All she needed was a routine prenatal check-up. But Rosa Campos dreaded the thought of visiting a northwest suburban Rolling Meadows clinic.
“I felt terrible because there was nobody who spoke Spanish there. I couldn’t say anything,” said Campos, a Mexican native who asked that her real name not be used. Desperate, she enlisted her husband’s nephew as an impromptu interpreter.
But when a doctor began asking about “most private matters,” Campos kept silent. The idea of sharing such intimate details with the nephew was too embarrassing.
“I felt like somebody was undressing me,” she said through an interpreter.
Others who don’t speak English tell similar tales of struggling to communicate with their doctors. It’s a problem often faced by immigrants and refugees as they increasingly flow into suburban hospitals and clinics, The Chicago Reporter has found.
By law, hospitals and even small private practices that receive federal funds are required to provide interpreting services. But many are limping along with a patchwork of makeshift methods to communicate with non-English-speaking patients, shows a Reporter survey of 200 suburban health care facilities.
Most rely on bilingual family members, off-site telephone interpreting services or untrained staff members who must interpret patients’ symptoms in addition to doing their regular jobs.
But such methods aren’t good enough, said Elizabeth Jacobs, senior attending physician at Cook County Hospital, who co-chairs the policy and research committee at the National Council on Interpreting in Health Care.
“As health care providers, it’s our professional obligation and duty to be able to communicate with patients. It’s truly the basis of medical care,” she said. “But I wonder if that’s possible under these conditions.”
From May through August, the Reporter surveyed 52 hospitals, 22 outpatient surgery centers and 126 community clinics located in suburban Cook County, and DuPage, Kane, Lake, McHenry and Will counties. The Reporter found that:
* One out of every five clinics offers no interpreting services of any kind.
* 12 hospitals, 5 surgery centers and 5 clinics employ interpreters.
* More than half of the facilities encourage patients to bring their families or friends to interpret.
* 145 facilities use employees with other jobs to interpret, and 80 of them rely on bilingual clerks, janitors or other employees with no medical background.
* Such employees were trained on interpreting skills at 22 facilities and evaluated at 26 facilities.
The Reporter’s findings show “a stark reality of how the health care industry has failed to respond to the needs of immigrants,” said Sandra Del Toro, policy and advocacy coordinator at the Illinois Coalition for Immigrant and Refugee Rights.
“They need to realize that they can’t just keep ignoring the growing immigrant community,” she said.
Hospital and clinic administrators say they want to help patients, but cannot afford the costs.
“A lot of what we hear is the frustration,” said Amy Lee, spokesperson for the American Hospital Association, which represents roughly 5,000 hospitals nationwide. “Because hospitals have so many financial stresses, it’s difficult for them to find the money for interpreters.”
Others say requiring doctors to provide interpreters is unconstitutional.
“Our right to free speech includes the right to speak in English, and requiring doctors to provide interpreters violates that right,” said K.C. McAlpin, executive director of ProEnglish, a national group of English language advocates based in Arlington, Va.
But the lack of trained, dedicated interpreters threatens the health of immigrants and refugees, advocates say.
For example, 8 percent of more than 4,000 uninsured patients surveyed in 16 cities were in need of an interpreter but did not get one, according to an April study by The Access Project at Brandeis University in Boston. Of that group, more than a quarter left the hospital without understanding how to take prescribed medications—a problem experienced by 2 percent of the general population.
“Our study shows that the lack of interpreters has a bearing on a whole experience that people have at hospitals,” said Carol Pryor, policy analyst at The Access Project. “It could potentially affect them in ways that might cause serious damage to their health.”
Immigration Wave
Over the last decade, immigrants settled in suburban Cook and five collar counties at a rate of more than 34,000 a year, defying historical patterns of immigrants flocking to poor urban centers.
“Many immigrants are moving right into the suburbs now—and not to the city at all,” said Robert Paral, fellow at the Institute for Metropolitan Affairs at Roosevelt University, who authored a 2000 study on the region’s immigrants.
By 2000, the immigrant population in the Chicago suburbs had surged to 790,000, a 77.5 percent increase from a decade earlier, according to the census. More than 15 percent of the population—or one in seven residents—is now foreign-born, up from 9.9 percent a decade ago.
The influx has brought an unprecedented linguistic diversity: One in five suburban residents now lives in a household where a foreign language is spoken, and one in 10 speaks English less than “very well.”
The Chicago suburbs feature a mix of languages drawn from around the world, including English, Spanish, Chinese, Vietnamese, Greek and Tagalog—a language of the Philippines. All in all, more than 37 languages are spoken in the region.
Immigration has also raised a slew of questions, most of them revolving around how courts, schools and other public facilities can cope with such a variety of foreign languages. But it is in hospitals and other health care facilities where one of the most costly and intimate effects of the immigration wave is taking hold.
The health care industry has long highlighted the expense of treating immigrants, who are more likely than others to be uninsured and unable to pay.
The annual cost to provide interpreters alone is estimated to be as much as $267.6 million nationwide, according to the Office of Management and Budget, a branch of the White House.
But others say the failure to provide language assistance will prove even more costly to the industry in the future.
They point out that census projections show the nation’s foreign-born population could more than double to reach 53 million by 2050.
In west suburban Aurora, Provena Mercy Center is taking no chances. The 356-bed hospital first hired an interpreter in 1996, and now spends about $80,000 annually to maintain a team of seven interpreters to meet soaring demand.
It’s expensive, but a valuable investment, said Nicholas J. Loise, vice president of marketing and planning. “We look at it as one of the ways that we serve our community,” he said.
During the 1990s, Aurora’s foreign-born population more than doubled, census figures show. More than a third of its residents now speak foreign languages at home, and one in five speaks English less than “very well.”
“Language barrier is always an issue. It’s very common in our community,” said Maricela Perez, parish nurse at St. Nicholas Catholic Church in Aurora.
In 1999, Perez interviewed 768 Spanish-speaking parishioners at the church, and found that more than half considered language as a barrier preventing them from seeking health care.
Yet, at most clinics, interpreters are in short supply, Perez said. “I’ve gotten in so many arguments over this,” she said. “They deny the [interpreting] service to my patients all the time.”
To tackle such problems, a group of advocates—known as Compañeros en Salud, or Partners in Health—gathers each month at Provena. The group started three years ago, relying on volunteers from grassroots organizations and others who serve Aurora’s burgeoning Latino community.
In 2000, the group created Language Access to Healthcare, a nonprofit interpreter bank. The agency dispatches its 23 trained interpreters, who speak Spanish, Albanian and Chinese, to area hospitals and clinics, and charges $25 an hour for the service.
“We began providing the service because of the tremendous need,” said Executive Director Sal Valadez. “We have to get beyond asking janitors to interpret in what sometimes can be life-and-death situations.”
Sound Business
In August 2000, an executive order signed by then-President Bill Clinton reminded physicians and hospitals receiving federal funds that, under Title VI of the Civil Rights Act of 1964, they must provide services that can be understood by non-English speakers.
To comply, they have a wide range of options, such as hiring interpreters, using bilingual employees, contracting with paid services or volunteers, or using telephone interpreting services.
But a guideline issued by the U.S. Department of Health and Human Services stresses that interpreters must be trained and provided at no cost, and that doctors should not rely on patients’ friends and families—especially children.
In Illinois, a similar rule has been on the books since 1993, when the General Assembly passed the Language Assistance Services Act. But the law is largely symbolic, imposing no penalties against those who fail to comply.
“The political climate at that time was much more conservative, and that made it hard to pass legislation that had more teeth,” said former state Sen. Jesus Garcia, who proposed the legislation. “My hope was always that, at subsequent time, the law could be beefed up, so that we’d have more enforcement authority.”
Garcia is now executive director of the Little Village Community Development Corporation, and also serves on the Reporter’s editorial board.
State Sen. Miguel del Valle, a Northwest Side Democrat, said he’s willing to sponsor a tougher bill.
“Now that we have a Latino legislative caucus that didn’t exist when this legislation was proposed, we ought to go back and see if we can strengthen the language that was put in there,” he said.
But, if events in other states are any indication, such an attempt could face stiff opposition.
In Virginia, for example, four doctors and ProEnglish filed a federal lawsuit in March, contending that President Clinton’s executive order infringes on their First Amendment rights.
“We are filing suit because this thing is outrageous, burdensome and—most of all—unconstitutional,” said ProEnglish’s McAlpin. “It’s the worst possible thing for the medical system.”
Other critics say the issue has less to do with free speech than with exorbitant interpreter costs.
For example, Language Line Services, which provides phone interpreters in 140 different languages, charges doctors between $2.20 and $4.50 per minute—up to $270 an hour—depending on the language and time of day.
The cost can far exceed the amount of reimbursements doctors receive for treating a Medicaid patient, which can be as low as $13, according to the Chicago-based American Medical Association.
“If I had to pay 10 or 20 times, out of my pocket, what I would get reimbursed for seeing a patient with an interpreter, I would think twice about if I was going to do it,” said Dr. Richard F. Corlin, immediate past president of the AMA. “It’s an absolutely foolish and counterproductive bit of legislation, which is clearly going to reduce access to care for those whom it was supposed to increase access to care.”
Advocates say such objections are shortsighted.
In fact, they say, providing interpreters is sound business: It will not only help attract more patients but save money by avoiding unnecessary tests and reducing costly emergency room visits.
“In the long run, what is more cost-effective? Having to do a ‘cat’ scan three times because a doctor doesn’t know that it was just done in another facility?” said Wilma Alvarado-Little, manager of interpreter services at Children’s Memorial Hospital in Chicago.
Interpreters can also ensure the delivery of good preventive care, said Ramon Sanchez, community coordinator at The Genesis Center for Health and Empowerment, a clinic in northwest suburban Des Plaines. Otherwise, “people will end up in emergency rooms, and it’ll get more costly,” he said.
Misdiagnoses—and expensive malpractice suits resulting from them—could also be avoided by having interpreters, said Mireya Vera, director of community services at Westlake Hospital in west suburban Melrose Park.
“When you think of the kinds of things that can go wrong when you don’t speak the person’s language, you can’t afford not to have an interpreter,” she said.
Diverse Workforce
Interpretation in medical settings can be a tricky business.
First, there’s the technical medical terminology to interpret.
“The fact that you are fluent in another language doesn’t necessarily mean that you are capable of interpreting complicated medical terms,” said Jing Zhang, director of community health programs at Asian Human Services, a Chicago-based nonprofit.
Even trained interpreters struggle sometimes, said Silvia S. Schrage, a trained Spanish interpreter and manager of Cross Cultural Communications at Sherman Hospital in west suburban Elgin.
When on duty, Schrage always carries a Spanish-English medical dictionary. “When you think about all the specialties in medicine, it’s very important that, if you don’t know something, you look it up,” she said.
Then there are cultural nuances for each patient.
“I feel very strongly that culture is as much a barrier to meaningful communication as language is,” said Elizabeth Keating, manager of multicultural services at Central DuPage Hospital in west suburban Winfield.
Good interpreters should know common medical and psychological problems, treatments, and even the history of patients’ native countries, said Aida L. Giachello, director of the Midwest Latino Health Research, Training, and Policy Center at the University of Illinois at Chicago.
Knowing that diabetes is prevalent among Latinos, for example, can help make a proper diagnosis, she said.
But, to some advocates, any solution that involves interpreters falls short. The goal, they say, should be to recruit more bilingual medical professionals, and train them on their interpreting skills.
“I’m real cautious about embracing interpreters,” said Carmen Velasquez, executive director of Alivio Medical Center in Chicago, where all staff members are bilingual. “We do not hire people we’re going to have to interpret for. That just doesn’t cut it.”
Mary Lou Siantz, immediate past president of the National Association of Hispanic Nurses, concurred. “People feel more comfortable with a doctor or nurse who can speak their language than with a third-party interpreter,” she said.
Others agree, to a point.
“I do believe that we should have a diverse workforce to meet the needs of all patients, but we are not even near that point,” said Jorge Girotti, director of the Hispanic Center for Excellence at the University of Illinois at Chicago College of Medicine.
In 2000, minorities made up 24.7 percent of all practicing physicians in the country, though they were 30.9 percent of the U.S. population, according to the AMA. The gaps were even wider among Latinos, who were 12.5 percent of the population but 5 percent of all doctors.
Closing that gap would be an enormous task, said William McDade, associate dean for multicultural affairs at the University of Chicago’s Pritzker School of Medicine.
“There are a lot of good would-be doctors out there who don’t get a chance,” he said. “It’s going to take a long-term strategy to figure out how to change that.”
In the meantime, Girotti said the next best approach is to have a trained interpreter. “It’s a good short-term remedy, at the very least,” he said.
Contributing: Maria Erdmann, Janelle Frost, Megan Marz, Heather J. Parker, Kristen Schorsch, Rupa Shenoy, Steve Sierra and Tamirra C. Stewart.