YAKIMA, Washington – When Maria Guadalupe Diaz-Lisaola and her husband, Refugio Cepeda, go to a medical appointment, it’s usually a businesslike affair. Over the years, Diaz and Cepeda have faced organ failures and transplants, cancer and open-heart surgery.
This appointment is different. Inside their specialist’s office, conversations muffled by a half-closed door are bookended by laughter.
It’s not often that Diaz and Cepeda, who cannot speak English, are able to have the type of open conversations that lead to cracking jokes with their health care providers.
This time, however, they were meeting with Bertha “Lily” Gonzalez, a Spanish-speaking diabetes specialist they’ve built a close relationship with since moving from Tijuana, Mexico, two years ago.
Gonzalez took a look at Diaz’s right arm, which had swollen to twice the size of her other arm. Cepeda said he was worried about her. He recalled a time before they moved to Washington when he’d take his wife to her dialysis appointments.
“I would step outside and walk to a small hill near the center and I’d cry. I was worried about her. I was worried about not having money to pay for gas to take her to her next appointment,” Cepeda says. “It’s a horrible thing, but we do everything together. We’re about to celebrate our 50th anniversary.”
“We’ve been married so long he just rounds up, it’s actually 47 years,” Diaz responds. The three laughed at Diaz’s loving correction.
Like the thousands of others in the area who speak only Spanish, Diaz and Cepeda have benefited from having access to a health care professional who speaks their language and shares their culture.
As Latinos have come to make up a greater percentage of Yakima County’s population, hospitals and health care providers have adapted their services to meet their needs. In recent years, this has meant combining in-person and electronic services to remove one of the most basic barriers to health care for non-English speakers – language.
In the last 50 years, the Hispanic population in the United States has grown sixfold from just shy of 10 million people in 1970 to over 60 million in 2020. During that time, Hispanics have faced an expansive web of barriers to health care, leading to some of the worst health outcomes in the country. Language, education, economics and culture are among the hurdles.
Studies from the Pew Research Center show that while Hispanic enrollment in postsecondary institutions like colleges and trade schools has more than doubled since 2000, Hispanic Americans are still less likely than Black, white and Asian Americans to be enrolled in college or have a bachelor’s degree.
These conditions lead to lower wages and limited career opportunities for Latinos, which in turn lead to a lack of access to health care. According to a 2022 report from the U.S Census Bureau, 17.7% of Latinos in the U.S. did not have health insurance, more than triple the 5.7% of uninsured white people in the country.
In Yakima County, which is 52% Hispanic and largely agricultural, local health care systems have had to adapt to the needs of the population. According to the Census Bureau, in 2021, 37,000 Spanish-speakers in Yakima County described themselves as speaking English “less than very well,” a term used by the bureau to identify people with limited English proficiency.
During and after World War II, Mexican migrant workers moved to the Yakima Valley to help meet a dramatic need for farm workers. That need has continued into today with the Valley’s apple, cherry, asparagus and grape crops.
Since those first migrations in the 1940s, the Latino population in Yakima County has grown to 130,000 people. In small communities like Granger, Toppenish and Wapato, Latinos make up more than 80% of the population.
To serve this population, hospitals and health care providers use in-person interpreters and translators in addition to services like video remote interpreting that connect patients to interpreters via audio or video.
“I could not do my job adequately without having access to those services,” said Amber Shapton, a nurse practitioner and primary care provider at Yakima Valley Farm Workers Clinic, a health center that serves around 180,000 people in Washington and Oregon.
Shapton, a Tennessee native who doesn’t speak much Spanish, has relied on interpreters employed by the Farm Workers Clinic for the past 10 years.
Like most other health care systems in the area, the Farm Workers Clinic uses a mix of certified medical interpreters, bilingual health care providers and online services to ensure Spanish-speaking patients can understand their doctor’s words and advice clearly.
Looking back on her time practicing in Tennessee, Shapton said she didn’t have access to in-person interpreters and that unless a patient brought a family member who could interpret, a consultation would usually consist of Shapton trying to communicate with her patient using her limited knowledge of Spanish medical terminology.
In Yakima, Shapton said, she feels like her patients have a good understanding of their health situations.
“I don’t feel like a patient is leaving the clinic without really knowing what is going on with their health or what the follow-up plan is,” Shapton said. “I know that they know how to take their medication, I know that they understand what we’re doing within the visit. I definitely think this is better care all-around for the patient.”
Dr. Jennifer Maxwell, the clinical medical director for the Farm Workers medical-dental clinic in Yakima, said the presence of medical interpreters during an appointment can help prevent the wrong information from being shared.
“I have seen patients taking their medications incorrectly. They may think they have a horrific cancer when really it was something benign,” Maxwell said. “The opposite can also happen. Some people leave not understanding the severity of their diagnosis. Really any situation that you can imagine, it can be exacerbated by a miscommunication.”
At hospitals like MultiCare Yakima Memorial, the largest in the county, and at the Farm Workers Clinic, new patients are asked when they set up their first appointment about their preferred language.
A note is added to the patient’s medical records. For Spanish speakers, this means from then on, all appointments, discharge papers, prescriptions and communications will be in Spanish.
Angelina Garcia, language access program manager at Memorial hospital, has been a certified medical interpreter for six years. She said working with the same providers consistently allows her to get to know their speech patterns and preferences for how to convey information.
“It’s a lot easier and a lot more fluid when we know the provider and how they speak with a patient,” Garcia said. “You usually feel a lot more comfortable when you interpret for the same provider consistently.”
Shapton said as a health care provider, consistent and long-term access to interpretation services like those offered at the Farm Workers Clinic has made her a better communicator.
Though she doesn’t speak Spanish, she’s worked with the same interpreter for almost a decade. Through that relationship, she has learned how to pick her words in a way that makes interpreting easier and more clear for her patients.
“There is a benefit to that. My MA (medical assistant) that I’ve been working with for almost the 10 years I’ve been here, she is already anticipating what I’m going to say,” Shapton said. “For example, I always say the same things when I’m talking about constipation. So when I talked about that, she’s already anticipating what I’m going to say based on the topic we’re talking about.”
Bertha Lopez, director of diversity, equity and inclusion at Memorial, said the hospital has staff dedicated not only to providing interpretation and translation services but also to determining the demand for these services and the best way to use them.
“I think we have been pretty innovative when it comes to language services and in developing EMR (electronic medical records) tools that we can use to translate special instructions to providers pre-discharge,” she said.
Lopez mentioned that at the height of the COVID-19 pandemic, nationwide health disparities and shortcomings were highlighted by the way in which minority populations were disproportionately affected by the virus. Infection rates and hospitalizations were highest among people of color.
Those trends held true in Yakima County, according to reports issued by the state Department of Health, prompting the hospitals to adapt to the increase in demand. “We had to change a lot in our systems to be able to accommodate,” recalled Lopez.
Lopez said Memorial partnered with a company that specializes in technology that allows for patients’ vitals to be monitored remotely. When paired with telehealth tools like video remote interpreting, providers were able to communicate with patients while minimizing contact. These technologies were incorporated into Memorial’s protocols after the threat of COVID subsided.
In the last few years, Lopez said health care providers have also been offered the opportunity by the hospital to study and test for medical interpreter certification. Both Memorial and the Yakima Valley Farm Workers Clinic use ALTA, a service that offers language testing and proficiency assessments for providers who want to be certified as medical interpreters or who want to become proficient in another language.
Memorial offers these courses to providers across their health care system. Gonzalez, Diaz and Cepeda’s diabetes specialist, works at Cornerstone Clinic and has her ALTA certification.
In 2022, Lopez said, more than 50 health care providers passed ALTA’s proficiency exam.
The Farm Workers Clinic also offers its physicians, nurse practitioners and other providers eligible for sabbatical leave, a four-week Spanish language immersion program in Guatemala. The program, Asociación Pop Wuj, sends health care providers to offer their medical services in eastern Guatemala.
Diaz and Cepeda are both in their mid- to late 60s. They moved to Yakima, where their four sons live, in 2021. They decided to make the move from Mexico when their health started to rapidly deteriorate. They needed access to better care.
“We were dying there (Mexico),” Cepeda said. “I had an issue with my thyroid, it was serious. I had lost 24 kilos in months. I was wasting away on a couch.”
While their experiences with Memorial have been mostly positive, the couple said they’ve gone to appointments at other clinics where interpreters were not made available.
“We were worried about being able to communicate with our doctors and we still worry about it,” Cepeda said. “Sometimes we’ll go to a clinic and there are no interpreters and it turns into a guessing game. The doctor will ask me a question and we’ll just sit and look at each other in silence. No one knows what to say.”
Cepeda and Diaz both said access to care is diminished entirely if they can’t communicate with a provider.
Diaz said on multiple occasions, she’s had trouble communicating with health care providers that her veins are hard to find when trying to start an intravenous drip. In these cases, she said she’s been poked multiple times in both arms with no success.
“It causes me pain and I don’t understand what they’re trying to do,” Diaz said. “I try to tell them that my veins are weak.”
In cases when she’s had access to an interpreter, Diaz said she’s communicated her concerns and doctors have been able to adjust accordingly, successfully inserting the needle the first time.
Gonzalez agreed. She’s seen how being able to communicate with patients who are used to struggling to communicate in English can lead to better health outcomes and better patient-provider relationships.
“When you find someone who speaks your language, respect, trust and a willingness to learn about your own health comes next,” Gonzalez said. “I’ve had patients tell me they’re motivated to make changes to their diets and other habits when they can actually understand what those changes are.”
At Memorial hospital, Garcia said she works with language access managers in other hospitals across the state to gauge how they’re meeting demands for interpretation services and determine what methods are working.
The group — Seattle Area Interpreting Leaders — is made up mostly of hospitals on the west side of the state. During their monthly meetings, Garcia said members exchange tips and knowledge on where to find interpreters who speak different and sometimes uncommon languages. She said as an interpreter in Yakima County, she’s able to focus mainly on services in Spanish, a luxury her colleagues don’t have.
Garcia said American Sign Language, Vietnamese, Cantonese and Korean are the next most common languages spoken by patients who need interpretation services.
While the services are not free, Lopez said their cost is mostly subsidized by federal and state funding. She said none of the costs for translating and interpreting are charged to patients. In return for the funding, Memorial is required to offer the services to anyone who needs them.
Lopez said the hospital also monitors statistics like the rate at which patients return to the hospital after 48 hours to see if anyone is coming back for reasons like not being able to understand discharge instructions. This helps the hospital determine what changes need to be made to its language services.
“We’re looking at quality metrics that will help us identify how we need to develop services for our patients and see if they’re equitable and if they’re able to help patients get past barriers they have,” Lopez said.
Between 2019 and 2020, Garcia said, the use of Memorial’s interpretation services increased a staggering 303%.
Other metrics compiled by Memorial show interpretation services are becoming more widespread and are used almost exclusively by Spanish speakers even in 2022 when more visitors were allowed after pandemic restrictions.
In 2022, Garcia said, 91% of video interpreting minutes were spent interpreting Spanish. That number was 96% for over-the-phone interpreting minutes. Combined between video and over-the-phone, Memorial provided almost 270,000 minutes, more than half a year’s worth of time spent interpreting. In 2018, she said, that number was about 5,000 minutes.
As their appointment with Gonzalez ends, Cepeda’s phone rings.
“Me van a hablar en inglés,” he says after looking at his phone. “They’re going to speak to me in English.”
Gonzalez reaches out for his phone and answers for him. “Hello, this is Refugio’s phone. Do you speak Spanish?” she asks.
The answer is no. Gonzalez says “alrighty” and grabs a pen and paper.
Diaz and Cepeda, who have another doctor’s appointment in a half-hour, said they spend all day fielding calls about follow-up appointments, prescriptions and other aspects of their health.
“Whenever we are with Lily and we get a call, she helps us get all the information since they’re not always in Spanish,” Diaz said. “It’s a great help. We need more providers like her, we need more interpreters. It’s how we can take care of ourselves.”
This story is part of “More than Words,” a Report for America initiative that brought together newsrooms covering Latino communities in eight states to examine the impact of language barriers on the social, economic, and educational advancement of Latinos and the local efforts to close this gap.