This section will look at some of the issues that have a bearing on the provision and effectiveness of healthcare interpreting, such as the availability, or otherwise, of language services in diverse immigrant languages; achieving balance between interpreting, cultural mediation and advocacy; and the development of training and assessment.
Adequate language services in diverse immigrant languages
The diversity of languages and dialects and their associated cultures across the world presents a unique challenge for the field of community interpreting when combined with the scope and scale of migration in today’s world that is bringing so many diverse languages into proximity within a given local community. Newcomers, or their children, may learn the dominant language(s) of their new home in due course; the problem is the linguistic and cultural barriers that arise immediately upon arrival for immigrant adults with respect to the dominant local community.
This is a problem unique to community services, which need to be able to reach all individuals equally regardless of their language. National governments can conduct their core functions in one or a handful of languages. International conferences routinely make their communications accessible to attendees in a small number of languages through the services of professional conference interpreters. Such a broad organisation as the European Union has, with considerable cost and difficulty, been able to accommodate an increasing number of languages in its deliberations and communications. Any service that requires face-to-face interaction with any and all members of the general public, however, is increasingly likely to face a unique challenge: that significant, and often growing, proportions of their local population do not share a common language with those who provide public services such as healthcare. Moreover, the languages and dialects spoken may be highly diverse.
For instance, well over one hundred distinct languages are spoken at home by public school students in New York City (some estimate that as many as 800 languages may be spoken in the city by all age groups).5 Parents of these students may not speak English or may speak it with a limited degree of proficiency. Therefore, such routine functions as parent-teacher conferences and healthcare encounters cannot be performed equitably without some linguistic accommodation. For a widely spoken minority language such as Spanish in New York City and in many parts of the United States, a hospital may be able to hire full-time Spanish-English interpreters with appropriate skills and training. For other languages not widely spoken in a given area (languages of limited diffusion, or LLDs) the same solution may be unavailable. Today, this kind of communication barrier is common in major cities, and even in villages and rural areas, in many parts of the world.
From the point of view of the potential interpreter of an LLD (for example, Tigrinya, Khmer or Nuer in the United States) there likely will be no language-specific skills training available. Moreover, the demand for interpreting in a given LLD may be so low that it would be unprofitable for a bilingual speaker of this language to seek training or accreditation, even if available, or to envision a career in interpreting. This is the obvious reason why volunteers and family members with some command of the provider’s language are so often called upon and is part of the rationale for providers choosing to ‘make do’ without needed language assistance.
As a consequence, it may be very difficult to locate anyone able to interpret with professional competency between a provider of health services and a given patient who may show up to receive healthcare. Remote interpreting via telephone, video or a computer link offers a partial solution by linking an interpreter of an LLD, located anywhere in the world, with a patient who speaks that language and a service provider. Remote interpreting assignments may thus provide enough work for the interpreter of a less widely spoken language to support a career in interpreting.
With respect to widely spoken language pairs, the ethical mandate to offer professional interpreting services in healthcare is only countered by costs, political will, awareness of need, and sometimes the reluctance of providers to utilise services already available. The critical problem is how to provide equivalent services in the case of the many other languages, with respect to which cultural barriers may be greater. There may be fewer educated bilinguals ready to be trained and employed as interpreters, and demand for their services may be limited in a given geographical area. Until solutions can be found for this imbalance, language services will remain unequal for speakers of different languages in the same locality.
Finding the right balance between interpreting and cultural mediation/advocacy
A second critical issue facing the field of healthcare interpreting centres around the role(s) of the professional interpreter is the possible contributions of bilingual family members, and needed support for immigrant and minority patients in addressing cultural conflicts and misunderstandings.
Studies have shown that bilingual family members accompanying a patient can contribute in many ways, such as clarifying cultural viewpoints and patient complaints and advocating for the patient (or the provider). However, research has also shown that, untrained in interpreting and not reticent to assert their own views, family members who interpret often inhibit clear, direct, and accurate communication between provider and patient. Accompanying relatives of the patient can be given the opportunity to offer their perspective without being expected to interpret as well. What reason other than costsaving and convenience is there to call upon bilingual adult family members to take the role of interpreter? This important question becomes more urgent in face of what Gentile (2017) describes as the de-professionalisation of interpreting under nationalistic political pressures and budget constraints even in countries that have previously supported professional interpreting.
A related issue is this: to what extent can a professional interpreter be expected to provide accurate and impartial interpreting (suppressing personal opinions) and also to provide cultural brokering and guidance for the benefit of patients unfamiliar with Western healthcare? Can the interpreter do both or are these two distinct roles?
Verrept (2008) discusses the establishment and history of a government-sponsored intercultural mediation programme in Belgium in which bilinguals trained as culture brokers are employed rather than professional interpreters filling a more limited role. Culture brokers meet separately with patients to share information and learn about their concerns in addition to interpreting where needed. A major obstacle from the beginning has been the reluctance of providers to bring in the mediators rather than continuing to rely on family members for interpreting. However, evaluations found significant improvements in quality of care when the mediators’ services were used. Patients were more willing and able to discuss their concerns with the mediators than directly with their physicians. To adequately fulfil their broad role, mediators needed extensive training. In this type of programme, support and advocacy for individual patients are emphasised over the usual impartial role of the interpreter (which by contrast may appear to serve the needs of the provider over those of the patient). This is a model that might work well in other settings.
Other solutions to the problem of providing both cultural support for patients and interpreting services have also been implemented. A paediatric specialty hospital in Seattle, Washington (USA), established a separate position of ‘bilingual patient navigator’ to serve alongside the regular interpreting staff (Crezee and Roat 2019). Bilingual navigators are assigned to assist selected families - those judged most likely to benefit from their services - by guiding, teaching, and supporting them, as well as interpreting as needed. Other patient families receive the usual professional interpreter services. An external evaluation of the programme at the end of two years (in 2011) showed ‘significant improvement’ in multiple areas including a lower no-show rate, shorter average length of stay, a greater number of interpreted encounters, and significant cost savings (ibid.'. 7-8).
Development of training and assessment
A third critical need is to work toward agreement on adequate levels of general education and professional training for interpreters. While good models and practices regarding certification of skills exist, there is a need for new ideas on the best ways of training interpreters and on how to prepare interpreter trainers. These questions are most acute with respect to initial training and assessment of interpreters of LLDs where the barriers include the lack of qualified trainers who speak these languages and bilingual training materials, as well as the problems of adequate testing and certification for multiple language pairs.