By Rachel Hodakowski
One prevalent manifestation of structural violence is the inadequate care that results from poor navigation of language barriers. Limited English-proficiency (LEP) Spanish-speaking individuals in North Carolina are at an inherent disadvantage due to inequalities built into societal systems. The inability of physicians to effectively communicate with LEP patients upholds this social hierarchy and further alienates North Carolina’s growing Hispanic population. In 2020, North Carolina had over one million Hispanic residents, with 31% speaking English less than “very well” (Tippett). North Carolina, however, does not have structures to adequately provide for this marginalized group’s needs. The stories of oral history participants highlight the effects of these macroscale societal structures on the individual, whether that is through lengthier wait times, insufficient translation, or the outright refusal of care.
Waiting for Care
Lengthier wait times can have direct negative consequences on health outcomes. Jacqui Laukaitis, a Chilean native and medical interpreter in Burlington, NC, reflects on her experience:
“Well, there’s been cases at the emergency room, for example, in which they see the patients that need an interpreter and they just set them aside until an interpreter arrives, so in the meantime, they’ve taken care of three or four patients…” (Laukaitis 54:25)
Laukaitis states that the staff did not know the extremity of the medical issues during these wait times. In addition, Laukaitis claims that the patients could have accessed an online interpreter, but they were not offered this service. Although the outcomes were not drastically different for these particular patients, the added wait time for an in-person interpreter is a barrier to patient care that negatively affects patient experience.
Laukaitis’ story has been corroborated in academic journals. According to a study in the Journal of the American College of Emergency Physicians Open, patients with primary languages other than English spent a median of 17 to 35 minutes longer in the emergency department before ICU arrival and experienced a 15% mortality rate compared to the 9% rate for patients with English as their primary language (Oca et al. 1). The exact cause of the increased wait times and mortality seen in this study are unknown and likely multifaceted. In Laukaitis’ experience, however, LEP Spanish-speaking patients were placed aside until an interpreter arrived, and healthcare workers were knowingly providing suboptimal care to a minority group. Treating LEP patients not as a priority upholds the social hierarchy and results in this inadequate care.
In instances where interpreters are readily available, sometimes patients are still not provided the care that they deserve. Sabra Jane Hammond, a physician at CommWell Health in rural Asheville, NC, reflects on the difficulties she faced communicating with patients through an interpreter:
“Unfortunately, when I’m working here, I work with a translator. I very rarely get to see my patients’ eyes. They look into the translator’s eyes, not into mine… It’s a much cruder form of what is being said, and so I’m not able to adjust my language and adjust my tone as well when talking to people.” (Hammond 14:39)
Hammond claims that when she looks in her patient’s eyes, she better connects with patients and gauges what they understand. However, when working with a translator, this is not possible and non-verbal communication is inhibited. LEP patients have this inherent disadvantage in forming a strong doctor-patient relationship. To deepen this issue, Hammond claims to have experience with interpreters who do not translate sentences word-for-word. According to an article in the North Carolina Medical Journal, North Carolina does not require certification for professional interpreters or training in interpreter ethics, communication, cultural competency, and the roles of an interpreter (Mejia 105). All interpreters in North Carolina are not upheld to the same standards of care, which can result in inaccurate interpretations and difficulties communicating with patients. The lack of certification for professional interpreters negatively impacts the vulnerable patients who rely on the interpreters for vital information, as seen in the case of Sabra Jane Hammond.
Refusal of Care
While some facilities have lengthier wait times or inadequate care for Spanish-speaking patients, other facilities refuse to provide care altogether. Certain practices require an interpreter to be provided, while others have limited interpreters that do not visit every patient. This refusal of care is a stark manifestation of structural violence, as it clearly demonstrates that LEP patients are not valued by the system. Chasity Hargrove, a pharmacy director at CommWell Health Clinic in Dunn, NC, reflects:
“[I was at] A dermatologist one time, and there was a big sign up that said something like ‘If you don’t have an interpreter,’ not ‘go home,’ but, basically ‘We can’t help you.’ Which kind of hurt my heart a little bit.” (Hargrove 34:42)
This office did not outright refuse Spanish-speaking patients, but they encouraged them to seek treatment elsewhere. The dermatologist was aware that they could not provide adequate treatment within the confines of the current structures. According to the United States Bureau of Labor Statistics, North Carolina has 2,380 employed interpreters – accounting for all languages and industries. When this is compared to the 350,000 Hispanic North Carolinians who speak English less than “very well,” the insufficient number of interpreters is apparent (Tippett). Rather than correct this lack of resources that resulted in the exclusion of certain populations from their practice, Hargrove’s dermatologist succumbed to the all-too-common manifestation of structural violence.
This is not the only instance of refusal of care for Spanish-speaking patients heard in the Southern Oral History Project. Jacqui Laukaitis also encountered this phenomenon and reflects:
“I’ve seen where the doctor just comes in and just kinds of checks them out and goes out the door and doesn’t even say anything to them when there has been no interpreter… I guess doctors figure if they can’t communicate, they just won’t communicate, and that’s not good care.” (Laukaitis 52:31)
In this instance, there was a supply of interpreters, but the physician visited the patient without an interpreter present. The exact cause of this decision is unknown, but, in the current system, physicians are short on time and likely unable to wait for the scarce interpreters to become available. In an article in the Federal Practitioner, the lack of time with patients is identified as a contributor to moral injury, or “the challenge of simultaneously knowing what care patients need but being unable to provide it due to constraints that are beyond our control” (Dean et al. 401). Even if physicians want to provide patients with an interpreter, they may feel unable to supply this resource due to the time pressure in the larger system. This lack of time in the current system leads to some patients receiving inadequate care, and the brunt of this burden easily falls on those at the bottom of the social hierarchy – such as these Spanish-speaking patients.
In our current system, LEP Spanish-speaking patients are often treated as an afterthought. The lack of professional interpreters in the healthcare system can cause longer wait times for patients, inaccurate translations, and the outright refusal of care – all of which can contribute to higher mortality rates. The social hierarchy places Spanish-speaking patients in a vulnerable position, which is exacerbated by the lack of health resources available to this population. In order for real change of structural violence to occur, oppressive societal structures need to be dismantled. In the meantime, more certified interpreters must be made available so this marginalized group receives sufficient care.
Dean, Wendy, et al. “Reframing Clinician Distress: Moral Injury Not Burnout.” Federal Practitioner, vol. 36, no. 9, Sept. 2019, pp. 400-2. PubMed Central, www.ncbi.nlm.nih.gov/pmc/articles/PMC6752815/. Accessed 25 Apr. 2022.
Hammond, Sabra Jane. Interview with Maddy Kemany. 27 June 2018 (Y-0028). Southern Oral History Program Collection (#4007), Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill.
Hargrove, Chasity. Interview with Shelby Smith. 15 July 2019 (Y-0101). Southern Oral History Program Collection (#4007), Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill.
Lakaitis, Jacqui. Interview with Isabell Moore. 2 August 2019 (Y-0108). Southern Oral History Program Collection (#4007), Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill.
Mejia, Cynthia. “The Echo in the Room: Barriers to Health Care for Immigrants and Refugees in North Carolina and Interpreter Solutions.” North Carolina Medical Journal, vol. 80, no. 2, Mar. 2019, pp. 104-6, https://doi.org/10.18043/ncm.80.2.104. Accessed 25 Apr. 2022.
Oca, Siobhan R., et al. “Effect of Language Interpretation Modality on Throughput and Mortality for Critical Care Patients: A Retrospective Observational Study.” Journal of the American College of Emergency Physicians Open, vol. 2, no. 4, July 2021. Wiley Online Library, http://dx.doi.org/10.1002/emp2.12477. Accessed 25 Apr. 2022.
Tippett, Rebecca. “North Carolina’s Hispanic Community: 2021 Snapshot.” Carolina Demography, 26 Oct. 2021, www.ncdemography.org/2021/10/18/north-carolinas-hispanic-community-2021-snapshot/?utm_source=Carolina%2BPopulation%2BCenter&%3Butm_campaign=2d98a02e60-EMAIL_CAMPAIGN_2021_10_25_06_38&%3Butm_medium=email&%3Butm_term=0_807b260e90-2d98a02e60-36743817. Accessed 25 Apr. 2022.
United States. Bureau of Labor Statistics. “27-3091 Interpreters and Translators.” United States Department of Labor, 31 Mar. 2022, www.bls.gov/oes/current/oes273091.htm#. Accessed 25 Apr. 2022.