"One time, I brought him downtown" to the Medical University of South Carolina, Ribeiro said through a translator during a visit to the clinic on a recent Saturday. "I had to pay for it. For me, that's a lot of money."

Run by Columbia-based Commun-I-Care, the 5-year-old Smiles clinic sees many patients from the Hispanic community in Berkeley County. In the last 18 months, the number of Hispanics who make use of the clinic has skyrocketed, now making up 40 percent of its patient base.

All sorts of area health care providers have seen the rising tide of Hispanic immigrants.

About 8.5 percent of MUSC patients speak Spanish, an increase of nearly a third over last year. Some 19 percent of the babies born at the hospital are Hispanic.

The trend presents a number of challenges to the health-care system. For starters, many patients speak little or no English. In response, hospitals and insurers have hired interpreters, offered community health care courses in Spanish and established 24-hour telephone translation services.

The lack of insurance coverage is another problem. More than a third of the Hispanic population nationwide is uninsured.

Many don't qualify for programs like Medicaid, while fears of deportation discourage others from enrolling.

"A lot (of these people) would fall into the category of 'working poor,' " said Nancy Bracken, interim director of the Sea Island Medical Center of Johns Island, a federally funded community health center. "Many work for employers that don't provide insurance. They work for cash. Or they're seasonal. Some work for landscaping companies or construction and do have insurance. But most of them don't."

Dr. Geoffrey Renk, the emergency room director at Bon Secours St. Francis Hospital in West Ashley, learned some Spanish while practicing in Los Angeles. When he arrived in Charleston in 1997, he rarely used his Spanish skills. Today, he converses in Spanish with patients almost daily.

As Renk points out, clear communication is key in health care because a doctor often depends on what a patient says to make a diagnosis. It can be a struggle even among people who speak the same language.

Still, despite the increase of Hispanic patients, MUSC is the only hospital in the area -- for now, at least -- that employs translators. It has two full-time translators and a third who works part-time almost exclusively for its women's services unit.

Hispanics "are frustrated with the difficulty of communication within the health care system," said Emma Mendez, a native of Puerto Rico who is one of MUSC's full-time Spanish translators. "It's something that needs to be worked on."

Clinics and community health outreach programs seem to be doing a better job of addressing the question.

For example, Project Care, a local effort to provide health care to the working poor, has a Spanish-speaking employee to help its Hispanic population.

At Sea Island Medical Center on Johns Island, where many of the signs are in both English and Spanish and which has long served Hispanic migrant workers, there are two translators plus an outreach specialist.

Hospitals, meanwhile, rely on a variety of measures to bridge the communication gap. For example, they use pagers to contact Spanish-speaking workers on campus who can be summoned at a moment's notice. They also use phone translation services such as California-based Language Line. Demand for these services is growing fast. Last year, Trident Health System saw a 17 percent increase in the use of its translation services.

Rather than hire translators, many health institutions, including Trident Health System, are now beginning to offer Spanish classes for their employees. The Trident classes, about 25 to 30 people at a time, are always full.

Aside from language barriers, doctors invariably find themselves treating patients without insurance.

A study in 2001 by New York-based health care research foundation Commonwealth Fund found that Hispanics were twice as likely as non-Hispanic whites to be uninsured.

The study found that Hispanics were more likely to work in industries that do not offer health benefits. And even within those industries that do offer health benefits, they were less likely to be offered insurance than their non-Hispanic counterparts.

At the same time, Hispanics marry younger, have children younger and live in families with only one worker, factors the study said make it more likely they will go without insurance.

The situation is better for Hispanic children, who have access to more publicly funded health insurance programs, but Hispanics are still less likely to use them.

According to the Urban Institute, a think tank, 37 percent of the 7.8 million U.S. children not covered by insurance in 2002 were Hispanic. Nearly two-thirds of the 2.9 million uninsured Latino children would be eligible for Medicaid.

Concerns about this issue led to the creation a couple of years ago of Consejo de Latinos Unidos, a Los Angeles-based Latino advocacy group run by Republican activist K.B. Forbes.

The group has helped lead nationwide efforts to get hospitals to provide the same discounts to uninsured patients given to managed care companies. It filed a lawsuit against California-based for-profit Tenet (owner of East Cooper Regional Medical Center), which recently began providing managed care-style discounts to uninsured individuals.

"The Hispanic community has never had a voice," Forbes said in a recent phone interview from a hotel room in Florida. "Most are U.S. citizens or residents. They're trying to protect their credit or their home. They'd do anything to make payments, but they get charged four, five, sometimes seven times more than anybody else."

In part, that's why many Hispanics rely on community providers.

At the First Baptist Free Clinic on Rivers Avenue, which caters to poor, largely uninsured area residents, at least 20 percent of the patients are Hispanic, a group that began showing up only in the last couple of years. Another free clinic, started off of Ashley Phosphate Road in the fall, has a patient population that is three-quarters Latino.

About 18 percent of the patients at the Sea Island clinic on Johns Island speak only Spanish.

Meanwhile, the Smiles for a Lifetime clinic quickly became a popular destination for Hispanic children needing dental care.

"We had to turn them away in the past because we didn't have anybody here who could speak Spanish," said Bill Hogan, who runs the clinic. It doesn't have to do so now because of the interpreter it hired. "We were slow to catch on with that community. But then we just kind of caught fire."