informal interpreters in medical settings

ISSN 1355-6509 St Jerome Publishing Manchester

The Translator. Volume 18, Number 2 (2012), 311-38 ISBN 978-1-1905763-35-1

Informal Interpreters in Medical SettingsA Comparative Socio-cultural Study of the Netherlands and Turkey

BARBARA SCHOUTENUniversity of Amsterdam, Netherlands

JONATHAN ROSSBoazii University, Turkey

RENA ZENDEDELUtrecht University, Netherlands

LUDWIEN MEEUWESENUtrecht University, Netherlands

Abstract. Between 2008 and 2010, academics in five European countries collaborated on an EU-funded project, Training Inter-cultural and Bilingual Competences in Health and Social Care (TRICC). Among TRICCs aims was to deepen understanding of informal interpreting through eliciting the perspectives of inter-preters themselves. To identify commonalities and differences in the experiences, attitudes and practices of informal interpreters in distinct settings, the Dutch and Turkish partners interviewed 15 young migrant adults in the Netherlands and 15 Kurdish speakers in Istanbul respectively, asking them about emotional and techni-cal aspects of interpreting, and about their expectations and roles, communicative challenges and actions. Thematic analysis of the 30 interviews corroborated the findings of previous research namely, that informal interpreters are highly visible, use diverse commu-nicative strategies, adopt various roles, and occasionally speak as primary interlocutors. Noticeable differences between the two sets of interpreters included their attitudes towards interpreting and their preferences for informal versus professional interpreting, both of which can be better understood in the light of the cultural backgrounds of the interpreters and the institutional and political frameworks within which they interpret. This comparative study appears to support Angelellis (2004a) claim that interpreted events are heavily influenced by socio-political and cultural contexts.

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Informal Interpreters in Medical Settings312

Keywords. Informal interpreting, Healthcare, The Netherlands, Turkey, Kurds, Policy.

Many medical interactions that take place throughout the world involve healthcare providers and patients of different cultural, linguistic and ethnic backgrounds. In some cases, the patient is a migrant, refugee, tourist or tem-porary visitor, in other cases, the member of an indigenous or long-established minority. When a healthcare provider has to deal with a patient with no or limited knowledge of the dominant language, the lack of a shared language can seriously threaten the interaction. Several studies have shown that the in-ability of patients to speak and understand their doctors language leads to a number of negative consequences for both parties, such as an increased chance of non-compliance, feelings of fear and despair, and problems in achieving rapport, all resulting in a lower quality of care as compared to the healthcare received by patients who share their doctors cultural, linguistic and ethnic background (Bhopal 2007, Ramirez 2003, Stronks et al. 2001).

In many countries, the number of patients from diverse backgrounds is significant. For instance, in the Netherlands around 20% of the population (about 3 million citizens) consists of first or second-generation migrants (Cen-tral Bureau of Statistics 2012), half of whom are from Western and half from non-Western countries, mostly Turkey, Morocco, Surinam and the Antilles. Research on the latter population has suggested that around half of this group have limited proficiency in Dutch. A study conducted in Rotterdam, a city where almost half of the citizens are of non-Western background, showed that, irrespective of whether or not interpreting is provided, one in three medical consultations between general practitioners and non-Western migrant patients is characterized by poor communication and misunderstanding, which ulti-mately results in low patient satisfaction (Harmsen et al. 2008:11). Although there are currently no official figures concerning the use of interpreters in Dutch general practice, preliminary results suggest that the majority of gen-eral practitioners make use of informal interpreters in communicating with those non-Western migrant patients who lack sufficient proficiency in Dutch (Meeuwesen and Twilt 2011:15).

In Turkey, on the other hand, it is the existence of a sizable indigenous minority, the Kurds, which poses the biggest challenge for medical commu-nication involving multiple languages. Statistics for the Kurdish population vary enormously, partly due to the lack of reliable official demographic data, partly because of the highly politicized nature of the Kurdish question, which has encouraged people, including scholars, to downplay or exaggerate the numbers. Back in 1996, for instance, the Kurds were estimated to make up between 5 and 25% of a population of around 60 million (Mutlu 1996:517), and the debate on figures continues (Gzel 2009). According to one recent study, 46% of Kurdish mother-tongue speakers in Turkey have not completed

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B. Schouten, J. Ross, R. Zendedel and L. Meeuwesen 313

their primary education, and 33% of this group have limited or no competence in Turkish, with women making up 90% of the total (Grsel et al. 2009:3, 6). Since many healthcare providers, including those of Kurdish origin, do not speak Kurdish, patients limited proficiency in Turkish frequently results in the need for interpretation. In a survey conducted in 2008 and 2009 among 253 doctors in the region of Diyarbakr, the most populous city in the East of Turkey,1 just under half of the doctors questioned reported having to seek the help of a member of staff or companion of the patient in order to communicate with the patient (Diyarbakr Tabip Odas 2009).

To deal with the above-mentioned communication problems, governments and NGOs have sought to expand the provision of professional interpreting and advocacy services. In the Netherlands, medical interpreting and translation services have been organized by the government since 1976 and provided for free since 1983. As the Dutch healthcare inspectorate regards the use of profes-sional interpreters as the golden standard, and the Law on Medical Treatment (1995) places the onus on healthcare providers to communicate in a language the patient can understand, ethnic minority patients in the Netherlands with poor language proficiency in Dutch have the right to a professional interpreter free of charge. The expenses are covered by the Ministry of Health, Social Welfare and Sport, and the interpreting is provided by the Dutch Interpreter and Transla-tor Service, which supplies professionally-trained interpreters working in over 130 languages. In daily practice, however, Dutch healthcare providers do not frequently deploy these professional interpreters, mainly because they are not familiar with the service. Instead, they tend to make use of family members and acquaintances the patients bring along to help them communicate with the doc-tor (Meeuwesen and Twilt 2011:15). Furthermore, in the coming years, the use of these informal interpreters is likely to increase, because the free provision of professional interpreting services will soon be scrapped. In a letter dated 25 May 2011, the Dutch Minister and Secretary of State responsible for health informed the Lower House that all funding for interpretation and translation services in healthcare would be withdrawn from the beginning of 2012. The main argu-ment used to justify these cuts is that patients/clients (or their representatives) are responsible for their own command of the Dutch language (Schippers and Veldhuijzen van Zanten-Hyllner 2011:4).

Whereas in the Netherlands official policy had aimed (at least on paper) to cater to the needs of inhabitants with limited proficiency in Dutch, up until the 1990s the Turkish state tried to solve the problem of inadequate com-munication between Turkish speakers and speakers of other mother tongues simply by insisting that the latter learn and use Turkish. This policy reflected the civic nationalist ideology of the Republic, which was encapsulated in the slogan One state, one nation, one flag, one language. The policy of stringent

1 The East of Turkey will subsequently be used to encapsulate the geographical regions of Eastern and Southeastern Anatolia.

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monolingualism climaxed in 1983 with the passing of Law 2932, nominally concerned with the prohibition of publications in languages other than Turkish but also declaring Turkish to be the mother tongue of all Turkish citizens and attempting to effectively ban people from speaking Kurdish (Kubilay 2004:72). However, since 1991 (when Law 2932 was repealed, although some limitations remained) a more flexible approach to minority languages and the Kurdish issue has prevailed, impacting also on the medical sector. On the one hand, there has been a marked increase in the number of Kurdish-speaking health professionals working in the East of Turkey, who now freely communicate with their patients using one of the two main Kurdish dialects in Turkey, Kurmanji and Zazaki;2 on the other hand, Article 18 of the Regulation on Patients Rights (Hasta Haklar Ynetmelii, 1998) at least shows some acknowledgement of the possible need for interpretation, stipulating that [i]nformation should be supplied to the patient in a comprehensible manner, using an interpreter if necessary (our translation and emphasis). So far, however, next to nothing has been done to train, accredit or pay professional interpreters, and doctors, patients and their interpreter-companions (including all those interviewed in this study) seem largely ignorant of this vague legal obligation.3 Thus, in Turkey as in the Netherlands, the use of informal interpreters be they family members, friends, untrained hospital staff or even fellow-patients persists as common practice. 1. Research background and objectives

Faced with this reality, between November 2008 and November 2010 scholars from universities and representatives of non-governmental organizations in Germany, Holland, Italy, Turkey and the UK collaborated on an EU-funded multilateral project, Training Intercultural and Bilingual Competences in

2 Although there is no statistical evidence available to support this claim, many Kurdish citizens and doctors working in the region have mentioned this development to us. In ad-dition, in the last three years, several meetings aimed at promoting the use of Kurdish in the medical sector have been organized by non-governmental organizations, events that would have been unthinkable just five years ago. These include the Mesopotamia Health Days conferences held in Diyarbakr in 2009, 2010 and 2012 and in Dohuk (Northern Iraq) in 2011, and the symposium on Mother Tongue and Health, jointly organized by the Turkish Medical Association and the Union of Health and Social Services Workers in Ankara on 27 March 2010. 3 In their pioneering study on community interpreting in Turkey, Ebru Diriker and ehnaz Tahir-Gralar likewise acknowledge that while numerous laws do mention, and contain measures relating to, interpreting in different public settings, [t]here are a number of loopholes and limitations that need to be overcome (2004:85); in particular, the authors point to the relatively arbitrary way in which interpreters are recruited and the failure of the Turkish authorities to demand appropriate academic and professional qualifications from would-be interpreters .

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Health and Social Care (TRICC).4 The objective of TRICC was to develop, run and evaluate training programmes and materials for people who had served or were likely to serve as informal interpreters, as well as for the healthcare workers and patients with whom they interact. At the same time, TRICC aimed to draw attention to the perceived inappropriateness of informal interpreting by minors in particular. Early on in the project, the Dutch partner carried out a set of structured interviews with informal interpreters. Meanwhile, the Turk-ish partner was conducting preliminary library and fieldwork on the hitherto unresearched area of informal interpreting in Turkey, consulting health pro-fessionals, patients and interpreters in the East of Turkey. When the Turkish team shared their findings with their Dutch and other partners in TRICC, they noted some interesting similarities and differences. To explore them more thoroughly and systematically, the Turkish group decided to adapt and apply the questionnaire their Dutch partners had used, in order to gather data that would enable a more structured comparison of the experiences, practices and attitudes of informal interpreters in these two countries.

The present paper reports on these data, documenting and discussing both the parallels and dissimilarities between informal interpreters in these ter-ritories at opposite ends of Europe. Our rationale for comparing the two sets of interpreters, who perform their tasks in such different settings, is to trace the impact of the socio-political and cultural context on informal interpreters and on the doctor-patient consultations interpreted by them. Since the 1990s, a strong tendency has emerged in the literature on interpreting, especially on community interpreting, to consider the role of interpreters in relation to the social contexts in which they operate (Angelelli 2004a, Berk-Seligson 1990, Davidson 2000, Hsieh 2006, Roy 2000, Wadensj 1992). Such research has been very effective in demonstrating the social and political situatedness of what Claudia Angelelli terms Interpreted Communicative Events (2004a:8), but the interpreters whose actions are analyzed tend to be professional in-terpreters, not informal ones. Moreover, these studies invariably focus on a single territory and rarely attempt to compare the experiences of interpreters in different geographical and cultural settings. Even Angelellis Revisiting the Interpreters Role: A Study of Conference, Court and Medical Interpreters in Canada, Mexico, and the United States (2004b) reveals surprisingly little about the relationship between the role definitions of the 293 interpreters surveyed and the conditions in the country in which they live and work, despite the fact that these three countries have quite different demographics and distinct political traditions, histories, institutions and norms with respect to interpret-ing. Our study aims to address this gap in interpreting research.

Previous research on informal interpreting in medical settings has largely involved critical analysis of the (recorded) performances of informal interpreters or discussion of the experiences of health workers and patients who

4 See http://www.tricc-eu.net/ (last accessed 13 March 2012).

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rely on these interpreters. The first line of research invariably documents the negative effects of informal interpreting on communication and on practical and clinical outcomes. For instance, it has been noted that interpreting errors are common (Flores et al. 2003), crucial information is lost (Bhrig and Meyer 2004, Cambridge 1999), important linguistic and discursive features of the communication are altered by interpreters (Aranguri et al. 2006), and quality of clinical care is compromised (Karliner et al. 2007). Results of the second line of research partly reflect these negative effects by commonly documenting negative experiences from the perspective of healthcare providers (Hornberger et al. 1997, Pchhacker 2000, Rosenberg et al. 2007), in particular when children are used as informal interpreters (Cohen et al. 1999). Patients themselves report more varied experiences, ranging from having more trust in informal interpreters as compared to formal ones (Edwards et al. 2005) to preferring professional interpreters because they offer a higher quality of service (MacFarlane et al. 2009, Ngo-Metzger et al. 2003).

Although these two lines of research have provided valuable insights into the practice of informal interpreting in healthcare settings, some crucial elements have so far been neglected. For one thing, we know remarkably little about this area from the perspective of the interpreters themselves. With the exception of a few isolated studies (Green et al. 2005, Rosenberg et al. 2008, Valds 2003), little has been published on how informal interpreters working in medical set-tings perceive their own roles and performances. In the present article, therefore, we focus on the interpreters themselves. However, as mentioned earlier, rather than offering a decontextualized and deterritorialized analysis of interpreters responses, we aim to examine the situatedness of interactions between healthcare providers, patients and interpreters in distinct socio-political contexts. In addi-tion, since it is widely recognized that the diverging cultural backgrounds of the parties involved can have considerable influence on the medical communication process (Schouten and Meeuwesen 2006:21), we will scrutinize how the cultural backgrounds of informal interpreters impact on the interpreting situation. At the same time, we are interested in seeing whether there may nevertheless exist more universal patterns of behaviour and discourse that stem from the particularities of the situation where an untrained volunteer interprets in a medical setting for a patient often the interpreters relative and a health professional.

2. Research design

For the sample in the Netherlands, we attempted to gather data from 20 young migrant adults through personal contacts and a snowballing method. The main criterion for inclusion was that they had experience in informal interpreting as children (at least before the age of 19) and/or currently interpreted on a regular basis. As we strove to gain a broad picture of the contexts and issues present in informal interpreting in medical settings, no criteria were set in terms of their ethnic background; in addition, we approached both men and

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women. Of the 20 interpreters approached, 15 agreed to participate (5 men, 10 women). These 15 interpreters had either migrated to the Netherlands as young children or were born in the country. Most (11) of them belong to the two larg-est ethnic minority groups in the Netherlands: Moroccans (8) and Turks (3).5 Other ethnic backgrounds in the Dutch sample were Azeri (2), Iranian (1) and Italian-Colombian (1). Three of the Moroccan interpreters interpret between Dutch and Berber, three between Dutch and Arabic, and two between Dutch, Berber and Arabic. The three Turkish respondents interpret between Turkish and Dutch, the two Azeris between Russian and Dutch, the Iranian between Farsi and Dutch, and the Italian-Colombian between Italian and Dutch. The mean age of the interviewees was 23 (the age range being 19-34), and all had been educated to at least secondary vocational level, with 10 being students or graduates of vocational education institutions or universities. The young-est age at which they had started to interpret was 6, the oldest 18. Length of experience in interpreting ranged from 5 to 16 years, with a mean of just over 10 years. The frequency with which the interviewees currently interpret varies greatly: some interpret just a few times a year, others interpret several times a week. All but one of them still interpret, mainly for one or both parents, or for other relatives. Two also interpret for acquaintances.

In terms of ethnicity, the group of respondents in Turkey was more homogenous than that in the Netherlands. All 15 interviewees (6 women, 9 men) were born in Turkey and live in or near Istanbul. They are connected with either of the two main groups commonly classified as Kurds: 9 are members of the Kurmanji-speaking minority, 4 are ethnic Zazas, and 2 are of mixed heritage.6 Eleven interpret between Turkish and Kurmanji, two between Turkish and Zazaki, and two between Turkish and both Kurdish dialects. At the time of the interviews, they were mostly in their twenties (ten respondents), three in their 30s, and two were 40, resulting in an average age of 28 (the age range being 22-40). As with the sample from the Netherlands, the majority of respondents (ten) were in, or had completed, tertiary education. However, in order to gain some insight into the experiences of less-educated Kurdish-speaking informal interpreters, who are probably more representative of those performing this activity at large, four people who had left school at or before the age of 14 were also interviewed. The

5 In tIn the Netherlands, people of Moroccan descent are estimated to number around 67,000, while there are around 91,000 individuals of Turkish descent (Central Bureau of Statistics 2012). 6 It has long been a controversial, heavily politicized issue in Turkey whether the Zazas (estimated to number somewhere between 500,000 and 3 million) should be considered part of the Kurdish minority, alongside the much larger group of Kurmanji-speakers, or whether they constitute a community quite distinct from them (van Bruinessen 1994). This debate parallels, and feeds on, the discussion on whether Zazaki is a Kurdish dialect that is a close relative of Kurmanji or an entirely different language (Scalbert-Ycel 2006). However, since many Zazas including our respondents seem to identify themselves subjectively as Kurds including our respondents seem to identify themselves subjectively as Kurdsseem to identify themselves subjectively as Kurds (van Bruinessen 1994:1), we decided to include Zazas among our respondents.

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mean age at which respondents had started interpreting was around 13, with the range being between 4.5 and 21, although most (9 out of 15) started at some point between 11 and 16. The interviewees had been interpreting for an average of more than 15 years. Similarly to the Dutch sample, there was great variation in the frequency with which respondents interpret, with the students generally only interpreting when they return to their hometowns in the summer, and the two housewives interpreting in different contexts on an almost daily basis. Seven of the interviewees said that they had only interpreted for older female relatives, while eight reported assisting both male and female relatives. Eight respondents (i.e. around half of the sample) mentioned cases where they had interpreted for strangers they met at the hospital or even on the way to the hospital.

The data we gathered from the interviews are accounts of the issues our respondents chose to talk about, guided by a broad topic list (see Table 1 for a sum-mary), to ensure that themes known to be relevant from the literature on informal interpreting were discussed. Interviews, lasting about 45 minutes, were thus held in a semi-structured in-depth format, to leave enough room for the respondents to tell their own stories, although themes were discussed in the same order in every interview. The questions addressed their background, personal history of interpret-ing, experiences of and feelings about interpreting (as well as feelings reported by those they interpreted for), roles, strategies and actions in the triad, and other emotional and technical aspects of their performances as informal interpreters. The resulting corpus of 30 interviews was subjected to a thematic content analysis. The most common or striking themes and issues are outlined below.

Language and family background Which languages do you speak at home, at the doctors office, with

friends, etc.? How proficient are you in these languages? How often do you speak these languages? For which family members have you interpreted? Do other members of your family interpret?

Interpreting experiences: general From what age have you been interpreting and for whom? In which situations? Are there differences between these situations? If so, why?

Technical aspects of interpreting Do you consider yourself a good interpreter? Are there specific topics that you find harder to interpret than others? Do you always succeed in interpreting, and if not, when and why does it

go wrong? And what goes well? Can you describe a situation in which miscommunication occurred? Why

did this happen and how did you solve it?

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Emotional aspects of interpreting What aspects of interpreting do you like? What aspects of interpreting dont you like? What are the easier and more difficult emotional aspects of interpreting?

Communication, attitudes and roles During medical conversations, how do you get on with the doctor and

the person you are interpreting for? How would you describe your role as an interpreter? Can you describe a situation in which a conflict arose during a medical

conversation you were interpreting? What causes communication problems between the doctor and the patient

(language, cultural issues, etc.)? What do the doctor and patient expect from you? In your opinion, what could be improved during medical conversations

with you as an interpreter? Would you prefer to have formal interpreters interpret for your family? Do you think your family prefer formal interpreters? Why?

Table 1. Topic list for interviews

3. Interview results

The results of the interviews can be summarized under three headings: tech-nical and emotional challenges; communication and attitudes; and role(s) of the interpreter.

3.1 Technical and emotional challenges

Two thirds (10) of the Dutch interpreters considered themselves good interpret-ers and felt they had sufficient command of both languages to give an adequate translation of the conversation. As a whole, the interviewees in Turkey seemed slightly less satisfied with their performances, with eight claiming that they interpret successfully and seven evaluating themselves negatively. Technical challenges of interpreting were mentioned in all the Dutch interviews, though particularly frequent reference was made to the difficulty of translating medi-cal terms, such as those relating to medication, body parts or diagnoses. Like their counterparts in the Netherlands, many (ten) of the interviewees in Turkey recalled facing difficulties rendering the names of body parts, illnesses and medical procedures into Kurdish. While eight attributed this to the limitations of their own vocabulary and to the fact that they had acquired Kurdish only within the family and community, not receiving any academic or specialist education in it, two stated that their mother tongue, Zazaki, was itself a vil-lage language (ky dili) that lacked specialist terminology, since it had not

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had the chance to develop and to be applied in different fields. Dutch-speaking respondents made a similar point about the Berber language, which they see as a language for the home that lacks equivalents to Dutch medical terms.

In addition to mentioning these technical challenges, both sets of interview-ees referred to negative affective dimensions of their interpreting work. Among the interpreters in the Netherlands, the number of such aspects mentioned in the interviews was three times higher (51 comments) than the number of positive emotional aspects (17 comments). Two thirds found it particularly challenging to interpret topics connected with sexuality, as they and/or the patients felt embarrassed to talk about sex, genitals and diseases related to sexuality:

Well, it is about being embarrassed, isnt it? You feel embarrassed towards the patient and also towards the doctor, you know. Once, there was this woman ... and she said: A doctor is a doctor, you can just [translate]. But I was so ashamed! I just could not [do it], but anyway, I had to tell everything, and she even started to talk about sex, that when she slept with that man it hurt .... At one point I thought: do I really have to translate all this? And she started to say where exactly it hurt, and then I thought: oh, these kinds of things are hard.7

Likewise, a significant majority (12) of the interviewees in Turkey either recalled their own awkward experiences of interpreting for a patient with a problem affecting their genitalia or with some other condition perceived as embarrassing or shameful, or speculated that such a situation would make them and the patient feel uncomfortable. One interpreter, for instance, recounted the difficulties he faced in getting his father to talk openly about a prostate condition. The grandmother of another interpreter had complained at home about having a burning sensation when urinating but told the doctor she had had a headache and mentioned some symptoms related to her ongoing diabetes and heart problem. According to several respondents in Turkey, patients and interpreters were especially uneasy about discussing taboo topics when the interpreter and/or doctor were of the opposite gender to the patient. A total of eight male interpreters mentioned occasions when they felt awkward about interpreting for a woman with a gynaecological problem or stated that they had not had such an experience but knew that they would find it very embarrassing or even impossible to deal with. Five respondents made the point that there are many patients who are ashamed of talking about such matters with a doc-tor of the opposite sex. However, those respondents in Turkey who addressed this issue gave the impression that what disturbed the relatives for whom they had interpreted was not so much being examined by a doctor of the opposite sex as talking about gynaecological and similar matters in the presence of a

7 Unless noted otherwise, all subsequent translations from the Dutch and Turkish are our own.

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young relative. Three respondents emphasized, moreover, that this seemed more disconcerting for female patients who were around the same age as their interpreter than it did for patients from an older generation.

A noticeable difference between the two groups of interpreters concerns their attitudes towards having to interpret for family members and acquaintances. Six interpreters in the Netherlands reported experiencing feelings of conflict between their obligation to interpret for their parents and their own, often hectic, schedules such feelings were not voiced by any of the respondents in Turkey. Furthermore, two Dutch-speaking interpreters expressed annoyance at the fact that their parents did not learn Dutch themselves: Sometimes I think: why dont you have command of the [Dutch] language? I understand that it is quite a difficult language, but it would really make things easier if my parents could speak Dutch. In contrast, a clear majority of the interviewees (12) in Turkey made it very clear that what upset them about performing this role was having to interpret at all for a person whose mother tongue (i.e. Kurdish) was actually the most widely-used language in that area, whereas the doctor was speaking Turkish, the mother tongue of a minority in Southeastern Anatolia, but the sole official language nationwide. Five interviewees commented on how sorry they felt that their parents and elders were in the humiliating position of having to rely on them. All 12 of the above-mentioned interpreters noted that it would be preferable if the patient and doctor conversed in Kurdish, so that there would be no need for an interpreter.8 As they saw it, getting someone to interpret between a Kurdish-speaking patient and a Turkish-speaking doctor effectively meant upholding the exclusive dominance of Turkish in the public sphere, whereas they wanted to see a higher degree of parity between these two languages. In the words of one of them, In fact, interpreting means doing something that is forced on you by the state.

Although interpreting was generally regarded as a burden, in particular by the Dutch-speaking interviewees, none of our interviewees had ever thought of refusing a request to interpret. At the very least, they felt they had a responsibility to help those in their family or community less capable of com-municating with the healthcare providers. Thus, respondents in both countries had ambivalent feelings about their interpreting work. Eleven interpreters in the Netherlands mentioned that it was normal to give something back to their parents or other family members, and that the act of interpreting was part of

8 This position concurs with the policy backed by activists and supporters of the former PeaceThis position concurs with the policy backed by activists and supporters of the former Peace and Democracy Party (BDP), the most popular party in many areas of the East of Turkey. The same idea underlies the efforts of the Diyarbakr Chamber of Medicine, who are engaged in various projects to develop Kurdish as a language of medicine and to improve the Kurdish competence of doctors working in the region. In 2009 the Chamber published a book, Krte Anamnez / Anamneza bi Kurmanc (Anamnesis in Kurdish), which presents Kurmanji and Turkish versions of the questions general practitioners and specialists will need when taking a patients history (Blbl et al. 2009). This was followed in 2010 by the publication of a manual for obtaining informed consent from Kurmanji-speaking patients.

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their responsibility to take care of them. In the Turkish case too, providing interpretation was regarded very much as part of everyday family life. Talk-ing about interpreting as a child, one woman commented, You see it like any other request, like Take this glass to the kitchen and bring an ashtray something usual normal a striking illustration of how interpreting is lumped together with the various other tasks children in Turkish and Kurdish societies are expected to perform for their seniors. This concurs with the find-ing of Rosenberg et al. concerning various family interpreters in Canada, for whom [i]nterpreting is just one of many family [sic] roles family interpreters carry out (2007:92).

Moreover, ten of the Dutch-speaking interpreters and seven of those in Turkey said that they actually derived satisfaction from helping people through interpreting. One of the latter, who grew up in a small village where very few people spoke Turkish, emphasized that being able to interpret heightened his status within the family and community and made him feel rather special. Other positive consequences mentioned were the fact that the interviewees had the opportunity to improve their own social, communicative and linguistic skills: It is instructive. . You learn specific words you never use, for instance in Russian or the other way around: I know the word in Dutch, but I dont know how to say it in Russian .... It was instructive to [interpret].

3.2 Communication and attitudes

Twenty-two fragments in the Dutch interviews refer directly to the medical communication process: 11 in positive terms, 11 in negative terms. In general, the interpreters in the Netherlands commented positively on their experience of communicating with general practitioners. Most of them were patients of the same GPs as their parents, so the family had established a relationship of trust with their doctor. In contrast, the negative fragments refer to communicating with medical specialists, with whom such a relationship is absent. According to the Dutch interviewees, specialists are impatient, use too much medical jargon, and seem to be annoyed by the fact that the interpreted communication takes up too much time.

The interviewees in Turkey pointed to three kinds of responses from doctors. Nine interviewees had not personally experienced any uneasiness or aggressive demeanour on the part of doctors when it became clear that the patient could not speak Turkish and that the interviewee was there to interpret. However, two respondents felt that the doctor was reluctant to communicate with them, giving the impression that he or she was thinking Ive got enough on my plate without having to deal with you lot, as one interviewee put it. The remaining four in-terviewees mentioned occasions when they had actually ended up arguing with doctors: in two of these instances, the interpreter believed the doctor was not giving the patient the attention they deserved, whilst in the other two the doctor

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simply insisted that the patient address him or her in Turkish, even though it was patently impossible for them to do so. Notwithstanding these quite extreme examples of conflict, the picture the respondents paint of doctors responses is probably very different from what one would have witnessed in Turkish hospitals and clinics twenty years ago, when doctors who communicated with patients in Kurdish faced persecution (Maviolu 2010:20).

Turning to interpreters perceptions of the process of communicating with the patient, ten Dutch-speaking interpreters reported negative experiences. They felt that patients demanded too much from them, for instance by get-ting them to repeat the same information over and over, or by asking them to translate information which was, in the interpreters opinion, irrelevant. They also sensed that patients were frustrated and distrustful, feelings that stemmed from them being entirely dependent on the interpreter. As for the interpreters in Turkey, although ten claimed that they had a good rapport with the patient dur-ing the consultation, four admitted that they often found elderly relatives rather stubborn, demanding and sceptical. One respondent related the story of when she had gone to see an eye specialist with her grandmother-in-law, who was hoping to have an operation to correct her sight. When the respondent relayed the doctors judgement that such an operation was too risky given the patients age, the grandmother-in-law accused the interpreter of deliberately adding this message in order to avoid the costs of such an operation. Another interpreter similarly recalled being accused by her own grandmother, who lived with her, of making up the doctors advice that she diet in order to save on food expenses. Such examples reveal the potential for problems when the informal interpreter has multiple and possibly conflicting interests with respect to the patient a situation all the more likely when the two are connected by the strong bonds of an extended family. As is evident from the two examples, things become more complex still when the patient has little grasp of health issues.

Suggestions made by interpreters in the Netherlands to improve doctor-interpreter-patient communication ranged from doctors allocating more time to these triadic conversations and showing more concern for their patients, to organ-izing formal interpreters in their practices, for instance by having them available a couple of hours each week. For two-thirds (10) of the interviewees in Turkey, the optimal solution was that Kurdish-speaking doctors should be employed or Turkish doctors coming to the area should learn Kurdish.9 For the most part, their prime demand was not that the Turkish state should provide professional interpreters but that the indigenous population should be able to communicate with doctors in their own language. As one student put it rather passionately,

9 With regards to areas outside the East with large Kurdish populations, three intervieweesWith regards to areas outside the East with large Kurdish populations, three interviewees suggested that Kurdish-speaking doctors could be deliberately hired there and Kurdish speakers would naturally gravitate towards such doctors. For a real-life example of the latter-mentioned phenomenon, see Maviolu (2010), a portrait of a Kurdish-speaking doctor working in Istanbul.

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Im not asking for my family to have a formal interpreter. because its my country Im living in . My family has been living on their own land for thousands of years. Thats why I want them to have their own doctors, using their own language. Were not Turks liv-ing in Germany; were Kurds living in Kurdistan . Were the real owners of this land . Im not demanding [professional interpreting services]; in fact I want exactly the opposite.

Aside from such ideological considerations, another reason why informal interpreters and their families in Turkey have doubts about the viability of interpreting as a solution to their communication problem is arguably the damage that negative experiences of informal interpreting have done for the reputation of interpreting in general. Based on a history of interpreting by inappropriate people10 with poor competence in both languages, with little biomedical knowledge, with no training in effective interpreting methods, and scant awareness of ethical issues such as confidentiality, transparency and accuracy, ordinary citizens and health professionals alike tend to tar all interpreters with the same brush. Thus, in the editors preface to Anamnesis in Kurdish, we find the comment Patient histories and complaints conveyed to doctors through an interpreter are unreliable and may give rise to wrong diagnoses and treatments (Adem Avckran, in Blbl et al. 2009:8). This generalization of course flies in the face of successful interpreting practices in healthcare settings elsewhere in the world.

While Dutch-speaking interpreters acknowledged the superior (language) skills of professional interpreters, 13 preferred to interpret themselves, giving both practical and affective reasons for this. Besides feeling obliged to help their relatives by interpreting, they also incorrectly assumed that it was too expensive to hire a professional interpreter, as well as overly complicated. In contrast, according to one interpreter, informal interpreting is simple: you ask your son and he goes with you. Or you have to arrange a [professional] interpreter, and I dont know, it sounds much more complicated than can you come with me, do you have time?. The misconception that patients themselves are responsible for solving their language problems, which is also widespread among healthcare practitioners, might have been leading these interviewees to resort to doing the interpreting themselves. However, many of their remarks also reflected a general sense of mistrust towards formal interpreters; they were, in essence, seen as outsiders. Doubts were expressed about professional interpreters ability to convey the patients emotions to the doctor. Respondents mentioned that patients disliked relating intimate details to formal interpreters and preferred to keep such things within the family:

10 For example, a child, or the husband of a woman who has come to see a psychiatrist about her marital problems.

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In particular when it is through the telephone. Because then, my mother will think What am I saying here to someone I dont know at all? ... You often talk about personal things with your doctor, and I dont know, I am almost 100% sure that my mother will think No, to arrange an unknown person for things like this goes way too far.

Almost all the interpreters in the Netherlands (13) stated that they would rather accompany their family members themselves, as they feel they are better able to do the job than professional interpreters, because they have firsthand knowl-edge of their relatives medical problems: I know about the whole situation, while a [professional] interpreter doesnt know my mother at all. He or she does the job and goes home. But I know my mothers complaints and when she suffers from them.

In marked contrast to their counterparts in the Netherlands, no fewer than ten of the respondents in Turkey looked positively on the possibility of trained professionals interpreting for non-Turkish-speakers, although, for the most part, they saw this as a second-best alternative to monolingual communication in Kurdish between the doctor and the patient. They thought that interpretation by a person appointed by the state an option that does not currently exist in the Turkish health system11 would be more reliable than interpreting done by family members. Two interpreters acknowledged that their seniors would be reluctant to divulge intimate and potentially embarrassing information to a stranger, but even more interviewees were of the opinion that those for whom they interpret would have more confidence in officially trained and appointed interpreters. Five interviewees felt that patients mistrusted their capabilities and motives, with some recalling specific occasions when an elderly patient did not believe their junior was fully and accurately recounting in Kurdish what the doctor had said in Turkish. One explanation proposed for this by an interpreter is that, for older generations, in rural areas of the Southeast in particular, being able to speak Turkish seemed like a fantastic achievement, one that they found difficult to associate with their own children. 3.3 Role(s) of the interpreter

While interviewees did tend to resort to fairly hackneyed metaphors of neutral and objective transfer to characterize their role, referring to themselves as transfer to characterize their role, referring to themselves as transfer to characterize their role, referring to themselves as relayers of messages from one language into another, the stories they told suggest that they were much more active and interventionist while interpreting,

11 In July 2011, the Turkish Ministry of Health announced plans to develop medical care, advice and interpreting services in English, German, Russian and Arabic, starting with the establishment of pilot projects in four resort areas in Western Turkey (Cantrk 2011). These measures, however, are targeted not at indigenous minorities but at the 30 million tourists who visit Turkey every year.

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sometimes filtering out information and orienting the medical consultation in a manner that no professional code of ethics would recommend.

For instance, an interpreter in Turkey commented that his grandmother, who lived with his family, had been ill for a long time and had constantly been complaining about her symptoms. Up until three days before their visit to the doctor, he listened to her complaints and arrived at his own diagnosis, but then stopped paying attention to her grievances. When it came to the appointment itself, he did not listen very carefully to the responses his grandmother gave to the doctor and essentially reported only the symptoms he had remembered, which did not include the most recent ones. The interpreter claimed that his behaviour, as reprehensible as it may be, was by no means unique. He argued that those who live with the people for whom they interpret believe they are familiar (and perhaps even fed up) with the patients complaints and think they know which ones are genuine and which are invented or irrelevant. The interpreter, today a medical student, admitted that he translated in a much more faithful and ethically acceptable way when his client was a stranger in the hospital where he was doing the rounds together with his professor. All the same, the case involving his grandmother certainly ties in with the findings of several researchers that untrained, informal interpreters are particularly likely to slip into the role of the primary interlocutor and ask questions and supply information of their own volition, rather than restricting themselves to relating what the other interlocutors have said (Baker et al.1998, Hasselkus 1992, Meyer 1998).

In another example, in order to give a patient more appropriate care, a Dutch-speaking interpreter advised the healthcare provider about the proper medication dose for her mother. This interpreter, who has a background in biomedical science, felt that she was more capable of assessing the right treat-ment for her mother than the nurse treating her:

The nurse did not consider increasing the dose for my mother, so I asked, Is it possible to increase the dose? She originally wanted to give my mother another medicine .... Since then my mother has been using that [increased] dose and it works perfectly for her. I can quite accurately assess what they need, what they want, and how they want it to be improved. So I sometimes talk based on my own feelings .... I want the best medicine, yes, the correct medicine, the optimal solution.

A further example indicating the responsibility the interpreters might feel to act on behalf of the patient, even when they hardly know him or her, was re-called by a Dutch interpreter who had accompanied an old lady to the general practitioner to discuss a heart problem. To make sure the patient obtained a referral to a cardiologist, this interpreter directed the patient to exaggerate her complaints:

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I once went to the doctor with this old lady and [the doctor] said: I only give a referral if she suffers because of her heart at night .... But the old lady said, I dont have any pain at night. Then I said to her in my own language, You do have pain at night, dont you?. Then she said, Yes?. I said, You just told me that you have pain at night. Because she desperately wanted a scan of her heart, but the doctor did not want to do that, so I was thinking: I feel sorry for her, lets just do that, maybe there is something wrong. But then the old lady said, It hardly hurts at night. I said, Just say you are in pain at night!. Because I knew what the doctor had just said to me, you know, so I said: Yes, she is in pain at night, but not as much as during the day. And then he said, Okay, if she is suffering at night, then I will write a referral.

In the interviews in both countries, we also heard about several cases where an interpreter claimed to have carried out rather more subtly selective and manipulative renditions in order to ensure that, within the limited time allowed by the medical interaction, the uneducated and elderly patient received what the interpreter believed to be the appropriate information about the illness and also acted in the way recommended by the doctor. For instance, one of the Zazaki-speaking interpreters in Turkey tended to use general expressions to render the doctors comments on the severity and consequences of the illnesses, partly not to shock the patients and partly because his language sup-posedly lacked the terms needed to describe a medical condition in detail. He translated fairly technical diagnoses with sentences like Theres no need to worry, Its a very simple problem, or This needs to be taken seriously. Another respondent in Turkey conceded that he had sometimes exaggerated the warnings or advice given by the doctor, since his father was not taking sufficient care of his health. For example, when a doctor said You shouldnt eat red meat, in Kurmanji this became, The doctor says you mustnt eat meat under any circumstances (our emphases).

Several interpreters reported leaving large chunks of discourse uninter-preted. This occurred when the interpreter deemed the patients talk redundant and (in the Dutch case) the doctors time ran out. Indeed, interpreters in both countries mentioned time limitations as an important factor determining translation strategies. One Zazaki speaker, for example, noted that a doctor in a state hospital only assigns two or three minutes to each patient; since this is not enough to relay everything the patient has said, the interpreter presents a refined and succinct summary of the necessary points based on what the interpreter has been told by the patient at home.

As is evident from the above examples, many of the interpreters we inter-viewed went far beyond offering a more or less literal rendition of what the interlocutors said to one another: they reported omitting, adding and modifying information, exaggerating or toning down, and involving themselves actively

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in the conversation to make sure patients felt understood and received the care they needed. In the Netherlands, 12 out of the 15 respondents reported un-dertaking such interventionist actions at one time or the other. Besides seeing themselves as competent translators, these interpreters perceive their roles as being advocates for the patient and persons of trust to whom the patient can turn for advice, mediation and support.

In Turkey, three interpreters professed having tried to present a word-for-word rendition of what other interlocutors said. In several cases, this strategy apparently led to communication difficulties, since the interpreter provided a literal Turkish rendition of a Kurdish idiomatic expression used to describe the symptoms of an illness a rendition which the doctor then struggled to decipher. Alternatively, when faced with a term in Turkish for which they did not know the Kurdish equivalent, four interpreters simply repeated the Turkish word one reported pointing to the relevant part of the body while doing so an effective strategy (according to two interviewees) since the patients had some knowledge of basic Turkish medical vocabulary. On balance, the proportion of interviewees in Turkey who reported taking steps such as paraphrasing, explaining terms and interjecting questions was somewhat lower than in the Netherlands (8 out of 15). All the same, at least four Turkish interpreters acknowledged trying to correct mistreatment or abuse, as the (US) National Council on Interpreting in Healthcare defines advocacy (NCIHC 2005:16), when they felt the doctor was not behaving ap-propriately towards the patient. The most striking example of this was when a young woman, who had her own appointment at a hospital, witnessed a doctor shouting at an old Kurdish woman and telling her that he would not treat her if she did not speak Turkish. At this point, the young woman came over to the patient and offered to interpret for her, while putting it to the doc-tor in no uncertain terms that what he had said contradicted the Hippocratic Oath and that she would complain about him to the hospital management and other authorities.

4. Discussion of the findings

Turning to examine the common threads in the responses of interviewees in the Netherlands and Turkey, a glance at our data on the technical aspects of informal interpreting and on the roles of the interpreter confirms the often-made observation (Arranguri et al. 2006, Flores et al. 2003, Meyer 1998, Twilt 2007) that informal interpreters are even less likely than their profes-sional counterparts to function as invisible, neutral conduits who more or less interpret word-for-word. Although several of our interviewees, in particular the ones in Turkey but also a few in the Netherlands, claim that they (strive to) translate literally between doctors and patients, probably because of a mis-guided view that machine-like interpreting is the ideal, their stories clearly

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show a different picture. Another related finding of this study that has been reported previously

(Green et al. 2005, Rosenberg et al. 2007, 2008) is that informal interpreters commonly act as advocates for their patients. The role of an advocate can entail a wide range of actions such as encouraging the healthcare provider to give more detailed information, manipulating the message of the doctor so that it will have more of an impact on the patient, resisting what is perceived to be discriminatory behaviour on the part of the healthcare provider and in perhaps its most extreme manifestation pushing the patient to say things that (according to the interpreter) will improve his or her chance of receiving suitable care. Furthermore, respondents from both countries mentioned cases where they had diverged further still from the conduit model and responded to, or addressed, the healthcare provider without being prompted to do so by the patient; in other words, they had performed primary interlocutor actions (Meyer 1998:3), a practice common among informal interpreters but less com-monly evidenced among professional interpreters (Rosenberg et al. 2008:92) and certainly strongly discouraged in codes of ethics and good practice.

Although the data from our interviewees do point to similarities of this kind across the two countries, which concur with the findings of previous research, there are also significant differences. Our analysis was based on a small sample of two sets of 15 interpreters, so at this stage we can only speculate as to the relationship of our findings to the situation and socio-cultural attributes of young migrant informal interpreters in the Netherlands on the one hand and their Kurdish-Turkish counterparts on the other hand. All the same, given the quite marked differences between the two sets of respondents with respect to some aspects of interpreting experience and behaviour, it seems reasonable to propose some tentative explanatory claims.

Our findings appear to corroborate the claims of Angelelli (2004b), Inghilleri (2003), Wadensj (1992) and others, namely, that interpreted com-municative events and the agents involved in them are heavily influenced by socio-political and cultural contexts. To demonstrate this, we may consider the factors behind the different attitudes informal interpreters in the two countries seem to have towards the task of interpreting. Our finding that interviewees in Turkey were on the whole and notwithstanding their preference for mono-lingual communication in healthcare settings rather less negative about interpreting for their elders or others than their Dutch counterparts, seeing it as more normal and less of a burden, might be seen as evidence for the influence of the cultural context and understood in terms of Hofstedes (2001) differentiation between individualistic and collectivistic tendencies. Many Kurds in Turkey, especially in rural areas, continue to assign great importance to the (extended) family and to respecting and assisting elders. This could be one reason why the interviewees in Turkey have never refused to interpret and, as adults, generally refrained from blaming patients for their inability

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to communicate on their own. In contrast, some interpreters in the Nether-lands, including those of Turkish origin, whose identifications of citizenship are multidimensional and who have inevitably taken on traits of the more individualistically-inclined indigenous culture alongside those of their herit-age culture (Phalet and Swyngedouw 2002), expressed irritation towards the demands of their parents and frustration with having to spend time and effort assisting their relatives. They also mentioned they wished that their parents or other family members for whom they interpret would learn Dutch.

Rather than applying merely a cultural model to understand such dif-ferences, though, we also need to see the interpreters professed thoughts and actions within the framework of their specific political and institutional constellations. The Kurdish-speaking interviewees non-judgemental approach to patients who cannot speak Turkish, for instance, is no doubt linked to their generally strong ethnic affiliation and to the accompanying belief that the onus should be on doctors to speak to their patients in Kurdish. As for the impact of institutional differences, the existence of the GP system in the Netherlands might explain why Dutch-speaking interpreters appeared far more satisfied with their encounters with GPs than with their meetings with specialists. Like their clients, they have probably built up a relationship of trust with the GP following frequent visits, whether as interpreters or patients. In Turkey, however, a system of family doctors was only established across the country in November 2010. Prior to that, and even now, it was (and is) very common for patients to refer themselves to the relevant department in the hospital. This system meant that patients and interpreters had less likelihood of coming into contact with the same doctor and thus building trust, unless they visited the same department in the hospital on a regular basis.

Whereas our interviewees and their relatives in the Netherlands appeared to prefer informal over professional interpreting, in Turkey the opposite was the case. There, the option of a professional service provided by individuals trained for the job appears to be relatively attractive to people who have only ever experienced interpretation done by their relatives and acquaintances.12 At the same time, the availability of professional interpreting services in the Netherlands and their absence in Turkey might well have influenced the manner in which the two sets of respondents interpreted. As has been noted, the interpreters in the Netherlands expressed greater satisfaction with their performances and recalled deploying methods that suggest a quite serious and competent approach to their interpreting work. About half of the interviewees reported endeavouring to enhance communication and understanding between parties by taking along dictionaries, making drawings, recapping information,

12 In a survey conducted among 54 patients at two Southeastern Anatolian state hospitals in 2009, 48% of respondents rated the interpreting they had received not very successful while 15% thought it was unsuccessful, leaving just 47% who were satisfied to some degree (Ross and Dereboy 2009).

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explicitly checking patients understanding, and repeating the same informa-tion several times. In the interviews from Turkey, we find relatively more cases where interpreters offered meaningless word-for-word renditions or supplied information independently without indicating they were doing so. To be sure, it is quite likely that the Dutch-speaking interpreters recourse to such measures primarily reflects factors such as a higher educational level and greater competence in both languages. However, even though none of the interviewees made a concrete link between their experiences of professional interpreting and their own interpreting performances, it may be speculated that the interpreters who employed such methods had witnessed, or heard about, the way professional interpreters did their job and were aware that ef-fective interpreting required a variety of communicative techniques and was more than just linguistic recoding, the latter being what many of the Kurdish speakers seemingly thought.

The attitudes of the two sets of interviewees on the question of informal versus professional interpreting differed in another notable way. Whereas one of the main objections to professional interpreting mentioned by respondents in the Netherlands was that, in this kind of arrangement, another outsider besides the doctor was party to the intimate details of the patient, the inter-viewees in Turkey thought quite differently; they predicted that they and their clients would feel more comfortable if an outsider were there with the doctor than if the interpreter were a family member a view that is arguably rooted in cultural conceptions of what is acceptable and unacceptable for people to talk about in the presence of younger relatives and/or of relatives of the opposite sex. As one respondent put it, Us Anatolian folk, and especially us Kurds, are much more conservative. A woman a mother even if shes a hundred years old, cant speak about some subjects comfortably with her children. Theres no way my sister can do that.

5. Conclusion

This small-scale study offers some rare insights into the experiences, attitudes and behaviours of informal interpreters from the perspective of the interpreters themselves. Some points to emerge from the interviews were common to respondents in both the Netherlands and Turkey, as well as familiar from the literature on non-professional interpreting. As such, they suggest the existence of common, cross-national tendencies in informal interpreting in medical settings, a possibility worthy of exploring more thoroughly in future research on this topic (see below). Besides common features, we also identified differences in the feelings, thoughts and practices reported by respondents in the two territories. Among these were the contrasting attitudes towards professional interpreting services, the greater use of quasi-professional strategies by respondents in the Netherlands, and

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Kurdish-speaking interpreters unquestioning willingness to interpret for their elders but at the same time their resentment at having to interpret in the first place. In the Kurdish-Turkish context, moreover, taboo subjects appeared to complicate communication between the doctor, patient and family interpreter in a quite distinct way. Although previous research has acknowledged that the role of interpreters should be considered in relation to the social contexts in which they operate, to date no study has contrasted the experience of informal interpreters in different geographical and cultural settings. To the best of our knowledge, this study is thus the first to suggest by means of comparison how the attitudes and practices of informal interpreters might be influenced by the conditions in the country in which these interpreters live and work.

The comparison is all the more interesting because of the very different social and political contexts surrounding medical interpreting in the two countries. In the case of the Netherlands, we have a prosperous and famously tolerant country where the state has until now favoured and funded profes-sional interpreting services targeted at migrants. Turkey, on the other hand, can be described as an economically less developed country, in which for many decades nationalist assimilationism and rigid monolingualism helped hinder the provision of interpreting services, which would have benefited above all Turkish-born citizens with limited proficiency in Turkish. The lack of professional interpreting services and of health workers competent in minority languages, combined with the previously hostile attitude towards doctor-patient communication in these languages, led to widespread recourse to informal interpreting. As we hope to have shown, traces of these distinct contexts can be discerned in the responses of our interviewees. All the same, while in terms of official policy the Netherlands and Turkey seem to belong to different stages on Uldis Ozolins four-stage international spectrum of response to multilingual communication needs in interpreting (2010) with Turkey edging from Neglect to Ad hoc and the Netherlands poised some-where between Generic language services and Comprehensiveness the reality on the ground in these two territories is not so different; in both, the use of untrained informal interpreters is common.

Since our analysis is based on two narrow samples, in order to arrive at more conclusive findings concerning interpreters from specific localities or communities, future research would have to include larger groups of respondents and reduce the variables related to the group(s) under examination, as Lucy Tse did in her 1996 study of 64 Chinese- and Vietnamese-Americans. A more true-to-life picture of the performance of informal interpreters could also emerge from analysis of actual doctor-patient-interpreter discourse, which would provide primary evidence of informal interpreters translation strategies, procedures and decisions (Bhrig and Meyer 2004, Cambridge 1999, Flores 2005). A further method to gain more insight into the experiences of informal interpreters and the socio-cultural influences on their performances would

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be stimulated recall, which involves showing interpreters video recordings of their own performances and asking them to comment on their thoughts, feelings and roles during the interaction (Leanza 2005).

Outcomes of such studies might also point to possible ways of improving the communication process between doctors, patients and informal interpreters. Development of training materials for bilingual laypersons and healthcare staff who frequently function as interpreters might be a solution, one for which the experience of TRICC proves illuminating (Meeuwesen and Twilt 2011:83). At the same time, in the face of the cuts to translation and interpreting services currently being made in the Netherlands and across the crisis-hit world, it is vital to push the case for professional interpreting and translation services. It is also important to educate professionals and laypeople alike about working with interpreters, whether professional or informal. An intervention study carried out in Switzerland, which aimed to improve communication between physicians and patients who speak a foreign language, is a good example of how physicians might be trained in using professional interpreters effectively (Bischoff et al. 2003).

As for the Turkish situation in particular, the tendency in the Southeast does seem to be towards monolingual doctor-patient communication in Kurdish and the sidelining of the informal interpreter. There is arguably even greater need, and more potential, for the development of interpreting facilities (involving Kurdish, other minority languages, and the languages spoken by refugees) in the major cities of Western Turkey, which could include the training of health workers, or other interested parties, as interpreters (Gven 2011). This was the conclusion drawn in a report by the vice-president of the Turkish Human Rights Association (IHD), who noted that the problem of medical communi-cation was particularly acute in areas where Kurdish was not widely spoken, above all in Istanbul (Erbey 2007).

The use of informal interpreters in healthcare is a reality in a country such as the Netherlands, where professional facilities are well-established, just as it is in a country like Turkey, where not even the groundwork for such facilities has been laid. Until now, much of the interpreting and translation studies community has disapprovingly turned a blind eye to non-professional interpreting, including interpreting in healthcare settings. However, non-professional interpreting is not just a fascinating subject and a rich source of research material, but also part of the everyday life of millions of people across the world, regardless of what official policies prescribe and what solutions interpreting scholars would prefer to see implemented. As such, it demands greater attention from the scholarly community.

BARBARA SCHOUTENDepartment of Communications Science, Amsterdam School of Communication Research, University of Amsterdam, Kloveniersburgwal 48, 1012 CX Amsterdam, The Netherlands. [email protected]

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JONATHAN ROSSDepartment of Translation and Interpreting Studies, Boazii University, Faculty of Arts and Sciences, 34342 Bebek, Istanbul, Turkey. [email protected] RENA ZENDEDELVrije Universiteit Medical Centre, PO Box 7057, 1007 MB Amsterdam, The Netherlands. [email protected]

LUDWIEN MEEUWESENInterdisciplinary Social Science Department, Utrecht University, Heidelberg-laan 2, de Uithof, 3584 CS Utrecht, The Netherlands. [email protected]

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informal interpreters in medical settings

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training intercultural