Interpreting Health: Cultural Barriers at New York City Hospitals

In order to serve its increasingly multi-lingual population, New York State requires interpretation services in all hospitals. But when caring for immigrants, the language barrier is just one of a myriad of issues health providers grapple with. Even though there is no statewide mandate for cultural sensitivity, many doctors say it’s become a necessary instrument in providing medical care for the city’s immigrant population.

Cover your cough poster in Arabic (Courtesy of the Department of Health)

Maha Attieh is the health program manager at the Arab American Family Support Center, and she has a constant stream of clients at her small office on Court Street in Brooklyn. Attieh’s job is to help new immigrants navigate a daunting and foreign health-care system. But she says she spends a lot of her time educating health providers about what alienates her clients.

“Like in the hospitals, if a Muslim person is dying they’re supposed to be facing east. Does the hospital know these things? If a Jewish [person is] dying when they wear their yarmulke, they should leave it on their head because of the religious issues,” Attieh says.

The city’s public hospital system, which receives the bulk of immigrant patients, established a special department, the Center for Culturally and Linguistically Appropriate Services (CLAS) in 2006. Attieh says she’s glad hospitals in the city are becoming more sensitive to the needs of the Arab-American community. But she says there are still cultural hurdles that make medical care an unpleasant ordeal for her clients.

On Christmas Eve, a 31-year-old woman from Yemen, wearing a traditional black robe decorated with red embroidery, walked into Attieh’s office for help with a Medicaid application. Halima (who did not want to use her real name because she didn’t want her community to know about her struggles), has eight children. The first five were born in her village in Yemen, where it’s traditional for women to give birth in their homes while kneeling on a special mat placed on the ground.

“My father’s father, he cut the umbilical cord and cleaned everything, he took care of everything,” Halima tells Attieh, in Arabic.

But when giving birth to her first American-born child at Kings County Hospital in Brooklyn, Halima found herself lying immobile on her back, hooked up to an IV, feeling helpless and exposed. She wanted to be in her customary position, on her knees. So she asked the nurses, but they refused. “This is our business, not yours,” Halima remembers them telling her.

Not knowing hospital rules or her rights as a patient, Halima found childbirth in Brooklyn frightening and traumatic.

Patients refusing medication, requesting specific foods, and preferring home remedies are issues hospitals in New York face daily. And major life events like birth and death are when cultural issues are likely to arise. Even though hospitals in the city are training their staff in cultural competency, they can’t always accommodate patients completely.

Surrinder Suri, a nurse at Elmhurst hospital in Queens, says when there are tragedies like still births, some of her patients ask to take the placenta home for burial in their back yards. But the hospital can’t allow that because of Department of Health regulations.

“We tell them we can give you a piece of the cord and you can put it in a test tube and you can bury it. So you find an alternative to help them carry their practices,” Suri says. To improve relations with the community, Suri says Elmhurst has been training its nurses in cultural sensitivity. They’re now open to Muslim women who insist on female doctors, and Chinese and Korean patients who hang numbers in their rooms as signs of good luck. But the line is drawn at what the hospital considers patient safety issues. Touching a newborn’s lips with honey is a traditional practice in many parts of the world–but in American hospitals it’s forbidden, for fear of botulism. It’s times like these when arguments between patients and providers occur.

Dr. David Rubinstein, director of cardiology at Elmhurst, finds that taking the time to find a middle ground with patients is crucial. “You have to be very sensitive to their family and community needs,” Dr. Rubinstein says. “The idea that you can just give a pill and think that a person is either going to take it or continue to take it is not correct.”

Dr. Rubinstein is trying to forge a relationship with the South Asian community living around Elmhurst hospital, which has a disproportionately high rate of heart disease. But he says it’s difficult to communicate — and not just because of language barriers. Last summer for example, he brought a group of college students to a Sikh temple to give a presentation about heart disease. But one of the students who helped organize the outreach project was upset when he found the older community members, mostly senior men, didn’t take him seriously because he was so young. He asked Dr. Rubenstein why they weren’t listening to him. Dr. Rubenstein replied, “Because people have to be approached in a certain way if we’re going to get the message across.”

Cultural differences in how to define illness and treatment also compound the communication problem — and can have fatal consequences.

Last year, Evens Jean, a language interpreter at Bellevue Hospital, was working with a Haitian patient and her doctor. In the patient’s previous appointment, many months earlier, she had been diagnosed with breast cancer.

“So by the time the patient came back to see the doctor it was already too late because the cancer had metastasized. The patient was asking the doctor, ‘Is there any way you can give me some pills or some ointment I can apply over that area because I don’t feel any pain.’ The doctor was trying to talk to her, saying ‘no,’” Jean says.

Jean, who was born in Haiti, understood the cultural barrier, and decided to step out of his role as an impartial interpreter and explain to the doctor why communication had failed. “I jumped in and told the provider that this is how it is in our culture. If we don’t feel the pain, if we don’t have an open wound, basically, we’re fine.”

That’s exactly the kind of situation Maha Attieh is trying to avoid at the Arab American Family Support Center. She desperately wants the women in her community to get screened for breast cancer before it’s too late. But she says it’s been a struggle to even get women to the hospital, and many don’t know they can request a female doctor.

“Our women, they don’t like to show the whole body in front of the doctor when they do their mammogram. They think it’s painful for them to do it, but we assure them that a woman will be doing the mammogram for them,” Attieh says.

A few years ago, Dr. Francesca Gany, director of the N.Y.U. Center on Immigrant Health, noticed the same thing. She saw data showing there were almost no Arab-American women getting screened for breast cancer in New York City. In an effort to counter this health disparity, she started an outreach program. It wasn’t simple. Many of the women had had negative experiences with the health-care system, and they were reluctant to return. They told her they received high bills they didn’t owe, and encountered providers who weren’t “sensitive to their needs or who could be racist about having immigrants come in for care.” After those experiences with the health-care system, Dr. Gany says “chances are they’ll never come back unless it’s dire.”

Back at the Arab American Family Support Center, Halima tells Maha she not only had a traumatic childbirth experience in the U.S., but she also struggles with the American health-insurance system. Halima’s henna-stained hands are clutching a plastic bag that holds eight passports, Social Security cards, birth certificates, old health-insurance cards, and pay stubs. Halima only knows a few words of English, and can’t read or write Arabic. Maha Attieh, who is filling out the Medicaid application for her children, asks Halima for a new document every few minutes, and she shuffles through the documents.

Because she didn’t understand the Medicaid re-enrollment form that was sent to her home, Halima missed the renewal deadline, and her eight children lost their insurance. Attieh says most of her clients get lost in the American health-insurance system, so they just go without it. Furthermore, she says many avoid public health insurance even if they’re eligible for it, because they think it will affect their citizenship applications. That means they don’t see doctors until they land in the emergency room, which ends up being more costly to their health, not to mention hospital budgets. For all these reasons, the Arab American Family Support Center started a health advocacy program last year. They trained six bilingual community members to be cultural navigators for the health-care system.

“They are our eyes and ears in the community, they let people know it’s okay to get health insurance, it’s okay to access health care because we are there to help them out,” Attieh says.

These navigators accompany immigrants to hospital visits, advocate for culturally sensitive care, and make sure patient and doctor are truly communicating. Necole Brown of Healthy Families Brooklyn helped train the advocates and says they help new immigrants learn the very basics.

“Okay, you have a health insurance plan, now you have to pick a primary care doctor. What does that even mean to somebody?”

Brown says the Center’s program is successful because the advocates come from the community itself, and they’re natural leaders that people flock to anyway. Not only is this program highly sensitive to the community’s specific cultural needs, it may also be more financially sustainable than hospital led programs.

Back in Queens, Dr. Rubenstein says it’s getting harder for him to raise money for his South Asian outreach program as the hospital’s budget is squeezed. Especially since Elmhurst doesn’t get paid for preventative medicine.

“It’s very difficult to find targets to treat and goals to measure with outreach activities. If you bring 1,000 patients into the hospital to get care and follow up, you’ve probably done a tremendous good to the community, but how do you track that? It’s very difficult,” Dr. Rubenstein says.

That’s why community based health programs run by groups like the Arab American Family Support Center are taking on a bigger role in immigrant health. These insiders are fluent in the cultural language that builds trust with hospitals — and trust is what’s needed to get people in, before there’s a crisis.

This series was conceived and produced as a project for The California Endowment Health Journalism Fellowships, a program of USC’s Annenberg School for Communication & Journalism.

American Sign Language interpreters: the theater world’s unsung heroes

By Maya Kroth SPECIAL TO THE U-T

Sunday, January 2, 2011

Doug Hlavay, with the American Sign Language interpreters, interprets for the deaf patrons at a performance of “Beauty and the Beast” at the San Diego Civic Theater. Photo by Earnie Grafton/The San Diego Union-Tribune.

ASL-interpreted performances are offered regularly at La Jolla Playhouse, Broadway/San Diego and San Diego Junior Theater, and by request at the Old Globe Theatre and other theaters. Liz Mendoza’s Stage Signs of San Diego maintains a calendar of ASL-interpreted performances throughout Southern California via its Yahoo group. Upcoming interpreted performances include:

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Billieann McLellan signing “welcome.” Photo by David Brooks / Union-Tribune

LynnAnn Garret signing “theater.” Photo by David Brooks / Union-Tribune

Suzanne Lightbourn signing “heartfelt.” Photo by David Brooks / Union-Tribune

Billieanne McLellan looks sharp as she stands outside the Casa del Prado Theater in Balboa Park one recent Saturday, wearing a black-velvet blouse, black trousers and black patent-leather shoes. Her long, red hair is pulled back into a low ponytail, and her nails are impeccably manicured: Today they’ve got to look flawless. She cuts through the bustling lobby and dashes toward the front of the theater, where her partner (or “team,” in industry parlance) is waiting near the stage. Also dressed in black, Lynn Ann Garrett has her hair slicked back and her eyelids shaded dramatically in dark shadow, to better show up under the hot lights of the theater. Against the heavy, black-velvet curtain, the two women seem to almost disappear as if into a blue screen, only their hands and faces standing out from the sea of black.

And that is just the way they like it. Because they’re American Sign Language (ASL) interpreters, two of about 10 actively working in San Diego theaters, all of whom would tell you it’s their job to be invisible, as much as possible anyway, so as not to detract attention from the “real” stars performing on stage. That humble attitude, combined with the huge volume of work that goes into doing what they do, makes this one of the most underrated gigs in show business.

Interpreters typically work in teams of two to mount a single ASL-interpreted performance, for which they spend many dozens of hours — some say even hundreds — preparing. Beginning weeks in advance, they get together to pore through scripts line-by-line and divvy up characters, often juggling two dozen or more between them, many of which speak simultaneously.

With their “team,” they will strategize to find the best way to translate a playwright’s words into a wholly different language that has a grammar and syntax all its own, while retaining as much of the script’s subtler features — such as cadence and double entendre — as possible. They will read up on the background of the playwright and research the political history of the epoch in which a play is set. They will Google the definitions of words they don’t know, or allusions they don’t get. Then they will try to figure out how to explain the reference in signs before the actors on stage have moved on to the next line, because otherwise the whole thing derails.

And they will try to make their interpretation appropriate enough to avoid raising the ire of a discerning deaf patron like Tom Humphries, a UCSD professor and frequent theatergoer.

“The really good theater interpreters know when to make the translation literal enough to preserve the original English of a playwright,” Humphries writes in an e-mail. “The best example of this is with Shakespeare or a well-known musical, when I want to see the famous lines, not bad translations of them.”

The Bard is a particular challenge for ASL interpreters.

“It requires almost a double interpretation,” says McLellan. “Once from Shakespearean English to English that I can understand, then from English to ASL.”

While some things (like iambic pentameter) are bound to be lost in translation, certain other literary devices don’t have to be.

“If there’s, say, a rhyming joke in English, we have to make it rhyme in American Sign Language,” says Liz Mendoza, whose company Stage Signs assigns ASL interpreters for productions at San Diego Junior Theater and Broadway/San Diego.

She explains that just as spoken rhymes comprise words that sound alike, signed rhymes are built from hand shapes that look alike. “It might not be the exact same translation, but it’s the exact same experience.”

Shared experience is an ASL interpreter’s ultimate goal, which is why so much preparation goes into each performance. It’s not enough to merely translate a play word for word (though theaters that lack a budget for interpreters may employ captioning services to do just that). Interpreters also try to visually convey the kinds of aural cues — a foreign accent, a tone of voice — that help hearing audiences better understand a character. To do this, interpreters will attend as many dress rehearsals or performances of a given play as possible in order to see what the actors on stage are doing. Mimicking certain physical traits — a hunch, a trademark scowl, a haughtily upturned nose — can add texture to a deaf patron’s understanding of a character, while also clarifying which character is speaking.

“ASL is as much about facial expression and what the entire body is doing as what their hands are doing,” says Stephen McCormick, La Jolla Playhouse’s Director of Education and Outreach who oversees the interpreters. “It’s a beautiful art form.”

While signing songs from musicals, for example, the interpreter’s gestures may become larger, more rhythmic and graceful, to impart a bit of the melody and lyricism a hearing patron takes for granted. Interpreters complain of sore backs and shoulders from having to stand and sign constantly for two hours, breaking only at intermission. And that’s to say nothing of the emotional toll that some plays may take.

“I equate it to when actors play murderers, or people that are a little bit crazy,” says interpreter Suzanne Lightbourn, who observed a change in herself while preparing to interpret the vile lead character of Man in the La Jolla Playhouse’s recent production of Dostoevski’s dark “Notes From Underground.” “My team said she noticed she was snapping at her partner a lot, and I realized, yeah, I’ve been taking my grumpy pills in the morning! It gets in you.”

This raises the inevitable question: To what extent should sign-language interpreters be considered actors? The answer varies depending on whom you ask.

According to Mendoza, who received her training at a weeklong interpretation workshop at Juilliard, the overlap is minimal.

“We mimic what the actors do on stage, in order for the deaf audience to identify who’s speaking,” she says. “We’re not actors per se, because we’re just taking what the actors give us. It’s not originating from us.”

Lightbourn, by contrast, says the two are very close: “Probably about 99 percent. You can’t be inhibited with your body. You have to really put yourself into the actor’s role and give what the actor’s giving.” Many who have some acting or theatrical training in the past say the experience has improved their interpretations.

The line between robotic, detached translation and overacting is a fine one to walk.

“Many interpreters have the false belief that they need to perform or act the lines in a play. I’m sorry, but most interpreters are terrible actors and can’t pull that off,” writes patron Humphries. “I guess the difference between good and bad interpreting is a bit like good and bad acting: You certainly know it when you see it.”

The work, though demanding, is not exactly lucrative. Paid around $500 per performance, an interpreter’s hourly rate, with all things considered, can be as low as a few dollars. And there’s a limited number of outlets in San Diego that even have the budget for their services: Broadway/San Diego, San Diego Junior Theater and the La Jolla Playhouse are the only major houses that offer a regularly scheduled interpreted show, while others, including the Old Globe Theatre and Moonlight Stage Productions, may provide interpreters upon request.

“You can’t make a living off of just interpreting for theater,” Mendoza says flatly, noting that even her peers in New York City are not able to make ends meet without taking day jobs interpreting for public schools, hospitals and courts. Even the most active theater interpreters spend only about 20 percent of their working hours on performances.

“We really do it for the love of it,” says Mendoza.

For Mendoza’s frequent interpretation partner Doug Hlavay, the payoff is more than just economic: “Any time a member of the deaf community has an experience at the theater that evokes some type of emotion — laughter, tears — that makes all the prep worthwhile,” he says.

“They’re having a direct relationship with the content of the play,” echoes Lightbourn. “You’re not in the middle anymore. That’s when it feels like you’re doing a good job.”

Maya Kroth is a San Diego writer.

Medical interpreters are a patient’s right

Federal and state law requires assistance for patients with limited English. New national competency standards begin in 2011.

December 27, 2010 By Francesca Lunzer Kritz, Special to The Los Angeles Times

Even people who speak English fluently often find that conversations with healthcare professionals sound like Greek to them. So imagine if you speak only Greek or Spanish or Farsi and want to have, say, an in-depth conversation with an oncologist about the risks and benefits of an aggressive form of chemotherapy.

Until recently, the most likely interpreter in such an encounter would be a family member, often a poor choice because he or she might be reluctant to share bad news or be unfamiliar with medical terminology. But new developments are helping patients with limited English communicate better with their healthcare providers — including a 2-year-old California law that requires health insurers to provide interpreting (oral) and translating (written) services to patients with limited English proficiency, draft standards on how medical interpreting should be conducted in hospitals, two new certification bodies for medical interpreters and the rapidly increasing use of remote interpretation service by phone or video conference.

200,000 words in TFT-LCD litigation translation

December 2010

LA Translation  performed the translation of 200,000 words from Korean, Japanese, and Chinese into English for TFT-LCD litigation in November and December, 2010.  The translation had to be done in a short time within one week, but the team of certified translators worked day and night to meet the deadline.  The clients were happy with the consistently high quality of work done in a short time at a very reasonable rate.

Spanish, Korean and Sign language simultaneous interpreters and equipments for Paralos Ninos and First5LA events in Los Angeles

December 2010

LA Translation has provided Spanish, Korean, and Sign language simultaneous interpreters and equipments for a series of Paralosninos and First5LA events in Los Angeles in November and December, 2010.  The events are held once or twice a month in the neighborhoods of Downtown and Korea Town for the parents of elementary school students about baby and child friendly education environment. LA Translation takes pride in facilitating communication between the committed non-profit organizations and the parents who need the information provided.

800,000 words for Kia Automobile from English into Arabic, Chinese, Russian, Spanish, and Portuguese

November 2010

LA Translation provided Kia Automobile Co. the translation of 800,000 words from English into Arabic, Chinese, Russian, Spanish and Portuguese for 50 days in October and November, 2010.   The translators were carefully selected from only those who had prior experiences in automobile translation. The project manager successfully handled the project to meet the deadline with high quality work that the client deserved. This is one of the large multilingual projects the company handled in the second half of 2010 including English into Danish translation for Hyundai Heavy Industry and English into Italian, Spanish and Portuguese translation for Hyosung Co., Ltd.

Provided Spanish ,Portuguese, and Vietnamese simultaneous conference interpreters and equipments for UCLA event

October 21-28, 2010

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Provided interpreters for a 2-week patent litigation

between Checkmate and Biovision in Seoul, Korea

October 18-30, 2010

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