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Department of Psychology  Departement Sielkunde Language, access and the politics of care: A South African story Leslie Swartz and Bonginkosi Chiliza.

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Presentation on theme: "Department of Psychology  Departement Sielkunde Language, access and the politics of care: A South African story Leslie Swartz and Bonginkosi Chiliza."— Presentation transcript:

1 Department of Psychology  Departement Sielkunde Language, access and the politics of care: A South African story Leslie Swartz and Bonginkosi Chiliza Sanja Kilian, Tessa Dowling, Mawande Dlali, Jénine Smith, Ereshia Benjamin, Sybrand Hagan, Marion Heap with MRC/NRF funding

2 Ten poorest countries in the world by GDP Psychiatrists per 1,000,000 population Source: World BankSource: WHO Democratic Republic of Congo1.1 Liberia0.2 Zimbabwe0.6 Burundi0.1 Eritrea0.6 Central African Republic0.2 Niger0.3 Sierra Leone0.2 Malawi0.1 Togo0.2

3 Ten poorest countries in the world by GDP Psychiatrists per 1,000,000 population Number of languages spoken Source: World BankSource: WHO Source: http://www.ethnologue. com http://www.ethnologue. com DRC1.1 215 Liberia0.2 30 Zimbabwe0.6 19 Burundi0.1 3 Eritrea0.6 12 CAR0.2 71 Niger0.3 21 Sierra Leone0.2 24 Malawi0.116 Togo0.239



6 Source: UNHCR The UN refugee agency

7 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 Afrikan ers

8 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…”


10 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)

11 Understanding the current situation 1.The new elites 2.The role of global psychiatry 3.A tradition of making the personal invisible in psychiatry 4.Changing academic careers in health care in South Africa 5.Nursing as writing 6.Task shifting 7.Resources 8.Personal responses to historical positioning

12 How informal interpreters help us make up stories Constructing or obscuring “insight” Cultures of mystery and bureaucracy Let’s get (very) happy

13 “Insight”

14 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)

15 I noticed that I was losing my mind VS Something in her head was also not so nice

16 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:

17 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”.

18 “Culture”

19 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: No Interpreter 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): Yes Interpreter Y: But now I want to find out when she fell ill. Clinician (Dr.E): Yes.

20 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.

21 “Happy”

22 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?)

23 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 14990 Omissions 2411 0 Substitutions 19660 Total 5726 0

24 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?

25 Disrupting these stories

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

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