Plain language for interpreting in consulting rooms

Curationis 30(4): 73-78 Intercultural communication is by nature a complex activity. In a multilingual society like ours, it will inevitably surface in the health care sector. The services of an interpreter are often considered to break the impasse in this comm unication process. The communication problem between the two parties, the service provider and client/ patient, is often not simply a matter of language but societal factors o f which the liaison interpreter should be aware of also plays a major role for effective extended


Introduction
Intercultural communication is a complex u n d ertak in g -m ore so in the South African context as a result of the previous political policies, w hich led to cultural and linguistic isolation betw een various c o m m u n itie s .T h e p ro b le m o f com m unication betw een two parties is often not sim ply a m atter of language; it is equally created and com pounded by the fact that the two parties are separated by a w ide gap o f power.This pow er gap is directly related to class, race and/or c u ltu re , o fte n to g ender, and to the differential pow er relations betw een a professional and his or her lay client.The need for an interpreter is realised in such an intercultural context, and the role of an in te r p r e te r as a c u ltu ra l b ro k e r becom es invaluable.
F or the linguistically ill-inform ed, the linguistic problem that arises is often so lv e d by th e m ere p ro v isio n o f an interpreter.T his is a step in the right direction, but should be enhanced by a le rtin g th e d iffe re n t p a rtie s to the complex nature o f the linguistic activity that is about to take place and to the lim itations o f the interpreter as a human being.
The article is sub divided as follows: firstly the objectives and the rationale for th e re v ie w is s ta te d ; s e c o n d ly the intercultural reality with reference to the difficulties occurring when interpreting in health care is highlighted; thereafter the mental efforts are considered from the view point o f the interpreter and how it can be eased during the interpreting process; and finally one concludes by com plem enting the availability o f the interpreter.
The aims o f this article arei) to consider from the viewpoint of the interpreter the complex nature of intercultural com munication during consultation with reference to the W estern Cape; and ii) to discuss the lim itations o f the interpreter with reference to the m ental efforts o f interpreting and to determ ine in which m anner the presence o f the interpreter can be facilitated.

The rationale
This review sets out to characterize the uniqueness o f intérpreting in the health care to gain a better understanding and in s ig h t in to th e p h e n o m e n o n .F u rtherm o re, th e m o tiv atio n fo r the review also flows from the fact that most o f the research on language barriers originates in developed countries that experience an influx o f people from less affluent countries, and are encountering new difficulties w ith com m unication re la te d to la n g u a g e an d c u ltu re (Schlemmer, 2005: 2-3).In South Africa the m ajor problem is not encountered with im migrants but with fellow South Africans.The latter is a concern m ore so in South Africa because it seems rare to have personnel dedicated to interpreting.
As part o f the im plem entation strategy o f the Western Cape language policy that was launched in February 2005, it is proposed that professional health care interpreter posts need to be progressively established in each hospital to provide quality health care interpreting services (Cole, Law rence, N yubuse & G odden 2003:42-43).The reality is that there are very few professional interpreters and isiXhosa speaking nurses, and general assistants are often called upon to assist; sometimes even the patients' relatives are requested to interpret.This is confirm ed by the E m zan tsi re p o rt (C ole, et al 2003:28-29), which states that the biggest demand for interpreting services is clearly in the Departm ent o f Health, where the need for health workers and patients to understand one another is often a m atter o f life and death.

The South African reality
I n te rp r e tin g b e c o m e s p a r tic u la r ly in fo rm a tiv e an d w o rth w h ile w h en distinctive languages and cultures are involved.Speech (as well as writing) is a culturally constructed act that includes various aspects, such as socialisation and gender, w hile the linguistic system is part of all the other systems o f culture.One should also think o f interpreting as the rep ro d u ctio n o f c u ltu re, sin ce it tra n sfe rs c e rta in a sp e c ts o f c u ltu re b elo n g in g to one g ro u p to th o se o f another.Along these lines, one should think of language in culture and not just language and culture (Fourie 2003:36).M any cultural groups, particular those coming from or living in rural areas, will fo r in s ta n c e , h a v e d if f ic u lty in understanding an interview conducted via a learned corpus that is not suited to their educational level or background.
S in c e th e re a lis a tio n o f th e new dem ocratic dispensation in South Africa in 1994, cross-cultural cooperation has been responsible for the developm ent of th e in te r c u ltu ra l 'r a in b o w n a tio n '.Repeated cross-cultural com m unication among the same people could eventually create an interculture with its ow n norms (Fourie 2003:38).
As a starting point, one can take the statistics (addendum A) regarding the level of education and that of the cultural g ro u p in g s o f th e W e ste rn C a p e (addendum B).Regarding language and health care, it involves the fundam ental principle that the ordinary citizen should not only have access to h e a lth care facilities.The o p p osite side o f this principle is often that the ordinary citizen should converse and m ake his health problem known.A proper understanding o f th e illn e s s a ris e s th ro u g h com m unication, w hether it is by the health care practitioner or institutions en tru sted w ith the resp o n sib ility for health care.This com m unication is by no other means than language.
According to the latest census figures, South A frica currently has an estim ated population o f 45 million.Yekiso (2004:7) points out that 70% o f this population speak indigenous African languages.It is a p o p u la tio n c h a r a c te r is e d by multilingualism and multiculturalism.Yet, d e s p ite th is lin g u is tic and c u ltu ra l diversity, English and A frikaans are still the sole languages used in trials and the keeping of court records.A significant segment of the population still finds itself in the tentacles o f a language barrier in so fa r as c o u rt p r o c e e d in g s are concerned.A study carried out by Viljoen and Nienaber (2001:121-135) shows that there is overwhelming support for the use of accessible language in a legal context from both legal professionals and clients.Unfortunately, the practice often shows the opposite.It also shows that it takes less time to understand a m essage that is conveyed via accessible language and The reality o f the situation in South Africa is that there are eleven official languages, nine o f which are indigenous languages and the other tw o being E nglish and Afrikaans.The nine indigenous African languages, in turn, have several dialects th a t are n o t n e c e s s a r ily m u tu a lly intelligible.The decision to have eleven o ff ic ia l la n g u a g e s m ay h a v e b e en prom pted m ore by a need to heal the divisions o f the past and the need to build a united and dem ocratic South Africa than on the basis of considerations of practicality.
The mentioned statistics are also relevant to in tercu ltu ral co m m u n ic a tio n as it relates to liaison (including com m unity) in terp re tin g .T he ro le o f the liaiso n interpreter is to facilitate com munication between a public service provider (i.e.doctor, (para) legal professional) and a user o f that service who does not share the same language or culture.In this case he or she is called a liaison interpreter because the starting point is recognition th at the p ro b lem o f co m m u n ic a tio n between these tw o parties is not sim ply a m atter o f language or culture.(M uller 1996:56;Crawford 1994;S w artz 1992:11-13 andL esch 1999:113-130).
The situation is further com plicated for the in terp reter by the m ere fact that languages have several registers, e.g. that there are a greater percentage of correct responses.
specialist, conversational, etc., which are generally defined as the social/intellectual level o f the speaker.W hen interpreting in a m edical context, the interpreter must be able to determ ine the patient's register and comm unicate with him or her on that level.Otherw ise, the interpreter runs the risk o f alienating the patient or promoting the 'n o d d in g sy n d ro m e ', th at is the patient will nod in agreem ent out o f fear or embarrassm ent without understanding what is being said.H ealth professionals and interpreters need to be aw are o f the q u ic k n o d , b e c a u s e m a n y o f th e questions posed in their context require 'yes' or 'n o ' answers.
Som e p atien ts m ay have a com plete absence o f register with regard to certain s u b je c ts .P a tie n ts m ay h a v e g re a t difficulty in discussing gynaecological problem s, for instance; m any w om en have never given nam es to body parts such as the vagina, or to aspects o f sexual activity such as 'single partner', 'multiple partners', or even 'sexual intercourse'.The interpreter m ust therefore be clear and diplom atic at the same time.Despite her best efforts, the patien t m ay still provide the w rong inform ation, none at all, or simply succumb to embarrassment (Ergueta 1992:12).
In order to overcom e such culturallybased difficulties, it is helpful for the interpreter to m eet the patient before the interview, so the interpreter can determine the p atie n t's educational background, attitudes tow ard health care and other aspects o f his or her social background.The interpreter will then know which re g iste r is m ost a p p ro p ria te fo r that particular situation.E ven a bicultural in te r p r e te r m ay h a v e d if f ic u lty in identifying and translating m any o f the terms used because o f an abundance of dialects in a given language.The patient may not be able to explain w hat actually took place during an accident or which sy m p to m s a p p e a re d first u n less the in te rp rete r en co u rag es the p atien t to speak more freely.This may take time.

E n g lis h -s p e a k in g
h e a lth c a re professionals tend to speak a jargon of their own.There are two possibilities for overcom ing this: either the interpreter should take responsibility for simplifying the m edical language, or the doctors and n u rses should m ake an effo rt to use everyday expressions.Experience has shown that the second approach is prefer able.Otherwise, the interpreter may have to in te rru p t freq u en tly to ask fo r an illustration o f a point before it can be interpreted.
O ften, patients w ho have learned the m eaning o f a word in one context tend to apply it in other contexts, often wrong ones.Thus, one patient w ho was told that she was to be "discharged tomorrow" concluded that she was going to develop "a discharge from below " .Doctors and nurses m ay want to have an idea o f the patient's perception o f the problem, state o f mind, educational background, selfim a g e o r a ttitu d e to w a rd s h e a lth .N uances m ay be lost, and statem ents m isinterpreted, if the interpreter tries to polish the patient's language.This is also w h y s u m m a ris in g is d a n g e ro u s , e s p e c ia lly in a p s y c h ia tric se ttin g (Ergueta 1992:12).
M any p atients tend to add irrelevant m aterial because it lessens their feeling o f em barrassm ent.Often, in answering health-related questions, they are more comfortable if the attention is not focused on their m edical problem, especially if it is o f a 'personal' nature.Cultural factors m ay also com e into play: m any patients believe that health is directly related to th in g s su c h as th e w e a th e r, th e environm ent and certain eating habits.Thus, w hat may appear to be irrelevant inform ation is, from their point o f view, highly relevant.If they are prevented fro m g iv in g a fu ll a c c o u n t o f such circum stances, they may conclude that no one is interested in their case.They m ay even becom e 'alienated' and lose confidence in the m edical environment.For all these reasons, it is usually better for the interpreter not to cut the patient short and to render faithfully all seem ingly irrelevant information.
T h e n o n -v e rb a l a s p e c ts o f com m unication, e.g.intonation patterns, facial expressions and gestures, tell their own story.It is important for all involved in the interview to be able to see, as well as to hear, each other.Interpreters who 'act o u t' their message are likely to be m ore effective in comm unicating.They s h o u ld b e a w a re , h o w e v e r, o f th e differences in body language o f different cultures.
Research carried out by the now defunct N ational Language Project in the early 1990s (N tshona 1999:144-150) showed clearly that there is a crisis in the health service in and around Cape Town, where the English-or Afrikaans-speaking health care providers and the isiXhosa-speaking patients do not understand one another.T h e re is re a so n to b e lie v e th a t the situation has not changed dramatically if one looks a t the sta tistic s -lim ited inroads have been made.The reality is that there are no professional interpreters and is iX h o s a -s p e a k in g n u rse s, and general assistants are often called upon to assist; sometimes even the patients' relatives are requested to interpret.This is confirmed by the Emzantsi report (Cole et al 2003:28-29), which states that the biggest dem and for interpreting services is clearly in the D epartm ent of Health, where the need for health workers and patients to understand one another is often a m atter of life and death.

The aforem entioned report confirm s the following (Cole et al. 2003:29):
• There are no official interpreters in health (W estern Cape), and the main need is for interpreting betw een isiXhosa speakers and non isiXhosa health workers.

•
The main source o f interpreters at present is nurses, nursing assistants, auxiliary staff and com m unity volunteers.The interpreting is entirely informal.
It is mainly the nursing staff who is used and their services are not recognised; they complain that it keeps them from their w ork and they are not paid, nor is it reason for promotion.
• Health care interpreters require m ore than just linguistic knowledge; they need to have knowledge of medical terms but, more importantly, they need to have em pathy and sensitivity for the doctor-patient relationship, an awareness of the role and responsibility of the interpreter in this relationship, and an ability to deal with patients' socio-cultural perspectives o f health problems.
• The linguistic problem s in the current situation include the fact that the informal isiXhosa interpreter may not always have adequate knowledge o f English or Afrikaans, whereas others com plain that they do not always understand the 'deep rural isiXhosa' of some patients.The recom m endations contained in the Emzantsi report include, am ong others, that health care interpreters require both p ro fe s s io n a l la n g u a g e p r a c titio n e r training and specific health interpreting.
In th e W e ste rn C a p e , h e a lth c a re in te rp re te rs a re lik e ly to be n e w ly r e c ru ite d la n g u a g e p r a c titio n e r s , p o ssib ly w ith lim ite d e x p e rie n c e in interpreting.Along these lines one can argue for the need o f accessible language use.

An interpreter's perspective
T he m o st s trik in g an d c h a lle n g in g p h e n o m e n o n in in te r p r e tin g is its fundamental difficulty for the interpreter.Performance problems do not only occur in fast, inform ation-dense or technical speeches, but also in clear, slow speech segments in which no particular obstacle can be detected (Gile 1995:159) The question that arises is: how can one assist the interpreter as an intercultural broker in the perform ance o f his or her duties?One way o f assisting in the case of liaison interpreting is via language use.It becom es essen tial that the service provider should use accessible, plain language and lim it the use o f a rich corpus or learned language.English has a very long history and a rich corpus that has d e v e lo p e d o v e r c e n tu rie s.T h is corpus can rightfully be em ployed with great efficiency in different linguistic situations.But, once again, one should caution against the variables that could work against efficient com m unication if the corpus is used.
To make this corpus more digestible in a liaison interpreting context and to ensure that interpreting becom es m ore than a symbolic gesture, one will argue in favour of plain language -with all its limitations.W hat is plain language?D errick Fine (2001: 19-21) describes plain language as clear, u nderstandable, accessible and u s e r frie n d ly .It is th e r e fo re u n d e rs ta n d a b le an d in fo rm a tiv e language, with a clear and well-organised structure, a clear and user-friendly layout and design for written m aterials, using visual back-up w hen speaking, and an appropriate and user-friendly tone and body language w hen speaking.
F or readers and listeners at different levels, plain language means writing and speaking at a level that m ost people can understand.A plain language approach to c o m m u n ic a tio n fo r th e sa k e o f interpreting in a m ulticultural context re q u ire s th a t th e se rv ic e p ro v id e r (professional) think o f plain language as part of effective communication.It should be borne in mind that there are degrees or levels of plainness.W hat one usually achieves is a re la tiv e p lain n e ss, i.e. 'plainer' language that is an improvement on the original source language rather than perfectly plain language.For the interpreter, there are basically two approaches: i) to put into plain language before interpreting, and ii) to put into plain language during interpreting.The latter approach requires m ore m ental effort because it also entails rephrasing and adoption capabilities in order to ensure effective intercultural communication.
The danger o f not using plain language in the case o f in te rp retin g is fu rth er com plicated by the gravitational model o f linguistic availability.This m odel o f language proficiency is applicable to the lexicon, syntactic and oth er linguistic rules.It rep rese n ts the statu s o f the individual's oral or written command o f a language at a particular tim e and in the particular circum stances by describing the relative availability of lexical units and linguistic rules.
The model consists o f a variable and an in v a ria b le part.T he la tte r re fe rs to la n g u a g e e le m e n ts o f w h ic h th e availability is assum ed to be constant or to vary very slowly.This applies to the most basic rules o f grammar and to a small n u m ber o f the m ost freq u en tly used words in the language.The variable part is m uch larger, as it includes dozens o f rules and m any thousand s o f w ords, idioms and metaphorical language.(Gile 1995:216) I w ant to argue that plain language is closer to the nucleus and that its lexical items and linguistic rules and structure belong to the invariable part.This m eans th a t p la in lan g u ag e is m ore re a d ily available for the interpreter to retrieve from his or her 'black box'.The dynamics o f the gravitational model make provision fo r th e in te r p r e te r to im p ro v e th e availability of the linguistic material in his o r h e r a c tiv e zone.T he u n d e rly in g principle is that the m ore freq uently words and rules are used, the stronger the centripetal effect will be, which means that words used very frequently becom e more available than words or rules used less frequently.The interpreter can better his or her production by ensuring that (d iffic u lt) lan g u ag e used fre q u e n tly within a particular zone is readily available to him or her.Unfortunately, the problem is not solved if our aim is effectiv e c o m m u n ic a tio n a c ro s s c u ltu r a l boundaries and the pow er gap barrier, sim ply because the clien t is not in a p o sitio n to grasp the lin g u istic item immediately, even if he or she has com e across it in the past.The opposite o f the aforem entioned principle applies in this C ape language policy.Em zantsi Associates.

Conclusion
It It is com pounded by the fact that they are separated by a wide gap o f power.This p o w e r d is c re p a n c y b e tw e e n a professional and his or her lay client c o u ld c o n tr ib u te to in e ff e c tiv e communication.The liaison interpreter should be more proactive in the sense that he or she should not only interpret for the clients, but should represent their interests, assess their needs and help them obtain w hatever they are entitled to.In urban South A frica today, the clients/ patien ts req u irin g these serv ices are u disadvantaged in term s o f education, location and socio-political power.They are o fte n th e s o c ia lly m a rg in a l o r p re c a rio u s in h a b ita n ts o f th e m o st econom ically deprived, far-flung, urban sq uatter areas, and includ e the rural newcomer, the very old and young, and th o se w ith fe w e r e m p lo y m e n t possibilities . These performance problems are exacerbated in the case o f densely inform ative speeches or highly technical speeches, and are c o m p o u n d e d b y th e p o s s ib ility o f insufficient understanding o f the source language.The effort m odels o f Gile (1995) were d ev elo p ed to d e sc rib e th e in te rp la y b etw e e n d iffe re n t sets o f c o g n itiv e o p eratio n s in v o lv ed in sim u ltan eo u s in te rp r e tin g (S I) an d c o n s e c u tiv e in te rp r e tin g (C l).T h e s e s e ts o f operations were grouped into 'efforts', which com pete for a lim ited am ount of processing capacity.The Listening and A n a ly s in g E ffo rt (L ) in c lu d e s a ll re c e p tio n an d c o m p re h e n s io n o p e ra tio n s; th e M em o ry E ffo rt (M ) designates the storing o f inform ation in the interpreter's short-term m em ory for the interval betw een the m om ent the speech is heard and the com pletion o f its formulation; and the Production Effort (P) represents all operations extending from the mental representation o f the message to its actual form ulation in the target langu ag e. T h ese th ree e ffo rts m ake demands on the interpreter's processing capacity at any tim e, together w ith a Coordination Effort (C), which represents the additional cognitive load required for m a n a g in g th e th re e e f f o r ts sim ultaneously.W hen the sum o f the a v a ila b le c a p a c ity e x c e e d s to ta l requirem ent, the necessary cog n itiv e balance betw een the efforts is disrupted, which results in failure sequences, with different errors and om issions.This is e v en m o re c o m p le x in th e c a se o f consecutive interpreting, in the sense that tw o phases can be distinguished.The first phase constitutes listening and analysis, note-taking, short-term memory and c o o rd in a tio n , w h ile th e se co n d constitutes rem em bering, note-reading and production.It becom es essential for th e in te r p r e te r to b a la n c e th e s e req u irem en ts, as he o r she has only lim ited m en tal e n erg y a v a ila b le fo r coordinating all these m ental efforts.
regard, nam ely that the stim ulated words C E N SU S IN B R IE F 2001: Statistics South Africa 2nd edition.South Africa, Pretoria, and rules tend to drift outw ard (away from the centre o f the system ) and with C O L E , P ; LA W REN CE, L ; NYUBUSE, N & G ODDEN, J .2003: Costing the Western that also the m eaning thereof.

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