TRANSLATION IN THE HEALTH SERVICES SYSTEM

by María Cornelio
Reviewed for Apuntes by Leticia Molinero, apuntes@intrades.org

Maria Cornelio is a full-time translator who also teaches translation at New York University. In addition, she reviews translations for two major medical institutions in New York City, Columbia-Presbyterian Medical Center and the New York State Psychiatric Institute. She finds that one of her biggest problems, as a reviewer, is having to review translations done by people who are not professionals. The prevalent use of non-professionals stems from the common misconception that anyone who is bilingual can do a translation or interpretation, and that is absolutely not the case.

An increasingly important part of her work is educating decision-makers in an attempt to prevent them from making embarrassing and costly mistakes. She begins by stating that there are four major skills or skill groups that people need in order to be able to do a competent translation or interpretation.

The first skill is linguistic ability
The person who works with language must have excellent skills: Translators need writing skills and interpreters, oral skills. They also need to have a complete command of syntax and grammar. The problem is that people tend to think that a bilingual can do this type of work and they don’t necessarily realize that, even though someone speaks a language fluently, they may not necessarily know the proper grammar and the proper syntax to use. They also need to have an extensive vocabulary in both languages. It is not enough, for example, that a translator or interpreter who speaks Spanish have an extensive Spanish vocabulary; they also have to know enough English to understand fully the source document.

The problems encountered fall under several categories:

Technical knowledge, lack of familiarity with idioms
Frequently, medical translations are done by foreign physicians residing in the United States. They may have good command of medical terminology and even of Spanish grammar and style, but they may not have sufficient knowledge of idiomatic, non-medical English. A case in point is the mistranslation of the term “feeling blue ” in a post-partum depression study. The term simply meant being depressed after giving birth. The physician who translated the document incorrectly used “blue-baby syndrome,” the only medical term he felt was appropriate in that context.

The use of Spanish by some US Hispanics
Another problem is people whose English is fluent but whose Spanish is not as good. This happens a lot with Hispanic people who grew up in this country and who have not had formal training in Spanish. They may be able to speak very fluently and correctly, but when it comes to writing, they don’t have the grammar, they don’t have the syntax, they don’t have the richness of vocabulary to be able to render all the terms into Spanish. They understand the English original but they don’t know the Spanish equivalent of all the terms that appear in the document.

Faulty Translations
Cornelio tells us that another problem she comes across is lack of knowledge of English grammar: “I’ve seen stem cells translated as tallos celulares (cellular stems) because they don’t know grammar, they don’t know which is the adjective and which is the noun, so they turn it around and, they are speaking Spanish all right, but…it’s not the correct translation.”

She is surprised to see that these problems are so consistent and frequent, and concludes: “That’s why it is important to make sure that whoever does your translation is just as competent in English as they are in Spanish.”

Good bilinguals, poor translators
Some physicians are very competent in both languages: their English is great, their Spanish is great…but they are not really precise in their use of language, they lack the translator’s perception and training. Translators have something in common with lawyers, and that is the importance they assign to the use of accurate language. This is a special relationship with language that not all bilinguals have.

Cornelio cites the following example: “I received a translation where the English said: ‘You will be injected in a muscle’, and then the Spanish: ‘se le inyectará un muslo’; almost exactly the same words (with one extra syllable). A muscle can be anywhere in the body; muslo is a thigh, so if the Spanish says ‘you will be injected in the thigh,’ I’m not going to accept that, I can’t accept it as a reviewer. In that particular case, I called the translator and said: ‘Look, I’m sorry, you have to change this’, and she replied: ‘what’s the big deal? The thigh is a muscle!’ But not every muscle is a thigh! When you are doing therapy or a clinical study and the English says: ‘you will be injected in a muscle,’ it could be any muscle in the body…it could be the arm, the buttocks or it could be the thigh. If the Spanish restricts it to the thigh and the investigator, knowing that the English says a muscle, decides that the patient is going to be injected in the arm -- if there is an infection, and there is gangrene, and there is an amputation -- there may also be a lawsuit. So lawsuits are things that translators have to think about, and that is what I mean when I say that you have to think like a lawyer.”

Proofreading and editing
Most translations into Spanish are for the patients, as practicing physicians in this country are supposed to be fluent in English. So, in order to communicate well with the patients, presentation and formatting concerns are important. For example, the font size should be a consideration if the document is addressed to older or visually-impaired patients. However, a non-professional translator may use a font 10 where the English original uses a font 14 without thinking that maybe the original writer decided that a larger font would be more appropriate in this particuar case.

Some translators change the original format for reasons known only to them. So one has to look not only to the content but to the format as well and this is something that a professional would know how to do. People who are not professionals are not aware of this.

The second skill is specialized knowledge of the field
This is the second group of skills required of a professional translator. Most fields have a certain vocabulary that one needs to use, they have certain concepts that one needs to know in order to be able to do a translation. It is not enough to write with the help of a dictionary. Some people say, “it is a medical translation and I speak Spanish, I will just go to the dictionary and get the medical terms and I will be OK.”

Handouts were distributed to illustrate these points. An expression such as “Relation of cholesterol-year score to severity of calcific atherosclerosis and tissue deposition in homozygous familial hypercholesterolemia” would not be readily understood by the lay English speaker, as it requires knowledge of a specialized field.

Cornelio uses this example to make people who don’t know other languages realize that even in English, being able to understand a text depends on having knowledge of a particular field, of specialized terminology, etc. Therefore, a medical translator should be conversant with medical matters in both languages.

Target audience
“The other issue in terms of the various skills required of the competent translator is familiarity with the target audience, and that is again something that doesn’t happen with people who have not been trained in translation and it also doesn’t happen with people who are not aware of where the translation is going or who are not familiar with the population to whom it is directed. I think that two things are important here: One is to beware of stereotyping.”

“I remember once, when I was giving a presentation at a hospital. I was speaking of the importance of professional translation so that the patient can understand what he is reading. Finally, one of the doctors said : ‘Well, María, it doesn’t really matter who we have doing the translation . Most of our Hispanic patients don’t have much education. They wouldn’t be able to tell the difference between a good translation and a bad translation.’” “Trying to contain my anger, I said: Doctor, I’m sure you have English-speaking patients who say to you: ‘well, I don’t have to call you if I ain’t got no symptoms, right?’ You are not going to write that in a consent form.”

“First of all, the patient knows you don’t speak that way so the first thing he’s going to say is: ’He is talking down to me’ and secondly, it doesn’t matter whether the person has a lot of education or a little. We are lucky because we are highly educated, but not everybody is. And anyway, people really have the right to speak whichever way they wish.”

“That is no excuse for poor grammar or syntax, etc., because that is simply disrespectful, and I think that is what happens when people ask someone who is unqualified to do a translation (‘you know this is going mostly to Hispanics who don’t have much education, so it doesn’t really matter…’). Well, that is a sign of disrespect. People are human beings. People deserve respect and to have correct information -- especially in the medical field where somebody’s life may be at stake.”

Culture and educational level of target audience
“The other problem is the culture and educational level of your target audience, because there are several different registers that you can use. Depending on who your audience is, you can vary the vocabulary or the syntax.”

Cornelio points out that very frequently translators do not understand the need to change register and often provide translations written at the physician level when addressing patients. Sometimes the translations are done by doctors, and the investigators in charge of the studies do not understand why their documents are being rejected by the reviewer. It is then necessary to explain that the doctor wrote thinking in terms of communicating with another doctor. However, if the patient is a child or an adult with little formal education, the communication is totally lost. Therefore, translators need to pay particular attention to the register of the document they are given to translate. They do their target audience a disservice when the English uses an easily-understood lay term and the translation uses a medical term that the reader is not likely to understand.

As illustrated in one of several handouts that were distributed during the presentation, in a description of mitochondrial disorders, the following simplifications were made in texts addressed to patients:

“-Number 1: ‘multisystemic diseases,’ changed to ‘it affects different organ systems,’ that’s all it means.
-Number 2: ‘heterogenous clinical manifestations’ all that means is ‘a wide variety of symptoms.’
-Number 3: ‘a same genetic mutation can result in distinctive clinical phenotypes,’ changed to ‘the same type of changes can result in different illnesses.’
-Number 4: ‘distinct mutations can result in the same clinical phenotype,’ changed to ‘different types of changes can result in the same illnesses.’
-Number 5: ‘manifestations of the diverse clinical syndromes,’ changed to ‘various signs and symptoms can appear in patients,’ ‘clinical simply means something that manifests in patients or refers to them, that’s all it is.’”

Concerning the register of translations, a handout was distributed with examples taken from several documents showing the same information addressed to medical professionals, adults and children.

For the physician: “If the patient suffers from hypercholesterolemia…,” for the adult: “if you suffer from high levels of cholesterol in your blood,” for the child: “if you have a lot of cholesterol in your blood.”

“Cephalea is one of the symptoms of the flu.” Cephalea is simply a headache. Therefore, for the child who doesn’t know what cephalea is, it would be better to write: “if you have the flu, you might get a headache.” However, Cornelio has seen many translations that use the word cefalea for headache, because it is used in some Latin American countries. The problem is that it cannot be used when addressing a child. According to Cornelio, “if one says ‘dolor de cabeza,’ any child would understand that. The excuse that ‘we say this in my country’ is not enough, you have to make sure that you know who the target audience is, and translate accordingly.”

In another example: “Its safety and effectiveness in curing pneumonia…,” for the adult “it is safe and effective in curing pneumonia”, for the child “it is safe and works well to cure pneumonia.” According to Cornelio, “Now, if the English says ‘it is safe and works well’ I don’t want to see ‘es inocuo’ in a Spanish document addressed to a child because no child is going to understand that. So, again, you have to make sure that you keep in mind the register that you’re given.”

Awareness of the purpose of the translation
We spoke earlier about the importance of linguistic ability, of specialized knowledge, and of knowing who the target audience is. The fourth set of skills the translator must have is being aware of the purpose of the translation.

The translator must be familiar with the different types of translations that may be necessary in the medical setting. Some of these provide information, others are legally binding documents and still others are designed to obtain information.

Documents that provide information are generally written at a lower register because they are intended for the patient. Most of them are patient-education materials, teaching people how to manage chronic illness: For example, telling patients with diabetes what kind of diet they should eat, to make sure that they check their insulin levels, etc. Some documents talk about illness prevention, or how and when to take medication.

Some institutions do a lot of research in conjunction with other countries. In this case it is necessary to translate all of the documentation, not only for the patient but also for the researchers who are going to be using the protocol. Of course, the Spanish has to be translated to a higher register because it will be read by the physicians or professionals carrying out the study. The same holds true in translating medication inserts for pharmaceutical companies doing business abroad. But the biggest market for Spanish translations in this country is really in documents written for the patient.

There is a second type of document, which is legally binding, called the informed consent form. This form is intended for patients who are undergoing surgery or invasive medical procedures or for people who participate in clinical studies. The language of this form is strictly regulated by the Federal government. These documents are often mistranslated because translators may not pay attention to or be aware of the legal subtleties involved. For example, when the subject is told that the research drug will be provided at no cost, many translators use the word gratuito. However, attorneys at some research institutions prefer to avoid the word free, choosing instead at no cost, because free may be interpreted as being economically coercive to low-income people.

There are also documents written for the purpose of obtaining information from patients. These have to be very accurately translated or the data they are designed to gather may become distorted. An example is the verb to circle, as used in a questionnaire requiring a child to circle the correct answer to a question. If the purpose of the evaluation is to determine cognitive function and hand-eye coordination, and the translation of circle says marca instead of rodea con un círculo, it will not allow the clinician to learn whether the child can draw a circle around a figure or not.

Standard language
And finally, there is the issue of standard language. “Many people feel insulted when they are addressed in Spanglish: “Don’t they think that I know any better? I might say marqueta but I know it is mercado and I don’t want to see it in a medical document as marqueta.” In addition, if the document is trying to assess memory problems, somebody who doesn’t use Spanglish may not remember marqueta because that’s not part of their lexicon, but mercado is. If they don’t remember mercado when they are asked to repeat the word a few minutes after having heard it, you can suspect that there is a problem. But if the document uses a Spanglish term, the problem may be with the translation and not necessarily with the patient.”

This presentation provided an excellent overview of the issues involved in translating documents for the healthcare field. These issues are important for translators and for the decision-makers whose job it is to determine who is going to do the translation. The examples and anecdotes engaged the audience and made a forceful argument for using language professionals rather than untrained bilinguals.