Cleveland Was Slow to Address Language and Culture Barriers to Reach Spanish-Speaking Residents During Pandemic

click to enlarge Cleveland dropped the ball in bridging culture barriers during the pandemic - Cleveland City Hall, Erik Drost/FlickrCC
Cleveland City Hall, Erik Drost/FlickrCC
Cleveland dropped the ball in bridging culture barriers during the pandemic

In the early months of the pandemic, Cleveland Councilwoman Jasmin Santana, who represents a West Side ward with the densest population of Latinos in the city, said health department officials reassured her that when the city released urgent health updates, they would be translated into Spanish.

It didn’t happen.

The city put out public releases, sometimes daily, as the pandemic evolved – about safety precautions, work restrictions, and how many people were infected with the virus – but the information didn’t seem to make its way to the Spanish-speaking residents in Santana’s ward, where close to 40% of residents are Hispanic.

When she pressed again, this time with city communications officials, Santana said she was told the city didn’t have resources for translation.
One high-ranking city official suggested Santana and her office should create Spanish-language versions to distribute, she said.

The reaction startled her.

“I almost didn’t know how to respond,” Santana said. “That's when I started really realizing, ‘You know what? This is a huge issue for the city.’ Who would have thought that a city with more than 300,000 residents wouldn’t be ready to have their communications translated?”

(A city spokesperson did respond to questions about what Santana was told.)

Santana’s concerns as a councilwoman were rooted in what she’d witnessed growing up in her community and later as a health outreach worker: that language and trust act as barriers to resources that can improve or save lives.

The COVID-19 pandemic has intensified pressure on a chronically underfunded public health system that already faced staggering disparities in access to medical care and health outcomes, especially for people with limited English proficiency.

But the crisis also has offered an opportunity, which some local health departments have embraced, to forge relationships and connections that could outlast the virus.

Cleveland, a city that declared racism a public health crisis almost a year ago, with officials vowing to tackle disparities and inequities, has seen some progress but it has been sluggish.

Despite a windfall in pandemic aid, Cleveland still has not beefed up its own contract tracing operations by adding bilingual staff. Instead, it has relied on the state health department for virtual assistance with Spanish-speaking residents and a language translation line. The health department has stepped up its efforts to provide fliers on vaccine clinics into Spanish in recent months, according to a review of its social media posts.

Tracking a virus

To control COVID-19, officials first have to know where a virus is spreading in a community.

The work of identifying and containing outbreaks starts with case investigators and contact tracers, health workers who reach out and interview people who are infected with a virus or infectious disease and people in the community who have been around them. Often lengthy and personal, the interviews include questions about work, family life and health history.

Santana realized how crucial those conversations were when her husband, who does not speak English, was diagnosed with the virus. The councilwoman asked the health department employee who contacted him for someone who spoke Spanish to talk to him about his symptoms. They told her they didn’t have anyone, she said.

“And so I had to translate everything for him,” she said.

It was awkward, she said. And it made her wonder how many Spanish-speaking residents just hung up, without sharing vital information that could help protect their families, neighbors or co-workers.

It was a question that was hard to answer. The city was posting on a public dashboard how many white, Black and Asian residents tested positive, were hospitalized or had died due to complications from COVID-19. But it did not include information on Hispanic residents.

What Santana did learn was this: Nine months into the pandemic, the health department had failed to hire a single contact tracer fluent in Spanish.
Communicating trust

The U.S. Centers for Disease Control and Prevention (CDC) recommends health authorities recruit bilingual staff from the community to work as contact tracers and community health workers to overcome language, cultural and resource barriers.

“Not only are these individuals fluent in the language of the population, but they are trusted and knowledgeable about cultural practices and societal norms, thus best able to communicate effectively,” the guidelines state.

In Cleveland, where, according to Census data from 2019, 11.9% of residents identify as Hispanic and where 14.7% speak English as a second language, community leaders like Evelyn Rivera were “floored” when they read in December in Cleveland Scene about Santana’s experience, which she shared at a council meeting.

“It was beyond imagination that [not having bilingual contact tracers] was possible with this life-and-death issue. The importance of finding out who might be spreading the virus to, it was so critical that we [had to] get involved,” said Rivera, a psychologist who has worked in the Latino community in Cleveland, Akron and Columbus for more than 30 years.

LatinOhs, a grassroots Latino coalition Rivera belongs to, sent a letter to Cleveland Department of Public Health Interim Director Brian Kimball, Mayor Frank Jackson and members of City Council demanding the city immediately hire bilingual contact tracers. It was signed by dozens of Latino residents, community organizers and concerned citizens.

The Dec. 8 letter cited grave concerns that the city wasn’t employing bilingual workers to follow up with families that might struggle to navigate the system and that language and cultural barriers left “the Latino community at a much greater risk.”

[Editor’s note: Reporter Claudia Longo was one of the community members who signed the letter.]

Waiting for answers

Prior to her election to City Council, Santana worked as a community health outreach worker, first for MetroHealth Medical Center and as part of an effort to target lead poisoning and housing-related health issues in the Clark-Fulton neighborhood.

She remembers meeting Latinas who had late-stage breast cancer – with tumors so large they were visible outside of their breasts by the time they sought treatment. Many lived within walking distance of the hospital.
“Why did you wait this long?” she’d ask.

The hospital is big, they’d tell her. They didn’t have health insurance. “They didn’t know who to talk to,” she said.

With that past experience in mind, Santana said she first appealed to city officials about the translation and interpretation issues privately in emails and personal conversations to prioritize the hiring of bilingual contact tracers and translating materials.

When that didn’t work, she started asking questions publicly during a December hearing of the council's public Health & Human Services committee meeting,

“I'm just wondering if there's any plans to hire Spanish-speaking contact tracers or if you have them already in place,” Santana asked.

Interim Health Director Brian Kimball responded that the city was “looking and searching” for people to hire and that the city was providing training to a department employee who was fluent in Spanish.

“We recognize that it has been a challenge internally so we have identified that and we're looking to correct that,” he said.

At the same meeting, Tracy Martin-Thompson, who oversees the health department, told Santana that the city had employed a “national search organization” to identify potential bilingual candidates.

It turns out, the search firm was a temporary hiring agency the city already had on contract. And the job description, which Santana requested, didn’t specify preference for any Spanish-language skills.

At the urging of city officials, Santana said she forwarded six resumes from bilingual community members to city health officials a few weeks later and was told that they would possibly hire at least three workers.

Media outlets The Land and La Mega Nota filed public records requests for emails between the councilwoman and city officials on Feb. 22 – six weeks ago – but Cleveland has not released them.

When Cleveland’s coronavirus caseloads were highest, the city had an estimated 80 contact tracers, including full time and temporary staff as well as volunteers, Latoya Hunter-Hayes, a city spokeswoman said. Currently, the health department has 14 temporary staff working as contact tracers. Hayes said the city has not hired any bilingual contact tracing staff since Santana raised the issue in December.

"We previously worked with and continue to work with a temp agency to assist us in hiring English-speaking and bilingual contact tracers. Once the agency identifies candidates who meet the requirements, they will be hired." Hunter-Hayes said.

The city did not respond to questions about whether any case investigators were bilingual.

The state has provided bilingual contact tracing help since August 2020, she said. Ohio health officials said at least two virtual contact tracers who speak Spanish have been made available to the city health department.

The city also uses a service – it’s called Language Line – to provide interpretation, Kimball said.

Language Line is essentially a three-way call using a qualified interpreter who can share information from health officials and also ask questions and get answers in a person’s preferred language.

Using the Language Line appears to meet requirements of the city’s Language Access Plan, established in 2017 in cooperation with the Legal Aid Society of Cleveland. Other health departments, like Cuyahoga County, also use it in addition to bilingual health staff.

For Santana, that type of translation isn’t enough. While it might be necessary in some circumstances, especially for languages that are less common, it shows a different level of care and commitment to residents when the city chooses to hire bilingual staff from the community, she said.

Plus, her husband was not offered the Language Line or one of the state employees, so she doesn’t know how consistently those options are used.
City leaders also have yet to respond to the letter from Rivera and other community leaders.

“At this point, I don't know exactly where we're at,” Rivera said. “I do know that we were helpful to the team in identifying potential people to take those positions. So resumes have been referred to the people that make the decisions. And now we're kind of waiting.” she said.

‘An entry point’ to culture

Inside a broken refrigerator in a Clark County duplex, where a local Hatian-Creole family quarantined last year, sat a lesson for the local public health department: spoiling meat.

The Clark County Combined Health District, which serves about 140,000 residents in West-Central Ohio, had rented the house to offer space for families to spread out to avoid exposure or isolate as they recovered from the virus.

Many of the families were non-English-speaking Mexican, Guatemalan and Hatian-Creole families who work at large plants that process and distribute food. They were at high-risk for infection because they live, travel and work in close quarters. Initially, health officials struggled to get them information about the virus.

Contact tracing initially was strained and involved making awkward three-way calls with translators, Kyle Trout, a health educator who handles communications for the district, said. During one mass testing in June, 800 people tested positive – a majority of them were Haitian-Creole or Spanish-speaking residents.

When a refrigerator in one of the duplex units burned out — twice, actually — Trout peeked inside and saw food the district provided was untouched. With the help of an interpreter, he found out why.

“It turns out it wasn’t food they would eat,” Trout said. “We realized it was a pretty limited menu.”

The district expanded the food options to include tortillas and bread, and more families started taking and using the food, he said.

Clark County is one of the places where the urgency of the pandemic and a boost in resources has led to stronger relationships and improved services for non-English speaking residents, who make up 3.6 percent of the county’s population.

Last year, Ohio recruited more than 250 full-time contact tracers to help state efforts and local health departments, including more than 30 who fluently speak a language other than English, including Spanish, Hatian-Creole, Russian, Arabic and Mandarin, Alicia Shoults, a spokeswoman for the Ohio Department of Health said.

Multilingual candidates were critical for building trust with minority communities and identifying and tracking COVID-19 cases across the state, she said.

The state deployed 10 Spanish-speaking contact tracers and one Haitian-Creole speaker to Clark County, Shoults said.

In addition to help from the state, the district reached out to local churches, already a hub for the non-English speaking communities, slowly building up trust and capacity. The district now has bilingual and multilingual contact tracers and community educators - both volunteer and paid, Trout said.

It can more quickly translate public health messages to distribute online and on fliers at churches, stores and neighborhood gathering spots.

Trout said the new connections – in both language and culture – have helped the district move forward “leaps and bounds” with the way it serves the community now, and once the pandemic abates.

Cleveland’s neighbor to the west, Lorain County, also has a high concentration of Spanish-speaking residents, many of whom moved to the area from Puerto Rico starting in the late 1940s for better-paying jobs in steel mills near the Lake Erie coast. Just under a third of the city of Lorain’s population identifies as Hispanic or Latino, according to the most recent U.S. Census figures.

Lorain County Health Commissioner David Covell said he has made it a priority during the pandemic to hire staff that reflects the community the department serves. Of the county’s 15 contact tracers during the pandemic; four of them are bilingual, including two nurses and two support staff.

“We look [to hire] folks that are bilingual, preferably that are from the community, too, that share some commonalities where they may know the people in the community so people would feel more comfortable.” Covell explained.

Covell said the process of building trust with the person on the other side of the line during a contact tracing call is essential.

During calls, where contact tracers identify who patients have been in contact with, they also check to see if residents need help — food, medicine or other basic needs — to be able to isolate safely. Sometimes contact tracers make sure food is delivered to residents’ doorsteps, Covell said.

In several cases, the relationship likely saved lives, Covell said. In one instance, contact tracers dialed 911 after their follow-up calls revealed a resident's health had deteriorated.

Rivera, who is bilingual and lives in Cleveland, said shared language is an entry point into culture.

“If I can enter the culture through the language, there's a better chance that I'm going to connect and build the trust,” she said.

A COVID-19 contact tracer who speaks the same language has the best opportunity to enter into a family's life and build a relationship with an understanding that information will be kept private.

That can be particularly important for the Latino culture, Rivera said.

In some cases, it can be hard for Latinos to share personal details contact tracers may seek, like who they have been around or who else may have been exposed to COVID-19, she said.

Juan Manuel Schwartzman, who is bilingual, was hired to work for Lorain County Public Health in November. The 26-year-old Shaker Heights resident said he applied for a contact tracing job in Cleveland first but never heard back.

Schwartzman has experience in social work from his previous position working for an agency focused on mental health services and is passionate about helping the Hispanic community understand more about COVID-19. He also understands parts of the culture that have to be navigated.

Schwartzman lives in a multigenerational household, similar to many Hispanic residents he talks to as a contact tracer.

“You can’t tell a Latino that they need to isolate themselves from their own family,” Schwartzman said. “That's a non-starter.”

City ‘dropped the ball’

The conversation about contact tracers – Cleveland’s lack of response, its excuses about the expense of translation and interpretation – has “opened up a can of worms,” Santana said.

It has hit a nerve, she said, about how little is done to provide information in Spanish across many systems, including courts, which provide documents, like subpoenas, only in English. Or the lack of bilingual 9-1-1 emergency dispatchers.

“This is beyond COVID,” Santana said. “They dropped the ball here. They really did. But I want to continue that advocacy that the health department needs to have more bilingual workers….Let's not waste another pandemic.”

Though slow, there has been some progress. Before Santana and advocates started speaking out, the city had shared only a handful of translated materials in Spanish about handwashing and quarantine, mostly provided by other public health agencies. More recently, the health department has stepped up efforts, sharing multiple translated fliers about recent vaccine clinics. They’ve partnered with Hispanic churches and organizations to bolster vaccination efforts as well.

A spokeswoman told The Land and La Mega Nota in an email that the city will “continue to build our relationships and partnerships with community groups to help us to reach non-English speaking and other underserved populations.”
Nationally, Hispanics are three times as likely to be hospitalized for COVID-19 and more than twice as likely to die from problems related to the disease, compared to people who are white and non-Hispanic, according to the U.S. Centers for Disease Control and Prevention.

Santana and Councilman Kerry McCormack, who chairs the Health and Human Services Committee, pressed the city administration on that point during a January meeting.

Health Director Kimball told the council that ethnicity information is being collected and would be shared in partnership with Case Western Reserve University, which in December, signed a six-month, $299,000 contract to assist the health department with its response to the pandemic.

“We have begun to develop a report,” Kimball told the committee.

Last week, more than a year into the pandemic, Cleveland’s health department for the first time reported how many Hispanic residents were affected by the virus. It showed that since February of 2021, Hispanic residents made up 6.6% of new cases, though ethnicity information is missing for 40% of the cases. Hispanic residents made up 8% of patients hospitalized and 8.5 % Clevelanders who have died from COVID-19.

The report is only available in English.

Claudia Longo is a bilingual reporter for La Mega Nota and The Land who lives in Mayfield Heights with her husband and two kids. She is passionate about the Hispanic community and social issues.

Rachel Dissell is an independent Cleveland-based journalist who works with Cleveland Documenters and the Northeast Ohio Solutions Journalism Collaborative.

This story is sponsored by the Northeast Ohio Solutions Journalism Collaborative, which is composed of 20-plus Northeast Ohio news outlets including La Mega Nota and The Land.