When
I was a resident working at Bellevue Hospital in Manhattan, the majority of my
patients were immigrants freshly arrived to the U.S. from all parts of the
world. Most did not know English, and required the intervention of a third
party interpreter for the completion of their health care exams. Of course, it
was always easier for me to communicate on a one-on-one basis with those
patients from Spanish-speaking countries, because I had a fair command of the
language and didn’t need to use the LanguageLines telephone interpreter
otherwise provided.
During
my time there, one experience that I would come across time and again was a
patient who would struggle to read the letters I put up on the screen. I would
look at their age and think to myself, ‘it’s probably nuclear sclerosis, or
perhaps some macular chorioretinal scarring, or corneal scarring or
astigmatism, that is contributing to their difficulty’. And I would proceed to
do the refraction and find no improvement. And then I would do the exam which
revealed no cataracts or corneal or retinal scarring, and I would wonder why I
was not getting a better visual acuity measurement. Was it amblyopia?
Many
times the patient didn’t say anything to me. He would just struggle through the
lines. Or he would ask me if he could
say the letters to me in Spanish, but still struggle through. One or two
letters would come in loud and clear on the 20/80 line, but not much else. Just
for good measure, I would put numbers on the screen. All of a sudden, a break-through occurred.
The 20/80 line plunged down to 20/30, as the patient quickly read the numbers
on the wall.
There
were patients who would even struggle with the numbers, and for those I would
use the tumbling E’s which, when the patient pointed out all the line
directions correctly, would confirm my suspicion. That is, that I was dealing
with a literacy issue and not a visual one.
According
to Wikipedia, the definition of functional
illiteracy is “ having inadequate reading or writing skills in a language,
as would be required for daily living and employment tasks that require reading
beyond a basic level”. The article goes on to say that a foreigner living in a
country with a language non-native to his own which he cannot read or write is
considered functionally illiterate.
My
blog has been born from the fact that
the majority of patients in the community where I work are functionally
illiterate. Outside their very insular Latino community within the borders of their
town, they cannot communicate with the English-speaking world. But, the
majority are literate in their own native language of Spanish.
However,
there are still some patients that I come across who, unfortunately, may not
have had access to education in their home country. Although they can
communicate easily orally in Spanish, which does not give any indication of a
deficit, when confronted with reading tasks such as visual acuity taking, the
problem emerges. If a doctor is not thinking about the possibility of
illiteracy, then it is very easy to assume that the problem is solely visual.
A
literacy chart provided by the United States CIA Factbook from 2003 looks at
the literacy rates of various Central & South American countries and
compares them to those of the U.S. at that time. ‘Literacy’ was defined as ‘age
15 and older that can read & write’.
In 2003, the literacy rate in the U.S. was 99% of the total population.
By comparison, Puerto Rico was 94.1%. The highest rates behind the U.S. came
from Uruguay 98% and Argentina 97%. The lowest were Nicaragua 67.5%, Guatemala
70.6%, Honduras 76.2%, El Salvador 80.2%
and Peru at 87.7%. More recent estimates from 2012-2015 show an increase for
all said countries, but still trailing behind the U.S.: Uruguay 98.5%,
Argentina 97.9%, Nicaragua 82.8%, Guatemala 83.4%, Honduras 88.5%, El Salvador
88% and Peru 94.5%.
With
better access to education for all citizens, literacy rates will continue to
improve world-wide. This is still an ongoing work-in-progress. Until literacy
is achieved for all, doctors working with an immigrant population need to think
about not only functional literacy in their multicultural practices, but also the
general literacy of their patients. This issue needs to be considered,
particularly if the eye exam points to a 20/20 eye, but the visual acuity
result says otherwise.
References
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