Identifying autism in a very young child is difficult under the best of circumstances, but Nelsinia Ramos faced a special challenge seven years ago when she sought a diagnosis to explain her young daughter Jennifer’s developmental delays.
Ramos spoke little English, but she was determined to find out what was wrong with her daughter, who was not yet 2.
“The language barrier added to the frustration because I couldn’t really explain what was going on with her, even though I tried my best,” says Ramos, who now speaks fluent English.
Some 50 million people living in the U.S. speak languages other than English in their homes, and 22 million speak only limited English.
For many, access to health care is limited by their inability to communicate their medical needs, in large part because of a lack of qualified interpreters in the nation’s hospitals, says Glenn Flores, MD, who has long studied the problem.
“We are not providing the best care to patients when language barriers aren’t being addressed,” he tells WebMD. “This is a quality of care issue, and it makes both ethical and economic sense to address it.”
13 States Require Reimbursement
In an editorial appearing in Thursday's New England Journal of Medicine, Flores called on federal and state officials to enforce a federal mandate requiring language assistance for patients with limited English proficiency.
Thirteen states currently require third-party reimbursement for hospital-based interpreters, but they are not the states that need such laws most, Flores says.
“The states with the largest non-English-speaking populations don’t have these requirements,” he says.
A survey of hospitals in New Jersey, where a quarter of the population speaks a language other than English in their homes, revealed that only 3 percent provided full-time interpreters. That translates to one interpreter for every 235,260 people, Flores says.
When interpreters aren’t available, health care providers tend to rely on bilingual family members, friends, or even hospital staffers who aren’t trained medical interpreters. A study of interpreter-caused medical errors, conducted by Flores and colleagues, found that more than three-quarters, or 77 percent, involved nonprofessional interpreters.
The school-aged children of immigrants often serve as interpreters for their parents because they tend to be more fluent in English. This practice presents special problems in the health care setting, Flores adds.
Interpreters Cost Effective
The U.S. Office of Management and Budget estimates the cost of providing adequate language services to everyone who needs them to be around $4 more for each doctor visit during emergency department, inpatient, outpatient, and dental visits.
Flores says providing these services would save health care dollars by preventing unnecessary hospitalizations and treatments.
In 1997, emergency medicine specialist Louis Hampers compared the care given to patients at a Chicago hospital who were not fluent in English to the care given those who were.
Non-English speakers tended to be admitted to the hospital more often and they were given more IV fluids and unnecessary tests.
Hampers, who now works at Children’s Hospital of Denver, tells WebMD that addressing the language barrier in health care not only makes sense from an ethical standpoint, but from a legal and business standpoint as well.
“If you can prevent one hospitalization for every 100 patients by having an interpreter, that interpreter would no doubt pay for themselves.”
To make the legal point, Flores recounts the case of a Hispanic teenager living in Florida who collapsed at his girlfriend’s house after attending a high school baseball game. Paramedics who responded to the girlfriend’s 911 call overheard her say that the boy had complained of being “intoxicado” before he collapsed.
The emergency workers didn’t speak Spanish so they assumed she was saying he was intoxicated. But the word also means “sick in the stomach” in Spanish.
“It took 48 hours for hospital workers to do a CT scan,” Flores says. “It turned out that he had large blood clots in his brain probably resulting from a ruptured artery.”
The boy ended up losing the use of both arms and legs as a result of the treatment delay. He sued the hospital, which settled out of court for $71 million.
Luckier Than Most
Ramos, who lives in Milwaukee, Wis., knows she was luckier than most people with limited English skills when she sought a diagnosis for her daughter because she had access to an excellent bilingual clinic run by Children’s Hospital of Wisconsin, now directed by Flores.
Because of Ramos’ single-minded determination, Jennifer began receiving special services very early in life, even before her autism diagnosis at age 2. She is now 9 years old and Ramos says it is clear the early attention has helped her.
“For many (non-English-speaking) families who have children with special needs, those needs aren’t identified until the children reach school age,” she says.
By Salynn Boyles, reviewed by Louise Chang, MD
SOURCES: Flores, G. New EnglandJournal of Medicine, July 20, 2006. Glenn Flores, MD, professor of pediatrics, epidemiology and health policy, Medical College of Wisconsin; director, Center for Advancement of Underserved Children, Children’s Hospital of Wisconsin. Louis Hampers, MD, section chief for emergency medicine, Children’s Hospital of Denver and University of Colorado School of Medicine. Nelsinia Ramos, Milwaukee, Wis.