Reflections by Karen Peterson-Iyer
The case of Ana Lopez, an immigrant from the southern Mexican state of Oaxaca, puts into sharp relief the profound culture gap that can exist between patients and health care providers. For most patients-even English-speaking ones-the hospital itself can seem a bit like a foreign land with a distinctive "culture." It has its own unique style of dress (hospital scrubs, white coats), language (technical, medical vocabulary, communicated primarily through the medical charting system), leadership hierarchy (those with the most medical expertise command the most authority), and even style of reasoning (an emphasis on privacy of information and on the informed consent of the individual patient-as-decision-maker). The existence of this clinical "culture" is not necessarily inappropriate to the goals of medicine-for example, to relieve the suffering of the patient, if possible by curing the patient's disease or injury. But it does potentially contribute to the "cultural" gaps between patient and provider. This is particularly and profoundly true when the patient, like Ana, is from a culture set apart from mainstream U.S. society. Ana experiences this gap not only in terms of language, but also in terms of health care practices and beliefs as well as her overall level of vulnerability and empowerment.
Ana is very likely disempowered by the sharp juxtaposition of her own rural, community- and family-centered life with the pressing demands of the bureaucratic and high-tech hospital environment in which she finds herself. As Nayamin Martinez points out in her commentary on this case, Ana and her family are very likely unfamiliar with technical terms such as "C-section," "neonatal encephalopathy," "neonatal ICU," and so forth. Moreover, Ana's situation is particularly difficult since her primary language is one that few health care providers are likely to speak, and since many of those same health care providers are sure to assume, wrongly, that Ana speaks Spanish.
Ana hails from a sub-community of Mexican migrant farm workers, Mixtecs, that is rapidly growing in the United States, and particularly in California. Although hard numbers are difficult to obtain, one survey conducted in San Diego County and cited by the New York Times in 1995 found that 40 percent of migrant farm workers spoke indigenous languages rather than Spanish.1 Among indigenous Mexican workers, Mixtecs are the largest single ethnic group; it is estimated that they make up 5-10 percent of the total agricultural workforce.2 The Mixteco language and culture far predates the Spanish conquest of Mexico, and today there are approximately a half million Mixteco speakers, almost one-fifth of whom have lived in the United States for at least part of their lives. Like Ana, many are illiterate, and most speak neither English nor Spanish. As a group, they are concentrated in the most labor-intensive of U.S. agriculture, for instance, berries, tomatoes, grapes, stone fruit, citrus, and cut flowers.3
Most migrant agricultural workers like Ana live in poverty, often in extreme poverty, and they and their families suffer disproportionately from a variety of acute and chronic health problems. The U.S. Bureau of Labor Statistics has found that farm workers suffer the highest rate of chemical-related illness of any occupational group.4 Farm workers' exposure to pesticides has been linked to disproportionately high rates of certain cancers and of birth defects.5 Further, heat-related illnesses and death are prevalent among farm workers, as exemplified by the recent death (from dehydration and heat exhaustion) of Maria Isabel Vasquez Jimenez, a 17-year-old farm worker who emigrated from Oaxaca to pick grapes in California's Central Valley. Maria, who (like Ana) was pregnant at the time, collapsed after many hours of work with little access to water or shade.6 In spite of such dangers, relatively few state or federal workplace safety precautions exist for farm workers; and even when regulations do exist, they are routinely ignored by the agricultural industry.
In a health care setting, the biggest barrier Ana faces as a Mixtec immigrant is that of language interpretation. Generally speaking, language barriers can result in misdiagnosis, delayed and inferior medical care, inappropriate medications, and unnecessary (or overdue) hospitalization. The fact that East Valley Hospital did not have on staff a trained Mixteco interpreter is not too surprising; but, as the others who have commented on this case point out, the staff certainly should have made every effort to contact a professional interpreter from outside the hospital so that they could communicate thoroughly and effectively with Ana and her family. Minimally, the hospital could have sought out an interpreter during the relatively long period of time that Ana's baby remained in the NICU.
Ana's consent to the Cesarean section and other procedures may not have been required, insofar as her situation was classified as an emergency. Yet her consent still should not have been assumed from her acquiescent manner. That is, her acquiescence could have been more indicative of her fear, her lack of understanding, or her desire to respect the authority of her health care providers than of her actual agreement to the suggested procedures. According to the Migrant Clinicians Network, Mexican farm workers, as patients, are not likely to ask for clarity or disagree with a physician's diagnosis or treatment recommendations.7 Health care providers, if they genuinely are to seek out informed consent, must move towards incorporating these kinds of cultural nuances. In a similar vein, Ana's husband Hugo's tentative manner with the nurse may reveal a respect for the nurse's authority; and his "polite refusal" to the nurse's suggestion that they visit the cafeteria (as well as his subsequent silence) may in reality have been motivated by embarrassment over a lack of financial resources to pay for cafeteria food.
In other ways, too, financial issues play a notable role in this case. The fact that Ana and her family are poor means that her access to prenatal care was apparently spotty, at best. Her exposure to pesticides is a by-product of her low-wage job, and she may never know for certain whether or not this exposure is connected to her baby's medical challenges. Across the country and around the globe, environmental health concerns such as this one are particularly worrisome for poor communities like Ana's, where environmental hazards tend to be disproportionately concentrated. As for her husband Hugo, his concern not to lose his job (and the income it generates) keeps him from being present at his son's birth and very likely affects his ability to be reliably present throughout his son's care in the NICU. His limited schedule contributes to Ana's communication problems, since Hugo is the only family member who speaks Spanish; that is, she would have had to limit her verbal communication to times when Hugo could be present. The case does not specify whether or not East Valley Hospital remained open for extended work hours, accommodating schedules like Hugo's, but this is one possible way such hospitals can combat the problem of family members having only limited access to hospital staff.
Since Ana's hospitalization related to pregnancy and birth, she did eventually gain access to Medicaid, with the social worker's help; but many patients who are undocumented are unable to do so. Moreover, even when patients like Ana are able to get signed up for Medicaid-sponsored programs, low Medicaid reimbursement rates often make it extremely difficult to find doctors and institutions who will provide them with care. Ana's undocumented status apparently caused her to hesitate before signing up for Medicaid, presumably out of fear of deportation. This sort of anxiety and disempowerment is a reality of life for undocumented persons who live "under the radar" in the United States today; and this dynamic may contribute to an underutilization of medical resources. According to a recent study by the RAND Corporation, the share of medical costs attributable to undocumented immigrants is about half as large as their numbers would merit.8
Indeed, some immigrants like Ana may supplement or even at times replace Western clinical medical care with various methods of folk healing. Ana's family's desire to bring in a curandero to help heal her son is part of a strong undercurrent among Mexican immigrant communities, including especially indigenous Mexicans. A curandero is a healer of physical or spiritual illnesses who tends to command great respect from the community. He or she may use ancient techniques involving herbs or incantations; or, as in the case of Ana's baby, may perform an "egg cleansing"-in which an intact egg is passed over a patient's body in order to release unhealthy energies and aid in the patient's healing. Incorporating this sort of healing method-especially as long as it would not directly compromise the medical needs of a baby such as Ana's-would be one important way the hospital staff could honor and respect Ana's cultural background and belief system. This in turn is bound to strengthen and empower Ana, enabling her to retain a more active role in her baby's ongoing health. Instead, the nurse's sharp response, while undoubtedly well-intentioned, likely had the opposite effect, further disempowering Ana and her family while inadvertently demeaning their desires and overall belief systems.
This brings me to the final aspect of Ana's case I will discuss here: the overarching issue of patient vulnerability and empowerment. In the U.S. clinical health care system, the qualities that allow a patient to thrive-financial resources, the capacity to understand complicated medical terminology, the ability clearly to communicate (in English) one's desires, and the propensity to advocate for one's own needs-are, for the most part, lacking in patients like Ana, a young, poor, and illiterate immigrant. The "ideal" patient in a U.S. hospital is a strong and articulate individual decision maker who can negotiate often complicated medical options. According to this set of expectations, Ana is indeed vulnerable and deserves our compassion and care.
Yet Ana needs more than compassion; she also needs respect and empowerment. She is not simply a poor and vulnerable teenager; she is very likely a courageous woman who has endured great hardship in order to seek out a better life for herself and for her family. Moreover, even in the often disempowering setting of a hospital, Ana and her family find the courage to seek out the resources they need in order to facilitate her baby's healing. As Rebecca Hester points out in her commentary on this case, this demonstrates not something "lacking" on Ana's part but rather a strong commitment to her baby's and her own well-being, using the tools given by her own culture and worldview.
Two very important sources of empowerment for Ana are her family and communal ties. Family can be a great source of strength to immigrants, particularly to immigrants from places like Mexico, where the value of familismo (attachment, loyalty, and commitment to family obligation) is undeniably woven into the culture in myriad ways. For Ana, drawing upon her family and communal connections is a way to reclaim her strength in a tremendously difficult situation. The hospital staff should do everything it can to facilitate and respect these ties. The case as written does not indicate in much detail the level of accommodation that the hospital staff made for the presence of Ana's family; and this of course can vary dramatically across hospitals and medical clinics. Insofar as East Valley Hospital's goal, however, is to heal Ana and her baby, and to relieve their suffering, the staff must take care to honor the family and community ties that are most likely central to how Ana understands herself and her obligations. This may mean making accommodation for extended hours for family visits or setting up family meetings with interpreters present or trying to accommodate communal practices such as a visit from a traditional healer.
Did the East Valley Hospital staff act competently? Perhaps-given the unquestioned cultural assumptions of Western medicine. Were they caring? It certainly seems so. Did they seek Ana's consent? They tried to, given the constraint of a serious language barrier. But, as Marc Tunzi so elegantly points out in his commentary on this case, it is not what the hospital staff did that was problematic; it is what they failed to do. They did not go out of their way to find a Mixteco interpreter. They did not take time to learn more about the healing practices that Ana and her family requested. And they did not suspend judgment long enough to consider that Ana's requests may have made sense, from her own cultural point of view. To take these steps would have indicated a more open and dialogical approach, one that would have gone a long way toward bolstering and empowering Ana in the face of her many challenges.
1Seth Mydans, "A New Wave of Immigrants on Farming's Lowest Rung," New York Times, 24 August 1995.
2Farmworker Justice, 2007.
3Mixteco/Indigena Community Organizing Project, accessed at accessed here
4U.S. Bureau of Labor statistics, 52 Fed. Reg. 16050 (1987).
5Mills, P, "Cancer Incidence in the United Farmworkers of America 1987-1997," American Journal of Industrial Medicine 40 (2001): 596-603; and Vincent F. Garry et. al., "Pesticide Appliers, Biocides and Birth Defects in Rural Minnesota," Environmental Health Perspectives 104 (April 1996): 394-399.
6Garance Burke, "Farmworker's Death Prompts Calls for California Reform," Associated Press, 5 June 2008.
7New York Center for Agricultural Medicine & Health, Migrant Clinicians Network, 2006.
8Kevin Sack, "Illegal Farm Workers Resort to Health Care in the Shadows," New York Times, 5 May 2008, p. A1 and A14.