J Med Humanit (2008) 29:137–146 DOI 10.1007/s10912-008-9058-0

Bilingualism in the World of Health and Illness Sander L. Gilman

Published online: 1 July 2008 # Springer Science + Business Media, LLC 2008

Abstract The movement of peoples across linguistic boundaries means the existence of individuals who speak, to a greater or lesser extent, more than one language. How such individuals have in the past and can in the present serve as mediators within the health care system is described and the need for closer attention to such resources stressed. Keywords Bilingualism . Hospital . History . Medical access . Ethnic hospitals Here’s a thought experiment: You are very suddenly taken ill. You clearly need to go to a hospital. Enter into the hospital, go to the admissions desk and say as clearly and loudly as possible that you need to see a doctor immediately. You are quizzically answered by the person behind the desk in a manner completely unintelligible to you. You are in a culture that does not speak your own language. What do you do? I had this problem decades ago in a small city in a Central Asian Republic of the Soviet Union when I came down with food poisoning in the middle of the night. No one it seemed, from the tea lady on the landing to the concierge at the hotel, spoke any of the languages that I knew. The results were less than pleasant and made me very aware of the need for some level of bilingualism on the part of the hospital (if not on the part of the patient). The result was—by the way—a 5-h wait until I could call the American Embassy in Moscow and find an English-speaking local physician. My real experience was very different than that cinematic moment when the characters played by Bill Murray and Scarlett Johansson visit a Tokyo hospital in Sofia Coppola’s Lost in Translation (2003). There the absolute absence of any common language between Johansson, who has broken her toe, and the orthopedist magically leads to quick and easy treatment with no questions about payment. All the while, Murray mimes his comic lack of comprehension to an elderly Japanese man sitting in the waiting room, who laughs uproariously, since we all know the truism that the comic transcends language. By the way, the broken toe is healed just as magically in the next scene in the film. The cinematic S. L. Gilman (*) Emory College, Atlanta, GA, USA e-mail: [email protected]

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illusion is merely a continuation of our wonder at the characters’ ability to comprehend beyond the confines of language in the hospital. This confusion of tongues is hardly new. In late nineteenth-century New York City, there was suddenly yet another language present in the immigrant enclave of the East Side: “A different language is now heard there. Neither German not English nor yet Gaelic but what is called the Yiddish, or Jewish, a jargon of old German, Hebrew, Polish, and Russian with the addition of Hungarian where the Jews come from Hungary.”1 This mix of tongues was, in point of fact, a “real” language, Yiddish, and like the many other tongues heard on the streets of the East Side, speaking Yiddish also blocked access to public services. The initial answer to equal access of non-English speakers to health care in North American cities with large immigrant populations was the creation of “Jewish” (and Norwegian and Polish and German and Italian) hospitals that offered succor in a language and a tradition recognized by its members. (This was quite different than the model of the Protestant benevolent societies from which such institutions were copied.) Chicago’s Michael Reese Hospital, named after the Jewish benefactor who provided its initial funds in his will, was opened in 1881 for the illness and suffering of everyone in the community, but its primary audience was the huge numbers of Yiddish-speaking Jews on the West Side. However, in Chicago and New York City, Jews (and Norwegians and Poles and Germans and Italians) were also regularly admitted to large public hospitals such as Cook County and Bellevue. And there, over a hundred years ago, the language problem was present. Although there was a German, Italian, and French Hospital in nineteenth-century London, the large Jewish population did not support a “Jewish” hospital for local reasons. There had been a short-lived “Jews’ Hospital for the Aged Poor and the Education and Employment of Youth” in London as early as 1807 as well as maternity and nursing homes supported by the Jewish community but no general hospital.2 The Jews’ Hospital of the early nineteenth century was a home for the indigent aged and a training ground for young Jews to enter service. Language skills were assumed for the young but not for the old. The “German Hospital” founded in 1845 had as its aim to “cater for poor German emigrants...in the East End [who] did not speak English, and it was felt they were at a disadvantage in expressing their needs to English doctors and nurses, and in communication with other patients.”3 While nominally a Protestant hospital, special wards were given over to Jewish patients who spoke German, and a kosher kitchen was created in 1900. In 1895, even the public Colney Hatch Asylum had a kosher kitchen and employed “an interpreting attendant (Mrs. Freedman) for those patients who spoke only Yiddish although patients themselves were frequently used as interpreters.”4 Colney Hatch was the asylum to which most mentally ill East End Jews were committed. In Manchester, the question of a Jewish hospital was also debated at the turn of the twentieth century; one of the primary reasons given was the “considerable disadvantage in Manchester’s secular hospitals where, speaking little English, they would struggle to be understood and understand.”5 Jewish opponents to the creation of such a hospital argued (an argument heard loudly in the early twenty-first century about other immigrant groups) that potential hospitalization would “act as an incitement for the Jews to learn English. After all [Rabbi Singer] claimed, ‘A gift for languages is notoriously a very general endowment among the Jews.’”6 Learning English in anticipation of illness and hospitalization strikes one as an odd notion; learning it in a hospital setting as quite unacceptable. The Eastern European Jews were like most other immigrant groups in London:7 “The immigrants come over in a wretched state, they have no knowledge of our language...” “German, Dutch, and Hebrew languages are more commonly spoken than English.”8 The solution to the absence of a “Jew’s Hospital” in mid-nineteenth century London was to fund

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the treatment of the poor in existing hospitals: “They have special wards in the London and Metropolitan Free Hospitals” where “the arrangements and cooking are specially adapted to Jewish habits.”9 These are funded by the community, which also “dispensed tickets for every hospital in London.”10 In addition to the evident support of religious and social practice, there was always a structure of linguistic mediation for the Jewish poor: “The intimate connexion between sickness and pauperism” led to the creation of social institutions by the Board of Jewish Guardians in London.11 A general “Jew’s Hospital” was created by “immigrant, Yiddish-speaking working men” only in the first decade in the twentieth century.12 The East End of London in 1900 was as firmly Yiddish-speaking as was the East Side of New York. While the children of immigrants came to speak English “with a regard for grammar and a purity of accent far above the average of the neighbourhood,” as a reporter for the Daily Graphic noted in 1895, the dominant language of the East End was Yiddish.13 In Manchester, the Jewish Ladies’ Visiting Association, composed of “English” Jews put on “Shakespearean recitals” for the immigrants as well as providing them with access of medical and health care. “Shakespearean English would have remained every so slightly outside the linguistic capabilities of the Russian immigrants,” as one historian notes.14 How much more would access to medical treatment have been beyond their linguistic capacities? This was to be one of the reasons for the creation of a Jewish hospital in a world of increasing suspicion of the Jews and other immigrant groups.15 The unintended consequence of the creation of Jewish access to medical care in immigrant societies of the nineteenth century, whether in New York or London or Buenos Aires, was that Jewish immigrants could always draw on the initial support of those who spoke their own languages for appropriate succor, if not treatment. Translation was not only the means of accessing treatment but also the creation of a supportive environment within the medical world, a world in which the isolation of the ill and the insane was exacerbated by their inability to communicate. Today, should you find yourself in the real situation of being unable to speak the language of the emergency room admissions staff in the United States, don’t expect any magic moment of comprehension. The hospital has the legal obligation to provide you with a translator. But what does that mean? A magic moment when your pain reaches past language and touches the empathy of a health care worker as in Lost in Translation? The reality is that what you ideally hope for is that a translator is available who, will not only understand your spoken and written language but also its cultural implications and nuances. The Civil Rights Act of 1964 has required this for 40 years, and yet it is more often than not the case that it is impossible in the real world of health and illness. What we experience is, at best, a potpourri. When we eavesdrop in a hospital, we may hear a Russian-speaking woman speaking “heritage” Russian to her daughter who is interpreting. Certainly there is empathy, but there is also anxiety, even panic. The daughter may know her mother well, but she probably does not have the vocabulary to understand and facilitate her mother’s understanding of her medical situation. We may see a medical student who has studied Chinese at university interpreting for a Chinese-speaking man using herbal medication. The medical student’s sense of the “real” nature of evidence-based or allopathic medicine may dominate her attitude towards “home remedies,” the homeopathic or herbal treatments that her patient is taking. If we are very lucky, we may find a Haitian woman speaking Creole and being told about an abnormal mammogram from a trained simultaneous interpreter who knows both Creole and the medical world.16 Or, we may read of the case of the illegal Chinese immigrant, Ming Qiang Zhao, about whom Nina Bernstein wrote recently in the New York Times, who was admitted to a hospital in New

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York after collapsing on the street “and where one of his roommates, a 19-year-old waiter with uneven English, served as the interpreter:” In Mr. Zhao's hospital room, visitors began to hope for his recovery. After three weeks, he seemed responsive when they called his name. So it came as a shock when Mr. Chung, the waiter acting as a translator, relayed a new request from a doctor: Would they agree to let Mr. Zhao die? Mr. Chung, who would soon return to work at an Asian restaurant in South Charleston, W.Va., translated the request for a “do not resuscitate” order as best he could, and drew his own conclusions. “Maybe some people don't like Chinese,” he said.17 All of these patients have claim on adequate representation and, in each case, the hospital may well believe that it is offering this. The Americans with Disabilities Act of 1991 mandates adequate “bilingual” access for the profoundly hearing impaired, and yet sign interpreters are also in short supply, and few if any health care professionals can use American Sign Language. The wide range of what is available leads to difficulties of communication and problems of access. Different models of bilingual access potentially provide different health outcomes and offer a wide variety of the meanings of bilingualism in the context of institutions dealing with health and illness. Dozens of medical and health care interpreter programs exist in the United States from Boston University’s certificate program for Legal, Medical, and Community Interpreting for Cantonese, Mandarin, Portuguese or Spanish to the New Brunswick Community Interpreter Project that trains English–Spanish bilingual Rutgers students in the skills of medical interpreting for service in local clinics and hospitals. All intend to prepare interpreters for the health care arena. Thus we have a “natural” place for trained bilinguals within the work force, a complex resource needed by society.18 Trained bilingualists would also answer a major problem in the health care system. Fifty percent of patients from different ethnic groups who present to the American health care system for evaluation and treatment are monolingual in languages other than English. (The rest displaying various degrees of linguistic competence.)19 The health care system should be bilingual by law and need, but it is rarely so. And yet do we want to train health care professionals in language competency? Do we want to mandate, as part of the training of those who heal and serve, that they have a level of command of languages other than English, which would enable them to provide nuanced access to the health care system for everybody? While the easy answer would be: “of course we do,” the reality is that health care programs (from medical schools that train physicians to 2-year colleges that train medical technicians with whom you spend most of your time in hospital) are presently so crammed with material that such training would be, at best, superficial. While a smattering of language knowledge is certainly better than none, in the cases noted above, it can do more harm than good. Language facility and cultural literacy are linked, and this is vital in the health care setting where the presumptions about the very nature of the body, of cure, of disease, can differ radically or subtlety from one linguistic setting to another. Could we require some degree of bilingualism at least for those students entering from high school or an undergraduate program? Such language requirements have been radically reduced over the past 20 years, and the stress on learning languages in a cultural context (which means spending time in the language contact area) has been only recently resuscitated. Even that might not include any language training that would be relevant to the medical cultural and the mediation of medical cultures.20

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One way to remedy the problem and to give added value to bilingualism on the part of individuals is to recruit bilinguals. In the city of Chicago, there are over 50 languages represented in relatively large numbers in the public schools. Often (if not always) they are seen as barriers to integration into an English-speaking world. Access is spelled: economic advantage for speakers of English. Given that the health care system is a HUGE part of the American economy—15% of it to be exact—there is clearly an impetus to enter into the economy through the wide range of professional schools that cater to this segment. Learning English—to be as simplistic as possible—means that my child can become a doctor (or dentist or nurse or health care worker) and have a good income while achieving social status in our society. But there is the odd hidden corollary in this argument: forget or repress your first or second language because there is no value for it in the health care system. Bilingualism is a sign of second-class citizenship. What we need is to place added value on bilingualism in recruitment for the health care professions, and we need to make it a value-added segment with some attention to the additional knowledge that must be acquired (through externships abroad, through classes taught with a bilingual instructor, etc.).21 Access could be facilitated if bilingualism were recognized as a strength not as a hidden flaw. The Federal Department of Health and Human Services in a 1995 survey of the needs for health care interpreters (undertaken by New York Task Force on Immigrant Health) noted that: Interpreting and interpreters need to be taken more seriously. They are often under utilized and under publicized. In the training and screening of interpreters, the following characteristics should be noted: * bilingualism; * culturalism (awareness of cultural beliefs); * interpersonal skills; and * adherence to a code of ethics (mostly confidentiality). Any trainer in this area should be a person who has actually translated in a health care setting, has a solid grasp of techniques needed for effective interpreting, and be an effective teacher.22 Some such programs reflecting community needs do exist. For instance, the state of Rhode Island has a large number of Portuguese and Spanish speakers, and the Brown Medical School and Rhode Island Department of Social Work regularly recruit bilinguals to become medical interpreters. However, the numbers of health care professionals with such skills remain limited even in a state where there are potentially larger numbers of bilinguals from which to recruit.23 In officially bilingual Canada, the University of Ottawa has created a French-language stream for their hospitals in Ottawa, which are all Anglophone. Because, many patients are Francophone, the hospital recruited and trained Francophone physicians and trained them in a “communication skills laboratory” in bilingual interviewing techniques. They received detailed feedback over their training with regular reviews of videotaped interviews that stressed the linguistic and cultural specificity of their French-speaking clients. This was such a success that it is now extended to Anglophone physicians in the same system. It was clear that bilingualism combined with training enhanced practitioner’s specific skills, knowledge of the patient, and self-awareness of cultural presuppositions on both sides.24

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In the United Kingdom, the University of Wales College of Medicine reacted positively to the Welsh Language Act of 1993 that guaranteed access of Welsh speakers to the National Health Service. The College quickly identified bilingual (Welsh–English) staff to ensure that central service functions (information services, administration, finance and personnel) would be able to function in Welsh. They both advertised for bilinguals and gave preference to bilinguals in hiring. They also undertook a census of bilinguals already employed within the NHS. Such a census of bilinguals in any health care setting in the United States would turn up surprising results, but none is mandated. In the United States, of course, the most recent Supreme Court findings on affirmative action have made the specific recruitment of bilingual minorities in higher education settings, including professional schools, difficult if not impossible. While bilingual skills are necessary in all health care settings on all levels of expertise, for certain specialties, such as psychiatry, language skills are an absolute necessity. Language is often the site or the means of the expression of symptoms, and for bilinguals, the nuances of the second language are necessary for an evaluation by psychiatrists, psychologists, and psychiatric nurses. It is imperative that such mental health care professionals have real language skills. The expression of complex emotions in speech and gesture, the very understanding of emotional pain, is impacted by the facility with language and the culture that it expresses. Taking a psychiatric history—which is in many cases a fairly mechanical undertaking—becomes fraught if the language competence of the person taking the history is limited. Here even “translation” may not be an advantage because it demands the transformation of one system of knowledge into another. What is normative behavior in one cultural context may be translated into deviant behavior in another. In 2002, Drennan and Swartz commented on the complex use of the 11 “official languages” in South Africa in the context of psychiatric evaluation.25 (Never mind the need for South African Sign Language for some patients.) The problems of “interpretation” seemed to vanish in the psychiatric hospital setting because all of the psychiatrists were trained in a specific vocabulary of diagnosis and analysis no matter what their linguistic specificity. This is very different when the same cases are evaluated forensically when the very nature of the action demands a multi-cultural and linguistic sophistication because of the awareness in the institutions of the widely divergent legal meanings of insanity within the cultures of the new South Africa. Thus the culture of the institution can also manipulate the very nature of language for bilinguals. In the United States today, a large proportion of the psychiatrically underserved population are those who have English as a second language or no English at all. How do we evaluate them? The official limiting of minority acceptance to training programs and state limitation on these programs has made depression one of the most frequently under-diagnosed illnesses among this ethnic population. Often there are different standards and different stigmas associated with mental health and mental illnesses such as depression. For instance, gender roles inherent in all linguistic communities can exacerbate illnesses such as depression, which can be seen as “unmanly” in some communities. In addition to the nuanced differences in responding to the diagnosis of recognizable, transcultural mental illnesses, there are, of course, mental illnesses that demand a deep knowledge of a specific culture in order to be diagnosed. In Japan and among first-generation Japanese-Americans is the appearance of taijin kyofusho, a syndrome in which an individual is convinced that he or she is offensive to others because of appearance or body odor. This is not what the quasiofficial American psychiatric manual, The Diagnostic and Statistical Manual of Mental Illness (DSMIVR), defines as body dismorphic disorder, but it is a specifically Japanese manifestation that relies on the highly structured narratives defining shame and the perceived transgression of social and linguistic boundaries.

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One case of the clash of cultures that is well documented and relies not only on the differences in diagnostic systems but also on the failure of the possibility of translation is the case of Lia Lee, the 9-year-old daughter of Hmong immigrants in California, who developed symptoms of epilepsy. In the Hmong community, she was diagnosed as possessed and was so treated by her parents. The American medical establishment was all that seemed to be available to her family, but its presuppositions violated everything that they believed about health and illness. The Lees’ fear of American medicine was based on their anxiety about blood taking, as the Hmong believe that the body contains a finite amount of blood, which is not replaceable. The doctors they encountered in California considered the Hmong to be ignorant, backward, and too reliant on animal sacrifices and other unacceptable practices. During Lia's treatment, the assumptions and beliefs that both parties brought to the patient–doctor interaction were never adequately explored. Monolingual doctors often took advantage of their powerful position, and there developed a lack of trust and respect between the family and the doctors. By 1988, Lia was brain dead after a tragic cycle of misunderstanding, overmedication, and linguistic clashes between Western and Hmong models of illness.26 A support system for the monolingual mentally ill is lacking, and one reason it is lacking is the limited access to bilingual mediators and health care professionals within these communities. Bilingualism has yet a further health advantage within at least some communities. It serves as the means of access for monolinguals, but it also constitutes a community that spans two models of health and illness and is able to use aspects of both to the advantage of any given individuals. What if the Lees really understood both systems of medicine through an ability to use both Hmong and English? They would have been able to balance the demands and expectations of each. The use of herbal or homeopathic medicines among groups such as the Dominicans in New York City means that there are physical spaces, such as the Dominican “botonicas,” where alternative healing can take place but where allopathic public health interventions can also be situated. This ability to shift medical images and implications on the part of bilingual and, therefore, bicultural speakers heightens their awareness of their very constructedness. Thus we may be able to explain what has become called the “Hispanic paradox.”27 With higher poverty rates, less education and worse access to health care, health outcomes for Hispanics, especially Mexicans, were equal to or better than those of non-Hispanic whites. Even accounting for the artifacts of epidemiology, such as census undercounts, misclassification of deaths, and emigration, does not alter the underlying paradox. What are the cultural protective factors? Without underplaying the importance of social and economic factors in the overall health of a community, bilingualism and the resultant cultural sensitivity may well play a significant role. When we look at social practices that impact on health such as smoking, MexicanAmericans, according to the yet unpublished work of Barry Chiswick, an economist at the University of Illinois—Chicago, smoke significantly less than any other immigrant group present today in the U.S. Among Mexican immigrants, they find lower levels of smoking than the native born, and while the gap diminishes with duration, it never closes. Among immigrants from the former Soviet Union, smoking levels are higher than the U.S.-born; the difference diminishes with duration in the U.S., but never closes. A similar but weaker effect is found among Middle Eastern immigrants. Generally there is a tendency for those who come from low or high smoking countries to have low or high smoking levels at arrival; while their smoking increases or decreases with duration, the gap never closes. Immigrants and natives have similar responses to changes in incomes and prices.28 According to one more general study, “Hispanics” as a group (not a very good cultural or linguistic category) smoke more the more they are integrated into American culture. At

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that point, they stop being “Mexicans” and become “Hispanics,” as Hispanics are generally understood as linguistically acculturated to a greater degree. While gender plays a major role in who smokes, girls smoke more than boys among 6th and 7th graders, bilingualism and biculturalism also continues to play a defining role. Highly acculturated “Hispanic” adolescents smoke more than truly bilingual or less acculturated ones. Thus the better one can see both sides of the cultural divide through bilingual competence, the less likely it is that you will smoke.29 One further example of the “Hispanic Paradox” is that highly acculturated Mexicans have a markedly higher rate of obesity in the U.S. than their Mexican cousins. For example, Mexican-born men and women in the U.S. have the smallest waist circumference; true bilinguals, Mexicans who are American-born speakers of English have intermediate waist circumference, but U.S.-born Spanish speakers have the largest waist circumference. Again, gender plays a role, as men are always larger than women.30 The corollary is that Type II diabetes, often the result of obesity, is best treated through education with a bilingual community health worker than with monolingual ones.31 Again being able to bridge the gap, being able to see both sides of the cultural divide, makes one less like to be overweight and, if overweight, more likely to undertake an effective remedy. Bilingualism is an important part of the world of health and illness. Whether in diagnosing and treating, in defining or describing, the question of multilingual (and cultural) competence may serve as an advantage. It may explain resistance to certain social practices or provide a model for how health care can be better (or at least, well) delivered. Bilingualism in a multicultural world means being attuned to the specificity of the needs of any given patient or client. Being bilingual is one more way of speaking about “holism,” that buzzword at the center of a reconceptualization of medicine as reflecting the totality of the individual. Language use remains a core aspect of this totality, often overlooked or denied, but central nevertheless. Given its importance, it is vital that we continue to stress the role of bilinguals in our often-monolingual society. Endnotes 1 “Over on The East Side,” The New York Times (27 August 1895): 13. 2 Report of the Managers of the Jews’ Hospital, Mile End (London: J. Tyler and Co., 1816). 3 G. Black, Lord Rothschild and the Barber: The Struggle to Establish the London Jewish Hospital (London: Tymsder, 2000), p. 31. 4 C. A. Reeves, Insanity and Nervous Diseases amongst Jewish Immigrants to the East End of London, 1880–1920, (Diss., University of London, 2001), p. 31. 5 R. Lester, “Thy Needy Brother”: Jewish Welfare in Manchester, c. 1884–1904: The Jewish Ladies’ visiting Association and the Manchester Jewish Hospital (London: The Author, 2005), p. 42. 6 Ibid, p. 43 quoting the Jewish Chronicle, 14 September 1900. 7 See the general discussion in K. Waddington, Charity and the London Hospitals, 1850–1898 (London: The Royal Historical Society, 2000), which does not discuss any of the Jewish medical structures. 8 J. H. Stallard, London Pauperism amongst Jews and Christians (London: Saunders, Otley, and Co., 1867), p. 5. 9 Ibid, p. 21. 10 Ibid. 11 Ibid, p. 63. 12 Black, p. 3. 13 Ibid, p. 11. 14 Lester, p. 26. 15 D. Porter, “’Enemies of the Race’: Biologism, Environmentalism and Public Health in Edwardian Britain,” Victorian Studies 34 (1991): 159–174.

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16 A. Kalet, F. Gany and L. Senter, “Working with Interpreters: An Interactive Web-based Learning Module,” Academic Medicine 77, No. 9 (2002): 927. 17 N. Bernstein, “Being a Patient: Recourse Grows Slim for Immigrants Who Fall Ill,” The New York Times (March 3, 2006). 18 A. Pavlenko, Emotions and Multilingualism (Cambridge: Cambridge University Press, 2005). 19 B. J. Sadock and V. A. Sadock, eds., Kaplan & Sadock’s Comprehensive Textbook of Psychiatry, 7th ed. (Baltimore: Williams & Wilkins, 1998): 25.3. 20 M. Robinson and P. Phillips, “An Investigation into the Perceptions of Primary Care Practitioners of the Education and Development Needs for Communicating with Patients who May Not be Fluent in English,” Nursing Education Today 23, No. 4 (2003): 286–98. 21 B. R. Chiswick, Y. L. Lee, and P. W. Miller, “Immigrants’ Language Skills: The Australian Experience In a Longitudinal Survey,” International Migration Review 38 (2004): 611–54 as well as B. R. Chiswick and P. W. Miller, “Linguistic Distance: A Quantitative Measure of the Distance Between English and Other Languages,” Journal of Multilingual and Multicultural Development 26 (2005): 1–11. 22 See the 1995 survey, “Report on Research Project-Access Through Medical Interpreter and Language Services,” conducted by the New York Taskforce on Immigrant Health for the U.S. Department of Health and Human Services at http://www.hhs.gov/ocr/atmil.htm. 23 A. D. Monroe and T. Shirazian, “Challenging Linguistic Barriers to Health Care: Students as Medical Interpreters,” Academic Medicine 79, No. 2 (2004): 118–22. 24 J. Drouin and C. Rivet, “Training Medical Students to Communicate with a Linguistic Minority Group,” Academic Medicine 78, No. 6 (2003): 599–604. 25 G. Drennan and L. Swartz, “The Paradoxical Use of Interpreting in Psychiatry,” Social Science and Medicine 54 (12) 2002: 1853–66. 26 A. Fadiman The Spirit Catches You and You Fall Down (New York: Farrar, Straus and Giroux, 1998). 27 L. S. Morales, M. Lara, R. S. Kington, R.O. Valdez, J.J. Escarce, “Socioeconomic, Cultural, and Behavioral Factors affecting Hispanic Health Outcomes,” Journal of Health Care for the Poor and Underserved 13, No. 4 (2002): 477–503. 28 M. Wenz, B. R. Chiswick and J. Tauras, “Smoking Among Immigrants in the United States,” unpublished paper in progress, Department of Economics, University of Illinois at Chicago, 2004. 29 J. A. Epstein, G. J. Botvin and T. Diaz, “Linguistic Acculturation and Gender Effects on Smoking among Hispanic Youth,” Preventive Medicine 27, No. 4 (1998): 583–9. 30 J. Sundquist and M. Winkelby, “Country of Birth, Acculturation Status and Abdominal Obesity in a National Sample of Mexican-American Women and Men,” International Journal of Epidemiology 29, No. 3 (2000): 470–7. 31 E. Corkery, C. Palmer, M. E. Foley, C. B. Schechter, et al, “Effect of a Bicultural Community Health Worker on Completion of Diabetes Education in a Hispanic Population,” Diabetes Care 20, No. 3 (1997): 254–7.

References Bernstein, N. “Being a Patient: Recourse Grows Slim for Immigrants Who Fall Ill.” New York Times, 3 March 2006: A1. Black, G. Lord Rothschild and the Barber: The Struggle to Establish the London Jewish Hospital. London: Tymsder, 2000. Chiswick, BR and PW Miller. “Linguistic Distance: A Quantitative Measure of the Distance Between English and Other Languages.” Journal of Multilingual and Multicultural Development 26 2005: 1–11. Chiswick, B. R, YL Lee and PW Miller. “Immigrants’ Language Skills: The Australian Experience in a Longitudinal Survey.” International Migration Review 38 2004: 611–54. Corkery, E., C. Palmer, ME Foley, CB Schechter, “Effect of a Bicultural Community Health Worker on Completion of Diabetes Education in a Hispanic Population.” Diabetes Care 20, no. 3 1997: 254–7. Drennan, G. and L Swartz. “The Paradoxical Use of Interpreting in Psychiatry.” Social Science and Medicine 54, no. 12 2002: 1853–66. Drouin, J. and C Rivet. “Training Medical Students to Communicate with a Linguistic Minority Group.” Academic Medicine 78,no. 6 2003:599–604.

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Epstein, JA., GJ Botvin, and T Diaz. “Linguistic Acculturation and Gender Effects on Smoking Among Hispanic Youth.” Preventive Medicine 27, no. 4 1998: 583–9. Fadiman, A. The Spirit Catches You and You Fall Down. New York: Farrar, Straus and Giroux, 1998. Kalet, A., F. Gany, and L. Senter. “Working with Interpreters: An Interactive Web-based Learning Module.” Academic Medicine 77, no. 9 2002: 927. Lester, R. “Thy Needy Brother”: Jewish Welfare in Manchester, c. 1884–1904: The Jewish Ladies’ Visiting Association and the Manchester Jewish Hospital. London: Author, 2005. Monroe, AD and T Shirazian,. “Challenging Linguistic Barriers to Health Care: Students as Medical Interpreters.” Academic Medicine 79, no. 2 2004: 118–22. Morales, LS, M Lara, RS Kington, RO Valdez, and JJ Escarce. “Socioeconomic, Cultural, and Behavioral Factors Affecting Hispanic Health Outcomes.” Journal of Health Care for the Poor and Underserved 13, no. 4 2002: 477–503. “Over on The East Side.” New York Times. 27 August 1895: 13. Pavlenko, A. Emotions and Multilingualism. Cambridge: Cambridge University Press, 2005. Porter, D. “‘Enemies of the Race’: Biologism, Environmentalism and Public Health in Edwardian Britain.” Victorian Studies 34 1991: 159–174. Reeves, CA. Insanity and Nervous Diseases Amongst Jewish Immigrants to the East End of London, 1880– 1920. Dissertation: University of London, 2001. Report of the Managers of the Jews’ Hospital, Mile End. London: J. Tyler and Co., 1816. Robinson, M and P Phillips. “An Investigation into the Perceptions of Primary Care Practitioners of the Education and Development Needs for Communicating with Patients Who May Not be Fluent in English.” Nursing Education Today 23, no. 4 2003: 286–298. Sadock, BJ and VA Sadock, eds. Kaplan and Saddock's Comprehensive Textbook of Psychiatry, 7th ed. Baltimore: Williams and Wilkins, 1998. Stallard, JH. London Pauperism Amongst Jews and Christians. London: Saunders, Otley, and Co, 1867. Sundquist, J. and M Winkelby. “Country of Birth, Acculturation Status and Abdominal Obesity in a National Sample of Mexican-American Women and Men.” International Journal of Epidemiology 29, no. 3 2000: 470–7. United States Department of Health and Human Services. “Report on Research Project-Access Through Medical Interpreter and Language Services.” New York Taskforce on Immigrant Health, New York University School of Medicine (1995). http://www.hhs.gov/ocr/atmil.htm. Waddington, K. Charity and the London Hospitals, 1850–1898. London: The Royal Historical Society, 2000. Wenz, M, BR Chiswick, and J Tauras. “Smoking Among Immigrants in the United States.” Unpublished Paper in Progress. Department of Economics, University of Chicago, 2004.