The COVID-19 crisis has demonstrated the innumerable ways our health care system can rise to the challenge—and also how we fall short in caring for our most vulnerable patients.
In March 2020, as cases of COVID began to climb, I spoke with staffers of the Family Van, a mobile health clinic that provides preventive health services in some of Boston’s most underserved neighborhoods. They emphasized the difficulty of finding multilingual COVID information and how this made it difficult for non-English speaking patients to protect themselves. At the time, neither the CDC nor the state health department had released COVID information in languages other than English, Spanish and Chinese, leaving community health organizations scrambling to pull together multilingual information on short notice.
Over a year later, this continues to be a problem. Many state governments provide limited information about the vaccine in languages other than English, and some offer no language assistance at all on their vaccine-finder Web sites. It should come as no surprise that rates of COVID infection are several times higher among non-English speakers, a disturbing pattern that mirrors previous epidemics.
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To date, much of the discussion around improving care for non-English speaking patients has centered around medical interpreters. This is important; patients who use interpreters receive more preventive care, experience fewer adverse events and have greater medication adherence. However, COVID taught us that simply having an interpreter available at the point of care isn’t enough. There are many deeply entrenched, historically enforced barriers that prevent non-English speaking patients from receiving the care they need—barriers that begin far before a patient comes to the clinic and last long after their appointment—and it’s time for more comprehensive reform.
Recently, several programs have emerged to provide language-appropriate materials and care. This includes government-led efforts to translate outreach information into different languages, and community-led efforts such as the COVID-19 Health Literacy Project, an initiative I founded to translate COVID fact sheets into 40 languages.
Yet, these efforts are still stopgap solutions. To ensure non-English speakers aren’t sidelined again after this crisis recedes, we must address the barriers they face not only in receiving medical care, but also in accessing and processing it. We need to redesign each part of a non-English-speaking patient’s experience with the health care system—before, during and after an appointment.
Before patients even see a clinician, they need to be able to access health information in their native language. Hospitals and clinics can collaborate with interpreter services to translate health information (e.g., patient education materials, public service announcements). Our work with the COVID-19 Health Literacy Project also revealed that many bilingual providers are enthusiastic to help translate materials into their native languages, so health care organizations can consider building an internal database of multilingual staff available to help as needed.
Public health agencies can also play an important role. For example, they could hire translators and make them available on a remote, contract basis to clinical and social service organizations in rural or low-income communities that often have a shortage of interpreters. This is also why we’re transitioning the COVID-19 Health Literacy Project into a new nonprofit organization that provides free translation services to community-based organizations to translate health materials into the languages spoken by their patients.
Efforts to translate health information need to be paired with programs to ensure this information actually reaches immigrant communities. The key is to bring culturally and linguistically appropriate services to the places where people live and work. The medium is also important; evidence suggests non-English speakers prefer text messaging or in-person communication. A good example is New York City’s fleet of mobile vaccination vans, where bilingual staff help patients navigate each step of the COVID vaccination process in their own language.
When it comes to the appointment itself, health care organizations should strive to match patients with providers who speak their native language. Language concordance is associated with fewer medical errors, a greater understanding of illness and the treatment plan, and increased satisfaction. Of course, this isn’t always possible, and qualified interpreters should be used at all other times.
Following an appointment or hospital admission, patients are usually given discharge instructions that detail their new medication regimen, home care instructions, and follow-up appointments. However, for non-English-speaking patients, this document is seldom translated into their native language.
There have been some suggestions to use machine translation tools (e.g., Google Translate) to automate translation of discharge instructions, but this approach needs to go a step further. We should strive to turn discharge planning into a conversation that non-English-speaking patients can actually participate in. For example, prior to discharge, clinicians can provide patients with their translated discharge instructions, review them verbally (with an interpreter present) and give patients time and space to ask questions.
For these changes to work at scale, they need to be bolstered by policy reform. A good place to start is reinstating the regulations on language provisions rolled back by a recent HHS rule. Under the new rule, providers are no longer required to include notices on significant communications informing patients of their right to receive language assistance. In addition, not having a language access program is no longer a breach of regulatory compliance for many federally funded health care organizations. These changes are a step backwards and can lead health care organizations to deprioritize language access.
How can we pay for these initiatives? For one, as the government distributes $1.32 billion in funding to community health centers as part of the CARES Act, they could mandate a certain proportion go towards building the infrastructure needed to support non-English speakers. In addition, nonprofit hospitals could tap into their community benefit dollars—community-directed services that nonprofit hospitals must provide to justify their tax-exempt status—to fund these programs.
It is evident that our health care system is failing patients with limited English proficiency, and the time is ripe to take action, move away from stopgap solutions and implement comprehensive changes that support non-English speakers throughout the health care continuum.
This is an opinion and analysis article; the views expressed by the author or authors are not necessarily those of Scientific American.