Tip of the Week
Get Better Outcomes with Refugee Patients
The Center for Victims of Torture has just released a free, downloadable toolkit for providers who work with refugee patients.
Based on CVT’s clinical work with Karen refugees, Improving Well Being for Refugees in Primary Care: A Toolkit for Providers gives clinicians the tools to improve treatment plans for patients who have lived through traumatic experiences.
The manual depicts scenarios between a provider and patient to illustrate how asking questions in a more culturally-appropriate way can yield richer information to address a patient’s health issues. It includes concrete examples and recommendations for medical providers to incorporate into their practice.
Read more about the toolkit on CVT’s blog. Download the toolkit here.
Video Touts Breastfeeding for Somali Moms
Check out this video in Somali (with English subtitles) on the benefits of exclusive breastfeeding. The video was produced by Allina Health and WellShare International, with assistance from Somali WIC Breastfeeding Peer Counselors, and financial support from the Allina Foundation and the Minnesota Department of Health.
The Fading Image of an Immigrant’s Journey
Here’s a moving essay about a college student’s effort to understand more about the escape her grandmother made from the Philippines to the United States. Seeing My Heritage through My Grandmother’s Eyes is another of those stories that point out the immense gulf between the current moment and the world as it existed during and immediately after World War II.
Essayist Isabel Guarco’s orphaned grandmother, born in Manila in 1923, lived under Japanese occupation through the war years. Shortly after the armistice she fled to this country on a war bride ship. Guarco recounts her own trip to Manila to try to trace her grandmother’s life in the city. Except for a ledger line in an orphanage’s records, she finds, that world has largely disappeared.
It’s a story that reveals, again, the difficult path undertaken by so many immigrants and refugees, and how quickly the circumstance that provoked their exodus disappears in the mist of history.
Recording World Languages, Before It’s Too Late
If you’re trying to arrange interpreter services for patients, it may seem that the world already has too many languages. But here’s the other side of that coin: the number of languages that are at risk of disappearing entirely.
A recent Philadelphia Inquirer story reports on the Wikitongues project to record a significant portion of the world’s 7,097 languages. The project founder, Daniel Bogre Udell, figures that every two weeks, a language dies. Another 500, he estimates, are seriously at risk.
Find the Inquirer story here. Check out the Wikitongues website here.
The Interpreter Beside Marie Kondo
Okay, this story about the interpreter who makes the declutter maven Marie Kondo understandable in English might seem a little off track. But here’s the redeeming feature that makes the piece relevant — it’s also full of nuanced description of what raises top-of-the-line interpretation above its hum-drum counterparts.
Interpreter Marie Iida explains the research and attention to detail that go into her work in Marie Kondo’s Brilliant Interpreter Is the Unsung Hero of the Konmari Phenomenon, published in the online magazine Quartzy.
Gender Bias in Machine Translation?
Despite the advances in machine translation that have moved it from the ridiculous to the potentially useful, there remain glitches — particularly in the area of assigning gender, as pointed out in an article in Slator: Language Industry Intelligence.
A difficult trouble spot is in translations that go from English, which does not assign gender to nouns, to languages such as Spanish or French, which do.
Quoting a Dublin City University researcher, Eva Vanmassenhove, the Slator article reports, “In French and Spanish, for instance, ‘I am a nurse’ will still be given feminine translations while ‘I am a surgeon’ will result in masculine ones.
“Even more problematic is the following set of translations: ‘I am beautiful’ is translated into the male form in Spanish. However, ‘I am a beautiful surgeon’ is translated into a female form,” Vanmassenhove said.”
Read more about another complexity of the modern moment in “He Said, She Said: Addressing Gender in Neural Machine Translation.”
That Other Language, Art. A Path Toward Health?
Should the arts be considered an essential ingredient in general well-being? And should therapeutic art or hobby-based treatment be prescribed as part of a treatment plan?
The answer is yes, according to United Kingdom Health Secretary Matt Hancock, who has promoted a “social prescribing” initiative to the country’s doctors for maladies such as dementia, psychosis and mental illness, as well as ailments such as lung conditions.
Regarding the arts, Hancock says,
“They’re not just a right in their own terms as the search for truth and expression of the human condition. We shouldn’t only value them for the role they play in bringing meaning and dignity to our lives. We should value the arts and social activities because they’re essential to our health and wellbeing. And that’s not me as a former Culture Secretary saying it. It’s scientifically proven. Access to the arts and social activities improves people’s mental and physical health.”
About that Border Wall
How many miles of new wall has the Trump administration constructed along the 1954-mile border between Mexico and the United States over the past two years? Check out this graphic analysis by the New York Times for an answer.
Though Congress has approved funding for 124 miles of new funding, the current administration has added exactly zero miles of new barriers. Existing portions of wall and barriers stretch for 654 miles.
The Health Literacy Trap for Seniors
How many patients are capable of fully understanding the care instructions they’re given? The answer: barely one in ten.
A 2006 national survey found that 12 percent of patients fit the “proficient” health literacy category. Things get even more bleak for the elderly. For those 65 and older, only three percent qualify as proficient, while fewer than one in four can claim intermediate health literacy.
The results:
- Poorer health at higher cost,
- Higher hospitalization rates,
- Less use of preventative tests and immunizations.
According to an analysis in the New York Times, This Type of Illiteracy Could Hurt You, health care providers can’t view themselves as blameless. Says Rima Rudd, a Harvard University health literacy researcher, “We give people findings and tell them about risk and expect people to make decisions based on those concepts, but we don’t explain them very well. Are our forms readable? Are the directions after surgery written coherently? If it’s written in jargon, with confusing words and numbers, you won’t get the gist of it and you won’t get important information.”
Deported Cambodians: What Awaits Them
With the Trump administration poised to deport a large group of legal Cambodian immigrants to the United States, among the questions that arise is, How will those booted from the US adapt to Cambodia, a country that in many cases they’ve never known?
Those at risk of deportation include members of families that fled the murderous Khmer Rouge regime and were declared refugees in the US. But those who failed to become citizens and were convicted of felony crimes are now at risk of deportation.
For a glimpse of what awaits them in Phnom Penh, check out this New York Times piece, “Deported and Sticking Out: ‘This Ain’t Home. America’s My Home.'”
For a more detailed look at the politics behind the Trump deportation order, see “Dozens More Cambodian Immigrant to Be Deported from US, Officials Say.” A more Minnesota-specific account of how this deportation plan has roiled the local Southeast Asian community — “Deportation proposal shakes Minnesota’s Southeast Asian refugee community” — appeared in the StarTribune.
According to a Macalester College tally, Minnesota has the sixth largest population of Cambodian refugees — 5,530 — in the United States.
Honesty in Another Language
Want to be viewed more often as a liar? Try telling the truth in another language.
That, roughly speaking, is the conclusion of research conducted by University of Würzburg psychologists Kristina Suchotzki (photo, right) and Matthias Gamer.
In their experiment, the researchers asked participants to answer questions, sometimes honestly, sometimes not, in their native tongue and in a second language. Some questions had an emotional core; others involved a simple statement of fact. The results, as summarized by Medical Xpress:
- “It is not easy to tell when someone is lying. This is even more difficult when potential liars speak in a language other than their native tongue.
- “Most people don’t find it more difficult to lie in a foreign language than in their native tongue. However, things are different when telling the truth: This is clearly more difficult for many people in a foreign language than in their native one.”
The effect for non-native speakers: they are perceived as less truthful and trustworthy. The result could be especially dire for asylum seekers answering government officialdom’s questions.
Global Twin Cities Offers View of Cross Cultural News, Events
Here’s another way to keep up with the myriad local events that open up a window to the greater world. Check out Global Twin Cities, a website that features an extensive calendar of cross cultural events, a listing of community organizations, plus news, notes on restaurants, artists and more.
In terms of variety of events and news alone, this site is well worth a look. For example, the calendar for December 8 features links to events as disparate as The Voice of Egyptian Dance: A Tribute to Um Kalthoum, the Swedish Hiking Club’s jaunt around Como Lake, and Fiesta Decembrina Venezolana 2018 (Venezuelan Holiday party).
A Digest of Immigration News
Looking for a compendium of recent news and scholarly articles on immigration issues? Take a look at a special section of the online New York Times, Immigration and Emigration.
The most recent iteration includes news coverage of the clash at the US border between Central American caravaners and the border patrol, the Irish bid to restore birthright citizenship, Hillary Clinton’s perspective on European immigration, and the Trump administration’s latest move regarding Vietnamese emigres.
From Schools, a Warning on Language Services
Here’s another note on the consequences of inadequate language services, this time from the St. Paul public school system.
Como Park high school student and Karen immigrant Lor Ler Kaw got placed in mainstream English and social studies classes with fluent English speakers, even though he read at a second grade level. He was caught up in a district policy to mainstream ELL and special-ed kids in regular classrooms.
Parents George Thawmoo and Mary Jane Sommerville suspected their child needed special education services. Eventually they took their complaint to the St. Paul Department of Human Rights and Equal Employment Opportunity, which found probable cause that the district discriminated against the students on the basis of national origin.
In a negotiation ordered by the US District Court, the school district awarded Lor Ler Kaw’s family $12,500, and agreed to substantial changes in its ELL policies.
Not that anyone needed it, but the case is more evidence of the downside to inadequate language services. Read the complete story here.
Snow Emergency Rules, Translated
It’s tough enough to understand Twin Cities snow emergency rules for native speakers. Imagine trying to decode them if you’ve got a loose grip on English.
Here’s some help for limited-English speakers in Minneapolis and St. Paul. Both cities offer translated versions of winter parking regs on their web sites.
In St. Paul, motorists can find snow emergency rules in
In Minneapolis, translations are available in
Time to Learn Some Amharic?
Looking for a cheap and easy way to learn how to say hello and exchange a pleasantry or two with recent immigrants? Check out the language lessons — many of them free — at the Open Culture website.
You’ll find introductions to 48 languages, ranging from Spanish, German and French, to Amharic, Bambara, Lao, Swahili, Vietnamese and more. Many of these courses are Foreign Service Institute book and audio packages intended to prep the diplomatic corps for a new assignment.
There’s much more to this wide-ranging website, including in-depth interviews with literary luminaries such as Margaret Atwood, Jorge Luis Borges, Roland Barthes and Toni Morrison, plus some oddball diversions, such as how to make, wear and fight in medieval armor.
Singing about that Disaster
Here’s a twist on a communication problem that has bedeviled Minnesota’s emergency management departments. How do you let non-English speakers know about imminent hazards if your audience doesn’t speak English, or isn’t familiar with the nature of the hazard itself? Consider, for example, the prospect of a blizzard from the perspective of a just-arrived Somali.
While not exactly analogous, here’s an interesting twist on emergency communication from the Indonesian island of Simeulue. When a tsunami roared through Indonensia in 2014, more than 150,000 Indonesians perished. On Simeulue, just seven died.
Why the disparity? The answer is linked to a well-known song that allowed islanders to recognize the signs that predict a tsunami, and warned them of the steps necessary to save themselves.
Read more in this Foreign Policy article, Indonesia’s Indigenous Languages Hold the Secrets of Surviving Disaster
Views from the Migrant Caravan
A thousand words or a picture? Here are a pair of recent videos from the New York Times and Washington Post that offer a street-side view of the migrant caravan now making its way from Honduras, toward the United States.
New York Times: Anything is better than returning:
Washington Post: The Biggest Caravan in the History of Caravans
In case you doubted that it’s a hard language to master, here’s a video that demonstrates the quagmire through which English learners must wade. In this short film, Aaron Alon shows what happens when you apply consistent vowel-sound rules to English. The result is something that sounds like a version of Old English — sort of familiar, but often difficult to decode. Run through the video once and you’ll gain a new appreciation of the tough work that English learners take on.
DHS Autism Videos Reach Out to Diverse Audience
“On the Autism Spectrum: Families Find Help and Hope,” is a series of five short films produced by the Minnesota Department of Human Services that raise awareness and understanding of Autism Spectrum Disorder (ASD) and services available to Minnesota families. The videos are aimed at specific communities, including:
The films provide support for families experiencing ASD within communities that have historically underutilized available resources. Each 15-20 minute film features interviews with parents, advocates, medical professionals, educators, and community leaders speaking in the language of the target community, with subtitles in English.
Thinking in Two Languages
Here’s a thought-provoking article from Psychology Today that explores how language can affect memory and behavior. Author Viorica Marian, Ph.D., psycholinguist at Northwestern University, describes how memories of multilingual people are linked to the language used while the event occurred. “Memories,” she observes, “will often be more emotional when there is a match between the language spoken when the experience took place and the language spoken when remembering it.”
Among the results:
- multilingual speakers may experience more stress when taboo words are spoken in their native language;
- but they may be less biased and more consistent in their non-native language;
- and their assessment of risk may be altered depending on the power and variety of examples that come to mind — which, again, may depend on the language spoken when previous examples presented themselves.
Where’s the significance for health care providers? This is how Marian sees it: “How risky something feels affects the choices that we make for everything from medical decisions to national security. For example, in the United States, over 25% of doctors are foreign-born and many of their patients speak another language as well. It is important to be aware of how the language being spoken may be influencing the decisions we and others around us make.”
Accurate Interpretation: Could It Have Changed History?
What if it was widely understood that Soviet premier Nikita Khrushchev had said, “We will outlast you,” instead of “We will bury you,” in 1956 at the height of the Cold War?
What if, days before the atom bomb was dropped on Hiroshima, Japanese prime minister Kantaro Suzuki had been correctly understood to tell a US emissary, “No comment. We need more time,” instead of being thought to convey an attitude of “silent contempt”?
The perils of sketchy translation and interpretation are explored in a New York Times opinion piece, “Why Mistranslation Matters” by Mark Polizzotti. Pilizzotti, author of the recent book, Sympathy for the Traitor: A Translation Manifesto, lays out a series of translation- and interpretation-inspired misconceptions, starting with the so-called apple tree in the Garden of Eden.
From the CDC: Toolkits to Build Better Communication
Looking for a compendium of resources on cross-cultural communication and language access? Here’s a web page loaded with tips from the Centers for Disease Control and Prevention.
Among the links you’ll find here:
- a language access portal available via the National Institute on Minority Health and Health Disparities,
- help on how to address the National Cultural and Linguistically Appropriate Service (CLAS0 standards,
- the Guide to Providing Effective Communication and Language Assistance Services from the Office of Minority Health,
- plus more.
Separating Families? It’s Not the First Time
Native American boarding school students.
For anyone with children (or really, anyone at all) the news about Central American immigrant kids being separated from their parents is heart-rending. But that’s not to say that American history is free of numerous other similar examples.
Get some historical perspective in this piece by CNN: Actually, the US Has a Long History of Separating Families. The story is a brief reminder that African-American slaves, native people, Mexican immigrants in the 1930s and Japanese-Americans during World War II all experienced family separation.
CNN’s final analysis: “Critics say the policy… is not emblematic of who we are as a nation. Others say it runs counter to the America they know and love. But history shows policies like this have been implemented time and time again since the nation began.”
Lost (And Added) in Translation?
The topic in this short video isn’t health care — it’s about a new version of The Odyssey rendered by Classicist Dr. Emily Wilson. As the first woman to translate The Odyssey into English, she discovered that many men before her added sexist or misogynist terms that never existed in the original Greek.
Though interesting in itself, it also raises perplexing questions for health care providers. What cultural notes are being added or subtracted by interpreters during a patient/provider encounter?
Disparities and Provider Pay: A Bump in the Road
Here’s another dimension of the move toward outcome-based pay for providers. In a recent New York Times op-ed piece, Dhruv Khullar, a NewYork-Presbyterian Hospital doctor and researcher at the Weill Cornell Department of Healthcare Policy and Research, reflects on the difficulty in reaching similar outcomes for patients with radically different incomes and lifestyles.
“Value-based payment models try to measure quality, outcomes and costs — and reward or penalize providers based on their performance,” Khullar observes. “They generally adjust for patients’ medical problems, but not social ones.”
His experience as a resident with a load of impoverished patients showed him the flaw in buried within an unadjusted value-based payment system. “What strained our abilities,” Khullar writes, “was not our patients’ medical complexity, but their social problems: They were poorer, less educated, more isolated, from rougher neighborhoods. We quickly learned that while it’s hard to dose insulin, it’s harder still for a patient who speaks no English, has no refrigerator and regularly has his medications stolen.”
Read the complete piece — Is It Getting Harder to Care for Poor Patients?” — here.
The Top Ten: Films Featuring Interpreters
Of course you’ve been wondering, What are the top ten movies of all time that feature interpreters? Well, wonder no more. That list has now been assembled by the United Kingdom blog, Kwintessential. Take a look here.
The top ten includes familiar titles such as Lost in Translation, Zero Dark Thirty and Amistad. Then there’s the film, Desert Flower, that lays out the problems with non-professional medical interpretation.
But there’s also a touch of the screwball, such as the entry, The Mummy. This 1999 film features an Egyptologist, who, thanks to her knowledge of ancient Egyptian, stops a 3,000-year old mummy from destroying the world. Luckily.
Get the Latest Health Lit Lowdown
It’s time to check out the latest edition of the Minnesota Health Literacy Partnership’s e-newsletter, In the Know: Health literacy news and best practices.
The new issue covers topics such as health literacy training for dental professionals, and how to make informed consent more patient-centered. Plus you’ll find the usual helpful listings of health literacy resources and events.
View the newsletter here. And look forward to additional issues in the future, as In the Know moves to quarterly publication.
Bonus Tip: Last week’s tip, originally titled New to Using Interpreters, drew a worth-noting objection from a reader, who observed: “Utilizing the term ‘use an interpreter’ has become offensive and inappropriate in the field of language access nationwide. The proper term is to say “to work with an interpreter.” Interpreters are not objects to be used. Interpreters are professional human beings who are working very hard to raise the bar, have a code of ethics, and have a couple of national bodies that certify them professionally.”
New to Working with Interpreters? Here Are Some Basics
Have colleagues who are working with interpreters for the first time? Here’s a short video that covers the basics.
For old hands, the video’s directives might seem obvious, but for first time users these instructions on seating, sentence length, frequent pauses, maintaining eye contact and avoiding jargon might make the difference between a satisfying encounter and a mini-disaster.
The video is produced by Border TV, an arm of the Australian government. Find more videos — including a collection of interviews with refugees — here.
A Lighter Look at Immigrants’ Passage
Despite the many travails immigrants experience while adapting to a new life, there are also befuddling and ridiculous moments, some of which are captured in this charming, short video produced by The Guardian newspaper.
For instance, a Syrian refugee now trying to make sense out of his new home in Germany explains that among the many perplexing aspects of German social behavior is the loud sneezing — even among elf-sized German women. His son, meanwhile, says he was surprised that in prosperous Europe, he wouldn’t immediately get the things he wanted, such as a bike, merely by wishing to have them.
The film is part of the Guardian’s ongoing coverage of European and North American immigration issues collected under the heading, The New Arrivals. This impressive library of reportage and videos is available here.
The Refugees’ Journey: “A Dystopian Noah’s Arc”
If you’re ready for a jolt of compassion in the public discussion concerning refugees, check out this recent piece in the New York Times — “What Refugees Face on the World’s Deadliest Migration Route.”
The article, written by a doctor serving aboard a rescue vessel run by the NGO Proactiva Open Arms, describes a mission in which the organization’s 120-foot tug boat patrols for refugees wallowing in unseaworthy inflatables as they attempt the Mediterranean crossing from North Africa to Europe. The rescue boat ends up crammed with more than 400 refugees while the captain searches desperately for a port that will accept them.
It’s a gripping story, and another reminder of the harrowing conditions that refugees suffer both in their home countries and when they attempt to flee.
Videos Look at Getting Immigrant Docs into US System
Check out a four-part series on integrating immigrant and refugee physicians into the US health care system. Immigrant docs bring their training and cultural/language skills to their new environment, but overcoming the barriers to resume their medical careers in the US can be an arduous undertaking.
The video below profiles Cuban-trained doctor and immigrant Dr. Berto Torres, who returned to medicine with support from Minnesota’s unique immigrant physician integration effort.
Another Look at Implicit Bias
Here’s a quick brush up from Scientific American magazine on the topic, “How to Think about Implicit Bias.”
The authors — UNC Chapel Hill Psychology and Neuroscience Professor Keith Payne and Duke University Center for Cognitive Neuroscience postdoc Laura Niemi — observe again that everybody works off stereotypes in their daily life. You notice patterns, you make generalizations. And that leads often enough to over-generalizations and implicit bias.
Their short piece takes a look at the controversy surrounding the Implicit Association Test, which teases out evidence of implicit bias in subjects. And for anyone looking for new research-related traps to avoid, there’s a description of the Divining Rod Fallacy and its co-conspirator, the Palm Reading Fallacy.
The authors’ conclusion? “Many of us are more biased than we realize. And that is an important cause of injustice — whether you know it or not.”
Do Docs Really Speak Their Language?
So, that Spanish-speaking patient shows up in the clinic. The doctor believes he or she speaks Spanish well enough to get through the encounter. But is this a case of delusion? Would an interpreter be the better solution?
Here’s research that shows how accurate physicians are in self-assessment of their language ability compared to the results of actual testing of their language skills:
- The Impact of Language Proficiency Testing on Provider Use of Spanish for Clinical Care;
- Relationship Between Self-assessed and Tested Non–English-language Proficiency Among Primary Care Providers
The nutshell answer: One study found that docs who rated themselves as possessing high or low language proficiency had the clearest picture. Those who thought they fell in the middle of the scale were more likely to be flattering themselves. The other study revealed that once docs got test results, they felt less comfortable rolling out their Spanish in patient encounters.
The Interpreter’s Role, Explored with Subtlety
Though not quite from right down the street, this video series from the University of Glasgow on the complexities of the medical interpreter’s role is unusually well filmed and acted, with nuanced scripts that go beyond the usual easy answers.
Among the topics explored here are the sometimes difficult-to-draw professional boundaries, the perils of family-member interpretation, and how to deal with pesky interlopers. It’s well-worth checking out all five of these approximately five-minute films.
Refugee Stories, By Refugees
Looking for a window into the living conditions and thoughts of refugees? Check out Refugee Voices, a feature offered on the website of Refugee Center Online.
This space gives refugees an opportunity to write about their experiences and attempt to make sense of the trauma in their lives. The content varies from explanations of acceptable jokes in the Middle East, to descriptions of nights of terror in Congo.
The Refugee’s Dilemma, Fictionalized
In the world of literature, these are boom times for dystopian fiction and refugee sagas. A recent stand-out in the latter category is “Exit West,” by Mohsin Hamid.
The short novel starts with a set-up familiar to anyone who reads the newspaper. Violence in an unnamed Middle Eastern country drives the protagonists, Nadia and Saeed, from their home, leaving behind family and the familiar world.
The tale veers into the realm of magical realism as they escape to Greece, London and California through a series of doors that open and close unpredictably. But at heart the story is about the complex relationship between Nadia and Saeed, and the difference in their ability to cope with the relentless change that defines a refugee’s passage.
Here’s the New York Times’ view of Hamid’s concern in this novel: The author, says reviewer Michiko Kakutani, “is less interested in the physical hardships faced by refugees in their crossings than in the psychology of exile and the haunting costs of loss and dislocation…. In “Exit West,” Hamid does a harrowing job of conveying what it is like to leave behind family members, and what it means to leave home, which, however dangerous or oppressive it’s become, still represents everything that is familiar and known.”
For anyone working with refugees, “Exit West” offers a view of the hope and dismay that accompanies escape from the world’s many war-torn countries.