Critical Connection

Language isn't the only thing getting lost in the translation as Hispanic patients struggle to communicate with English-speaking ER doctors

"We've got to get the boca abreeed," yells the short, energetic ER radiologist in seventh-grade Spanish, butchering the phrase for "open his mouth." She chews her gum furiously and adjusts her pale blue shower cap. "You know, I speak French. It doesn't seem to help me in the ER."

Ten o'clock on Friday night and the Good Samaritan Emergency Room in Central Phoenix is hopping. A trauma team of 17 crowds around Rojilio, a 40-year-old man who has just been in a car accident and has a head injury. A thin stream of blood trickles from Rojilio's temple, and the smell of alcohol clings to the air around him. He struggles against the neck and chest restraints and flails his arms about wildly, making the X-ray tech's job impossible. Several members of the trauma team yell at him in the few words of Spanglish they can muster.

"No movee, buddy," one doctor says.

Dr. S. Reinhart and interpreter Maria Burruel work with a Spanish-speaking patient in the Good Samaritan ER.
Dr. S. Reinhart and interpreter Maria Burruel work with a Spanish-speaking patient in the Good Samaritan ER.
Dr. S. Reinhart and interpreter Maria Burruel work with a Spanish-speaking patient in the Good Samaritan ER.
Paolo Vescia
Dr. S. Reinhart and interpreter Maria Burruel work with a Spanish-speaking patient in the Good Samaritan ER.
Thirteen-year-old Gricelda Zamora died of a ruptured appendix.
Thirteen-year-old Gricelda Zamora died of a ruptured appendix.
Interpreter Cindy Arteaga translates for the mother of a newborn baby in an incubator at Good Samaritan. Arteaga floats through the hospital when she isn’t needed in the ER.
Paolo Vescia
Interpreter Cindy Arteaga translates for the mother of a newborn baby in an incubator at Good Samaritan. Arteaga floats through the hospital when she isn’t needed in the ER.
Maria Burruel must keep records of the patients she interprets for during her shift.
Paolo Vescia
Maria Burruel must keep records of the patients she interprets for during her shift.
Lucy Alday, an interpreter at Good Samaritan, stands at the bedside of a patient to help the woman and her mother understand what is happening and to interpret for the doctor.
Paolo Vescia
Lucy Alday, an interpreter at Good Samaritan, stands at the bedside of a patient to help the woman and her mother understand what is happening and to interpret for the doctor.
Interpreter Cindy Arteaga calls a hospital in Mexico about accepting a patient.
Paolo Vescia
Interpreter Cindy Arteaga calls a hospital in Mexico about accepting a patient.

No amount of medical training can change the fact that no one here can ask this man his name, where he is having pain, what has happened to him or what medications he is allergic to. No one can explain that the X-rays won't work unless he holds still. No one can explain that they must do a rectal examination to check for internal injuries. Veterinarians and baby doctors treat their patients all the time without the benefit of language. Still, a rectal probe is not the kind of thing you like to spring on a grown man.

Enter 19-year-old Maria Burruel. She is not a doctor or a nurse, yet she possesses a skill that is essential in Phoenix emergency rooms: Maria speaks Spanish. She is a trained, paid, full-time medical interpreter, and it is hard to imagine how this place muddled through before this job existed. She rushes into the hectic room and stands at the head of the trauma team. The doctors filter their questions and instructions for Rojilio through her.

Until 1999, Good Samaritan ER doctors often had to accommodate non-English-speaking patients by pulling a janitor to translate or hoping patients showed up with a bilingual family member.

There are other hospitals in the Valley that still do business that way, even those with emergency rooms that see twice as many Latino patients as Good Samaritan does.

But now Good Samaritan has a staff of 12 paid interpreters -- seven full-time, two part-time and three on-call. All are trained in medical terminology, anatomy, physiology and cultural sensitivity. During the program's first year, the interpreter staff translated for 33,500 people. The program is spreading gradually among the five Valley hospitals operated by Banner Health, the parent company created when Mesa Lutheran and Valley Lutheran bought Good Samaritan, Desert Samaritan and Thunderbird Samaritan hospitals in September 1999.

Translators started at Desert Samaritan in March and will start at Mesa Lutheran in July. Thunderbird will follow in the winter.

Perla Flores, director of Hispanic customer service and marketing for Banner Health, is coordinating the program, which costs $200,000 to $300,000 a year. She says the need was obvious.

"The most basic aspect of providing health care is communication," Flores says. "We can't know what's wrong with you if we can't communicate with you."

There's another good reason for hospitals to have interpreters like Maria: federal law.

The Civil Rights Act of 1964 prohibits discrimination against people from different countries. This extends to providing "linguistic accessibility" so that non-English-speakers get an equal shot at medical care. The U.S. Office of Civil Rights says this means all hospitals that receive federal funding -- and most do because of Medicaid and Medicare patients -- are required to offer qualified interpreters.


Ask local hospitals whether they offer interpreting services to Latino patients, and the question invariably comes up: "Is this about that Zamora girl?"

Almost everyone in the Valley health-care community seems to remember Gricelda Zamora, a 13-year-old Latina who died of appendicitis in the Good Samaritan ER after being airlifted from Mesa Lutheran in the spring of 1999.

According to the malpractice lawsuit filed by the girl's family, Gricelda's parents took her to Mesa Lutheran ER on March 16, 1999, with stomach pains. Hospital staff didn't speak Spanish, and Gricelda, who spoke English, was too ill to deal with them. She was given a pregnancy test and an X-ray, diagnosed with gastritis and sent home with instructions to schedule a doctor's appointment within three days. The Zamoras didn't have a family doctor, but her condition worsened, so they took her on March 18 to the Mesa doctor recommended by the hospital.

For disputed reasons, Dr. Stuart Agren's office did not treat the girl. The family claims she was turned down because the doctor's office could not confirm that the family had insurance. The Zamoras had to use a 14-year-old bilingual family friend to explain Gricelda's condition and the family's insurance policy to Agren's office. Agren claims that his office offered to treat her, and the Board of Medical Examiners has cleared him of wrongdoing. He could not be reached for comment.

Regardless, the Zamora family returned to Mesa Lutheran ER that same day. Eventually, Gricelda was diagnosed with a ruptured appendix and was flown by helicopter to Good Samaritan. She died there a few hours later.

The lawsuit against the hospitals and eight doctors involved is painted with broad strokes, claiming that what constitutes medical malpractice in this case is a general delay in treatment, misdiagnosis and incompetence. It does not claim discrimination. But in the Latino community, Gricelda's death provoked protests and cries of racism. Community leaders accused the medical community of consistently offering second-rate health service to Hispanic patients.

The interpreter program had been in place for three months at Good Samaritan when Gricelda arrived there. Several months after her death, Banner Health announced it would expand the program to all its hospitals.

Flores, the marketing director, says Gricelda's death made the value of the interpreter program even more obvious.

"We didn't point to the case or use it as a leverage -- it's too touchy," she says. "It wasn't the reason we moved forward with the program. It was just time. Look at the patient base that we're serving."

Good Samaritan spokesman Bill Byron says its ER did everything possible for Gricelda. A Spanish-speaking doctor treated her, but she was too far gone to save, Byron says.

Mesa Lutheran won't discuss the specifics of the lawsuit, but in reaction to the public outcry, the hospital retrained its staff to use the language line, a service that provides translators via telephone. It wasn't used in Gricelda's case.

"They had the language line at the time of this incident. Afterwards, it occurred to them to go back and make sure everybody knew how to use it," says Torie Jennings, the hospital media relations specialist.

Community leaders called a forum on Latino health care, and the Arizona Hospital and Healthcare Association set up a statewide task force on the issue.

The task force came to what seems like an obvious conclusion -- that doctors and nurses need to be able to communicate with patients.

"The most dramatic issue that we need to help hospitals and health-care systems with sooner than later is the language piece," says Fran Roberts, who sat on the task force.

In response, the hospital association formed a partnership with CyraCom, another telephone translation service, to try to encourage hospitals to use the devices. The service is similar to the language line but uses a two-way handset instead of a single handset that must be passed back and forth. Thirty hospitals across Arizona now have the service.

The task force members didn't review the translation services in place at local hospitals. If they had, they would have found ERs relying on rudimentary translation services and untrained interpreters who may or may not be available on the spot.

And if they looked today, they would find that not much has changed in most local emergency rooms for patients who speak Spanish.

It's hard to understand how hospitals can be sure they're ready for the Rojilios and Griceldas who arrive at their emergency rooms.

The Zamora family declined to talk about their case, but their lawyer, Ben Miranda, says the Zamoras could not read the specific discharge instructions for their daughter because they were written in English.

Jennifer Lopez, a 14-year-old family friend, made the doctor's office appointment for Gricelda, acted as a translator in explaining the family's insurance status and accompanied the Zamoras during their second ER visit.

Miranda says it's important to note that the hospital gave Gricelda a pregnancy exam during her first visit but not a test to determine blood-clot levels that may have been crucial to diagnosing her burst appendix.

"If you have a patient who is ill, and you have lack of a proficient interpreter in the room, and you have instructions being given to parents who only speak and perhaps write Spanish, that certainly to me seems to point out a problem," Miranda says.

And would pregnancy rather than appendicitis have been the first diagnostic guess for any 13-year-old girl?

"It's just speculation, but the question is, could it possibly be that this doctor, seeing a 13-year-old Hispanic woman with abdominal pain, immediately reached the conclusion that she was pregnant?" says Miranda. "That seems to be the likely explanation. Instead of looking for other explanations and answers, did he jump to this conclusion?"

Torie Jennings joined Mesa Lutheran three days before Gricelda's death. Suddenly, she had the nightmarish job of media relations for a hospital that was being publicly accused of racism and medical incompetence and was about to be named in a lawsuit. She says she learned from the experience that Mesa Lutheran isn't the only hospital in the area that needs to address its service to the Latino population.

"I think when we were in that community forum, there were people there that weren't talking about just that incident with Gricelda Zamora. They were there to address health care in general and what they perceived as secondary health care for the Hispanic community. Most of the people were giving testimonies about experiences they had at other hospitals. Everybody saw that we're not just talking about one hospital. We're talking about major issues," Jennings says.

Flores says she has not seen much beyond rhetoric since Gricelda died.

"This happened over a year ago, and how many hospitals have this program in place?" Flores says. "As a community person, as a Latina whose parents do not speak English, I think it should have been more of a wake-up call. Why don't these other hospitals have quality trained interpreters?"


Raquel Gutierrez has worked at the Phoenix Memorial ER since 1966. She comes in for two shifts a month these days to stave off retirement boredom. She speaks Spanish fluently, but for the other triage nurses, who do not, there is a single page of Spanish glossary words taped to a cabinet in the triage room.

"You make do," she says. "Some of the doctors and nurses speak some broken Spanish. Eventually they get the point across."

For the staff here, the idea of a full-time, paid interpreting team at this small community hospital seems laughable in the face of more pressing matters. Like the most dramatic nursing shortage Arizona has ever seen, they say. The ER is overrun with patients, and although beds sit empty upstairs for those who need to be admitted, there are no nurses to cover them. Still, Gutierrez admits that lack of bilingual services can be troublesome.

"If I'm an English-only health-care provider and the patient is Spanish-only, there is always a danger of misinformation," she says, explaining that she has seen charts written by English-speaking nurses that had nothing to do with the patient's complaint. "It will say 'hip.' And I'll ask the patient, 'What's wrong with your hip?' They say, 'Well, it's not my hip.'"

Gutierrez gestures to the page of glossary words.

"These words may sound really nice on paper, and a patient may be shaking their head in agreement but not understanding a word. Three days later they're back in the ER with the same problem."

Dr. Robert Laney is the only ER doctor who speaks fluent Spanish. He picked up the language while doing a Mormon mission in Bolivia. He says the Phoenix Memorial ER handles monolingual patients in a variety of ways. Some bring their own interpreters with them, or sometimes the hospital pulls a Spanish-speaker from housekeeping or registration.

"We get someone to explain on the most basic level what's going on," Laney says.

Phoenix Memorial estimates nearly two-thirds of the emergency room patients are Latino, and public information officer Laura Toussaint-Newkirk says interpreting services are in place to take care of them. The hospital has a grant that provides volunteers from Arizona State University. Their schedules vary depending on availability, and the grant money runs out in December. The hospital also uses staff with other duties and estimates that it uses the telephone service about twice a month.

Neither Laney nor anyone else during a six-hour visit in the emergency room mentioned the telephone services or ASU interpreters.

Hospital officials may think translation services work fine here, but 21-year-old Esmerelda from Zacatecas, Mexico, disagrees. She says there was no one to interpret on her behalf. Esmerelda is pregnant with her first child and had her first experience with American health care at the Phoenix Memorial ER. She was suffering from hyperemesis, a condition in which a pregnant woman is unable to eat and vomits constantly. It leads to dehydration and can be fatal if not treated.

The first time Esmerelda showed up in the ER, she was hospitalized for three days, and because she had no insurance, she was concerned about the bills. As an undocumented person, she wasn't sure what the state would cover for her, and no one could explain it to her clearly.

"I would talk to one office, and one person would tell me one thing; I'd talk to another office, and they would tell me something else. I don't know what to do," she says.

Worried about the cost, she left the hospital after only three days and ended up back there two weeks later, her condition worse. This time she was unable to bring her sister-in-law to interpret, and the hospital had no one available, either.

The doctor wanted to put in an intravenous tube that goes from the arm all the way to the heart. Esmerelda didn't understand what was happening.

"I was weak, almost fainting, and they wanted to put that tube in me. I didn't want to sign anything because I wasn't sure what they were doing to me. I was very scared, I felt like vomiting and I couldn't breathe when I saw the knives and needles they wanted to put in me."

Lack of interpreters can be a legal violation when it prevents staff from getting informed consent from a patient.

"I hardly ever knew what I was taking or what they were doing to me or my baby. There was no point in asking, because they wouldn't understand my question or know how to answer me."

At this time, Esmerelda's bilingual sister-in-law, Christy Junker, was working every day and could not be with her in the hospital.

"I would call to check up on her over the phone, and they didn't know me so they wouldn't give me information," Junker says. "To me this was curious. I know it's a rule of the hospital, but she doesn't know what's happening to her there. She can't communicate with them, and she doesn't have experience in the hospital. Things are different in Mexico."

"At least I wouldn't have problems with communication there," Esmerelda says. "And I wouldn't have to worry so much about how to pay for it."

How to pay is one of the most confusing hurdles for uninsured, Spanish-speaking patients, says Frank Lopez, director of public information for Arizona Health Care Cost Containment System (AHCCCS). This is Arizona's Medicaid program and health-care plan for people who don't qualify for Medicaid. Without an advocate, navigating the logistics of AHCCCS coverage can bewilder patients.

"I don't think there are people at the border who instruct undocumented people what to apply for," says Lopez. "People don't know where to go, they don't have insurance and they've run into an illness and need care.

"There are a lot of misconceptions amongst citizens here about what we give undocumented people. They think they get all this free health care; they don't. They get emergency care to stabilize a life-threatening situation."

And there are many twists and turns to that care. Esmerelda's midwife, Anita Martinez, tries to help her patients understand the system. They must have their paperwork in order: proof of residence, which can be difficult for people who don't have driver's licenses; and proof of income, which is tricky for people who are paid in cash. They have to get a letter from their employer, who often doesn't want to admit to hiring undocumented workers. Martinez says rumor, fear and misinformation abound.

She sums up the situation for monolingual Spanish-speakers in the health-care system with two words.

"They're lost," she says.

Esmerelda is lucky to have Junker to help her understand the insurance she is eligible for and to help her get prenatal care, pay for her prescriptions and translate doctor's orders. But Junker says even as a fluent English- and Spanish-speaker, the health-care system confuses her.

"There's no attention given to customer service," she says. "It's like the DMV. Except we're talking about your health."


Phoenix Memorial isn't the only emergency room struggling when a patient comes through the door unable to speak English.

Among Valley ERs with the highest numbers of Latino patients, only Good Samaritan and Maricopa Medical Center have full-time, trained interpreters. Maricopa went full-time with its interpreters six months ago to accommodate the 60 percent Latino population in its ER -- twice as much as Good Sam's Latino demographic.

Four full-time translators float throughout the hospital, including the emergency room, during the day. There is one person at night, one on the third shift and two on weekends. Maricopa says it made the interpreters full-time due to the tremendous and growing need, but it has always tried to provide human interpreters instead of using a translation device. This is not the case in all Valley hospitals.

The ER at St. Luke's Medical Center, located on East Van Buren, is surrounded by Latino neighborhoods but can only offer its patients the language line telephone services, which a hospital spokesperson described as "self-explanatory." The hospital would not respond to requests for estimates of how many Latinos use its emergency room.

St. Joseph's Hospital and Medical Center, on East Thomas Road, has a 30 percent to 40 percent Latino population in its ER and also has only the language line, although it hopes to hire interpreters eventually.

Maryvale Hospital Medical Center, Phoenix Baptist, Mesa General and Chandler Regional ERs all rely on the CyraCom telephones, or try to pull bilingual staff away from other duties. None has a full-time interpreting staff, despite a Latino patient population of 30 percent to 40 percent.

Even if emergency room staffs use the translator phones, the phone service in and of itself doesn't meet the requirements of federal law, says Ira Pollack, regional director of the Office of Civil Rights. It's considered a supplemental tool. OCR guidelines also mention that telephone services may not always have readily available interpreters who are familiar with the terminology required for certain situations.

And family and friends should not be used as interpreters because that could represent a breach of patient confidentiality, Pollack said; interpreters should be competent, preferably certified.

"A lot of people aren't even aware of their right to an interpreter," he says. "Many hospitals just tell them to bring in their family members. We consider that a violation unless they are first informed that an interpreter will be provided at no cost."

Hospitals generally get around the requirements by claiming to have bilingual staff, even though they may be housekeeping employees who aren't trained in medical terminology and have other full-time duties, Pollack says.

But if no one complains, nothing is likely to happen, Pollack acknowledges. The Office of Civil Rights, with a staff of fewer than 20 people covering Arizona, California, Nevada and Hawaii, doesn't have the resources to search out violations or do compliance reviews. The office investigates case by case, based on complaints.

Nationally, the office has pursued complaints and forced changes in Seattle, Minneapolis, Boston and Chicago.

In California, where activist groups have filed the most complaints, bigger hospitals such as California Medical Center in Los Angeles and the University of California-Davis Medical Center have provided interpreters for years. The Contra Costa County Hospitals were required to make changes a year ago after complaints filed by five San Francisco-area civil rights organizations alleged that the county discriminated against their clients who didn't speak English.

But no one in Arizona has complained. And nobody is standing at the border, informing new immigrants about their rights and handing them the phone number for the civil rights regional office in San Francisco.

Latino activists in Phoenix haven't gone the route of complaining to civil rights officials, either. The Zamora family didn't even file a complaint over Gricelda; their lawyer says his priority was taking care of the family through the lawsuit.

Federal regulations won't make hospitals more Latino-friendly, says Juan Guevara. He is director of the People of Color Healthcare Clinic, which recently opened through a partnership of St. Luke's Behavioral Health Center, Tempe St. Luke's, Mesa General Hospital and various Latino activist groups.

Hospitals are a long way from providing competent care to Latino patients, Guevara says, and the answer is separatism.

"Our community doesn't know or care about that law," he says. "It's just not being done.

"We figured out that hospitals are not going to do this," he continues. "We have not forgotten what happened [with Gricelda]. There is a serious lack of trust. Our communities don't trust those hospitals, so we decided to take it up on our own."

The idea behind the clinic is to reach people through community care and to show the hospitals -- which are contributing nurses and equipment but no cash to the clinic -- that there is a health-care market to tap there. St. Luke's and Mesa General are making an effort to treat people of color better, says Guevara, but the only language the hospitals understand is economics.

"What I'm talking about is, 'Do you want access to that market? Do you want to increase your market share? Do you want to make money off the Latinos and blacks?' That's the language they understand. They are being receptive to that."


Perla Flores is a Latina marketer in so many ways. Economic advantage is precisely the way she pitches Good Sam's interpreter program, saying you can't argue with the numbers.

"I think definitely Latinos are coming to the forefront of our economic pull. They have significant purchasing power and are an important part of our economic infrastructure and labor pool. I think people are noticing that," she says.

Flores believes that a program giving quality service to Latinos will draw in a valuable market for her hospital.

"I'm a marketer first," she says. "That way nobody can say I am doing this just because it's my people, although deep down inside my heart, I have been in their shoes."

Flores was born in Tijuana and came to the United States with her mother and siblings when she was 10. She grew up in the barrio del sol in San Ysidro, California, where she learned a new culture and language, but never forgot where she came from. She remembers her first health-care experience, when a machine injured her mother at her factory job. Flores was 11, and she interpreted for her mother at the hospital's ER.

"I was scared," she says. "She was our sole provider. There were four of us kids. I felt for her because she was in a lot of pain and couldn't express it to her health-care providers. On top of that I thought, 'How are we going to pay for this?' I was an 11-year-old thinking of that."

Flores appreciates the fact that children who accompany their parents to her hospital don't have to take on that burden. She also appreciates that the interpreter program creates opportunities for Latinas and Latinos in the health-care industry. She wants to mentor the young interpreters, and she can envision one of them having her job someday.

"These ladies are strong, in charge and can take a lot of pressure. And I'm not just saying that because I'm a Mexican woman and I can take a lot of crap. I have seen it in my own life. They are compassionate but strong, and that's a hard combination to find."

Many of the 12 Latina interpreters in the Good Samaritan ER were promoted from other hospital jobs. They not only translate, but also advocate for monolingual patients.

"They're like cultural brokers in a way," Flores says.

Language is the most basic and urgent need, but there is more to treating Latino patients. Making a proper diagnosis and influencing behavior often require understanding cultural nuances and culturally ingrained ideas about health care. That's why Irma Bustamonte gives cultural sensitivity training to both interpreters and medical residents at Good Samaritan.

The interpreters may be second- or third-generation Mexican-Americans who have lost touch with the more traditional aspects of their culture, says Bustamonte, who is Hispanic outreach coordinator for Phoenix Children's Hospital and a consultant for Good Samaritan.

"I think sometimes we take culture for granted," Bustamonte says. "We live our culture; we don't think about it until other folks say something like, 'Why do your people always do that?'"

Getting the medical community to fully appreciate cultural training can be a struggle, she says. "It's still seen as fluff. As far as culture goes, we are still just trying to raise awareness."

Bustamonte's job of explaining her people to white doctors is compounded by the diversity of the Latino people, making generalizations about Hispanics misleading. Some are Mexican-Americans who have been here for generations. Some are new immigrants from urban areas; some are from rural areas. Some are undocumented workers; some don't even speak Spanish.

None of this is made easier by the fact that some doctors are hesitant even to ask people about their ethnic identity.

"It's funny how politically incorrect ethnicity has become, but we can talk about sex at the drop of a hat," says Kevin Duke, one of two resident doctors who attended a recent class with Bustamonte.

The class isn't meant to be a comprehensive guide to Hispanic belief systems. This is Latino Culture 101 for gringos, where generalization rules. Bustamonte tries to explain complicated cultural concepts to her students, like marianismo, the idea that women should be like the Virgin Mary, and the hierarchy of family, with age and gender dictating who is in charge. She offers the doctors advice: Ask the patients what they think might be causing their problems, and don't be surprised if they have treated themselves with home remedies or don't follow doctor's orders.

"Sometimes you can find traditional beliefs underlying what people are or aren't doing to help their illness," she says.

In the quick 20-minute session she had with Duke and Ethan Bindelglas, another resident doctor, Bustamonte mostly fielded frustrated questions.

"So why don't they go to a primary care physician?" asked Bindelglas. "The fact that they go to the ER ends up being astronomically expensive, it's an inefficient way for them to get health care, and it's burdensome on them to spend eight hours in the ER. Why, if all these other clinics are out there?"

Duke chimes in with the answer before Bustamonte can respond.

"It's all about comfort. A lot of people have told me they feel more comfortable going to the ER," answers Duke.

Bindelglas says providing an ER interpreter is like treating the symptom rather than the cause.

"The comfort is we make it so easy for them to go to the ER by providing interpreters," responds Bindelglas. "It's stupid because it draws people into the ER who should be going to an urgent-care center. It's an incredible waste of resources."

Activist Guevara agrees that providing interpreters in the ER isn't going to solve all the problems, and a 20-minute cultural crash course barely scratches the surface of the major health-care issues facing Latinos.

A 1999 study by the Phoenix Behavior Research Center found that less than one-third of Latinos in the area had health insurance. A study released in March by the Centers for Disease Control found that 30 percent of Latinos in Arizona reported not being able to see a doctor because of cost. This was the highest percentage in the nation.

Uninsured people who think they can't afford health care often wait to go to the doctor until a condition has developed into an emergency. The ER is open after work hours, so people don't have to take time off. That may be the only time a family vehicle is available. New immigrants may not know they can go to primary-care clinics, and undocumented people may be afraid to seek services.

The result is generally a greater risk of health problems for Latinos in some areas where preventive care might lower rates. Hispanics in Phoenix are three times as likely as whites, for example, to get no prenatal care, and five times as likely to get inadequate prenatal care.

With clinics like the one Guevara has organized, activists hope they can move Latinos into the health-care arena before they have emergencies. And they can also make a dent in the kinds of diseases that flourish in isolated communities without a connection to health care.

Tuberculosis, for instance, can spread easily and become drug-resistant without good follow-through in completing antibiotic treatments. And in Maricopa County, Hispanics accounted for 40 percent of reported TB cases in 1999, even though they made up only about 20 percent of the population, according to the most recent census estimate in 1995.

"Interpreting programs put on a Band-Aid," Guevara says. "Our culture waits until an arm is falling off before going to the doctor. We're trying to change that culture."

It's a logical idea. But in the meantime, there is a nagging reality at hand. Hospitals must meet people where they are, and for the time being, they are in the ER.


Twenty-three-year-old Cindy Arteaga, a translator at Good Samaritan, is on her way to visit Sergio, a man from Chihuahua who is suffering from TB. Sergio first entered Good Samaritan through the ER, but he was admitted to the hospital a month ago.

When Arteaga isn't busy in the ER or in labor and delivery, she often floats throughout the hospital checking on Spanish-speaking patients. She explains to the front desk nurse that she is here to visit Sergio, and the nurse responds that he is in a bad mood. He's always in a bad mood. Arteaga just smiles and says she'd like to go in and keep him company.

She puts on a surgical mask that clamps around her head tightly with two thick rubber bands.

"So much for the hairdo," she says with a laugh.

She pulls on rubber gloves. It's an intriguing ensemble; Arteaga wears a bright-pink tank top -- too bright to be called bubble gum, but just shy of neon. A black chiffon skirt falls just below her knees; three-inch heels and a silver anklet complete the look. Her lips are lined with dark purple and filled in with a lighter shade, and her curled dark hair is streaked with highlights. Against the stark sterility of the hospital fluorescence, sea-foam green surgical scrubs, whites and pale blues, Arteaga is definitely the only bit of style moving around this place.

She steps first through one sealed door, then another that leads to a rounded, podlike room with a small window. Sergio is in isolation because of the infectious nature of his illness. He looks up from the fashion magazine he's reading as Arteaga walks through the door. He is skeletal, with protruding cheekbones, eyes dark and sunken, hair sticking out at odd angles. This is what doctors call a third-world illness. His bare feet dangle off the side of the hospital bed just above the floor.

It's no wonder he's in a bad mood. The food here stinks, he says, and he's been stuck here for a month. Arteaga explains some of his new medications and how they may cause nausea. She mentions that he can order Mexican food from the cafeteria downstairs. Sergio says he feels safer with Arteaga around to explain things to him.

But these interpreters aren't around just to make people feel safer. Arteaga translates to Sergio's sister complicated instructions for his care once he is released from the hospital. She explains that he wasn't accepted into TB housing, so he must have someone to look after him at home. She goes over the details of his medicine regimen.

Sergio has psychological problems, but Arteaga doesn't mention them. In some Latino families, mental problems carry a stigma, so interpreters may suggest psychological counseling to a patient when family members aren't around. Arteaga also does interpreting for psychological counselors, hoping to minimize cultural misunderstandings.

Arteaga was a unit clerk before she became a translator last year. She was called on often to interpret on top of her full-time duties. She says she enjoys being able to dedicate all her time now to interpreting and has had training in how to do it right. She had lots of personal preparation, though, interpreting for her monolingual parents.

"As a kid I had to go to job interviews with them," she says. "My family was dependent on me for them to get a job. I've been this link all my life."

She says her job as an interpreter has made her more confident.

"I'm that patient's voice, communicating everything that they're feeling. Everything they say is so critical and it has to be interpreted right."

And she's proud of how valuable she is to the patients.

"Before, people had to wait for the doctors," Arteaga says. "Now, they wait for us."

The majority of Spanish-speaking patients in the Valley will be waiting a long time for both.Against the stark sterility of the hospital fluorescence, sea-foam green surgical scrubs, whites and pale blues, translator Cindy Arteaga is definitely the only bit of style moving around this place.

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