McMaster University

McMaster University

Lost in Translation: Immigrants, refugees can't get adequate health care if they can't be understood

The Hamilton Spectator
Sunday, June 26, 2011
Andrea Hunter, Nikki Bozinoff and Katie Dorman

Phuong Nguyen, a 36-year-old woman who spoke little English, died on April 21, 1995, after a 23-day saga at a B.C. hospital. Coroner Jack Harding found that Nguyen's care had been complicated by significant language barriers and inadequate translation.

Nguyen had been unable to communicate her previous diagnosis of lupus to her health care provider. It was only once she was pregnant and suffered complications that her prior diagnosis became apparent. Nguyen's health care providers explained the serious health sequelae (negative after-effect) of lupus and pregnancy to Nguyen, without the use of a translator. Less than a month later, her child died in utero and she succumbed to complications shortly after.

Similarly, on Aug. 20, 1986, 55-year-old Harbhajan Singh Chattu lost his leg and experienced kidney failure due to vascular complications that had been misdiagnosed as back pain. The misdiagnosis occurred because Chattu did not have adequate English language skills to describe his symptoms.

A B.C. Supreme Court Justice found Chattu's physician negligent in his examination and diagnosis and awarded Chattu a $1.3 million settlement.

Sadly, decades after these incidents, medical translation services remain inadequate across the country, leaving thousands of people with health concerns literally lost in translation.

The City of Hamilton is a hub for newcomers. The city welcomes more than 3,500 immigrants annually; with those arriving under the refugee class doing so at twice the national average.

As medical students and practitioners in this diverse city, it has unfortunately not been uncommon for us to witness children providing interpretation for their families' medical issues, ranging from management of complex pain to diagnosis of sexually transmitted infections. These situations are socially and ethically disastrous, as they lead to, among other things, the reversal of caregiver roles between parents and children, missed days at school, psychological distress for the children, breach of patient confidentiality, and suboptimal provision of health services.

Hamilton is not unique in this respect. Earlier this month, health-care providers from across Canada congregated at the Canadian Refugee Health Conference in Toronto, where we heard similar stories of inequity and negligence in delivery of health care to newcomers.

When government-assisted refugees first arrive, settlement organizations, like Hamilton's former Settlement and Integration Services Ontario, are responsible for helping them access health services. Professional interpretation services are often provided during initial health-care visits, but are not easily accessible in the ER or for unscheduled visits.

Government-assisted refugees are usually transferred to primary care practices within a year, most of which have no allocated funding structure for translation services. Physicians are left to foot the bill, or more commonly, to communicate poorly without a translator. Immigrants and refugee claimants do not receive any funding for translation services and so are left to stumble their way through appointments from the very beginning.

For migrants needing translation, there are few options: Either the patient or the physician pays out-of-pocket for an interpreter or an untrained volunteer is recruited. Professional interpreters cost roughly $35 per hour, well out of reach for migrants living in financial precarity. A final option for a fortunate few is to be followed through at a Community Health Centre (CHC), where more flexible funding structures permit access to professional interpretation services.

A 2009 review conducted by Access Alliance, a Toronto CHC, emphasizes that the benefits that patients, providers, and health care institutions receive from professional interpretation services outweigh the costs of implementing these services.

Studies also show that language barriers limit the process of informed consent and contribute to preventable morbidity and mortality.

A number of precedents exist for comprehensive medical translation services. In parts of the U.S., for example, medical interpretation by telephone provides an alternative to in-person translation. Telephone translation may be less costly for short appointments and provides access to interpreters in nearly any language. Such a service is available within Canada, but is not routinely covered by existing funding structures.

Previous attempts to achieve a fully funded national translation program have been thwarted by bickering between the provinces, which provide health care services, and the federal government, which is responsible for costs associated with refugee health under the Interim Federal Health Program.

We urge all levels of government to take immediate action to address the serious shortcomings in the availability and quality of interpretation services within our health care system.

As demonstrated by the cases of Chattu and Nguyen, failure to employ a professional interpreter can unnecessarily impose immeasurable personal hardship and economic detriment. Beyond the potential for improved efficiency in the Canadian health care system, it is our nation's moral obligation to fulfil our commitment to equal access to health care for all.

Dr. Andrea Hunter is a pediatrician at McMaster Children's Hospital and St Joseph's Healthcare. Nikkie Bozinoff and Katie Dorman are medical students at the Michael G. DeGroote School of Medicine at McMaster University. They are also members of the Health Advocacy for Refugees Program.

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