South African Language Practitioners Council Bill B14-2013

South African Language Practitioners’ Council Bill [B14-2013] Submission To Parliament of the Republic of South Africa

From Dr Marion Heap Health and Human Rights Programme School of Public Health and Family Medicine Room 1.31, Level 1, Falmouth Building Health Science Faculty University of Cape Town Anzio Rd, Observatory, 7925 Email: [email protected] Tel: 021 406 6978 Cell: 084 981 3583

Attention Ajabulile Mtiya Committee Secretary Portfolio Committee on Arts and Culture 3rd Floor, 90 Plein Street Cape Town 8001 Email: [email protected] Tel: 021 404 8106 Cell: 083 709 8389 Fax: 086 544 0628

1 Contents

Introduction 3

About the submission 4

Professional interpreting services in health care are a public health 6 issue

Interpreting and translation services are a human rights issue 6

Notes on a pilot medical interpreter training 7

References 9

2 Submission

Introduction This document makes a submission to the Parliament of the Republic of South Africa. It concerns the South African Language Practitioners’ Council Bill [B14-2013]. The submission offers a view from the perspective of the consumer or user of an interpreter service. The users or consumers that are the focus of the submission include Deaf people and health care providers. Deaf capitalised refers to those permanently sensorily disabled people who are either born deaf or who become deaf as children and whose first language is South African Sign Language (SASL) and deaf lower case refers to the audiological condition, deafness.

In general South Africa still has no professional interpreting posts in health care – both for spoken and signed languages, although these are available in the justice system and in Parliament. These professionals and their services have always been lacking in health care despite the country’s 400-odd years of plurilingualism (Shell, 1994: xxv). In all the years leading up to 1994, there were no official interpreter posts in the public service, outside of the judiciary (Drennan and Swartz, 2002: 1854). In post-apartheid South Africa, no provision was made for official interpreter posts in health care in a recent revision of the public service post structure (see Beukes, 1996).

The submission, in view of the lack of professional interpreting posts in health care is concerned to draw attention to (1) The urgent need for professional accredited SASL interpreter services in health care (2) The equally urgent need for an accredited training for professional medical SASL interpreters

The submission is thus particularly concerned with the following – which will bring professional SASL interpreters in line with certain requirements for other health professionals

3  The regulation and accreditation of the training of SASL interpreters, including a medical speciality –  The registration and accreditation of SASL interpreters;  A code of conduct;  Professional organisations that will protect both the SASL interpreter on the one hand and the public on the other

The submission also suggests that by opening up opportunities for professional SASL interpreters in health care, it is possible to contribute to the following:  Provide and encourage the provision of opportunities for persons, especially from disadvantaged communities, to enter and participate in the language industry in the Republic  Contribute to an enabling environment for job creation in the language industry in the Republic

The submission would also like the Council to consider  Levels of payment for professional interpreters  Accredited SASL interpreting training for Deaf relay interpreters

About the submission This submission draws on findings of a long term project that aims to address language barriers in health care for Deaf people. A study (2008-2011) piloted the implementation of the first professional SASL interpreter service in out-patient health care in Cape Town. The study proved professional SASL interpreter services to be acceptable to both staff and Deaf patients. It (see, for example, Haricharan et al, 2013) demonstrated that for Deaf South Africans the right to health and access to effective health care is closely linked to language and can be achieved through providing Deaf patients with a professional SASL language interpreter. A professional SASL interpreter ensures their right to information about treatment in a language of their choice. It enables them to participate in decisions relating to their health, to give informed consent and to confidentiality. Importantly, it puts them on par with hearing patients and equalises access to non-discriminatory health care.

The professional SASL training also improved access to health care for Deaf patients. For example, there was a steady increase in requests over time (average 4 per month in 2008; average 13 per month in 2011). In 2013 the average per month for the first seven months is

4 33, which is a considerable workload given the limited numbers of professional SASL interpreters available.

The project responded to the ever increasing need for an interpreter by the following interventions (which are discussed in greater detail below): (1) Piloting an additional and novel ‘cluster’ service at an ophthalmology service; (2) Piloting the training of medical interpreters and (3) Piloting Deaf clinic assistants in certain facilities

This submission is made with the National Health Insurance in view. Currently a pilot research project is evaluating a model health district based free-to-patient professional SASL interpreter service in health care. As such the service will provide for all of the health facilities in a health district or sub-district depending on the population and the number and types of facilities. Such a service should be cost effective. It also addresses the challenges of a population such as the Deaf. These populations do not have a geographical base. Their health care attendance patterns are dispersed across geography and facility (see Map 1; Heap et al, 2006; Heap et al, 2006a) and cannot be predicted or confined to a single facility.

Staff for the model district based service will include salaried accredited trained SASL interpreters and salaried trained Deaf clinic assistants. The Deaf staff will work alongside the interpreter. Both sets of staff will form part of the wider district health care team. Professional SASL interpreters and Deaf clinic assistants will be as much part of the health team as doctors, nurse, pharmacists and other health professionals.

Services offered include those for individual consultations as well as those referred to as ‘cluster’ service. Such a ‘cluster’ service has been piloted at an ophthalmology out-patient clinic. It is run – entirely - by the Deaf clinic assistants. Staff advertises and organises, monthly, via bulk SMSing, for up to five Deaf people to attend ophthalmology out-patient clinic. On the designated appointment day the project supplies a professional SASL interpreter on a regular monthly basis. Clustering works well to allocate the scarce interpreter resource more effectively. However, it is not suitable for all conditions, where privacy may be more of an issue.

Professional interpreting services in health care are a public health issue In South Africa, up to 80% of consultations in health care are carried out across language barriers (Penn, 2007). The consequences for health as a result of miscommunication are

5 serious (Crawford 1999; Drennan 1996; Drennan 1999; Pillay 1999; Penn 2002; Levin 2006a; Levin 2006b; Levin 2006c; Schlemmer and Mash 2006; Watermeyer and Penn 2009; Deumert 2010). Deumert (2010) summarizes the consequences to include: ‘avoidance behaviour’ which occurs when people who are faced with language barriers tend to leave consultations until well into the late stages of illness; ‘errors in diagnosis and treatment’; delays in treatment as a result of excessive and unnecessary diagnostic test; problems with ‘health education and compliance’ because people are unlikely to understand their condition and treatment options

The interpreting needs of Deaf people in health care settings in South Africa are urgent. Research with Deaf people demonstrates problems similar to those experienced by hearing people but with some additional complications. When working with Deaf people, health care practitioners find it difficult to elicit histories, explain procedures, medication protocols and obtain consent (Barnett, 1999; Lezzoni et al, 2004; Haricharan et al, 2013). Access to health care is unequal (Ubido et al, 2002) and ‘unsatisfactory’ (Ludders, 1987; Lotke, 1995; Steinberg et al, 1998; Lezzoni et al, 2002; Lezzoni et al 2003; Lezzoni et al 2004; Haricharan et al, 2013). Deaf people are cut off from gaining proper information concerning health generally (Ebert and Heckerling, 1995; Haricharan, et al, 2013, and in particular HIV Aids (Chiltern, 1996: 23, Note 17; Haricharan et al, 2013).

Interpreting and translation services are a human rights issue. The South African Constitution (see, No 108, 1996) entrenches the right of access to health care on the basis of equality and freedom from any form of unfair discrimination on a number of grounds, including race, gender, sex, disability and language (Sections 9 and 27). The South African National Health Act (61 of 2003),1 on the issue of language states that: ‘The health care provider concerned must, where possible, inform the user… in a language that the user understands and in a manner which takes into account the user’s level of literacy’.2 The phrase where possible has, however, been the escape phrase for government up to now. This is even though the Patients’ Rights Charter3 also states that: ‘health information that includes the availability of health services and how best to use such services and such information shall be in the language understood by the patient’. Furthermore, the Patients’

1 http://www.acts.co.za/national_health/index.htm. 2 Chapter 2: Rights and Duties of Users and Health Care Personnel, section 6: User to have full knowledge, Government Gazette No.26565, Vol. 469, No. 869 (July 23, 2004). http://www.acts.co.za/national_health/index.htm. 3 http://www.doh.gov.za/docs/pamplets/patientsright/chartere.html.- see access to health care 6 Rights Charter includes rights such as the right to confidentiality, informed consent, right to health information and participation in decision-making.

Pillay (1999) has argued that if we are serious about the right of access to non- discriminatory health care on the basis of equality then professional translation and interpreting services must become common practice. There is much on paper. The challenge is to realise rights – to put them into practice.

Notes on a pilot medical interpreter training To address the problem of lack of formal interpreter training, in January 2010, the Health and Human Rights Programme of the School of Public Health and Family Medicine commenced a pilot two year training programme for medical SASL interpreters. The pilot explores a training programme that focuses on young people who have a strong sense of social justice, who are keen to learn, who have language skills and have an interest in it. They have a Grade 12 (i.e. have graduated from high school), but do not have the financial means to attend university –and tertiary education.

The project aims for an accredited training – that is courses must be approved by the South African Qualification Authority (SAQA)4. SAQA accredited courses are given a rating according to the National Qualification Framework (NQF). 5 Courses are rated NQF 1 – 10 and competencies expected for each level are described. 6 When courses are approved by SAQA they are recognized all over South Africa. South Africans can also add to and accumulate SAQA accredited courses over time. In this way, candidates, in the spirit of life- long learning can improve their education and employment prospects over time.

The pilot medical interpreter training includes courses in the following (see Table 1):  SASL  Interpreting

4 http://www.saqa.org.za/

5 http://www.nqf.org.za/

6 http://www.nqf.org.za/download_files/Draft%20level_descriptors.pdf

7  Health and health care  Human rights and ethics  Continuing professional development (CPD)  Computer skills (Word and Excel)

Each course includes theory and practice. For example, during Year 1 trainees do a SAQA accredited SASL course (NQF 4 or Grade 12 level) at the NGO, Sign Language and Development (SLED), 7 SLED being the only local organization that offers accredited SASL courses. The students then do the practice of their SASL at a local NGO – the Deaf Community of Cape Town (DCCT). At DCCT they work as volunteers and interact with Deaf people. In this way they practice their SASL.

Trainees attended a SAQA accredited course – Introduction to Community SASL interpreting – offered by University of the Free State (2011-2012). For practice of their interpreter skills, the project organized with the Department of Health (DOH) and UCT Human Research Ethics Committee for trainees to ‘shadow the trained SASL interpreters’. Shadowing is really a form of apprenticeship that allows for trainees to work alongside the professional interpreters in the health care facilities – and in this way learn while working. This is a tried and tested way of learning for medical practitioners and other health professionals

Colleagues in the DOH and at UCT assist us, voluntarily, with lectures and workshops on human rights, ethics and health and health care. UCT staff also assists with computer training and support

In addition we have organized extra SASL tutorials and activities that encourage general knowledge. We want to introduce a notion of Continuing Professional Development or CPD. CPD is a requirement for health professionals. We consider it equally appropriate for professional SASL interpreters so that they keep up to date with their profession and maintain high standards.

7 http://www.sled.org.za/

8 References

Aarons, D. 1995. Hands full of meaning Bua 10. (1): 8-10.

Barnett, S. 1999. Clinical and cultural issues in caring for deaf people. Family Medicine. 31: 17-22

Beukes, A-M. 1996. Language in the public service. In Towards a national language plan for South Africa. Final Report of the Language Plan Task Group. Pretoria: Ministry of Arts, Culture, Science and Technology, Pretoria.

Chavez, E.L., and E.R. Oetting. 1995. A critical incident model for considering issues in cross-cultural research. Failures in cultural sensitivity. The International Journal of Addiction 30: 863–874.

Chiltern, E.E. 1996. Ensuring effective communication: The duty of health care providers to supply Sign language interpreters for Deaf patients. Hastings Law Journal 47: 871.

Constitution of the Republic of South Africa No. 108. 1996. Government Gazette 378, no. 17678. Registered Newspaper. Cape Town.

Crawford, A. 1999. We can’t all understand the whites’ language: An analysis of monolingual health services in a multilingual society. International Journal of Sociology of Language 136: 27–45.

Deumert, A. 2010. ‘It would be nice if they could give us more language’–Serving South Africa’s multilingual patient base. Social Science and Medicine 71: 53–61. Drennan, G. 1996. Counting the cost of language services in psychiatry. South African Medical Journal 86: 343–5.

Drennan, G. 1999. Psychiatry, post-apartheid integration and the neglected role of language in South African institutional contexts. Transcultural psychiatry 36: 5–22.

Drennan, G., and L. Swartz. 2002. The paradoxical use of interpreting in psychiatry. Social Science and Medicine 54: 1853–1899. Flores, G. 2005. The impact of medical interpreter services on the quality of health care: a systematic review. Medical Care Research Reviews. 62 (3): 255-299

Haricharan, H. J., Heap, M., Coomans, F., London, L. 2013. Can we talk about the right to health care without language? A critique of key international human rights law, drawing on the experiences of a Deaf woman in Cape Town, South Africa. Disability & Society.

Heap, M. Haricharan, H, Cassidy, A. London, L .2012. Sign (SASL) language interpreting services working to advance the right of access to health care. Paper presented at the PHASA (Public Health Association of South Africa) Bloemfontein, 6- 7 September, 2013.

9 Heap, M., and H. Morgans. 2006. Language policy and SASL interpreters in the public service. In Disability and social change: A South African agenda, ed. M. Watermeyer, L. Swartz, T. Lorenzo, M. Schneider, and M. Priestley., 134–147. Pretoria: HSRC Press.

Heap, M., T. Lorenzo, and J. Thomas. 2009. ‘We've moved away from disability as a Lezzoni, L.I., B.L. O’Day, M. Killeen, and H. Harker. 2004. Communicating about health care: Observations from persons who are Deaf or hard of hearing. Annals of Internal Medicine 140, no. 5: 356–362.

Jacobs, E. A., Lauderdale, D.S., Meltzer, D., Shorey, J.M., Levinson, W., Thisted. R.A. 2001. Impact of interpreter services on delivery of health care to Limited- English-proficient patients. Journal of General Internal Medicine. 16: 468.

Jacobs, E. Chen, A., Karliner, L., Aggergupta, N., and Mutha, S. 2006. The need for more research on language barriers in health care. A proposed research agenda. The Millbank Quarterly. 84: 111-133.

Jacobs, E.A., Shepard, D.S., Suya, J.A., Stone, E.L. 2004. Overcoming language barriers in health care: costs and benefits of interpreter services. American Journal of Public Health. 94 (5): 866 – 9.

Karliner, L.S., Perez-Stable. E.J., Gildengorin, G. 2004. The language Divide. The importance of training in the use of interpreters for outpatient practice. Journal of General Internal Medicine19: 175-163.

Kaufert, J.M., Koolage, W.W., Kaufert, P. L., and O’Neil, J.O. 1984. The use of trouble case examples in teaching the impact of sociocultural and political factirs in clinical communication. Medical Anthropology. 8: 36-46.

Kellerman, K .1999. Discussion document on SASL and SASL interpreters services strategic planning, DEAFSA. Unpublished manuscript distributed to Workshop participants, Bloemfontein, 29 November – 1 December.

Ladd, P. 1988. The modern deaf community. In Miles, D. British Sign Language: a beginners guide. London: BBC Books.

Lezzoni, L. I., O’Day, B. L., Killeen, M., Harker, H. 2004. Communicating about health care: observations from persons who are Deaf or hard of health. Annals of Internal Medicine. Vol 140 50: 356-362.

Lezzoni, L.I., Davis, R.B., Soukup, J. O’Day, B. 2002. Satisfaction with quality and access to health care among people with disabling conditions. International Journal of Quality Health Care. 14: 368-81.

Lezzoni, L.I., Davis, R.B., Soukup, J. O’Day, B. 2003. Quality dimensions that most concern people physical and sensory disabilities. Archives of Internal Medicine. 163: 2085-92.

Lotke, M. 1995. She won’t look at me. Annals of Internal Medicine. 123: 54-7.

Lucas, C. and Valli, C. 1992. Language contact in the American deaf community.

10 San Diego: Academic Press.

Ludders, B. B. 1987. Communication between health care professionals and deaf patients. Health and Social work. 303-306.

Levin, M. 2006a. Different use of medical terminology and culture-specific models of disease affecting communication between Xhosa-speaking patients and English-speaking doctors at a South African paediatric teaching hospital. South African Medical Journal 96, no. 10: 1080–3.

Levin, M. 2006b. Editorial. South African Medical Journal 96, no. 10: 1058–1060.

Levin, M. 2006c. Language as a barrier to care for Xhosa-speaking patients at a South African paediatric teaching hospital. South African Medical Journal 96, no. 10: 1076–9.

London, L. 2012. Health care users’ experience as a focus for unlocking opportunities to access quality health services. Proposal submitted to the European Unions.

Madonsela, T. 2006. Promoting equality through administrative measures. In Reflections on democracy and human rights: A decade of the South African Constitution (Act 108, 1996), 15–26. Johannesburg: South African Human Rights Commission (available at http://www.sahrc.org.za/home/21/files/Reports/Reflection%20of%20democracy%20and %20human%20rights_10%20year%20review_%20200.pdf).

Morgan, R. 2001. Barriers to justice: deaf people and the courts. Issues in Law, Race and Gender, No 8. Law, Race and Gender Research Unit, University of Cape Town.

Penn, C. 2002. Cultural narratives. Folia Phoniatrica et Logopaedica 54, no. 2: 95–9.

Penn. C. 2007. Factors affecting the success of mediated medical interviews in South Africa. Current Allergy & Clinical Immunology 20, no. 2: 66–72.

Pillay, K. 1999. Access to health care services: Language as a barrier. Socio-Economic- Rights Newsletter. Community Law Centre. University of the Western Cape (September).

Schlemmer, A., and B. Mash. 2006. The effects of a language barrier in a South African district hospital. South African Medical Journal 96, no. 10: 1084–7.

Shell, R. C-H. 1994. Children of bondage: A social history of the slave society at the Cape of Good Hope, 1652–1838. Johannesburg: Witwatersrand University Press.