California has some of the nation’s toughest laws meant to ensure equal health care services for people who aren’t fluent in English.

But many limited English-speaking patients still lack the interpreters necessary to have meaningful communication with medical providers, particularly in emergency scenarios. The problem is acute for the communities of indigenous Mexican immigrants in California, advocates and practitioners say.

“The root of the problem is that until fairly recently, the huge indigenous population in California was under the radar,” said Sandra Young, a family nurse practitioner at a clinic in Oxnard and the president of the Mixteco/Indigena Community Organizing Project.

Many indigenous Mexican immigrants are farmworkers, the most recent arrivals in the state’s agricultural labor market, according to the Indigenous Farmworker Study, a California Endowment-funded study completed in 2010.

Nearly half of the indigenous Mexican farmworkers in the state can be found in the Central Coast region from Oxnard to Watsonville. The study identified 23 different indigenous languages spoken in California agriculture, representing 13 Mexican states.

Of the households in Monterey County that speak a language other than English at home, nearly a third speak English less than very well, according to the U.S. Census Bureau.

The consequences of inadequate interpreter services can be dire. In one recent case, Young said, a Mixtec child presented in a Ventura County emergency room with an apparent respiratory infection. It turned out that the child had choked on food and was suffering from a blocked airway. The child died.

“Can you say this was because they weren’t able to give an accurate history?” Young said. “Well, no, I don’t think you can say that – but I think you can ask the question: Would they have suspected a foreign body, is it possibly a language interpretation question? In my mind, yes it is.”

Uneven Access on the Central Coast

In the Salinas Valley and Monterey County, where leaf lettuce and strawberries top the $3.85 billion annual crop, the area’s four hospitals provide uneven access to interpreter services for patients who speak indigenous languages.

Local hospital officials point to Natividad Medical Center in Salinas as the leader in providing language access to indigenous people.

The indigenous patient population at Natividad is relatively tiny – indigenous languages make up less than two percent of patient languages. But the hospital has built up its own network of interpreters, training 27 people who speak indigenous languages. A new six-month internship gives trainees even more hands-on experience.

“Slowly, we’re beginning to broaden our resources,” said Victor Sosa, the language access coordinator at Natividad. “One of the challenges of the indigenous community is there are no interpreters at a professional level.”

Sosa said the hospital is able to provide indigenous patients with interpretation services on the spot about 80 percent of the time. He has educated hospital staff on cultural and linguistic differences among indigenous people. Staff members know, for example, to identify not just which language the patient speaks, but which township in the Mexican state of Oaxaca, for example, that person comes from in order to pinpoint the different dialects within each language.

The field of medical interpreting, Sosa said, is coming of age now, but there’s a lot of work to be done in California.

“My perception is a great majority of organizations don’t provide effective communication,” he said. “Many times, the problem is they perceive that language access is an added cost and they don’t want that burden.”

The hospital that serves one of the county’s largest concentrations of indigenous farmworker communities, Mee Memorial in King City, has had a challenging time providing interpreter services, said Annette Hayes, the hospital’s quality and risk management officer.

Mee Memorial has a contract with Language Line, among other language service providers, but Language Line has only Mixteco interpreter services on demand full-time.

The southern Monterey County area where the hospital is located is more populated with Triqui people. As a result, the hospital hasn’t yet used the Mixteco services provided by Language Line, Hayes said.

Hayes said she’s checked with about seven language services nationally and internationally that do health care interpreting, but none can offer 24-hour Triqui language interpretation.

To assess the language needs of hospital patients, the hospital relies first on Spanish language speakers. “Most of them speak a little bit of Mexican-type Spanish,” Hayes said of indigenous patients. “So usually we’re able to determine they’re Oaxacan.”

She said the hospital works with the Greenfield office of the Centro Binacional para el Desarrollo Indigena Oaxaqueño, an organization that serves indigenous migrant communities of Mexico in California. But those services are usually coordinated ahead of time, Hayes said, and many of their clients come through the emergency room or the clinic rather than scheduled appointments.

When providing an interpreter is impossible in an emergency situation, hospital staff make do. Indigenous patients hopefully speak a little Spanish, and the trained Spanish-language interpreters on staff can get by that way.

“It’s not ideal because they’re not medical interpreters,” Hayes said of relying on family members who speak a little Spanish. “We do a lot of hand signals and pictures and that type of thing, but it is very, very difficult.”

Mee has plans to work on developing a network of indigenous language interpreters, and has identified two students – one in high school – who may be the hospital’s language access future.

A Statewide Problem

Access to interpreter services in health care facilities is a persistent problem in California, said Ellen Wu, executive director of the California Pan-Ethnic Health Network.

“Even though there are laws on the books, the consumers don’t necessarily know about them – that they have a right to ask for them,” Wu said. “No one’s monitoring whether they’re being complied with, and providers aren’t always prioritizing this.”

It’s difficult to track whether the state department of health is monitoring the state Kopp Act of 1983, Wu said. Complaints about violations are filed with the local district offices, but they’re not categorized by race, ethnicity or language, she said. Isolated limited-English immigrant groups also may be hesitant to report violations, she added.

For communities that are more concentrated in certain geographic areas, when health care providers do find someone to interpret, sometimes the interpreter and the patient know each other, raising ethical issues. Other times, providers rely on the ad hoc interpretation skills of family members – children, even. But relying on untrained interpreters in the medical setting is risky, Wu and other experts say.

The indigenous languages are largely unwritten languages, and there are no words for many medical issues providers need to communicate, Young said. That’s been a challenge for the form-heavy U.S. health-care system. And while some health care providers have turned to on-demand telephone interpreter services, Young said, there are a few reasons why those services aren’t ideal for the indigenous Mexican languages. First, not many language services offer the languages; there are dialectical differences among the indigenous languages, and indigenous Mexican people typically come from rural areas without a lot of technology – the idea of communicating with a doctor through a stranger on the telephone doesn’t necessarily engender a lot of trust.

But despite the difficulties there’s a growing awareness among California hospital leaders of the importance of meeting indigenous language needs, said Jeanette Anders, who manages Language Line’s health care market.

Studies have shown cost savings from investment in adequate interpreter services, Anders said, given that poor communication can lead practitioners to order unnecessary lab tests, or that discharge instructions not in a patient’s language can mean the patient ends up back in the hospital.

Beyond the goal of quality care, there’s the law – from Title VI of the Civil Rights Act to a panoply of state laws.

“We know in Monterey County there are sizable indigenous populations,” said Jeffrey Ponting, indigenous program director for California Rural Legal Assistance, a legal aid organization. “To not provide services to them is, in my opinion, a violation of state and federal law.”