Language Barriers and Access to Care

Language barriers present a significant challenge for health care providers in a country with a large and growing population of immigrants. In the United States, 8.1% of the population speak English either “not at all” or “not very well,” and that percentage has nearly doubled since 1980 (Diamond & Jacobs, 2010). This is a problem not only for people working in direct patient care, but also for those trying to improve access to health care for individuals and communities. As the implementation of the Affordable Care Act (ACA) continues, Americans who have limited English abilities may face additional difficulties signing up for insurance plans.

Image from Yahoo! Voices.

The Spanish-language version of the ACA marketplace website, Cuidado de Salud, has been experiencing problems. Although the site allows users to learn about the ACA in Spanish, people cannot yet use the site to enroll in health insurance plans, and it is not known when that part of the site will be functional. In the meantime, Spanish speakers must use the English-language version of the marketplace website to enroll. One woman told CBS news last week that she would have already enrolled in a health insurance plan online, but has not because she only speaks Spanish (Rivers, 2013). The ACA website offers information in 12 other languages, although the resources available vary significantly by language. Some languages, such as French Creole and Chinese, offer marketplaces and translated applications. The sections for other languages, such as Hindi and German, simply instruct people to call for assistance (U.S Centers for Medicare and Medicaid Services, 2013)

The Spanish-language ACA website. Image from El Latino San Diego.

There are other options available to help people who do not speak English enroll in health insurance. The ACA hotline offers assistance in over 100 different languages, and is available 24 hours a day. People who speak languages other than Spanish may experience wait times, however, of up to eight minutes for help in their native languages (Chin, 2013). People with limited English proficiency may also be able to find assistance at local agencies, lists of which can be found on the ACA website. The website does not, however, allow users to search for organizations that offer help in a specific language. Public health workers in some areas have also been working with specific immigrant populations to increase enrollment. In the Chicago area, for instance, community health clinics and government representatives have been working on outreach in communities of Laotian, Polish, Congolese, and Vietnamese immigrants (Corley, 2013)

According to American FactFinder, 14.1% of people in Washtenaw County speak a language other than English at home, and 4.1% speak English less than “very well” (U.S. Census Bureau, 2013). These people may need additional help in finding and enrolling in health insurance places. A search of the ACA website brings up 123 sites offering local help for people in the Ann Arbor area, and some of these sites offer language assistance. The Arab Community Center for Economic and Social Services (ACCESS), for example, offers free enrollment appointments for individuals and families in Arabic, Bengali, Hindi/Urdu, Spanish, and Chaldean (U.S. Centers for Medicaid and Medicare Services, 2013).

I have encountered a number of patients in my clinical rotations who spoke limited English, and many of those patients also faced struggles with poverty and other social issues. Our job as health care providers is not just to treat sick people, but to help ensure that our patients and our communities have access to the health care they need. Making sure that people who need health insurance are able to get health insurance is one way to work toward that goal. There are resources available for people with limited English proficiency to access health care plans under the ACA, but people may not be aware of what is out there and may need our help to locate assistance in their languages.

Pregnant? Pour Yourself a Glass

This fall, Dr. Emily Oster, an economist and professor at the University of Chicago, published a book titled “Expecting Better,” which examines standard health and diet recommendations often made by prenatal providers and current evidence.  Many of her findings are seen as somewhat controversial, including her claims that bed rest may do more harm than good, it’s okay to avoid exercising for the 9 months of your pregnancy (Saint Louis, 2013), and eating that turkey sandwich is probably fine (Oster, 2013).  Her conclusion that has garnered the greatest response from the media and the public, however, is that “light” consumption of alcohol during pregnancy will not result in adverse outcomes (Oster, 2013).  

Research presented in economist
Emily Oster's new book suggests that
a glass a day in later trimesters is fine.
Photo from the NY Daily News.

Oster indicates that, in the two larger, longitudinal studies she based that portion of her book on,  “no difference between the children of women who abstain and those who drink up to a drink a day” exists (Oster, 2013).  She suggests that, “based on this data, many women may feel comfortable with an occasional glass of wine – even up to 1 a day – in later trimesters” and “1 to 2 drinks a week in the first trimester” is  (Oster, 2013, Saint Louis, 2013).  Oster’s explanation is that, drinking slowly decreases the quantity of alcohol that reaches the fetus and that episodes of binge drinking are what put children at risk for birth defects and cognitive disabilities (Saint Louis, 2013). 

Health organizations from across the country, including the American College of Obstetricians and Gynecologists (ACOG), the Centers for Disease Control and Prevention (CDC), and the National Institute on Alcohol Abuse and Alcoholism (NIAAA), have been responding to the release of Oster’s book (Saint Louis, 2013).  Most recognize the dangers of misleading women to believe that their fetus will not be exposed to alcohol at all and that there is plenty of room for variation in how limitations are perceived by women and how individual women metabolize alcohol.  Others strictly maintain that abstinence from alcohol during pregnancy is the only safe option, citing statistics regarding fetal alcohol syndrome and the lack of a precise understanding its effects (Oster, 2013). 

Some experts have expressed
concern that limitations may be
easily misinterpreted.
Photo from Pennlive.com

What I find to be the most challenging question raised by Oster’s book is not necessarily whether or not women should feel free to have a couple glasses of wine during pregnancy. Educating individual patients about what drinking “lightly” means during different trimesters and the risks of consumption beyond those limits seems both manageable and ethically correct.  What seems more troublesome is deciding what health care providers’ message to the general public should be.  It seems unethical to continue telling the public that absolutely no alcohol should be consumed if that is not what the evidence suggests.  However, it also seems irresponsible to endorse “light” alcohol consumption, as that could be widely misinterpreted, whether or not specific limitations are provided (for example, “one drink a day” can easily be interpreted as “seven drinks a week”).  I am definitely interested in continuing to explore the way providers and other experts in the field of public health weigh the risks and benefits different approaches to providing new evidence to the public. 

A Cure for HIV?

The fight against HIV has and continues to be a taxing battle on patients, families, and health care providers. According to the CDC, the incidence of perinatal HIV transmission in the United States has significantly decreased by 90% since the mid-1990s (2013). Despite these efforts, there are still 1,000 infants born every day with HIV and 330,000 children living with the deadly virus (Christensen, 2013).

Mother and child with HIV.

An article recently posted by CNN announced an exciting advancement in the fight against HIV in infants. A pediatric physician and professor, Dr. Hannah Gay, from the University of Mississippi Medical Center, prophylactically treated an infant with aggressive antiretroviral therapy before HIV transmission was even confirmed. To Dr. Gay's surprise, after receiving treatment for over a year then stopping treatment for 5 months, the 2 year old infant was free of "replication competent" HIV virus (Christensen, 2013).

While these results are remarkable, the researchers are hesitant to announce a 'cure' for HIV until this protocol can be replicated in more studies. Dr. Gay believes a key component to this success was the timing of the aggressive treatment, which began within 30 hours after the baby was born (Christensen, 2013).

HIV testing in Africa.

This advancement in HIV treatment offers a new found hope to infants, however it shouldn't negate the importance of preventative care. Unfortunately, there are several barriers that contribute to pregnant women receiving adequate prenatal care. For instance, in North Africa and the Middle East, only 3% of HIV infected women received antiretroviral medications (Christensen, 2013). This is largely due to the expensive nature of the medications. Additionally, access to care and HIV screening are barriers that hinder preventative treatments.

The Center on Globalization and Sustainable Development has made a commitment to eliminate perinatal HIV transmissions by 2015. They are doing so by focusing on preventative care. More specifically, their objectives are to prevent mothers from becoming infected, prevent unwanted pregnancies in HIV infected women, increase access to HIV testing for pregnant women, and to improve access to diagnostic services and treatments for mothers and infants with HIV. While this goal may seem highly ambitious, I think it's a great initiative and has potential to inspire other health care professionals to strive toward making improvements in preventative care.

Sharing Breast Milk

Sharing breast milk has become a controversial topic as breastfeeding becomes increasingly popular once again. Although breast milk sharing has existed for centuries, in the form of wet nurses, the way in which we are able to share breast milk has evolved with modern society. The health benefits of breastfeeding are exponential (American Academy of Pediatrics Breastfeeding Policy) and providers are recommending that women breastfeed exclusively for the first six months of their child's life and continue to breastfeed for at least the first year  (American Academy of Pediatrics, 2012). However, there are cases where mothers are unable to breastfeed due to a variety of conditions. Thus, instead of using formula to feed their babies, many mothers would prefer to buy breast milk from a breast milk bank or directly from other women. However, milk from hospital-based breast milk banks where the breast milk is pasteurized and screened is very expensive. This is why many mothers often turn to purchasing breast milk online.

Donor Breast Milk

                 The New York Times published an article last week based on a research study in Pediatrics, the American Academy of Pediatrics journal. The study found that breast milk from online breast milk sharing sites is often contaminated, which could lead to adverse infant health outcomes (Keim et al., 2013). Researchers discovered that the milk collected from online breast milk banks was contaminated with high levels of bacteria, and in two cases, salmonella (Bakalar, 2013). In some cases, this milk is donated; in other cases women sell their milk for as little as $1.50 per ounce (Bakalar, 2013). There are only thirteen official breast milk banks in the United States, and they sell the milk for as much as $6.00 per ounce (Bakalar, 2013). Since babies who are one month old need approximately twenty-five ounces per day, many families are not able to afford this breast milk for long (Bakalar, 2013). This is why breast milk sharing via the internet has become popular. However, the New York Times article concludes that breast milk sharing can be dangerous as one can never guarantee the quality of the breast milk.

Breastfeeding Mom & Baby

              However, Lamaze International published an article written by Suzanne Barston on their Science and Sensibility blog in response to the media's take on this topic. Barston (2013) recommends that parents and health professionals do not take extreme stances on this research. She questions the way in which the breast milk in the study was packaged and shipped, as this may have led to contamination. Barston (2013) suggests that we should try to improve the ways that breast milk is stored and shipped, as online breast milk sharing may still be a safe and affordable option for many women. It is also important for parents to form relationships with donors to develop trust. 

             Further, Barston (2013) dislikes the unfavorable way in which news articles have framed breast milk sharing. The negative framework surrounding donor breast milk and formula makes mothers feel guilty about whichever dietary choice they make for their infants. More research should be done on cost-effective, safe, and accessible ways to share breast milk.