Map of life expectancy at birth from Global Education Project.

Monday, November 13, 2006

Talking about talking . . .

about talking about talking.

C. Corax astutely asks whether it is ever appropriate for medical interpreters to engage in behavior other than interpreting. Many people answer "Yes." They argue that if it is the job of the interpreter to facilitate communication, they should intervene when they observe miscommunication due to cultural barriers between physician and patient. The most commonly cited examples are discordant health beliefs and practices, essentially the typical subject matter of medical anthropology. Maybe the parents believe their baby has empacho, a sickness believed to be caused by a ball of food lodged in the digestive tract. (The doctor would probably diagnose colic.) Maybe they consult a curandero, or believe that they have been cursed. The doctor, meanwhile, may be assuming knowledge about entities such as viruses or abnormally dividing cells that they do not have.

Well, yeah, occasionally stuff like this comes up. Every time I start to talk about cultural competence, somebody brings up the book The Spirit Catches You and You Fall Down by Anne Fadiman, which tells a tale in which differing health beliefs between physicians and a Hmong immigrant family in California caused major problems. No doubt there are occasions when interpreters might contribute to mutual understanding by helping to explain such alternative viewpoints to the parties.

However, after reading transcripts of hundreds of medical encounters between immigrants and non-immigrant physicians, and interviewing more than 200 immigrants about their health and health care, I can say confidently that for Latinos, at least, such so-called "folk beliefs" are of very minor importance to culturally competent health care or cross-cultural communication. And to the extent that they are significant, you don't need an interpreter to achieve mutual understanding -- the doctor just has to ask. After all, I understand that people from California -- that magical LaLaLand where the sun always shines and everybody gets around on rollerblades -- believe in the healing power of crystals. However, I don't hear that east coast docs need to learn all about this in order to take care of them.

The fact is that all medical encounters are cross-cultural -- between the culture of medicine, and the culture of the real world where human beings actually live. I don't take the credit for that discovery, by any means. One of the most compelling explorations of the canyon between doctor and patient was made by Elliot Mishler, whose Discourse of Medicine is back in print. (It's not exactly beach reading -- quite academic.) Elliot (with whom I am acquainted) distinguishes between the Voice of Medicine and the Voice of the Lifeworld. He finds patients continually thwarted in their efforts to tell their stories, and to place their experience of health and illness in the context of their lives. Instead physicians, who remain imperiously in control of the agenda and process of the medical encounter, relentlessly deflect the discourse to the biomedical conception of the patient they have acquired through socialization in medical school and residency.

Yet those of us who happen to speak English don't have an interpreter with us when we see the doctor, to explain to us the significance of Coombs titers and help the physician understand that the patient's ability to follow a diet or a medication regimen is constrained by family and work responsibilities. The problem is more complex, to be sure, when the cultural distance between doctor and patient is particularly great. It is likely that distance is greater between a former Salvadoran peasant and a North American doctor whose own father probably went to Harvard too, than it is between that doctor and an Irish-American auto mechanic -- but the difference is not as much as most people think.

Asking interpreters to step in and try to fix this problem is to call for a great deal of skill and judgment. Whether it really results in better communication, more satisfactory relationships, and better medical outcomes, is an empirical question for which we have essentially no data. Perhaps it just introduces more problems than it solves, and interpreters generally should stick to trying to be a "black box" translator.

However, that doesn't really work either. True equivalence of meaning between different languages does not exist. In fact, it is impossible to define, because we can only think using language. The only way to judge that statements in different languages are equivalent in meaning is to ask a bilingual person for an opinion -- and such opinions may differ. What is more, meaning depends on context, and on the hearer. What I am writing here will not have exactly the same meaning to every listener. (In Speech Act theory, we call the response evoked in the hearer or reader the perlocutionary force of the utterance. More on that later.) Interpreters can't just translate everything literally, because that often just doesn't work.

Sometimes, of course, an interpreter may confront a genuine emergency, a situation in which ordinary human ethics demand intervention, regardless of what professional codes of ethic we may write. For example, the interpreter realizes that a child is in danger, and that the doctor does not. My personal view, pending more data, development of better training and standards for interpreters, and better understanding of how communication in general can be facilitated and improved, is that interpreters should be very restrained and cautious about stepping out of the role of simply converting meaning, as best they can, from language A to language B. But if they do go beyond that, they must make their behavior fully transparent to both parties, interpreting everything they say as well as everything the parties say. In the data I described in my last post, they did not do so.

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