Language Access Part 3: Strategy, Policy & Resources - WNC Health Policy Podcast Ep. 7
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Under federal law, language access is a legal obligation for all recipients of federal funding. However, because “many healthcare providers are not aware of their responsibility, have not prioritized the issue, or have not been held accountable through consistent enforcement of these laws,” language barriers remain a significant challenge for many Western North Carolinians.
Home to over 70 different languages and high levels of illiteracy, communication barriers in healthcare facilities make accessing healthcare difficult for a large portion of Western North Carolina.
Between differing spoken languages, cultural contexts, physical means, and literacy, language access is one tool that can improve health outcomes in WNC. To learn more about language access in our region, join us for the final installment in our WNC HPI Language Access podcast miniseries.
Transcript
AR: Andrew Rainey (host)
RM: Rosalia McHattie (WIN Interpreter Network)
MR: Monserrat Ramirez (Cenzontle Language Justice Cooperative)
AV: Aaron Vidaurri (Buncombe County DHHS)
LK: Dr Leah Karliner (UCSF)
RW: Rosalyn Wasserman (MAHEC)
MW: Maggie Woods (Division of Broadband Access & Digital Equity)
GR: Gretchen Ramirez (Division of Broadband Access & Digital Equity)
Introduction
AR: You're listening to the Western North Carolina Health Policy Initiative podcast. I'm Andrew Rainey. In each installment we’ll speak about different public health strategies for improving health and well-being in Western North Carolina (WNC).
Recorded between the studios of AshevilleFM and the mountainous internet waves of Appalachia, in this installment, Part 3 of a 3 Part miniseries about language access and healthcare in WNC.
If you’re new to this conversation and listening on the HPI website or a podcast app, I recommend you listen to Parts 1 and 2 first to get a broad picture of the topic and hear about whats working and not working in WNC. However, if you’re listening on the radio, stick around but know that some of your questions may already have been answered in an earlier episode. Go to www.wnchealthpolicy.org to check those out.
Now, in Part 3, we’ll hear about recommendations for improving language access in WNC and different resources recommended by our guests to get started on building language access.
It’s important to note here that some of the policies and strategies we’ll hear about today impact a small portion of the total population with language access needs. However, while a few conversations focus on spoken language access, the underlying policy stands to benefit all North Carolinians.
Let’s start with a quick re-introduction of each of our recurring guests who we’ve had on each installment of this series:
RM: My name is Rosalia McHattie, I’m the Health Access Programs Manager at the Western Carolina Medical Society
MR: Hi my name is Monserrat Ramirez I’m one of the founding members of Cenzontle Language Justice Cooperative.
AV: My name is Aaron Vidaurri. I’m the Language Access Coordinator for the Buncombe County Health and Human Services.
AR: As a disclaimer, all guests were recorded at separate times! While everyone is featured in each installment of this series, different sections will feature different guests more heavily.
Strategy and Policy
AR: In the last installment, we heard a list of challenges that are facing WNC in providing language access. We won’t touch on all of them again here, but we’ll think about policy strategies and resources WNC by fitting them into four broad categories, each featuring both new and recurring guests.
The first is COST. We’ll hear about a recent study out of California showing how language access can provide savings for the institutions using it. We’ll also look at organizational strategies being used in Buncombe County to help manage costs.
The second category is WORKFORCE & TRAINING. We’ll learn of two opportunities to train medical interpreters, as well as potential state legislation to improve medical interpretation quality.
Third is INFRASTRUCTURE. While we heard some about clinical infrastructure in Part 1, in this installment we’ll speak with a state division that is working on broadband infrastructure projects across the state and in WNC.
And the last and maybe most important category today is OUTREACH. We’ll hear more from Cenzontle language justice cooperative, and opportunities for making a better connection between healthcare facilities and our multilingual region.
COST
AR: Let’s jump in with cost. This is possibly one of the biggest obstacles with language access in WNC, but as we’ll see, there’s evidence that improving language access stands to save payers money, including patients, the state, and insurers.
Let’s talk now to a new guest who has researched this area.
LK: My name is Leah Karliner, I’m a primary care physician and a professor of medicine at the University of CA, San Francisco.
AR: Of course, the bay area is quite different than WNC, but Dr Karliner’s study does point to some features of interest for us in WNC. Let’s hear what they did:
LK: So in 2017, I published a study that was focused on evaluating something the hospital had done which was to provide convenient access to professional interpretation at the bedside of every patient whose preferred language was a non-English language or who had Limited English Proficiency (LEP). So, we focused on evaluating 3 things; one was 30-day readmissions, another was length of stay, and then we estimated hospital expenditures, and how they might have changed as a result of this intervention that was meant to increase access to professional interpretations.
AR: Ok, so this study is hoping to see what happens when the hospital provides interpreters in the rooms. . .how did that impact cost?
LK: Yea, so we did a little bit of a thought experiment, and we looked at the average cost of each admission for this patient population, and they went from 17.8% readmission in the beginning, to 13.4%, which is a pretty big decrease. . . and we estimated that we averted 119 readmissions, and so, had an estimated monthly hospital expenditure saving of $161,400.
AR: So by having interpreters easily accessible to patients with language access challenges, their readmission rates went down and there was a pretty high estimated monthly savings. . .
LK: By the way, we subtracted the cost of the interpreter minutes during that timeframe, so this is an expenditure savings above and beyond paying for the interpreters that allowed for those savings. . .
AR: So I’m hearing that the monthly hospital expenditures are resulting in pretty impressive savings at about $160,000/month even after covering the initial investment, but what does that actually mean for the players on the ground? Could you describe where the savings are actually felt?
LK: Yea that’s a great question. So who’s really saving the money? It’s really those who pay for the care. . . which is really the health insurance plans, which can be in a setting where with publicly health insured, it’s the public who saves the money, right? So Medicaid, Medicare, it’s the public and those payers who are saving the money. certainly, private insurance companies, as well, can be saving money.
AR: So folks who are paying for care are saving approx $160,000 cumulatively a month. Which means both the private and government insurers. I’m interested that insurance companies stand to save money here because they’re often powerful lobbyers in NC who may see a benefit in encouraging better enforcement of language access law.
Anyway, we heard they save by lowering readmission rates, but how did patients themselves save?
LK: I will say, we didn’t measure the savings for the patients, but patients lose money when they’re in the hospital. If they’re working people, they lose money by not working. If their family members need to take off, particularly if they’re non English speaking and their family member whose bilingual is a younger person who is working and needs to be present in that hospital because there’s not good interpretation - and not just to support them, you know, emotionally but also to help interpret for them, which, you know, shouldn’t be happening but often does happen - then those people are losing money in the workforce, so that’s tax money. . . .so, the downstream effects are quite large for you know for patients and communities. And it does have downstream effects for the local economy.
This doesn’t measure that this just measures what was billed for a hospitalization, so it’s really the people paying for the hospitalization.
AR: So while we’re wondering about the costs of language access, this research helps us see that once language access tools are in placethere’s some money to be saved, and that could help policy movement. Unfortunately, it seems that hospital systems often wait too long to make this sort of change. But this also gives WNC’s health systems something we can learn from.
LK: You know, most places in the country that have developed robust language access programs did so because of a lawsuit. Because when a big error is made, the Office of Civil Rights gets involved, and the settlement of the lawsuit often will insists on a more robust approach. Plus it will cost the health system a whole lot of money. And so from a financial perspective, to have a health system be proactive, realize that to invest in that is a small investment compared to having a very, very, very costly lawsuit. And so that’s just smart business from my perspective.
AR: While we see there’s both medical and financial gains to be made with language access, it can still be hard to get it off the ground. However, it turns out that some funding issues already have solutions on the policy level. Some interpretation services actually can be reimbursable. On NC’s DHHS webpage there are several billing codes that Medicaid providers can use to cover the costs. You can check out Medicaid’s website for more, but essentially, it seems that hospitals and clinics can go ahead and access some funds for language access tools.
Let’s say you have some tools already in place but the cost is heavy and you’re not sure what to do next. Here’s Aaron Vidaurri, the language access coordinator of Buncombe County’s DHHS on some organizational strategies that can help reduce costs in your budget:
AV: I guess my best recommendation when it comes to budgeting is to have it have its own line, have its own place where it’s like “ok I have to think about it, what did we spend last year?”, was it more than the year before? Is it growing?”, and if we maxed out on what we’ve allocated for it, what are we going to do? Like, we still need to provide the services, so finding out the rates and then what can you afford? If we at least think about those budgets, when the fiscal year is coming up and we’re planning them, its going to be a lot more intentional than if its just coming out of a line where all sorts of other things are coming out of. . . it needs to be in its own category on your budget.
AR: So, I’m hearing that one way of managing the costs affiliated with language access is by just making sure there’s a place for it in your organization’s budget. I guess that provides you with a range of data, too, that could help you reduce costs too right? How do you gather that information?
AV: So yeah, trying to come up with ways to track the data internally. If the software medical record system has an area to capture language preference, you know, making sure that staff are using that correctly. and as you’re moving forward as an organization, thinking about “hey where can we capture this data? how can we make sure that everybody that’s calling in is being helped?” is a key component. . .and making sure that you’re asking the people that know, so maybe its checking in like if you have a front desk area with your staff that work there, and be like, “Hey, how often does someone come in that are speaking another language and if they do, are we recording that somehow?”. Like, how does that work? Then you have to figure out a way that’s easy for staff to use, that they’re going to use it reliably, and how can you pool and share the data?
AR: So because data’s a really important part of managing cost, any organization looking at how to handle the cost of beginning language access needs to build that in.
AV: We always want to keep in mind we all have budgets to work in. So, taking steps forward and being able to plan as it grows. . .you know, maybe if you start with a small step and say alright, we’re going to have some over the phone interpretation services and start there. And then maybe you’ll say “hey this has grown our ability to reach out and bring more people in,” so then maybe you can develop having more funding. . . and then you can say alright maybe we can invest in having a nurse or some doctors that speak these languages, and make sure they are tested and certified to be able to provide care at that level. . . then that will increase the services you can provide even more or, if you can’t go that route, maybe it’s worth investing in having an interpreter on-site and see how that increases the level of care. Especially as you see what are the languages that you’re serving most. And then you can kind of focus and be like, “Ok, lets beef up around Spanish and Russian, and let’s make sure that we have over-the-phone that we can use for the other languages as they come in. . .” And just keeping in touch with the data because the language need can change and grow instantly depending on what’s happening. You can have a large influx all of a sudden of a new language that nobody is prepared for and how quickly can you adapt to have services in that language when it comes in?
AR: For returning listeners, we spoke briefly about the steps you can take to improve language access, and in this case, most efficiently use your limited resources, in Part 1 of this series, with something called language access plans. Aaron, could you recommend any resources for folks who want to look over those plans to better build language access in their organizations?
AV: Sure, yea, I mean people can reach out to me. My email is aaron.vidaurri@buncombecounty.org . I’m happy to help and provide any information that I can. LEP.gov is the government website that has all the information on language access, they have sample plans, so it’s a great resource to tap into. It talks about 4 factor identification for your languages to help you really be able to identify: “what are the languages I need to be assisting?” “What are the primary languages that we encounter?” Loads of resources to figure out how to just start this journey in language access. So you, know, definitely a site to visit.
There’s also plainlanguage.gov, if you’re interested in more information about plain language and how you can make sure that the materials you are writing are easy to follow. And there’s a lot of intersect between that and language access, you know, and how it gets to having your documents translated. If you can make that source English be clear and concise and accurate, its going to help with the message as it gets translated into other languages, and it will also help with the cost of the translation, because if your message is shorter and more concise its going to be less expensive to translate.
AR: As a quick recap, we have an example of language access tools can save a health system and payers a lot of money. And organizations that want to start create a space for it in your budget, set up ways to track data internally, and use plain language, which not only improves the quality of access for any kind of language user, but also reduces the cost of translation. . .
After the break we’ll revisit another policy and strategy area on language access in healthcare by examining workforce and training opportunities.
BREAK
[musical humming]
Hi everyone, Andrew here on the WNC HPI Podcast, the show that looks at public health strategies to improve health in WNC. We’ve been talking about cost and language access with Dr Leah Karliner and Buncombe County’s Language Access Coordinator, Aaron Vidaurri.
Be sure to check our website at www.wnchealthpolicy.org for the transcript or to listen again. Coming up, we’ll be hearing about workforce development in WNC. . .
And now back to the show:
WORKFORCE & TRAINING
AR: Before the break, we heard how one 2017 evaluation found that language access tools actually save payers like insurance companies and patients money while improving access to care! It turns out that it can also stands to positively impact another big challenge in WNC’s healthcare systems: the workforce.
LK: There’s a lot of data in a lot of different settings to show that use of trained interpreters increases satisfaction with clinical encounters for both patients and physicians. And certainly its not just about physicians but its also about the other healthcare team members, of course, right? And nursing staff is so important in this situation, as well. . .
AR: As NC, like the rest of the US, is and has been facing massive healthcare workforce shortages in nursing, behavioral health, primary care and public health, and burnout is one of the factors impacting these workers, it turns out that having better language access programs could also contribute to workforce retention by improving workplace satisfaction.
LK: It costs so much less to provide the interpretation minutes than to have someone readmitted to the hospital. And staff weren’t focused on cost - they were focused on quality of communication, quality of care delivery, that they could do their jobs well, which they really care about. And that impacts their experience, their satisfaction with their job. . .
AR: So to reduce workforce burnout and cost, we also need to think about how to increase our language access workforce in our region. . . Here’s Aaron again:
AV: One of the big challenges is finding and maintaining bilingual staff that are qualified in those positions. It’s expensive to live around here so opportunities come up and they’re going to move on, so staffing is always difficult. . . So being able to have incentives. .. like, we’re piloting and we’ve started a bilingual pay incentive program with the county so if you speak another language, you have to pass testing and show that you’re qualified to do your role in the other language. You get a stipend on top of what you’re already getting for being able to speak it.
Then also training goes a long way.
AR: So better incentives are important and then the training, which could mean letting your staff know the proper procedures for calling in an interpreter, using "I Speak…" cards, and other strategies mentioned in Part 1 of this series. However, in this section, we’ll look specifically at training to become a medical interpreter for spoken languages. And it turns out there’s at least a couple training opportunities right here in WNC:
AV: I know that MAHEC has a program for medical interpreters. My staff has taken some courses through them in the past.
RW: MAHEC is one of 9 AHECs across the state of NC - the Mountain Area Health Education Center, or MAHEC.
AR: MAHEC serves a 16-county region in Western North Carolina and is the largest Area Health Education Center in North Carolina. It evolved to address national and state concerns with the supply, retention and quality of health professionals and along with the NCCHW and the Dogwood Health Trust, supports the Health Policy Initiative. We’ll go now to Rosalyn Wasserman to learn about some current opportunities for expanding the interpreter workforce in WNC:
RW: My name is Rosalyn Wasserman. I’m a continuing education planner here at MAHEC. My division offers and has for years and will hopefully continue to offer for years a professional medical interpreter training series. It’s at least 40 hours; we offer it at least twice a year, in the winter and in the summer.
AR: As we’re talking about programs and resources for addressing the language access workforce in WNC, could you tell us about who you’re looking to bring into these medical interpretation classes?
RW: The classes are designed for bilingual individuals who currently provide interpreter services or intend to provide interpreter services in any language, in any health or human services settings. . . As well as interpreters, supervisors or anyone who writes or implements Title VI compliance policies.
Sometimes we get healthcare providers, often times it’s just bilingual individuals who have been pressed into service with their own loved ones or neighbors who have limited English proficiency (LEP), and they realize they don’t know the terminology and there’s a lot more to it than just knowing the language. . . there’s terminology, and ethics, and professionalism, and there’s a lot that goes into correct medical interpretation.
AR: Could you speak to some of the benefits this kind of training would add?
RW: Well in addition to the obvious benefits to that interpreter, the patient and the provider, this is a workforce development issue. These are bilingual individuals and that’s a bonus in many healthcare settings. . . and to be able to learn to do it properly is. . they’re investing in their own careers as a professional medical interpreter. . . This training opens up whole new vistas for them. Most local employers recognize the training we do, and that gives them a bump in the hiring. Also, both series that we offer, offer the number of hours required so that individual can take national board certification by one of the 2 national entities: IMIA [International Medical Interpreters Association] or CCHI [Certification Commission for Healthcare Interpreters].
AR: NC doesn’t require a particular level of medical interpretation. Could you describe what that national board certification offers?
RW: And that national board certification preparation is important and its also a wonderful tool to have because many of the larger health systems in NC, and certainly at the national level, are requiring their medical interpreters to be nationally board certified.
AR: Could you tell listeners about what attending the sessions is like?
RW: Our series this year and in previous years, pre-COVID, were all in person, and then during COVID we switched to live webinars and a combination of live webinars and self-study. And MAHEC is one of a few of the NC AHECs who offer this across the state, and some of them are continuing with that hybrid format of self-study and a live webinar with an instructor as part of the training . . . but for our in person training they should anticipate very lively discussions. We have two instructors who teach 2 different curriculums - they are experts and medical interpreters themselves - and there’s a lot of discussion and interaction and a learning of language that is specific to health and human services. And it’s also a support - there’s a camaraderie that develops among people who are bilingual with each other - and then they can form study groups and continuing their education on their own. Because one thing with medical interpretation, you never stop learning. There’s always new medical terminology or policy changes or disease updates or medication changes, and they really have to be up on the terminology that goes along with that. So its a lifelong study.
AR: Across WNC, Spanish, Russian, Ukrainian, and American Sign Language (ASL) are the biggest language groups requested. In what languages are these medical interpreter trainings offered?
RW: For both series, the courses are taught in English with the exception of our summer series - the medical terminology class is taught in Spanish, so you do have to be Spanish-English fluent. But the rest of the courses are in English and for any language pairing. And we see a similarities of interpreters who come to our trainings not only from our region but from beyond across the state - those are primarily the languages.
But other parts of the state have other language paring needs. Among the Hmong people, we have the Marshall Islands, Marshallese, Indian Gujarati dialects. And also Central and South America - individuals don’t always speak Spanish, sometimes there are indigenous languages and that’s also can be included in the training we do, because you’re learning to interpret in your language and building your own base of language. But I remember in one class a few years back, we had 12 distinct language pairs represented in WNC. It isn’t just Spanish, Russian or Ukrainian – there are other language pairs. But those predominantly come to the forefront, yes.
AR: I can imagine that some bilingual folks might be hesitant to take classes due to cost, is that considered in these courses?
RW: Certainly, thank you for asking about that. We’re able to offer discounts for staff who work at nonprofits or school systems or governmental entities - health departments, for example. We also believe in learner-based education that we also offer a discount for full-time students so if someone is juggling classes at a community college or university and wants to take this training and is bilingual, there’s a way for them to be able to afford it.
That said, it sure would be nice if we had some sort of scholarship fund established for this. It’s so vital to the health and wellbeing of our friends and neighbors, and we have these bilingual individuals who are interested and capable of learning and then applying this within their communities, which is our community. . . and sometimes they just don’t have it, or they aren’t working as an interpreter at a nonprofit, or they aren’t in school, and they are paying for it out of their pocket. . .and it sure would be nice to have some sort of scholarship fund set up.
But as I’ve said, we try to keep the cost so it is affordable. Because remember - it is 40+ hours of training, so it’s a lot of bang for your buck. You get a lot of good information out of this series..
AR: How can people learn about current medical interpreter trainings at MAEHC?
RW: So, you can just go to MAHEC.net/interpreter [redirects to: https://mahec.net/home/event/72252] and that will connect you with either our winter or summer training, whatever is coming up next. And then with the other NC AHEC’s who offer this also throughout the year, you can just put into your search engine “NC AHEC course catalogue” and then in your search terms, ‘medical interpreter.’
I should say too in addition to the NC AHEC offerings, other entities outside of the NC AHEC system do offer online and other trainings as well.
AR: And actually, the WIN Interpreter Network is another trainer group in WNC. Here’s Rosalia again:
RM: Recently we received a grant, and our goal, if we are able to renew this grant, is to be able to provide training to people that speak more than one language - like if they are bilingual in English, as well. . . WIN has been licensed to become training for them to become interpreters and spread in that area. We have been licensed to begin training, it’s just that we need to have more people trained to be able to get schedules and to perform with different groups in different areas. Because it’s not only in the city of Asheville - we want to go to different cities. I know there’s a request from Marion, as well, that is asking us to start a training session and we’re working on that, we’re getting 2 more interpreters to get certified as trainers as well.
AR: So folks can reach out to WIN, as well as MAHEC, to learn about upcoming interpreter training opportunities! We heard about MAHEC’s website, but Rosalia, can you share how folks can contact WIN about interpreter trainings?
RM: Number one, they can look for our website, mywcms.org, and they can look for language services and that’s the whole information on what we do about language access. And also if they want to be apart of our interpreters group they can contact us.
AR: We’ve really just been speaking about spoken language access workforce development, but this is a good time to flag that there a multiple areas for workforce development around language access, including folks with physical constraints:
RM: I know the NC DHHS, which is the Deaf and Hard of Hearing Services. . .
AR: There are two Centers for the Deaf and Hard of Hearing in WNC, including one in Asheville and the other in Morganton. Both gave excellent presentations to the HPI Friday Forum in the fall of 2023. We were reminded that there are many different kinds of languages used within this community, although ASL is perhaps the best known.
RM: …then also the ASL community has this RID. . .
AR: RID the registry of interpreters for the deaf. This is available by the state of NC. The North Carolina Interpreter and Transliterators Licensing Board keeps records of the 475 licenses issued in the state for 2024. A policy opportunity exists in the state adopting a similar standard for medical interpreters of different spoken languages, such as the national certification.
AV: The fact that there’s not like “hey, here’s this one testing you’ve gotta have this, there’s a law.” But even then, you’ll still run into, like, this person has a degree from a university, but this person may not have that degree but they’ve been interpreting for years, so then they have like 20 years of experience of interpreting where its gone really well. But yeah, certification is tricky cause there’s not one standard way of being certified.
AR: So one policy venture here is adopting a certification process like that on the national level, and then building pathways for bilingual folks to enter that interpreter workforce.
Before moving on from workforce and training policy areas, I want to plug that there’s a lot more work to talk about with workforce development than we covered here. If you listen back to Part 1 of this series, you’ll hear insight into trainings needed by all staff to ensure appropriate use of personnel.
The Centers for the Deaf and Hard of Hearing in Buncombe and Burke Counties can also provide great information.
I would also recommend listeners to check Part 2 of this series to hear more about how Community Health Workers are an important part of this language access workforce.
And to quickly cite an area beyond our scope here: education is another huge policy area that’s important to involve in this conversation given the 18.7% of WNCians with low levels of literacy in English.
Of course, in the near future, to look at sustaining our workforce in any field, we’ll need to think about language:
AV: I was at a meeting in Raleigh and they had someone from the State Demographers Office, and they had been working on projections for population growth like 10, 20 or 30 years out. And the fastest growing populations were gonna be Spanish-speaking, and they were the only also populations where the average age was getting younger.
AR: Everywhere in NC, then, needs to look at multilingualism for businesses and infrastructure to grow and flourish.
After a quick break, we’ll hear about a third area of strategy and policy development that intersects with language access: infrastructure. . .
BREAK
[musical humming]
Hi everyone, Andrew here on the WNC HPI Podcast, the show that looks at public health strategies to improve health in WNC. We’ve been talking about language access workforce with Rosalyn Wasserman of MAHEC, Rosalia McHattie of WIN, and Buncombe County’s LAC, Aaron Vidaurri.
Be sure to check our website at www.wnchealthpolicy.org for the transcript or to listen again. Coming up, we’ll be hearing about the intersection of broadband infrastructure and language access. . . .
And now back to the show:
INFRASTRUCTURE
AR: We heard before the break how there are a couple of training opportunities for bilingual folks to become medical interpreters in WNC. As we wait for this workforce to expand, we’re needing to look for other ways to meet the needs on the ground. Here’s Rosalia:
RM: Yea, we have a very big community of Vietnamese speaking people, and that is one of the things I am looking for. I mean, I am trying to find an interpreter in the area that speaks Vietnamese, but unfortunately we haven’t been successful so we need to use telephone service for that.
AR: Without local interpreters, another strategy for WNC, as Rosalia mentioned, is using technology. It doesn’t replace the need for trained interpreters, but it it does expand access to our current workforce. Here’s Aaron again:
AV: The easy fix is the over-the-phone interpreters and it goes a long way . . . . but its not always going to be successful, especially if you’re out in the field and there’s not good internet or reliable cellphone service. So you might have to have an in person interpreter in that situation because you can’t access it over the phone or you can’t do a video remote.
AR: This leads us to our 3rd policy area for this show: Infrastructure. Inconsistent internet access - whether cables and wires, the cost of network, a computer or phone, or the digital know-how - is referred to as the digital divide. This a big issue for getting spoken language interpreters into rural areas, but it also impacts all North Carolinians! Brought into the spotlight following COVID-19, one state executive order sought to address health inequities across our state and in WNC by “increase(ing) broadband access and to address digital, financial, and health literacy.”
GR: So there was an Andrea Harris Equity Task Force, that drove the ideas of digital divide. Governor Cooper - that was a task for he did - and then they went from that into “we have a need” and they established the Office of Digital Equity and Literacy. It was originally a party of 3, and they were trying to get things done. And eventually it grew into what it is today.
AR: That’s Gretchen Ramirez
GR: I’m with the broadband infrastructure office which is under the Division of Broadband Access and Digital Equity, and I previously came from the Office of Rural Health, so I do a little bit of a health background. And I’ve worked on some projects in WNC to improve access to health as well as broadband.
AR: Could you tell us about the projects this executive order has brought to WNC?
GR: Well, I'll say, one of the first things that the broadband infrastructure office has been doing is is running grant programs. We have a lot of money that's come into the State to be able to offer to communities. One of the programs we're doing right now is the CAB program, It's Completing Access to Broadband, where we're working with individual counties. To get proposals in from Internet service providers that meet their needs. And then kind of going through an evaluation process. I will say that 8 of the counties that are currently participating in phase one are in Western North Carolina: Avery, Burke. Haywood, McDowell, Buncombe, Swain, Macon, and Polk.
They came and said, “You know, we are interested in this.” The program is currently ongoing right now, so there's no awards that have been made yet. But it is a process. So, for instance, let me see Haywood County so, or Haywood or McDowell - they're in round one. So the proposals closed. And now we are working with evaluation teams to evaluate the proposals. And even though the the grant will be between North Carolina DIT and the Internet service provider, we are taking the information and the the influences from the county cause. They know what they need the most in this evaluation process to really partner and try to find the best solution for their county with the money that's available.
AR: So this relatively new division is connecting individual counties with grant money, and currently 8 of the counties in WNC are in process to receive this money to bring in broadband infrastructure. To keep learning about this division, we’re joined by a colleague of Gretchen’s.
MWL I’m Maggie Woods, I’m deputy director of the NC office of Digital Equity and Literacy so we’re sister offices with the office that Gretchen is a part of, the broadband infrastructure office and so were focused on all other elements of the digital divide, making sure that people can afford the internet, that they have the devices they need have the digital skills to use those devices, and then to ensure that that online content is accessible and good for everyone.
I will just note that Gov. Cooper has made closing the digital divide a key part of his policy agenda and so in establishing the NC Office of Digital Equity as a part of the new division on broadband and digital equity, we became the first state in the nation to have an office of digital equity and we remain the only state I believe to have such an office.
AR: Because the Governor and the General Assembly are of different political persuasions, how likely is broadband access work to continue should their be a political change in an upcoming election?
MW: Closing the digital divide is a bipartisan issue. And our legislature has been a leader in ensuring that this division has the funding that it needs. The funds are federal, as well, and so, even with the change of Governor, our offices or our division should remain the same.
AR: And I guess federal funding also takes it out of typical state budget concerns?
MW: Currently all of our funds are coming either from State appropriated ARPA funds - so, American Rescue Plan Act - or from the infrastructure Investment and Jobs Act funds, both offices in the division. And I just wanted to piggyback off of what Gretchen said around, you know, the goal of ensuring that 100% of households and businesses have internet, is that between the funding that we have from these different sources, we believe we can get there by the end of 2029. So we believe that the infrastructure challenge, at least the challenge that we're seeing today, will be solved at that time.
AR: That’s huge - resolving current broadband infrastructure challenges statewide by 2029! How can our listeners learn more about this policy work, and how it might play out in the counties of WNC?
MW: We do have a map of all of the counties that have digital inclusion plans, which includes every single county in Western North Carolina. And you can connect with the leads of those planning processes. So if you haven't been a part of the planning process, and you think that you need to be involved in this work - and you probably do if you're listening to this - we can make sure that you are connected to the right people, and you can always reach out to our office as well and make sure you're connected. And then, importantly, there have been several funding opportunities available to nonprofits, local governments, regional entities, schools across the State, and more are on the horizon. So through our office, we expect more funding opportunities to be released in early 2025. There’s also some federal opportunities coming up, as well. So, highly encourage you to stay connected to our office, and make sure your connected to those networking opportunities and those funding opportunities.
OUTREACH & EDUCATION
AR: We hope to hear more about broadband access and digital equity in a future installment of the podcast, but until then, we’ll finish up with one more area of work that is critical both to language access as well as all other facets of healthcare: Outreach. This is a key area - and often underdeveloped area - for healthcare systems
LK: It impacts patient experience, which we know is super important. Patients’ trust of the medical system, and trust of the medical system that impacts their future health, because then they come back in appropriately, they prevent future illnesses, they treat them early on. So there’s real impact when people end up in the hospital that we don’t think of on the healthcare side. You know, we're focused on the patient, trying to get them, well, trying to get them body care, try and get them out the door, so that we have a bed for someone else who needs it. But we don't think often enough about how much that can impact patient and their family.
AR: We’ll turn now to Monse Ramirez of Cenzontle Language Justice Cooperative to hear some on ways for healthcare entities to build better relationships with our language-rich region:
Monse, we’ve probably saved some of the most important parts of this conversation for last. Thanks for being here. Could you speak about outreach efforts and strategies medical organizations could consider?
MR: yeah, like, whenever I think of that question and the strategies, outreach definitely comes to mind, how they're doing that relationship building a lot of the times.
I was recently interpreting for one of the Language Access Collaborative meetings, and there was this beautiful panel where local organizations who do work with immigrants, with refugees. And one of the questions was about, “how can the local governments work and do better to connect with immigrant and refugee communities?” And one of the panelists said that a lot of the times people are literally fleeing and running away from their countries because of their government, and the lack of trust or fear about their government. And they come here to the US and probably aren't gonna trust the government because of their lived experiences. So, a lot of the ways that organizations do outreach is not gonna hit that population because of people's lived experiences, because of the lack of trust, because of the trauma that people have faced.
So, you have to get a little creative, you have to really do the work, and it takes work to connect and build relationships, and truly bring people in. It's not just gonna be like, “okay, I'm gonna post it on Facebook, or I'm gonna post it on our church’s bulletin board,” because the people that are you're trying to bring in, that you're trying to connect with, that really do need access to these resources are not gonna go look at that bulletin board, their not gonna go to that website, in order to get that information. So getting creative is something that people should be thinking about.
Language Justice Framework
AR: As Cenzontle is a Language Justice Cooperative, could you tell us about how language justice is different than language access? And while it’s not a policy, how that framework can improve services in WNC?
MR: So for us, here at Cenzontle, language access and language justice mean 2 different things. Language Access doesn't truly do that outreach or that cultural competency in order to be able to meet people where they are. . . A lot of the times it's just for people who don't speak English. . . . whereas language justice really takes it a step further. Language justice pairs interpretation and translation with an analysis of how power operates through language. . . .so, it really takes into consideration all the different creation of tools and strategies for survival and transformation. It has a lot to do with allowing people to exist in their full identities and be able to communicate and be heard in the language that they feel the most comfortable and powerful in. . .
…and part of the definition that we use talks about verbal and nonverbal languages. I would say, just to take it a step further, it's not just for people who don't speak English. It's even for English speakers. We have a lot of conversations about what even proper English and proper Spanish is. . . we talk a lot about all the different nuances and the ways that people express themselves, the ways that they speak, even in English. Who gets to decide what the proper or correct form of English is? Who gets to decide what the correct and proper way of Spanish is. Black English, indigenous languages, as well. It goes way beyond just people who don't speak English and have a need access to be able to communicate with people who do speak English. But it really is about going deeper - like, what are people's connections to language? In what ways have they been marginalized because of the way that they communicate because of the way that they pronounce things because of the way that they're expected to be or show up in spaces.
AR: So in some healthcare settings, there may already be some sense of language access tools like interpretation that are being used. But if I’m hearing you right, however, language justice provides the social context and history to the barriers that area present which may still affect the quality of health care of patients, even with an interpreter present.
MR: Yeah, it goes a lot deeper than just providing a language service for people who don't speak English. And it gets really personal, because a lot of the connections that we have with ourselves, with our family members, with our histories, has a lot of connection to language. . . We know in the US, there's been so much history of language loss because of colonialism, because of genocide. . . there have been the boarding schools for indigenous people that they weren't allowed to speak their own languages, and because of that, those languages have been lost. . . through enslavement, people being taken from their homes. Also being made illegal for people to learn how to read and write English. Even today, with immigration, with having to assimilate . . . for myself, growing up always hearing, like, "you have to learn how to speak English without an accent. . . So yeah, it's such a part of our personal history, and everyone has a connection to language. . .
AR: Elements of that ‘justice’ framework seem to resonate with some of the other strategies we’ve heard about for improving healthcare in WNC. Community Health Workerss for example, know better how to navigate those in between cultural spaces that providers may not get.
MR: And some of the components of language justice have a lot in common with what I imagine health workers do already: relationship building, outreach, training, and capacity building. And this continuous loop of implementation and evaluation . . . You have to go and find the people to get them the resources, to get them the training. . . you have to build those relationships so that there can be trust, and people know where to go, who to come to, and it doesn't happen overnight, you have to constantly be connecting, get buy-in, trying different protocols and tools in order to implement it, and then, always, having that evaluation. So I feel like the components that create a multilingual space, have a lot in common with the components to just connect with people in general. . .
AR: And Monse, would you recommend any resources for folks wanting to learn more about language justice in WNC?
MR: So, we have a creating multilingual space guide that we share with clients that goes over the different components that it takes in order to build a multilingual space and explaining how it goes beyond just providing interpretation beyond just providing translation and really being able to create a space where people are able to show up and participate to the fullest extent.
There are also other organizations that have developed similar toolkits. There is this one group called Right to the City. They have a language justice toolkit for organizers that is way longer than Cenzontle’s. They have so many tools and resources from how to hire an interpreter, to how to create an organizational assessment to be able to see where it is that you all need to grow as an organization in terms of language justice. They have different checklists, lots of things. And that's available online as a PDF there are also just some one pages that we have developed as Cenzontle on how to set up a Zoom call that will have interpretation and how to assign interpreters.
And another podcast, that I would shout out is a podcast, called ‘Se Ve Se Escuchan’ (Seen and Heard) that came out of the Center for Participatory Change. And they have many podcast episodes around language, justice, and they go into more of the personal connection with language. There's an episode about Gulah Geechee people and their language. So it got. It talks about what it means to be an English speaker, and have a connection to language what it means to be a Spanish speaker or an indigenous language speaker. It goes kinda on the the next level beyond just interpreting and translation. So that's a really good podcast too.
AR: We talked about workforce and medical training earlier, but language justice speaks to a whole other component of health and well-being. Are there other trainings you’d recommend?
MR: Cenzontle and a lot of social justice Interpreters were trained on the curriculum that came out of Highlander Research and Education Center, based in Tennessee. And from there they created a curriculum for interpreting for social justice, and a lot of us are trained up on that curriculum. It covers anything from, like, practical things, of being an interpreter. How to use the equipment, how to set up a space, but it also talks about like the ethics the the role of the interpreter. And also we have this lens of power, privilege, and oppression as interpreters.
There's, like, all these different types of situations that we get put in as interpreters that are created and caused by the lack of trust, the lack of access to resources. Those kind of situations happen every day. And I'm sure that as healthcare providers, y'all see those situations happening, maybe just in English - like, it happens. But because people are already marginalized because of language, it happens even more.
AR: Cenzontle offers non-medical interpreters, translation and consulting. You can learn more about their services at their website: cenzontle.coop.
OUTRO
AR: You've been listening to the WNC Health Policy Initiative Podcast through the NC Center for Health and Wellness at UNCA. To listen again or learn more about public health issues in WNC, check out the website wnchealthpolicy.org, or on Apple Podcasts or Spotify.
If there’s a WNC health issue that you’d like to hear more about, speak about, or comments about anything you’ve heard on an HPI podcast, feel free to send us an email at info@wnchealthpolicy.org.
A big thanks to the AshevilleFM Studios where this installment was recorded.
Another big thanks to Asheville-based Appalachian ballad singer Saro Lynch-Thomason for humming the old shape note styled ballad Lady Margaret and Evening Shade in the mid show break. You can learn more about her work and regional music traditions at sarosings.com.
Other music included in the podcast includes old ballad, Little Margaret, performed on banjo by Cath and Phil Tyler. Found on the FreeMusicArchive, it is licensed under an Attribution- Noncommercial-Share Alike 3.0 United States License.
Additional music includes the tracks Some Nights End, When the Guests Have Arrived, Lover’s Hollow, Blister Creek, Talens Bal, & Night Watch by the Blue Dot Sessions; These tracks are found on the FreeMusicArchive under license attribution international CC BY 4.0.
Be sure to check the website for more HPI podcast episodes and other resources at wnchealthpolicy.org. Thanks for listening.
