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 C O M M U N I C AT I N G I N P R O F E S S I O N S A N D O R G A N I Z AT I O N S

series editor: Jonathan Crichton

Communicating Across
Cultures and Languages in
the Health Care Setting

Claire Penn and Jennifer Watermeyer

Communicating in Professions and Organizations

Series Editor
Jonathan Crichton
University of South Australia
Adelaide, SA, Australia
This ground-breaking series is edited by Jonathan Crichton, Senior Lecturer
in Applied Linguistics at the University of South Australia. It provides a
venue for research on issues of language and communication that matter to
professionals, their clients and stakeholders. Books in the series explore the
relevance and real world impact of communication research in professional
practice and forge reciprocal links between researchers in applied linguis-
tics/discourse analysis and practitioners from numerous professions,
including healthcare, education, business and trade, law, media, science
and technology. Central to this agenda, the series responds to contempo-
rary challenges to professional practice that are bringing issues of language
and communication to the fore. These include:

• The growing importance of communication as a form of professional

expertise that needs to be made visible and developed as a resource for
the professionals
• Political, economic, technological and social changes that are trans-
forming communicative practices in professions and organisations
• Increasing mobility and diversity (geographical, technological, cul-
tural, linguistic) of organisations, professionals and clients

Books in the series combine up to date overviews of issues of language

and communication relevant to the particular professional domain with
original research that addresses these issues at relevant sites.
The authors also explore the practical implications of this research for
the professions/organisations in question. We are actively commissioning
projects for this series and welcome proposals from authors whose experi-
ence combines linguistic and professional expertise, from those who have
long-standing knowledge of the professional and organisational settings in
which their books are located and joint editing/authorship by language
researchers and professional practitioners. The series is designed for both
academic and professional readers, for scholars and students in Applied
Linguistics, Communication Studies and related fields, and for members of
the professions and organisations whose practice is the focus of the series.

More information about this series at

http://www.palgrave.com/series/14904
Claire Penn • Jennifer Watermeyer

Communicating
Across Cultures and
Languages in the
Health Care Setting
Voices of Care
Claire Penn
Health Communication Research Unit,
School of Human and Community
Development
University of the Witwatersrand
Johannesburg, Gauteng, South Africa
Jennifer Watermeyer
Health Communication Research Unit,
School of Human and Community
Development
University of the Witwatersrand
Johannesburg, Gauteng, South Africa

Communicating in Professions and Organizations

ISBN 978-1-137-58099-3    ISBN 978-1-137-58100-6 (eBook)
https://doi.org/10.1057/978-1-137-58100-6

Library of Congress Control Number: 2017954943

© The Editor(s) (if applicable) and The Author(s) 2018

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We dedicate this book to those who do what matters in real time and space
 Acknowledgements

The Researchers The work and insights described in this book reflect the
efforts, vision and energy of a wonderful team of researchers and research
assistants whose ‘lived’ experience with qualitative research methods in
some very demanding contexts has added great texture and understand-
ing to this field. Our deep thanks go to Victor de Andrade, Paula Diab,
Melanie Evans, Berna Gerber, Carol Legg, Motlatso Mlambo, Joanne
Neille, Lesley Nkosi, Dale Ogilvy, Jai Seedat, Samantha Smith, Gabi
Solomon and Tina Wessels, for their pioneering work in health commu-
nication across cultures in South Africa.

The Research Assistance Team at the Health Communication

Research Unit Bianca Burkett, Johanni du Toit, Harriet Etheredge,
Victoria Hume, Caitlin Longman, Sonia Mbowa, Rhona Nattrass, Sheryl
Neel, Megan Scott, Tshegofatso Seabi and others.

The Healers Carol Baker, Astrid Berg, Edwin Cameron, Ashraf

Coovadia, Paul Farmer, Bernard Gaede, Mike Levin, Aldo Morrone,
James Nuttall, Bruno Pauly, Neil Prose, Paul Roux and others.

The Funders South African National Research Foundation (NRF),

South African Netherlands Research Program on Alternatives in
Development (SANPAD), South African Medical Research Council
vii
viii Acknowledgements

(MRC), Fogarty International, American Speech-Language-Hearing

Association, Mellon mentorship funding, Friedel Sellschop funding,
University of the Witwatersrand Faculty Research Committee grants,
Swedish Research Council, The Wellcome Trust, MRC HIV/TB Initiative
Funding (in collaboration with the Aurum Institute), Carnegie
Foundation and KidzPositive.

The Enablers Large portions of this manuscript were written while CP

was in residence at the Rockefeller Foundation in Bellagio and at the
Stellenbosch Institute for Advanced Studies (STIAS). These contexts pro-
vided peace, space and companionship, which enabled creativity and
consolidation of a body of research. PATA is acknowledged for its huge
role and continuing efforts. Drama for Life at the University of the
Witwatersrand has been a constant companion in many of our projects.

The Advisers and Mentors Srikant Sarangi, Neil Prose, Tom Koole,
Leslie Swartz, the late Chris Candlin, Brett Bowman, Garth Stevens,
Hanna Ulatowska, Audrey Holland, Elisabeth Ahlsén, Jens Allwood.

The Voices The opinions, experiences, narratives and perceptions of all

who have taken part in our research. Their precious stories have yielded
deep insights.

Thanks go to Caroline Kennard for her efficient editorial assistance.

We thank our families for their forbearance and support of a vision.
 Contents

Part I Background and Central Constructs    1

1 Prologue   3

2 The Context of Health Communication: Global, Local

and Theoretical  25

Part II Research Methods and Challenges   59

3 Methodological Issues: Approaches, Pitfalls and Solutions  61

Part III The Evidence 117

4 Islands of Good Practice 119

5 Language Diversity in the Clinic: Promoting and

Exploring Cultural Brokerage 171

ix
x Contents

6 Verbal and Non-Verbal Dimensions of the Intercultural

Health Setting 207

Part IV Implementation 263

7 Putting It All into Practice: Some Examples and Advice 265

8 Conclusions and Implications: Paradoxes and Principles 313

Appendix 347

Index 359
 List of Abbreviations or Acronyms

AIDS Acquired Immune Deficiency Syndrome

ART Antiretroviral Therapy
ARV Antiretroviral
CA Conversation Analysis
CAM Complementary and Alternative Medicine
CARM Conversation Analytic Roleplay Method
CD Communicable Disease
CHW Community Health Worker
CP Claire Penn
CVA Cerebrovascular Accident
DA Discourse Analysis
DM Diabetes Mellitus
DGs Disability Grants
DVD Digital Versatile Disk
EMS Emergency Medical Service
HAART Highly Active Antiretroviral Therapy
HCRU Health Communication Research Unit
HIV Human Immunodeficiency Virus
ICF International Classification of Functioning, Disability and Health
IRB Institutional Review Boards
JW Jennifer Watermeyer
MDR-TB Multiple Drug-Resistant Tuberculosis
MRC Medical Research Council

xi
xii List of Abbreviations or Acronyms

NCD Non-communicable Disease

NGO Non-governmental Organization
NHI National Health Insurance
PATA Paediatric Aids Treatment of Africa
PMTCT Prevention of Mother-to-Child Transmission
RA Rheumatoid Arthritis
TB Tuberculosis
UNAIDS The Joint United Nations Programme on HIV and AIDS
VCT Voluntary Counselling and Testing
WHO World Health Organization
XDR-TB Extremely Drug-Resistant Tuberculosis
 List of Figures

Fig. 1.1 Map of South Africa indicating our sites of research 6

Fig. 1.2 The voice of medicine and the voice of the lifeworld
(Photographs by Yeshiel Panchia) 12
Fig. 2.1 The pill burden associated with treatment of drug-resistant TB 33
Fig. 2.2 The chain of communication in TB care contexts 36
Fig. 2.3 Ecological model of potential influences on pharmacist-patient
communication (After Watermeyer 2008) 38
Fig. 2.4 Ecological model of micro and macro influences on
communication in emergency care settings 40
Fig. 3.1 The three Rs (After Penn 2013) 63
Fig. 3.2 Participatory action research as incorporated into our research 65
Fig. 3.3 Example of a multidimensional polyphonic notation system
(Smith 2009) 101
Fig. 3.4 Our research ‘lab’ in Mpumalanga 104
Fig. 4.1 Site 1, an HIV/AIDS clinic at a tertiary hospital in the
Western Cape (psychiatry.uct.ac.za) 122
Fig. 4.2 Site 2, a child psychiatry clinic in Khayelitsha (vocfm.com) 130
Fig. 4.3 Site 3, an HIV/AIDS clinic in Mpumalanga 138
Fig. 4.4 The deck, above and below 141
Fig. 4.5 Ethnographic notes from observations of the patient
support group 142
Fig. 4.6 Site 4, an HIV/AIDS clinic in rural Eastern Cape 146

xiii
xiv List of Figures

Fig. 4.7 The Keiskamma Guernica, based on the painting by Pablo

Picasso, depicting HIV’s slow destruction of a community 146
Fig. 6.1 Metaphor themes and examples 219
Fig. 6.2 Example of a visual illustration of the battle metaphor
such as found in an HIV/AIDS counselling manual 220
Fig. 6.3 Mount Legogote in Mpumalanga 225
Fig. 7.1 The communication bus 281
Fig. 7.2 The DRIVE model 282
Fig. 7.3 Example of a transcribed call used in the training workshop 287
Fig. 7.4 Training workshop methods 292
Fig. 7.5 Examples of team ideas of the ideal clinic space 305
Fig. 8.1 Intersecting narratives on Prevention of Mother-To-Child
Transmission male non-involvement (Mlambo 2014) 320
Fig. 8.2 The entrance to the Chris Hani Baragwanath Academic
Hospital in Soweto (Photo: AFP) 330
 List of Tables

Table 3.1 Arthur Kleinman’s eight questions 75

Table 3.2 Some useful methods and ideas for intercultural research
in the clinical setting (After Penn 2013; Penn and
Armstrong 2017) 107
Table 4.1 Features of relevance emerging from sites 121
Table 4.2 Completed research on language in the HIV/AIDS clinic 123
Table 4.3 Patient perceptions of care at Site 1 126
Table 4.4 Patient perceptions of care at Site 2 136
Table 4.5 Patient perceptions of care at Site 3 140
Table 4.6 Patients’ comments about the qualities of a good doctor
at Site 4 149
Table 4.7 Caregiver and staff perceptions of care at Site 5
(Watermeyer 2012) 153
Table 4.8 Eight qualities of care identified at the islands of good
practice154
Table 4.9 Patient perceptions about quality of care at other sites 161
Table 5.1 Examples of the content of asides (uninterpreted sections)
emerging in 17 mediated interactions (After Penn and
Watermeyer 2012b) 186
Table 6.1 Comparison of priorities for information exchange during
the consent process 245
Table 6.2 Reported barriers to enrolment in trials 246

xv
xvi List of Tables

Table 7.1 Structure and content of the two informed consent

protocols270
Table 7.2 Enrollers’ perspectives on ‘challenging’ participants 273
Table 7.3 Strategies for improving communication in informed
consent processes (After Penn and Evans 2009, 2010) 275
Table 7.4 Examples of participant feedback from communication
training278
Table 7.5 Strategies that reportedly facilitated communication
during the consent process 280
Table 7.6 Verbal and non-verbal communication strategies presented
to participants 283
Table 7.7 Communication behaviours pre- and post-training 285
Table 7.8 Feedback from workshop participants 288
Table 7.9 A comparison of recommendations across two sites 301
Table 8.1 Elements of the ‘Communication in Health’ course 324
Table 8.2 Guidelines for teaching culturally safe communication skills 334
 Part I
Background and Central Constructs
 1
Prologue

Introduction
Communication has been identified as the single biggest barrier to health
care in a global world, and the provision of culturally and linguistically
appropriate services is a top priority, particularly in the light of the
increased migration patterns and complex illness burden imposed by dis-
eases such as HIV/AIDS.
Responding to such complex challenges of communication, within the
past decade, the Health Communication Research Unit at the University
of the Witwatersrand in South Africa has produced a body of research
which has had a significant influence on ways in which intercultural
health interactions can be viewed.
Using methods from the social sciences and linguistics, this project has
explored, in detail, same- and cross-language interactions in the health-
care setting, the role of the mediator in such settings and ways in which
interactions can be modified to improve communication.

© The Author(s) 2018 3

C. Penn, J. Watermeyer, Communicating Across Cultures and
Languages in the Health Care Setting, Communicating in Professions
and Organizations, https://doi.org/10.1057/978-1-137-58100-6_1
4 1 Prologue

Our research goals have been:

1. To describe and analyse cross-language and intercultural interactions

between health professionals and patients and to understand the role
of the interpreter in this process.
2. To establish the perceptions of the different participants (patients,
health professionals and interpreters) regarding the role of the inter-
preter and the language dynamics of medical interviews.
3. To assess the influence of different sites of service delivery on the
process.
4. To develop and implement appropriate guidelines for training health
professionals who work in cross-cultural and cross-linguistic contexts.

The research to date has examined cross-linguistic communication

and interpreting practices in the areas of HIV/AIDS, TB, genetic coun-
selling, psychiatry, respiratory illness, stroke, disability, audiology, phar-
macy, antiretroviral (ARV) treatment, paediatrics, diabetes, emergency
care and general health issues. Our research has also focused on cultural
beliefs regarding illness and causality as well as the impact of healthcare
systems on rural communities. The findings of some of these studies
have shown an urgent need for revision of current practices, as well as
linguistic and cultural tailoring of information for the patient, to ensure
successful transfer of information and concordance. The research has led
to the formulation of recommendations for policy and practice as well
as the development of communication skills training programmes for
health professionals. Efficacy studies on training programmes suggest
that the communication behaviours of health personnel can be modified
effectively and demonstrably after appropriate context-specific
training.
This book represents the consolidation of this decade of experience
into a text which will hopefully significantly influence ways in which
communication practices in all intercultural health settings are managed
and understood. The culturally diverse context in which this research has
taken place has obvious and immediate application in a wider interna-
tional context, given globalization and increased patterns of migration.
 Introduction 5

Four lines of research have emerged from the research:

1. The first body of evidence stems from an investigation of intercultural

healthcare interactions in various settings and the examination of a
range of verbal and non-verbal features in such settings which facili-
tate and inhibit such interactions.
2. The second line of research has been concerned with the impact of a
third party (interpreter or cultural broker) on the dynamics of such
settings and the perceptions of the participants around this process.
3. The third body of research (including the new field of genetic counsel-
ling) has explored cultural explanations of illness and how these may
interface with the medical model.
4. The fourth line of research focused on the understanding of how this
knowledge can be transferred into training and development models
for individuals and institutions.

Having had the opportunity to work at numerous sites, across numer-

ous diseases with multiple participants and across multiple languages,
this book offers us a chance to stand back, take stock and take a bird’s-eye
view—in other words a perspective about the whole. We have worked in
seven of the nine provinces of South Africa and across six of its official
languages. Figure 1.1 shows some of our sites of research.
Much of our work has been published, and we do not want to make
the mistake here of repeating that work and its findings. Indeed, our own
perspective on that work has often changed with time and with hindsight
and with the emergence of new evidence. Rather we use this book as an
opportunity to begin to compare and contrast the evidence and to inter-
face the collective experiences with our growing insights and the global
literature, and our experience at sites with patients and doctors.
Thus, while part of the book is very much about making sense of the
real evidence (and we now have a lot of that) and highlighting useful
methods and recurrent themes, the other part is very much forward-­
looking and drawing connections where none existed, making recom-
mendations or observations which are novel and which will hopefully
influence new ways of addressing practice.
6 1 Prologue

Fig. 1.1 Map of South Africa indicating our sites of research

This text presents these findings and shows how the methods we have
developed are unique and have wide potential application. The text is
intended for health professionals, language specialists, medical educators,
researchers and practitioners, and includes a range of theoretical, meth-
odological and empirical considerations. We have developed a set of rec-
ommendations for reframing the notion of ‘cultural safety’ in health care.
This will hopefully influence both individual and systemic practices for
managing diversity.
There is a clear relationship between effective communication practices
and outcomes which can be measured in tangible benefits for patients,
the health professional and the institution. Among documented benefits
for the patients are increased accuracy of diagnosis, understanding of
treatment, improved adherence to treatment and research protocols,
 Introduction 7

greater satisfaction and greater likelihood of returning for follow-up treat-

ment. Potential benefits for the health professional include increased
speed and efficiency, more accurate diagnosis, less stress and burnout and,
in turn, greater job satisfaction and, because of the improved use of the
diagnostic power of the interaction, less dependence on costly diagnostic
tests. Institutions benefit from effective communication, as they are likely
to experience decreased turnover of staff and financial savings, and argu-
ably, most importantly, they comply with the legal and ethical obligation
of providing equitable services to all patients.
To date much of the research on such factors has not been done in the
context of the multi-lingual clinic, and where it has, some of the methods
of measurement have been unidimensional. The complexities introduced,
for example in the mediated healthcare interaction in a situation of lin-
guistic and cultural diversity, are not well understood and require meth-
ods which capture such interactional complexity. Further, little is known
about the effect of disease on the process. The work of our project has
thus been deliberately framed within a multi-dimensional perspective of
the problem. In addition to the direct evidence we have of recorded inter-
actions, we have the perceptions of the participants, as well as narrative
and ethnographic perspectives on sites of practice and from particular
illness and communication experiences. It also seems important to con-
sider the impact of the broader ‘macro’ context in health care and to
understand the socio-political and institutional context of the
interaction.
Many South African patients continue to experience numerous poten-
tial barriers to accessing the healthcare system, interacting with health
professionals or adhering to treatment regimens. These barriers are linked
to factors such as stigma and discrimination, poverty, unemployment,
gender, education, religion, literacy, access to treatment and health care,
financial resources, and trust of the healthcare system or health profes-
sional. In other words, the separate world views of the participants in
healthcare interactions have a very real impact on the process and often
cause breakdowns, which have marked consequences in terms of effi-
ciency of diagnosis and treatment.
Fascinating material has emerged from the project. As reflected in the
dissertations and publications produced, we have a body of unique material
8 1 Prologue

which spans a range of healthcare settings, a range of diseases and a number

of health professionals (see the table in the Appendix for details of each
study). We have patient narratives and health professionals’ perspectives,
and we have delved into the verbal and non-verbal minutiae of clinical inter-
actions. We have discovered multiple barriers to care and glowing islands of
good practice. We have seen how things can be demonstrably changed and
the impact that these changes have on the process of communication and on
the participants’ attitudes and behaviours. We have found that an examina-
tion of the micro-content of health interactions frequently provides insight
into broader societal issues. This suggests that many of the solutions to cur-
rent global healthcare challenges may lie in the voices of these ordinary
people and how communication takes place across this intercultural space.
We begin in this text to coalesce this material and offer some explana-
tions, solutions and methods for reframing these challenges based on
some remarkable and exciting evidence.
The following are considered some central values to this project.

F ocus on Everyday Practice and Authentic

Methods
Based on the belief that the study of everyday, local and particular is espe-
cially valuable, the emphasis in this book is a close examination of everyday
practice in a range of settings. Our research has enabled us to bear witness
to the stories and experiences of ordinary patients and health professionals.
As Jonny Steinberg (2010) has indicated in relation to effective implemen-
tation of new health policy and universal coverage of ARVs in South Africa,
“A great deal will depend on what ordinary people think and do.”
Our focus has been on just that. Methods of data collection, tran-
scription, translation and analysis have been developed with an empha-
sis on capturing accurate and nuanced language use. We have examined
interactional aspects such as openings and introductions, length, cou-
pling, symmetry and the search for collaborative moments (moments
in the interviews where participants and observers endorse mutual
understanding). Our methods also include participant observation, and
the exploration of the everyday life, experiences, events and problems
 Focus on Everyday Practice and Authentic Methods 9

of our participants through interviews and narrative methods. Some of

our methods have encouraged self-reflection —health professionals
reviewing videotapes and transcripts of their own practice— and hear-
ing their explanations for their behaviours.
In this text we also wish to highlight and illustrate the methodological
challenges of such research and to discuss in detail some lessons learned
and some mistakes made and to develop some recommendations about
these tools and their potential future use. These methods also have
enabled a certain way of presenting evidence from the project. We also
want to ensure that there is a depth and richness of illustration in this
text. As one of the health workers interviewed in this project observed,
“Sometimes the direct voice of the patient is more powerful and beautiful
than any secondary analysis or interpretation of what was said.”
Some of the evidence that we have is embedded in the narratives— sto-
ries of patients about their disease. As Rita Charon (2008) has indicated,
such narratives provide a remarkable perspective on the patient’s world
and form an important diagnostic and therapeutic function. This is par-
ticularly the case in contexts where a strong oral tradition exists. We have
stories about disability, about diseases such as HIV/AIDS and of health-
seeking paths. There are stories of resilience and adaptation to illness.
We also have the stories of doctors— doctors disillusioned with the
system, and some developing methods of communicating which are par-
ticularly unique and powerful.
We present some of these narratives in the text to provide the reader
with an opportunity to blend and merge voices of the health professional,
the patient and the mediator or third person who is so frequently present
in such interactions.
Similarly, the technique of conversation analysis, which we have used
for analysis in some of our studies, allows for the illustration of very detailed
interactional material, and the text includes a number of verbatim extracts
between health practitioners and patients which provide the reader with a
detailed understanding of both verbal and non-verbal components.
We are acutely aware of the ethical complexities of research of this
nature. By definition, this book deals with vulnerable populations of peo-
ple who are often sick, poor or uneducated. These are the very people who
have been marginalized by society, and their voice is often ­misrepresented
10 1 Prologue

and silenced. Our qualitative methods seek to directly represent their

voices, and we believe it is our ethical obligation to do so. Both of us have
been active members of our university’s ethics committees for a number
of years. All our research has received ethical clearance from the relevant
Institutional Review Boards and informed consent was obtained from all
participants. We have taken care to anonymize the people involved and to
use pseudonyms where necessary. In some instances however, and partic-
ularly where we highlight excellence of settings, we have chosen not to
completely anonymize all of the clinic details. Similarly, finding and using
the appropriate terminology within clinic spaces has proven an important
but challenging aspect of our research endeavours. As will be described in
more detail in Chapter 3, the words we use to refer to those who work in
clinics and with patients have direct links with our own approach to
research, our views of participants and our perceptions of ourselves as
researchers in the clinic space. In our research we have seen that when
issues around team membership, acknowledgement of role and the use of
inclusive terminology have been actively considered and addressed, there
have been positive consequences.
While this book reflects the products and efforts of a long-term partner-
ship, at times we discuss our own experiences and perspectives on particu-
lar projects, and we have taken care to label these perspectives as particular
to one author. We have also on occasion included ‘small stories’ (Bamberg
and Georgakopoulou 2008) to illustrate our research experiences.

Emergent Themes
In this text we highlight some of the themes which have emerged from
the research and which have a cohesive potential, in terms of both theory
and practical import.
Some examples link to:

• A consideration of the interface between a Western biomedical health-

care framework, which operates alongside established systems of tradi-
tional medicine.
• The powerful influence of gender on the health communication pro-
cess. What factors help women to express themselves and enable their
 Emergent Themes 11

voice to be heard? What barriers to care exist for women, and how can
the clinical relationship assist in resolution of these issues?
• The interaction between disease, poverty and communication. We are
interested in exploring what Paul Farmer et al. (2006, 2013) refer to as
“structural violence” imposed in a context of poverty and how tempo-
ral and spatial factors interface with health communication.
• Why do community structures of support sometimes have limits?
• How do the voices of different generations interface in the health con-
text? Our body of research on grandmothers, for example, has high-
lighted a number of differing models of illness causation.
• The delicate tension between the emergence of established organiza-
tional routines in healthcare interactions, in a context of fluidity and
uncertainty and scarce resources.

Just as many of the problems in health delivery link to communication

issues, so too do many of the solutions. Some of these are surprisingly
practical and simple and are described and illustrated in the text. For
example, asking the right questions, changing the seating in the interview
or the tea room arrangements in a clinic, negotiation of language rules,
the conscious deployment of non-verbal strategies (e.g., the use of ges-
ture, facial expression and using props) are some mechanisms that have
been explored. Similarly, ways in which vocabulary and terminology can
be clarified and understood have been a feature of our research.
The essence of our research endeavour is, in short, to blend the voice
of the lifeworld with the voice of medicine (Mishler 1984) and to use
communication as that bridge.
This is beautifully illustrated by the following pair of photographs
(Fig. 1.2), taken (with permission of all participants) in a diabetes clinic
in a large hospital in which one of our projects was sited.
In the one picture we see the messages of the clinic (in this case about
foot care) and the standard mediator for that message (the nurse ­educator)
whose primary role is to educate patients coming to the clinic about the
­complexities of diabetes management. In the other picture we see part of
our drama intervention involving actors, patients, nurses and facilitators,
the use of a cell phone and a snapshot of a group interaction whose goals
were entirely similar. The images complement each other and indicate the
potential role of communication strategies in helping to bridge the gap.
12 1 Prologue

Fig. 1.2 The voice of medicine and the voice of the lifeworld (Photographs by
Yeshiel Panchia)
 Emergent Themes 13

We have some really pleasing evidence for how such factors enhance
communication, reduce barriers to mutual understanding and promote
concordance even in the most challenging intercultural contexts. It is in
the initial and subsequent interface between the health system and the
patient that lives can be changed or that paths are set. We have begun to
see the emergence of what we call ‘magic moments’ in clinical settings—
points at which the participants collaborate and show evidence of mutual
understanding and intention. Such moments mostly occur around non-­
medical topics and are characterized as having greater interaction, being
more informal and personalized, demonstrating more coupling and mir-
roring behaviours, facial animation, increased eye gaze, forward body
posture and increased gesture. Such findings have major implications for
medical education.
Interwoven into this discussion is a consideration of biomedical ethics
and the role that communication factors play in this field. We consider,
for example, how communication variables are central to determining
and enhancing autonomy, self-efficacy and decision-making capacity and
can be actively enhanced in cross-linguistic research trial settings.
Other questions and solutions are more complex. How, for example,
can communication dimensions interface with the barriers to care which
continue to exist in the context of HIV/AIDS? What are the language
dimensions of the process of disclosure? Why do fewer than 30% of
women take up counselling services and why is there no apparent decline
in new infections in pregnant women? The fact that staying alive depends
on maintaining high adherence rates to ARV regimens in order to pro-
mote treatment success requires a detailed understanding of the language
of the pharmacy which is considered in depth in this text. Similarly, com-
munication is implicated in the complex treatment regimens and in rec-
ommended nutritional practice for patients.
How can some of our findings influence confidence and effectiveness
of young doctors working in contexts of cultural and linguistic diversity?
What mechanisms will best aid and assist systems and settings to cope
with what has been termed ‘organizational shock’ brought about by the
rapid and profound demographic changes and the complexity and sever-
ity of the diseases encountered?
14 1 Prologue

Emerging Solutions
This text aims to address some of the above issues and offer some concep-
tual and some practical proposals for individuals, institutions and policy.
Amongst some of the issues we explore (and which inform the last section
of the book) are the following:

 he Move Towards a Revised Model of Cultural

T
Brokerage

Our findings have strengthened the notion that in an intercultural set-

ting, a traditional conduit model of interpreting (where interpreters are
expected to remain neutral and merely transfer information verbatim
between patient and health professional), is ineffective and a cultural
brokerage model of interpreting is most effective for the transmission of
meaning in intercultural contexts. In this model the cultural broker acts
as a mediator between the health professional and patient, offers a cul-
tural framework in which the message can be interpreted and assists
both parties to negotiate cultural and linguistic barriers in order to
achieve a specific communicative goal. The text presents the discrete
profiles of cultural brokerage interpreting which have emerged in differ-
ent settings.

Islands of Good Practice: Characteristics of a Caring

Clinic

In our setting, because systems of health care are often underdeveloped or

even malfunctional, because the monitoring of such systems may be
erratic and because of profound resource limitations imposed by the
needs of a developing country, such difficulties are mapped daily onto the
clinic and its people. Ironically, this has created a space or vacuum which
has enabled an opportunity to exercise creativity, resourcefulness and
adaptation, and this has enabled the emergence of unique organizational
routines. A fascinating picture emerges in some cases about not only how
the role players have made do in a context of scarce resources, but also
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