Merced County, like the rest of California, is home to a growing population of ethnic minorities. The county also offers a glimpse into the future, a window onto how healthcare services might need to change to address the needs of a changing community.
The rapidly growing Latino community is not a minority in Merced – it makes up almost 55 percent of the population, according to the latest Census data. The county is also home to thousands of Laotian refugees. More than 45 percent of the Merced County population speaks a language other than English at home.
That poses some unique challenges for the health care providers in the county, from language barriers and cultural obstacles to lack of access for undocumented and uninsured immigrants.
Translators are widely used in clinics and at Mercy Medical Center, Merced’s hospital. The hospital has a full time Hmong interpreter, and Spanish-speaking employees are found throughout the health care system.
But sometimes the language problems go deeper than just interpretation, according to Palee Moua, director of cultural services at Healthy House in Merced. Healthy House provides translation services to area doctors and clinics.
The Laotian, Hmong and Mien language structures are very different than English, and some things don’t translate well, she said. If a doctor allows a child or family member to translate for a patient, potentially dangerous misunderstandings can take place.
Moua gives an example of an elderly Laotian man who came to the doctor with a variety of health issues: diabetes, hypertension, high cholesterol and stomach pain. He brought his son with him to translate. He was given medications for each of his conditions, and told to take them once a day.
His conditions didn’t improve, but the man insisted he was following the doctor’s instructions. Moua was finally called in to try to determine what was happening. She found that he was taking one medication each day, rather than each one each day.
In Southeast Asia, doctors usually treat one problem at a time, she said – perhaps treating diabetes first, and waiting until the patient has that under control before addressing the next condition.
“People feel if they take too many medications, it will kill them,” Moua said.
The cultural barriers are the most severe with the Hmong refugees, and were explored in the 1997 book “The Spirit Catches You and You Fall Down – a Hmong Child, Her American Doctors and the Collision of Two Cultures,” by Anne Fadiman. The book documents the clash of beliefs between the Hmong shaman spiritualism and western scientific medicine through the difficulties of a Hmong family in Merced whose daughter developed epilepsy.
The medical community in Merced has come a long way since then, and there are now training sessions for the shamans, introducing them to the technologies used in Western medicine, so they can reassure patients that western medicine can help them, while the shamans attend to their spiritual needs.
The shamans are trained to recognize emergency situations like heart attacks, strokes and appendicitis, and to get those patients medical care immediately, Moua said.
Transportation is also an obstacle, Moua said, because the hospital, Mercy Medical Center, moved from south Merced, where the poorer Southeast Asian and Hispanic populations are, to a new facility in north Merced.
The older Laotian refugees don’t drive, and their children are working and don’t have time to drive them, Moua said. They are uncomfortable taking public transportation if no one else on the bus speaks their language.
Robert McLaughlin, a spokesman for Mercy Hospital, said the hospital ran a shuttle after the move, but found very few people used it. The hospital maintains a clinic in the south Merced area that is well-used, he said.
Latinos have a different set of problems, stemming mostly from a lack of health insurance. Many Merced County Latinos are undocumented, and so are not covered by MediCal.
Federally-qualified health clinics offer treatment to everyone, on a sliding payment scale depending on the patient’s ability to pay, noted Michael O. Sullivan, chief executive officer of Golden Valley Health Centers, which operates 25 health centers in Merced and Stanislaus counties.
“Undocumented immigrants are a segment many people don’t talk about,” Sullivan said. “No doubt many of them are not here legally. They come here for employment, and they have no access to health care. They can come to this health care system (Golden Valley) and get care.”
The federally qualified clinics get reimbursement for that treatment, but if the patients need specialty treatment, they are frequently out of luck. Specialists are in short supply in Merced County, and without insurance, it’s tough to get treatment, said Tammy Moss Chandler, the county’s director of public health.
“Access to health care is not a human right in this country,” she said.
A big question mark is what happens after 2014, when (and if) the federal health care act takes affect. It does not include undocumented residents, Sullivan said – “And there are a ton of undocumented people here, and they aren’t going away.”
That means millions of Californians still won’t have health coverage, Sullivan said. Hospitals have to treat them in emergency rooms, but it’s unclear who foots the bill for that, he said. “Someone has to take responsibility…Politicians don’t want to recognize that.”
Most private practice doctors don’t accept many uninsured patients – they are running a business, and can’t afford to give away services. Doctors who do see uninsured immigrants are already not getting paid, and then face the cost of providing an interpreter, noted Moss Chandler.
There is a shortage of primary care as well as specialty doctors in the county, Moss Chandler said, which makes access to health care that much more difficult. Many of the doctors in the valley are recruited from foreign countries, and nurse practitioners and physician’s assistants are used to fill in the gaps, Sullivan said.
Many of the language and cultural problems will be resolved with time, Sullivan said. The second and third generations of Mexican and Laotian immigrants will be legal residents, they will speak English and will have integrated into the culture.
But a bigger health care challenge that affects Latino, Southeast Asian and portions of the white population is likely to remain. Almost a quarter of the county’s population lives below the poverty level. Poverty is a driving factor in many health problems such as diabetes, coronary heart disease and strokes.
Merced County ranks near the bottom of California’s 58 counties in those chronic disease categories, Moss Chandler said. The county is worked with Santa Cruz and Monterey counties in the Central California Alliance for Health to get people enrolled in health programs.
The problem is an American one rather than an immigrant one, Sullivan said. Newly arrived Mexican immigrants are relatively healthy – they work hard in the fields and haven’t been exposed to the high calorie, high cholesterol fast food diet.
Simple exercise strategies like walking and bicycling are risky in violence prone poorer areas. The stress of living in that violent atmosphere and dealing with discrimination and isolation is also detrimental to the health of immigrant populations, Moss Chandler said.
Health care providers will have to get beyond the walls of the hospitals and clinics to address those problems, Sullivan said. “That’s where health care needs to go, toward wellness and prevention,” he said.