Tag Archives: language rights

Bridging Theory and Practice for Language Rights

Check out a newly published article in the Journal of Health Care for the Poor and Underserved, co-authored by Health Justice Director, Nisha Agarwal, on the importance of language access in the pharmacy setting. This is an area where the evidence about the importance of providing language concordant services for patients who are limited English proficient (LEP) keeps growing and, despite all the discussion in medical circles about “evidence-based” policymaking, we continue to face resistance at state agencies charged with protecting and advancing public health. Instead of collaborative discussions about how to improve access to prescription medications for immigrant communities and reducing health disparities, we hear complaints about how language assistance services might put huge chain pharmacies out of business – immigrant scape-goating at its worst.

We’re taking our fight to the pages of research journals, as well as to the corridors of power in Albany and to the streets until we win. Join us in this effort! Send us an email and let us know that you’d like to join the coalition to ensure Safe Access for Everyone to prescription medications (SafeRx): healthjustice[at]nylpi.org.

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Do You Understand Your Prescription Labels?

We here in NYLPI’s Health Justice Program, along with our partners Make the Road New York, are getting ready to hold a press conference at 12:30pm on Tuesday, December 14 near City Hall at Broadway and Park Place (East side of Broadway).  We will use that opportunity to release our new report detailing our findings from a monitoring study of language access in pharmacies, and to join with consumers, advocates, and State Assemblyman Richard Gottfried, State Senator Jose Peralta, and Councilmember Julissa Ferraras in calling for the state legislature to pass a bill that would ensure standardized prescription drug labels and language assistance services in chain pharmacies all across New York State.

It may seem like  common sense, but prescription drug labels are only effective if patients are able to understand them.  That feeling of confusion upon returning home from the pharmacy and not understanding how to take the medication is universal.  With dozens of ways for a pharmacist to write “take once a day,” it is often challenging for patients to understand and act correctly on just one prescription instruction.  For those who take multiple medications, such as the elderly, and for the over 2.4 million people in the New York who speak English less than “very well” and are therefore considered limited English proficient (LEP), though, the lack of translation and prescription label standardization makes labels literally incomprehensible.

The consequences of patients’ misunderstanding prescription labels can be dire and costly.  Every year, unintended misuse of prescription medications causes over one million “adverse drug events,” resulting in expensive visits to the emergency room, hospitalization, and even death.

Everyone should be given the opportunity to understand their prescription medication labels.  Fortunately, solutions exist to this serious health problem that are simple, inexpensive, and efficient for pharmacies to implement.  Creating easy-to-understand, standardized prescription labels, and providing that information in a patient’s language in person or over the phone, can significantly improve health outcomes.

Since 2007, NYLPI and Make the Road have been championing the issue of safe access to prescription medications in New York State, particularly with regard to language access.  We worked with the New York State Office of the Attorney General to enforce existing laws relating to language access in pharmacies, which resulted in settlement agreements with seven chain pharmacies operating across the state.  We also worked with the New York City Council to pass the Language Access in Pharmacies Act, which requires chain pharmacies in the city to provide translation and interpretation services for LEP consumers filling prescriptions.

This past summer, Make the Road and NYLPI surveyed over 250 chain pharmacies across New York—including Rite Aid, Duane Reade, K Mart, CVS, Pathmark, Target and Walgreens—to determine the extent to which pharmacies were complying with the city law and Attorney General settlement agreements.  Chain pharmacies not bound by local law or the settlement agreements were also surveyed to determine whether additional regulation actually improves access to services for patients.

What we found encourages us that our efforts thus far are significantly improving the health and safety of all New Yorkers.  It also pushes us forward in our work toward making that goal a reality.  Among other findings, our results show that:

  • The settlement agreements and local law have led to significant improvements in the provision of language assistance services compared to when we began this work in 2007.
  • However, nearly 50% of pharmacies surveyed were still unable to state that they met the prescription label translation requirements of the laws.
  • Further, almost 30% of surveyed pharmacies could not state that they provided mandated interpretation services for medication counseling.
  • Pharmacies not subject to the settlement agreements or local law provide the poorest access to limited English proficient consumers.

While the oversight and additional regulation by state and local authorities have had a positive impact on patient access to pharmacies, more needs to be done.  The city law only covers New York City chain pharmacies and the settlement agreement expires in 2013.  In addition to the ongoing language barriers, the fact remains that many consumers, regardless of the language that they speak, continue to have a difficult time understanding the instructions and labels that accompany their medication, and there is little in existing law to help them.

The state bill, championed by Assembly Member Gottfried and State Senator Tom Duane, contains provisions that would ensure that all patients can better understand their prescription medications.  The bill, which would apply to all chain pharmacies across New York, would authorize the State Board of Pharmacy to create a framework for standardized prescription labels that are easier for consumers to understand.  It would also expand upon the legal requirements already contained in the local law and would codify many of the translation and interpretation requirements of the settlement agreements.

We hope you will join us at the press conference, and will sign on to show your support for New York Assembly bill A11627 (Gottfried) and Senate bill 8365 (Duane) and to call on members of the Assembly and Senate to sponsor and support the legislation.

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The Hypocrite’s Oath: Latino Immigrants and Health Access in the Hamptons

This post, by Health Justice Director Nisha Agarwal, first appeared on the Race-Talk.org blog and is also available on Huffington Post.

Like many New Yorkers did this summer, I boarded a Hampton Jitney from the east side of Manhattan in late August and made my way to the finger tips of Long Island.  Instead of landing on the beach, however, I found myself in the crowded office of a small community-based organization bursting with children and parents, canned goods and clothing swaps, and the bilingual chatter of Latino immigrants seeking help for any number of different problems.  I was with a colleague, and we were there to meet a client.  Here is her story:

In late July, Laura was rushed to the emergency room of a local Hamptons hospital due to severe stomach pains.  She is only a teenager, undocumented, uninsured, and uncomfortable speaking anything but Spanish to discuss complicated health matters.  After some ten hours spent unattended on a hospital gurney, Laura was finally seen by a surgeon the following morning.  No one explained to her, in a language she could understand, why her stomach was on fire or why she was about to receive an operation.  Turns out it was appendicitis.

Laura was admitted to the hospital for 24 hours after her surgery and then summarily discharged, even though she was still in pain.  No one talked to her about a discharge plan or explained self-care strategies to use in the wake of her operation.  All she knew, through the help of family members advocating on her behalf, was that there was still a drainage tube in her body, and she would have to go to her surgeon’s private office to have it removed.

At this private office, Laura was told that she would have to pay $1500 upfront to extricate the tube, and if she didn’t pay it they couldn’t do the procedure for her.  The emergency room of the hospital where she was originally treated, and to which she returned after this extortionate demand, also refused to remove the tube, insisting again that she go to the surgeon’s private office.  Her fear mounting, Laura turned to her primary care physician and the local community group for help.  Together they advocated with the hospital and the surgeon to have the fee for the tube removal reduced to $300.

Sitting in the surgeon’s waiting for the second time, Laura and her family were subjected to a verbal assault by the physician who initially treated her.  She was the reason he and his assistant had to get up in the middle of the night to come to the ER and operate, he shouted.  She was ungrateful for the fact that he wasn’t getting paid for the services he was providing to her.  Oh, and he also wanted to know—in front of all of the other patients in the waiting room—was she in the country legally or illegally? Only after his anger was vented did the surgeon remove the drainage tube from Laura’s body, but as a parting gift, he also reneged on their payment arrangement and billed her $5000.

As a civil rights-oriented health care lawyer in New York City, I thought I knew what racial and ethnic disparities in health care looked like, and how they manifested themselves.  But Laura’s case surprised even me.  Here we had potential violations of federal and state discharge planning laws, language access regulations, patient dumping statutes and financial assistance laws, not to mention flagrant disregard for the medical profession’s codes of conduct and a whiff of fraud and consumer protection violations.

What is more, hers is potentially not the only story of its kind.  In our interview, Laura’s sister mentioned another family member who had been turned away from the emergency room of the same Hamptons-area hospital.  The director of the community-based group where we were conducting the interview also knew of a similar case.  To her, the mistreatment was targeted toward a specific patient population.  As an Irish-Catholic nun, she noted, she had little problem accessing high-quality, respectful care from the same surgeon who treated Laura.  However, the same was not true for the low-income Latino/a residents of the community whom she served.

Since meeting with Laura, I have wondered how cases like her come into being.  What are the factors that allow doctors—people who have pledged to do no harm—to exhibit openly hate and bias, to take actions that actually threaten the lives and well-being of some category of their patients?  What are the dynamics that make it acceptable for immigrant patients seeking relief from pain and illness to be turned away from their local houses of healing?  How does this happen in a place known to be the summer playground of New York’s financial and cultural elite?  Do the Haves not have enough?

As has been mentioned previously on this blog, this has been a long, hot summer of hate and injustice against Latinos and immigrants, and I can’t help but think that the vitriol spewed into our airwaves is creating a space—a social sanction—for overt acts of harm.  After all, Long Island is the place that anti-immigrant provocateur Steve Levy calls home, and whose blistering comments against the undocumented are only the most public example of the kind of anger that led to Marcelo Lucero’s brutal murder two years ago this fall.  Levy and others like him have also complained that Mexican “anchor babies” are the reasons hospitals on Long Island are in financial distress.  It should come as little surprise to us, then, that some physicians at these very hospitals have adopted a hostile attitude toward those patients that they see as a threat.

As a health care advocate, I have to be attuned to these broader dynamics around race and immigration, for they are directly impacting the clients I serve.  And, as racial justice activists, we all have to be vigilant of the many manifestations of hate – not only in the extreme examples of violent crimes and assaults, but also the quiet, painful attacks that take place in our schools, workplaces and hospitals.

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They Had Plenty of Time: Monitoring Pharmacy Compliance with Language Access Laws

This post is by Rylee Sommers-Flanagan, a summer intern with the Health Justice Program and a student at Emory University in Atlanta, GA.

According to the US Census of 2000, ten years ago over 35% of the then 8 million residents of New York City were foreign born, and 47.6% spoke a language other than English at home. Since then, these numbers have only grown.

Given those demographics, it’s fitting for federal, state and local law to require pharmacies (as well as hospitals, other health care facilities, and all city agencies providing direct public services) to provide language assistance services to limited English proficient (LEP) customers or patients. Language assistance services entail translation (of written documents) and interpretation (of the spoken word). Because New York also requires that pharmacists counsel customers with regard to their prescriptions, both types of service are indispensable.

Even so, when activist organization Make the Road New York teamed up with us to file a civil rights complaint with the New York State Office of the Attorney General (OAG) in July of 2007, the results of the ensuing investigation were predictably disappointing. The OAG found seven chain pharmacies with names you’ll recognize – A&P, Costco, CVS, Duane Reade, Rite-Aid, Target, and Wal-Mart – in violation of the law and came away with seven settlement agreements, requiring newly specific and official translation and interpretation services.

In all cases, the deadline for implementing the required improvements was at latest May 15, 2010. They had plenty of time.  We’re now trying to figure out whether pharmacies have used that time to get in line with their legal obligations.

Unfortunately, verifying compliance may not be so simple. On a recent visit to a CVS/Pharmacy and then a Rite-Aid, I asked which languages they could print on their labels and was promptly informed that no pharmacy employees could answer my questions unless I was a customer. The cold shoulder response makes monitoring pharmacies significantly more challenging, and it seems unlikely to be an accidental roadblock. We’ve heard through our contacts in the industry that many of the pharmacies are trying only to comply with the letter of existing laws and not their spirit.  And we also know they’re resisting language access requirements in other states.  Our allies in California report that pharmacy lobbyists–many from the same companies that signed settlement agreements in New York–are telling regulators on the left coast that it is not possible, difficult or too expensive to provide language assistance services.

This is troubling, to say the least, and patently untrue.  Recently, for example, we spoke with representatives from a an international firm called RxTran that is well-equipped to create a database of translated warnings and instructions for easy use by pharmacists as an integrated part of their work routine. In fact, RxTran designed such an economically feasible and work convenient product—it typically costs less than $2 per day—that even some small, independent pharmacies have purchased database access.

It may be that the chain pharmacies are lazy or greedy and near-sighted (imagine trying to attract customers to whom you are incomprehensible). But for either possibility, we need to remember their pattern of negligence and, now call for the follow up.

Failing to provide accurate translation and interpretation has proven devastating on many occasions. Examples range from the children who vomit endlessly until they arrive in an emergency room (only to discover parents have been administering topical medications orally), to the little old ladies who take eleven times the amount of prescribed medicine (due to faulty translation of the word ‘once’). The United States, for better or worse, has not declared English a national language – can the illness and death ultimately associated with simple language errors really be declared an acceptable side effect of pharmacy arrogance?

Enforcing language access laws may be as difficult as passing them but we, who deserve to comprehend what makes us well or sick, must hold the Rite Aids, Duane Reades and CVSs accountable for that information, in all the languages we speak.

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Balancing the Scales of Health Justice for Uninsured Immigrants

This post features Liane Aronchick, a volunteer attorney at New York Lawyers for the Public Interest.  She has coordinated the Working Group on Medical Repatriation at NYLPI since October 2009.

Less than a month after the devastating earthquake in Haiti, the U.S. military halted airlifts to treat seriously injured Haitians from Port-au-Prince to Florida hospitals.  The decision to halt came quickly after Florida Governor Charlie Christ requested that the U.S. Department of Health and Human Services reimburse the hospitals that were treating the injured Haitians, causing speculation that hospitals did not want to treat Haitian patients without some kind of compensation.

The hospitals vehemently denied refusing patients simply because they could not afford care, but the controversy nevertheless highlights the adversarial stance that hospitals take when required to provide health care to non-citizens. When a seriously injured and uninsured patient arrives for treatment at a hospital, the hospital’s priorities shift, placing financial compensation above treatment and care when that patient is a non-citizen. The hospital will stabilize the patient, but the caliber of long-term care and follow-up deteriorates based on the patient’s nationality.  Indeed, it has become a regular practice in hospitals to repatriate uninsured non-citizens in need of long-term and intensive care to hospitals in their home countries—where resources are often scarce and treatments are limited. This practice is known as “medical repatriation” or “medical deportation.” What’s more, transferring hospitals fail to sufficiently investigate whether the transferee hospitals are even capable of providing the care the patient needs. In effect, the American hospital dumps the patient on an ill-equipped and poorly stocked hospital, potentially condemning the patient to death, but somehow it is permissible because the patient is a non-citizen.

Advocates and service providers in New York are banding together to strike a balance to the inequitable treatment that uninsured immigrants receive in American hospitals. New York Lawyers for the Public Interest, the New York Immigration Coalition and the New York Academy of Medicine have collaborated to create a working group on medical repatriation.  The goals of the working group are to 1) determine to what extent medical repatriation is being practiced by hospitals in New York State, 2) research the causes of repatriation, and 3) to develop long and short-term strategies to counter the practice.

To determine the extent and scope of the medical repatriation in New York State, researchers conducted structured interviews with service providers, including social workers, attorneys, policy workers and advocates, who are on the front-lines of patient advocacy.  The research revealed that, on average, hospitals in the New York area face approximately four repatriation cases per year.  While the majority of hospitals maintain that they do not repatriate patients against their will, the voluntariness of the patient’s departure is often murky when she never intended to leave the country. The hospital does not want to continue to provide the patient with uncompensated treatment. The patient no longer needs hospitalization, but she has nowhere to go and no one to care for her in the United States due to her lack of insurance. Left with little alternatives, the patient “elects” to depart, but mostly because she has no other choice.

The decision to repatriate an immigrant patient stems from a variety of social and legal factors. From the legal end, hospitals are bound by both state and federal laws to treat patients arriving with emergency medical conditions, regardless of the patient’s ability to pay. Due to the patient’s lack of insurance, however, the hospital is often unable to discharge the patient once the need for hospital-level care has ended. Hospitals are then forced to make economic decisions that prioritize financial resources over patient care, causing the patient’s and the hospital’s interests to diverge.   When the relationship between a large private hospital and an undocumented and uninsured immigrant patient becomes adversarial, it is more often than not the patient who suffers.

Communication between the patient and the hospital is a key social factor contributing to the repatriation trend.  When patients are unable to communicate with and understand their health-care providers due to a language or other barrier, their decision to return to their home country is not fully informed.  They do not realize that their decision to return to their home country could impede legal re-entry into the United States in the future, or compromise the quality of health care that they receive after they have been transferred.  Even when the patients are aware of their rights, their inherently weakened position in relation to the hospital impedes communication further; they may fear contesting the decision to repatriate because, as an undocumented immigrant, they are already on unequal ground.

The working group on medical repatriation has emerged to level the playing field between hospitals and immigrant patients. To counter the social causes of repatriation, a team of pro-bono attorneys will mobilize and intervene when a patient is at risk of repatriation without her consent.  This “legal rapid response team” would screen the patient for public benefits eligibility, educate patients and their families, in their own language, on their rights to appropriate discharge and about the immigration implications of their decisions to repatriate, and would otherwise conduct the kind of bedside advocacy that hospitals do not do once the relationship has turned adversarial. The team could also engage with hospital administration to negotiate alternatives to the international discharge, or when all else fails, pursue litigation. To affect the legal causes of repatriation, the working group could advocate for policy changes that benefit both hospitals and patients, like increased state funding for charity care or stronger civil and criminal penalties for inadequate discharges.

Importantly, the goal is not to generate or perpetuate adversity between hospitals and patients, but rather, to “fill the gaps” in patient services that hospitals do not often have the resources or training to provide.  Undocumented, uninsured and severely injured immigrants are featherweights on the scales of health justice. We on the working group want to weigh in.

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A Link to the Hearing World

This piece, by Health Justice Director Nisha Agarwal, will appear in the upcoming issue of NYLPI’s Pro Bono Clearinghouse newsletter.  It discusses a case that the Health Justice team worked on in conjunction with NYLPI’s Disability Law Center and advocates from around the country.

Imagine going to a hospital for heart surgery and not being able to communicate with your doctor or any of the nursing staff.  Imagine that your 13- and 9-year old children are made to serve as your voice instead: to ask questions for you, to explain the procedures to you, to tell you that post-surgery you had a stroke.  Imagine that your children are given pagers and pulled out of school whenever hospital staff need to speak with you, and that the younger child later attempts suicide because he thinks the problems you suffered in the hospital were his fault.  After all, his 9-year old vocabulary couldn’t find the right words to describe what was happening — to you, to himself or to others.

These are, roughly, the facts of Loeffler v. Staten Island University Hospital, a case decided by the Second Circuit Court of Appeals on October 6, 2009.  Robert Loeffler was a man who was profoundly deaf and sued Staten Island University Hospital for failure to provide him with a qualified sign language interpreter, as required under the Americans with Disabilities Act and the Rehabilitation Act.  NYLPI became involved with the case at the appeals level, organizing a broad national coalition of disability and language rights groups to provide amicus support to the plaintiffs.  Our brief highlighted two issues: (1) the proper legal standard to apply in “deliberate indifference” cases of this kind under disability law and (2) the importance of having competent, qualified medical interpreters in the health care setting, not just for people who are deaf but also for individuals with limited English proficiency and other communication barriers.  Our coalition of amici wanted the members of the court to understand not only the legal right they were being asked to clarify but also, more importantly, its significance.

And understand they did.  Oral arguments took place in March and were notable for the impassioned questioning of one judge on the panel, who described as “inhumane” the use of the Loeffler children as interpreters.  The court’s eventual decision found for the Loefflers on all points of law and remanded to the district court for trial.  In the concurrence, the court concluded, powerfully, by recognizing that the case is “not the dawn of never-ending liability for the Hospital, it is what Congress required – a link to the hearing world.”  For NYLPI, the case was an important opportunity to bridge the disability and language access communities and take part in an important victory for many of the communities we serve.

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Hospital Mismanagement and the Perpetuation of Racial and Ethnic Disparities

This post, by the Director of NYLPI’s Health Justice Program, originally appeared on the blog of the Committee of Interns & Residents, which is fighting for the right to unionize at St. Barnabas Hospital.  You can read more about CIR’s efforts here.

Last summer, on her wedding night, Juana R. arrived at the St. Barnabas Hospital emergency department with severe abdominal pain.  A Spanish-speaker, Ms. R. needed an interpreter to communicate effectively with her providers, but she was never given one.  Instead, from the moment of her arrival at the ED, to her transfer to the ICU, to her eventual discharge a month later, she was systematically silenced by the hospital.  Invasive tests and procedures were performed without obtaining Ms. R.’s consent (she signed a litany of documents in English only).  Various medication regimens were attempted, many of which caused extreme pain and nausea, but Ms. R had no way of properly communicating these problems to her providers.  Only after legal intervention did this patient receive the communication assistance services she needed in order to understand her diagnosis and the reason for her admission.  Now, over a year after her discharge from Barnabas, Ms. R. remains emphatic that she will never again return to the hospital for care. She describes what she endured as a nightmare. [1]

As previously reported on this blog, Ms. R.’s case resulted in St. Barnabas Hospital being cited by the State Department of Health for failure to comply with public health regulations.  More broadly, her experience speaks to the ways in which poor hospital administration can compromise patient care and exacerbate racial and ethnic disparities in health care.

Well-known studies about the relationship between race and health care have focused on the individual patient-provider interaction – on how inter-personal biases and prejudices can sway treatment decisions.  However, in my experience as a civil rights lawyer in this field, I have found that institutional racism is a more salient factor than individual animus in explaining my clients’ negative encounters with the health care system.  Patients like Ms. R. are denied the interpretation services to which they are entitled not because of the ill will of particular caregivers, but because, more typically, hospitals like Barnabas are not managed well enough to have the policies and practices in place to ensure timely access to important support services – a systems failure that hurts patients and providers.

My office has also found that, across the city, health care institutions will steer Medicaid and uninsured patients, who are disproportionately people of color, into poorly equipped and under-staffed clinic settings while “better” patients (i.e. white, privately insured patients) are sent to the faculty practices.  At the broadest level, this upward redistribution of health care resources has meant that hospitals located in New York City’s low-income communities of color have closed down over the past decade, while facilities located in more affluent white communities have thrived.  In some cases, the hospitals that shut their doors had patient populations that were over 90% African-American, Latino and Asian.

Viewed in this way, the primary way to eliminate racial and ethnic disparities in health care is to overhaul the institutions that create and perpetuate racial and economic disparities within medicine.  This means more people like Ms. R. stepping forward and demanding investigations of unlawful practices at hospitals like St. Barnabas.  It also means more communities raising their voices against hospital policies that enrich some while impoverishing others.  Ultimately, it means more of us—all of us—speaking out against health care institutions designed to promote private gain over the public’s health.


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