Department of Psychology

Departement Sielkunde

Language, access and the

politics of care: A South

African storyLeslie Swartz and Bonginkosi Chiliza

Sanja Kilian, Tessa Dowling, Mawande Dlali, Jénine Smith, Ereshia Benjamin,

Sybrand Hagan, Marion Heapwith MRC/NRF funding

Ten poorest countries in the world by GDP

Psychiatrists per 1,000,000 population

Source: World Bank Source: WHODemocratic Republic of Congo 1.1Liberia 0.2Zimbabwe 0.6Burundi 0.1Eritrea 0.6Central African Republic 0.2Niger 0.3Sierra Leone 0.2Malawi 0.1Togo 0.2

Ten poorest countries in the world by GDP

Psychiatrists per 1,000,000 population

Number of languages spoken

Source: World Bank

Source: WHO Source:http://www.ethnologue.com

DRC 1.1 215Liberia 0.2 30Zimbabwe 0.6 19Burundi 0.1 3Eritrea 0.6 12CAR 0.2 71Niger 0.3 21Sierra Leone 0.2 24Malawi 0.1 16Togo 0.2 39

 

Linguistic diversity of countries in the world (highest to lowest)

 

CountryDiversity

Lang Indig Immi

1 Papua New Guinea 0.988 839 839 0

18 South Africa 0.877 44 28 16

44 Singapore 0.756 31 24 7

74 Canada 0.603 174 89 85

95 China 0.512 300 297 312

9 United States 0.334 422 216 20613

5 Netherlands 0.302 41 15 2615

0 Australia 0.211 245 212 3316

5 Sweden 0.155 24 14 1016

6 United Kingdom 0.148 56 13 4323

0 North Korea 0.000 1 1 0

Source: UNHCR The UN refugee agency http://www.unhcr.org/pages/4a0174156.html

Some South African (language) history

• Conflict of colonial powers – England and the Netherlands

• The struggle for Afrikaans (replaces Dutch as an official language in 1925)

• The project of language as a project of empowerment for white Afrikaners

Politics of language and liberation

• 1976 uprising started with rejection of Afrikaans

• Afrikaans as ‘language of the oppressor’

• SA constitution: 11 official languages and promotion of SA Sign Language

• Reclamation of Afrikaans as a predominantly black language post 1994

• Ronelda Kamfer: “Now that I speak Afrikaans…”

The transformation question

• Fantasy of sufficient resources (eg – defence budget, 13 departments of health)

• Cronin: “It is a discourse of representative redistribution. Transformation has come to mean not transformation but the elite redistribution of some racial, class and gendered power (whether in the boardroom or the Springbok rugby team).” (Cronin, 2006)

• Paradoxes of equality and inclusion• Language• Institutional culture• Disability (cf Bantjes et al 2015)

Understanding the current situation

1. The new elites2. The role of global psychiatry3. A tradition of making the personal

invisible in psychiatry4. Changing academic careers in health

care in South Africa5. Nursing as writing6. Task shifting7. Resources8. Personal responses to historical

positioning

How informal interpreters help us make up stories

• Constructing or obscuring “insight”

• Cultures of mystery and bureaucracy

• Let’s get (very) happy

“Insight”

Xa ndisondela kweli planga kugalelwe into engathi si-snuff, like nto engathi yi-tea bag seyiqhaqhiwe, qha ayikho ninzi ithiwe shweleshwele, eyi ndahlala ndaqonda ukuba makhe ndihlala apha phantsi ndizulise nje wethu, andikho zingqondweni ndiyaziva, xa ndijonga elaa planga hayi sana eli planga lisenza laa nto. Ndihambe ndiqonde uba ndiya kumama e-4, umama mos (As I was approaching this plank there was something that looked like snuff on it, it looked like a broken tea bag but there wasn’t much of it. I sat down. I thought I should sit down to calm down. I noticed that I was losing my mind, and I could feel it as I looked at this plank again it was still doing the same thing. I went to my mother at [number] four, mama mos)(Interpreter interjects)Interpreter (Y): Ok, khawume, khawume. (Ok, wait, wait.)Interpreter (Y): Where did I end. The story is long? (Interpreter laughing)

I noticed that I was losing my mind

VS

Something in her head was also not so nice

Clinician: Ok, het sy enige ander siektes behalwe hoë bloed? (Does she have any other illnesses beside high blood pressure?)Interpreter: Uthi kukhona mhlawumbi esinye isigulo owakhe wanaso ngaphandle koku une-high blood? (She is asking if you have ever had other sickness other than the high blood pressure?)Patient: Kukuphambana nje nale nto ye-high blood, bathi ndinayo ndingazi uba ubanjani na xa unayo. (It’s insanity and this high blood pressure they say I have, I don’t know how a person is when she has it.)Interpreter: Nee. (No.)

Example 2:

Example 3

A patient describes being in love her priest. The psychiatrist asks whether these feelings were based on an actual relationship with the priest.

Patient’s response: “There is no relationship, it’s in me, inside”.

Interpreter rendition of this response: “The man was unaware of this”.

“Culture”

Clinician (Dr.E): When did she fall ill for the first time?Interpreter Y: When did your sickness first manifest?Clinician (Dr.E): Mental illness?Patient 12: I got the traditional sickness when I was young.Interpreter Y: (in a raised voice) (OH, YOU WERE STILL YOUNG?)Pati ent 12: I could not go to school. I became sick to be a Sangoma [according to tradition].)Interpreter Y: Being mentally disturbed?Patient 12: Being mentally disturbed nê (A South African colloquialism for ‘you see’) , I was healing a child but he bewitched me.Interpreter Y: Mh.Patient 12: Another initiate.Interpreter Y: The doctor would like to know that, since you receive this government grant, when, and in what year, did you get sick because so you could get the disability grant?)Patient 12: (It started in 19-, 2006.)Clinician (Dr.E): What is she saying?)/Interpreter Y: Were you getting a grant? Patient 12: NoInterpreter Y: Sickness?/Patient 12: I was not getting a grant.Clinician (Dr.E):WHAT IS SHE SAYING? WHAT IS SHE SAYING?Interpreter Y: She said in 2006, she/(Clinician interjects)Clinician (Dr.E): Started to/(Interpreter interjects)Interpreter Y: With the grant.Clinician (Dr.E): YesInterpreter Y: But now I want to find out when she fell ill.Clinician (Dr.E): Yes.

Patient 2: I got dressed and then the pastor arrived at my place and started a church service at home. We prayed and prayed and we noticed that, that woman, who I had touched earlier when it felt like I was being choked, didn’t want to stay. She said it’s time for her to cook, and she went home, closed the doors and peeped through windows.) Interpreter Y: So you are suspecting her?(No response from patient)Interpreter Y: Are you suspecting her?Patient 2: No, I’m not suspecting her.Interpreter Y: Uhm, so that after that(Patient interjects) Patient 2: They are my neighbours - I don’t suspect her.Interpreter Y: After that they get other people to pray in their house.Registrar (Dr.C): Uhm.Interpreter Y: But that lady who took her to that person didn’t want to come into their house.Registrar (Dr.C): Uhm.Patient 2: And I don’t sleep at night, some things that I do not know are beating me.Interpreter Y: So she thinks it’s that lady who is busy with her. Registrar (Dr.C): I see.Interpreter Y: About muthi stuff.

“Happy”

Clinician (Dr.E): Ek sien sy is nou hartseer, maar vanoggend toe sy opgestaan het, was sy gelukkig toe? (I see that she is sad at the moment, but when she woke up this morning was she feeling happy?)Interpreter Y: Uthi ugqirha uyakubona ngoku unenyembezi, ekuseni ngoku ubuvuka ubunjani? (The doctor said, she sees that you are in tears, in the morning how did you feel?)Patient 11: Bendiright. (I was all right.)Interpreter Y: Sy sê sy was oraairt gewees. (She said she was all right.)Clinician (Dr.E): Was sy bietjie gelukkig of baie gelukkig? (Was she somewhat happy or very happy?)Interpreter Y: Ubuphume uvuya kakhulu okanye ubunjani ekuseni? (Were you very happy or how did you feel in the morning?)Patient 11: Ndiphume ndivuya. (I was happy.)Interpreter Y: Oh, baie gelukkig. (Oh, very happy.)Clinician (Dr.E): Issit. Hoekom is sy dan so gelukkig? (Is that so. Why is she so happy?)

Pattern of interpreter errors across 13 interpreted diagnostic interviews

Nature of

Error

Number of

errors

Errors

deemed

clinically

significant

Errors making patient

appear more ill

Errors

making

patient

appear

less ill

Additions 14 9 9 0Omissions 24 11 11 0

Substitution

s 19 6 6 0

Total 57 26 26 0

Systemic underpinnings to not understanding

1.Psychiatric diagnosis as escape route

2.“Cultural expertise” as spurious but powerful leveller

3.What are the benefits within our system to not understanding patients?

Disrupting these stories

The challenges

These are partly of language but also challenges of • Politics/power• Bureaucracy• The struggle for visibility