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Archive for the ‘Language Access’ Category

Consumer info fact sheets  translated into WA’s threshold written languages   (Chinese, Lao, Khmer ( Cambodian), Korean, Russian,  Somali, Spanish, and Vietnamese) were posted on Dec. 16, just one week before the deadline to start an application for coverage to be effective Jan. 1, 2014. In an unrelated development, HBE  decided on this brief extension  for completing applications due to various  problems people have had in being able to use the online forms and or access phone customer services.  Regarding the translated fact sheets, it’s taken almost 6 months for their publication to replace the original problematic versions that were taken down from the site.
However, the new fact sheets are not easy to find as they are not posted on the consumer website,  but located exclusively on the HBE corporate website.  The corporate site features a line at top right-hand side of homepage entitled “Information in Other  Languages” which links to the fact sheets page, plus also links out to the consumer website.  In contrast, the consumer Healthplanfinder site (which is in both  English and Spanish) does not offer any such subject line, nor does it display a link to corporate site.  The Healthplanfinder site likewise does not contain any readily visible clear statement of consumer  language access or disability access rights, except for a message in tiny font on bottom of the homepage that says [sic] : If you need additional language or disability accomodations, you may call 1-855-WAFINDER (1-855-923-4633)  On the Spanish version of the website, this statement illustrates yet another example of  faulty translation, as the term “disability accomodation” is twice translated, and very ungrammatically, as  “discapacidad alojamiento”  which means disability lodging.  Sure enough, a quick check on Google Translate  English > Spanish reveals  “lodging” as the first  translation for “accommodation.”  Since 2012 advocates had been recommending the inclusion of multilingual tag lines and/or translated summaries sections for the website. Interpretersymbol

Information on some metrics for the Healthplanfinder call center became available last week with the release of the  November Healthplanfinder Data Report. On the language access side of things (p.10 of the report)  the numbers are not encouraging: the call center received almost 12,000 calls in Spanish, but handled only some 1600 of them. The call center in Spokane has bilingual Spanish-English staff (reported as 6 out of 80 employees at start-up) on site and routes calls in other languages to a telephonic interpreter service. For calls in all languages besides Spanish combined, 1045 were actually handled (answered)out of 3621 calls attempted. The report does not state if the multilingual calls are included in the totals for approximately 35,000 calls  handled in November or the almost  158,000 calls throttled (deflected from the system, i.e. not put into the queue to await a response).  While the HBE is said to be increasing staffing for the call center,  any increases planned for its language capacity are as yet unknown. Given the demand, it would seem that Spanish-speaking callers too could benefit from immediate access to interpreter services.

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The irony was not lost for me that while writing on the positive results of the FDA’s use of  translation services, that here in my state, once known as a national leader in language services, we are still struggling to get quality translations for our Health Benefits Exchange (HBE).  The efforts  to achieve this goal have been a major focus for the Washington State Coalition for Language Access, and its been a year now since we co-authored with Northwest Health Law Advocates the report Language Access in Washington under the Patient Protection & Affordable Care Act  expressly for the HBE efforts. Now with 175,000 enrollees, Washington State deserves the praise it’s getting for the record-breaking enrollment figures in the new health insurance  marketplace Washington Healthplanfinder, WA_Healthplanfinder_RGBespecially compared to the situation in neighboring Oregon and to the federal Healthcare.gov platform. But the picture is much less rosy regarding providing equal access for Washingtonians with limited English proficiency (LEP), who now number some 8% of state population or half-million residents, representing an increase of 210 % in the past decade . Demographic data on enrollees is said not to be available.

We are now less than 2 weeks away from the enrollment deadline for coverage to start Jan. 1, 2014, and the consumer fact sheets that were intended to inform the public of the options under the ACA have not yet been made available to Washington’s LEP population. Even though work began in July to replace the problematic original translations – errors brought to HBE’s attention by advocates- there are still no consumer fact sheets available in Washington’s  threshold languages ( in written form these are: Chinese, Lao, Khmer, Korean, Russian, Spanish, Somali, and Vietnamese).

In addition, the Spanish versions of the paper application for Healthplanfinder, while continuing to be publicly available, have contained horrific translation errors.  In the section  which inquires about the applicant’s citizenship status, the phrase ” Non-citizen legally present in the US”  was translated into Spanish to mean just the opposite,  i.e., the translation says “ non-citizen not legally present….”  ACA, complete with the  I-word in Spanish in version #1.  After the mistake was identified on Oct. 15 , again by advocates,  staff said they took immediate action to have the vendor correct it.  The screenshots included here show the sections containing the mistranslations.

Spanish version #1

And yet, advocates identified that the new translation contained the same error, just written with different wording.   Here is Spanish version #2, as it appeared on Nov. 14: Screen shot 2013-12-05 at 11.00.31 AM

This one particular error may now have been recently corrected  for a 3rd iteration, through volunteer  efforts of local language access advocates trying to beat the clock to help consumers. However, we hear anecdotally that more translation concerns persist and can’t be confident that there are not similar errors in the translations in the other languages.

What remains a mystery is how this sorry state of affairs has come about, and if there were ever robust quality assurance measures in the procurement chain for the translations. It is beyond comprehension how such blatant errors could be made given that the work was done by vendors holding official State contracts who must affirm that they use  qualified translators and proper translation procedures. And if this is happening in Spanish, the 2nd most used language in both our State and nationally,  and thus one for which there is an ample number of nationally-certified translators available to do the work, there is a real reason to fear that similar egregious errors may exist in other language translations.

Shortly before Thanksgiving, HBE staffers announced  at a meeting of its Health Equity Technical Advisory Committee, that work halted back in June to create a Language Access Plan  (LAP) for the HBE requested by the TAC , will resume in the new year.  LAPs are meant to serve as blueprints to guide the work of agencies and programs to comply with the laws requiring they provide language services, and  to help prevent the kind of  problems that we’ve being seeing here in the other Washington.  I’ll continue to report on the work in progress.

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I just learned that October is Health Literacy Month, via an article entitled  “Hospital discharge summaries are a health literacy issue” (a guest post by another physician) published on the KevinMD.com  blog.

(Background: this article had originally been posted on another blog called Engaging the Patient, sponsored by  Emmi Solutions, a healthcare communications firm which is promoting Health Literacy  Month.) 

The first paragraph described a patient as being a very elderly Filipino woman, and the article went on to explain how she had suffered some serious adverse effects because there was  a problem with how her Rx medicines had been prescribed.  Turned out that two of her meds had been combined into a single pill, a fact that was not apparent from the patient’s medication list.

But I was left wondering why the patient’s ethnicity was mentioned at all, since there was no discussion of any relevance to her health issues nor about if she had limited English skills, which also does not automatically track with ethnicity.  So I was surprised to read the following conclusion to the case study:

My hope is that this case illustrates the ways in which we might address health literacy issues using fail-proof systems-based approaches, rather than narrowly focusing our efforts on how we can build our patients’ capacity to interact with the health care system. Yes, teaching this patient to be a more fluent reader and to understand her prescription labels would have been ideal.

And we should have taught her to be more engaged and given her a phone number that she could call post-hospitalization to reach a Tagalog-speaking provider with questions about her discharge instructions or medications. But while we are working on engaging her with her care and teaching her to read prescription labels and providing enhanced communication support, let’s do what we can to “fix” the health literacy problem without involving Ms. Reyes at all.

Somehow the author made a non sequitur jump to depict the patient as  Limited English Proficient (LEP), but never once spoke of utilizing the services of  an interpreter at the hospital or if any  instructions had been translated for the patient.  It was likewise not mentioned that a pharmacist could have played an important role in the case. Seemingly this young physician knew nothing of the duties of the hospital to ensure communication between providers and patients, and is disseminating this scenario as typical.

So a response was in order.  I’m happy to say that my comments on the article were accepted for posting, and hope they will help make a dent.

My message for Health Literacy Month is that we need to seize the teachable moments.

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Several national health advocacy groups have put out an alert about some key changes to language access standards that have just been proposed for the communication responsibilities of certain federal agencies which regulate private health care plans. As we move forward towards the enactment of health care reform, it is critical that  everyone, including LEP individuals, have the same rights to get access to to plan information and help with insurance appeals.  Health insurance is of course a critical part of access to health care and thus of any individual’s health status. Communication is an essential part of health and health care.  Lack of communication access causes both personal harm and contributes to health inequalities between population groups, plus drives up health care costs for people and systems.  If the new proposed standards are enacted, they would roll back current rules which private insurance companies must follow to ensure language access for plan beneficiaries.

What you can do: there is a very short window of opportunity now available for  individuals and organizations to voice their concerns by submitting comments online to the federal government via a dedicated website.  The deadline for submissions  is 2 p.m, PDT, on Monday July 25 !

For details about this critical issue, and instructions on how to submit comments along with suggested language, please read the following memo from the National Senior Citizens Law Center (NSCLC), the Asian Pacific American Legal Center (APALC), and the National Health Law Program (NHeLP):

URGENT: Comments Needed on Important Language Access Standard

NSCLC, APALC and NHeLP asking advocates to submit by July 25

IMPORTANT: Please provide comments to the Centers for Medicare and Medicaid Services (CMS), Internal Revenue Service (IRS) and the Department of Labor (DOL) on proposed regulations governing private health care plans.  The regulations as proposed are a significant step backward from the version issued in 2010 and affect about 12 million individuals. They change the existing standards for oral interpretation and written translation in unprecedented ways. Please send in comments now and urge colleagues and networks to also take action.  

 The deadline for submitting comments to CMS on this proposed rule is 5 pm Eastern Time on Monday, July 25, 2011.

The National Senior Citizens Law Center (NSCLC), the Asian Pacific American Legal Center (APALC), and the National Health Law Program (NHeLP) urge you to submit comments using the guidelines below. Then, please spread the word to your listservs, networks, colleagues, and affected beneficiaries, near and far, who may care about language access issues!

Issue:  CMS, IRS and the DOL’s Employee Benefits Security Administration (EBSA) have jointly issued regulations governing the internal claims and appeals and external review processes for private group health plans and health insurance issuers (note: this does not directly impact Medicare and Medicaid plans).

These rules were first promulgated as interim final regulations in June 2010, and were relatively strong. After industry complaints, they were amended as of July 2011, and significantly watered down. The public has this opportunity to comment.

Here are the three major language access issues relating to internal claims and appeals and external review:

  1. Written translations for group health plans: The threshold for determining whether translation of vital documents is required is set at: 10% of county population for group health plans. Formerly this was at 10% of plan participants in a given language or 500 persons, whichever is less; where a group plan has less than 100 participants, 25% was used.
  2. Written translations for individual plans: The threshold for this group is also 10% of county population. This was set based on the Medicare Part C and D marketing regulation (a proposal that has since been changed as of 4/15/11 to 5%, as a result of many persons submitting comments against the 10%).  
  3. Oral interpretation: Although it has been well settled that civil rights law mandates that oral interpretation should be provided in the health and health insurance contexts for all languages, the proposed regulations set a new precedent and require oral interpretation ONLY in the languages that meet the 10% threshold.  This is a major issue that needs to be addressed.

The new proposed standards completely fail to recognize the needs of the approximately 12 million limited English proficient individuals in the United States that are estimated to be affected by these regulations. Many of these individuals may receive marketing materials and calls in their primary languages, but will not be able to access plan review and appeals under the new rules. Even Spanish speakers will be left out in most of the country, as only 172 counties meet the 10% county population threshold for Spanish (out of 3,143 counties in the United States). Besides Spanish, the new proposed translation threshold is met by Navajo in 3 counties (1 county each in AZ, NM, UT), Tagalog in 2 counties (both in AK), and Chinese in one county (CA). Only 177 counties would require translated materials. Only one county in the entire nation would have translations in more than one language: the Aleutians West Census Area (population of 5,505 total persons) would have Spanish and Tagalog translations.

We need everyone – even advocates that don’t usually work on private insurance issues and those who have never commented on a federal rule – to take action now.

What You Can Do: 

1. FILE COMMENTS:

a)   Go to   www.regulations.gov

b)   Enter keyword or ID as “group plan” and hit the “SEARCH” button

c)   Scroll down and choose “Group Health Plans and Health Insurance Issuers: Internal Claims and Appeals and External Review Processes” and click on “submit a comment” on right side

d)   Although the regulation is proposed by three agencies, you only need to submit once. The agencies will share the information.

e)   Paste in the comments below and edit them, or write your own, then “Submit.”

f)   You are not required to fill out other fields, although it may be helpful to provide your affiliation. If you wish, you may be anonymous.   Comments submitted are viewable online (after a processing period) by the general public.

SAMPLE COMMENT:

On behalf of [organization/myself], I wish to comment on the 10% threshold for translation and oral interpretation of private plan materials in the internal review and appeals contexts. I am… [add 1-2 sentences about yourself, organization or work with LEP individuals].  The 10% standard is far too high.  A more appropriate standard would be “5% of the plan’s population or 500 persons in plan’s service area, whichever is less” for large group plans, and 25% of population for small plans. Oral interpretation should be provided in all languages at all times. {Consider adding information about the impact on your clients when they cannot get documents in a language that they understand.}

2. Forward this email to all of your contacts – other advocates, providers, interpreters, beneficiaries affected, and urge them to also file comments.  The more comments filed, the more CMS/IRS/EBSA are likely to pay serious attention to this issue.

3. If you are bilingual or work with LEP populations, consider having them file comments in other languages as well as in English, for impact.

For more information about commenting and the proposed regulations, see www.nsclc.org and www.healthlaw.org .  Please feel free to submit detailed comments if you prefer.

Katharine Hsiao  khsiao@nsclc.org

Georgia Burke  gburke@nsclc.org

Kevin Prindiville kprindiville@nsclc.org

Mara Youdelman  youdelman@healthlaw.org

Doreena Wong dwong@apalc.org

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Can We Afford Personalized Medicine?

Special treatment for ‘high profile’ patients; exasperation for the rest of us

Health Insurers Making Record Profits as Many Postpone Care

People Who Donate Organs For Transplants Can Have Difficulty Getting Insurance

Foundations, Conflicts Of Interest And Drugmakers

Mission Crash: The Intolerable Policy Incoherence in US AIDS Policy, Global and Domestic

 Office of Minority Health Awards Major Project to Support
CCHI’s work on Healthcare Interpreter Certification

WA Governor signs precedent-setting healthcare worker safety laws

Washington is first state in nation to ban toxic pavement sealants

HHS awards $4.9 million to support families of children with special health care needs

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Things are still beyond grim as the work on Washington State’s  budget continues. However, on February 4, there was a more hopeful sign when the  Senate approved its version of the Supplemental Budget, including a provision to continue the Basic Health Program, although in reduced scope, by drawing on the Life Sciences Discovery Fund. The  LSDF was established in 2005 from WA’s share of national tobacco settlement funds.  Both the Governor’s budget and the one previously approved by the House had cut  BHP, along  with the DSHS long-standing  interpreter services program for  Medicaid and CHIP patients  These potentially promising developments however have garnered less attention than another set of proposals in HB 1847 ,which would  to sustain funding for BHP by eliminating tax exemptions for Big Banking,  and sales taxes on elective cosmetic surgery and private jets. 

While advocates regard these developments as positive, the struggle is far from over. The Supplemental budget is now undergoing the reconciliation process by both houses and will needs the Governor’s approval; the Biennial budget  will have its turn next. Both contain deep cuts in virtually every area of life affecting Washingtonians, with the worst cuts affecting the most vulnerable populations, especially immigrants and refugees. WA Budget cuts 2011.

The history of these two programs is of particular note at this critical time.  The original intent of the Master Tobacco Settlement Agreement was to fund health services in the states for those affected by smoking.  At the time, Gov. Gregoire, aware that the state would come into additional funds from that source by 2009, planned a move to combine them with private monies to develop a biotech sector.  In a  2005 commentary prescient of current threat of extinction for the Basic Health Program (which began as a 1987 pilot project and became permanent in 1993) the Seattle Weekly had reported:

It will be controversial because originally the tobacco settlement money was supposed to be used to help states offset the health care costs associated with smoking. In 2003, when Gary Locke floated an idea similar to the Life Science Discovery Fund—he called it Bio21—Senate Majority Leader Brown told Seattle Weekly she didn’t like the idea of using tobacco money for biotechnology. “We are one of the few states that has remained true to using that money for health care,” she said at the time. Expect the debate over the best use of the tobacco money to continue.

As I had written previously, in late October 2010, after the Governor had issued her call for “across the board budget cuts” from every state agency, the LSDF awarded $5 million to a private company engaged in personalized medicine research.  Last week, LSDF awarded $600,000 in commercialization grants to four research projects.

The Interpreter Services program also was created as a result of federal litigation, in this case as a result of a 1991 Consent Decree negotiated with the Office of Civil Rights in response to lawsuits and civil rights complaints filed against DSHS for failing to provide equal access to services for clients with limited English proficiency  By law, in this case the Civil Rights Act of 1964, title VI, recipients of federal funds must not discriminate against program beneficiaries on the basis of race, color, or national origin.  Courts have defined lack of language access as a form of discrimination based on national origin. However, the responsibility to fund language services is ultimately that of providers. Since  techncially Washington funded the DSHS program voluntarily, it is now able to seek to de-fund it, unlike other mandatory programs. But in doing so, the state would also forgo specific federal funds that it has been receiving that have covered 50-75% of the total costs, as the Washington State Coalition for Language Access explains in a fact sheet:  WASCLA DSHS Interpreter Services Talking Points January 2011

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A front-page article published on February 1 by  The Seattle Times, now the Emerald City’s  sole remaining daily newspaper, purporting to describe new state demographic trends, is causing outrage at a very critical time. At this very moment  the draconian cuts proposed by the Governor to balance the budget, are the subject of  contention in the Legislature  as advocates  struggle to convince lawmakers to preserve at least the semblance of a safety net .  The program cuts would disproportionately affect poor immigrants and refugees and communities of color, as the planned terminations cut deeply into a range of services from state food assistance, citizenship programs, Medicaid medical interpreter services, to health insurance plans which now cover noncitizen adults and some 27,000 children enrolled in the Children’s Health program of Apple Health for Kids, among other vital services.  In addition, other bills being considered would promote racial/ethnic profiling of state residents, including requiring citizenship checks of applicants for drivers’ licenses to those targeting youth for incarceration on the basis of presumed but not proven gang affiliations.

So it seems like more than a coincidence that the Times story Illegal-immigrant numbers in state jump 35% in 3 years was published the day before the Senate Ways & Means Committee was to hold a hearing on the 2011 Supplemental Budget bill which encompasses all of the cuts. The Times article discussed a just-released report from the Pew Hispanic Center  entitled Unauthorized Immigrant Population:
National and State Trends, 2010,
about  results of the Census Bureau’s Current Population Survey. Beyond  just the damage that the inflammatory  and dehumanizing language of the article’s title can cause in the court of public opinion , it turns out that reporter Lornet Turnbull  got his facts wrong too.  Subsequently Jeff Passel, one of the authors of the Pew report, was interviewed by a reporter for local radio station.   Passel said that based on the Census data, there was no evidence that Washington’s undocumented population had increased, pointing to the high margin of error in the data analysis and its very small sample size, and more pointedly, that the Seattle Times had not done fact-checking with Pew.  The  Feb. 3 interview Dispute About Growth Of Undocumented Immigrants In Wash. can be heard in its entirety on the KUOW website.

In these desperate economic times, articles like this one in the Seattle Times serve only to scapegoat all immigrants for the economic woes of the state (and the nation) instead of focusing on the genuine causes of the recession.  Over 400 comments  have been posted in response so far, most of them of a hate-mongering nature.  Recognition that Washington’s regressive tax structure means that all of us contribute at the same (sales tax) rate to state coffers, regardless of immigration status or income, is handily overlooked by the ranters. Interestingly, the Times has posted a partial correction to the article, explaining that undocumented people constitute a small  fraction of the state’s population

A previous version of this story incorrectly stated that illegal immigrants accounted for nearly 5 percent of the state’s population, giving Washington the seventh highest rate of illegal immigrants in the nation. A Pew Hispanic Center report, on which the story was based, incorrectly attributed the percentage and ranking to Washington state rather than to the District of Columbia. The center has corrected the information in its online report to reflect that illegal immigrants comprise 3.4 percent of Washington state’s population, a rate that does not rank it among the top 10 states.

The story’s problematc title and other content inaccuracies however remain the same, its damage done.  Use of attention-grabbing headlines is a journalistic technique of course; likewise  fewer readers ever bother to go back to read corrections.

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The end of the year with its annual holidays found many  of us here in Washington State feeling anything but in a festive mood, given the imminent decimation of core health and human services, as part of  the Governor’s proposal for balancing of the state’s  budget in the new year and for the biennium.  On September 13th, Governor Gregoire’s Executive Order 10-04 instructed all state agencies to make reductions in their allotments from the State General fund in order to meet the requirement for a balanced  budget. On September 29, DSHS issued its initial plan of how the 6.3% across-the-board budget cuts would be applied to Department programs to meet this mandate. The proposed cuts were aimed at every program and service (included some entirely state-funded and other linked to Medicaid)  not technically defined as “mandatory,” affecting the state’s most vulnerable populations in all age-groups from pre-cradle to grave, and including  primary care delivered at community health centers.

By December, a supplemental budget proposal with even worse news was issued, containing further  proposals for achieving the needed $4 billion in savings to balance the budget. The drastic cuts to almost every aspect of civic life, was driven by outcomes of  ballot measures  from the November elections, which dashed any hopes even of short-term new revenue generation  from snack sales, rejection of a first-ever state income tax to have been levied only on the wealthiest among us, and hamstrung future legislative efforts to raise taxes with the 2/3 majority approval stipulation.  By December 30, the Governor released the latest list of planned budget cuts,and the timeline for their elimination. While some of the worst of the cuts have been staved off or delayed temporarily, it still remains to be seen whether the remaining services will be funded, even in vastly reduced mode, and how many human beings affected by the cuts will even survive.

While at this stage in my life nothing surprises me any more, the discrepancy between what is happening to these most basic of services and the treatment of the high-profile, socially attractive high tech sector by state government should be a wake up call to all of us who value a decent society. While the majority of Washingtonians have not misbehaved, it seems like the most vulnerable among us are being singled out for punishment.

State Dollars > Private Venture

During exactly same time period that the budget cuts were first announced in October, another state agency, the Life Sciences Discovery Fund, gave a grant of $5 million to a private, for-profit business, the Omeros Corporation, a Seattle biopharmaceutical company, for  research into speculative personalized medicines. The grant to Omeros was rolled into a package deal for the firm, that included $25M from Paul Allen’s Vulcan Capital. Even Xconomy: Seattle‘s biotech reporter Luke Timmerman expressed great surprise at this development in his Dec. 14 article entitled Life Sciences Discovery Fund Debunks Perceptions with Omeros Deal, Shows State Can Bankroll Companies. If the research ever pans out, then there is the possibility of financial returns to the state at some unknown time in the future.

A bit of background: Washington’s Life Sciences Discovery Fund was established by the Legislature in 2005 to disburse the tobacco settlement funds allocated to the state. While the the fund originally had been allocated $350M for a 10-year period, when the State’s budget crisis threatened to shut down the program in 2009, it survived with a budget cut of 41% or $39M in funds for FYs 2009-2011. The LSDF’s  stated mission is as follows:

The Life Sciences Discovery Fund supports innovative research in Washington state to promote life sciences competitiveness, enhance economic vitality, and improve health and health care.

which the  program website further explains as intending to “foster growth of the state’s life sciences sector and improve the health and economic wellbeing of its residents.”

But given the crisis situation we now face–in context of course of the ongoing national recession–emergency measures are needed.  It hardly seems the time for state government to be investing in private companies, purely ethical issues aside for the moment. Obviously, it’s going to take more than redirecting the “mere” $5M given by the LSDF to a private venture to save public health services in Washington State, but those funds certainly could have turned things around for a good number of the axed programs, such as the Basic Health Program insurance plan and so many Medicaid services.  While research is important, without access to care, medical innovations are meaningless.  What good is research, if there is no safety net? Given the LSDF’s mission, it should be part of the logical solution needed  now: making sure that all Washingtonians can benefit from the medical knowledge available today. And the state government can take a leadership role too in education on the need for investment in our human capital. Despite laments over the election outcomes,and grim prognostics, the official ChooseWashington.com website continues to highlight the array of attractive tax incentives, some of which I had commented on previously, for certain types of companies to set up shop here, along with the absence of a personal income tax.

Another part of the Governor’s plan to balance the budget, announced December 14, is to eliminate Boards and Commissions. No mention was made in this announcement, however, about the status of  a brand-new board, the Global Health Technologies Competitiveness Board established in July 2010, after SB 6675 Creating the Washington global health technologies and product development competitiveness program and allowing certain tax credits for program contributions, was approved by the Legislature and signed into law by Gov. Gregoire. Per RCW 43.374.010, among the Board’s charges are seeking funding from the private sector, foundations, and the federal government in order to issue grants to local enterprises …to stimulate our economy and foster job creation in the emerging field of global health while improving the health of people in our state and the world. The program is required to be administered by a 501(c)6 tax-exempt nonprofit organization, which contracts with the Dept. of Commerce for administrative services.

The Global Health Technologies Competitiveness Program (GHTCP) was awarded $1M by the Legislature (evidently not subject to the budget cuts) and issued its first RFP in mid-November, with awards expected to be announced early in the new year, along with a second RFP announcement, according to the Washington Global Health Alliance.

Think Globally, Act Locally ?

These new developments beg the question of just exactly what these specific state-funded programs are doing to improve the health  of Washington residents in the here and now. I write these words from the perspective of understanding full well how domestic and  international health are inextricably linked, whether regarding diseases rapidly transcending national borders or concerning the impact of international trade agreements on availability of medicines for US Medicaid programs, just to name a few examples. I myself am alive today partly as a result of medical advances developed here in Seattle, and I am also directly involved with both local and global health equity work, which makes me even more appalled at what is going on. Global health has been described as Seattle’s “next hot industry,” but few are the public voices applying critical thinking skills to analyze what this actually means for local folks. One of the exceptions is that of Seattle journalist Tom Paulson, who now offers insights on his Humanosphere blogsuch as a November 2010 story on a still-vague, 5-year  $1M  Swedish Medical Center pilot project called Global to Local targeting two low-income communities in  South King County.  Tom pointed out the irony  of this program being rolled out at the very same time that well-established and proven-effective, public health services are being slashed. According to the article, G2L is based on a concept that the “best practices” used by local actors in overseas health programs can be applied here at home too, while structural reasons for domestic health and healthcare inequalities are not addressed. And another observer, Steve Gloyd, MD of Health Alliance International and the UW Dept. of Global Health, has opined that there can be an upside to calling global health an “industry”:

“Maybe using the word will shock people into recognizing that when a local biotech firm says it is working on a vaccine to help people in Africa, some will see it is actually just trying to make a few people in Seattle rich.”

Next year, a new nonprofit called Global Health Nexus will commemorate the 50th anniversary of the Seattle World’s Fair with a major conference and exhibition showcasing the region’s global-health advancements. One has to wonder if anyone working to improve health at the local level will be invited to present, or if we’ll be able to afford the registration fees. Perhaps advocates can submit an abstract for a session there featuring real-life Washingtonians sharing first-hand accounts of the outcomes of state budget cuts on preventable health problems, such as  a child who has  been experiencing asthma attacks since elimination of the Children’s Health Program; an adult with diabetes who had to get their leg amputated due to lack of non-emergency podiatry care;  or the relative of a patient who died due to a wrong diagnosis resulting from lack of a medical interpreter;  or we could show  videos of overflowing ERs full of patients bumped from the Basic Health Program and unable to be seen at community clinics. Then maybe we could pass the hat among the rich and famous to take to up a collection for local health.

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Many important conferences are scheduled from September  to the end of the year.   Last week I was  fortunate to be able to attend the second annual meeting of the  Consortium of Universities for Global Health at the University of Washington here in Seattle. I’ll report  on that later.

Some other notable conferences, including those in which I am involved in running and/presenting,  are:

International “Selling Sickness” Conference in Amsterdam, October  7-8, sponsored by the Dutch Ministry of Health and Health Care Inspectorate,  Gezonde Scepsis, Healthy Skepticism International, and the  World Health Organization, Regional Office for Europe.
While I won’t get to be there in person, my poster will be there  and also posted here on the blog .

Summit VI of the Washington State Coalition for Language Access  (WASCLA) will take place in Seattle on October 15-16.  Run entirely by volunteers, including yours truly, I’m on the team organizing the conference and also a presenter for a plenary session on Community Advocacy & Engagement.  And FYI to those interested in attending: early bird registration rates have been extended to October 1.

The  Diversity Rx 7th National Conference on Quality Health Care for Culturally Diverse Populations will be held in Baltimore on October 18-21. Sadly I’ll be missing this top-notch biannual event.

Heading into November, the Washington State Pharmacy Association will hold its annual meeting in Vancouver, WA on the 5th and 6th, where together with  pharmacist and  attorney colleagues from WASCLA, we’ll be speaking on Language Access at the Pharmacy.


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More recent heartening news — literally and figuratively– was the March 31 launch of the “Retire Ronald” campaign by Corporate Accountability International.  CAI began work  in the late ’70s as INFACT ( Infant Formula Action Coalition) , to create global awareness  and action to curb the inappropriate marketing of baby formula in poor countries which caused devastating health and economic effects.  Today the organization campaigns to change harmful corporate practices in many fields. Health continues as a major focus, so mounting concern about the now-global problem of childhood obesity prompted its new Retire Ronald campaign. Fast food, today an international industry, is part of the problem;  McDonald’s business success its emblematic of its pervasive and detrimental reach.   Since its start almost 50 years ago, McDonald’s has utilized an array of multimedia marketing pitches, both overt and subtle, specifically targeting children.  The ubiquitous ads and events, in all their forms,  often feature Ronald in likeness or in person.  Detailed information about the Retire Ronald campaign, including  deconstruction of ads and  backgrounders on promotional  techniques used by McDonald’s , and a 28-page  report Clowning with Kids’ Health: The Case for Ronald McDonald’s Retirement, can be found the CAI website and the group’s Facebook page.  Readers also have the opportunity to sign an online retirement card to convey their messages to McD’s corporate office.

Companies the size of McDonald’s are able to utilize multiple venues and a range of techniques to disseminate their messages to potential customers of all ages: children,  youth, and adults. Of McDonald’s several websites, for example, its corporate site features a special section for students, which touts the many facets of its corporate social responsibility plus information on job and scholarship opportunities. In the FAQ section along with facts on company  operations,  item #14 in the Q & A  presents distorted information about nutrition :

Isn’t it healthier for me to make lunch for my kids rather than buy it at McDonald’s?

Actually, a 4-piece Chicken McNuggets with Apple Dippers and milk contains fewer calories and fat than a homemade grilled cheese sandwich, cup of tomato soup and glass of lemonade.

Not only is the question not answered (and seems to address parents, not students) only a single type of McDonald’s fare is compared to single type of homemade meal, hardly a valid analysis!  Parsing out comparisons between numerous McD items in contrast with a full array of possible home-prepared lunches could be the basis for an excellent lesson plan in independent living classes, for example.

Ronald McDonald has his own website directed at children with interactive online games, and messages informing parents that the activities help kids develop their fine motor skills . The main company site features products, nutrition information and special promotions along with “multicultural marketing” pages targeting at young African-AmericanAsian American ( with sections in Chinese and Korean) and Latino customers, the latter version in Spanish.

Through my own work that spans involvement with Healthy Skepticism ( an NGO which aims to  promote health by countering misleading promotion of medicines) and my background as a nutrition educator and a mom of  children now grown , I was glad to learn of the Retire Ronald campaign.  My interest was further piqued because in the advocacy world too, I’ve been hearing other concerns related to Ronald, that make one wonder just how family-friendly he really is.

For starters, beyond just  problematic promotions,  is the fact that there are McDonald’s restaurants located in hospitals ,including in at least 30 in childrens hospitals around the country.  According to a 2006 study published in Pediatrics, some 30% of  all US hospitals had fast food restaurants located on their premises.  The researchers also found that:

…the presence of a McDonald’s restaurant in a children’s hospital was associated with (1) increased fast food purchasing by parents, (2) the belief that McDonald’s Corporation was a hospital benefactor, and (3) more positive perceptions of the healthiness of McDonald’s food.

And when hospitals try to put words into action with their own health messages to patients and families, by eliminating  fast food , they have faced corporate pushback.  This was the experience of a new CEO at the Cleveland Clinic ,which specializes  in cardiac care, when he tried to break a 10-year lease with McDonald’s.

The company’s clown mascot is further  known around the world through his namesake Ronald McDonald House Charities . RMHC sponsors Ronald McDonald Houses, which meet the vital lodging needs of  families of seriously ill children being treated at hospitals outside of their home communities. Reviews of  company history have revealed that McDonald’s got involved with charitable work not purely out of altruism as is commonly believed, but to enhance its own image and thus its bottom line,  through branding opportunities . According to research cited by CAI ( see pages 5 and 27 of the full report)  Fred Turner, former McD’s CEO and Chairman once told an interviewer:

We got into it [ charitable work] for very selfish reasons,  It was an inexpensive, imaginative way of getting your name before the public and building a reputation to offset the image of selling fifteen cent hamburgers. It was probably ninety-nine percent commercial.

RMH facilities are lodge-style  homes-away-from-home , usually situated adjacent to hospitals, in cities around the globe. The Houses in the US typically charge $10-$25 per night and RMHC Global has a universal access policy as part of its mission, stating that:

…..families either stay at no cost or are asked to make a donation up to $25 per day, depending on the house. The RMHC Global Policy is that families are never turned away; if its not possible to pay, the fee is waived.

There is a great need for this service, as in addition to the medical expenses, families also face enormous uncovered non-medical costs just at the time when income is decreased due to the sick child’s hospitalization and care needs.  With  hospital stays typically lasting  from weeks to many months, even paying for  subsidized temporary lodging ,while also paying rent or a mortgage back home, may be impossible.  As illustration of the  great demand  for lodging support are the facts that many RMHs keep waiting lists, and that many like the RMH in San Diego, report having had to turn away hundreds of families each year due to lack of space.

RMHC is  a 501(c)3, tax-exempt US charitable organization, separate from the McDonald’s Corporation, it’s principal corporate sponsor.  The RM Houses are run by local chapters of the  RMHC, and each chapter is incorporated as an independent  charitable organization in its home state, and conducts local fundraising, including at McDonald’s stores . For more about the links between McDonald’s and RMHC, see Our Relationship with McDonald’s.

There is the irony  of course that this essential healthcare support service is so heavily supported by the sales and promotion of unhealthy food.  But there are other issues too about the conditional welcome, or even exclusion, that some families may encounter at individual RMHC  facilities, and how RMH employees may be treated.

There seems to be some variability in the universal access policy, although the vast majority of the RMHC chapter websites that I reviewed– including  Springfield, MOPhiladelphia, Minneapolis, SeattleAustin, TXClevelandLos Angeles, just to name a few– explicitly state that no one is ever turned away because of inability to pay.  In New York City however, this does not seem to be the case, as their RMH website says only that There is a $35.00 fee per night, per room to stay at Ronald McDonald House of New York, and offers no information on flexibilities.

While Salt Lake City  RMH too has the open financial policy, published on its website is the stipulation that “For those who do not speak English an interpreter will need to accompany them on their first visit“. I’ve heard anecdotally that telephonic interpreting is not acceptable , although this service is commonly utilized by hospitals to complement live interpreter services.   Especially for families arriving after business hours, this requirement can be impossible to meet;  it resonates as mean-spirited and  exclusionary.  The Birmingham AL  RMH  website states that families can bring a friend or family member who can translate…..if you do not speak English.  (FYI,  interpretation refers to spoken or signed language, while translation is exclusively of written work; these terms are frequently confused). While I’m not an attorney, I do know that  these are the kind of policies which need to be reviewed for compliance with civil rights laws pertaining to  public accommodations.

The  validity of the warm, fuzzy, caring  attitude associated with Ronald in all his manifestations has at times been the subject of headlines regarding issues that have arisen at individual  RMHs  including:

  • a 2005 case in Baltimore, where a family of a child about to undergo heart surgery, was initially turned away by the facility because the patient’s blind mother was accompanied by a guide dog, in supposed violation of a RMH  “no pets” rule .
  • a 2007 case in Houston, where the mother of an infant who had just undergone surgery for a brain tumor, was admonished for nursing him  in a common area of the RMH, with implications made that if family wished to continue their stay , breastfeeding should be done only in the family bedroom.
  • a 2009 case in Miami, where the former assistant manager of RMH of South Florida has filed a lawsuit alleging violation of labor laws as she was often required to work off the clock, and did not receive  $20,000 in overtime  pay for  her customary 70-hour work weeks.

It’s important to know too that sponsorships by major corporations, which come product promotion ties, are not the only way to meet the housing needs of sick kids and their families. All around the country (and the world too) there are grassroots endeavors, by both organizations and individuals,  providing patient lodging. To learn more , visit the website of the National Association of Hospitality Houses.

Retiring Ronald could be a positive step to improving the health and well-being of our children, one meal at a time.

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