Saving Lives in Many Languages

By Carol Velandia

[Language Access Services - "welcome" and many hands]


Development, implementation and appropriate oversight of Language Access Services (LAS) are ways to reduce healthcare disparities, increase social justice and improve public health. In the United States, there are over 25.2 million people who are limited English proficient (LEP)[1], and though an inability to clearly communicate is not a disease, it causes more surgical delays, leads to falls, infections, longer length of hospital stays, and even death for those who can’t communicate in English when visiting the doctor. LEPs receive suboptimal care and experience negative healthcare outcomes.

The following table shows the different outcomes experienced by LEPs as compared with the rest of the population.


Types of Physical Harm Experienced From Adverse Events
No harm No detectable harm Minimal temporary harm Moderate temporary harm Severe temporary harm
English Proficient 45% 25% 20% 5% 1%
LEP 40% 10% 25% 20% 4%

Table 1 [2]


Martin Luther King Jr. once said: “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” This is especially true when we think about the LEP population. LEPs are a vulnerable population even before setting foot into our country. Many are fleeing violence and/or poverty in their countries of origin, and some are willing victims of human trafficking (illegal, unsafe and yet a often viewed as better than staying in their country). They arrive in this country and become, once more, victims of poverty, unemployment, underemployment, and even violence. Some of them also become ill or injured, go to the hospital and then become victims of discrimination on the basis of national origin. Since they don’t speak English, they will most likely receive substandard care when visiting the emergency room. Those who discriminate against this population are not xenophobes or even bad people. On the contrary, they are well intentioned and want to help, but end up discriminating against them because they don’t know what to do when a patient doesn’t speak English. They may try to help, relying on poor foreign language skills, getting family members to act as interpreters or turning to machine translation apps such as Google Translate. However, not only are they unwittingly discriminating, but they are also jeopardizing the health and safety of the very patients they are trying to help[3], [4], [5].

“Those who discriminate against this population (…) end up discriminating against them because they don’t know what to do when a patient doesn’t speak English.”

Today, we have the legislative tools to prevent these disparities, but more work is needed to translate the current regulations into actionable goals. Title VI of the Civil Rights Act prohibits discrimination on the basis of race, color, and national origin in programs and activities receiving federal financial assistance[6]. Executive Order (EO) 13166 of 2000 is the pathway to implementing Title VI, because it: “requires Federal agencies to examine the services they provide, identify any need for services to those with limited English proficiency, and develop and implement a system to provide those services so LEP persons can have meaningful access to them”[7]. The creation of the Culturally and Linguistically Appropriate Standards (CLAS) has been a significant step in connecting Title VI and EO 13166 as it applies to healthcare. These standards were created by the Office of Minority Health (OMH) in 2000 with the purpose of “advancing health equity, improve quality, and help eliminate health care disparities by establishing a blueprint for health and health care organizations[8]. Some of the 15 CLAS standards address language and clearly state that patients should be able to receive care in their preferred language, whether verbally or in writing, and that the language proficiency of those providing language services (interpreters, translators or bilingual personnel) should be tested for competence.

Many healthcare institutions think that implementing CLAS might be costly. They don’t realize, however, that not providing the services might be even more costly. Healthcare expenditures represent approximately 18% of the gross domestic product (GDP) in the United States, a number that is likely to rise to 20% in 2020. Some of these expenditures are associated with unnecessary treatment, but others are caused by communication and systemic barriers associated with cultural and linguistic differences[9]. Legal costs due to miscommunication can be hefty. A prime example of this was the case of Mr. Willie Ramirez, a Hispanic patient who became a quadriplegic because the word “intoxicado” was misinterpreted. In Spanish, that sounds like “intoxicated” but it actually means food poisoned. The cost of the settlement was $71 million[10].

“Healthcare expenditures represent approximately 18% of the gross domestic product (GDP) in the United States, a number that is likely to rise to 20% in 2020.”

Implementing CLAS standards and paying close attention to training both interpreters and bilingual personnel will improve healthcare outcomes for LEP patients. What constitutes a professional interpreter is often misunderstood. It is widely assumed that “bilingual” personnel, family members or untrained, ad-hoc interpreters can interpret. However, it has been proven that unqualified interpreters are more dangerous than no interpreter at all; in fact, they are responsible for 22% of medical errors, as compared to 12% caused by professional interpreters and 20% caused by direct communication without the use of an interpreter[5].

The U.S. has legislation at the federal level, trained medical interpreting professionals exist and all the research backs LAS up. So what is still needed?

  • Legislation at the state level requiring hospitals to use trained and certified interpreters.
  • Full cooperation and engagement by hospital leaders when implementing and widely disseminating protocols governing language services.
  • Rewards for hospitals that demonstrate quality improvement for LEP patients.
  • Community Awareness; LEP persons should be informed of their rights to receive accurate communication when visiting their doctor.

Limited English proficiency is not a disease, but understanding when and how to use Language Access Services should be as important as the using hand sanitizers to prevent infections.




[1] Pandya, Chandasi; McHugh, Margie; Batalova, Jeanne, 2011, Limited English Proficient Individuals in the United States: Number, Share, Growth and Linguistic Diversity. LEP Data brief. National Center on Immigrant Integration Policy. Retrieved November 24, 2015 from: http://eric.ed.gov/?id=ED527752

[2] Agency for Healthcare Research and Quality, Rockville, MD. (2012) National Healthcare Quality Report. June 2013. Retrieved November 18, 2015 from http://www.ahrq.gov/research/findings/nhqrdr/nhqr12/index.html

[3] Agency for Healthcare Research and Quality, 2012, National Healthcare Quality Report, http://archive.ahrq.gov/research/findings/nhqrdr/nhqr12/2012nhqr.pdf

[4] Leah S. Karline r, Elizabeth A. Jacobs, Alice Hm Chen, and
Sunita Mutha, 2007, Do Professional Interpreters Improve Clinical Care for Patients with Limited English Proficiency? A Systematic Review of the Literature, Health Research and Educational Trust
DOI: 10.1111/j.1475-6773.2006.00629.x

[5] Flores, Glenn, Milagros Abreu, Cara Pizzo Barone, Richard Bachur, and Hua Lin, 2012, Errors of medical interpretation and their potential clinical consequences: a comparison of professional versus ad hoc versus no interpreters. Annals of emergency medicine 60(5), 545-553.

[6] Chen, Alice Hm., Youdelman, Mara K., Brooks, Jamie, The Legal Framework for Language Access in Healthcare Settings, Beyond Title VI , Society of General Internal Medicine 2007 Division of General Internal Medicine, San Francisco General Hospital, University of California, San Francisco, CA, USA;National Health Law Program, Washington, DC, USA; Center for Genetics and Society, Oakland, CA, USA. DOI: 10.1007/s11606-007-0366-2

[7] Supreme Court of the United States, Lau v. Nichols, 483 F. 2d 791 – Court of Appeals, 9th Circuit 1973, Retrieved November 18, 2015, from: http://www.nabe.org/Resources/Documents/Advocacy%20page/LauvNichols.pdf

[8] National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Healthcare, n.d. Retrieved from https://www.thinkculturalhealth.hhs.gov/pdfs/EnhancedNationalCLASStandards.pdf

[9] Berwick, D.and Hackbarth, A (2012). Eliminating Waste in US Health Care. American Medical Association, 307(14), 1513-1516. Doi:10.1001/jama.2012.362

[10] Price-Wise, G., 2008, Language, Culture, and Medical Tragedy: The Case of Willie Ramirez, Health Affairs Blog, Retrieved from: http://healthaffairs.org/blog/2008/11/19/language-culture-and-medical-tragedy-the-case-of-willie-ramirez/


[Carol Velandia]

Carol Velandia M.B.A, C.H.I. P.M.P. is a healthcare and judiciary interpreter and also a Social Work student. In her dual role as an interpreter and as social worker in training, she works with culturally diverse populations, especially the limited English proficient (LEP) population. Her professional goal is to find avenues to bring about adequate Language Access Services and promote the Cultural and Linguistically Appropriate Standards (CLAS) and thus facilitate equal access to justice, healthcare and education to individuals with LEP. As the Administrator of the Interpreters Division at ATA she has advocated to raise the standards for interpreters of all tracks of the profession. She was an expert panelist at the Department of Homeland Security in 2014 on the topic of Language Access where she provided a definition and a profile of the professional interpreter. Simultaneously, she promoted ATA’s position paper on this topic, a team effort. In her role as a healthcare interpreter at Johns Hopkins, she created and directed the video: “Saving Lives in Many Languages”. The video was awarded with the first prize in the Patient Safety National Summit held at Johns Hopkins Institutions in 2013. The video was later endorsed by the institution on their “The Promise of Medicine” campaign. She is also the recipient of the President’s Fellowship on Cultural Competency at the University of Maryland and is working on a white paper on this topic.

Image by geralt via pixabay.com

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