In Singemasa v. Kapiolani Medical Center for Women and Children, the case revolved around the tragic death of a child whose mother was Limited English Proficient.

Cultural Barriers in Healthcare: A tragic language access case

Quote about how cultural differences can make providing healthcare difficult.

“All of the communications with Mrs. Singemasa were in English although her native language is Chuukese,” according to a lawsuit alleging that lack of language assistance contributed to the death of a nine-month old baby in a Hawaii hospital. The case was filed in Hawaii Circuit Court (a state court) in late 2016.

The hospital involved denies the allegations and is contesting the case. The baby’s parents claim the “hospital failed to properly examine, diagnose and treat the baby and failed to take adequate measures to communicate with the baby’s mother, Terie Singemasa, who speaks Chuukese and little English,” according to Mrs. Singemasa’s attorney.

According to the U.S. Census, Hawaii has among the highest statewide rates of limited English proficiency in the United States, with nearly 12.5% of Hawaiians being limited English proficient or LEP. More than half of all Hawaiians who speak Asian and Pacific Islander languages are also LEP, according to the Census Bureau’s American Community Survey.

The Census Bureau defines Asian and Pacific Islander languages as the following: “Chinese; Korean; Japanese; Vietnamese; Hmong; Khmer; Lao; Thai; Tagalog or Pilipino; the Dravidian languages of India, such as Telugu, Tamil, and Malayalam; and other languages of Asia and the Pacific, including the Philippine, Polynesian, and Micronesian languages.”

Ms. Singemasa’s native language, Chuukese, is spoken on the Chuuk Islands in the Federated States of Micronesia in the Pacific. Chuukese is a Micronesian language for Census purposes.

COFA Islanders and Cultural Barriers in Healthcare

A map of Mironesia, including Palau and the U.S. Marshall Islands

Micronesia, together with the Marshall Islands and Palau, comprise the Compact of Free Association or COFA, an international agreement establishing and governing the relationships of free association between these nations and the United States. In the 20th century, the COFA nations were ground zero for open air nuclear weapons testing by the U.S. military, especially in the 1950s. The resulting radioactive fallout has had serious consequences for COFA islanders. A 2011 report entitled “The Case for Justice for Micronesians in Hawai‘i” by the Hawai‘i Appleseed Center for Law and Economic Justice stated that “… many [COFA] islanders suffer disproportionately from serious health problems linked to nuclear weapons testing.”

According to the U.S. Census and other government data, approximately 15,000 people from the COFA states live in Hawaii. With such a small population, finding qualified interpreters who are fluent in COFA languages and English can be challenging. Cultural differences between the COFA states and the United States can compound the challenge of providing LEP COFA natives with effective assistance in their languages that they can understand.

In addition, Chuukese and other COFA languages may also not have direct equivalents for English medical terminology, creating potential difficulties for LEP COFA islanders to fully participate in conversations about their medical care with English-speaking providers. Hawaii state law requires publicly funded hospitals to provide qualified language services, similar to the federal legal requirement.

A January 2017 report, “Hawaii’s COFA Islanders: Improving Health Access and Outcomes,” confirms these linguistic and cultural challenges.

“Language and cultural barriers are some of the factors that complicate access to health care for COFA islanders… In our conversations with Chuukese advocates, we learned that they come from an oral communication culture, where the strength of verbal agreements obviate the need for paper forms, photo identification, contracts, documents, and email. This poses significant challenges for enrollment in insurance and access to care.

Furthermore, critical health documents are usually not translated into the native languages of the COFA islander populations. This further exacerbates the challenge in reaching and serving this high need population. In addition, like many immigrant populations, COFA islanders must reconcile their traditional family structure and cultural values with those of their new home. Chuukese deeply value large families with communal upbringing of children, which comes at odds with the push for family planning in our current health care system… Understanding these dynamics is instrumental in disseminating information and resources about health care.”

Providing Qualified Interpreters

The Honolulu Civil Beat (December 1, 2016) reported on providing LEP Hawaiians with qualified interpreters or translators in healthcare settings:

“It’s a critical service to provide in a hospital setting, said Helena Manzano, executive director of the state’s Office of Language Access.

‘People in Hawaii tend to not complain,’ Manzano said, ‘so we don’t know if these services are happening.’

It’s hard to find qualified interpreters for clinics and hospitals, says Dr. David Derauf, executive director at Kokua Kalihi Valley. But it can ‘completely change a medical visit,’ by providing a more thorough patient history, he said.

In Hawaii’s larger hospitals, lack of access to language interpreters can affect the care and access that members of Hawaii’s immigrant communities receive, according to Dina Shek, legal director of the Medical-Legal Partnership for Children in Hawaii.”

The tragic death of a nine-month old baby speaks to many poignant issues and considerations. Concerning language, this case reveals the difficulties and challenges of assisting limited English proficient people who speak relatively rare languages, or languages of lesser diffusion.

Cultural differences can further complicate providing qualified assistance to speakers of such languages, which can also be additionally difficult where the relevant language may not have equivalents for medical, legal, and other similar terminology. Preparing for such situations is critically important, and as this wrenching case suggests, can have life or death implications.

Read some of Bruce Adelson’s other blog posts to learn about more developments in language access law, and be sure to contact us if you’re interested in a consultation about your own organization’s compliance with federal language access law.

© Bruce L. Adelson, special for Bromberg.  2017 All Rights Reserved The material herein is educational and informational only.  No legal advice is intended or conveyed.

Bruce L. Adelson, Esq, CEO of Federal Compliance Consulting LLC is nationally recognized for his compliance expertise concerning many federal laws.  Mr. Adelson is a former U.S Department of Justice Civil Rights Division Senior Attorney. 

Mr. Adelson teaches cultural and civil rights awareness at Georgetown University School of Medicine in Washington, D.C.