State seeks ban on using kids as medical translators
San Mateo County Times, 10/24/2005
By Garance Burke
MERCED
Diagnosed with a variety of ailments but unable to communicate with her doctor, Laotian refugee Ker Moua enlisted her youngest son as her medical interpreter.
The 12-year-old, Jue, was the liaison between his mother and the doctor who diagnosed her as having a prolapsed uterus, the result of bearing 14 children. She began taking her medication in the doses her son described, but soon felt so dizzy she couldn't get out of bed for two days.
“She tells me where it hurts and then we go to the doctor together. But I don't really know what a uterus is,” said Jue, whose English is peppered with words from his sixth-grade textbooks and terms from the football field. “She tells me things I don't know how to say. Sometimes I tell the doctor something else.”
Jue’s mistranslation of the doctor’s orders caused his mother to take the wrong dose of her medication. While the error did not cause lasting harm, it’s exactly the kind of problem California medical officials want to correct.
The use of children as medical interpreters is a common practice in immigrant-rich states such as California, where they often are the only ones available to speak for their parents.
Yet a growing number of studies have illustrated the potentially lethal consequences of faulty translations, leading health care regulators and a state assemblyman to seek an end to the practice.
In November, the California Department of Managed Health Care will hold public hearings about draft regulations that would prevent children from interpreting at private hospitals, physicians’ offices or clinics. The rules would not apply in emergencies.
California would be the first state to implement such a wide-ranging prohibition, said Mara Youdelman, staff attorney with the National Health Law Program in Washington, D.C. Other states have restrictions, but none goes as far as California's proposal. Rhode Island, for example, requires that all hospitals provide interpreters who are older than 16, but the rule does not extend to doctor’s offices or clinics.
State Assemblyman Leland Yee, D-Los Angeles, is sponsoring a bill that would prevent children from translating for their parents at public hospitals and any clinic that receives public money.
Experts say children lack the vocabulary and the emotional maturity to serve as effective interpreters. In a state in which 40 percent of the population speaks a language other than English at home, policy makers say California’s proposed ban could set a national precedent.
“The federal government has acknowledged its a form of discrimination not to provide adequate interpretation,” said Dr. Glenn Flores, who directs the Center for the Advancement of Underserved Children at the Medical College of Wisconsin and has testified before Congress about immigrants access to health care. “States around the country will be saying that if California finally does something about it, we can do it, too.”
In the case of Ker Moua, Jue’s mistranslation of her dosage did not cause his mother lasting medical harm. But that's a rarity: Two of every three mistranslations have clinical consequences, according to a 2003 study Flores published in the American Academy of Pediatrics.
Child interpreters also shoulder a heavy emotional responsibility. They are privy to confidential medical information about their parents and can be the first family member to learn of a serious illness. In many cases, they also are the ones to deliver the bad news.
“If they are the ones telling their mom she has cervical cancer, that's a problem,” said Dr. Alice Chen, the medical director of the general medicine clinic at San Francisco General Hospital. “I've seen kids who walk away thinking they caused it.”
That role was one of the motivations behind Yee’s legislation.
“I was extremely uncomfortable when my parents asked me to interpret for them,” he said. “We have got to understand that it is not an appropriate role for children.”
If the efforts in California are successful, finding substitutes for child translators won’t be easy.
California has more residents classified as limited English speakers than Texas and New York combined and has a chronic shortage of medical interpreters. Large public hospitals often have staff interpreters, while smaller community clinics tend to rely on their bilingual staff. Private practices might offer no translation services at all.
For relatively obscure languages such as Hmong, the system typically relies on children such as Jue.
His mother and father arrived in California in 1989, as part of a resettlement program of thousands of Hmong, an ethnic minority in Laos that aided the United States during the Vietnam War. Jue, the youngest, was born a few years later. The family soon moved to Winton, a farming town near Merced.
The new rules proposed by the state Department of Managed Care, if instituted, would require private health plans to provide patients with trained, adult interpreters.
They could take effect by March.
The California Association of Health Plans, which represents the state’s largest managed care plans, estimates that translating medical materials and hiring a fleet of professional interpreters could cost as much as $15 million.
Who will pay for those services is expected to be a key point of debate in the months ahead.
“This is going to be a battle,” said Cindy Ehnes, director of the Department of Managed Health Care, which regulates the industry. “There is no question that hospitals are extremely concerned about additional costs.”
Many hospitals already have begun using cheaper alternatives, such as telephone or video interpretation services. But health care industry representatives say the new regulations could boost costs for everyone.
“We discourage the use of children, but in an emergency they may be the only resource you have,” said Leanne Gassaway, the association's vice president of legal and regulatory affairs. “You can't just add $15 million to the system and not expect premiums to go up for everyone.”
The proposed rules also concern physicians worried about the costs of professional interpreters. Some could be forced to end services to immigrants who don't speak English, said Tom Riley, director of government relations at the California Academy of Family Physicians, which represents family doctors.
“You may be the doc in the trenches doing all the right things, caring for a diverse limited-English-proficient population, but you could be hit by this bill in a way that you cannot economically survive,” he said.
The estimated $15 million in costs doesn't take into account the cost of Yee’s bill for public clinics and hospitals.
Support for a prohibition against child interpreters is not universal.
State Sen. Abel Maldonado, R-Santa Maria, said there should be a place in the health care system for children to translate for their parents, if that’s what the family wants.
He opposes Yee’s bill, saying he wouldn't want his relatives forced to rely on strangers to discuss their medical information. For years, Maldonado interpreted for his father, a former guest worker who speaks only Spanish.
“To have a bill in place that would keep a person like me away from their father or mother I just can't agree with,” Maldonado said. “This is abusive legislation.”
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