injured on the job, they don't get paid.

Finally, I spoke about role exchange in medical interpretation, using data from pediatric clinics where doctors and nurse practitioners are communicating with limited English speaking mothers. We've observed that nurses and social workers who are called on to interpret often conflate their professional roles with that of interpreter. They may substitute their own judgment for that of the physician, edit what the mother says because they think they have a better idea of what the doctor ought to hear, and take over the interviewing process. Interpreters with inadequate training engage in inappropriate socializing with the mother, take it upon themselves to provide health education -- not necessarily accurately or coherently -- and also edit mother's remarks for what they consider to be biomedical relevance. Medical interpreting is a profession that requires high ethical standards as well as skills that go beyond just being bilingual. (Thanks to my colleagues Kari White and Rachel Heckscher for their contributions to this work.)

Now, I know there are a lot of folks out there who think that the real problem is that there are too many immigrants in this country, especially people who haven't yet fully mastered English and people who aren't here legally. I will discuss those issues at greater length and I hope we can have some dialogue about it. But meanwhile, whatever you may feel about the situation, these are the facts.

Editor's note: We're glad that Dr. Rick is back in circulation. Stop by Critical Condition for his return to the blogosphere. We hope that CC will get back to regular updates. I should be back Sunday.

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