Healthy Choices

California pharmacies resist push to translate drug labels

When Chek Lun Wong picks up his prescription medication for hepatitis B at his local Walmart, he doesn’t understand a word.

“I give them the prescription and my license and they give it to me. I don’t read the bottle,” said Wong. “I usually just ignore it if I don’t understand it.”

The 63-year-old Wong, who told his story with the help of a Chinese translator at the Paul Hom Asian Clinic in East Sacramento last weekend, is one of thousands in the capital region and the state who struggle to take their medication correctly because of a language barrier – an issue that some health advocates want rectified at a California State Board of Pharmacy meeting later this month.

On Saturday at the free medical clinic on Folsom Boulevard, Wong waited among a steady stream of Chinese and Vietnamese patients, most of whom spoke little to no English, to get the prescription for his next refill and to listen to instructions on their use from a Chinese-speaking volunteer. Kai Ming Tan, one of the many UC Davis students who staff the clinic, often writes out directions for Wong in Chinese characters.

When Wong goes to the pharmacy to pick up his prescription bottle, labeled in English, he will rely on this information to take the drug.

“Patients need things written down,” said Tan. “If a medical student is presenting, (the patients) can’t keep it in their head. They need something written down so they have something if they go home and forget what I said.”

Currently, the California State Board of Pharmacy requires pharmacies to provide an interpreter for non-English speakers free of charge, either in person or by phone, when requested at the pharmacy counter. The board itself is required to provide written translations of basic instructions in Spanish, Korean, Russian, Chinese and Vietnamese, in addition to English, on its website. But most pharmacists will not – and are not required to – print translated labels on the bottles themselves.

At its July 31 meeting, the board will consider, among other potential changes, requiring pharmacies to do just that.

Most pharmacists believe the system in place is working, said Jon Roth, chief executive officer of the Sacramento-based California Pharmacists Association. Limited-English speakers can use a telephonic translation service to get instructions on prescription drug use, which the pharmacist calls when the customer arrives. The customer hears the instructions and can also request a fax of the translation.

Roth said most pharmacists would not feel comfortable dispensing medication in a language they do not understand, especially considering that the pharmacist would be held liable for any potential mistake in the translation.

“We think the potential for error outweighs the potential gain for a patient receiving medication in a translated form,” said Roth. “We don’t think mandating a translation is patient-centric. We think that’s counter to patient care because the pharmacists cannot validate what they are handing over to the patient.”

According to the latest census data, more than one of every four Sacramento-area residents – 573,000 of about 2 million people over the age of 4 – speaks a language other than English at home. Statewide, 44 percent of California’s 38 million residents speak a foreign language at home.

Senate Bill 204, authored by Senator Ellen Corbett, D-San Leandro, in February 2013 and sponsored by the California Pan-Ethnic Health Network, initially fought for printed translations on pill bottles. But after meeting “quite a bit of resistance” from pharmacists and prescribers, the senator and supporters decided to delete the translation requirements from the bill and reassess the issue, said Sarah de Guia, director of government affairs for CPEHN. She said they will attend the July 31 board meeting in order to “figure out how to move this forward, hopefully with more support in the future.”

While the pharmacy board has the authority to update translation standards at its meeting, Dr. Sergio Aguilar-Gaxiola, director of the UC Davis Center for Reducing Health Disparities, said legislation likely will be necessary to make what he considers a long overdue change.

“It’s not enough to explain something in a language that is potentially not understood – I would not consider that quality care,” he said. “I know it is expensive and it is complicated, but it is more expensive not to provide the right treatment in a way that patients will comply with. They will potentially be in harm’s way, which will require them to use emergency services, which is also expensive.”

The Board of Pharmacy regulates about 6,500 community pharmacies statewide and 500 hospitals, in addition to 140,000 entities holding pharmacy licenses including mail-order pharmacies, drug wholesalers and clinics, said Virginia Herold, executive officer of the board.

Roth said a translated label requirement would disrupt the workflow of the pharmacies and that they would incur “greater waste and higher costs” from the need to switch to larger bottles to accommodate the translated languages.

A 2009 survey administered by the board found that bilingual wording was among the top five customer suggestions for making the label easier to read, along with larger print, highlighted directions, easier wording and doing nothing.

Sara Gaeta, a 64-year-old Sacramento resident who speaks only Spanish, said the directions on her over-the-counter cold medicine are written in English, so she takes them to her daughter – a certified nurse at Sutter Medical Center in East Sacramento – to translate.

Gaeta, a native of Veracruz, Mexico, said she would support having customers’ labels tailored to their preferred language.

“There are a lot of families that don’t understand English,” said Gaeta, through a translator. “That can be a problem for those of us who don’t know the language well. It would be great if they were in Spanish, because it would benefit us all considering the large Latino population here.”

In addition to the translation component, the pharmacy board will address other potential changes to label requirements at its July 31 meeting, including the need to distinguish between generic and brand-name medication and stating how the drug treats a diagnosis, rather than just the diagnosis itself, said Herold.

The most recent change to the regulations, issued June 26, increased the font size of the labels from 10-point to 12-point type. Some pharmacists opposed the change, arguing that the larger font would mean larger bottles, which could prove detrimental to patients who might move their medication to smaller bottles and lose the instructions entirely, said Herold.

For the July 31 meeting, the pharmacy board will bring in a panel of national experts, including the director of the New York Board of Pharmacy, which approved label translations in the spring of 2013. The panel presentation will be followed by a public discussion.

“I hesitate to guess what the board is going to do, but there’s certainly a group of people that are very interested in doing that (requiring translations),” she said. “The reality is if somebody hands you something in a language you can’t read, you’ve got to find a way to figure out what it says.”

But, Herold added, “If pharmacists really are the last check between the prescriber and the patient, that is a pretty weighty responsibility.”

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