Trust, Translation, and HAART
- Trust, Translation, and HAART
Alna is a young Sudanese refugee who only recently arrived in the United States. She suspects that her husband has HIV, and she worries that she and her children might be infected or at risk for being infected. She travels nearly an hour on city buses with her small children to seek help at a local clinic that offers free care to refugees. She speaks minimal English and communicates with clinic staff mainly through a menu of pictures. On a follow-up visit to the clinic, Alna learns that she is HIV-positive.
Though it is likely that she contracted HIV from her husband, she refuses to inform him about her HIV status because she fears marginalization from her small community, that her husband will beat or kill her, and that she will be alienated from her children. She also refuses to admit interpreters into the room because she does not trust them to keep her HIV status confidential.
Only a few interpreters speak her language, which is generally uncommon in the United States. Even with languages in common, however, tensions from their past in Sudan strongly persist among members of local Sudanese refugee communities. Alna's physician and nurse continue to encourage her to admit an interpreter, and they assure her that interpreters have to keep all information confidential. However, her body language and limited English expressions suggest that she will not trust any interpreter.
Alna's physician and nurse briefly leave her room. "This is pretty frustrating," the physician says. "How can we treat her if we can't communicate with her, and how can we communicate with her without an interpreter? She needs HAART (highly active antiretroviral therapy), but for that to be effective, we need to help her understand how important it is to adhere to the prescription regimen to keep the viral load low. Without an interpreter, our hands are tied."
"If she spoke Spanish," the nurse says, "we wouldn't even question whether there should be an interpreter; we'd just have one there. What should we do?"
- Commentary
This case raises two interesting and important issues. The first concerns the moral dimensions of interpreters' roles in health care. The second concerns patients who make decisions that might not promote their clinical best interests, and the ways in which professional caregivers try to make sense of this.
A patient's consent to have interpreters participate in her interactions with health care professionals requires careful attention if she is from a small language community. In small communities, there is greater potential for patients to suffer stigma and marginalization. Ideally, this shouldn't matter because interpreters are bound by duty to keep patients' protected health information confidential; this does not assure Alna, however. It's important for Alna's caregivers to recognize that, from Alna's point of view, the presence of an interpreter is a significant risk. Alna has a lot to lose if an interpreter does—even mistakenly—disclose information about her HIV status. If there is a breach of confidentiality, it's not clear whether Alna's caregivers would ever know or whether they could respond in a way that would preserve her physical safety or help her socially and emotionally.
It's worthwhile to further imagine how a refugee's experiences could influence how she assesses risk differently from someone who has never seen war or suffered the humiliation of ethnic cleansing, genocidal displacement, forced migration, and persistent fear of rape. If Alna's caregivers want to understand her distrust of an interpreter, they must look beyond her clinical situation. For example, one way to see Alna's distrust is as a product of racial and ethnic distrust forged by years of imperialism. Under British rule, different groups of Africans were effectively pitted against one another to compete for the favor of their colonizers; racial, ethnic, and nationalist tensions are exacerbated when one group of Africans is seen by other groups as having been complicit with white occupation. This historical context can clarify how transgenerational distrust produces and is simultaneously a product of deeply entrenched patterns of oppression.
This brief canvassing of political particulars...
