Interpreting Health: Medical Translation in a City of Immigrants

When Inocencia Nolasco landed in the Wycoff Hospital room with phlebitis, an inflammation of the veins, she knew exactly how she felt, but couldn't explain it to anyone there.

"When I arrived the doctor didn't know Spanish. We didn't understand each other, and finally I called a friend who could come and be my interpreter," Nolasco says.

Nolasco was lucky that she had a bilingual friend who could come to the hospital, but excruciating hours were wasted. "Time was passing and I was in pain. It was really horrible," she says.

Nolasco was in the ER a decade ago. Until quite recently it was common that patients had to wait for hours for language interpreters at hospitals. Dr. Danielle Ofri, an internist at Bellevue hospital in Manhattan, says it was a confidentiality nightmare ripe for miscommunication and error.

"We rely on whoever is available, whether it's a clerk who's bilingual, a cousin, a six-year-old kid, an uncle in a taxi cab calling from their cell phone. There are so many things that are highly inappropriate, but we would do that," Ofri remembers.

In 2003, with immigration levels rising, health advocates began filing complaints against hospitals in the state attorney general's office. They argued that without language services, immigrants couldn't get equal medical care.

Nisha Agarwal, an attorney with New York Lawyers for the Public Interest, says, "When language access isn't provided, it's like doing veterinary medicine, just guessing randomly what they needed to do instead of having a conversation with the patient."

In 2006, New York State passed regulations requiring all hospitals to provide free interpretation for patients within 10 minutes of arriving in the ER, and 20 minutes elsewhere in the hospital. The city has taken additional steps -- in 2008, Mayor Michael Bloomberg ordered all public hospitals to have a language access plan. This fall, major pharmacy chains were required to translate prescriptions into the top seven languages spoken in the city.

Many hospitals now rely on telephone interpreters to be the crucial link between patients and doctors. By dialing a central number, within a minute doctors can be connected to someone who speaks one of 180 languages. Each room at Bellevue now has one of these special phones installed.

One day recently, Dr. Ofri visits Tong Woo Lee, a Korean American patient who is isolated in a room at Bellevue. They speak to each other while holding telephones to their ears. Dr. Ofri wears a mask and she tries to maintain eye contact, but it's difficult.

"Can you tell me a little bit about when you first started to feel sick?" Ofri says into the phone, while looking at Lee. There's a slight pause. Lee listens to the interpreter's voice, and looks away. He responds in Korean. Line-by-line, their sentences are translated. The conversation takes twice as long as it would if they were speaking the same language.

Through the telephone interpreter, Lee tells his doctor that he called an ambulance because his back hurt so much he couldn't walk. He assumed it was because he had lifted something heavy. But Ofri tells him that he has a more serious problem -- an infection in his spine.

On this day, Ofri has 20 patients to see, and can only spend a few minutes with each one. She tells Lee -- through the interpreter -- that he may have tuberculosis, which is why he's in isolation with an IV in his arm, being subjected to tests.

According to Ofri, the interpretation phone is much better than the old ad-hoc system of hoping there's a native speaker nearby. But she still finds it a frustrating and awkward tool. Her bedside manner goes by the wayside because there's no possibility of chitchat, and the interpreters speak in neutral voices that don't always transmit her tone. Ofri is always worried that details about her patients are lost in translation.

"I don't always know what they're saying and I think vice versa. It's like speaking underwater; everything's a little bit blurry. It's the sensation that we're doing pretty well, but I can't be completely confident, and it's frustrating and it's frightening. I imagine it's frightening for the patient. I'm nervous I'm going to miss something or do something wrong, but it's also the best we can do," she says.

When a person walks into one of the city's public hospitals now, they are greeted by signs with directions in 12 different languages. In fact, so many immigrants rely on Bellevue that it has become a leader in the interpretation field. Bellevue has built a remote simultaneous medical interpreting center for the hospital's top eight languages right on site, similar to the system used at the United Nations. On the fifth floor of Bellevue, 28 people are sitting at stations waiting for their phones to ring. They're grouped by language. There's an area for Spanish, Mandarin, Cantonese, Russian, Polish, Bengali, French, and Haitian Creole.

Simultaneous interpretation means the workers translate each word as they hear it, so the two ends of the conversation don't have to wait for each sentence to be repeated. The workers were trained to create the illusion that doctor and patient are speaking directly to each other.

On average, this in-house system, called TEMIS (Technology Enhanced Medical Interpreting System) receives almost 6,500 calls a month, and more than half of them are for Spanish speakers.

Walking through the cubicles, the eight languages mingle together, creating a cacophonic soundscape that mirrors the city's diverse population.

Evens Jean, a French and Haitian Creole interpreter who has language maps taped to the walls of his cubicle, says the stakes are high -- patients are essentially trusting their lives to his voice. And even using this innovative system, he knows there are communication gaps.

"Not every single patient is going to see things from the American perspective, they come from their own culture with their own baggage, they have a way of seeing and understanding health care," Jean says.

In many cases -- for both doctors and patients -- cultural interpretation is equally important as word-for-word translation. Many interpreters report they hear patients saying yes, even when they don't really understand.

Dr. Ofri, the internist at Bellevue, has seen this many times.

"It's a different cultural experience to be at a doctor's at other countries. So many of my patients are extremely respectful, they say yes to whatever I say no matter what. So I don't know if they know what I'm saying and agree, or they have no idea what I'm saying and say yes because that's what they're supposed to say and be polite. So, yes can mean any one of a hundred things," she says.

That's why Ofri says it would be ideal if every immigrant patient could have a bilingual and a bicultural interpreter at the hospital. But she says that's not realistic given the hospital's budget. For her, the true connection often begins after she and her patient hang up the interpreter phones and the physical exam begins. It's the age-old non-verbal conversation between a sick person and their healer.

"When you touch someone, it's an intimacy, an unromantic intimacy, but an intimacy nonetheless, and sometimes in that setting the patients can really tell you what's going," Ofri says. "So that's when our connection is formed."

Bellevue hospital alone spends $2.5 million a year on interpreting. And Maribel Castillo, the hospital's language access coordinator, says she sees the need rise each month. But Castillo maintains that even though the service costs the hospital a lot of money, it's a necessity.

"This kind of service helps the patient adhere to treatment and for them to get better, and that's what ultimately matters the most," Castillo says.

But even with the hospital's efforts, a 2008 survey by the New York Immigration Coalition and Make the Road New York showed that one out of five limited English proficiency patients in the city felt their medical care had been compromised by language barriers. Almost half said they wanted to ask a question but couldn't.

Theo Oshiro, director of health advocacy at Make the Road, says even if hospital administrators may understand the regulations, information about language services doesn't always trickle down to caregivers, like nurses, aides, and receptionists with whom patients interact.

"A lot of front-line staff have not been trained. [They] don't know how to access the system of the hospital to get an interpreter quickly. Just a couple of years ago I was talking to a hospital resident, he was saying, 'I can't understand a lot of people at my hospital, I don't know what they're saying, I don't know what their complaints are,'" Oshiro says.

Advocates agree the 2006 language access regulations have had a big impact, like ending the practice of using bilingual children to interpret sensitive topics for their parents. But patients say the quality of interpretation still varies widely across the city. In September, the New York State Department of Health issued a citation to St. Barnabas in the Bronx because of its failure to provide an interpreter to a Spanish speaking patient.

Nisha Agarwal, the attorney with New York Lawyers for the Public Interest, represented that patient in court. "She did not get an interpreter at all, and when she did get interpreters, in the hospital, it was usually somebody who had been pulled in from somewhere else who was actually not trained to be an interpreter. So half the time they couldn't even do a good job," Agarwal says.

A good medical interpreter is much more than just bilingual. The interpreter must know medical terminology, and never insert her own opinions into the translation. But one problem is it's up to the hospitals to train their own staff -- and to figure out how to pay the interpretation bills. Language access is an unfunded mandate in New York.

"New York has been quite good in terms of language access issues. Our state regulations are very strong. Some of the ways New York has not been as much of a leader has been in terms of funding language services," Agarwal says.

The language of medicine is difficult to understand, even for native English speakers. The names of diseases, medication instructions, and general hospital systems are confusing, especially when people are worried about their health. When these issues are compounded by language and cultural barriers, many immigrants are lost and can't make informed health decisions. There's no question that language access in hospitals has improved since Inocencia Nolasco landed in an emergency room where no staff spoke Spanish. But hospital administrators across the city say the need for trained interpreters outweighs the supply. And with an ever-growing immigrant population, the need is getting acute.

This story was produced as a project for The California Endowment Health Journalism Fellowships, a program of USC's Annenberg School for Communication and Journalism.