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Communication breakdown

For foreign-born, language barrier and cultural misunderstandings can cause confusion, medical errors, and death

For a decade, Dr. Steffie Woolhandler has been haunted by a patient she couldn't help.

The woman, a 41-year-old native of Haiti who spoke no English, visited the obstetrician regularly during her pregnancy, but never mentioned her coughing fits.

A week after giving birth to a son, the woman died of tuberculosis -- a disease that doctors could have easily treated with antibiotics if they'd caught it in time.

''She told us that where she came from, everybody coughed," recalled Woolhandler, an attending physician at Cambridge Health Alliance and a professor at Harvard University. ''There was definitely a breakdown in communication."

Such cultural misunderstandings and language barriers are quite common between American doctors and their foreign-born patients, causing a host of problems from discrimination and confusion to major medical errors and death. Language barriers and cultural misunderstandings are the main reason, after finances, that immigrants get fewer and poorer quality medical services than US-born English speakers.

Miscommunication can also drive up the cost of care for everyone, said Dr. Michael Grodin, a psychiatrist at Boston Medical Center and director of the hospital's refugee center.

''Ninety percent of medicine is history, the rest is exams and tests," he said. ''If you don't understand the language and can't get a history, you have to order more tests and get more treatments. You save money when you can communicate."

Immigrants are getting less than half the health care that US-born Americans get, even though 58 percent have insurance, a recent study found. And they are at some length subsidizing the care that US-born patients purchase because they each pay a lifetime average of $80,000 in taxes for services they will never use, said Woolhandler, also one of the authors of the study published in last month's American Journal of Public Health.

About half of all American adults struggle to find, understand, and make use of basic health information such as doctor's instructions and insurance forms, according to a 2004 report from the Institute of Medicine, a scientific panel that advises Congress. The problem is exacerbated for the 8 percent of the population who, in the 2000 census, reported not speaking English very well.

The number of people in Boston with limited English skills is even higher, with between one-fourth and one-third of foreign-born residents speaking such limited English that they are ''absolutely having trouble" navigating the health-care system, said Ian Bowles, president of Massachusetts Institute for a New Commonwealth, a nonpartisan think-tank.

Add to that the cultural differences that can bewilder or even offend people unfamiliar with the norms of American health care. People from South America or east Asia commonly want family members directly involved in their medical care, but hospitals have to worry about privacy. In some African cultures, questioning or even making eye contact with an authority figure is disrespectful, but the doctor needs confirmation that the patient understands. A Muslim female may be offended that a male doctor asks her to disrobe, though the doctor believes it's necessary for an exam.

Halima Mohamed, director of operations at Whittier Street Health Center in Roxbury, was trained as a physician in Somalia and often translates not only the language, but also the cultural values for the clinic's Somali-speaking patients.

''I am often on the other side of the drape when the patient is having an exam," said Mohamed.

The biggest challenge, she said, comes when cultural practices clash with the doctor's suggestions.

In one case a Somali woman was having trouble getting pregnant, so the doctor, who had adopted a son, suggested the woman do the same.

''That's a sin," Mohamed recalled the woman saying. If she were to adopt a son, he would not be able to touch her when he got older because in her culture, it is forbidden for men to touch women with whom they are not married or blood relatives.

More than half of the patients at Whittier speak little or no English and the waiting room buzzes with chatter in Spanish, Somali, and Haitian Creole. Most of the staff is bilingual, covering about 20 languages. Patients who need interpreters are often scheduled so that someone who speaks their language will be available, otherwise a telephone translation service is used.

Sharriff Mohamed, a patient at Whittier unrelated to Halima, has experienced first-hand clashes between the American style of medical care and his Islamic values and limited English skills.

Mohamed, who came to the United States from Somalia six years ago, said he usually gets by on his ''broken English," but the first year he was here he asked for an interpreter during a visit where the doctor was trying to explain his upcoming surgery. ''The doctors use a different English with different terminology. It's a weird language that no one knows but them," said the 50-year-old Mission Hill resident. ''I was not comfortable with myself and understanding the medicine and the process.

Mohamed said that when a male interpreter wasn't available, he would rather use his limited English than have a female one. On another occasion he canceled an appointment because a male provider was not available.

''Here the man and the woman are the same, but in my culture the man and woman are separate," he said. ''I am not satisfied talking to a lady about my internal problems. I have a wife and she could be another man's wife. That's wrong."

Experts agree that merely translating language is not enough. The ability to understand the culture, speak the patient's language and work the medical lingo is crucial, which is why experts also agree that family members, especially children, should never be elected to translate.

''It's malpractice to have a child translating," said Grodin at Boston Medical Center. ''There's issues with autonomy and privacy, and you can't burden a child with that kind of responsibility. It's not their job, it's the hospital's job."

''What if the relative does not know medical terminology and the doctor says appendicitis?" said Dharma E. Cortes, who trains medical interpreters at Cambridge College and also works as an instructor at Cambridge Health Alliance. ''You don't know how the family member is translating that to the patient. You don't know the emotional impact the doctor's news will have on a child. And, if I have to talk about my sexual practices, I don't want my child there."

In 2000, a state law mandated that all emergency medical facilities offer interpretation services for whomever they can reasonably expect to come through their doors -- meaning that hospitals in Boston have to offer more services than those in North Adams.

Hospitals that don't comply could face a lawsuit from the patient or the attorney general. So far none has been filed, and ''most of the hospitals on whose doors we have knocked have made a very serious effort," said Ernest Winsor, an attorney with the Massachusetts Law Reform Institute, which is now assessing compliance with the law. Before the law ''many hospitals were doing this anyway, but many more were not."

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