Title VI of the Civil Rights Act of 1964 declared that “No person in the United States shall, on the ground of race, color or national origin, be excluded from participation in, be denied benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance.” With the passage of Medicare and Medicaid legislation in 1965, (as well as the provision for community health centers in the anti-poverty program), Title VI’s requirements for nondiscrimination in medical care became applicable to just about every hospital, health center, clinic and physician in the United States. Yet for many years, health care professionals did not see providing services to patients in their own language as a legal requirement, even though the immigrant population in the United States was rising rapidly. It was only in 2000 that President Clinton signed an executive order making it clear that Title VI applied to persons with limited English-language proficiency.
Although the law might have been slow to recognize something as obvious as the importance of patients and health providers being able to communicate in a language they both understood, foundations, advocacy groups and some policy-makers grasped its significance much earlier. In 1991, the Robert Wood Johnson Foundation determined that reducing the social and cultural barriers to health care would be one of its objectives. To reach this objective, it developed several programs to decrease language barriers to medical services. The most significant of these was Hablamos Juntos (We Speak Together, in English translation). In this chapter, Irene Wielawski, a free-lance journalist and former investigative reporter for the Los Angeles Times and Providence Journal-Bulletin, looks at Hablamos Juntos, examining its conceptual bases, observing the program in action at two sites, and offering some thoughts—based in part on the evaluation of the program—on the challenges to language-access programs and possible ways of overcoming them.
As this chapter illustrates, even an apparently simple idea such as providing Spanish-English interpretation can run into practical implementation problems. Reducing social and cultural barriers to care—including language barriers—requires thoughtful, sophisticated and multifaceted approaches. Perhaps the best illustration of the importance of understanding and working within the appropriate cultural context is found in Anne Fadiman’s book The Spirit Catches You and You Fall Down, the real-life story of how the great cultural gap between caring, well-meaning physicians and the parents of an epileptic Hmong girl led to a tragic series of misunderstandings. As Wielawski observes, the Foundation has learned from Hablamos Juntos and has adopted approaches to ensuring better communication between providers and patients in the context of its efforts to improve the quality of health care and reduce the inequalities in accessing it.