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"The National Health Law Program and PRRAC's Shared Goals,"

by Jane Perkins November/December 1999 issue of Poverty & Race

• A pregnant woman enters a hospital in South Carolina, ready to deliver. During the course of her labor, she seeks an epidural to reduce the pain. The epidural is refused because the woman does not speak English.

• A home health agency in the Northeast refuses to provide home care services to an African-American child. The agency says it is too dangerous for its home care workers to venture into the child’s neighborhood, a public housing complex. However, the home health agency is providing services to persons who live nearby.

• A county in California plans to rebuild its public hospital in the central county area, despite the fact that the overwhelming majority of poor African Americans, Asians and Latinos live in the east and west county areas. The population of the central county area is 80% white, and numerous hospitals and HMOs already serve the area. Transportation from the east and west county areas to the proposed central county facility is not good.

These scenarios clearly illustrate that race profoundly affects the delivery of health care in the United States. While the foregoing examples are more subtle than the WHITES ONLY signs of a previous era, they are no less potent in their consequences. Moreover, these are not isolated occurrences. To a great extent, health care delivery in America remains segregated according to race and class.

The National Health Law Program (NHeLP) is working with the advocacy and research communities to monitor discrimination in health care and address the many barriers that exist.

Monitoring disparities in health status and health care

One area of central focus for NHeLP is keeping the advocacy community aware of the racial disparities in health status and of the growing body of research which documents racial disparities in the delivery of health care services. These issues are highlighted at the Program’s web site, The Racial and Cultural Issues “corner” of the web site includes information about immigrant and minority health and cultural and linguistic access to health care. We have created a number of links to other advocacy organizations and to research projects studying the interactions of race and health. The web site also includes references to and reviews of noted literature and books, such as David Barton Smith’s excellent recent book Health Care Divided: Race and Healing a Nation.

NHeLP also discusses race and culture as a regular feature in its quarterly publication, Health Advocate. The Summer 1999 edition, for example, contains an article which discusses three separate reports demonstrating that minorities continually come up short when it comes to health status and health care. Minorities are at much greater risk of dying of AIDS, substance abuse and during childbirth. Since that publication, we have linked our web site to two additional very recent studies: The John Hopkins School of Public Health released findings that, in comparison with white patients, racial and ethnic minority patients receive inferior primary care. They have more trouble setting up appointments, and they wait longer to see a physician than white patients do. And the New England Journal of Medicine published a study that found 12.7% more white patients receive surgery when diagnosed with early stage lung cancer than black patients with the same diagnosis.

Advocacy to improve linguistic access

Through its Language Access Project, NHeLP also is working with researchers, interpreters, and community-based advocates to ensure linguistic access in health care settings. About 32 million people in the United States, 13.8% of the population, speak a language other than English at home. However, despite this large constituency, and laws that require recipients of government funds to provide appropriate language access to health care services, the current state of linguistic access to health care leaves much to be desired. Immigrants with limited English proficiency (LEP) often face substantial communication problems at almost every level of the health care delivery system. At the administrative level, simply scheduling an appointment can be an ordeal for LEP patients. At the clinical level, when communication barriers prevent health care providers from understanding their patients’ symptoms, proper medical care can be a near impossibility. The absence of a trained interpreter not only may lead to improper diagnoses and care, but also may call into question the doctor’s ability to obtain a patient’s informed consent. In communities throughout the country, providers continue to muddle through their contacts with LEP patients, relying upon their own rudimentary skills, patients’ family members, hospital service employees and other untrained interpreters.

In a national survey of key informants, the National Health Law Program identified three factors that contribute to language access problems. First, the number of different languages spoken in the United States has increased dramatically over the last 30 years. The current health care system is not equipped to operate in an environment where numerous languages are spoken. Second, current funding levels often are inadequate to meet the rising short-term cost demands for interpretive services. Unfortunately, the current situation is exacerbated by federal cutbacks on public benefits for immigrants. And third, while both federal and state laws require access to linguistically appropriate health care, these laws are little known and rarely enforced.

The National Health Law Program’s Language Access Project has worked to focus attention on these issues. In January 1998, the program published Ensuring Linguistic Access to Health Care: Legal Rights and Responsibilities. Distributed by the Kaiser Family Foundation, this manual is being used widely by attorneys, researchers, providers and policymakers. NHeLP works with community-based organizations and individuals to monitor language access and, where needed, to file complaints with the Office for Civil Rights or court actions. NHeLP also has served as a contractor to the U.S. Department of Health and Human Services Office for Civil Rights, providing training on managed care and language access to OCR investigators from around the country.

Jim Crow is alive and well in America’s health care system. The problems of health status and access have deep roots. Working with the advocacy and research communities, the National Health Law Program strives to address and stop the inequality.

Jane Perkins is the Director of Legal Affairs at the National Health Law Program (2639 La Cienega Blvd., Los Angeles, CA 90034, 310/204-6010.)

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