As California’s ethnic makeup changes, companies are facing new challenges in Serving Diverse Customers

Talk about the changing face of California. The pediatrics waiting room of Cigna’s Grand Avenue Health Care Center in Downtown Los Angeles has the film “Dennis the Menace” on television--with Spanish subtitles. The room is filled with Latina, Asian and African American mothers with small children, speaking a variety of languages.

It is in a clinic like this one that the changes in California’s population come home--where the increasingly variegated mix of ethnicities, languages and cultures come into conflict with white-dominated institutions.

Faced with such a melange of people, institutions such as this health center are finding that what worked in the past for a middle-class suburban population clearly does not meet the needs and expectations of a new mosaic of people.

For institutions such as political parties, the challenge is to find a way to engage an increasingly diverse electorate. For example, while Latinos make up more than a quarter of the state’s total population, they account for only 11% of the state’s registered voters.

For industry, the task is to find products or services that cater to new tastes or that are suited to less affluent consumers who may have come here from East Asia or Latin America rather than Illinois or New York.

At Cigna, that means providing good, affordable medical services in an effective and economic way--no matter what happens Nov. 8 to Proposition 186, the initiative that would create a single-payer health insurance system, and Proposition 187, which would deny almost all public health benefits to illegal immigrants.

Access to good health care is one of the prerequisites for upward mobility, and the lack of it can have dire consequences for the state.

“An unhealthy population can’t be fully employed, fully productive or fully educated,” said Susan Fogel, staff attorney with the California Women’s Law Center in Los Angeles, which provides legal services to poor women. “We all lose when people are not healthy.”

The challenge is especially urgent because there is an increasing use of managed-care systems such as health maintenance organizations--particularly to cut costs in the state-run Medi-Cal system. That means people from all income levels are increasingly thrown together at the same clinics.

Clinics such as the Grand Avenue Health Care Center find themselves on the front lines of this social change.

In this clinic, much of the staff now speaks Spanish, and many employees are also bicultural, with one foot in Latin America, one in North America. There are other languages as well: Thai, the Filipino dialect of Tagalog, Korean, even German.

Programs are being developed to help new arrivals navigate the labyrinth of a modern health maintenance organization. And a new class of physicians is emerging that is dedicated to treating a diverse patient population.

Even so, there sometimes remain misunderstandings, small crises of trust and mistakes that can be costly.

Rosa Roman’s first encounter with the system failed her. The 32-year-old immigrant from El Salvador sought emergency care at the Grand Avenue center for a sore throat, but was given short shrift because she spoke no English. That delayed by several weeks a diagnosis of leukemia.

“They gave me a shot of penicillin and some tetracycline, and that was it--they sent me home,” she said recently through an interpreter. An urgent-care worker “looked in my mouth and throat but didn’t really pay attention to me.”

But the health center eventually came through for her--perhaps a sign of how much things may be improving. When Roman returned for a follow-up visit, she saw one of Cigna’s Spanish-speaking family practitioners, Anastacio Vigil, one of a new breed of bicultural physicians.

He identified her problem and went out of his way to get her proper treatment. He ordered tests that revealed the leukemia. “She needed to go to the hospital right away,” Vigil said.

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Because Roman had no phone, Vigil dispatched an ambulance crew to the weathered frame house Roman shares with six children near Pico Boulevard and Sycamore Avenue in Los Angeles.

Vigil and another doctor met police at the house, found a friend to care for the children, and stayed with the family until 9 p.m., when Roman was finally taken to the hospital. The next day, Vigil called Roman’s husband, Miguel, 38, in El Salvador and told him to come back to Los Angeles.

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The institutional indifference Roman first confronted probably comes as no surprise to anyone who has ever visited a hospital or health clinic. For Roman, it was compounded by her lack of English and her passivity in facing a complex institution.

The problems of dealing with a diverse population go beyond health clinics. They are confronted by organizations ranging from telephone companies, whose services must link a wide range of ethnic groups, to supermarkets, which must stock a dizzying array of new and sometimes exotic foods, to advertisers, who must familiarize themselves with the nuances of Spanish and Korean slang.

And there are the well-known dilemmas facing schools, whose classrooms are filled with non-English speakers, and government agencies that must communicate with a citizenry whose history may make it suspicious of public institutions.

The magnitude of the change is clear. By 2020, Hispanics will be the largest ethnic group in California: 36.5%, up from 27.3% in 1993, the U.S. Census Bureau predicts. Non-Hispanic whites will constitute 34% of the population, down from 52% last year.

That trend has bred resistance, as evidenced by recent fights over English-only rules, bilingual education, affirmative action policies and, in the current election, Proposition 187.

But there are institutions like Cigna that are trying to adapt to the changes now. It is one of several HMOs going door to door to enroll immigrants and low-income Angelenos covered by Medi-Cal in clinics such as the Grand Avenue Health Care Center. This year, the state began a major push to enroll Medi-Cal recipients in managed-care plans.

The Grand Avenue clinic’s patient population is becoming one of the most diverse in the company. And with 30 health centers in Southern California, Cigna has become the state’s largest contractor for Medi-Cal. (Medi-Cal provides health insurance for state residents who meet certain income requirements--$750 a month or less for a family of two.)

The Grand Avenue center, a relatively new glass-and-steel building at 14th Street and Grand Avenue, is located near significant Latino, Asian-American and African American communities.

And as things change, some second-generation immigrants are finding things a little easier than their parents did.

In the obstetrics waiting room, Nancy Sabajan, 17, is pregnant and about to see her physician. She came to Los Angeles from Guatemala when she was a toddler and now speaks perfect English. She is pleased with the care she receives at Grand Avenue.

But it wasn’t always that way. She recalls receiving indifferent treatment from doctors as a child. With no insurance, the only treatment available to her was in the emergency room of County-USC Medical Center, she said. There were no regular checkups--her mother only took her there when she was ill.

“It felt very uncomfortable,” she recalls. “I wasn’t able to talk, to say what was wrong with me, because I was just a little girl. And it was hard for my mom, because she wasn’t able to speak English.”

Similarly, Sara Elena Loaiza recalls that her Mexican-born mother so distrusted the American medical establishment that she chose to travel from her home in California back over the border to give birth to Loaiza in Tijuana 32 years ago. “She felt there would be nobody here who would speak her language or where she could be comfortable enough to have her child,” Loaiza said.

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Things have changed. Loaiza is a network manager in Cigna’s Glendale office. Bilingual and bicultural, she heads a new program designed to ease the way for new immigrants in Cigna’s centers.

As immigrants make up a larger share of the Grand Avenue clinic’s patients, the staff is finding that their cultural expectations are coming into conflict with the traditional U.S. idea of medicine.

Some have little experience with doctors at all, or view them as fix-it people to be consulted only during times of illness. Others distrust Westernized medicine, favoring folk remedies instead.

Martha Galvan, the clinic’s physician in charge, recalls a diabetic Mexican American who would not take his medication, preferring to treat himself with liquid drained from boiled cactus--which he said was prescribed by a doctor in Mexico.

The increasingly diverse population also presents new kinds of health problems. There are higher rates of diabetes among some Latino men, for example. There is higher use of emergency rooms by immigrant patients. And tuberculosis has once again emerged as a serious health problem.

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Given all this, how well is the system as a whole dealing with this new population?

“Not very well,” said Lester Breslow, a professor of public health at UCLA and former director of the California Department of Health Services.

Medical schools are not preparing graduates to deal effectively with people of such widely diverse cultural backgrounds, he said, and the system for treating the poor is overwhelmed.

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Advocates for immigrants also criticize mainstream institutions for taking Medi-Cal contracts away from small community-based clinics, which they argue provide the most effective care.

“We see the big HMOs marketing to people and taking business away from providers who are culturally sensitive and do speak the language and have the trust of their patients,” said Fogel, the attorney at the California Women’s Law Center.

Added Rosemary Hutton, executive director of the Clinica Para Las Americas, a community-based clinic in Los Angeles aimed at Spanish-speaking immigrants: “They are very large institutions . . . and that’s very intimidating. They have systems and policies that our people don’t understand. . . . They may be bilingual, but they do not take into account the culture of the people that we’re dealing with.”

But mainstream health organizations say things are changing. “We provide extensive services beyond what’s in the traditional Medi-Cal system, and we provide practitioners of the same culture and language,” said Mark L. Wagar, president and general manager of Cigna Health Care of California. “We are not a threat to community based services . . . and we are looking for ways to include them in our future programs.”

To its credit--and notwithstanding the actions of one emergency room employee in Roman’s case--Cigna has taken aggressive steps to meet the challenges. The staff of the Grand Avenue clinic is ethnically diverse: 35% Latino, 20% Filipino, 5% Thai, the rest Korean or white. And the center has made it a priority to hire bilingual staff.

Elizabeth Gutrecht, an obstetrician and gynecologist, has made a career of treating Spanish-speaking and immigrant patients. She is bilingual and bicultural--her parents, both physicians, are from Argentina, but she was born in Minnesota and educated at Cornell University.

“I enjoy . . . working with the elderly Hispanic ladies especially, because there aren’t a lot of doctors who understand their concerns and who can speak to them,” she said. “I don’t feel that my role as a doctor is to impose my views on them, but to help them take care of themselves.”

About This Series

In the heat of a gubernatorial campaign, the candidates sometimes dwell on matters that have little to do with the larger problems facing Californians in the years ahead. This series looks beyond the rhetoric. The initial story set the stage by exploring the limits--and possibilities--of gubernatorial power. Other installments in the series:

* Last week: The living conditions of California’s poorest citizens--and what they augur for the state’s future.

* Today: Are demographic forces reshaping California more quickly than the political system can react?

* Fiscal straitjacket: Can the state government solve its budget problems and provide for future growth?

* Economy and education: Are California’s schools providing an underpinning for the state’s economic future?

* Environment: How will California balance environmental protection against the pressures of economic need?

State of the State: The Ethnic Mosaic

RHETORIC

KATHLEEN BROWN

“I . . . know that illegal immigration is a serious problem. . . . Unfortunately, as the issue of illegal immigration has gained in prominence, it has also gained in virulence. . . . Fairness says that we must go out of our way to prevent an ugly backlash against immigrants that would be both dangerous and shameful.”

PETE WILSON

“One of the federal government’s first responsibilities is defending our nation’s borders and enforcing our nation’s immigration laws. Today, it has flunked that test. Washington has lost control of our borders, but it is California that is paying the price . . .

“To Californians I say: We must not just claim reimbursement for past costs, but take action ourselves . . . to put an end to continuing costs.”

REALITY

* California Tomorrow: As it nearly doubles in size over a 30-year period, California will become one of the world’s most ethnically varied places. Hispanics, African Americans, Asians and other non-white groups will become the majority, posing still unrecognized challenges for the state’s power structure and institutions.

POPULATION 1980 1990 2010 Total 23,667,902 29,760,021 42,408,000 White 76.2% 57.2% 45.7% Hispanic* 19.2% 25.8% 36.3% African American 7.7% 7.0% 6.6% Asian, others 16.1% 9.2% 11.4%

* Can include persons of any race

Sources: U.S. Census Bureau; California Department of Finance