Healthcare, as it is defined by the Merriam-Webster Dictionary, means the maintenance and improvement of physical and mental health, especially through the provision of medical services (Merriam-Webster). When someone provides health care to a patient, they do not only help with the physical ailment, but they must also attend to the person as a whole. This poses a lot of issues with many different people. Different cultures have different ways that they are accustomed to dealing with certain situations. Therefore, it requires a lot more attention and understanding on the part of the health care provider, especially when dealing with an immigrant or refugee patient. This demographic specifically is a target for dealing with race-ethnicity and healthcare challenges in the United States.
The challenges that immigrants and refugees face in accessing equitable healthcare are language barriers, unfamiliarity with medical procedures, and prejudiced behaviors as a result of these misunderstandings. Because most immigrants and refugees have a language barrier, many of these patients get inadequate information from their exchange with their medical providers. This causes confusion and anxiety that is not a good representation of healthcare. Thus, their unfamiliarity with the medical procedures causes distrust between the patient and their medical providers. This is evident throughout the book, The Spirit Catches You and You Fall Down by Anne Fadiman (1997). Lia Lee, a Hmong child with seizures, came into the American Healthcare System and her story became a “tragic case of cultural miscommunication” (Fadiman, 1). Even though both her parents and the doctors were doing everything they could to help her with her medical issue, the fact that the interpreters did not know how to adequately translate what the doctor was saying for the Lees, caused Lia to suffer because of a constant battle between the doctors and the parents. At one point, the doctor on Lia’s case ended up putting her into foster care because her parents would not give her the anticonvulsant medication that he prescribed. This caused her seizures to become worse and made developmental deficits occur and become more pronounced (Fadiman, 79-92).
The interpreter, Sue Xiong, translated the situation in a way where Lia’s father, Nao Kao, believed that the social workers were actually police officers that took their daughter away. “The police came to take Lia away. Sue told the doctor that we didn’t give Lia any medicine and that is why the doctors got mad and they came to take Lia away. I was very angry. I almost killed the translator. I said, this is my child and I love her. The police said for 6 months Lia is government property” (Fadiman, 82). This heartbreaking situation is just one example of what a simple miscommunication can cause. Lia’s mother, Faoh, had the same heart-wrenching reaction to her daughter being put under Child Protective Services (CPS): “When I came home my husband told me that they took the baby and he said that they didn’t tell him where they took the baby. I didn’t know any English so I didn’t know what to think or what to say. I told my Elder relatives, but they said, well, if those people came to take her, then you can’t do anything. I cried so much I thought my eyes would go blind” (Fadiman, 82). These examples of miscommunication emphasize how mistranslation can cause fear of the unknown and add unnecessary stress. Communication is such a key factor in healthcare that when it is not done properly it could cause detrimental effects on patients. “Failure to communicate properly the seriousness of risk can have negative consequences: patients may fail to comply with instructions or elect not to have potentially life-saving treatment” (Renata F. I. Meuter, et al). This puts a lot of pressure on the translators.
Many times, translators are relatives or family members of the patient that have no special training and don’t fully understand the medical language. They may indeed translate what the doctor says word for word, however, this may not be something that the patient understands. Because languages are so diverse and have many various ways of saying the same thing there might be a different phrase to use when trying to convey a message in a way that the patient would understand. Another issue that arises when referring to language barriers is cultural competency. People from different cultures express pain differently as well as other indicators that are crucial in providing care. For example, not every culture conforms to an expected set of behaviors. For some people, “the expression of pain varies widely. Some are stoic and slow to express distress. Others are expressive and will share their smallest discomfort” (International Association for the Study of Pain (IASP)). This makes it hard for the provider to access the patient’s condition, as well as for the interpreter to accurately translate it. Different cultures use specific terms, expressions, or metaphors that can be very difficult to understand and navigate if one is not familiar with the language and the culture that is usually behind it. The fact still remains that a large percentage of the population in the US are not English proficient. According to The New England Journal of Medicine, “Some 49.6 million Americans (18.7 percent of U.S. residents) speak a language other than English at home; 22.3 million (8.4 percent) have limited English proficiency, speaking English less than “very well,” according to self-ratings” (Flores). With such a large percentage of the U.S. population that do not have English as their first language, means that there should be a lot more medical translators available.
That vast amount of patients who are in desperate need of interpreters in order to have proper medical care have no access to them. Patients who face such barriers are less likely than others to have a “usual source of medical care; they receive preventive services at reduced rates, and they have an increased risk of non-adherence to medication. Among patients with psychiatric conditions, those who encounter language barriers are more likely than others to receive a diagnosis of severe psychopathology — but are also more likely to leave the hospital against medical advice” (Flores). This could be because of fear of the foreign treatment options provided. Having to attend psychological treatment can cause embarrassment and for some people with language barriers, it may seem like the doctors are just handing them off because they are “crazy”. With proper medical interpreters, the patient can get the care that they need, as well as maintain a good, trusting relationship with their healthcare provider. The cost of providing oneself with a medical interpreter is on average $279 per person per year, according to the American Journal of Public Health (cite). The cost can become a great burden for poor immigrants or refugees, but I do not see it as a significant cost for the federal government. A 2002 report from the Office of Management and Budget estimated that it would cost, on average, only $4.04 (0.5 percent) more per physician visit to provide all U.S. patients who have limited English proficiency with appropriate language services for emergency-department, inpatient, outpatient, and dental visits. This seems like a small price to pay to ensure safe, high-quality health care for 49.6 million Americans (Flores).
Since communication is such a cornerstone of the healthcare business and the well-being of the patients, I think that creating a way to make medical interpreters available for everyone is a right and not a privilege. It is the definition of providing equitable healthcare to everyone who may need it. This is why it is important that when a patient comes in and a language barrier is made evident, they should be provided with a translator that not only has special training but also a relationship to the medical field. It is crucial that the interpreters have an understanding of the medical terms and medical field. This would eliminate possible misunderstandings between doctor and patient and potentially save many lives down the road. Many immigrants and refugees have a very particular set of challenges when faced with being sick and seeking medical attention. The fact that they have to deal with unknown medicine practices puts an additional stress on them. Many have treated their illnesses in a traditional, specific way for most of their life, then they are transported into an unknown environment where many develop fears of these new medicines as well as the ways that the physicians administer and practice medicine. In Lia’s situation, as described by Fadiman (1997), the Hmong people believe that illness is caused by a bad spirit, called the dab, that takes over the body. The way that one gets rid of the dab is by performing ritualistic animal sacrifices, as well as native herbal regiments to combat the dab. Although the Hmong people value children greatly, (this is evident because they took Lia to the hospital) they were not convinced by the doctor’s prescription of the medicine to battle the seizures.
Therefore, they took matters into their own hands, resulting in adverse reactions for both the patient and the parents. Another example is when the young Hmong women came to the hospital to give birth to their children. The doctors did not know how to operate around them because it is against Hmong custom for the women to scream or make any noise when birthing a child. Therefore, these women would come to the hospital at the very last minute and just end up birthing the babies in the wheelchair or in the parking lot of the hospital. “Wheelchairs at the MCMC were called “Hmong birthing chairs” because so many Hmong babies were born in them en route to the labor and delivery floor” (74). Other women who were told their baby was in breech position and needed an emergency cesarean section refused treatment because they were scared of being cut, so they ended up going home and trying to have the baby on their own as they used to do back in Laos. Fadiman (1997) recounts how one such woman attempted to give birth at home rather than have the surgery. “The paramedics came in wheeling this Hmong woman on a gurney. She was making no noise, just moving her head around in panic… I have a very clear visual memory of lifting the covers to reveal a pair of little blue legs, not moving, hanging out of her vagina” (71-72). The mother ended up recovering, but the baby died shortly after from oxygen deprivation.
The mother did not agree with the doctor when he said that it would be much safer for both of them if he performed a cesarean section but she tried to deliver the baby on her own anyway. This was because of the fact that she was afraid of undergoing surgery due to it being very uncommon in Laos. This example makes one wonder if there was some way that the doctor could have convinced her and potentially saved the baby’s life. This concept of understanding and being able to convince someone that your way is better than what they know involves having cultural competency. This entails “the ability to interact effectively with people of different cultures, helps to ensure the needs of all community members are addressed” (Cultural Competence). Perhaps if the doctor had the adequate training in cultural competency, the child could have been saved and more Hmong women would potentially be more comfortable with having this life-saving surgery. Many different cultures experience this issue of receiving treatment from an unknown source.
In a study done by Nico Nortjé analyzing pain expression of the African subculture, he found that “the ratio of traditional healers in sub-Saharan Africa is set at 1:500 people in comparison with one medical doctor per 40,000 people. It is therefore clear that traditional medicinal remedies are more accessible and play a major role in sub-Saharan Africa where 80% of the more than 1 billion people in 54 African countries still make use of traditional medicine” (Nortjé). If the African people that immigrated to America and were faced with going to the hospital where they would see a doctor instead of a traditional healer, they are less likely to cooperate with the treatment options. Nortjé’s study also revealed that if the healthcare provider built a good relationship with the patient, (such as the traditional healers would do) they would be much more receptive to the medicine and treatment that was prescribed. When doctors experience these miscommunications that end in tragedy, it can frustrate them and lead to prejudicial situations. Everyday routines that the predominant culture takes for granted such as time orientation, eye contact, touch, decision-making, compliments, health-beliefs, health-care practices, personal space, modesty, and non-verbal communication can vary dramatically between cultures, sub-cultures, and religions (Ferwerda). Extensive research has identified that there are some ways that a healthcare provider can be inclusive and demonstrate cultural competence. The first of these include maintaining an open mind and being knowledgeable about the differences between the predominant culture and the new one presenting itself. By including awareness, acceptance, and asking the patient for his/her cultural frame of reference, the healthcare provider can better themselves by including cultural competence in their practice.
According to Culture Advantage, an organization formed to help individuals develop cross-cultural awareness and communication skills, “Caregivers are expected to be aware of their own cultural identifications in order to control their personal biases that interfere with the therapeutic relationship. Self-awareness involves not only examining one’s culture but also examining perceptions and assumptions about the client’s culture” (Cultural Awareness). Awareness does not mean that one must agree or even comply with some of the premonitions, but that they recognize that they exist and that one should be respectful of them. In the same way, being accepting doesn’t mean that one is accepting those beliefs, but rather accepting the person as they are. Research indicates that religious beliefs and spiritual practices of patients are powerful factors for many in coping with serious illnesses and in making ethical choices about their treatment options and in decisions about end-of-life care. If one is accepting of the other person’s beliefs, then they are effectively helping them heal both inside and out. Being aware, respectful, and accepting of others’ beliefs will allow the patients to become more trusting and open towards the healthcare provider. This causes the patients to have a therapeutic relationship with their healthcare provider, thus improving the whole experience. The third factor in developing cultural competence is asking. There is no better way to understand and be aware of the difference in the cultural beliefs than to ask the patient. Asking patients about their beliefs and way of life is the best way to be sure you know how their values may impact their care. This would allow for the doctor or nurse to do their jobs to a better quality and make the patient happier overall. Asking helps doctors to get to know patients in a more personal manner, which can help them to avoid the pitfall of prejudicial behaviors. Cultural differences often result in mistrust among patients and doctors may cause prejudicial behavior. These key instances provide barriers to the patient’s access to equal healthcare.
When Dr. Neil, Lia’s doctor, was battling with whether to file a CPS report to take her into foster care, he struggled with this decision for a long time. He came to this decision to submit the file because he wanted to set an example in that community. As stated by Dr. Neil, You get so single-minded about a child’s welfare that you can pretty effectively suppress any kind of bad feelings you have about what you do to the parents. Which is that I felt that there was a lesson that needed to be learned. I don’t know if this is a bigoted statement, but I am going to say it anyway. I feel like it was important for these Hmongs to understand that there were certain elements of medicine that we understood better than they did and that there were certain rules they had to follow what their kids’ lives. I wanted the word to get out in the community that if they deviated from that, it was not acceptable behavior. (Fadiman, 79).
The differences in the culture were emphasized because of the lack of education and the fact that the Hmongs did not understand English made the doctors feel superior to them in a way. The complaints of the patients may not be taken seriously or they may be dismissed as unrelated to the initial diagnosis. In a study done by Suurmond, Jeanine, et al, exploring the negative healthcare experiences of immigrant patients, one of the major findings was that there were situations where “the respondents felt mistreated because of the care providers prejudicial behavior” (Suurmond et al). This included not taking their complaints seriously or misjudging their complaints on account of a previous misconception that the physicians may have held against the patient. This can stem from their cultural background or the general stereotypes that are associated with their race or ethnicity. In conclusion, healthcare is about taking into account not only a patient’s physical well-being but also their mental and emotional health. Language barriers and miscommunication create an inequitable division for immigrants and refugees denying them access to the health care that they deserve. The mistrust that forms between the healthcare providers and patients, due to the latter’s unfamiliarity with medical procedures and the former’s prejudicial behaviors are a serious concern when combating race, ethnicity, and healthcare challenges in the United States. A cornerstone of the nursing profession is therapeutic relationships with patients through effective communication. This involves active listening skills, developing strong, empathetic relationships and building trust between the healthcare provider and patient.
Without the presence of accurate information exchange, heartfelt and remedial communication is difficult to achieve, but not an impossible task. Raising awareness among nursing students early in their professional career about language barriers may lead them to seek opportunities to learn a language or explore opportunities of intercultural exchange. By researching and implementing these solutions to these issues, one can hope to provide this demographic with both an equal opportunity and equitable one.
