Pandemic imperiled non-English speakers more than others, Boston hospital finds
In March 2020, weeks into the COVID-19 pandemic, the incident command center at Brigham and Women’s Hospital in Boston was scrambling to understand this deadly new disease that appeared to be killing more Black and Brown patients than whites.
For Latinos, there was an additional warning sign: language.
People who were infected and who didn’t speak much, or any, English had a 35% greater chance of death.
Clinicians who couldn’t communicate clearly with patients in the hospital’s coronavirus units took note.
“We had an inkling that language was going to be an issue early on,” said Dr. Karthik Sivashanker, then Brigham’s medical director for quality, safety and equity. “We were getting safety reports saying language is a problem.”
Sivashanker dived into the records, isolating and layering the characteristics of those who died: their race, age, sex and whether they spoke English.
“That’s where we started to really discover some deeper, previously invisible inequities,” he said — inequities that weren’t about race alone.
Hospitals across the country have reported more hospitalizations and deaths of Black and Latino coronavirus patients than of whites. Black and Brown patients might be more susceptible because they are more likely to have a chronic illness. But when the Brigham team compared Black and Brown patients with white patients with similar chronic illnesses, they found no difference in the risk of death from COVID.
But a difference did emerge for Latino patients who don’t speak English.
To unravel this life-threatening health disparity, the hospital went to lower-income communities in and just outside Boston, where the coronavirus spread quickly among many native Spanish speakers who live in close quarters and have jobs they can’t do from home.
Some avoided coming to the hospital until they were very sick because they didn’t trust the care or feared detection by immigration authorities. Still, just weeks into the pandemic, COVID patients who spoke little English began surging into Boston hospitals.
“We were frankly not fully prepared for that surge,” Sivashanker said. “We have really amazing interpreter services, but they were starting to get overwhelmed.”
“We were panicking,” said Ana Maria Rios-Velez, a Spanish-language interpreter at Brigham.
Rios-Velez remembers searching for words to translate this new disease and experience for patients. Interpreters were confused about how close they should get to a patient. Some said they felt disposable in the early days of the pandemic, when they weren’t given adequate personal protective equipment.
When she had PPE, Rios-Velez said, she still struggled to gain patients’ trust from behind a mask, face shield and gown.
For safety, many interpreters were urged to work from home. But speaking to patients over the phone created problems.
“It was extremely difficult, extremely difficult,” Rios-Velez said. “The patients were having breathing issues. They were coughing. Their voices were muffled.”
And she couldn’t look her patients in the eye to put them at ease.
“It’s not only the voice. Sometimes, I need
to see the lips, if smiling,” she said. “I want them to see the compassion in me.”
Brigham added interpreters and bought more iPads so remote workers could see patients and amplifiers to raise the volume of patients’ voices above the beeps and machines humming in an ICU. The Mass General Brigham network is piloting the use of interpreters available via video in primary care offices. A study found Spanish-speaking patients used telemedicine less than white patients during the pandemic.
Brigham’s goal is that every patient who needs an interpreter will get one. Sivashanker said that happens now for most patients who make the request. The bigger challenge, he said, is including an interpreter in the care of patients who might need the help but don’t ask for it.
In the first surge, interpreters also became translators for the hospital’s website, information kiosks, COVID safety signs and brochures.
“It was really tough,” said Yilu
Ma, Brigham’s director of interpreter services. “I got sick and had to take a week off.”
Mass General Brigham is now expanding a centralized translation service for the entire hospital network.
Brigham and Women’s analytics team uncovered other disparities. Lower-paid employees were getting COVID more than nurses and doctors. Sivashanker said there were dozens of meetings with medical assistants, transport workers, security staffers and those in environmental services in which he shared the higher positive test rates and encouraged testing.
“We let them know they wouldn’t lose their jobs” if they had to miss work, Sivashanker said, “that we realize you’re risking your life just like any other doctor of nurse is every single day you come to work.”
Some employees complained of favoritism in the distribution of PPE, which the hospital investigated. To make sure all employees were getting timely updates as pandemic guidance changed, Brigham started translating all coronavirus messages into Spanish and other languages and sending them via text. The Mass General Brigham system offered grants of up to $1,000 for employees with added financial pressures, such as additional child-care costs.
Angelina German, a hospital housekeeper with limited English, said she appreciates getting updates via text in Spanish as well as in-person COVID briefings from her bosses.
“Now, they’re more aware of us all,” German said through an interpreter, “making sure people are taking care of themselves.”
The hospital also set up testing sites in neighborhoods with high coronavirus infection rates, including some where many employees live.
“No one has to be scheduled. You don’t need insurance. You just walk up, and we can test you,” Dr. Christin Price said during a visit last fall to a testing site in Jamaica Plain.
Nancy Santiago left the testing site carrying a free 10-pound bag of fruits and vegetables, which she’ll share with her mother.
“I had to leave my job because of [lack of ] day care, and it’s been pretty tough,” Santiago said. “But, you know, we gotta keep staying strong, and hopefully this is over sooner rather than later.”
Brigham recently opened a similar indoor operation at the Strand Theatre in Dorchester. Those who come for a coronavirus test are asked whether they have enough to eat, if they can afford their medications, if they need housing assistance and if they’re registered to vote.
“Many of the issues that were identified during the COVID equity response are unfortunately pretty universal issues that we need to address if we’re going to be an anti-racist organization,” said Tom Sequist, chief of patient experience and equity for Mass General Brigham.
Brigham’s work on health disparities comes in part out of a collaboration with the Institute for Healthcare Improvement.
“There’s a lot of defensive routines into which we slip as clinicians that the data can help cut through and reveal that there are some biases in your own practice,” said Dr. Kedar Mate, the institute’s president and chief executive officer.
“If we don’t name and start to talk about racism and how we intend to dismantle it or undo it,” Mate said, “we’ll continue to place Band-Aids on the problem and not actually tackle the underlying causes.”
“Poverty and social determinants of health needs are not going away any time soon,” said Price, who helped organize Brigham’s testing. “And so if there’s a way to continue to serve the communities, I think that would be tremendous.”
Brigham can’t say yet that its work lowered the risk of death from COVID for Spanish-speaking patients. The hospital hasn’t updated the analysis yet. Even when it does, determining whether the interventions worked will be hard, Sivashanker said.
“It’s never going to be as simple as, ‘We just didn’t give them enough iPads or translators, and that was the only problem,’ ” Sivashanker said. This story is part of a partnership of WBURFM, NPR and KHN (Kaiser Health News), a national newsroom that produces in-depth journalism on health issues.