Healthcare compromised by lack of interpreters - 18 June 2008

Marion Heap: The Cape Times,

MARION Heap, of the School of Public Health and Family Medicine, argues that the language barrier excludes many patients, including the deaf, from proper healthcare.

In 2006 my friend Makhaya (not his real name) died.

At his funeral, I could not help wondering: would a professional South African Sign (SASL) interpreter service have made a difference?

It took a long time before Makhaya's brain tumour was diagnosed. He went to a number of healthcare facilities, private and public. Healthcare focused on the vomiting, sent him for X-rays, and gave him antacids and dietary advice. Without an interpreter, it was difficult for healthcare to take a proper history and probe symptoms.

Makhaya had no way to express himself. He could not explain that in addition to the vomiting, his headaches were severe, he was slurring his signs, his eyesight was failing and he was finding it difficult to walk in a straight line. In due course, he became very ill, worn out by the vomiting and the pain.

He was admitted to a district hospital, and from there he was transferred to an academic hospital. At the academic hospital, a brain tumour was diagnosed. An emergency shunt relieved the inter-cranial pressure and later the tumour was removed surgically.
The reprieve was only temporary though, and the tumour regrew. Makhaya eventually succumbed at a chronic care hospital. He was 54-years-old.

This year South Africa became one of the first countries to ratify the UN Convention on the Rights of Persons with Disabilities. This means that in compliance with Article 9 (1) (e) of the Convention, South Africa is obliged to provide, among other services, professional sign language interpreters to facilitate accessibility to buildings and other facilities open to the public. The challenge lies in putting this progressive policy into practice.

South Africa is recognised as having one of the most progressive constitutions and language policies worldwide (Neville Alexander, "Proper use of mother tongue is the key to success", Cape Times, April 21). The Constitution provides for the rights to equality (Section 9) and access to healthcare services (Section 27 (1) (a)). Read together, these provisions should guarantee access to non-discriminatory healthcare on the basis of equality.

The Constitution recognises 11 official languages. SASL is not recognised as an official language, but it has status. The Pan South African Language Board has been mandated by the Constitution (Chapter 1) to promote and create conditions for the development and use of SASL (and Khoi and Nama) in addition to the 11 official languages. Section 6 (2) of the National Health Act (No 61, 2003) states that the healthcare provider must inform the user (of the health services) in a language that the user understands, and in a manner that takes into account the user's level of literacy.

Thus, we have many rights - on paper - but language barriers continue to present formidable challenges to accessing appropriate healthcare services for many people.

In the public health sector, English and/or Afrikaans tend to be dominant among medical professionals, while the majority of the patients speak one or other indigenous language. Even the signage at some of Cape Town's public hospitals is still only in English and Afrikaans.

When signs are translated into Xhosa - usually unprofessionally - they are often so badly translated that they have been described as "meaningless and offensive".

For example: the one advising pregnant women to phone a clinic when they are in labour, translated as "phone the clinic when your tummy is running" (Weekend Argus, March 12, 2005).

To overcome language barriers and to ensure equal access to effective, non-discriminatory healthcare, advocate Karrisha Pillay has argued that professional (ie trained and accredited) interpreter and translation services must become an integral part of service delivery.

My chief concern is deaf people, whose first language is SASL. The professional interpreting needs of deaf people are urgent.

There are only six professional, accredited SASL interpreters for a population estimated at between 500 000 and 1.5 million people.

Professional interpreting services in healthcare in this country are and always have been lacking - despite the country's long history of plurilingualism. All the major language groups of the world, African (Bantu and Khoisan), Indo-European and Malayo-Polynesian were represented at the Cape a few years into South Africa's colonial era. Yet, outside of the judiciary, there were no official interpreter posts in the public service in all the years leading up to 1994. This trend continues in post-apartheid South Africa: a recent revision of the public service post structure makes no provision for official interpreter posts in healthcare.

Without interpreters, health professionals and patients struggle to address the language gap and communicate across language barriers. Nurses (already over-burdened by cost-cutting measures and staff shortages), often carry the interpreting load without extra remuneration - or training.

In South Africa, we take the language problem for granted and "make do". The result is that the challenge presented by linguistic diversity has become almost invisible. But the consequences and problems remain hidden.

Deaf people bring these problems to light. They are the "particular" case that challenges the routinised strategies. They do so because signed languages are similar to, but different from, spoken language. Signed languages have the same linguistic structure as that proposed for all other languages.

They are learnt in the same way as spoken language, and anything that is expressed in spoken language can be expressed in signed language. You can gossip, flirt, fall in and out of love, joke, skel, give a lecture, make poetry and even talk in your sleep. Signed languages are only different in that they are visual-gestural languages that use the modality of space. But this makes them "seem" very different. As such, they are the rule breakers, the exceptions that "prove the rule".

Our survey of the healthcare and communication experiences of deaf people in Cape Town identified problems such as delays in diagnosis, missed appointments, repeat visits, misdiagnosis, misunderstandings, misuse of medication, as well as anxiety and distress. Athalie Crawford has described similar problems for Xhosa-speaking patients trying to access healthcare without knowing the language - including the distress and anxiety.

It is time to take our rights seriously. This means a much greater emphasis on marginalised languages as well as on the training of interpreters and translators, professionalism, and accreditation.

Until professional interpreting services are an integral part of healthcare services, we will not bridge the language gap and a majority of South Africans will continue to be deprived of their constitutional right to healthcare.


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