Translation and Knowledge Mediation in Medical and Health Settings [1 ed.] 9789057182396

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LINGUISTICA ANTVERPIENSIA NEW SERIES Themes in Translation Studies 11/2012

LINGUISTICA ANTVERPIENSIA

NEW SERIES Themes in Translation Studies 11/2012

ARTESIS UNIVERSITY COLLEGE ANTWERP DEPARTMENT OF TRANSLATORS & INTERPRETERS

TRANSLATION AND KNOWLEDGE MEDIATION IN MEDICAL AND HEALTH SETTINGS

Edited by Vicent Montalt & Mark Shuttleworth

Contents Vicent Montalt-Resurrecció & Mark Shuttleworth Research in translation and knowledge mediation in medical and healthcare settings

9 Matilde Nisbeth Jensen & Karen Korning Zethsen Translation of patient information leaflets: Trained translators and pharmacists-cum-translators – a comparison

31 Raquel de Pedro Ricoy Reading minds: A study of deictic shifts in translated written interaction between mental-health professionals and their readers

51 Demi K. Krystallidou On mediating agents’ moves and how they might affect patient-centredness in mediated medical consultations

75 Tatjana R. Felberg & Hanne Skaaden The (de)construction of culture in interpreter-mediated medical discourse

95 Sara Pittarello Medical terminology circulation and interactional organization in interpreter-mediated medical encounters

113 Dolores Ross & Marella Magris The role of communication and knowledge management as evidenced by HCP vaccination programs in the Netherlands, Germany and Italy: Possible suggestions for medical translators

133 Sonya Pritzker Translating the essence of healing: Inscription, interdiscursivity, and intertextuality in U.S. translations of Chinese Medicine

151 Pilar Ezpeleta Piorno An example of genre shift in the medicinal product information genre system

167 Ana Muñoz-Miquel From the original article to the summary for patients: Reformulation procedures in intralingual translation

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George Major & Jemina Napier Interpreting and knowledge mediation in the healthcare setting: What do we really mean by “accuracy”?

207 Sylvie Vandaele & Marie-Claude Béland Les modes de conceptualisation des unités d'hérédité au XIXe siècle : Spencer, Haeckel et Elsberg

227 Maribel Tercedor-Sánchez & Clara I. López-Rodríguez Access to health in an intercultural setting: The role of corpora and images in grasping term variation

247 Book reviews Gambier, Y., & van Doorslaer, L. (Eds.). (2011). Handbook of translation studies (Volume 2). Amsterdam: John Benjamins. Printed edition. 197 p. Gambier, Y., & van Doorslaer, L. (Eds.). (2011). Handbook of translation studies online (2nd ed.). Available online at: http://www.benjamins.nl/online/hts/

(Denise Merkle)

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Pedersen, J. (2011). Subtitling norms for television: An extrapolation focussing on extralinguistic cultural references. Amsterdam: John Benjamins. 240 p.

(Kristijan Nikolić)

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Remael, A., Orero, P., & Carroll, M. (2012). Audiovisual translation and media accessibility at the crossroads: Media for all 3. Amsterdam: Rodopi. 439 p. (Jan Pedersen)

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Flotow, L. von (Ed.). (2011). Translating women. Ottawa, ON: University of Ottawa Press. 341 p. (Encarnación Postigo Pinazo)

283 Mus, F. & Vandemeulebroucke, K. (ass. d’Hulst, L. & Meylaerts, R.) (Eds.) (2011). La traduction dans les cultures plurilingues. Artois Presses Université : Arras. 256 p. (Dirk Weissmann) 288

Alphabetical list of authors & titles with keywords

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Alphabetical list of contributors & contact addresses

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Research in translation and knowledge mediation in medical and healthcare settings 1

Vicent Montalt-Resurrecció Universitat Jaume I Mark Shuttleworth Imperial College London

1. Background “A word, discourse, language or culture undergoes ‘dialogization’ when it becomes relativized, deprivileged, aware of competing definitions for the same thing. Undialogized language is authoritative and absolute.” (Bakhtin, 1935/1981, p. 427) Health—defined by the World Health Organization as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (Preamble to the Constitution of the World Health Organization)—is one of the most fundamental values in today’s societies. The physical, mental and social aspects of health indicated by the WHO suggest contexts in which communication is bound to be a major contributing factor.

1.1. Medical and healthcare settings Medical and healthcare settings are embedded in a complex and varied continuum of communication, interaction and dialogue—ranging from the laboratory to the clinic and to patient education—in which participants of all kinds—patients, physicians, nurses, the general public, researchers, healthcare managers, policy makers, technicians, journalists, writers, translators, interpreters, etc.—each with different linguistic and cultural backgrounds, take part in different ways and for different purposes. In such a continuum of communication, interaction and dialogue, many genres and forms of discourse co-exist. Because of the complexity and variety of these different forms of interaction, medical and healthcare settings offer a rich environment for research in translation and interpreting from a “dialogic” (Linell, 2009) perspective. Medical and healthcare settings are defined in this paper by the social interaction and discursive processes that take place in them as much as by the research processes, therapeutic actions, specific concepts and knowledge repositories that constitute them. Knowledge, in the previous sentence, is taken to mean the factual information accumulated collectively

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across centuries through processes of various kinds, one of which is scientific research. However, knowledge also refers to the individual and social act of knowing, of being aware of something. And, of course, one cannot acquire the former without the latter.

1.2. The construction of knowledge In his Ethics, Spinoza (1632–1677) establishes several ways of knowing. According to him the most basic form of knowing is the immediate perception achieved through our senses. The second way of knowing is through symbols, that is, “[…] from the fact that having read or heard certain words, we remember things and form certain ideas concerning them, similar to those through which we imagine things […]” (Spinoza in Runes, 1957, p. 197). Finally, Spinoza refers to reason and intuition. In this issue of Linguistica Antverpiensia New Series – Themes in Translation Studies, we are particularly interested in knowledge acquired through symbols such as words, texts, discourses and other representations, which are all mediated ways of knowing. In his Philosophy of Symbolic Forms, Cassirer (1874–1954) explores the symbolic nature of human cognition and communication and proceeds to underline the constructive nature of symbolic forms and actions. According to him, we do not know the world directly but through the mediating power of symbols. We can access reality only through the symbolic mediation of concepts and signs, never in an immediate way (Cassirer, 1923/1998, p. 20). In fact, we construct knowledge by means of symbols, and in particular verbal symbols, that is, words and the concepts that they refer to. According to Cassirer, scientific knowledge in any discipline is a construction or symbolic elaboration that we human beings make out of a portion of the reality surrounding us. This construction or symbolic elaboration is always carried out under certain cognitive and socio-cultural conditions. As pointed out by Cassirer (1923/1998, p. 14) the fundamental concepts of any science, as well as the means through which it formulates its questions and finds its solutions, are not passive copies of a pre-existing entity, but the intellectual symbols created by that particular science. Scientific concepts in general and medical concepts in particular do not exist in nature, but are constructed by human beings (see Vandaele & Béland, in this issue). Medical language is the semiotic expression of knowledge and is also determined by cognitive and socio-cultural conditions. For Cassirer (1923/1998, p. 27), the verbal sign is not merely the final wrapping of thought, but its essential organ. The sign does more than simply serve the communication of a given content that is already out there

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waiting to be expressed and shared. Rather, the sign is the instrument through which such content is actually defined, categorized and fully constituted (Montalt-Resurrecció, 2005, pp. 59–60). Friedman (2011) points out that what is central in Cassirer’s philosophy is in line with the following statement: The conception of human beings as most fundamentally “symbolic animals” interposing systems of signs or systems of expression between themselves and the world, then becomes the guiding philosophical motif for elucidating the corresponding conditions of possibility for the “fact of culture” in all of its richness and diversity. (p. 1) Functional Systemic Linguistics has focused on the link between knowledge, language, communication and cognition. According to Halliday (1998), […] the grammar of every [natural language] is a theory of human experience […] [it] is also an enactment of interpersonal relationships. These two functions, the reflective and the active, are each dependent on the other; and they, in turn, are actualised by a third function, that of creating discourse.” (pp. 185–186) Following Cassirer and Halliday, it can be argued that language does not simply reflect or codify something that is already there. There are no natural categorizations (see Pritzker, in this issue), but […] many ways in which the phenomena of our experience can be seen to be related to one another. What the grammar does is to impose a categorisation: it treats a certain cluster of phenomena as alike in certain respects, and hence sets this cluster apart from others which it treats as being different. (Halliday, 1998, p. 187) In short, “[…] the way things are is the way our grammar tells us that they are” (Halliday, 1998, p. 187). One of our starting points is that there are far-reaching links of interdependence—as yet unexplored—between knowing, communicating and mediating. The reasons why these links have not been explored so far are complex and varied. Latour and Woolgar (1986) have responded to this lack of awareness of the symbolic and rhetorical nature of scientific knowledge, and from their ethnographic research in the science laboratory they come to the conclusion that “[scientific] writing is not so much a method of transferring information as a material operation of creating order” (p. 245).

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In other words, when writing, scientists are not merely transcribing what is already clear in their minds. Text-making goes beyond materializing or expressing something that already exists in the mind and goes hand in hand with sense-making. By communicating verbally and nonverbally, we constantly shape and reshape—and often create, as in the case of neology—the scientific concepts that we need for our purposes as well as the arguments in which they are embedded and the social interactions that we pursue. The authors of primary knowledge can be viewed as the first translators whose task it is to conceptualize and reconceptualize newly discovered entities and attributes of already defined entities (see Vandaele & Bélard, in this volume). Bazerman (1998) goes one step further and states that the abovementioned interdependence between knowledge and communication has actually been surpressed. He also points out some of the reasons why: Over the past centuries, several forces have tended to surpress our consciousness of the rhetorical, communicative and symbolic character of scientific knowledge—thereby suppressing the awareness of the role of language in the production of knowledge: the desire to get closer to the material object and the empirical experience of it; the warranting of the representation through material practice; and the desire to remove misleading forms of representation. (p. 15) One of the consequences of this suppression is a radical separation between knowledge, on the one hand, and language and communication, on the other. Even communication among experts is often seen as a secondary process, epistemologically much less relevant than knowledge “itself”.

1.3. Knowledge and translation The subsidiary, inferior nature ascribed to communication is seen even more clearly outside highly specialized scientific circles. As highlighted by Fuller (1998, p. 35), popularizing practices have often been rejected as “simplifications” and “adulterations” of scientific truth by the scientific community, as if science—and medicine in our case—could not be intrinsically accessible to the lay person. Therefore, mediating intraculturally and interculturally and intralingually and interlingually are viewed as an unavoidable inconvenience that distorts “pure” knowledge. Such ideas are ideologically loaded in that they establish hierarchies that separate experts from lay people. Highly specialized registers and discourses are seen to occupy a

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privileged position in which experts hold power, whereas non-experts have little say in what can be described as a highly monological environment. Such a belief in “pure” knowledge and the supression of our consciousness of the rhetorical, communicative and symbolic nature of medical and healthcare knowledge affects or can affect the way in which translation in medical and healthcare settings is studied (or not) and understood. In the context of translation studies, the old conduit metaphor can be taken to mean that there is a source text and a target text, and that the operation activated between them consists of merely transmitting the information from source to target in the most accurate way (Reddy, 1979). In line with the views on the linguistic construction of knowledge discussed in Section 1.2, many of the contributions to this issue demonstrate that such metaphors are no longer adequate for the description of the intricacies and complexities that constitute translations engaged in knowledge mediation. What is more, the monological, static view of communication in medical and healthcare settings, in which researchers and health professionals occupy the central position, and in which they are the only ones to generate true knowledge, is becoming obsolete. A more dialogical view is emerging, which reflects the complexity and variety of forms and processes at work in different communicative settings. In this emerging dialogical view, the patient is beginning to occupy the centre of attention and interaction (for a review of the concept of patient-centredness in today’s healthcare, see Krystallidou, in this volume).

1.4. Knowledge mediation The constructive power of symbols in general and verbal language in particular resides in the dialogism that inspires much of the research presented in this volume. But constructionism should not be misunderstood. As Linell (2009) writes, […] the term “constructionism” may invoke unfortunate associations of “fabrication”, as if our understanding of the world is entirely fictive, just “stories” told by people who hold certain interests. Surely, there are myths and fantasies, individual as well as collective, that are at best indirectly related to anything “real”, but this is not true of most of our everyday pratical knowledge, nor of course of scientific knowledge. When we “construct” the world, it is a question of intersubjective co-construction with the help of others and artifacts. It is also a partial construction in the sense that the world itself provides the material for construction. (p. 19)

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According to Linell, many dialogists prefer the term “mediation” precisely because the term “construction” is liable to be misinterpreted. Very much in line with Cassirer, Linell (2009) asserts that Our understandings of the world come to us in a necessarily mediated form, never “immediately”, at least not in an absolute sense of being entirely unaffected by the capacities and limitations of the cognising subject. It seems reasonable to distinguish between basically three or four (interrelated) types of mediation. Note, however, that we take “mediation” to mean co-constitutive mediation, that is the mediating means (resources, apparatuses) are not merely “neutral” vehicles for supporting the interaction (or causal relation) between some pre-existing entities, such as objects in the world and mental concepts. (pp. 19–20) At this point, it is worth underlining the two sides of the same coin that converge in the co-construction of knowledge: mediating means and mediators. Each language and culture—in both the national-ethnic and the socio-professional senses, as we will argue in Section 1.5—has different resources and apparatuses that reflect asymmetries with other languages and cultures, and that constitute a rich object of study. A situation in which a foreign patient engages in dialogue—either orally or through written texts—with a health professional who writes or speaks in a different language constitutes a clear example of how interlingual aspects converge with both national-ethnic and socio-professional aspects of culture. Like translators, mediators are no longer understood as neutral vehicles or passive conduits for the transmission of pre-existing entities. They are viewed as co-constructors of knowledge and meaning-making symbols, be it within the same language or in a different target language. In fact, in the field of interpreting, contributions (e.g., Angelelli, 2004; Bolden, 2000; Metzger, 1999; Roy, 2000; Wadensjö, 1992, 1998) have evolved over the past two decades towards an understanding of the role of the interpreter as an interactive participant in cross-cultural communication rather than as simply someone who relays linguistic messages from one language to another (Angelelli, 2004). Among the types of mediation proposed by Linell (2009)— perceptual, practical, artifact-based, etc.—and very much in Spinoza’s way of thinking, we find semiotic mediation: “[…] the interactional and contextual construction of meaning builds on the use of signs: words and other symbols […]” (p. 21). From the perspective of translation studies, mediation has been defined as “[…] the extent to which translators intervene in the transfer process feeding their own knowledge and beliefs in their processing of a text” (Hatim & Mason, 1997, p. 147). Hatim and Mason (1997) establish three types of mediation: (1) minimal mediation, which Venuti (1995) calls

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foreignization, (2) partial mediation and (3) maximal mediation, also referred to by Venuti (1995) as domestication. These categories are based on interlingual translation in intercultural contexts, in which culture is defined in national and ethnic terms. When we shift to intralingual translation in contexts where culture is viewed in socio-professional terms, that is, where culture is constituted of different knowledge and discourse communities that do not share many of their resources and apparatuses, the definition by Hatim and Mason (1997) seems to work in that mediators—translators and interpreters—all tend to “feed their own knowledge and beliefs in their processing of a text” (p. 147). They do so in order to facilitate new audiences to join the dialogue from different epistemological perspectives, thus moving away from a monological framework, in which lay audiences eager to become involved feel very much like “foreigners” or outsiders with no right to talk. In this context, mediators, rather than culturally “domesticating” the source text, recontextualize it to make it accessible and counterbalance the experts’ monologue. Hence, accessibility, dialogue and participation become critical elements in mediation processes and ends.

1.5. Recontextualization and reformulation Some types of recontextualization and reformulation have received attention from translation studies scholars from different perspectives. For example, from a system-oriented perspective Lefevere (1985) and Hermans (1999) are among the authors to have drawn attention to rewritings of different kinds, such as adaptation for children or summary. From a functional perspective, Nord (1997) has introduced the notion of heterofunctional translation to designate translations in which “[…] the function or the functions of the original cannot be preserved as a whole or in the same hierarchy for reasons of cultural and/or temporal distance” (p. 51). Heterofunctional translation is often referred to as transgeneric translation or genre shift (Montalt-Resurrecció & González Davies, 2007) because a change of function in the target text often corresponds to a change of genre in the target culture. To return to our healthcare settings, now that we have argued that primary knowledge in any research process is already an act of construction, an act of mediation, an act of translation (see Section 1.2), we are in a position to argue further that the construction of medical knowledge is not restricted to communication among experts. Medical knowledge is constantly recontextualized in response to the rich and complex variety of dialogues between different knowledge and discourse communities. “Recontextualization” and “reformulation” are thus two of the most critical concepts in this issue. Martin and Veel (1998, pp. 83–85) highlight three reasons why scientific discourse recontextualizes. The first and most

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obvious reason is what they call “the emergence of new fields of scientific activity” (Martin & Veel, 1998, p. 83). The second reason is “new sets of social relations for users of scientific discourse” (Martin & Veel, 1998, p. 84). A third kind of recontextualization takes place “as new modes of representing and (re)producing knowledge emerge” (Martin & Veel, 1998, p. 84). Our main concern in this issue is new sets of social relations for users of medical and healthcare knowledge. At the centre of these new sets of social relations in medical and healthcare setting, we find patients. For our own purposes, we will differentiate recontextualization—the move to a target context with different participants, purposes, expectations, values, etc.—from reformulation—a textual operation of rearranging and reexpressing the content in a different target text. In addition, we will apply these terms to interactions both within the same language and culture, and between different languages and cultures. Both recontextualization and reformulation can be observed at different levels of discourse. Consider, for example, “de-terminologisation” (Montalt-Resurrecció forthcoming; Montalt-Resurrecció & González Davies, 2007;), an umbrella term that includes explanation, definition, exemplification, illustration, analogy, comparison and substitution by a more popular term, among others: It is a process of recontextualisation and reformulation of specialised terms aiming at making the concepts they designate relevant to and understandable by a lay audience. This process is motivated by specific cognitive, social and communicative needs, and takes place as part of a broader process of recontextualisation and reformulation of discourse. (Montalt-Resurrecció, forthcoming) Determinologization (see Ezpeleta Piorno, Muñoz-Miquel and Tercedor & López-Rodríguez, in this issue) is the opposite of “terminologisation” understood as “[…] a process of semantic and lexico-grammatical distillation through which a given concept specializes and becomes a differenciated term […]” (Montalt-Resurrecció, forthcoming). This process is the kind of mediating operation that field experts carry out to label the entities that they conceptualize. Recontextualization and reformulation in medical and healthcare settings prompt us to consider culture in two different—yet often complementary—ways. On the one hand, we will take culture to mean the set of values, beliefs, institutions, preferences, habits, etc. shared by a particular national, ethnic or linguistic group. On the other hand, we need to take on board a second, narrower, view of culture as the set of values, beliefs, institutions, preferences, habits, etc. shared by well-defined knowledge communities—such as health professionals, patients, biomedical researchers—within the same national, ethnic or linguistic group.

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1.6. Shifts in recontextualization and reformulation The “shift”, a well-established concept in translation studies, refers fundamentally to “[…] small linguistic changes ocurring in translation of ST to TT” (Munday, 2001, p. 55). Although the term was first introduced by Catford (1965), Vinay and Darbelnet (1958) had already referred to the same concept in their translation procedures. Van Leuven-Zwart’s concept of translation shifts (1989, 1990) comprises two models: (1) a microstructural comparative model with three main categories— modulation, modification and mutation and (2) a macrostructural descriptive model, designed for the analysis of translated literature (Munday, 2001, p. 65). Shifts are at the heart of recontextualization and reformulation both intralingually and interlingually. As will be seen in the articles in this volume, shifts can take place in written, oral and visual modes, and at different levels, ranging from lexical items to bigger units such as genre (see Montalt-Resurrecció & González Davies’s (2007) concept of genre shift). This special issue also demonstrates that shifts can affect personal reference (de Pedro Ricoy), specific notions (Major & Napier, Vandaele & Béland), terminological units (Pittarello, Tercedor & López-Rodríguez), syntactic structures and genre conventions (Ezpeleta Piorno, MuñozMiquel) as well as discursive practices (Pritzker).

1.7. Research questions There are a number of questions that arise from the perspective that we have presented so far. What happens to knowledge, language and communication when knowledge is socially co-constructed and circulated both in interlingual and intralingual contexts? What roles do translators and interpreters play in knowledge mediation? How do they behave? How does their behaviour affect and become affected by their audiences and contexts? How is knowledge mediated between “national”, ethnic cultures? How is knowledge mediated between different professional and non-professional cultures? How do different knowledge and discourse communities establish (or not) their dialogues? How are concepts and arguments shaped and reshaped in the different genres of the complex communicative continuum of medical and healthcare settings? How do language and social interaction vary in different genres? Some of these questions and other issues have been addressed by the authors of this volume, as will be seen in Section 2.

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2. Individual contributions to the volume Although a common thread through all the articles in this issue is knowledge mediation in medical and healthcare settings, the different contributions focus on a wide variety of cultural contexts (Australia, Belgium, China, Denmark, Germany, Italy, Mexico, the Netherlands, Norway, Spain, the United Kingdom and the United States of America), of languages (Chinese, Danish, Dutch, English, German, Italian, Norwegian and Spanish) and of genres (both oral—consultation and other medical encounters—and written—patient information leaflets, summaries of product characteristics, medical leaflets, original articles and summaries for patients). The contributions to this volume can be grouped in several ways, depending on the criterion that one applies, and all of these appear to be virtually equally coherent. One could organize the articles in terms of interlingual vs. intralingual mediation, written vs. oral mediation, mediation across time, space and knowledge communities, mediation across different language pairs, mediation across different genres, etc. However, since our main purspose is to underline the relevance of knowledge mediation as a concept and practice, we have assembled the articles into three main groups based on Halliday’s three metafunctions (see also Section 1.2): (1) participant-centred knowledge mediation (Nisbeth Jensen & Zethsen, de Pedro Ricoy, Felberg & Skaaden, Krystallidou, Pittarello), (2) text-centred knowledge mediation (Pritzker, Ezpeleta Piorno, Muñoz-Miquel) and (3) concept-centred knowledge mediation (Major & Napier, Vandaele & Bélard, Tercedor & López-Rodríguez). Of course, there are overlaps between these three general groups that deserve attention, and these will be briefly addressed in the following sections.

2.1. Participant-centred approaches to knowledge mediation The first group of articles focuses on the interpersonal dimension of discourse, that is, on the roles, behaviours and performances of the different participants in the process—translators, interpreters, medical professionals, patients, patients’ relatives, the general public, etc. The Patient Information Leaflet (PIL) is a crucial genre for adequate communication between health professionals, patients and pharmaceutical laboratories as far as taking medicines safely and efficiently is concerned. Although PILs are intended to be easily understood by patients, a number of researchers have highlighted that many PILs are not user-friendly. What is more, because of difficulties in understanding some of the concepts that PILs contain, many patients do not take their medicines as prescribed. The fundamental cause of this lack of reader-friendliness may be found in the qualifications and academic backgrounds of the translators of PILs. Nisbeth

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Jensen and Zethsen address this important issue in their article entitled Translation of Patient Information Leaflets: Trained Translators and Pharmacists-cum-Translators—A Comparison. They start from the following question: do trained translators translate PILs in a different way from pharmacists-cum-translators? Their hypothesis is that subject-matter experts translate differently from trained translators in cases where expert– lay communication is further complicated by interlingual translation. In their analysis, they focus their attention on two elements that affect comprehension in a negative way in this particular genre: (1) Greek and Latin terms and (2) nominalizations. One of their main findings is that pharmacists-cum-translators make use of more Greek and Latin-based terms and introduce more nominalizations than trained translators. Indeed, their findings demonstrate that these two groups of professionals really do translate PILs in different ways, and that the differences affect readerfriendliness. Patients not only need highly specific descriptions and instructions concerning their medicines, but also more general information about the conditions affecting them. Medical leaflets (MLs) are designed to fulfil the wishes of patients to know more about their diseases in order to participate more effectively in their therapeutic process and to take informed decisions about issues concerning their health. But communicating factual information is not an easy matter and cannot be separated from interpersonal and interactional aspects. Knowing the factual information needed is the first step in the process and establishing the right kind of dialogue with patients is a further—probably more challenging—step. This is especially important in the case of specific groups, such as the mental health patients investigated by de Pedro Ricoy. In Reading Minds: A Study of Deictic Shifts in Translated Written Interaction between Mental-Health Professionals and Their Readers de Pedro Ricoy draws our attention to writer–reader interaction patterns and how they differ across cultural and linguistic settings. Her aim is to compare the interaction between mentalhealth experts and their readers before and after knowledge has been mediated through translation between English and Spanish. She focuses on how writer–reader interaction is achieved in written texts addressed to patients in the clinical context of mental health. In particular, she investigates non-obligatory shifts of personal reference and discovers that there is a shift in tenor, which reflects a change in the relationship between the participants. In particular, the explicit difference between addressees and other participants that we find in the source text tends to be blurred in the target text. In the next article, we move from the written to the oral mode and to the complex area of medical encounters. Patient-centredness is an emerging paradigm in healthcare, in which patients are moved to the very centre of attention in communicative processes. Patient-centredness is challenging in that it represents a radical departure from doctor-centred or medicine-

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centred approaches to healthcare. In On Mediating Agents’ Moves and How They Might Affect Patient-Centredness in Mediated Medical Consultations Krystallidou problematizes this key notion in heathcare systems today. She looks at patient-centredness in multilingual, multicultural settings and focuses on whether linguistic and cultural mediation affects its essence. Her data are taken from a corpus of transcribed video-recorded mediated consultations that took place in an urban hospital in Belgium. Patientcentredness is potentially compromised in interlingual and intercultural situations where an interpreter is required because the immediate contact between patients and health professional vanishes, and with it the immediacy and individuality expected in patient-centred environments. Krystallidou’s study offers a potential challenge to patient-centredness as it occurs within a mediated medical encounter in which a self-professed patient-centred doctor is participating. It accomplishes this by attempting to study the different ways in which the participants in a medical encounter— the doctor, the patient and the mediating agent (MA)—can have an impact on the communication, and the overall relationship that exist between doctor and patient. Factors considered include both verbal and non-verbal cues (such as gaze). More generally, the article also seeks to make a contribution to the fields of linguistics, translation studies and medical communication. In The (De)construction of Culture in Interpreter-Mediated Medical Discourse Felberg and Skaaden address perceived communication problems with minority patients, which are often ascribed to cultural differences. Culture is frequently used as an explanatory tool for most perceived complications. According to the authors, many of the perceived problems have nothing to do with culture, but with a lack of concentration or a lack of language proficiency—often caused by ad-hoc solutions such as using the patient’s relatives, sometimes even children, to deal with situations where a professional interpreter is required. Felberg and Skaaden not only question the real causes of such perceived problems but also warn that resorting to the concept of culture may lead to “othering” minority patients. By “othering”, they mean emphasizing the difference between Us and the Other, downplaying “their culture” and creating a potential to ascribe the source of the problems to attributes of the Other. One consequence of “othering” minority patients is that it makes it possible to disclaim one’s own responsibility for problem solving. Another consequence is that it conceals rather than reveals the problem. Felberg and Skaaden propose several alternative strategies to overcome perceived communication problems. Their aim is to avoid malpractice in medical professionals, which may threaten not only minority patients’ health but also the integrity and status of medical personnel. The study by Pittarello, a paper entitled Medical Terminology Circulation and Interactional Organization in Interpreter-Mediated Medical Encounters, is based on an analysis of two medical encounters that

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took place between foreign tourists and medical practitioners in a hospital in northern Italy. These encounters are subjected to a qualitative analysis to determine the way in which medical terminology circulates (e.g., in terms of the medical practitioners’ choice of a “professional” or a “nonprofessional” variety of medical language). Pittarello also investigates the linguistic and social organization of the mediated interaction in terms of turn-taking, sequences, communication exchanges and the shifts that occur (e.g., in register and interaction structure) as a result of the way in which interlocutors’ utterances are translated. Within this context, the paper aims to examine the approaches used by medical interpreters in the two encounters analysed to translate medical terminology and to promote or to exclude the active participation of the different interlocutors. Of key importance for boosting or impeding participation is the predominance of dyadic (i.e., monolingual) or triadic (i.e., bilingual interpreter-mediated) sequences and in particular the shifts that are introduced. Medical interactions are also seen as enshrining specific expectations, which are chiefly cognitive in nature (e.g., those based on observations about what is going to happen) but can also be affective (i.e., those that involve the selfexpression of participants). The encounters offer interesting, in-depth data that present interactions as highly nuanced communicative situations (such as the use by the doctor of the TL in the presence of the interpreter) that do not always conform to previously posited assumptions about what occurs in such interactions. The paper reaches a number of concrete conclusions on the basis of the encounters studied. The aim of the paper by Ross and Magris (The Role of Communication and Knowledge Management as Evidenced by HCP Vaccination Programs in the Netherlands, Germany and Italy: Possible Suggestions for Medical Translators) is to offer insights into the interlingual mediation of health communication in three European countries and to look at its implications for medical translation practice and translator training. The article studies HPV (Human Papilloma Virus) vaccination campaigns in the Netherlands, Germany and Italy and the communicationrelated factors that have affected the campaigns’ success rates in each of these three countries. The focus is on the translator’s role in communication and knowledge management. The paper contains a comparison of publicservice communication in the three countries under investigation, and also discusses the socio-political conditions of the campaigns as well as their outcomes. Translators are seen as “communication professionals” and “knowledge managers” who use their linguistic and cultural expertise to offer clear communication in complex intercultural situations. In this context, the paper also considers the extent of the possible overlap between medical translation and medical writing. The role of translators in disseminating medical information is seen in the social context in which it takes place, and the possibility is discussed that medical translators exercise more far-reaching choices than is usual in most areas of translation, in

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terms of the assertiveness with which medical translators act in the interests of all communication partners.

2.2. Text-centred approaches to knowledge mediation As will be seen in this section, context, discourse, genre and intertextuality play critical roles in what we have called text-centred approaches to knowledge mediation. Chinese medicine is becoming increasingly popular in many countries and cultures outside China. This popularity is motivated by and also motivates interesting dialogical processes in which the asymmetries of different medical systems become apparent. These asymmetries can be of different types—mainly conceptual, social and cultural—and they offer an extremely rich field for translation-oriented research. In Translating the Essence of Healing: Inscription, Interdiscursivity, and Intertextuality in U.S. Translations of Chinese Medicine Pritzker focuses on a highly functional genre, the textbook, which in her case is deeply rooted in healing practice. In line with dialogically oriented researchers, Pritzker views translation as dialogue between two parties. She considers what happens to knowledge when it is mediated between distant—geographically as well as epistemologically—medical cultures, such as Chinese Medicine—which is based on a rich textual tradition—and Western Scientific Biomedicine. In particular, she investigates what happens when Chinese medicine is translated from Chinese into English. Pritzker looks at a single Chinese term, “jing”, in three different translations to demonstrate how each translation into English is an inscription of complex interrelationships in the source and the target contexts. What Pritzker calls “living translation” unveils a number of issues related to intertextuality and interdiscursivity that go beyond mere linguistic encoding, decoding and re-coding. Following the work of some genre theorists (Bakhtin, Bazerman, Swales, Bhatia, etc.), Vilha (1999) underlines the need to look at medical genres that depend on one another as systems. In her paper An Example of Genre Shift in the Medicinal Product Information Genre, Ezpeleta Piorno looks at expert-to-lay communication, but in this case from the more comprehensive perspective of genre systems. Unlike most of the other papers, Ezpeleta Piorno’s contribution is centred on the question of intralingual rather than interlingual translation. It shares with MuñozMiquel’s article a discussion of determinologization and syntactic structures, and with both that paper and that of Nisbeth Jensen and Zethsen a focus on medication information designed for patients. The paper has two objectives. The first objective is to offer a description of the dynamic continuum of medical communication in the pharmaceutical sector, consisting of product information genres, that exists within the system of genres described. In this respect, the paper focuses on the restraints, the

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genre conventions and the sequence requirements that are imposed by the metagenres specific to the genre system. The second objective is to illustrate the genre shifts that occur when material is intralingually translated between the summary of product characteristics and the package leaflet. The paper presents a discussion of how various specialist-tospecialist genres (such as the summary of product characteristics and the company core data sheet) lie behind the presentation to the public of essential product-related information in the form of package leaflets (also known as PILs). The paper explores the three kinds of information that are needed by medical writers and translators: (1) conceptual, (2) contextual and (3) textual. The paper argues that translators who possess this information are able to work more efficiently on a progressive basis. Interdependence, recontextualization and reformulation play critical roles in Ezpeleta Piorno’s research. Patients increasingly wish to know more and thus be more empowered to engage in the dialogue with other participants in their healing process. Cutting-edge biomedical research may be of interest for certain groups of patients, particularly those with chronic diseases. There is a growing awareness of this need in different research settings and some biomedical journals have started to provide summaries for patients of articles originally conceived for researchers. In From the Original Article to the Summary for Patients: Reformulation Procedures in Intralingual Translation Muñoz-Miquel deals with such issues in the particular context of the research journal Annals of Internal Medicine. She draws the reader’s attention to expert-to-lay translation, but in this case, intralingual translation. Recontextualization and reformulation play critical roles in this research. Greater ease of access to information and the promotion of patient education have increased the demand for medical texts aimed at a wide, non-specialized, heterogeneous audience. In this context, it is essential to know what procedures are required to make specialized knowledge accessible to non-experts. Muñoz-Miquel’s paper presents a corpus-based exploratory study that describes the procedures used to reformulate, intralingually, medical knowledge from a highly specialized genre, the original article (OA), into a genre derived directly from it but addressed to laymen, namely, the summary for patients (SP). The linguistic and textual shifts that take place when translating an OA into an SP are taken as the basis for explaining the reformulation procedures used. The results of the study contribute to the characterization of the SP from a text genre perspective, and provide keys to writing and reformulating for both medical translators and experts in the field.

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2.3. Concept-centred approaches to knowledge mediation Conceptual mediation focuses on what happens to factual information in communication processes and the way in which concepts are shaped and reshaped through dialogues of various kinds across space and time. The paper by Major and Napier, Interpreting and Knowledge Mediation in the Healthcare Setting: What Do We Really Mean by ‘Accuracy’?, could also have been included in Section 2.1 on participantcentred approaches to knowledge mediation because it explores the doctor– patient consultation and analyses some of the ways in which interpreters render factual information. However, we have preferred to include it in this section because it investigates interaction from the conceptual perspective of what is today perhaps a less fashionable topic within translation studies: the concept of accuracy. Major and Napier offer a nuanced discussion of this notion in the context of interpreter-mediated healthcare interaction. Their data are derived from an investigation into doctor-patient consultation role-plays conducted with professional interpreters working between Australian Sign Language (Auslan) and English. The question of how interpreters operate in this respect has not received a significant amount of attention in the existing literature. The article is the first to apply Wadensjö’s (1998) taxonomy of renditions to analyse the ways in which signed language interpreters convey health information. Within this context, Major and Napier’s data indicate that interpreters often produce renditions that are reduced or expanded (rather than close), but that these do not detract from the message or the interaction as a whole since interpreters respond dynamically to the situation by making implicit information more explicit, by adding cohesion, or by including visual information in the signing to make the message clearer. Although the use of role-plays can be said to represent a limitation in view of their non-authentic nature, on the positive side it can be argued that they allow researchers to carry out a systematic comparison of the performance of different interpreters. In so doing, they provide more robust data that can be used for the purposes of healthcare interpreter training. Since scientific concepts in general and medical concepts in particular are constructed or mediated semiotically, socially and culturally—as we have pointed out in Section 1—they are not fixed entities. They not only change synchronically—across different knowledge communities, national-ethnic cultures and languages—but also diachronically. For example, we tend to think that a scientific and medical concept such as “gene” is and has always been totally objective and immutable. In fact, it has not and is not, as Vandaele and Béland show in Les Modes de Conceptualisation des Unités d’Hérédité au XIXe Siècle: Spencer, Haeckel et Elsberg. Vandaele and Béland start from the premise that the study of metaphorical conceptualizations can shed light on the understanding of both popularization and translation. Vandaele and Béland

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focus on the evolution of one crucial concept for biology and medicine, that of the unit of inheritance. According to the authors, it is important to look back at history and to study how scientific thought has evolved to achieve a better understanding of how discourse is constructed by borrowing elements from existing theories and how the metaphors that have nourished those theories have been used and translated. In very much the same way that rocks show successive geological periods, theories and their metaphorizations have left their traces in discourse up to the present. The authors formulate the hypothesis that although some well-established metaphors in biomedical discourse have become or will soon become obsolete, they are still being used either naïvely or at the service of particular rhetorical ends. In their historical analysis of this concept, the authors investigate, on the one hand, how the unit of inheritance is designated, described and conceptualized by three authors—Spencer, Haekel and Elsberg—writing at the pre-experimental period towards the end of the nineteenth century; and, on the other hand, how various metaphorical conceptualizations are expressed in English and French. In their article entitled Access to Health in an Intercultural Setting: The Role of Corpora and Images in Grasping Term Variation, Tercedor and López-Rodríguez provide an analysis of terminological variation. Of interest to them are, for example, the communicative reasons for choosing one term rather than another. Like Pittarello, Tercedor and LópezRodríguez are concerned with how medical concepts are lexicalized differently depending on the aspect of the concept that is being highlighted or the particular context in which the term is being used. The authors take their data firstly from an international project in the Yucatan peninsula, Mexico, that aims to provide Mayan and Spanish audiovisual materials for the promotion of healthcare, and secondly from a research project designed to investigate lexical variation. The possibilities provided by terminological variation for improving interlinguistic and intercultural communication are investigated in the paper. The study also explores ways in which corpora— and, in particular, corpora of semi-specialized medical texts—can be exploited to shed light on this kind of variation by means of the use of particular lexical, grammatical and paralinguistic patterns such as search terms. Finally, the paper offers a discussion of the vital role played by images in the localization process required to bridge the gap between medical practitioners and lay audiences.

3. Conclusions One thing that we hope that this publication has achieved is to show the wide variety of activities that contribute to the overall concept of what may loosely be termed “medical translation”. Medical and healthcare translation is a rich area that includes multiple different modalities, activities and areas

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of expertise, and a consideration of it cannot of course be limited to purely linguistic matters such as equivalence or terminology, as would have been the case in the not-too-distant past within the discipline. At least seven thematic tracks can be identified in this special issue: (1) expert-to-lay communication (including translation and interpreting), (2) translator and interpreter behaviour and performance, (3) the translation of specific genres, (4) intralingual translation, (5) intermodal interpreting, (6) interdiscursivity and (7) conceptual change. A number of these—or, arguably, all of them—break new ground in research terms. This multiplicity of approaches represents a wealth of perspectives, which see translation variously conceptualized as reformulation, recontextualization, dialogue and, of course, mediation. Mediation itself turns out to be a multifaceted concept that is differently reflected in each of the twelve contributions, and one that permits us to encompass such a wide range of different topics within the space of a single volume. This diversity of approaches is complemented by a similar wealth of methodologies that include the use of corpora, interviews, focus groups, and observation and analysis of both real and simulated situations. This volume has brought together perspectives from interpreting and translation studies, and also from the study of intralingual mediation. Not explicitly discussed in these pages, but nonetheless of great importance, is the need to ensure that these separate sub-disciplines should be integrated so that a dialogue might exist between them. Interpreting can serve as an inspiration to scholars of translation in raising awareness of the non-verbal and of the truly dialogic nature of knowledge mediation, of the participants involved in the process and of how their feelings, thoughts and actions are reflected in language. Translation can inspire those who research interpreting to attend more closely to the critical importance of the verbal— and in particular, of the terminological, intertextual, generic, discursive and semiotic elements that are embedded in texts. Finally, intralingual and interlingual mediation can inform each other in bringing to the fore the cultural aspects in two complementary ways. On the one hand, intralinguistic mediation, that is, adaptation for different audiences, provides those who study interlinguistic mediation with an awareness of different expert and non-expert cultures, that is, doctors, nurses, different groups of patients, general public, etc. On the other hand, scholars of intralingual translation can learn much from interlinguistic translation about the importance of awareness of different “ethnic” and “national” cultures. Although a certain amount has already been achieved, there is clearly much that remains to be done, both in terms of launching further investigations into all these individual areas and with regard to developing common repertoires of aims, priorities, approaches to and insights into this fascinating and vital area.

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Acknowledgements We should like to thank all the contributors for their hard work and patience in complying with our constant requests for modifications during the various steps in the editing process. We are delighted with the finished product and believe that it more than compensates for the effort that has been put in by everyone. At the same time, we should like to thank the reviewers whose input was essential earlier on in the process, and to express our deep gratitude to Aline Remael for her tireless energy and unending encouragement and guidance throughout every step of the way, and also to her colleagues Katrien Lievois and Jimmy Ureel for their help in bringing the collection to the state of completion that you now see.

References Angelelli, C. (2004). Medical interpreting and cross-cultural communication. Cambridge: Cambridge University Press. Bakhtin, M. M. (1935/1981). The dialogic imagination: Four essays. C. Emerson & M. Holquist (Translated into English. Russian original: four selections from Voprosy literatury i estetiki, 1935). Austin, TX: University of Texas Press. Bazerman, C. (1998). Emerging perspectives on the many dimensions of scientific discourse. In J. R. Martin & R. Veel (Eds.), Reading science: Critical and functional perspectives on discourses of science (pp. 15–30). London: Routledge. Bolden, G. (2000). Toward understanding practices of medical interpreting: Interpreters’ involvement in history taking. Discourse Studies, 2(4), 387–419. Cassirer, E. (1923/1998). Filosofía de las formas simbólicas : El lenguaje. A. Morones (Translated into Spanish. German original Philosophie der symbolischen Formen. Erster Teil, Die Sprache, 1923). México D. F.: Fondo de Cultura Económica. Catford, J. C. (1965). A linguistic theory of translation. Oxford: Oxford University Press. Friedman, M. (2011). Ernst Cassirer. In E. N. Zalta (Ed.), The Stanford encyclopedia of philosophy (Spring 2011 Edition). Retrieved from http://plato.stanford.edu/ archives/spr2011/entries/cassirer/ Fuller, G. (1998). Cultivating science: Negotiating discourse in the popular texts of Stephen Jay Gould. In J. R. Martin & R. Veel (Eds.), Reading science: Critical and functional perspectives on discourses of science (pp. 35–62). London: Routledge. Halliday, M. A. K. (1998). Things and relations: Regrammaticising experience as technical knowledge. In J. R. Martin & R. Veel (Eds.), Reading science: Critical and functional perspectives on discourses of science (pp. 185–236). London: Routledge. Hatim, B., & Mason, I. (1997). The translator as communicator. London: Routledge.

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Hermans, T. (1999). Translation in systems: Descriptive and system-oriented approaches explained. Manchester: St. Jerome. Latour, B., & Woolgar, S. (1986). Laboratory life: The construction of scientific facts. Princeton, NJ: Princeton University Press. Lefevere, A. (1985). Why waste our time on rewrites?: The trouble with interpretation and the role of rewriting in an alternative paradigm. In T. Hermans (Ed.), The manipulation of literature: Studies in literary translation (pp. 215–243). Beckenham: Croom Helm. Linell, P. (2009). Rethinking language, mind, and world dialogically: Interactional and contextual theories of human sense-making. Charlotte, NC: IAP. Martin, J. R., & Veel, R. (Eds.) (1998). Reading science: Critical and functional perspectives on discourses of science, London: Routledge. Metzger, M. (1999). Sign language interpreting: Deconstructing the myth of neutrality. Washington, DC: Gallaudet University Press. Montalt-Resurrecció, V. (2005). Manual de traducció cientificotècnica. Vic: Eumo. Montalt-Resurrecció, V. (forthcoming). La desterminologització del discurs especialitzat: Una necessitat per facilitar als pacients l’accés al coneixement. Termcat: Barcelona. Montalt-Resurrecció, V., & González Davies, M. (2007). Medical translation step by step: Learning by drafting. Manchester: St. Jerome. Munday, J. (2001). Introducing translation studies: Theories and applications. London: Routledge. Nord, C. (1997). Translating as a purposeful activity: Functionalist approaches explained. Manchester: St. Jerome. Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19–22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948. Reddy, M. J. (1979). The conduit metaphor: A case of frame conflict in our language about language. In A. Ortony (Ed.), Metaphor and thought (pp. 284–310). Cambridge: Cambridge University Press. Roy, C. B. (2000). Interpreting as a discourse process. Oxford: Oxford University Press. Runes, D. D. (Ed.). (1957). The Ethics of Spinoza. New York: Kensington. van Leuven-Zwart, K. M. (1989). Translation and original: Similarities and dissimilarities (I). Target, 1(2), 151–181. van Leuven-Zwart, K. M. (1990). Translation and original: Similarities and dissimilarities (II). Target, 2(1), 69–95. Venuti, L. (1995). The translator’s invisibility: A history of translation. London: Routledge. Vilha, M. (1999). Medical writing: Modality in focus. Amsterdam: Rodopi. Vinay, J. P., & Darbelnet, J. (1958). Stylistique comparée du français et de l'anglais. Paris: Didier-Harrap.

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Wadensjö, C. (1992). Interpreting as interaction: On dialogue interpreting in immigration hearings and medical encounters (Dissertation). Linköping University: Linköping Studies in Arts and Science No. 83. Wadensjö, C. (1998). Interpreting as interaction. London: Addison Wesley Longman.

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This special issue of Linguistica Antverpiensia and this article are part of the research project 2010-2012 (FFI2009-08531/FILO), funded by the Spanish Ministry of Science and Innovation (MICINN).

Translation of patient information leaflets: Trained translators and pharmacists-cum-translators – a comparison

Matilde Nisbeth Jensen Aarhus University, Denmark & Macquarie University, Australia Karen Korning Zethsen Aarhus University, Denmark

Numerous studies have shown that Patient Information Leaflets (PILs) are generally difficult to understand for ordinary people and that this may be one of the reasons why a high percentage of patients fail to take their medication correctly. A study by Askehave and Zethsen (2002), based on textual analysis and relying on comprehensive extratextual procedural knowledge, has shown that translated Danish PILs were, without exception, more complex than their STs. But why is this so? One possible explanation could be that PILs are very frequently translated by pharmacists, who do not possess the linguistic tools and translational knowledge necessary for expert-to-layman translation or interlingual translation. This article reports on an empirical study that falls into two parts. The first aims to identify possible differences in the translations of these two types of translator in terms of lay-friendliness. The second aims to describe the nature of the differences found between these two types of translator, and discusses whether they could potentially be detrimental to lay-friendliness in PILs.

1. Introduction An extensive amount of research has been conducted into expert-lay communication and the intricacies it involves; however, what happens when expert-lay communication is translated? This is the case with Patient Information Leaflets (PILs) in the European Union (EU). A PIL is the written information included in a medicine package, which has to accompany all medication and inform patients about dosage, side effects, etc. According to EU law, PILs must be supplied by the pharmaceutical company seeking authorization to market the medicine in the EU. Original PILs are normally produced in English, the language of the authorization procedure, and must subsequently be translated into all EU languages. Several studies have shown that PILs are difficult to understand (e.g., Askehave & Zethsen, 2000b, 2003; Clerehan & Buchbinder, 2006; Dickinson, Raynor, & Duman, 2001; Lægemiddelstyrelsen, 2004; Pander Maat & Lentz, 2010; Raynor, 2007) in direct contrast to the intention of the genre. Patients today demand to be actively involved in their own health, and the concept of patient empowerment has attracted increasing attention; however, in order for patients to be empowered, it goes without saying that

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it is essential that they understand the information provided. Thus, the importance of lay-friendliness in patient information cannot be emphasized enough. A study from the UK shows that up to 50% of people on long-term medicines do not take them as prescribed (Haynes, Ackloo, Sahota, McDonald, & Yao, 2008). Several explanations for this are given, one of them linked to the misunderstanding of prescription instructions and limited education about the medication (Haynes et al., 2008, p. 19). In relation to lay-friendliness in PILs, research focus has almost exclusively been on the English-language PIL. However, a complication that can further challenge lay-friendliness in PILs is translation. A single study, based on textual analysis, has shown that translated PILs (EnglishDanish) are more complex than their source texts (STs) (Askehave & Zethsen, 2002). Askehave and Zethsen analyse the nature of the increased complexity and offer several explanations for this phenomenon, for example the fact that the PIL is a mandatory, and therefore extremely regulated, genre (Askehave & Zethsen, 2003), and also that a skopos conflict may exist between (a) providing correct and lay-friendly patient information and (b) ensuring a fast and smooth approval procedure (for example, by not deviating from previous terminological practice) (Askehave & Zethsen, 2002). Perhaps the most important explanation, according to Askehave and Zethsen, is the fact that many PILs are translated by pharmacists who may not have the necessary translational skills, and they venture the hypothesis that these medical translators revert to the expert register they know, even when the English PIL (the ST) is layfriendly. Askehave and Zethsen did not know to what extent Danish pharmaceutical companies use medical professionals for translational purposes, so in 2010, Nisbeth Jensen carried out a study in order to find out who the translators of Danish PILs were. The study shows that Danish pharmaceutical companies use either medical professionals or translators to an almost equal extent (Nisbeth Jensen, forthcoming). However, it was also shown that the companies using pharmacists as translators currently have a greater number of EU PILs, that is, the majority of Danish PILs are translated by pharmacists. To our knowledge, there has never been any empirical research on how the two types of translator do in fact translate PILs, and hence whether some of the comprehension difficulties found in connection with PILs can be linked to the choice of translator. The aim of this study is therefore to test the following hypothesis: Subject matter experts translate differently from trained translators in cases where expert-lay communication is further complicated by interlingual translation. At the same time, we will attempt to answer the following research questions: If there is a difference, how is it manifested in the TTs?

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Is the difference of a nature likely to be detrimental to layfriendliness?

2. Background and legal framework Ensuring lay-friendliness in translated PILs is a goal that relies on a complex process (see Fig. 1 below) and due to the fact that PILs are governed by legislation, limited freedom is available in pursuit of this goal. The PIL became a legal requirement in 1992 with Council Directive 92/27/EEC requiring all medication packages to be accompanied by a PIL (Council of the European Communities, 1992), which means that the PIL is a so-called mandatory (i.e., legally regulated) genre (Askehave & Zethsen, 2003). Therefore, it is governed by several regulations and standards, which influence both the structure and content of PILs, and also their translation. According to Article 59(1) of Directive 2001/83/EC, PILs must be drawn up in accordance with the Summary of Product Characteristics (European Parliament and Council, 2001). Like the PIL, the Summary of Product Characteristics is one of the documents that must be produced by the pharmaceutical companies when applying for marketing authorization with the European Medicines Agency (EMA), but this text is an expert-to-expert text which describes contents, side effects etc. for a professional readership such as doctors and other healthcare professionals using expert terminology. The fact that the PIL must be drawn up in accordance with the Summary of Product Characteristics turns it into a type of “intralingual translation” (Jakobson, 1959/2000; see also Zethsen, 2007, 2009) as it comprises a change in receiver group from expert to layperson (as opposed to interlingual translation, which takes place between two languages). According to Article 63(2) of the above Directive, PILs must be “written and designed to be clear and understandable, enabling the users to act appropriately, when necessary with the help of health professionals”. Furthermore, this article states that PILs must be “clearly legible in the official language or languages of the Member State(s) in which the medicinal product is placed on the market”. The EMA has become increasingly aware of the importance and challenges linked to lay-friendliness and has introduced several initiatives to improve PILs such as templates in all EU languages, a readability guideline and user testing of each PIL. In relation to translation, it is very problematic, however, that the user testing is only mandatory for a single language version. This could in principle be any language version, but the English PIL is always produced first as it has to be submitted first in the marketing authorization process, and also, the materials to be submitted after the user testing must be in English, which means that usually it is the English version that is tested. English-language PILs constitute only a fraction of the EU PILs – through the Centralised Procedure, all PILs must

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be available in all EU languages, which means that all leaflets must be translated into 23 languages. 1 The translations from English into all other languages are made after the opinion of the Committee for Medicinal Products for Human Use has been received, which means after the EMA has granted the marketing authorization.

Figure 1: The production process of a Danish PIL (Askehave & Zethsen, 2011)

2.1. What does EU legislation say about translation? We know from the above that PILs should be legible, clear and easy to read in all EU languages and that this is the responsibility of the marketing authorization holder (in consultation with the EMA). There are very few guidelines from the EU about the important process of moving from an approved and tested English PIL to 23 language versions of this ST so it is very much left to the mercy of the marketing authorization applicants. A little help, or rather the only help, is to be found in the “Guideline on the readability of the labelling and package leaflet of medicinal products for human use” (European Commission, 2009). In this document, the EU Commission states the following (2009, p. 22): (1)

(2)

During the drafting of the original package leaflet every effort should be made to ensure that the package leaflet can be translated from the original to the various national languages in a clear and understandable way. The quality of translation should be the focus of a thorough review by the applicant/marketing authorization holder once the original package leaflet has been properly tested and modified. It is important

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(3)

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that the outcome of the user consultation is then correctly translated into the other languages. Strict literal translations from the original language may lead to package leaflets which contain unnatural phrases resulting in a package leaflet which is difficult for patients to understand. Therefore, different language versions of the same package leaflet should be ‘faithful’ translations allowing for regional translation flexibility, whilst maintaining the same core meaning.

Re 1: It is not very clear what exactly is meant by this requirement and consequently how it is to be fulfilled – apart from ensuring that the original ST is as clear and easy to understand as possible. Each language pair will undoubtedly pose its own challenges to the translator because of language system differences, cultural differences, etc., but there is nothing a pharmacist drafting the original English PIL can do about that. The only suggestion that comes to mind would be a translation guide explaining the conscious choices made in the original with lay-friendliness in mind, for example reminding the translators by means of specific examples that the active voice, personal pronouns, lay terms, etc. are deliberate choices and should not be changed back into expert register. Such a guide could be very valuable, but we doubt that this is how the requirement is interpreted and that such guides are in fact produced. Re 2: When the pharmaceutical company has produced the translations, the national medicines agencies – in Denmark, the Danish Medicines Agency – have 14 days to check the translations and report back to the EMA and the pharmaceutical company using Quality Review of Documents (QRD) Form 1 (European Medicines Agency, 2010). Again, it is not very explicitly described exactly how this check should be carried out. The national medicines agencies have to rate the overall quality of translation on a scale of Very Good, Good, Acceptable or Unacceptable, but the categories are not further defined or explained. Furthermore, according to the QRD Form 1, focus is on “Missing words or sentences”, “Scientific [sic] incorrect translations (e.g., terminology)”, “Inaccuracies (incorrect translations – including spelling, punctuation, grammatical mistakes)” and “Editorial, stylistic changes (e.g., rephrasing)”. Clearly, the main focus of these categories is on technical correctness and accuracy and not on layfriendliness. This could be very problematic as the translations are not user tested, which means that these checks by the Member States constitute the only real control mechanism that is supposed to ensure that the receivers are provided with lay-friendly texts. Re 3: This is the only direct recommendation as regards the translation process, but it remains quite vague, and it only concerns macrostrategies. The guidelines warn against “strict literal translation”; instead, translations should be “faithful”, and preserve the “core meaning” of the original thus allowing for “regional flexibility”.

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The warning against strict literal translation seems somewhat unnecessary as this kind of translation is very unusual, and it is quite selfevident that it would not be a good overall strategy when writing for laymen. The recommendation of faithful translation reflects the fact that the technical information in a PIL is crucial, but the reader (if a trained translator) may be somewhat confused by the use of the concept of “faithful” translation, which is normally contrasted with “free” translation in Translation Studies (though the two concepts are not mutually exclusive). When referring to preserving the “core meaning” and allowing for “regional flexibility”, the concept of free translation is evoked. This contrast may create confusion, and it is hard to tell from the recommendation how much flexibility is allowed in reality.

3. Medical translation and translators Medical translation is one of the oldest disciplines of translation (Fischbach, 1986, p. 16), and literature on the subject is quite extensive. However, not many empirical studies focus on the medical translator as such. Quite a few scholars, though, have discussed who should translate medical texts, and opinions diverge. Whether medical professionals or professional translators should translate medical texts is even said to be the oldest discussion in the medical translation field (Fischbach in Márquez Arroyo, 2007, p. 74). Below is a literature review of professional translators vs. pharmacists-cum-translators.

3.1. Professional translators Even though professional translators may have some medical knowledge, some argue that they are not able to perform medical translation because they are not subject-matter specialists. Translation businesses sometimes find that translators lack medical translation expertise (Andriesen, 2001, p. 5). A translator without extensive medical knowledge might have difficulties both in comprehending the ST and in re-expressing the meaning in the TT (Gile, 1986, p. 27). Professional translators, on the other hand, would be familiar with different translation techniques and instruments, which is why some scholars find that professional translators produce better translations as they master “the techniques of translation, research and documentation” (Lee-Jahnke, 2005, p. 81).

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3.2. Pharmacists-cum-translators Previous research within Translation Studies has shown that medical professionals have a tendency to translate in an uncritical and very direct way (Askehave & Zethsen, 2000b, 2002) and that some medical professionals see literal translation as the ideal way of translating (González Davies, 1998, p. 100). This may, however, result in inelegant and sometimes incomprehensible texts (Gile, 1986, p. 28). Also, some medical professionals view specialized terminology as the most important factor in medical translation. This is, for example, seen in a study carried out by González Davies in which she had medical specialists assess students’ medical translations. The specialists saw specialized terminology as being of paramount importance, whereas syntax and grammar were the least relevant points, and cohesion and coherence were considered to be of minor importance (1998, pp. 99–100). Moreover, medical professionals tend to stick closely to their expert language to ensure medical accuracy (Gal & Prigat, 2005, p. 489). Other researchers have found that medical professionals have weak writing and translation skills (O’Neill, 1998, p. 74). Of course, some researchers also say that both translator types can perform medical translation (e.g., Montalt Resurrecció & González Davies, 2007, pp. 34–35), or that preferably, the two groups should work together (Askehave & Zethsen, 2000b, p. 36). From the above, it appears that pharmacists-cum-translators may well lack the skill of maintaining or adjusting the level of formality and complexity of the PIL text, and it seems fair to hypothesize that, in relation to lay-friendliness, there may be linguistic differences between Danish PILs from pharmaceutical companies that use medical professionals and those from pharmaceutical companies that use professional translators. In spite of the many opinions (only some of which rely on empirical research), there seems to be a lack of empirical research investigating and comparing the translation products of professional translators and medical professionals, respectively, to see if any differences are found.

4. Study design A contrastive corpus of 54 English EU PILs and their Danish translations was compiled to investigate the differences in the translation products of the two types of translator. The corpus consists of PILs from pharmaceutical companies using pharmacists as translators (n = 27) and from pharmaceutical companies using trained translators (n = 27). The corpus selection, analysis framework and analysis procedure are further described below.

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4.1. PIL corpus Based on investigative findings that identified who the majority of Danish PIL translators are (Nisbeth Jensen, forthcoming), it was possible to source PILs from each contacted company and match these PILs with a translator type. All language versions of EU PILs that have been authorized through the centralized procedure are freely available on the EMA website (http://www.ema.europa.eu/). These PILs have all been through the EMA’s strict authorization process including being subjected to the same legal requirements and time constraints, and using these authentic PILs ensures ecological validity. Furthermore, these PILs are meant to live up to the requirements of producing a clear and understandable text that enables its users to act appropriately.

4.1.1. Corpus selection Some pharmaceutical companies stated that they sometimes used translators and sometimes pharmacists. However, to avoid blurring translator categories, only pharmaceutical companies exclusively relying on either translators or medical professionals were included in the corpus. Furthermore, identical double PILs (i.e., PILs for similar drugs where two or more PILs were identical, and thus not new translations) and PILs reserved for use by health professionals were excluded. PILs intended for initial use by a health professional, but potentially for later selfadministration, were included as such PILs would be the only source of information for patients when they were at home, and, for example, needed to inject themselves. These criteria left a sample of 27 PILs translated by translators. When the potential corpus of PILs translated by medical professionals was subjected to the same criteria, a potential corpus of 76 resulted. It was not possible to match the two corpora based on medicine type as the medicines encompassed too many different diseases and conditions. The 27 PILs translated by translators were spread over seven pharmaceutical companies, as were the PILs translated by pharmacists. The pharmaceutical companies that used only translators had a number of PILs ranging from one to five (1, 3, 4, 4, 5, 5, 5) whereas the number from the seven pharmaceutical companies using pharmacists-cum-translators ranged from three to 27 (3, 5, 8, 9, 11, 13, 27). In order for the two corpora to be as similar and comparable as possible, with PILs from all seven companies, a spread was chosen for the medical professional corpus similar to that of the translator corpus but proportionate to the number of PILs each company had (2, 3, 4, 4, 4, 5, 5). The random sampling function in Excel was used for the actual choice of pharmacist PILs.

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4.2. Analytical framework To be able to assess whether any differences exist between the translation products from pharmaceutical companies that use translators and pharmacists, respectively, and to gain insight into the nature of potential differences, an analytical framework was necessary. For the purpose of this article, two elements have been selected for analysis: an example of the medical register used in PILs – the use of Latin-Greek terms, as well as a feature of specialised register in general – the use of nominalization.

4.2.1. Latin-Greek terms Because a PIL is an expert-to-lay genre, the use of medical register should be limited to elements that the lay receiver will understand. Latin-Greek (LG) terms are one of the most frequently quoted elements hampering layfriendliness, both in English and in Danish, one reason being that patients may misunderstand terms that medical experts consider to be “common” (Thompson & Pledger, 1993), indicating a gap between what experts would perceive as common terminology and what laypeople would (Dahm, forthcoming; Hadlow & Pitts, 1991; Jucks & Bromme, 2007). The use of LG terms in Danish is even more problematic than in English because of the linguistic differences in usage between English and Danish (Pilegaard, 1997; Zethsen, 2004). LG terms are much more widespread in everyday discourse in English than in Danish as Zethsen points out: “In contrast to English, Scandinavians still mostly use native, simple and immediately understandable words [...] when talking about a medical subject in a non-expert context” (Zethsen, 2004, p. 134). When LG terms are transferred from English into Danish, the complexity level is thereby drastically raised. It is therefore possible for a translator to make a text more or less lay-friendly depending on her/his choice of terminology.

4.2.1.1. Analysis of LG terms The analysis of this category was not as straightforward as distinguishing between “LG term transferred” and “LG term deleted or replaced”. For example, the LG term may or may not have an equivalent in Danish lay register, or sometimes the translator might choose to use both the Danish lay term and an LG term. Therefore, two main categories were elaborated, that is, “LG terms – lay-friendly option” and “LG terms – non-lay-friendly option”. The category “LG terms – lay-friendly option” includes translation procedures where:

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(1) the translator has used a Danish lay term instead of the expert LG term as in: ST: injection TT: indsprøjtning Explanation: The translator could have chosen the term “injektion”, but this term belongs to Danish expert register. (2) the translator has changed the order, that is, s/he gives the Danish term first followed by the original LG term in parentheses as in: ST: if you are taking diuretics (a type of medicine also called “water tablets” which increases the amount of urine you produce) TT: hvis du tager en type medicin, som kaldes vanddrivende tabletter (diuretika). Disse forhøjer den mængde urin, du producerer or (3) the translator has added a Danish lay explanation or lay term to a LG term as in: ST: purpura TT: purpura (spontan blødning i hud og slimhinder) Explanation: purpura (spontaneous bleeding in skin and mucous membranes) The category “LG terms – non-lay-friendly option” includes translation procedures where: (1) the translator has transferred an LG term (without further explanation) in cases where no single Danish word exists in lay register as in: ST: polycystic ovarian syndrome (PCOS) TT: polycystisk ovariesyndrom (PCOS) Explanation: the syndrome PCOS does not have a name in lay Danish, but it will be more difficult to understand for a Danish layperson, because the term “ovary/ovarie” is not used in lay Danish; instead, the lay term is “æggestok” [egg stalk]. (2) the translator has transferred an LG term and lay word or explanation without any changes (such as deleting the LG term) as in: ST: XX may also be given directly into a vein (intravenously) TT: XX kan også indgives direkte i en vene (intravenøst) Explanation: In lay Danish, the term “intravenously” is not used; therefore, the fact that the term has been maintained is likely to hamper lay understanding. Moreover, the lay reader does not necessarily know that “intravenously” is an explanation of “in a vein”. It could be interpreted as further information.

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(3) the translator has transferred an LG term even though a lay alternative exists in Danish register as in: ST: XX is recommended for women who have had their menopause TT: XX anbefales til kvinder efter menopausen. Explanation: In lay Danish, the term “menopause” is not used, but instead the term “overgangsalderen” [transition age]. (4) the translator has introduced an LG term even though a lay alternative exists in Danish register as in: ST: It works by making the blood clot at the site of bleeding TT: Det virker ved at få blodet til at koagulere på det sted Explanation: In the Danish translation, the expert term “koagulere” (coagulate) is used; the natural choice would have been the lay term “størkne”, which means “clot”.

4.2.2. Nominalization The use of specialized terminology is often quoted as one of the main reasons why medical texts are difficult for laypeople to understand (Bromme, Jucks, & Wagner, 2005; MHRA, 2005). However, a text can also be translated in a more or less lay-friendly manner at clause level. One of the most quoted elements said to cause difficulty at clause level is the use of nominalizations. In an experimental study, Coleman (1964, p. 186) found that transforming nominalizations using active verbs makes a text easier to comprehend than their nominalized counterparts. The fact that nominalizations may cause problems for laypeople is supported by many other scholars and several reasons have been addressed (Askehave & Zethsen, 2000a; Charrow, 1988; Schriver, Cheek, & Mercer, 2010). First of all, nominalizations make a text impersonal (Charrow, 1988, p. 98). Also, texts including nominalizations are more compact, harder to read and more abstract (Becker Jensen, 2007, p. 53). Halliday (1994) argues that nominalization makes a text difficult for laypeople to understand: This kind of nominalizing metaphor probably evolved first in scientific and technical registers, where it played a dual role: it made it possible on the one hand to construct hierarchies of technical terms, and on the other hand to develop an argument step by step, using complex passages ‘packaged’ in nominal form … [T]he writer presumably knows exactly what it means; but the reader may not, and so this kind of highly metaphorical discourse tends to mark off the expert from those who are uninitiated. (p. 353)

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For the analysis, nominalizations were coded both in instances where a nominalization was introduced or split up. An example of an introduction of a nominalization in the corpus (i.e., non-lay-friendly option) is: ST: To stimulate growth TT: Til stimulering af vækst Explanation: For the stimulation of growth An example of a nominalization being split up (i.e., lay-friendly option) is: ST: Some patients… experienced the development of heart failure TT: Nogle patienter... udviklede hjertesvigt Explanation: Some patients…developed heart failure

4.3. Qualitative analysis procedure The 54 PILs were coded using the qualitative analysis software Nvivo (2011) by one researcher. The researcher did not know to which company and translator group each PIL belonged. As some sections of every PIL are based on a template, the first part, for example, saying “Read all of this leaflet carefully before you start using this medicine”, only non-template sections were analysed as only in these sections would the translators have some freedom of choice. Each translated PIL was compared with the English ST PIL, and each lay-friendly element and non-lay-friendly element coded. This procedure was repeated twice for each PIL. Lastly, all codes were checked for consistency.

4.4. Quantitative analysis For each PIL, the rate per 100 words for each linguistic feature was calculated based on the TT word count. The two groups were then compared using an independent samples t-test to test whether significant differences exist in relation to the use of LG terms and nominalizations. A p-value of If one of the speakers signals his or her distrust towards the interpreter; e.g. because of ethnicity. How may this drain the interpreter’s energy? Any examples? mSora1-18:25 > one thing I have noticed is that some people [i.e., professionals, e.g., medical personnel] regard the interpreter as the client’s representative. They even use the word dere [i.e., the Norwegian ‘you (plural) pronoun’ to refer to the interpreter and client/patient collectively].

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The assignment of the interpreter to the position of the Other is manifested here by the fact that some professionals even address the minority language–speaking party and the interpreter with the joint plural form of the pronoun ‘you’ (Norwegian dere). In sum, the patients’ Otherness emanating from their culture is frequently foregrounded in identifying the source of a perceived communication problem. This finding is in line with the tendency in Kale’s study, in which 55% of the respondents wanted the interpreter’s task to be extended to cultural mediation (Kale, 2006, pp. 31–32; see Kale, Ahlberg, & Duckert, 2010, p. 820). Moreover, medical personnel frequently expressed the need to learn more about foreign cultures in order to regain control (Kale, 2006, pp. 31–32; see Kale, Ahlberg, & Duckert, 2010, p. 820). The constructions above predominantly represent institutional discourse as a meeting between a Norwegian individual (the Self) and a foreign culture (the Other). This construction of the “problem source” consequently influences how medical personnel perceive the interpreter’s role. Construction in this sense pertains to Potter’s view of reiterating a certain image by recurrently naming, talking, and writing about a certain phenomenon in a certain way, as defined in the Introduction. In the below discussion we see ‘othering’ as a consequence of a particular use of the concept ‘culture’. Within this construction, the interpreter, being assigned membership in the Other culture, is assumed to be an excellent source of information about the Other. (In fact, this perspective is so deeply rooted that the possibility of the interpreter being of Norwegian ethnicity is never mentioned.) Accordingly, the solution to the problem of communication is to place the interpreter in the role of a cultural oracle. In the next subsection we analyze the concept ‘culture’ with the aim to explore where this strategy may lead. Hence, we first outline difficulties with defining the concept. Then, we go on to identify problems with using ‘culture’ in an explanatory function and illustrate that these are caused by culture’s intersection with language, individual and group.

4. Discussion Culture is recurrently used as a self-explanatory concept in our data. Moreover, in literature on linguistics and interpreting, language and culture are often mentioned in the same breath. However, how does one define culture? The answer is that there is no universal definition for the concept of culture, the Norwegian anthropologist Unni Wikan (2002, p. 80) holds. She points to counts showing that anthropologists had already come up with 156 different definitions of the concept by 1954. The multitude of definitions is also pointed to by the linguist Ingrid Piller who describes culture as “an ideological construct called into play by social actors to produce and reproduce social categories and boundaries” (Piller, 2011, p.

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16). The concept of culture is best portrayed by its complexity. Scollon and Scollon (2001, p. 109) dismiss the concept culture as an explanatory tool, and in terms of cultural practice replace it by the term discourse systems, i.e., human behavior as manifested in the interplay between forms of discourse, face, 6 ideology, and socialization. The relationship between linguistic utterances and their context is a recurrent topic in linguistics, and one that has gained ground in the past decades through a dialogical approach to language in which context and interactivity are considered “resources in the meaning-making process” (Linell, 2009, p. 17). This development is due to the recognition that linguistic meaning is intrinsically connected to its context. Before continuing, it is worth noting that the overlap between language and culture is partial in that “certain aspects of language are reasonably considered noncultural [e.g., our articulatory ability], and certain aspects of culture are non-linguistic [e.g., proximity patterns]” (Langacker, 1994, p. 31). In terms of interpreting, our primary interest lies in aspects of the two phenomena that overlap. The boundary between language, culture, and individual is not an easy one to draw, for more than one reason. The linguist Ronald W. Langacker (1994) describes the relation between language and culture as dependent on language’s social nature—a convention or “deal” between the members of a linguistic community: . . . the strongest dependency of language on culture is the fact that language is itself a cultural entity, at least to the extent that linguistic structures are conventional and acquired through social interaction. (Langacker, 1994, p. 31) Langacker (1994, p. 26) simultaneously sees language and culture as partly overlapping with the individual’s cognition. However, language and culture are not psychological phenomena, he stresses, because the specific meaning of a linguistic utterance comes into existence in a specific context, as part of a convention that is being constantly renegotiated. Early definitions of culture frequently emphasized culture as something that was shared and transferred between generations (Piller, 2011; Wikan, 2002). Today most anthropologists agree that culture refers to a sum of knowledge and experiences that have been acquired in a community, and are therefore not innate (Wikan, 2002, p. 80, p. 87). The reason anthropologists stopped enhancing the previously emphasized criterion of “sharedness” is tied to difficulties with determining the size of the community that share a belief, value, or habit: What would it mean if we said that there must be agreement in a population on knowledge and values for a culture to count as such? The question would logically be: Among how many people? A

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thousand? A hundred? Ten? Two? The question is unanswerable. Rather, as Strauss and Quinn (1994) have argued, “culture” comprises all knowledge and experience embraced by a group or collectivity of people. (Wikan, 2002, p. 80) 7 A primary problem linked to the concept of culture has to do with the fact that each individual has access to a multitude of cultures, based on generation, gender, profession, region, religion, and other forms of “communities” (Scollon & Scollon, 2001, p. 3). In our day and time, such multitude even includes virtual reality. This aspect was displayed in the Norwegian media after the terror attacks in Oslo in 2011 (VG, 2 Dec. 2011, pp. 12–15) in a way that serves to illustrate the point made by Scollon and Scollon, as well as the relationship between individual and linguistic convention. In their evaluation of the terrorist’s mental state, the first two psychiatrists assigned to the case concluded that the man was psychotic. According to media reports, one of the symptoms on which they based the diagnosis was what they regarded as his extended use of neologisms. What the two renowned psychiatrists did not know, however, was that the concepts they classified as neologisms (e.g., Justicar Knight, National Darwinism) are conventionalized concepts in the virtual world of war games such as Warhammer and World of Warcraft. Hence, the terms he used were conventionalized linguistic currency in communities to which the terrorist was attached, and not his individually coined neologisms. The “nestedness” of culture just illustrated implies that each individual is embedded in a multitude of partly overlapping “communities” or discourse systems, much like the contents of a Russian matryoshka doll (to use a somewhat simplified metaphor). This “nested” nature of the phenomenon ‘culture’ makes it a poor explanatory tool, be it for the interpreter or the medical professional. In an explanatory function, therefore, “the word ‘culture’ often brings up more problems than it solves,” as stressed by Scollon and Scollon (2001, p. 138). The next problem with the concept relates to the recognition pointed out by Langacker (1994, p. 26) that all aspects of language and culture are not represented in each individual’s cognition; it is simply impossible for the individual to account for all the nuances in a language or culture (as illustrated by the psychiatrists in the terrorist evaluation). Although it must still be assumed that individuals have some sort of cognitive representation of linguistic and cultural units (this is, after all, what enables us to negotiate), we have no guarantee the representations are identical in two individuals (Langacker, 1994, p. 26). The next excerpt from the interpreting students’ chat discussion on the Moslem concept mahram, serves to illustrate the lack of a guarantee that our representations are identical, even though we tap into the same linguistic or cultural convention:

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(8)

(m = male, f = female, Pers = Persian, Sora = Sorani, Viet = Vietnamese, Mand = Mandarin, Fren = French, Urdu = Urdu followed by the time posting) mSora1-20:28 > it’s not only Moslems who wish to have a female doctor, there are many NORWEGIAN women who want a female doctor fUrdu1-20:29 > A Moslem woman is reluctant to shake hands because it is forbidden to have body contact with other men than those closest to them, something which is difficult to understand for Norwegians. mPers1-20:29 > How many percent of doctors in all Moslem countries are women? mSora1-20:31 > There are very few women doctors in the Islamic countries mSora2-20:31 > if you are really sick you cannot wait to get a woman doctor mSora3-20:31 > But it’s not only doctors they refuse to see, it also concerns the use of male interpreters. mPers1-20:33 > According to Islam a doctor is mahram. mViet1-20:34 > What is mahram? fUrdu1-20:35 > a male doctor cannot be mahram, can he? mPers2-20:36 > if what mPers1 says is true, then it is not such a big deal whether the doctor is male or female. fMand1-20:37 > what does the concept Mahram mean? mSora1-20:40 > Mahram? Many different people can be mahram to a woman, but they feel ashamed to talk about certain things. Hence it has to do with Shame. mFren1-20:41 > hey, you really have to explain mahram!!!! fUrdu1-20:41 > a woman’s brother, father, husband, and son are Mahram. mPers1-20:41 > plus doctor. mSora2-20:42 > Agree with mPers1

The French, Mandarin, and Vietnamese students clearly signal their “nonmembership” in the part of the cultural convention embracing mahram. The students debating the concept’s content and ascribing different values to it, all share experiences from a Moslem world (Iran, Iraq, and Pakistan), however. They reveal their differing conceptualizations of mahram despite their common Moslem background. Being an excerpt from a discussion among interpreting students, the example thus serves as a reminder that the interpreter is an individual that does not share all frames of reference with the interlocutors he is serving. This is of course also true with regard to the professional interlocutor, the GP or nurse, who belongs to a professional

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culture with specific terminology that the interpreter may be unfamiliar with. As pointed out by Langacker (1994, p. 31), professional conventions typically illustrate that certain cultural conceptualizations are created and maintained by the linguistic expressions that represent them. If responsibility for explicating terminology in contact with patients does not remain with the medical professional, but is left to the interpreter, miscommunication may arise. A final problem with the concept of culture is linked to its ability to cover up the fact that “cultures do not meet, individuals do” (cf. Wikan, 2002, p. 83; cf. Scollon & Scollon, 2001, p. 138). Herein lies the concept’s stereotyping force and its link to the phenomenon of ‘othering’ as defined above. This effect is expressed in the chat posting from the Amharic student in (9). The posting opposes an other student’s claim that the interpreter should act as a cultural mediator or advocate, and explains what may be the negative consequences of such an extended interpreter function: the individual as “a wonderful human being” may be lost behind the “exterior” of culture: (9)

(m = male, Amha = Amharic, followed by the time of posting) mAmha1-19:43 > The individual hiding behind the foreign culture may be a wonderful human being who could make himself understood against all odds, if he or she were given the chance to do so. Here, in my opinion, a good interpretation will reduce prejudice. Moderator2-19:45 > And how may interpreting help the individual be seen? mAmha1-19:47 > The professional party in the dialogue will be unable to simply sit and think about the exterior that often contributes to prejudice, but has to listen to the individual in front of him as well. In this situation, the interpreter may contribute to cultural understanding by giving a correct rendition.

In the process of ‘othering’, minority patients become a large but excluded group of people categorized as non-Norwegians through the constructions of culture. The approach suggested by the student in (9) offers an alternative to ‘othering’. The student expresses the idea that the interpreter’s function should be restricted to relaying and coordinating the interlocutors’ talk in order for the two individuals–doctor and patient–to meet. This is in line with an approach where the interpreter’s and the medical professional’s areas of expertise are clearly distinguished. Thus, the medical professional is forced to focus on the individual patient and cannot hand over control to the interpreter (Skaaden & Felberg, 2011).

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5. Concluding remarks This article has illustrated how medical professionals waive their responsibility over institutional dialogue when facing a language barrier. Frequently, this is done by placing the problem source within the patient’s culture. When the difference between Us and the Other is recurrently emphasized, potential is created to ascribe the source of a problem to attributes of the Other; thus, ‘othering’ the minority patient. The construction of “their culture” as the problem source makes it possible to disclaim one’s own responsibility for problem-solving. Such a strategy is at odds with medical personnel’s area of responsibility as constructed in the legal documents cited in 3.1. The legal documents maintain an understanding of knowledge mediation as an interactive enterprise, but clearly draw a line between the medical professional’s and interpreter’s areas of responsibility. Because the medical professionals identify the interpreter as part of the Other, problem-solving is left to this individual as an encyclopedic agent of ‘culture’. Our deconstruction of the concept of culture displays this solution’s shortcomings. As illustrated, such a strategy may more often conceal than reveal the core problem. Moreover, due to the constant interplay between the individual’s cognition, the context and language, the interpreter—an individual—is in essence a problematic mediator of cultures. An alternative construction would be to refrain from using culture as an overall explanatory tool and reframe the assignment of the problem source. Communication via an interpreter is a complex and challenging endeavor. However, some elements of the communication process can be influenced and controlled in order to lower the risk of misunderstanding. An alternative strategy is to maintain the boundary between the interpreter’s and medical professional’s areas of expertise. Another strategy would be to address aspects of the medical culture and constructions more explicitly; for example, through explicitness in imparting information and explaining terminology, expectations of patient-therapist relations, parenting, shame and taboos, gender, and so on. Downplaying “their culture” as the main explanatory tool for perceived barriers in patient-doctor relations will force medical professionals to regain control over institutional discourse and address the individual patient directly. By leaving control with the (sometimes untrained) interpreter, the medical professional stands the risk of malpractice. In the long run, such a strategy may not only be a threat to minority patients’ health, but may also jeopardize medical personnel’s own professional integrity and status.

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Kale, E. (2006). ‘Vi tar det vi har’ Om bruk av tolk i helsevesenet i Oslo. NAKMIs skriftserie om minoriteter og helse. Oslo: NAKMI. 2/2006. Kale, E., Ahlberg N., & Duckert, H. (2010). Hvordan håndterer helsepersonell språklige barrierer?: En undersøkelse av tolkebruk i helsevesenet. Tidsskrift for Norsk Psykologforening, 47(9), 818–823. Langacker, R. W. (1994). Culture, cognition, and grammar. In M. Pütz. (Ed.), Language contact and language conflict (pp. 25–55). Amsterdam: John Benjamins. Linell, P. (2009). Rethinking language, mind, and world dialogically: Interactional and contextual theories of human sense-making. Charlotte, NC: Information Age. Maccallum, E. J. (2002). Othering and psychiatric nursing. Journal of Psychiatric and Mental Health Nursing, 9, 87–94. Merlini, R. (2009). Interpreters in emergency wards: An empirical study of doctorinterpreter-patient interaction. In R. De Pedro Ricoy, S. Perez, & C. W. L. Wilson. (Eds.), Interpreting and translating in public service settings: Policy, practice, pedagogy (pp. 89–115). Manchester: St Jerome. Meyer, B. (2001). How untrained interpreters handle medical terms. In I. Mason (Ed.), Triadic exchanges: Studies in dialogue interpreting (pp. 87–107). Manchester: St Jerome. Mikkelson, H. (1996). Community interpreting: An emerging profession. Interpreting, 1(1), 125–129. Piller, I. (2011). Intercultural communication: A critical introduction. Edinburgh: Edinburgh University Press. Potter, J. (1996). Representing reality: Discourse, rhetoric and social construction. London: Sage. Pöchhacker, F. (1997). Kommunikation mit Nichtdeutschsprachigen in Wiener Gesundheits- und Sozialeinrichtungen (Part 2). Vienna: Gesundheitswesen der Stadt Wien. Pöchhacker, F. (2004). Introducing interpreting studies. London: Routledge. Pöchhacker, F. (2008). Interpreting as mediation. In C. Valero-Garcés & A. Martin (Eds), Crossing borders in community interpreting: Definitions and dilemmas (pp. 9–27). Amsterdam: John Benjamins. Rudvin, M. (2006). Negotiating linguistic and cultural identities in interpreter-mediated communication for public health services. In A. Pym, M. Shlesinger, & Z. Jettmarová (Eds.), Sociocultural aspects of translating and interpreting (pp. 173–190). Amsterdam: John Benjamins. Rudvin, M., & Tomassini, E. (2008). Migration, ideology and the interpreter-mediator: The role of the language mediator in educational and medical settings in Italy. In C. Valero-Garcés & A. Martin (Eds), Crossing borders in community interpreting: Definitions and dilemmas (pp. 245–267). Amsterdam: John Benjamins. Scollon, R., & Scollon, S. B. K. (2001). Intercultural communication: A discourse approach. Malden, MA: Blackwell. Skaaden, H. (2003). On the bilingual screening of interpreter applicants. In Á. ColladosAís, M. M. F. Sánchez, & D. Gile (Eds.), La evaluación de la calidad en interpretación: Investigación (pp. 73–85). Granada: Interlingua.

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Skaaden, H. (2007, April). Public sector interpreting: A case for the constitutional state. Paper presented at Critical Link 5. Sydney. Skaaden, H. (2010). Tolken: Håndverker eller tusenkunstner? In S. Dillevig et al.(Eds.), Nettopp norsk. Bok og nett i ett. Studieforberedende utdanningsprogram (pp. 470–473). Oslo: Aschehoug. Skaaden, H., Felberg, T. R. (2011). Språkbarrierer og profesjonell integritet i psykologers virke [ Language barriers and professional integrity in psychologists’ practice]. Tidskrift for Norsk Psykologforening, 48, 535–537. Skaaden, H., & Wattne, M. (2009). Teaching interpreting in cyber-space: The answer to all our prayers? In R. De Pedro Ricoy, A. Perez, & C. W. L. Wilson (Eds.), Interpreting and translating in public service settings: Policy, practice, pedagogy (pp. 74–89). Manchester: St Jerome. Valero-Garcés, C., & Martin, A. (2008). Crossing borders in community interpreting: Definitions and dilemmas. Amsterdam: John Benjamins. Wadensjö, C. (1998). Kontakt genom tolk. Stockholm: Dialogos. Wikan, U. (2002). Generous betrayal: Politics of culture in the new Europe. Chicago: University of Chicago Press. Woloshin, S. et al. (1995). Language barriers in medicine in the United States. JAMA, 273(9), 724–728.

_____________________________

1

The survey directed at fastleger (i.e., GPs with appointed patients) was carried out by IMDi in cooperation with the research organization Synovate MMI and the Norwegian Directorate of Health. The aim was to map the availability of interpreting services, as well as the GPs’ attitudes and routines when facing language barriers. The questionnaire was compiled by Hanne Skaaden in cooperation with coworkers at IMDi and Håkon Kavli of Synovate MMI. The statistical analysis was handled by Synovate MMI. Norway’s 3,872 GPs were mailed via channels of The Norwegian Directorate of Health and offered NOK 500 to respond. The response rate was 42% (n = 1,596), thus, statistically representative for the population of GPs as a whole.

2

There is a growing body of literature on the interpreter’s role in the medical setting in particular (e.g., Angelelli 2004b, 2008, Valero-Garcés and Martin 2008). Here we do not engage in this line of discussion, however. From our vantage point, the medical setting is part of the wider public sector setting (see Mikkelson, 1996, p. 126), and we define the interpreter’s function in the public sector setting accordingly (see above and Jahr et al., 2005, Skaaden, 2003, 2007). For discussions of an expanded interpreter function, see for example Angelelli, 2004a; Fox and Avigad, 2007; Galal and Galal, 1999; Jareg and Pettersen, 2006; Pöchhacker, 2008; Rudvin & Tomassini, 2008.

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3

The program will be freely available at www.tolkeportalen.no at the end of 2012.

4

See the Health Personnel Act (Lov om helsepersonell) and the Specialist Health Services Act (Lov om spesialisthelsetjenester) at www.lovdata.no.

5

The excerpts from the chat discussions are translated from Norwegian, and the translations mirror that Norwegian is the students’ L2.

6

The concept face is widely employed in sociolinguistics and discourse analysis, as defined by Scollon and Scollon (2001, p. 45) in the following way: “Face is the negotiated public image, mutually granted each other by participants in a communicative event.”

7

This definition is much in line with that of the philosopher Alain Finkielkraut (1997, p. xv): culture, according to him, “consists of that which expresses the life of a people, group or collectivity, but which escapes the limits of collective being.”

Medical terminology circulation and interactional organisation in interpreter-mediated medical encounters

Sara Pittarello University of Trieste

Two medical encounters taking place in a Northern Italian hospital are analysed in this paper from a qualitative point of view, based on the author’s previous research. The aim is to reveal the strategies adopted by medical interpreters, in these two specific cases, to translate medical terminology and promote/exclude interlocutors’ active participation. This latter aspect is influenced by the way the interaction is socially and linguistically organised and, in particular, by how interlocutors’ utterances are translated. The prevalence of dyadic or triadic sequences and especially the shifts between such communication exchanges are pivotal in fostering or hindering interlocutors’ participation. Furthermore, medical interactions, as a form of institutional talk, enshrine specific expectations, which are mainly of a cognitive nature but may also be affective, as in the two encounters observed. By conveying such expectations and expressions of personal interest, interpreters have proved to contribute to the fair distribution of active participation among primary interlocutors. Hospital ethical approval and subjects’ written informed consent have been obtained.

1. Introduction This study aims to illustrate the strategies adopted by interpreters in medical settings to convey medical terminology and to promote or, alternatively, exclude the interlocutors’ active participation in the encounter. For these purposes, two mediated encounters are here examined from a qualitative point of view. Attention will be first paid to how medical terminology circulates in the consultation (Bersani-Berselli, 2009a, 2009b), by also exploring the doctors’ use of medical terms and, second, to how the mediated interaction is organised in terms of turn-taking, sequences and communication exchanges, as well as shifts between such exchanges (Baraldi, 2009a, 2009b). The specific interactional organisation namely promotes, or else excludes, the participation of primary interlocutors in the encounter. In the author’s mind, such investigation is quite timely in view of the few in-depth studies on discursive interactions, able to show the contribution of all participants to the encounter’s success or failure. The analysis will start from observations on the dialogic process and the relationships between interlocutors during medical consultations. In this

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respect, the linguistic analysis of transcribed interactions, as proposed hereafter, is crucial to detect structures of discursive behaviours.

2. Different linguistic varieties at play during medical encounters An issue to which great attention has been devoted by researchers is the use of specialist terminology in mediated medical encounters. As stated in the introduction, its circulation in healthcare settings is one of the two underlying threads of this paper too. According to Bersani-Berselli (2009a, 2009b), a sort of “non professional” variety of medical language coexists with the “professional” one. It derives from the extension of common language to include medical terms and phrases. The analysis of a sample of medical consultations revealed that doctors mainly resort to the “professional” variety when addressing other professionals directly, when writing/reading medical reports or in the treatment phase. In such cases, the doctor is addressing a peer who shares the same technical knowledge. No further explanation is therefore needed. On the other hand, the large sample of data collected—approximately 100 consultations—(Bersani-Berselli, 2009a, pp. 462–463), indicates that healthcare staff, in most of cases, adopt a “non professional” linguistic variety and avoid technical terminology when their utterances are to be conveyed to patients and hence when addressing the interpreter, in order to minimise the risk of communication failure. This happens for example during the complaint, the examination and the treatment phases, as confirmed by the excerpts reported hereafter. The author observed that shifts from this identified pattern may occur on certain—limited—occasions (Bersani-Berselli, 2009a, p. 466). For example, hedges may be introduced, especially in the form of diminutives, as is the case in the first encounter. This results in a significant lowering of the linguistic register. Such shifts may signal the healthcare staff’s attempt to maintain control of the conversation, which is the case, according to Bersani-Berselli (2009b, pp. 166–167), when they perceive that their “leadership” has been undermined by the presence of interpreters or by patients. Notably, out of the six phases identified by ten Have (1989, p. 118)—opening, complaint, examination or test, diagnosis, treatment or advice, and closing—technical jargon is used more frequently during diagnosis and treatment. It is almost absent, on the other hand, during complaint and verbal and/or physical examination so as not to hinder or stop the information flow and to avoid misunderstandings (Bersani-Berselli, 2009b, p. 155), as confirmed by the cases examined below. An explanation might be that the patient is only the “immediate” addressee in diagnosis and treatment, whereas the true addressees are, indirectly, other professionals. It is worth noting that the way interpreters translate medical terminology, which tends to respect the tenets illustrated above, might

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depend on several intertwining factors, as evidenced in the following consultations. This justifies the need to analyse real interpreting sessions in the medical field, so as to evaluate interpreters’ strategies and investigate the underlying reasons which might have caused them.

3. Promotion/exclusion of interlocutors’ active participation The second issue of this paper, that is, interactional organisation and, consequently, implicit or explicit strategies adopted by medical interpreters to favour/hinder interlocutors’ active participation, is here discussed on the basis of Baraldi’s research (2009a, 2009b). Baraldi notices a direct link between the way utterances are translated by interpreters and the distribution of participation among interlocutors. He observes that any mediated interaction is characterised by a rather complex social and linguistic structure. With reference to the social organisation of the interaction, this is to be understood as a communication system based on adjacency pairs and enabling interlocutors to act. From a linguistic point of view, since any mediation/mediated interaction involves two languages, it comprises both dyadic (monolingual) and triadic (bilingual interpretermediated) exchanges (Valero Garcés, 2007, p. 35). The latter ensure coordination among interlocutors speaking different languages. In mediated interactions, moreover, interpreters frequently shift between dyadic and triadic exchanges. This leads to a specific “structure” or form of translation (hereon referred to as “translation structure”), that is, a specific organisation of interactive sequences, which affects interlocutors’ participation. The interpreter’s translation may thus foster/hinder interlocutors’ participation. In this specific context, as already proposed in previous paragraphs, the term “mediation” consequently refers to the process enabling interlocutors to take part in the interaction. It is in itself a form of interaction and communication system, which is required when the understanding is hindered by linguistic and cultural barriers, among others. The mediation process, moreover, is to be viewed as part of the wider system of the institution where it occurs, that is, the hospital/healthcare centre (Baraldi, 2009b, p. 48). In institutional—and hence in medical— settings, interactions which took place at different times are frequently connected, since a doctor may refer to something which was already stated in a previous medical consultation or to previous actions. (Mediated) medical interactions, like all kinds of lay-professional encounters, belong to institutional talk, as they embody its three basic features: specific goal orientations, linked to the institution-relevant identities; special organisational constraints; and institutionally-specific interpretative frameworks for the interaction (Heritage, 2005, p. 106). Since doctor-patient interactions are goal-oriented, interlocutors understand the meaning of actions performed and words uttered by referring to the

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institutional tasks or ultimate objectives of the interaction itself (e.g., to cure and treat patients). This understanding is based on expectations on the nature of the event and participants’ roles in it. In the case of medical consultations, for example when advice is provided to patients, cognitive expectations seem to prevail (Baraldi, 2009b, p. 53). These are based on observations about how things work and what is going or not going to happen: the doctor will for example expect the patient to have a chief complaint. Baraldi observed that in mediated medical encounters, practitioners tend to entrust interpreters the task of reporting to patients the instructions they generated. This is based on the expectation that by doing so the patient will more likely accept the treatment requirements, as evidenced by the analysis of real interpreting sessions (Baraldi, 2009b, p. 53). In medical contexts, interpreters are called on to report the healthcare staff’s utterances so that patients adhere to doctor’s recommendations/prescriptions. If in the everyday practice interpreters tend to align themselves to the doctor’s point of view, on certain occasions, however, they might give voice to the “personal expression (or self-expression)” of patients (Baraldi, 2009a, p. 8, italics in the original), which reveals the presence of affective expectations. These reflect the self-expression of participants, whose personal views are encouraged or accepted within the interaction. Despite being rather rare in medical consultations, affective expectations might be formed as well, as evidenced in the two cases below. Real practice also demonstrates that when doctors express their personal interest or appreciations of participants’ experience, interpreters may either omit to convey these expressions to patients and respond directly to doctors, or they may report such information to patients and vice versa (Baraldi & Gavioli, 2007). A failure to translate interlocutors’ personal expressions causes distance between doctor and patient. Interpreters play a crucial role in this respect, since they may facilitate or else inhibit participants’ personal expressions. By conveying them, they contribute to the fair distribution of active participation, addressing interlocutors’ interests and needs. Accordingly, medical interpreters may promote cultural adaptation to the institutional setting, that is, acceptance of explanations/instructions provided within the hospital system, and exclude patients from actively participating in the interaction. Conversely, they may enable all interlocutors to be involved in the encounter, by intervening and expressing their voices (Baraldi, 2009b, pp. 59–73). Specific patterns of expectations and turn-taking sequences are consequently implied (Baraldi, 2009a, pp. 11 and 13). The shifts between sequences and communication exchanges (Baraldi, 2009b, pp. 72–73), and hence between different “translation structures”, reflect the promotion/exclusion of interlocutors’ participation. Some general trends can be summarised in this respect, which will be

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useful in the analysis of the two encounters below: 1) dyadic exchanges incorporating cognitive expectations are likely to hinder interlocutors’ active participation; 2) the shift from a triadic structure to a dyadic one including affective expectations creates the conditions for empowering dialogue; 3) the shift from a dyadic to a triadic exchange aims at promoting active and fair participation of primary interlocutors. Real practice shows that when a shift from a triadic to a dyadic exchange takes place and affective expectations are involved, the interpreter supports the interlocutor by resorting to different tools. 1 In mediated medical encounters, interpreters are also frequently addressed directly (dyadic exchanges), as emerges in the first encounter below, or else included in the interaction in any case, even when not receiving the speaker’s visual attention, as is the case in triadic exchanges. They consequently seem to be recognised as active participants in the encounter by primary interlocutors (i.e., healthcare staff and patients), if compared to interpreters working in other settings, who tend to be more “invisible”, as demonstrated in the author’s previous studies (Pittarello, 2009, pp. 78–79 and 104). Interpreters’ active participation in medical encounters and their shifting between different translation structures are confirmed by the following interpreting sessions. The two encounters selected are now presented against the background of the research context illustrated above, in order to exemplify the strategies adopted by interpreters to convey medical terminology and promote/exclude interlocutors’ participation.

4. Corpus features and data analysis The research further builds on the material collected in 2008 in selected health care units of a Northern Italian region (Pittarello, 2008, 2009), in line with the “case study” research method (Pöchhacker, 2002). The material comprised a questionnaire administered to 85 respondents (15 community interpreters and 60 healthcare personnel), 18 recorded interviews, the participant observation of 26 mediated encounters and the corpus-based analysis of four observed encounters. The aim, on that occasion, was to compare expectations and needs of the healthcare personnel on the medical interpreters’ role in Italy with the opinions of community interpreters who work in the field. Interpreting practices were then analysed based on results achieved. For the purposes of this paper and owing to space constraints, the analysis focuses on two out of the 26 mediated encounters which were observed in the previous study (Pittarello, 2008, 2009). These consultations were chosen as they better illustrate the two underlying issues of this paper: the circulation of medical terminology during the encounter as well as the specific organisation of the interaction, which fosters or else hinders

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interlocutors’ active participation, as explained in previous paragraphs, through the shifts between dyadic and triadic exchanges. The sessions also depict, to some extent, some key characteristics of medical talk which are worth mentioning in this context: conversational asymmetry between interlocutors, particularly evident during the verbal examination and whenever medical issues relevant to the main topic of the encounters are treated; pursuit of an external goal; and doctors’ unilateral control of the interaction, as evidenced by the information content and the turn-taking (Cambridge, 1999). The conversation, moreover, follows a pre-established pattern, corresponding to the standard phases identified by ten Have (1989). The interactions took place respectively in the Emergency Department (ED) and the Healthcare Service for Tourists (HST) 2 of a Northern Italian hospital, frequently visited by foreign tourists in summer. 3 Interpreters and doctors’ names have been replaced with fictitious initials to protect anonymity. Different doctors and interpreters were involved, thus giving an account of diverse personal attitudes and of their impact on the mediation itself. It should be noted that I2 is a trained interpreter and translator, whereas I1 has a degree in foreign languages. The following table outlines the main features, indicating place, duration and language requested as well as the interpreter (I), doctor (D) and patient/user (P/U) involved and the main reason for complaint. English and German were used as vehicular languages, since patients/users were not English or German native speakers. 4 The cases examined only aim to provide an example of the complex nature of medical mediation, without any claim of completeness. Table 1: Summary description of mediated medical encounters Department

Duration

Language

I

D

P/U

Reason for visit/ chief complaint

A ED

3’11’’

English

I1

D1

P=Swedish child U=father

Neck pain

B HST

19’32’’

German

I2

D2

P=child U=mother living in Austria

Gingival infection

4.1. Medical interactions in Emergency Departments: main features The focus on mediated encounters occurring in an ED is due to their better highlighting the need to communicate with patients immediately and effectively. EDs are namely high pressure healthcare settings, where complex interactions are involved in order to provide urgent care to patients, with whom the medical staff need to interact rapidly. These medical encounters, if compared to consultations in other departments, tend to be rather fast and dynamic. Furthermore, the immediate and emergency

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nature of such encounters justifies the frequent lack of the opening and closing phases. Due to the speed at which medical consultations take place in an ED setting, the physical and verbal examinations also tend to be performed at the same time (Merlini, 2007, pp. 439–440) and patients may have to wait before being informed about the diagnosis or being given any advice. This is due to the temporal discontinuity of interactions taking place in institutional, and hence in medical, settings. The first encounter analysed only deals with communicating diagnosis and treatment procedures to patients, since both the “complaint” and “examination or test” phases had previously occurred. The second, on the contrary, comprises almost all the six ideal phases and well depicts the influence of interactional structures on fair participation distribution. A further characteristic typical of ED encounters is the lack of doctor’s preliminary knowledge on patients’ case history. Consequently, patients are frequently questioned on their previous medical history. In the HST, interpreters also welcome patients and collect their personal data and information on symptoms. This might explain why these consultations at the HST mainly started with a dyadic exchange between the doctor and the interpreter. The latter is already familiar with the patient’s conditions and reason for complaint and thus reports the relevant information collected to the doctor. The greater autonomy enjoyed by interpreters in the HST might also be due to the relatively low case severity. Selected encounters will now be analysed separately, so as to provide real examples based on the two topics of medical terminology circulation and interactional organisation. Excerpts only refer to the most relevant turns and transcriptions are not reported integrally, owing to space constraints. 5

4.2. Encounter A: Swedish child suffering from neck pain The first encounter, embodying the typical traits of an ED medical consultation, only comprises the final phases of diagnosis, treatment/advice and brief closure. The patient is a young girl from Sweden suffering from neck pain and accompanied by her father. They are admitted to the consulting room to hear the orthopaedist’s diagnosis on the x-ray findings. With reference to the encounter’s translation structure, the prevalence of triadic exchanges is observed (lines 1 to 65 out of 91), since I1 immediately translates the primary interlocutors’ utterances. The sole exception is a dyadic sequence between the father and I1 towards the end of the encounter, triggered by the father’s request about whether booking the subsequent check-up visit with the orthopaedist is mandatory. The request is dealt with directly by the interpreter, as it regards routine administrative information (Pittarello, 2009, pp. 77–78).

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As far as medical terminology is concerned, no specific term is used. Three aspects are nevertheless worth mentioning. Firstly, the doctor prescribes a small neck brace (“collarino”) for a couple of days. Presumably, the use of the diminutive is not to be automatically interpreted, as in Bersani-Berselli (2009a, p. 466), as a doctor’s shift from the standard use of medical terminology, for him to maintain control of the conversation. The adoption of a “lower” linguistic register might be due to D1’s attempt to get closer to the interlocutor, by using a short (and affectionate) form. The patient is namely a child, who will necessarily wear a smaller neck brace. Secondly, D1 recommends paracetamol, yet this information is not immediately transmitted to the user by I1, who is keen to convey information on how long the collar needs to be worn. D1 hence repeats this advice in English (line 22) and this time the interpreter transmits the information, also adding the word “tablets”: Example (1) 22 23 24 25 26 27 28 29

D I U I U I D

30 I 31 U

okay↑ paracetamol↑ paracetamol↑┌ do you ┐have perhaps↑= └ yes ┘ =yes= =tablets= =yes= =for the- for= =anche sciroppo °(andrebbe bene lo stesso)° also syrup would be fine as well syrup syrup ((pronounced as [sairəp])) syrup (.) we have the::: we have the paracetamol

Interestingly, D1 chooses the word “paracetamol”, rather than the brand names “Tachipirina” or “Efferalgan”. The two latter are more in use in Italy, where the chemical name of the compound is less known because it is not widely used as an over-the-counter analgesic as in other, especially English-speaking, countries. This choice might be due to the doctor’s willingness to transmit information more effectively by resorting to a term which is more likely to be understood by a Swedish patient, thus showing possible awareness of the cultural background. Furthermore, owing to the interpreter’s zero rendition, D1 attempts a direct interaction with the user, by mentioning the term in English (line 22). Notably, I1 autonomously suggests administering tablets (line 26) and D1 intervenes to say that syrup is fine as well (line 29). In doing so, he demonstrates that he has understood the interpreter’s suggestion and endeavours to gain control over the turntaking, especially to play his role of expert within the encounter. The additional question posed by I1 (line 23) and her attempt to explain the use of paracetamol might be interpreted as efforts towards a better

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understanding, probably because she is not sure whether the recipient is familiar with the term, as English is not his native language. D1’s willingness to communicate directly with the user is proved by his numerous interventions in English (lines 22, 47, 60 and 62–63) and the frequent use of feedback markers—especially “okay”—signalling the need for confirmation from either the user (line 22) or the interpreter (line 39). The doctor’s behaviour, in the author’s view, proves to be contrary to Bersani-Berselli’s assumption (2009a) that it is extremely rare for doctors to address patients directly in the presence of interpreters. Bersani-Berselli observed that mediated interactions seem to be preferably composed of doctor-mediator pairs (and vice versa) and mediator-patient pairs (and vice versa) (p. 461). In this specific case (Example 2), not only does D1 address the user directly in the vehicular language (lines 60 and 62–63), but he also resorts to gestures in order to be understood. He even adopts a simplified language, devoid of any medical term, in reply to the father’s question on how he can recognise evidence of improvement in his child: Example (2) 60 D 61 U 62 D 63

=THIS is better ((slowly shaking his head from right to left)) okay (.) that is better (.) without pain (.) without pain= =with less pain (.) with less pain (.) no- not zero pain (.) three days it should be:: right

The third interesting aspect can be seen in Example (3): when D1 reports that the child might have to undergo an “x-ray” (line 39), the father asks for confirmation by using the word “tomography” (line 44) and I1 will afterwards align with his linguistic choice (line 52 versus line 41). The term tomography—an advanced form of imaging—is more specific if compared to “x-ray” and less widely used by laymen, at least in Italy. Notably, the observer has no further hints to whether the child has undergone a “simple” x-ray or a (computed/x-ray) tomography. It seems nevertheless that by choosing a more specific and technical term rather than its hyperonym, the father shows good command of the medical language relevant to this specific case. He thus raises the linguistic register of the encounter since the interpreter aligns with the user’s term. D1’s choice is again in the direction of a more direct and immediate information flow. Example (3) 39 D 40 41 I 42

okay↑ perché per valutare se fare o no dei::: una radiografia che okay because to evaluate if to do or not some an x-ray which ┌sarebbe meglio non fare┐ would be better not to do └and then they ┘ decide if she is to: to do: uh a new x-ray plate ┌ (by then) ┐okay↑

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43 44 45 46 47 48 49 50 51

U I D I U I D

52 I

└ o:::kay ┘ the doctor ┌ specialist ┐ talked about tomography↑ └ but just- ┘ mhm yes perhaps (.) maybe┌ yes ┐but= └ mhm ┘ =only if- ┌ it is the case but we hope not┐ but if is the case u::h she has= └ digli che noi speriam┘ speriamo di no tell him that we hophope not =done the tomography okay↑=

Notably, D1 supports his statement (line 40) by explicitly inviting I1 to translate that the medical staff hope an x-ray will not be needed (line 51). By doing so, D1 shows he is in sympathy with the father. Secondly, by resorting to the first person plural he demonstrates that he identifies himself with the institution. 6 To conclude, by explicitly inviting the interpreter to translate through a verbum dicendi, he addresses the interpreter directly as a full participant in the encounter.

4.3. Encounter B: an unshared diagnosis The second encounter, taking place in the HTS, involves, as patient, a small child suffering from gingival infection and accompanied by his mother. They live in Austria yet are not German native speakers. D2 is not an Italian mother tongue speaker either. Five sequences can be identified, which embrace all the six ideal phases of a medical encounter: 1) opening, complaint and verbal examination—all included in the same sequence because of their concision (lines 1-40); 2) physical examination (lines 41–99); 3) diagnosis (lines 100191); 4) treatment and advice (lines 192–340); 5) administrative procedures and clarifications aimed at dispelling the mother’s doubts (lines 341–421). Throughout the encounter, triadic exchanges prevail, with only a few exceptions. Worthy of notice in the first sequence is D2’s control over the turn-taking, which confirms the enhanced conversational asymmetry of the complaint and verbal examination phases. At this stage, it is D2’s prerogative to give the turn to the other interlocutors, by posing questions aimed at collecting relevant information for the diagnosis, and to take the turn back without displaying any feelings or making any comments. Owing to his institutional role and command over two linguistic codes (the technical one and ordinary speech), he may choose between an authoritarian and an empathic conversational style (Merlini, 2007, p. 439). In this specific case, he opts for a rather authoritarian style, which will lead to the user’s distrust and will consequently be softened by the doctor to counterbalance the lack of confidence he created. Notably, the rapid

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sequence of questions, replies and respective renditions builds a triadic configuration based on cognitive expectations, where almost all utterances are elliptical, with no verbs. Only a few lines of this sequence are reported to give an overview of what is illustrated above. Example (4) 7

I

8

U

9

I

15 D 16 I 17 U 18 I

also können Sie bitte erklären was war- was das Problem ist↑ so can you please explain what the problem was is Zahnfleischentzündung gingivitis mhm lei dice che ha un’infiammazione alla gengiva she says that he has gingival inflammation mhm poi e poi↑ then and then und dann↑ and then (er) kann nicht essen he cannot eat anything non mangia niente he does not eat anything

After collecting some general information, the physical examination begins (line 41, Example 5 below). I2 translates D2’s explanation on why he needs to examine the baby by resorting to the third personal pronoun: “also er möchte sicher sein dass Sie die gleiche Entzündung meinen also an der- an der gleichen Stelle”, “well he would like to be sure that you mean the same inflammation at the same area”. The mother’s reply is not reported to D2, who insists on examining the child, and I2 softens the mother’s irritated utterance (line 69), by transforming it into a question (line 72), probably because she is not familiar with the use of the term in a medical context and hence doubts the mother’s suspicion. Example (5) 41 D 42 I

69 U 70 I 71 U 72 I

allora adesso do un’occhiata so I will now have a look mhm ↑ (.) der Arzt wird ihn jetzt untersuchen the doctor will examine him now ( ) ich weiß was es ist (.) er hat auch ähm ä:::hm (.) Pilz auf die Zunge I know what it is he also has fungus on the tongue Pilze↑ fungi Pilz fungus possono esserci dei funghi ai dent- e:::hm sulla lingua↑ do fungi on the teeth on the togue exist

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The third sequence (Example 6) starts with the doctor’s diagnosis: the child has developed gingivitis and herpetic stomatitis due to teething (lines 114– 126). Notably, D2 introduces the medical term by using a relative clause where he resorts to the first person plural (lines 114–115). The same structure, which is also repeated later, hints at his sense of belonging to the medical class and the use of the verb “ho visto” (line 122) suggests that his diagnosis is the result of careful analysis during the physical examination. This strategy might be justified by the need to dispel the perceived mother’s mistrust. In I2’s rendition only the relevant medical information is conveyed, without reference to either of the personal pronouns used by D2. What is worth noticing is the translation of the sole technical term in the whole encounter (herpetic stomatitis). The term is introduced by the doctor (line 117), who endeavours to communicate directly with the mother in English, as is frequently the case throughout the whole consultation, yet with no success, since the mother does not speak English. I2 asks her whether she knows the meaning of the term and explains it (line 120), actively translating a term which might be too technical and hence difficult to be understood. As the mother displays her disagreement with the diagnosis (lines 154–165), I2 interestingly shifts from the brief dyadic exchange with the mother to a triadic configuration conveying the emotional content (affective expectations) of the mother’s utterance (lines 166–172), as might be inferred from the adversative conjunctions and the colloquial expression (lines 166–167). In her rendition she reformulates what is illustrated by the mother, stressing her feelings and perceptions (lines 167, 169 and 172) and resorting to the indirect speech and a different person perspective. This is due to the potentially negative impact of the utterance and denotes the need to clarify the utterance source. Example (6) 114 D 115

117 D 118 I 119 U 120 I 121 U 122 D

126 D

allora dilla questo (.) allora il bambino ha due cose (.) ha (.) una cosa che so tell her this so the child has two things he has one thing that noi chiamiamo stomatite erpetica (.) we call herpetic stomatitis her- herpetic stomatitis mhm↑ wissen Sie was es ist↑ do you know what it is ┌┌ Stomat└└ also äh:::m ähm das ist Herpes es ist ein Virus well it is herpes it is a virus ja yes dopodiché dopodiché ho visto che gli incisivi laterali stanno emergendo and then I have seen that the lateral incisors are erupting crea una situazione (.) di infiammazione sulle gengive mhm↑

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127 I

creates a situation of inflammation on the gum mhm also die- die- ähm die seitliche [sic] Zähne so the lateral teeth

129 I

werden beim Auftreten are erupting

131 I 132

und wenn sie auftreten dann (.) ähm dann ä- ä:::hm hat man solche Symptome and when they erupt then you can have this kind of symptoms

154 U

=ja der ha- de:::r- dies ist äh:::m das heißt in Deutsch äh:::m (.) yes he has it is it is called in German wie ich vorher gesagt habe He- ä:::hm na jetzt sage immer Herpes (.) as I have said previously well I always say herpes

155

158 159 I 160 U 161 I 162 D 163 U 164 165 166 I 167

125

auf die Zunge und des hat er seit Monate (.) halbes Jahr (bestimmt) on the tongue and he has had it for months half a year for sure ┌ dice che il- il problema sulla lingua- ┐ she says that the problem on the tongue └ so immer (geht) aber es kommt ┘ immer wieder so it always goes but it always comes back again ce l’ha ce l’ha avuto e- e:: riemerge sempre he has it has had it and it always re-emerges sì ma no- no- non ┌ significa ┐ che il problema non c’è ┌ cioè ┐ yes but it doesn’t mean that the problem is not there I mean └ ab┘ └ aber dies ┘ hat mit dem nichts zu tun das hat er seit zwei Tage::↑ (.) und die vier Zähne but this has nothing to do with it he has had it for two days and the four oben die hat er seit halbes Monat bei ein Jahr (.) ┌ °hat er die Zähne° ┐ upper teeth he has had them for six months one year he has the teeth └ però vabbé cioè ┘ that’s ok but I mean il problema della lingua non è il motivo per cui lei è venuta qua= the problem on the tongue is not the reason why she came here

169 I

=quello che le interessa è- è la gengiva […] what concerns her is the gum

172 I

perché dice che i denti ce li ha GIÀ da mezzo annas she says that the teeth he has already had them for half a year

191 D

okay è un- è una stomatite erpetica↑ che il bambino ha avuto (.) va bene↑ okay it is a herpetic stomatitis which the child has developed okay

At the beginning of the following sequence (Example 7 below), the treatment is illustrated in a triadic structure. D2 again maintains control over the turn-taking and the mother only intervenes through feedback markers. Utterances are rather short and immediately translated. Remarkably, D2 stresses that the syrup will heal both the gum infection as well as the spots on the tongue, thus showing his endeavour to take into

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account the mother’s perspective and concerns. He also resorts to the imperative form while explaining the treatment. No technical term is used and the indications provided are rather simple. Notably, I2 does not translate the mother’s repetition that teething is not the cause of the problem. D2 takes the turn back to shift topic and start the administrative procedure. The mother looks quite disappointed when reading the prescription (i.e., Zovirax syrup), since Zovirax was also prescribed, as a cream, by the doctor at home. Structures are here mainly triadic, yet when this misunderstanding arises in lines 192–195, probably owing to language difficulties, I2 attempts to convey the emotional load in a couple of renditions, by stressing the mother’s main concern (line 276). This triggers the doctor’s alignment with the interpreter in the attempt to reassure the mother, as might be observed in the frequent use of explicit invitations to translate (e.g., “tell her”, which is repeated eleven times throughout this sequence). Worthy to note is D2’s use of verba dicendi on two occasions (lines 204 and 303), which underline his need to convey such information to the mother. I2 adopts two different strategies in this respect. The first consists of the use of the indirect speech which signals detachment from assuming responsibility for the utterance, owing to the potentially negative impact of its content. The second strategy is a reformulation of the doctor’s statement into a sort of echo-question (Ciliberti, 2009, p. 98), implying major involvement of the interlocutor who can reply and express her view, by confirming or denying the doctor’s perception. I2 further softens the impact by resorting to a rhetorical device named litotes, an understatement generated by denying the opposite (“nicht komplett überzeugt”, line 304) of the adjective used by D2 (“perplexed”, line 303). The suspicion enshrined in the doctor’s utterance is hence moderately conveyed. I2’s mediation shortens the relation distance between D2 and the mother: her affective involvement is transmitted to D2 who actively participates and tries to establish a direct and unmediated relation with her. He addresses again the mother in English and uses feedback markers even when I2 is translating his utterances (“no no no no”, “mhm”, “capito?”, “ecco”, “andiamo”). Furthermore, despite rejecting the mother’s questions on other possible infection causes, he slightly mitigates the diagnosis (lines 318–319 and 334–336). Example (7) 192 D 193 194 I 195 U

(.) allora io prescrivo delle eh:::m medicin- sciroppo per il ehm per il so I prescribe some medicine syrup for the eh:::m per il viru- per il virus (.) okay↑ for the virus okay er verschreibt┌ jetzt einen Saft gegen diese- dieses Herpes dieses Virus┐ he prescribes now a syrup for this herpes this virus └ ja mhm mhm ja alles klar (ja) okay ┘ yes yes everything clear yes

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=e dille che (.) non- eh:::m che lei ha sottovalutato troppo quel discorso and tell her that not that she has underestimated too much that issue delle macchie sulla lingua of the spots on the tongue der Arzt meint Sie ha:ben das Problem auf der Zunge auf diesen Flecken untergeschätzt the doctor thinks that you have underestimated the problem on the tongue on these spots

276 I

l’importante è che riesca a mangiare per lei the important thing for her is that he can eat

303 D

dilla che io vedo↑ (.) che lei è un po’ perplessa (.) dilla tell her that I see that she is a bit perplexed tell her ähm Sie sind nicht komplett (.) überzeugt oder↑ you are not completely convinced aren’t you

304 I

318 D 319 320 I 321 U 322 I

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può darsi che la- può darsi che la stim- stomatite (.) non it might be that the stomatitis is not sia causata dai denti ma comunque di sicuro ha una stomatite virale caused by teething but anyway for sure he has viral stomatitis also es kann sein dass die (.) Stomatitis nicht an die Zähne (.)= so it might be that the stomatitis is not by the teeth mhm ↑ =nicht an den Zähnen liegt= not caused by the teeth

334 D

dille questo anche se non è- non è causato dai denti↑ tell her this even if it is not caused by teething

336 D

ma comunque di sicuro ha una stomatite virale but anyway for sure he has viral stomatitis mhm okay er hat bestimmt eine Stomatitis= he has for sure stomatitis ach so I see =auch wenn nicht- also auch wenn die Zähne nicht die richtige Ursache sind even if not so even if the teeth are not the right cause

337 I 338 U 339 I

In the final sequence, not reported as not strictly relevant for the purposes of this study, a more active participation of I2 is to be noticed since administrative information is involved. Attention should however be paid to a personal intervention of I2, who asks for clarification on the medication dose prescribed, showing her active translation role (“di Zovirax quantoparliamo di milligrammi”, “Zovirax how much, we 7 are talking about milligrams”). D2 replies that he was referring to millilitres. Thanks to I2’s personal intervention and consequent rendition (“er hat Milliliter geschrieben nicht in Milligramm”, “he has written millilitres not in milligrams”), the mother eventually realises that the doctor is referring to

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syrup and not to cream as she previously thought. It is, perhaps inadvertently, the interpreter’s mediation that dispels the implicit misunderstanding, shortens the distance and promotes alignment between the initially conflicting views of the primary interlocutors.

5. Conclusions The qualitative analysis of two mediated medical encounters, involving foreign tourists as patients in a Northern Italian hospital, has proved useful to detect the way medical terms circulate and the organisation of the interaction. This latter aspect has influenced the preferred “translation structure” adopted by interpreters, consequently favouring or else hindering interlocutors’ active participation. The two medical interpreters have deployed specific strategies, which are summarised below, in terms of translation of medical terminology, register variation and promotion of interlocutors’ participation. Being aware of the limitations of the qualitative approach to corpus analysis, which focuses on a limited set of data, this study might, however, be useful for promoting further research in these two directions so as to validate results obtained on a larger scale. Most encouragingly, however, the overall trends illustrated in this article are corroborated by numerous examples in the corpus of data previously collected (Pittarello, 2008, 2009). The results obtained show that medical knowledge is explicitly mediated by the interpreter for the good of patients through specific choices and strategies, in the attempt to shorten the distance and soften potentially conflicting views between primary interlocutors. With respect to the two cases observed, ensuring that information is conveyed effectively and accurately seems to be the hub around which the interpreters’ choices and strategies have implicitly or explicitly revolved. A prevalence of triadic exchanges was noticed in the encounters selected. The shifts from dyadic to triadic sequences, which included affective expectations, allowed for fairer participation of primary interlocutors and enabled patients to express their perspectives and emotional load. In the cases examined, contrary to what emerged in previous research (Bersani-Berselli, 2009a, 2009b), doctors frequently endeavoured to interact with patients directly. By doing so, they show more a shift in relational patterns rather than a loss of confidence in the interpreter’s translation skills (Merlini, 2009, p. 83). Such attempts are signalled by the doctors’ use of English as vehicular language (both encounters) and of feedback markers aimed at obtaining confirmation of patients’ understanding (B). Doctors were ready to renounce specialised medical terms (almost absent in the cases observed) and even resort to gestures or

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lower the register in order to be better understood (A) and thus ensure the effectiveness of the information flow. Although the medical language was rather simple, interpreters further explained the few technical terms, presumably due to their concern that patients might not fully understand them. It should be recalled that the vehicular language was used in both cases. The conversational asymmetry (i.e., doctor’s control over turn-taking and topic) was mainly registered when medical issues were dealt with. In such cases, when patients intervened or when a dyadic exchange took place between the patient and the interpreter, the doctor tried to regain conversational control so as to re-establish his conventional role. On these occasions (e.g., Encounter B), interpreters tended to counterbalance the asymmetry and mitigate patients’ perceived mistrust. Notably, utterances with a potentially negative content (B) have been reformulated by the interpreter in her renditions so as to soften the impact through different strategies (use of indirect speech, shift from affirmative to interrogative sentences and use of rhetorical devices). She thus acted as a “filter” between conflicting views and shortened the relation distance between primary interlocutors, promoting their active participation in the interaction. The result consisted of the doctor’s alignment with the interpreter so as to reassure the patient/relative. A conflict was also prompted by a misunderstanding due to the mother’s misinterpretation (B). This contributed to her mistrust towards the doctor, but was unconsciously dispelled by the interpreter thanks to an autonomous intervention as “active translator”. The interpreter also overcame the mother’s lack of confidence by giving voice to her feelings (affective expectations) and thus acting as point of reference for her. The mother’s perceptions were namely conveyed to the doctor, thus promoting interlocutors’ active participation. Interpreters’ mediation has hence proved to aim at the above mentioned objective of ensuring the effectiveness of the communication flow, through different linguistic and interactional strategies. In both the cases analysed, interpreters displayed great solidarity with patients through active listening, feedback markers and numerous personal interventions. The analysis suggested in this study confirms the high versatility of medical interpreters’ roles and tasks as well as the numerous variables they have to deal with. Adequate support and proper training are essential in order to overcome the merging of linguistic, cultural as well as administrative tasks and to achieve the institutional tasks or ultimate objectives of medical interactions, whether they are mediated or not.

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References Atkinson, J. M., & Heritage, J. (Eds.). (1984). Structures of social action: Studies in conversation analysis. Cambridge: Cambridge University Press. Baraldi, C. (2009a). Empowering dialogue in intercultural settings. In C. Baraldi (Ed.), Dialogue in intercultural communities: From an educational point of view (pp. 3–28). Amsterdam: John Benjamins. Baraldi, C. (2009b). La mediazione interlinguistica e interculturale: Una prospettiva sociologica. In L. Gavioli (Ed.), La mediazione linguistico-culturale: Una prospettiva interazionista (pp. 41–80). Perugia: Guerra Edizioni. Baraldi, C., & Gavioli, L. (2007). Dialogue interpreting as intercultural mediation: An analysis in healthcare multicultural settings. In M. Grein & E. Weigand (Eds.), Dialogue and culture (pp. 155–176). Amsterdam: John Benjamins. Bersani Berselli, G. (2009a). Lingua comune e lingua speciale nelle consultazioni mediche mediate: Un’analisi lessico-terminologica. In S. Cavagnoli, E. Di Giovanni, & R. Merlini (Eds.), La ricerca nella comunicazione interlinguistica: Modelli teorici e metodologici (pp. 453–472). Milano: FrancoAngeli. Bersani Berselli, G. (2009b). Selezione lessicale e mediazione orale in consultazioni mediche presso ospedali pubblici: Un’analisi lessico-terminologica. In L. Gavioli (Ed.), La mediazione linguistico-culturale: Una prospettiva interazionista (pp. 151–170). Perugia: Guerra Edizioni. Cambridge, J. (1999). Information loss in bilingual medical interviews through an untrained interpreter. The Translator, 5(2), 201–219. Ciliberti, A. (2009). Fenomeni di “coinvolgimento” in incontri mediati medico-paziente. In L. Gavioli (Ed.), La mediazione linguistico-culturale: Una prospettiva interazionista (pp. 81–110). Perugia: Guerra Edizioni. Heritage, J. (2005). Conversation analysis and institutional talk. In R. Sanders & K. Fitch (Eds.), Handbook of language and social interaction (pp. 103–147). Mahwah, NJ: Lawrence Erlbaum. Merlini, R. (2007). L’interpretazione in ambito medico: Specialità di lessico o di ruolo? In D. Poli (Ed.), Lessicologia e metalinguaggio (pp. 433–452). Roma: Il Calamo. Merlini, R. (2009). Seeking asylum and seeking identity in a mediated encounter: The projection of selves through discursive practices. Interpreting, 11(1), 57–92. Pittarello, S. (2008). L’interprete e il mediatore nelle strutture sanitarie del Veneto: Aspettative, percezioni e prassi. MA Thesis. Scuola Superiore di Lingue Moderne per Interpreti e Traduttori, Università degli Studi di Trieste. Pittarello, S. (2009). Interpreter Mediated Medical Encounters in North Italy: Expectations, Perceptions and Practice. The Interpreters’ Newsletter, 14, 59–90. Pöchhacker, F. (2002). Researching interpreting quality: Models and methods. In G. Garzone & M. Viezzi (Eds.), Interpreting in the 21st century: Challenges and opportunities (pp. 95–106). Amsterdam: John Benjamins. ten Have, P. (1989). The consultation as a genre. In B. Torode (Ed.), Text and talk as social practice (pp. 115–135). Dordrecht: Foris.

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Valero Garcés, C. (2007). Doctor-patient consultations in dyadic and triadic exchanges. In F. Pöchhacker & M. Shlesinger (Eds.), Healthcare interpreting: Discourse and interaction (pp. 35–51). Amsterdam: John Benjamins.

_____________________________ 1

Such tools include, among others, active listening, conveyance of information which takes into account the interlocutor’s perspective on person and culture, feedback on the effects of one’s own actions in terms of interlocutors’ understanding, checking of interlocutors’ perceptions and positions, etc. (Baraldi, 2009a, pp. 25–26, 2009b, p. 71 and 73).

2

The HST is similar to an outpatients’ clinic devoted to the handling of less severe cases.

3

For further details on the interpreting service provided in this healthcare unit, see Pittarello (2009, pp. 68–69).

4

This aspect might influence interpreters’ renditions, especially in their use of medical terminology, which might be simplified or omitted owing to the interpreter’s awareness of the patient’s imperfect command of the vehicular language. The surrounding context nevertheless enabled the observer to detect possible reasons for such behaviours.

5

Transcriptions follow, to a large extent, Atkinson and Heritage’s (1984) graphical conventions. The transcription of Encounter B is available in Pittarello (2008), whereas that of Encounter A is taken from the work of Sara Verdini, whom I warmly thank. The initials “D”, “I”, “P” and “U” refer respectively to: doctor, interpreter, patient and user, the latter term being hereafter used to indicate the person accompanying the patient to the encounter.

6

The same pronoun is also adopted by the interpreter in her rendition. The use of personal pronouns and specific address forms is useful to understand the alignment of interpreters with either of the parties. The third person singular mainly indicates detachment and intention to deny all responsibility for the utterance. The use of the first person, on the contrary, may suggest a cooperative attitude and the endeavour to share the responsibility about what is being said or, alternatively, it may express a strictly personal view and consequently the highest degree of autonomy and detachment from the original utterance. For further comments on the use of personal pronouns in the data collected, see Pittarello (2008, 2009, pp. 80–84).

7

Note the first person plural, signalling identification with the institution (Ciliberti, 2009, p. 98).

The role of communication and knowledge management as evidenced by HCP vaccination programs in the Netherlands, Germany and Italy: Possible suggestions for medical translators

Dolores Ross & Marella Magris University of Trieste (Italy)

The main objective of this paper is to study mediation aspects in health communication, particularly in the field of HPV (Human Papilloma Virus) vaccination in three countries: the Netherlands, Germany and Italy. As an additional research question we will try to understand the extent to which medical translation and medical writing can be integrated, in the perspective of a greater recognition of the translators’ role as knowledge managers. After comparing the quality level of public service communication in the three countries, we will discuss outcome and socialpolitical conditions of the HPV campaigns. Considering the growing importance of communication professionals in institutional health settings, we will explore possible implications for the social role of medical translators and raise the question of the extent to which translators of medical information material may be allowed to stretch the boundaries of translation and operate more far-reaching choices concerning medical writing. The relevance of this study is to gain insight into health communication in three different language communities and to consider implications for medical translator practice and training.

1. Introduction In this paper we discuss general parameters of health communication as evidenced by the HPV (Human Papilloma Virus) vaccination campaigns, introduced in the Netherlands, Germany and Italy at approximately the same time. We will explore the factors that have determined the different success rates of the immunization campaigns in the three countries: in the Netherlands, a relatively low success rate that slightly improved thanks to a better tailored follow-up campaign; in Germany, an initially high attendance rate followed by a significant drop; in Italy, campaigns that had good scores from the onset but showed strong interregional differences. Determining the success factors of an immunization campaign is an important research question, because of its enormous economic and health impact. Since communication plays a key role in these campaigns, we will first compare the information quality of public services in the three countries (Section 2). Accessible public information is a popular research item investigated within the framework of applied linguistics on “key populations” (Hall, Smith, & Wicaksono, 2011, pp. 52–75). One of these key populations is formed by “preliterate, illiterate or underliterate people” (Hall et al., 2011, p. 53), who are a major concern for public

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communication. The language planning efforts undertaken for fostering access to public services appear to be on different levels: compared to the Netherlands, in Italy and Germany awareness among public service providers of the existence of key populations with different profiles and needs is a more recent development, dating back to the 1990s. Of the latter two countries, Germany seems to have gained ground more quickly, at least in the private sector. In Section 3 we will focus on the relevance of health communication in social and economic terms providing some general information on how health-related issues are communicated in the three countries. Medicine “is one of the highly competitive international fields of research and practice where knowledge transfer and effective communication require a particular sensitivity of specialists towards language” (Busch-Lauer, 2001, p. 849). This requirement is closely linked to explorations of the receivers’ dimension, where measuring health literacy and tailoring the information transfer are crucial issues. The rapidly growing research field on health literacy shows that this is a complex and multifaceted concept (Berkman, Davis, & McCormack, 2010, p. 18) and one of the major factors influencing health status (Perrin, 1998, p. 23, see also van Ballekom, 2008, p. 18). In Section 4 we will take a close look at the three immunization campaigns and then briefly report about two Trieste research papers. Although rather small-scale, these studies confirm the intercultural contrasts in communicative skills already highlighted in the preceding sections. Our investigation of medical writing and communication then brings us to a second research question: what consequences may this have for translator training and practice? Making reference to studies on intercultural communication—an important theme in contemporary discourse analysis (Hall et al., 2011, pp. 92–94)—and to sociologically oriented translation studies with their growing emphasis on translation as a social practice (see, for instance, Heilbron & Sapiro, 2007; Pym, Shlesinger, & Jettmarová, 2006; Wolf & Fukari, 2007) we will bring arguments in favor of an integrated approach between medical writing and medical translation. Considering that the required professional profiles in translation are undergoing radical changes (Gouadec, 2007, p. 173), we will hint at possible new tasks for the translator in health contexts, situated on a more social and communicative level. The traditional tasks of the medical translation profession are described in detail by Montalt Resurrecció and González Davies (2007), but these authors also bring medical translation closer to technical writing. Actually, in order to meet the rapidly changing requirements in today’s health sector, the translator might be called on to perform higher order skills of textual and discourse competence, with increasing use of genre-based competences. In this perspective, translators act more as knowledge managers, applying their knowledge to deal with

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complex intercultural situations and thereby generating intellectual capital (Risku, Dickinson, & Pircher, 2010, pp. 88–89).

2. Public service providers’ communication in the three countries Fostering access to public services is an increasingly important “arena of action for language planning” (Hall et al., 2011, p. 116). The essential point is to ensure equal access to public communication so that “language differences don’t limit clients’ access to education, health, legal services” and other public domains (Hall et al., 2011, p. 117). Another crucial issue is that communication can have an impact on people’s behavior. Public and social services quite seldom limit themselves to information transmission, mostly they also pursue the aim of convincing and educating people. Proper communication can form and change one’s attitude, and this in turn can have an impact on people’s behavior (Hoeken, Hornikx, & Hustinx, 2009, p. 14). Progress in this field is, however, not equal in the three countries, as we will argue in the next subsections.

2.1. The Netherlands Since several decades public and social services in the Netherlands investigate the question of how to efficiently access the public. In 1973 the Dutch parliament nominated a Commissie Duidelijke Taal (Commission for Clear Language) to assist public officers in addressing citizens in plain language. Since then, great efforts have been made to foster access to public information (Bohnenn, Ceulemans, van de Guchte, Kurvers, & van Tendeloo, 2004, p. 36). Among the most famous publications in this field is the style guide Schrijfwijzer, first edited in 1979 and written by discourse analyst Jan Renkema (e.g., Renkema, 1995). At present, there are a great deal of public and private bodies in the Netherlands involved in language assistance and counseling. In 2011 the research project Begrijpelijke Taal (Comprehensible Language) received strong financial support from the Dutch Scientific Council NWO for large-scale collaboration between researchers, private companies and public bodies (Sanders, 2011). It has been estimated that, when checked against the Common European Framework of Reference for Languages, which considers a scale of six levels ranging from the lowest, A1, to the highest, C2, 95% of the Dutch population has a reading comprehension of the Dutch language at B1 level. 1 It is therefore highly desirable for institutional and public settings to lower the linguistic level of their information in publications addressing citizens. Adaptation of the communication flow is not only necessary for illiterate and underliterate people, but also for other key populations, such as linguistic minorities and persons with language-related impairments. It is

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precisely against this background that the call for plain language also became a question of protecting the rights of all citizens to have equal access to information. There is increasing awareness in the Netherlands that the educational aspects of communication and information can have great economic and social benefits. The principal benefits of good communication are: fewer queries, money and time saving, better image for the service providers. Even more significant is the fact that communication can be used as an instrument for social regulation. To influence people’s behavior, governments and public administrations can choose between different policy instruments, particularly legislation, social regulation and financial instruments (e.g., special taxes or tax benefits). An important instrument of social regulation is proper information and education (Hoeken et al., 2009, pp. 18–19, quoting an outstanding advisory report for the Dutch government published in 1992). Specific professionals in organizational knowledge management— defined as “the systematic support of knowledge creation and sharing in an organization rather than the managing of personal knowledge for individuals” (Risku et al., 2010, p. 84)—are voorlichtingsambtenaren in public services and institutional settings (i.e., officers assigned to information and orientation tasks), patient informers in healthcare settings, judicial documentalists and terminology managers in the legal sector, among others.

2.2. Germany In Germany, the movement for a leichte or einfache Sprache began to develop approximately fifteen years ago. In the beginning, it was clearly focused on the needs of people with learning difficulties, but it was then gradually extended to other groups, such as elderly people and migrants. More recently, a study on literacy in adults (Grotlüschen & Riekmann, 2011) has highlighted the importance of plain language for wide sectors of the population: a striking percentage of 14.5 of the working-age population is functionally illiterate, that is, they can read or write single sentences, but not continuous texts. The growing awareness of the gap between citizens and institutions has led, among other things, to the creation of a drafting team in the German parliament, with the specific task of enhancing the readability of laws. Another consequence is the establishment of several private firms that offer services of text simplification in various fields and for different text types—services that are often described as translations into easier, more comprehensible texts. In addition, some universities are now increasingly active in this field: the University of Dresden, for instance, offers a free service in which volunteering medical students “translate” various types of reports in a more accessible language. 2

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2.3. Italy In this country too, data on literacy are far from being encouraging. The final analysis of the Italian data from the international ALL study (Adult Literacy and Lifeskills), for instance, has revealed a rather dim picture, with 48.8% of the population scoring at the lowest of five levels for document literacy (Gallina, 2006, p. 24). When commenting the data, the author speaks of a “dramatic limitation of the Italian population’s competences as regards functional literacy” (Gallina, 2006, p. 25). Interest of the public services in how to appropriately use language in different discourse situations is a rather recent development in Italy. According to Cortelazzo, di Benedetto, Viale and Ondelli (2006, p. 5), prescriptions for plain language in Italian administrative settings started in the 1990s, and the first style book for public administrations dates back to 1993. In 2002, the Department of Public Function issued a first directive for the simplification of administrative texts, which was followed by a second one in 2005. On the whole, there is increasing awareness among public and social services that for efficient communication to occur it is not important what you write but what the receiver understands (Cogo, 2009, p. 12, see also pp. 46–48). A very active research center in this field is operating at the University of Padua, providing counseling to many public bodies. Furthermore, the Accademia della Crusca, the Italian Language Academy, has been involved since 2009 in a project for the simplification of institutional, mainly administrative, texts. 3 In many communication fields the shift from providing specialist information to informing the public has still to be made, but Italy is definitely trying to close the gap. Among public services where communication to the citizens plays an important role—political and institutional settings, justice and other— healthcare can be considered a primary sector. In the next section we will focus on communication in this field.

3. Health communication and knowledge management There are numerous campaigns or public actions in which good communication plays a central role. These actions are often pretested and evaluated by researchers to check how much effect they may have (Hoeken et al., 2009, pp. 22–23). This is particularly the case with health information, which often aims at changing behavior patterns: people must be convinced to be vaccinated, to follow a certain therapy, to undergo clinical tests, etc. (Hoeken et al., 2009, p. 22). Generally speaking, health information easily reaches and influences the target group, because everybody feels involved in health matters, as these are correlated with quality of life and life expectancy (Hoeken et al.,

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2009, p. 31). The healthcare sector also provides the best data about the extent to which communication actually succeeds in influencing people’s behavior (Hoeken et al., 2009, p. 21). There are several reasons why information in health settings is of paramount importance: protection of the patients’ rights to be informed and to have equal access to healthcare services, cost saving, the pivotal role of ethics in this field. Proper information is also a very sensitive issue because of the potential asymmetry of communication between healthcare providers and patients. There are different potential scenarios: healthcare providers and patients share the general language proficiency but not the sublanguage (health literacy), providers face patients with poor language proficiency and health literacy, providers and patients come from different cultural and linguistic communities—the first belonging to the dominant language, the second to a minority language. Especially in a situation of “unequal prestige between cultures” (Prunč, 2007, p. 44) there is a higher risk of imbalance of power, giving rise to communication gaps and language problems that “can hinder multiple aspects of healthcare, including access, health status, use of health services, and health outcomes” (Angelelli, 2004, p. 19). The three countries examined here have very different approaches to health communication problems, as will be described below.

3.1. The Netherlands In this country patient informers are trained for making expert information accessible to the general public. Thanks to their mastering of the specific functions of language and its interpersonal dimensions, they are crucial liaison persons who allow for efficient knowledge transmission. Patient informers are a firmly established professional category in every healthcare setting in the Netherlands but most prominently in hospitals. The importance of health information was already acknowledged in this country in the 1970s, when proper information came to be considered as a means of strengthening the patient’s legal position (van Ballekom, 2008, p. 40; Waldmann, 2008, p. 10). At present, there is a differentiation of professional profiles into patient communication managers, patient information assistants and patient communication advisors. There is also growing involvement (and co-decision) by health insurance companies in patient communication, not only to ensure cost control and legal implications control, but also to guarantee patients’ rights (see, for instance, De Ridder, 1999, p. 62). The position of the Dutch patient is empowered by the Wet op de Geneeskundige Behandelovereenkomst (Law on Medical Treatment, 1995), which establishes the public’s right to be informed about diagnosis, therapy and health condition (van Ballekom, 2008, pp. 42–44; Waldmann, 2008, p. 7).

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Better information turns out to be cost-effective for hospitals, as it guarantees higher compliance to therapy, greater patient autonomy and satisfaction, less suffering and fewer frightened patients (Waldmann, 2008, p. 13, p. 17).

3.2. Germany Nowadays, the key role of information in health settings is fully recognized in Germany as well. According to Ose (2011, p. 41, p. 50), however, this country came to tackle the issue of patients’ rights later than other European countries. The urge to strengthen information and consultancy services began to be felt in the 1990s, and—unlike in the Netherlands—it did not lead to the emergence of a new professional role in hospitals and other healthcare institutions. Instead, it led to the development of independent bodies, whose role in the dissemination of patient information and in the promotion of a new culture of communication with the patient can hardly be exaggerated. The Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen (Institute for Quality and Cost-Effectiveness in the Health System), for instance, investigates the pros and cons of various treatment options and publishes its results on its website, in German and in English. Moreover, the institute aims at fostering the quality and costeffectiveness of the German health service by providing both evidencebased reports on new drugs, therapies etc. and understandable information for patients and citizens. Another body, the Ärztliches Zentrum für Qualität in der Medizin (the German Agency for Quality in Medicine), not only provides patient information on various subjects, but has also put forward some checklists to evaluate the quality of information, the reliability of portals, the choice of medical sites etc. In all these contexts, great value is put on the goal of empowering patients, so that they can play an active role in decision-making about their treatment. This process of shared decision making strictly depends on the quality of the information provided: evidence-based information is considered to be the best solution, that is, information on diagnostic examinations and treatments that draws on particular scientific resources, for instance, on randomized controlled trials and meta-analyses. And indeed, evidence-based information represents the frame of reference for the activities, guidelines and standards of the above-mentioned bodies, which in turn seem to influence the communicative approach in hospitals and other health settings. Most websites of German hospitals now have specific patient-oriented sections that provide brochures and other material on various diseases and treatments. Often these websites are certified by bodies such as HON (Health on the Net), which evaluate the quality of medical information available on the internet.

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3.3. Italy The Italian healthcare system does not employ patient informers, but since immigration flows increased, hospitals started to use cultural mediators for communication with immigrants. In some fields of healthcare information clear progress towards language simplification has been made. The most important example may be Patient Information Leaflets, which in Italy can be drafted either according to the standards of the European Medicines Agency (EMA) or in compliance with the guidelines of the Ministry of Health. The two systems differ in terms of reader orientation, the EMA leaflets being substantially more user-friendly. In 1997, however, measures were taken by Italian authorities to improve the readability of at least some of the other leaflets as well (i.e., those referring to over-the-counter medicines). Another case in point is informed consent forms, which often show a tendency towards clearer formulations: here the need for patient-oriented solutions is particularly acute, not least because of the possible legal consequences of ineffective communication (see Magris, in press; Montalt Resurrecció & González Davies, 2007, pp. 64–67). However, other less standardized text types still need to be improved as regards terminology, inclusion of explanations, etc. This also applies to patient information leaflets on the websites of Italian hospitals, which, if available at all, are more complex and less transparent than their Dutch or German counterparts (see Magris & Ross, 2012, for more details). And yet, there is a growing consensus on the importance of good communication practices, as extensively explained in Cogo (2009). The medical code of conduct in Italy (2006) 4 explicitly states that the physician has to take into consideration the patient’s understanding capacity, in order to ensure maximum adherence to diagnostic-therapeutic proposals. Another important reference in this respect is the Florence chart (2005), 5 which aims at fostering greater patient autonomy. In consideration of this and similar documents it seems that in Italy, too, health communication is slowly shifting towards a new, more patient-centered approach. A slightly different stance is taken by the Italian Ministry of Health in its Guidelines for online communication on health matters, published in 2010. 6 These guidelines stress the need to optimize linguistic aspects such as sentence structure, but at the same time they insist on the importance of technical language as a guarantee for the author’s reliability and professionalism, which means that the author-centered approach is still at least partially recommended. In conclusion, all three countries, albeit with different degrees of emphasis, show a strong trend towards developing increased self-decision for patients, shared responsibility and “the importance of effective communication in the building of a successful relationship” in the healthcare provider-patient interaction (Angelelli, 2004, p. 15).

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4. Case study: HPV campaign in three countries Since vaccination programs belong to “the world’s most cost-effective public health strategies” (Waisbord & Larson, 2005, p. 1), they may offer interesting insights into communication strategies. In our study we have taken a look at the implementation of the HPV immunization program in the Netherlands, Germany and Italy. The Human Papilloma virus is one of the main viruses responsible for cervical cancer. Cervical cancer is the second most frequently occurring cancer in women worldwide, the fifth most frequently occurring in the Netherlands (van ’t Klooster, Kemmeren, de Melker, & van der Maas 2011, p. 14), and the fifth or sixth in Italy. 7 In Germany its incidence and mortality are significantly higher (see ECCA, 2009, p. 5). After introduction of the quadrivalent HPV vaccine in 2006 several national vaccination programs were started in the United Kingdom, Canada, Australia and other countries, because the vaccine can protect against approximately 70% of all cases of cervical cancer (van Keulen, 2010, pp. 2–3; van ’t Klooster et al., 2011, p. 17). Italy, Germany and the Netherlands followed suit shortly after. According to the European Cervical Cancer Association (ECCA, 2009), all three countries offer the vaccination free of charge to at least one age cohort of females. In the following sections we will show in greater detail how the campaign has been implemented in the three countries.

4.1. The Netherlands The vaccine has been on the Dutch market since 2007. HPV immunization was introduced in 2009, to be provided to all females aged 13 to 16 (birth cohorts 1993 to 1996). In addition to this catch-up campaign, the vaccination was incorporated in a vaccination program for 12-year-olds (van ’t Klooster et al., 2011, p. 13). The latter was an on-demand vaccination, supported by invitation and public education (ECCA, 2009, p. 6). The catch-up campaign had a quite negative outcome: take-up was between 45 and 50%, which is a very low percentage compared to the usual 95% rate for RVP (Dutch vaccination program). The Research Organization TNO was therefore commissioned to perform a study on the social and psychological determinants of the low compliance to the HPV campaign and to trace failures in the nationwide information campaign (van Keulen, 2010, pp. 1–2). The TNO study revealed that social-demographic factors (age, education) had little impact on the low vaccination acceptance, and the knowledge level of the target population was generally good. Instead, social-psychological factors, such as attitude, current ideas (about security,

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sexuality, confidence in the public sector, etc.), risk perception and other, had played a significant role (van Keulen, 2010, pp. 2–3). A crucial factor was negative publicity. According to the TNO study, media attention for the anti-vaccination lobby had a significant emotional effect on the target population (van Keulen, 2010, p. 3; see also ECCA, 2009, p. 6). This is in keeping with what Waisbord and Larson (2005) state about the acceptance process of immunization programs, which have to face the “formidable” challenge that a “global, fast-paced communication environment makes it possible for negative publicity and anti-immunization positions to be disseminated quickly” (pp. 5–6). According to TNO another important factor determining the low success rate was the campaign material: existing information was limited and obsolete, and the information managers had clearly failed to understand the importance of interactive media such as Hyves, indicated as the girls’ favorite internet resource. TNO’s recommendations consisted essentially of the following: better targeted and tailored future campaigns, adequate information transmission using more communication channels such as news media, multimedia, social networks and platforms, and variation in information (van Keulen, 2010, pp. 4–5). In April 2010 the Dutch campaign restarted, this time organized by a marketing office. The program boasts a better communication strategy and is much more interactive, including weekly chat sessions, a mini-magazine, online forums that can correct inexact information quickly. In addition, texts were simplified and made more attractive, as exemplified by the new brochure issued by the Rijksinstituut voor Volksgezondheid en Milieu (National Institute for Public Health and the Environment, 2011, Prik en bescherm). Preliminary results of the HPV campaign in 2010 show a slight increase in vaccine coverage (van ’t Klooster et al., 2011, p. 53), however, trust in this vaccination remains relatively low.

4.2. Germany HPV vaccination was first introduced in 2006 and since 2007 it has been recommended by the Ständige Impfkommission (Permanent Commission on Vaccination) for girls aged 12-17 years. Vaccination is given on demand (ECCA, 2009, p. 8). The vaccines for this age group are paid by the statutory medical insurance companies. The costs, however, are subject of heated discussion, as they are held to be excessively high in international comparison (see Bönig, 2008, p. 29). At first, the campaign obtained very high rates (up to 80%), which in the following years, however, dropped dramatically: now the national average is as low as 30%. It must be stressed that the rates vary

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substantially from one Land to another (ranging from 20–21% in Hessen and Brandenburg to 46–48% in Saarland and Schleswig-Holstein). 8 According to some experts, the main reason for this poor outcome could be linked to organizational aspects: while in the Netherlands vaccination programs are centrally organized and applied, in Germany there is no public vaccination program at national level. Moreover, awarenessraising campaigns are planned and conducted at regional level, which probably explains some of the above-mentioned variations. Another major factor that reversed the campaign’s initial outcome is the emotional coverage of some cases by mass-media. In 2007 two girls died shortly after having been vaccinated. Even though there appears to have been no causal relationship between vaccination and the deaths, the news raised concern and fears, and many girls and their parents began to change their attitudes towards the program. As far as the information campaigns are concerned, Germany seems to offer a wide variety of materials, ranging from flyers to brochures, which are available at various places (drugstores, medical practices and counseling centers), to a huge number of online documents, and even to DVDs and books (pro familia, 2008, pp. 37–40). The efficacy of some of these information materials has been tested on women in order to improve their readability and acceptability. One of the studies (pro familia, 2008, pp. 30– 36), for instance, employed a think-aloud method in order to identify the strengths and weaknesses of a particular brochure. The results indicated that purely evidence-based information should be accompanied by more concrete and catchy descriptions and narrative parts.

4.3. Italy In Italy, the HPV vaccine was introduced in some regions in 2007, but no more than one year later, in 2008, an agreement was signed between State and regions implementing a national vaccination scheme. Since then, the right to free participation in the programme has been granted in most Italian regions; the vaccine is provided free of charge to women aged twelve through local health centers with direct invitation by letter (ECCA, 2009, p. 8). Today, Italy occupies the third position in Europe, after Great Britain and Portugal, with a coverage rate of 65%. 9 This result is well below the initial target of 95%, but is nevertheless quite satisfactory when compared with Germany and especially the Netherlands, moreover Italy has not registered any significant decrease in coverage with time. Despite the centrally organized program, there is strong variation among regions, with Puglia, Toscana, Basilicata and Veneto showing the best outcomes (75– 80%), Campania and Sicilia the worst ones (27 and 34%, respectively). This may be partly due to regional differences in the vaccination program

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itself (e.g., different cohorts eligible for free vaccination, different numbers of doses, etc.), 10 but also to differences in the organization of information campaigns: some regions, such as Emilia Romagna, are very active, whereas others are still lagging behind (see ECCA, 2009, pp. 8–9 for some details on different approaches by the Italian regions). It may be noted that, although take-up in Italy is relatively high, this might be due more to other factors than to the efficacy of the information campaigns, as the information available on the subject has been considered unsatisfactory. 11 There is therefore still room for improvement and, as some experts stress, not only organizational, but also communicative factors will make the difference for the future success of the immunization campaign. 12 Summing up: immunization “is a story of both successes and failures” (Waisbord & Larson, 2005, p. 1). Convincing people to accept immunization is more complex than it might seem. It is not simply a matter of disseminating knowledge about vaccines: the distribution of adequate information remains an influential factor. In the next subsection, we will briefly report on two research papers from the University of Trieste analyzing patient information leaflets. The three countries discussed above are now taken together for reasons of space.

4.4. Patient information leaflets in the three countries The first study is an MA paper, written by a Trieste student (Usai, 2010), based on a small corpus of five information leaflets per country used for the HPV campaign. The study shows that the Dutch and German campaigns are generally more user-friendly and more comprehensible for a non-specialist public, better tailored to the target group of young females and their parents (some leaflets also address school teachers), graphically they are more appealing, with more illustrations. By contrast, the Italian linguistic material is mostly characterized by an author-centered approach that results in excessively scientific information (Usai, 2010, p. 181), a limited use of illustrations, poor consideration for the primary target group and the increasing numbers of healthcare users from immigrant circles with low literacy. The study also hypothesizes that the Italian authors show more restraint when dealing with delicate subjects or taboos, for instance, when explaining concepts relating to sexuality (Usai, 2010, p. 181). On the other hand, the Dutch and German texts give full priority to objective, neutral information and almost totally refrain from using persuasive elements (Usai, 2010, p. 124, p. 173), which might be not the most effective strategy to counteract emotional reactions and foster compliance to the program. The same kind of contrast, but on a more linguistic level, has been evidenced by Magris and Ross (2012) on the basis of a corpus of patient information leaflets on medically assisted procreation. The Dutch and German texts, mostly hospital publications, were more target-oriented, the

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language was more simplified and terminology was better explained, while the Italian texts, mainly available from patients’ associations and private clinics, were more content-oriented and definitely less user-friendly. Taken together, these findings point to different dissemination competences, differences between a more target-oriented approach and a more author/content-oriented transmission. This brings us to our second research question: to what extent can medical writing be integrated into medical translation and what kind of role may translators play in the important communication processes going on in healthcare settings? This will be the subject of the last section.

5. Translators as knowledge managers In Magris and Ross (2012) we concluded tentatively that translators working in health communication might benefit from adopting dissemination strategies and interaction modes used by language communities with good communication skills. Translators might thus put forward innovative translation strategies in the target text and implement more drastic choices, for instance by adding clarifying glosses, using more down-to-earth synonyms, simplifying syntactic structures, etc. This does not imply being less loyal to the source text or to the target text, but simply being loyal to all interaction partners: medical staff, nurses, patients, mediators. In this way the medical translator engages him/herself in knowledge management tasks. This seems already to be going on in medical translation practice, as illustrated by Montalt Resurrecció and González Davies (2007). In their comprehensive survey, the authors outline paths for becoming a highly skilled problem solver by discussing translation strategies, text genres, terminology management etc. At the same time they illustrate how the traditional focus on terminological equivalence gives way to other relevant aspects such as style and register shifts, formal conventions, issues relating to both translation and writing. Among what could be termed the “common tasks” of medical translators Montalt Resurrecció and González Davies (2007, pp. 27–28) include translating web pages and research articles, but also revising or drafting original texts, rewriting and adapting texts, as well as knowledge management. Adequate knowledge management requires a keen awareness of text genres. Medical information is indeed carried out “through well-established genres” (Montalt Resurrecció & González Davies, 2007, p. 61), some of which are internationally conventionalized with regard to content and structure, while others are language/culture-specific. Within a genre-based approach, medical writing and medical translation are closely interrelated. Text writing is one of the fundamental elements of today’s digital society with its global communication environment, its multimodality and

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increasing variety of information materials: combination of oral and written sources, of internet and print material, creative use of graphic material and illustrations. In this dynamic context, according to Pym (2004), the traditional bilateral sender-receiver model gives way to a “model in which texts are generated by a group of specialists and are then communicated to a wide range of receivers situated in many cultures” (p. 16). In a society where an “increasingly relevant role” is “played by teams, tools and time” (Risku, 2010, p. 107), the translators’ position and tasks change rapidly. In many fields, professional translation practices are already evolving in new directions, “stretching and even breaking the boundaries of translation” (Koskinen, 2010, p. 15). But especially in professions that have a strong public orientation, i.e., service professions such as healthcare (Antia & Yassin, 2001, p. 871), where important matters relating to personal health and public finance are at stake, a more assertive role of the translator can be a benefit for all the communication partners. The idea that translators act as communication managers and providers of knowledge transfer has just started to circulate: Knowledge management […] has gained increasing importance in the business world of the last decade. […] Although it is obviously being regarded as a knowledge profession, the field of professional translation is rarely included in general discussions on knowledge work. (Risku et al., 2010, pp. 83–84) When translators apply their knowledge, they generate intellectual capital (Risku et al., 2010, pp. 88–89). Reflection on this dimension has particularly gained ground in the field of literary translation, where concepts as the imbalance of cultures and the translator’s “social capital” are opening new horizons (see, for instance, Heilbron & Sapiro, 2007). This is in line with recent efforts in Translation Studies to provide a coherent framework for analyzing translation as a social practice (Wolf, 2006, p. 129). In his introduction to Sociocultural aspects of translation and interpretation, Pym (2006) observes: […] for some scholars and more particularly in some fields of research, the focus has shifted from texts to mediators. […] We would like to know more about who is doing the mediating, for whom, within what networks, and with what social effects. (p. 4) The imbalance of power, inherent in so many community settings, favors a higher mediation role and is at odds with the present undefined status of the translation profession. One aspect of this indefiniteness is the position of healthcare translators in relation to community interpreters. While community interpreters are often required to “engage in explanation, cultural brokerage, and mediation” (Angelelli, 2004, p. 13), it remains to be

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investigated in which way medical translators may play an active role in fostering communication between the interaction partners. Montalt Resurrecció and González Davies (2007) leave no doubt: “medical translators do not simply translate. They have also become writers, terminologists, revisers, web creators, multilingual knowledge managers, language quality control experts, community interpreters and community experts” (p. 28). From our own investigation we can also conclude that medical translators should be empowered. Considering that the translator’s fundamental work tool is the use of parallel texts, we think that this material may be analyzed by translators to their own benefit not only for the sake of terminology and phraseology but also in order to acquire insight into the way they are structured and organized in other languages and cultures. Taking this material as a model, the translator may feel authorized to move beyond pure lexical-semantic concerns and introduce changes into the linguistic contents, privileging, if necessary and depending on the text genre, the target readership. This would imply information restructuring operations, use of different document presentation strategies, changes in interpersonal focus, and other interventions that can also involve content information. Comparison of medical communication material in different language communities makes clear what is a good performance and what not. Translators could act as importers of efficient communication strategies from other cultures.

6. Summary and outlook The empowerment of translators fits well with increasingly important concepts in health communication such as social inclusion and health literacy. As shown in this paper, there is a different degree of awareness in the Netherlands, Germany and Italy of the importance of information and communication management. It may be hypothesized that in the important field of medical communication, translation will be increasingly linked to medical writing, allowing translators to act as knowledge managers and information brokers. Further investigations on how the boundaries of translation could be stretched are necessary. References Angelelli, C. (2004). Medical interpreting and cross-cultural communication. Cambridge: Cambridge University Press. Antia, B. E. & Yassin, K.M. (2001). Coming to terms with the patient’s terms on the patient’s terms: terminology in public health in the developing world. In F.

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Mayer (Ed.), Language for Specific Purposes: Perspectives for the new millennium (Vol. 2) (pp. 871–881). Tübingen: Gunter Narr. Berkman, N. D., Davis, T.C., & McCormack, L. (2010). Health literacy: What is it?, Journal of Health Communication: International Perspectives. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/20845189 Bohnenn, E., Ceulemans, C, van de Guchte, C., Kurvers, J., & van Tendeloo, T. (Eds.) (2004). Laaggeletterd in de Lage Landen. The Hague: Nederlandse Taalunie. Bönig, C. (2008). Die HPV-Impfung zur Prävention von Gebärmutterhalskrebs. Studienarbeit. Norderstedt: Grin. Busch-Lauer, I. A. (2001). Languages for medical purposes: Results, projects and perspectives. In F. Mayer (Ed.), Language for Specific Purposes: Perspectives for the new millennium (Vol. 2) (pp. 849–854). Tübingen: Gunter Narr. Cogo, C. (Ed.) (2009). Scrivere di screening. Materiali informativi nello screening citologico. Milano: Inferenze, Gruppo Italiano Screening del cervicocarcinoma, Osservatorio Nazionale Screening. Cortelazzo, M., di Benedetto, C., Viale, M., & Ondelli, S. (Eds.) (2006). Comunicazione istituzionale e semplificazione del linguaggio. Università della Calabria. Retrieved from http://uil.unical.it/test/formazione/Com_istituzionale. pdf De Ridder, R. (1999). Political foundations of the concept of “liaison interpreting in the community”. In L. Mathibela, E. Hertog, & H. Antonissen (Eds.), Liaison interpreting in the community (pp. 59–65). Hatfield: Van Schaik. ECCA (European Cervical Cancer Association) (2009). HPV vaccination across Europe. Brussels: ECCA. Gallina, V. (Ed.) (2006). Letteratismo e abilità per la vita. Indagine nazionale sulla popolazione italiana 16-65 anni. Roma: Armando. Gouadec, D. (2007). Translation as a profession. Amsterdam: John Benjamins. Grotlüschen, A., & Riekmann, W. (2011). leo. - Level-One Studie. Presseheft. Hamburg: University of Hamburg. Retrieved from http://blogs.epb.uni-hamburg.de/leo/ Hall, C. J., Smith, P.H., & Wicaksono, R. (2011). Mapping applied linguistics. London: Routledge. Heilbron, J., & Sapiro, G. (2007). Outline for a sociology of translation. In M. Wolf & A. Fukari (Eds.), Constructing a sociology of translation (pp. 93–106). Amsterdam: John Benjamins. Hoeken, H., Hornikx, J., & Hustinx, L. (2009). Overtuigende teksten. Bussum: Coutinho. Koskinen, K. (2010). What matters to Translation Studies. In D. Gile, G. Hansen, & N. Pokorn (Eds.), Why Translation Studies matters (pp. 15–26). Amsterdam: John Benjamins. Magris, M. (in press). Verso un uso consapevole della terminologia nell’informazione medica rivolta al paziente. In Atti del IV workshop “Modena Lexi-Term” (Padova, 12–13.5.2011). Magris, M., & Ross, D. (2012). Die Kommunikation im Bereich der Assistierten Reproduktion: Ein Vergleich zwischen Deutsch, Niederländisch und Italienisch. In C. Di Meola, A. Hornung, & L. Rega (Eds.), Perspektiven Vier. Akten der 4.

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Tagung Deutsche Sprachwissenschaft in Italien (Rom, 4–6.2.2010) (pp. 243– 256). Frankfurt am Main: Peter Lang. Montalt Resurrecció, V., & González Davies, M. (2007). Medical translation step by step. Translation practices explained. Manchester: St. Jerome. Ose, D. (2011). Patientenorientierung im Krankenhaus: Welchen Beitrag kann ein Patienten-Informations-Zentrum leisten? Wiesbaden: Springer VS. Perrin, B. (1998). How does literacy affect the health of the Canadians? Retrieved from http://www.nald.ca/library/research/howdoes/howdoes.pdf pro familia (2009). Dokumentation Fachgespräch. Die HPV-Impfung: aktuelle Datenlage und Anforderungen an Information und Beratung. Frankfurt am Main: pro familia. Retrieved from http://www.barmer-vv.de/download/hpv_doku_ profamilia_2009_07.pdf Prunč, E. (2007). Priests, princes and pariahs. In M. Wolf & A. Fukari (Eds.), Constructing a sociology of translation (pp. 39–56). Amsterdam: John Benjamins. Pym, A. (2004). Propositions on cross-cultural communication and translation. Target, 16(1), 1–28. Pym, A. (2006). Introduction: On the social and the cultural in Translation Studies. In A. Pym, M. Shlesinger, & Z. Jettmarová (Eds.), Sociocultural aspects of translation and interpreting (pp. 1–25). Amsterdam: John Benjamins. Pym, A., Shlesinger, M., & Jettmarová, Z. (Eds.) (2006), Sociocultural aspects of translation and interpreting. Amsterdam: John Benjamins. Renkema, J. (1995). Schrijfwijzer. The Hague: SDU. Risku, H. (2010). A cognitive scientific view on technical communication and translation. Target, 22(1), 94–111. Risku, H., Dickinson, A., & Pircher, R. (2010). Knowledge in Translation Studies and translation practice. In D. Gile, G. Hansen, & N. Pokorn (Eds.), Why Translation Studies matters (pp. 83–94). Amsterdam: John Benjamins. Sanders, T. (2011). Krachten gebundeld voor begrijpelijke taal. Onze Taal, 5, 130–131. Usai, F. (2010). La lingua come strumento di prevenzione: L’HPV in tre realtà linguistiche. Trieste: Università degli Studi di Trieste. Van Ballekom, K. (2008). Voorlichting in ziekenhuizen. Codinne: Centre d’Education du Patient. van Keulen, H. (2010). Onderzoek naar de HPV-vaccinatiebereidheid: Samenvatting van een onderzoek naar de HPV-vaccinatiebereidheid bij moeders en dochters naar aanleiding van de inhaalcampagne in Nederland (TNO-rapport KvL/GB, 2010.040. Retrieved from http://www.tno.nl/downloads/KvL-L.10-08.1177Nm1. pdf van ’t Klooster, T. M., Kemmeren, J. M., de Melker, H. E., & van der Maas, N. A. T. (2011). Human Papillomavirus vaccination catch-up campaign in 2009 for girls born in 1993 to 1996 in the Netherlands. Bilthoven: National Institute for Public Health and the Environment. Waisbord, S., & Larson, H. (2005). Why invest in communication for immunization: Evidence and lessons learned. Retrieved from http://www.globalhealth communication.org/tools/21

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1

www.bureautaal.nl.

2

For additional information, see http://www.washabich.de.

3

http://www.accademiadellacrusca.it/progetti/progetto_singolo.php?id=8471&ctg_id=27

4

http://www.privacy.it/codeome.html

5

http://salute.aduc.it/documento/carta+firenze_10097.php

6

http://www.salute.gov.it/imgs/C_17_pubblicazioni_1473_allegato.pdf

7

http://www.lilt.it and http://www.airc.it/tumori/tumore-all-utero-e-cervice-uterina.asp#cose

8

http://www.frauenaerzte-im-netz.de/de_news_652_1_831_hessen-und-brandenburg-sindschlusslichter-bei-hpv-impfung.html

9

http://www.121doc.it/press/hpv-vaccinazioni-italia-terza-7387.html

10 http://www.epicentro.iss.it/problemi/hpv/pdf/Aggiornamento_datiHPV_31_12_2011_ validato.pdf 11 See survey conducted by Censis, the Italian Institute for Social Studies, http://www.sanitainc ifre.it/2011/11/hpv-per-4-donne-su-5-info-poco-chiare-su-rischi-e-vaccinazione 12 http://www.ondaosservatorio.it/elementipagine/29/it/articoli-divulgativi/1851/hpv-vaccinatameta-delle-adolescenti

Translating the essence of healing: Inscription, interdiscursivity, and intertextuality in U.S. translations of Chinese Medicine

Sonya Pritzker University of California, Los Angeles

This paper examines the translation of Chinese medicine (CM) texts into English. In what I here call “living translation,” written translation in CM is approached as an ongoing process of reading, writing, communicating, and practicing that works to encode multiple dialogues with past, present and future actors. Translation in this framework is presented as a “conversation in motion,” an unfolding event in which authors draw upon morally grounded notions of medicine, personhood, and self in order to create CM through extended translations. In entering directly into the stream of these conversations, observing how different authors and translators approach the interdiscursivity of CM at the level of textual translation, I discuss the possibilities that this dialogic view of translation opens up for understanding textual translation as a living practice that directly mediates the ways in which CM is practiced in English-speaking populations.

1. Introduction

Chinese medicine (CM), including acupuncture, massage, herbal medicine, and Chinese nutrition, is becoming increasingly popular as a form of “alternative” or “complementary” medicine in the U.S. In many cases, this popularity is founded upon various notions of what constitutes health, what counts as “illness,” and how healing should ideally unfold. It is not surprising, then, that drastically different English-language translations of CM texts exist side by side. The differences inherent in these translations are amplified by the fact that there are currently no agreed-upon standards for translating CM into English. Heated debates are thus constantly arising over issues such as whether source-oriented or target-oriented approaches best suit the translation of CM into English, whether biomedical terminology should be used as a basis for translating ancient Chinese medical texts, or who—Chinese or Westerners, practitioners or scholars— should have epistemological rights to say what CM is (see Pritzker, 2012a). In this field, language becomes a tool for engaging in multiple dialogues that extend across time and space in an ongoing stream of interaction. With this in mind, this paper examines the text-based translation of CM into English. This paper thus looks towards a single Chinese term, 精 jing, in order to demonstrate the many ways in which each translation of even a single term emerges as an inscription of the complex, morally and socially grounded interrelationship(s) between author, original, and

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audience. The concept of “living translation” lies at the heart of my discussion. Living translation is first and foremost crafted after MacIntyre’s notion of “living tradition” (MacIntyre, 1981). MacIntyre, who recognizes the dynamic nature of tradition, focuses on the involvement of diverse and often disagreeing participants in the creation of tradition. Viewing translation through this lens reveals it as similarly ongoing, emerging in multiple acts of re-translation that position actors within a social world where participants have varying access to STs, and meanings are made and remade in open-ended “living narratives” (Ochs & Capps, 2001) that both continue and transform linguistic, personal, and social meanings. Living translation is further theoretically grounded in Jakobson’s distinction between “interlingual” and “intralingual” translation (Jakobson, 1966). Whereas interlingual translation is the term Jakobson (1966) uses to define what is commonly understood as “translation proper” or “an interpretation of verbal signs by means of some other language” (p. 233), intralingual translation refers to “an interpretation of verbal signs by other signs of the same language” (p. 233). In intralingual translation, then, concepts, interactions and perspectives are translated vis-à-vis a “circumlocution” that functions to define, paraphrase, and describe their meaning. Living translation sits at the intersection of these two forms of translation, incorporating the interlingual shifts between Chinese and English as well as the multiple interpretive moments where original Chinese terms and concepts are interpreted through extended intralingual English explanations. Living translation also relies heavily on the Bakhtinian concept of “dialogicality,” wherein “there is a constant interaction between meanings,” in both text and talk (Bakhtin, 1981, p. 426). Through both interdiscursivity, understood as the mixing of genres, discourses or styles (Fairclough, 1992; Wu, 2011), and intertextuality, understood as the interpellation of texts with pieces of other texts (Fairclough, 1992; Kristeva, 1980), textual products of living translation thus unfold as a set of “conversations” that authors carry on with ST authors (see Gadamer, 2006)—as well as readers, students, and patients. These conversations further work to encode the language of CM in multiple formats that themselves carry on the process of living translation through their publication and consumption, variably reproducing the practice of CM through the mediated mixing of genres and styles of talk and the intermixing of strategically selected historical texts. In this sense, living translation also builds upon the dialogic view of interpretation or spoken translation put forth by Wadensjö (1998), a perspective that challenges the traditional binary distinction of “source” and “target,” and demonstrates that translation is actually achieved in the conversation between two parties. By focusing on interpretation, rather than written translation, Wadensjö especially highlights the real-time interactive unfolding of translation. Applying this perspective to the crafting of texts, however, opens up the possibility that each author of Chinese medical texts

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is engaging in a “scribal culture” (Montgomery, 2000, p. 19) that extends from China to the U.S. and to Europe and beyond, and spans thousands of years of discourse and practice. Within this scribal culture, answers to ageold questions about source and target, the morality of translation, and the ideal method of translating are answered and re-answered in inscriptions that themselves live on in interpretations by readers. The process of mapping these conversations becomes important here, primarily because the living nature of textuality in CM only begins with the way the texts are written. It continues in the social life of the texts, and the way they are taken up (Iser, 1978; Poulet, 1969; Ricoeur, 1976; Sterponi, 2004). This perspective complicates the traditional boundaries separating text from non-text, as “extratextual” factors permeate the interpretation and use of texts along sometimes unexpected lines (Hanks, 1989). For scholars of translation who focus mostly on texts, it opens up the possibility of looking at the entire enterprise of publication within CM as a continuous, creative event where people are involved in a set of conversations that are themselves indexes of living history. What is especially relevant in CM is that the translated material is also enacted upon living bodies as healing practice. So in addition to considering and assessing the multiple ways in which certain instances of translation participate in acts of cultural violence through the strategic domestication of key concepts (Venuti, 1992, 2000, 2005), living translation further demands an appreciation of translation as it occurs “in action,” (see Zhan, 2009). From this perspective, it becomes possible to be a direct witness of the link between translation and practice in the growing field of CM. After first reviewing the concept of textuality in CM in China and the U.S., the paper examines the ways in which authors working to create English-language texts variably draw on different types of morally grounded conversations to create vastly different translations of 精 jing, or “essence.” I conclude with a discussion of how living translation opens up the possibility of bringing a more dialogic, involved perspective to the analysis of textual translation. I further argue that, with this close examination or mapping of the interdiscursive and intertextual dialogicality in specific translations, it becomes possible to understand the link between textual translation and practice, including both diagnosis and treatment, in the field of CM.

2. Textuality in CM CM, wherever it is practiced, is a deeply textual tradition. In contrast to biomedicine, where even the most recent textbooks are considered suspect because of the rapidly changing knowledge in the field (Konner, 1987, pp. 14–15), in CM classic texts, memorized and recopied over hundreds of years, are considered canonical and authoritative. For centuries following

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the creation of these classic treatises, scholar-practitioners have offered diverse commentaries interpreting the material. Rather than offering straightforward translations or even explanations, commentaries are also used as opportunities for authors to generate innovative strategies for utilizing classical wisdom in treating patients (Furth, 2007). As Karchmer explains, this has to do with the cultivation of a certain clinical and literary style for Chinese physicians. “To become a virtuouso CM doctor,” Karchmer (2004) thus writes, “is to learn how to ‘make a text your own’” (p. 219). The classic texts in CM are, in this sense, simultaneously authoritative and open to interpretation, at once grounded in an inscribed “chain of authentication” (Agha, 2007, p. 218) and yet innovative at the same time. In addition to classical texts and commentaries, CM also boasts a rich and varied case study genre. In case study texts, individual physicians provide evidence in the form of specific illness events—usually listing symptoms, diagnosis and prognosis, treatment, and results. Within case studies, it is still common practice to cite specific passages from canonical texts in the textual performance of expert knowledge. Even in the standardized textbooks that are common in contemporary China, classic texts are quoted liberally. Newsletters, pamphlets, and popular texts on CM today, in both Chinese and English, are likewise constructed as a simultaneous conversation with the documented past of CM, as well as with the desired future. Contemporary texts in both languages are also shaped by the complex relationship between CM and biomedicine that has developed over the past century (see, for example, Karchmer, 2004; Scheid, 2001, 2002; Taylor, 2004). Here, for example, biomedicine’s reliance on experimentation and anatomical knowledge has challenged CM, which is less rigidly defined by the terms of modern medical “science,” to validate its claims on truth, illness, and the body.

2.1. Intertextuality and interdiscursivity in CM in China From the above, we see that texts in CM are both richly intertextual and deeply interdiscursive. They are invariably built “with respect to other text occasions” (Silverstein, 1996, p. 81). The intertextuality of Chinese medical texts thus unfolds in the process by which each text in CM, even each term, is oriented towards a host of other texts (see Bauman, 2004) as specific authors explain the meaning of the body, illness, and healing by interpellating particular products with ample quotes from classic and modern texts. Texts in CM also demonstrate a high degree of interdiscursivity, where alongside intertextual citing of historical and contemporary sources, authors actively weave together multiple styles and genres in the creation of a single product. In so doing, they simultaneously use intertextuality and interdiscursivity to legitimate their claims vis-a-vis

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dominant forms of biomedicine, as well as contributing to and participating in an elaborate conversation that spans both space and time. In this, Chinese medical texts can be considered “multiply dialogical” (Irvine, 1996, p. 151). From this perspective, texts in CM can productively be approached as revelatory of an ongoing “architecture of social relations” (Silverstein & Urban, 1996, p. 14). Far from being a rigid sedimentation of abstract ideas, textuality in CM is “a mode of social action” (Hanks, 1989, p. 103) in which author-practitioners simultaneously draw upon their experience as well as the work of past scholar-physicians to respond to other texts, communicate with future practitioners, and create innovative practices. In this sense, textuality is approached by participants as a personally meaningful “social relation” (Farquhar, 1994, p. 206) that is as structured by the intentions, hopes, moral imperatives, and politically situated struggles of authors. These “extratextual factors” seep into the language of the books, and “indicate that the boundaries of text are best conceived as extremely permeable, incomplete, and only momentarily established” (Hanks, 1989, p. 105). The set of theories and practices known today as CM can thus be understood as an emergent process of complex interaction, where the living, breathing practice of medicine is always and constantly engaged with the written record.

2.2. Chinese medical texts in translation English translations of CM, like in Chinese, include direct translations of classics, translations and original commentaries on classics, translations of case studies, and translations of contemporary textbooks. There are composite texts based on other translations, spiral-bound teacher-organized texts, and original texts introducing CM to students, patients, and the public. As in Chinese, there are also scholarly journals, newsletters, and pamphlets. Each of these “translations” regularly organizes itself around a series of quotes from classic Chinese texts, sometimes gathering such material from other translations and sometimes from original sources. Many of the English texts are also written as guides to clinical practice, and most also discuss Chinese medical concepts in terms of their biomedical “Others.” As in Chinese, then, each English language text in CM is a richly interdiscursive inscription of multiple conversations with past, present, and future actors, each with complex allegiances to various political, moral, and cultural communities of practice. Each translated text thus also indexes a multiply dialogic and heteroglossic conversation that unfolds between the author-translator and the original. In this sense, the writing of Chinese medical texts, whether they are direct translations or adaptations, is first constituted by the ways in which particular authors approach and understand the Chinese material, especially the way they tackle its inherent intertextuality and

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interdiscursivity, its embeddedness in thousands of years of Chinese texts and practice, and its complex relationship with biomedicine. Translated texts are also necessarily created in dialogue with other English-language texts, with the other authors they seek to complement or contrast, and of course, always with the scientific biomedical paradigm they either seek to challenge or to support. Finally, each text is also created as a conversation between the author-translator and his or her imagined audience, with their desires, their demands, and their language always shaping translation decisions. In all of these cases, the crafting of texts is undertaken with particular strategies, particular ideologies of what it means to translate authentically, what it means to heal, and what it means to be historically or clinically accurate each of these “conversations” emerges within the text in a way that draws readers into certain styles of thinking about and practicing CM. As such, they deeply influence the ways in which CM is brought to life in the English-speaking world, and can thus be considered living translations.

3. Inscribing essence In this article, we enter directly into the stream of these conversations, observing how different authors and translators approach textuality in CM. Through a detailed examination of three translations of the concept of 精 jing, I show how a single Chinese term is translated over time in multiple texts. Although most authors use the English term “essence” in order to translate jing interlingually, their intralingual explanations of what such a translation means differ considerably. Observing these productions from the perspective of living translation reveals how translation comes to life in the real-world practice of creating texts for reader consumption. The texts examined below were chosen for this analysis because they are widely used in Western, English-speaking CM educational programs, usually four-year courses of study that include both lectures and clinical internships. As such, the texts are drawn upon to teach specific concepts to students who will use such concepts in clinical practice. Because all of texts examined here are hybrid productions emerging out of personal experience, readings of other texts, and desires to shape practice in different ways, I do not present them in the traditional format of ST/TT comparison. Instead, I approach the texts from an anthropological perspective that relies on the examination of the social, cultural, and historical factors influencing the production of specific works of translation. This broader data informing the analyses was collected as part of a two-year ethnography of translation in CM, where I conducted open-ended interviews with translators in China, the U.S., and Europe, attended multiple translation seminars and debates, and followed several students

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and teachers as they learned the language of CM in translation in one California program (Pritzker, 2011, 2012b, in press). Before proceeding—and at the risk of creating my own necessarily partial and oversimplified translation of CM—I will venture to introduce a few key Chinese medical concepts to help ground the following discussion. First, and very generally speaking, the Chinese medical body is considered to be a dynamic, interconnected whole, where each organ and each bodily substance is always actively engaged in a process of balancing and rebalancing vis-à-vis every other part of the material body as well as the emotions, thoughts, and physical environment. Diagnosis in CM unfolds as an assessment of the patterns of flow within this system, essentially naming the overall picture or constellation of patterns and presentations that together reflect the unique interaction of constitutional, environmental, lifestyle, and psychosocial processes in each individual. Healing, through herbal formulas, acupuncture treatments, massage, and dietary recommendations, aims at encouraging the body to recalibrate according to its own particular needs. The accurate assessment of the body’s environment is thus a critical step in designing a treatment for a specific individual. The term I examine below, jing, is understood to be, along with qi, blood and fluids, one of the most fundamental substances in the human body. Jing lies at the root of a great many diagnostic patterns related to symptoms as diverse as fatigue, urinary incontinence, sexual disorders, and poor memory, and is affected differently by a vast array of Chinese medicinal substances (primarily herbs) and acupuncture points. Practitioners’ understanding of jing is a critical component of the way they approach not only diagnosis and treatment, but also the creation of formulas and acupuncture treatments for related conditions. In the context of this article, however, jing’s importance not only emerges as a result of the particular definition evidenced through various translations. As we shall see below, the translation of jing further functions as an index for the whole of the way certain authors guide readers towards particular types of practice. In this sense, the translation of jing—including the ways in which intertextuality and interdiscursivity are variously enacted in the interlingual and intralingual definitions of the term—serves as a rich example of the ways in which translation acts to mediate practice in contemporary CM.

3.1. Example one: Elemental essence Essence, in its widest sense, is anything essential to the maintenance of life. Elemental Questions (sù wèn, jīn guì yán lùn) states: ‘Essence is the basis of the body.’ (Wiseman & Ellis, 1996, p. 23)

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This first example derives from translators who are well known as being committed to linguistically precise translations based on specific terms in original Chinese texts. The writing is a series of simple, declarative sentences, peppered with Chinese characters, pinyin, and extensive footnotes embedded within each chapter. It is a direct translation of a specific Chinese ST, and in particular the standard national first-year textbook addressing basic theory in CM, although “there are substantial additions from a variety of sources intended to make the text easier for Western readers” (Wiseman & Ellis, 1996, p. ix). As such, it reproduces the intertextuality of the original Chinese, with straightforward, declarative quotes from classic texts embedded seamlessly within the body of the text. The text, entitled Fundamentals of Chinese Medicine, is consciously intended to be used as a textbook for American and European students learning CM. This translation strategy is reflective of a distinctive and very public philosophy of translation. It is a philosophy that is based on the sourceoriented, “foreignizing” method of Chinese medical translation developed by Nigel Wiseman. This translation philosophy is based on the belief that in order to “transmit Chinese medical knowledge to the West, we must translate, not reinvent” (Wiseman, 2002, p. 22). Relating the need for a source-oriented approach to the esteem in which the translator holds the TL and culture, Wiseman further argues that a source-oriented approach is the only proper way in which to maintain an appropriate respect for genuine Chinese medical wisdom. In Wiseman and Ellis’ translation of essence, this translation philosophy shapes the work at many levels. The intertextuality in the ST, for example, is reproduced both in the use of quotes and the inclusion of classic text names in pinyin with tone marks, as well as in the footnotes that define terms using Chinese characters. Their translation of jing reproduces the general and somewhat ambiguous Chinese statement about the centrality of jing in the process of living. In choosing here not to “reinvent,” Wiseman and Ellis are thus asking readers to learn how to think about essence, and to diagnose and treat patterns related to essence, in the same way that the Chinese students are encouraged to think about it. At another level, Wiseman and Ellis also produce their work in a dialogue with the other translations they see available, translations that they complain do not include proper glossaries, use standard terminology, or translate exactly based on a single authentic Chinese text. In this sense, the final product that they generate is already also interdiscursively linked to other foreign-made products. In this case, it is a morally situated conversation that asks readers to alter their perspective on language in CM. As such, in addition to being a direct translation, it is simultaneously a critical dialogue, a challenge to readers to shift the basis upon which they approach the source. Through this example of living translation, then, CM is produced as a historically referenced, textually grounded practice with a

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definite terminology and a straightforward set of meanings that is linked directly to the practice of CM as it occurs on the ground in China.

3.2. Example two: The poetry of essence Essence, the translation of the Chinese word Jing, is the texture that is specific to organic life…Essence is a kind of deep, “soft,” “juicy” potential inherent in living beings which forms and fills the life cycle as it unfolds. (Kaptchuk, 2000, p. 55) This translation emerges from a paperback book, elegantly illustrated and produced in a contemporary font. Like the Wiseman and Ellis text, it is also written as an introduction to the basic concepts of CM, covering everything from Chinese medical anatomy to treatment. The target audience includes English-speaking students of CM, but here it also includes other, more public audiences—patients and everyday interested readers. And so in contrast to the first text, it also includes chapters on the art and philosophy of CM, complete with poetic discussions of the nature of truth and the spirituality of treatment. It is extremely popular and has already come out in a second edition. The writing in this text is poetic and flowing, and, like the first text, is interspersed with some Chinese characters and some pinyin transliterations, as well as many literal illustrations of various parts of the human body with one or more meridians depicted along the isolated chest or leg. It is not a direct translation of any single Chinese text, emerging more as a hybrid built, as the author explains it, out of years of studying Chinese classic texts, seeing patients in hospitals and clinics, and working with academicians at Harvard. It has emerged, he explains in his introduction, as a result of personal experience as well as scholarly encounters with science, medical history, and anthropology. It has also developed, he writes, in interactions with patients who “have demanded that my practice of CM embody authenticity and relevance” (Kaptchuk, 2000, p. xxiv). In this sense, Kaptchuk’s The Web That Has No Weaver: Understanding Chinese Medicine is a text that is deeply interdiscursive at many levels: social, cultural, textual, personal. The final result emerges out of this interdiscursivity as a decidedly practical and moral project, a living translation that seeks to provide an authentic and “relevant” medical guidebook, For Kaptchuk, then, text creation is an act of hope. It is a social action geared towards the development of clear strategies rather than the “hermeneutic” teasing out of “intellectual problems” (Kaptchuck, 2000, p. xxv). In this sense, the text is a conversation in which Kaptchuk engages his readers by inviting them into a “distinct” world of CM, which he frames as a different ethos of body, illness, and healing. Rather than challenging

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readers to learn about the historically situated practice of CM, however, it takes them on a narrative journey that produces CM as a complementary and alternative medical practice with holistic techniques and a foundation in poetry. In contrast to Wiseman and Ellis, then, Kaptchuk refuses to ask his readers to formulate their practice of CM, and their understanding of “essence,” as a direct copy of those of Chinese practitioners. Instead of relying fully upon any one original Chinese text in interpreting jing, then, Kaptchuk mixes genres (poetic, literary, medical), weaving a hybrid definition of the term that locates “essence” amongst familiar Western metaphors of depth, softness, and “juiciness.” In so doing, he allows his readers to situate jing within an emerging and hybrid Western paradigm of the body/self—a “radically distinct” model in which the depth, uniqueness, and individuality of the self demands recognition in order to be deemed relevant and authentic (see Barnes 1998). Here, the space opens up for the practice of CM to change and “grow,” through translation, according to the radically distinctive medical system that English-speaking readers feel that they need now.

3.3. Example three: The science of essence ‘Essence’ is the material base of the human body and of many of its functional activities. (Deng et al., 2005, p. 35) This text is a hardcover, thick textbook from China, one of the first translations of CM that originally appeared in 1987. The preface to the Revised Edition, from which this translation of jing is derived, highlights the international, authoritative status of the text, which has been and continues to be required in most Chinese medical programs in the U.S., and is heavily drawn upon in the crafting of state and national board exams in the U.S. The text is comprehensive, covering basic theory, diagnosis, and treatment, but also going into a great deal more depth than either of the texts examined so far with regards to needling methods and the treatment of specific biomedical disease categories such as “dysmenorrhea” and “nocturnal enuresis.” The text was originally “compiled” under the supervision of the Chinese Ministry of Public Health in the 1980s. Based loosely on Essentials of Chinese Acupuncture (a Chinese textbook) and supplemented by “the results of many years of teaching and clinical experience,” the foreword states, “Chinese Acupuncture and Moxibustion was continually revised, substantiated and perfected” (Deng et al., 2005, Foreword). This text, also known as “CAM,” is thus clearly a compilation that blurs the line between translation and original product. It is an inherently intertextual and interdiscursive product that incorporates quotes from ancient physicians and classic texts, translating them basically into an

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English that also makes liberal use of biomedical terminology. The first edition, and to a certain extent the revised edition, is poorly edited, with many grammatical errors, typos, and awkward statements. The many illustrations that it includes, however, are extremely realistically rendered, and often include colored depictions of specific organs, muscle groups, and meridians. The translation philosophy supporting the production of this text is, like the others we have examined thus far, richly interdiscursive and deeply moral. The foreword talks about “enriching the world’s science and culture,” a project that is linked to the legitimation of CM as a viable mainstream scientific and cultural product (Deng et al., 2005, Foreword). In terms of its intertextuality with classic, source knowledge, it commonly quotes the classics as a legitimation strategy as well as a tactic of cultural representation. The book leverages a scientific, rational interpretation of these classics, however, in translating them into contemporary scientific terms. As a hybrid product emerging out of the ongoing conversation with imagined consumers, the text produces CM as a modern science and technical practice. By linking jing to bodily “materiality” and “functionality,” then, CAM offers Chinese medical students and practitioners the opportunity to think about “essence” in contemporary biomedical terms like “genetics” or “pathophysiology.” It is clear that with this step, the authors are seeking, through a living translation, to shape a distinctly modern interpretation of CM where it can be seamlessly integrated alongside biomedicine in contemporary practice.

4. Discussion and conclusion That the library of texts in CM is richly intertextual in its reliance upon the selective quotation of other texts, and interdiscursive with respect to multiple academic, clinical, social, and historical genres, is indisputable. In this paper, I have shown that this inherent interdiscursivity challenges different translators to construct meaningful texts that somehow capture a particular slice of this giant “mangle of practice” (Pickering, 1995). I have shown that the way this emerges is far from arbitrary, that this project is informed by each authors’ particular engagement with various ideologies of authenticity, morality, and hope, and by conversations with real and imagined audiences. Where Wiseman and Ellis (1996) espouse ideologies of source-oriented translation, and take original texts to be authentic, Kaptchuk (2000) focuses more on the authenticity of the contemporary moment, and the way that he sees CM as a remedy for the existential pain affecting contemporary Westerners. Deng et al. (2005), on the other hand, translate with the authenticity of biomedicine in mind, and imagine they are speaking to readers who, like them, want to find a role for CM in the great scientific world of healing. Visions of humanity, philosophy, and poetry

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play a role in all of these perspectives. The desire to shape practice, to influence minds, to contribute to the advancement of science or the evolution of consciousness, all of these things are very real factors shaping the choices that translators make and the particular pieces of the conversation that they highlight with their texts. In this sense, translation in CM is a living practice in which present, past, and future authors carry on meaningful dialogues with their students, their patients, and their biomedical colleagues. Understanding textuality and translation as living practices, themselves zones of encounter with far-reaching implications, compels a series of questions related to the social politics of translation in CM. Who or what, we might ask, is being “conquered” in each form of translation? Where might the original lie in the stream of interdiscursivity that is textuality in CM? If we can agree that the original “melts away” in this constant recitation and strategic quoting of past scholars, does it then become acceptable simply to translate only what seems to matter in the moment? These are not just “linguistic” questions. The source-oriented versus target-oriented question, for example, generates serious cultural and political disagreements about what the epistemological foundation for “source” should be. When it comes to translating texts, then, translation is a deeply moral issue linked to the respect one proffers to the source culture/author vis-à-vis the language one uses to reproduce the work in a faithful (or unfaithful) manner in another context. As Judith Farquhar (1994) notes, in CM, it is also a personal and social issue, as past authors and physicians are approached as personal teachers with whom one develops an intimate relationship. The questions of authenticity, biomedicalization, and commensurability are also equally embedded in the everyday social, cultural, personal, and moral lifeworlds of participants, made all the more complicated by the fact that, in the continuous reproduction of textuality in CM, there are always multiple sources and multiple targets. Whether or not they explicitly address these issues, inscriptions emerge from the ways in which authors engage with these types of moral, social, personal questions. In this engagement, original material is reinscribed with particular values and affective, epistemic, and moral stances. Each text is not equally interdiscursive with every community, and authors must choose who to talk to and what about, which of the multiple sources and multiple targets they want to engage, and the type of practice they seek to generate. Translators also have to work consciously to establish their own authority within these communities, and their very right to translate, through various kinds of evidence (Pritzker, 2012b). The texts themselves can thus be approached as indexes of the living practice that is CM. As such, living translation is already, even at the “static” level of text, a conversation in motion.

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An example of genre shift in the medicinal product information genre system

Pilar Ezpeleta Piorno Universitat Jaume I, Spain

Medical writers and translators need information of three kinds: conceptual, contextual and textual. When in possession of this information, they can progressively improve their efficiency. Textual genre has proved to be useful to linguistic mediators of professional texts, providing them with the communicative and textual competence required. I suggest that the scope of textual genre can usefully be widened to include the notion of genre systems. This notion can be particularly useful for obtaining contextual information and understanding complex communicative activities in professional groups and can help enhance the professional competence of medical writers and translators. This paper has a two-fold objective: to describe the dynamic continuum of medical communication that operates in the genre system constituted by product information genres in the pharmaceutical sector also considering the restraints, genre conventions and sequence imposed by metagenres; and to illustrate the intralinguistic genre shift translation process that takes place between the summary of product characteristics and the package leaflet.

1. Introduction This paper builds on the tradition of genre studies and the work of the GENTT (Textual Genres for Translation) research group 1 by arguing that some genres form sets of interdependent genres or genre systems as a means of performing complex social actions, and that the scope of textual genre analysis can usefully be widened to include the notion of genre systems. Acquiring competence in genre and genre systems can be considered an effective means of acquiring the abilities needed by medical writers and other linguistic mediators of professional texts, like translators, as it facilitates their socialization as communicative agents in the medical and pharmaceutical sectors. I shall concentrate on the communicative process carried out by pharmaceutical companies, which is intended to facilitate the prescription of the medicine by the competent intermediaries (prescribers, dispensers, etc.) and its safe use by patients and the general public. This process is structured in a system of genres that I have called the medicinal product information genre system. I shall describe the genre system, the interconnections between the genres involved, and the metagenres interacting with them, paying particular attention to genre shift (Montalt Resurrecció & González Davis, 2007, pp. 162–164) between the summary

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of product characteristics and the package leaflet as an intralingual translation process which operates from a more to a less specialized genre.

2. Genre theory and genre systems in discourse communities To be a good specialized writer or linguistic mediator, one of the skills that is most evidently required is the ability to understand and produce texts that conform to the conventions of the areas of expertise one is working with, where the very deep conceptual and contextual knowledge required determines the way in which textual and communicative competence should be acquired and applied. The connection between genres, situated discursive practices and the activity of professional groups seems clear, especially if genres are considered as devices which combine the formal, socio-communicative and cognitive aspects of communication (García Izquierdo, 2005; García Izquierdo & Montalt Resurrecció, 2002) and as symbolic structures (Schryer & Spoel, 2005) which bring social and textual resources shaped by past practitioners forward for current practitioners to use. Studies in genre thus, are well positioned a) to produce results that relate texts to their professional contexts; b) to help to understand how actions are carried out by professional communities; and c) to improve professional linguistic practices in professional communities. Carolyn Miller’s article “Genre as social action” reconceptualized genres as “typified rhetorical actions based in recurrent situations” (1984, p. 159). This perspective provided a framework for understanding genres in terms of exigency, purpose and social action (Devitt, 2000). Reflecting Miller’s work (1984) and following Bakhtin’s (1986) insights, researchers exploring textual genres in professional settings (Bhatia, 1997; Freedman & Medway, 1994) expanded the concept of audience to include their shifting and changing social contexts. Studies were published exploring the “fluid and dynamic” (Freedman & Medway, 1994, p. 11) nature of genres, how genres are related to complex forms of agency (Schryer, 2001), issues of power and hierarchy (Giltrow, 2001), and social intentions (Bazerman, 1994). Concepts such as genre systems (Russell, 2001; Yates & Orlikowski, 2001, 2002), genre ecologies (Spinuzzi, 2003), family of genres (Ezpeleta Piorno & Gamero Pérez, 2004), or genre networks (Schryer & Spoel, 2005) emerged to explain the complex interaction of genres in the workplace. The theory of genre applied to translation and its correlation with the acquisition of specialized writing and translation competences started also to be explored (García Izquierdo, 2005; Montalt Resurrecció, Ezpeleta Piorno, & García Izquierdo, 2008; Trosborg, 1997).

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3. Methods and framework Our theoretical and descriptive framework of genre systems is informed by Bazerman’s (1994) notion of “systems of genres [as] interrelated genres that interact with each other in specific settings” (p. 79), and the ongoing theoretical development of this view by researchers such as Berkenkotter (2001); by the mentioned Russell (2001), Spinuzzi (2003), Yates and Olikowski (2001, 2002); and by the GENTT research group (Ezpeleta Piorno & Gamero Pérez, 2004; Montalt Resurrecció et al., 2008). Genre systems are collections of genres that, despite having different characteristics, are related to each other either because they rely on each other or because they complement each other in a specific communicative context within a specific discourse community. The advantage of studying communicative actions using a genre system approach is that while genres and genre systems both have attributes, a genre system additionally has relational properties that indicate links among constituent genres. Whether the multiple operations of a single genre or the interactions of various genres are being examined, a genresystems approach highlights larger complex and dynamic networks of power relations with legal implications and practical consequences. Yates and Orlikowski’s (2001, 2002) empirical work on the use of genres in organizational practice illustrated the fact that genres are linked to each other so as to constitute a structure that coordinates communicative actions, and thus they create expectations about the purpose, the content and form (including expectations about structuring devices and linguistic elements) of the whole system as well as those of its constituent genres. A genre system designates the participants involved, who typically initiates which genres, and to whom such genres are typically addressed. The different genres are also related by their relative timing and location, which may be physical or virtual, within the system. Altering the sequence of the constituent genres may create a different variant or invalidate the overall purpose of the genre system. As Schryer and Spoel have pointed out, metagenres help to elaborate the legal, ideological and power operations of genre systems, especially within institutional contexts, but also between institutions and companies or individuals (2005, pp. 256–257). They regulate and reinforce typicality in terms of the macro- and microstructure of other genres and provide a valuable way to understand the dynamics of institutional interrelations among genres. Berkenkotter (2001) has explained that metagenres can be seen as “a mediational means or tool for stabilizing practices” (p. 339). Thus metagenres such as institutional guidelines can be constraining and enabling, “ruling out certain kinds of expression, endorsing others” (Giltrow, 2001, p. 191). As previously stated, one of the advantages of studying communicative actions using a genre system approach is that they provide

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the linguistic mediators with the contextual and textual knowledge required. Genre systems description is particularly useful, then, not only for recognizing the aspects of communicative interaction of the whole structure but also for understanding the specific function that each of them fulfils and the specific textual requirements imposed by the whole communicative structure, metagenres included. In the following sections I first of all present an overall contextual description of the dynamic continuum of medical communication that operates in the genre system constituted by product information genres in the pharmaceutical sector. To do so, I consider the restraints, genre conventions, and sequence imposed by their different settings and users, and especially by those metagenres specific to the genre system. Then I present the different genres and explore the textual properties and relations between genres, paying particular attention to two of the salient genres of the system, which are closely related: the summary of product characteristics (SPC) and the package leaflet (PL) in terms of their content and form. Finally, the intertextual operations that take place between the specialized genre and the lay-friendly genre are explored. For this last purpose, I illustrate the intralinguistic translation process from the SPC into the PL, taking the example of a particular medicinal product (VIAGRA 25 mg film-coated tablets), and using as a framework Montalt Resurreció and González Davis’ (2007) proposals on genre shift strategies and determinologization procedures.

4. Description of the medicinal product information genre system The process of medicinal product information and promotion of a medicinal product for its marketing, sale and use implies a sequence of interrelated communicative actions structured in a genre system that I have called medicinal product information. Medicinal products are highly regulated in the European Union (EU). The dynamics of institutional interrelations among the genres involved are set out in a complicated system of metagenres issued by regulatory authorities such as regulations, directives and institutional guidelines. These govern how, when, where, and in what form such products will be allowed to be marketed and sold within the EU so as to safeguard and guarantee the highest possible level of public health and to secure the availability of medicinal products to citizens (Directorate General for Health and Consumers (DGHC), 1986–2012b, chap. 2). Thus, the connections between the genres involved, the information given, the structuring devices, stylistic and linguistic aspects, and even translation matters, are standardized and normalized. The rules and regulations governing medicinal products for human use in the EU are collected in Volume 1 of The Rules Governing Medicinal

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Products in the European Union (DGHC, 1986–2012a). The legislation is supported by a series of guidelines addressed to professional writers and scientific staff which are compiled in Volume 2 of the same publication. Specifically, Volume 2C contains, among other things, a list of regulatory guidelines related to the full information to be included in the SPC and PL, stylistic matters and requirements for the readability of the labelling and PL (DGHC, 1986–2012b). These also have to be read in conjunction with other relevant guidelines, recommendations and templates developed by the Quality Review of Documents (QRD) group (European Medicines Agency (EMA), 1995–2012). Advertising and promotional material of medical products is also subject to strict and specific control measures and effective monitoring by the European and local authorities. The series of interrelated communicative actions structured in the genre system is enacted within and across pharmaceutical and medical communities, and its ultimate purpose is to facilitate the prescription of the medicine by the competent healthcare intermediaries and to secure its availability and safe use by patients. The range of participants involved in the process is very wide. They are: researchers, scientific staff, medical writers and linguistic mediators working directly or indirectly for pharmaceutical companies or the Marketing Authorization Holder (MAH), who generate the genre system and compose the various documents involved in the process; the authorities —mainly the European Medicines Agency (EMA), The Working Group on the Quality Review of Documents (QRD), and The Directorate General for Health and Consumers (DGHC) of the European Comission— which regulate and supervise the process; healthcare professionals (prescribers, dispensers, etc.) who are the competent intermediaries; and, finally, patients and the general public who use the product. The knowledge generated in laboratories and hospitals is distributed top-down (Montalt Resurrecció & González Davis, 2007, p. 46) and the scope of the involvement and responsibility of the various participants in the genre system is dissimilar.

4.1. The genres of the medicinal product information genre system The main genres of the system are: the summary of product characteristics (SPC), the package leaflet (PL) and the labelling. Pharmaceutical companies or MAHs are legally obliged to provide the SPC to prescribers and dispensers. MAHs must also ensure that medicines will reach patients and users accompanied by the PL and with the approved labelling (DGHC, 1986–2012b). There are also other genres involved, such as the company core data sheet (CCDS), the company core safety information (CCSI), periodic safety update reports (PSURs), promotional texts, etc. This set of interdependent genres whose purpose, content, timing and form typically interconnect is implemented in a well-defined sequence that offers a wide

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spectrum of communicative situations of decreasing degrees of required expertise and formality. The central document, the summary of product characteristics (SPC), contains the essential information for healthcare professionals on how to use the medicinal product safely and effectively. It is written in accordance with the CCDS and the CCSI, which are prior documents containing all the relevant information concerning the product (DGHC, 2009a). The SPC, in turn, is the document on which the patient information leaflet and the labelling are based. The package leaflet (PL), also known as patient information leaflet (PIL) or package insert, is the leaflet included in the pack with the medicine. It is a summarized and simplified patientfriendly version of the SPC, and it has to be composed in such a way as to ensure that it is accessible to and readable by non-professionals, so that they can use their medicine safely and appropriately. Besides, any promotion of a medicine, advertising, press releases, etc. (when allowed) has to be drawn up in accordance with the SPC and must be within the terms of the most up-to-date SPC (DGHC, 1986–2012b, 2008). In addition, there are a series of documents prepared by the MAH which are not always made available to the public and which have to be used as reference for periodic safe reporting and in the preparation of the SPC (DGHC, 2009a). The company core data sheet (CCDS) or core data sheet (CDS) is a summary of the key characteristics of the product. In addition to product information, it contains safety information and pharmacovigilance data. It also includes information on indications, dosing, pharmacology and other issues concerning the product. Many companies compile a product monograph or product profile that is quite similar to the CCDS and includes much if not all of the same information. A practical option for the purpose of periodic reporting is for each MAH to use the safety information contained within its major document (the CCDS) as a reference, and then create a new document: the company core safety information (CCSI). This document contains the pharmacovigilance section of the CCDS in its entirety or a summary of it. It is intended as the minimum safety information for the product in all the countries of the world where that product is marketed. A CCDS may be updated as necessary and accompanies the periodic safety update reports (PSURs). PSURs present the worldwide safety experience of a medicinal product at defined times post-authorization (DGHC, 1986–2012a, 1986–2012b).

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Product Monograph Labelling Company Core Data Sheet Periodic Safety Update Reports

Package Leaflet Summary of Product Characteristics Advertising texts

Company Core Safety Information

Press Releases

Figure 1: Medicinal product information genre system template (adapted from Montalt Resurrecció & González Davis, 2007, p. 69)

4.2. Summary of product characteristics and package leaflet: content and form The Summary of product characteristics has an agreed standard template which ensures consistent presentation of data across all SPC documents and enables the specialized reader to retrieve the information easily. The documents “A guideline on summary of product characteristics” (DGHC, 2009a) and “Quality Review of Documents (QRD) human product information annotated template: revision of the product information” (Quality Review of Documents Group (QRD), 2012, pp. 4–8) provide the standardized headings, the phrase sets and phraseology that should be used and/or included when necessary, and give advice on the principles of presenting information. Sections 1 to 3 of the template contain pharmaceutical data; Sections 4 and 5 contain clinical information (Section 4 relates to the clinical usage of the medicine and Section 5 includes the relevant scientific information and pharmacological details); Section 6 contains pharmaceutical particulars, and Sections 7 to 10 include administrative information.

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Phraseological units are provided for all sections. For example: “”, “” (QRD, 2012, pp. 4–8). Consistent medical terminology has to be used and the documents must be worded in clear, concise and unambiguous language. The use of the Medical Dictionary for Regulatory Activities (MedDRA) (2012) should be applied throughout the SPC, particularly for Sections 4.3, 4.4 and 4.8. The lists of the Standard Terms Database published by the European Directorate for the Quality of Medicines and Healthcare (EDQM) of the Council of Europe (2008) cover dosage forms, routes and/or methods of administration, and containers, closures and delivery devices used for medicines. The EDQM also provides standardized nomenclatures and quality standards for medicinal substances and products, which are published in the European Pharmacopoeia (EDQM, 2010). Package leaflets, too, have a standardized template where headings and sets of phraseological units are set down, such as: “Talk to your doctor before X”, “”, etc. (QRD, 2012, pp. 10–15). Other institutional guidelines on the readability of PLs contain indications on text type, size and font, the design and layout of the information, the print colour, syntax, style, paper weight, and use of images, etc. There are also specific recommendations for blind and partially-sighted patients (DGHC, 2008, 2009b).

5. Summary of product characteristics and package leaflet genre shift The medicinal product information genre system description shows that the different genres in the system deal with the same topic, but they fulfil different functions and each of them covers specific reader needs. These textual relationships, called referential and functional intertextuality, are of relevance to the medical writer and translator (Montalt Resurrecció & González Davis, 2007, pp. 55–56) because they underline the fact that genres are dependent on each other as far as communication is concerned but have to be written according to different processes of rhetorical composition with decreasing degrees of specialization and formality. To illustrate these intertextual operations we have chosen two of the genres that are more closely related: the SPC and the PL. PLs are composed from SPCs in a translation process known as genre shift —also known as heterofunctional or transgeneric translation— (Montalt Resurrecció & González Davis, 2007, p. 163) in which changes in rhetorical purpose and audience inevitably affect the texture and manner of re-presentation in predictable ways (Fahnestock, 1998). In this particular instance of intralinguistic genre shifting, the source genre, the SPC, is an

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expository genre addressed to experts and professionals, and the target genre, the PL, is an instructional genre addressed to lay readers. Genre shifting is used to bridge the gap between the patient’s right to know and the patient’s ability to understand, and guarantees the continuity of communication between different expertise communities. If we put the templates of both genres (QRD, 2012, pp. 4–8, 10–15, presented as Tables 2 and 3 in the Appendix) side by side, we can observe that major structural changes are introduced, PLs are simpler and shorter. The information on pharmaceutical data in Sections 1 to 3 of the SPC is presented in different places, mainly at the end of the PL (Section 6), and sometimes more than once. In PLs the information on clinical particulars (Section 4 of the SPC) goes at the beginning of the PL (Sections 1 to 3). Relevant scientific information, pharmacological properties and pharmaceutical details in SPCs (Sections 5 and 6) are reduced to the minimum in PLs. Table 1: Comparison of SPC and PL templates SPC 1. Name of the medicinal product

PL {(Invented) name strength pharmaceutical form}

2. Qualitative and quantitative composition

{Active substance(s)} 6. Contents of the pack and other information What X contains

3. Pharmaceutical form

[6.] What X looks like and contents of the pack 1. What X is and what it is used for

4. Clinical particulars 4.1 Therapeutic indications 4.2 Posology and method of administration 4.3 Contraindications

4.4 Special warnings and precautions for use 4.5 Interaction with other medicinal products and other forms of interaction 4.6 Fertility, pregnancy and lactation 4.7 Effects on ability to drive and use machines 4.8 Undesirable effects

3. How to X 2. What you need to know before you X Do not X [2.] Warnings and precautions [2.] Other medicines and X [2.] Pregnancy breastfeeding [2.] Driving and using machines 4. Possible side effects

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4.9 Overdose

[3.]

5. Pharmacological properties 5.1. Pharmacodynamic properties 5.2. Pharmacokinetic properties 5.3. Preclinical safety data 6. Pharmaceutical particulars 6.1. List of excipients 6.2. Incompatibilities 6.3. Shelf life 6.4. Special precautions for storage 6.5. Nature and contents of container 6.6. Special precautions for disposal 7. Marketing authorization holder

6. Contents of the pack and other information What X contains 5. How to store X

[6.] Marketing Authorization Holder and Manufacturer

8. Marketing authorization number(s) 9. Date of first authorization/renewal of the authorization 10. Date of the revision of the text

[6.] This leaflet was last revised in

As Montalt Resurrecció and González Davis point out (2007, pp. 162–164), besides structural simplification, there are other procedures used by linguistic mediators when genre shifting specialized genres into genres for patients: • • • • • • •

Synthesizing information. Expanding relevant information for the target reader. Shifting from author and content to reader comprehension. Adjusting tenor to achieve more personalized communication. Simplifying syntax. Using verbs instead of complicated nouns or noun phrases. Determinologizing complex terms.

In order to illustrate the shifts introduced and the procedures employed when genre shifting SPCs into PLs, we will compare the original SPC and the target PL of a particular medicinal product, VIAGRA 25 mg film-coated tablets (Pfizer Limited, 2009–2010), putting different examples of original

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fragments of the SPC and the mediated corresponding fragments of the PL side by side. In Example 1 below, information concerning clinical usage of the medicine, pharmaceutical particulars and pharmacological details of the SPC is synthesized to the minimum in the PL, and content focus third person declarative mode of the SPC is translated into second person factual conditional in the PL: “if you are… your doctor may”. Thus, the missing information in PL and any possible action will be handled by the reader of the SPC, the doctor. The reader of the PL is considered a non-powerful participant and any interpretation and form of action by patients is excluded. Also, the passive sentence “co-administration of sildenafil with ritonavir is not advised” and the negative wording “in any event the maximum dose of sildenafil should under no circumstances exceed 25 mg within 48 hours” are translated into an active positive sentence: “your doctor may start you on the lowest dose (25 mg) of VIAGRA”. Example 1 [SPC] [4.5 Interaction with other medicinal products and other forms of interaction] Co-administration of the HIV protease inhibitor ritonavir, which is a highly potent P450 inhibitor, at steady state (500 mg twice daily) with sildenafil (100 mg single dose) resulted in a 300% (4-fold) increase in sildenafil Cmax and a 1,000% (11-fold) increase in sildenafil plasma AUC. At 24 hours, the plasma levels of sildenafil were still approximately 200 ng/ml, compared to approximately 5 ng/ml when sildenafil was administered alone. …

[PL] [2.] [Taking other medicines:] If you are taking medicines known as protease inhibitors, such as for the treatment of HIV, your doctor may start you on the lowest dose (25 mg) of VIAGRA.

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[SPC] This is consistent with ritonavir’s marked effects on a broad range of P450 substrates. Sildenafil had no effect on ritonavir pharmacokinetics. Based on these pharmacokinetic results coadministration of sildenafil with ritonavir is not advised […] and in any event the maximum dose of sildenafil should under no circumstances exceed 25 mg within 48 hours. When shifting from author and content to reader comprehension, to facilitate the PL’s readability, other changes are also introduced, as in Examples 2, 3, 4 and 5. In the next example, the information listed in the SPC is translated into descriptive full sentences. In addition, the heading “Pharmaceutical form” of the SPC is expanded into the PL’s heading “What VIAGRA looks like and contents of the pack”: Example 2 [SPC] [3. PHARMACEUTICAL FORM] Film-coated tablet. Blue rounded diamond-shaped tablets, marked “PFIZER” on one side and “VGR 25” on the other.

[PL] [[6.] What VIAGRA looks like and contents of the pack] VIAGRA film-coated tablets are blue, with a rounded-diamond shape. They are marked “PFIZER” on one side and “VGR 25” on the other side.

In Example 3 below, relevant information for the target reader is clarified. As in “for oral use” translated as “Swallow the tablet whole with a glass of water”. Also, technical terms like “posology”, “toleration”or “indicated” are omitted. Complete sentences are used instead of noun phrases; for example: “sexual activity” is translated as “you plan to have sex”. Moreover, imperatives, bold type and modality are used to increase the degree of obligation and to express emphasis and caution, as in: “you should…”, “you may find…”, or in the sentence “Viagra is not indicated for” rewritten as “Viagra should not be given to”:

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Example 3 [SPC] 4.2 Posology and method of administration For oral use. Use in adults: The recommended dose is 50 mg taken as needed approximately one hour before sexual activity. Based on efficacy and toleration, the dose may be increased to 100 mg or decreased to 25 mg. The maximum recommended dose is 100 mg. The maximum recommended dosing frequency is once per day. If VIAGRA is taken with food, the onset of activity may be delayed compared to the fasted state. […] Use in children and adolescents VIAGRA is not indicated for individuals below 18 years of age.

[PL] 3. HOW TO TAKE VIAGRA Always take VIAGRA exactly as your doctor has told you. […] The usual starting dose is 50 mg. You should not take VIAGRA more than once a day. You should take VIAGRA about one hour before you plan to have sex. Swallow the tablet whole with a glass of water. […] You may find that VIAGRA takes longer to work if you take it with a heavy meal. […] Special considerations for children and adolescents VIAGRA should not be given to individuals under the age of 18.

In the following example we can observe how specialized terms are dealed with so that a non-specialist reader can understand them. The characteristic nominalization of scientific language, for example, “contraindications”, “hypersensitivity”, is translated into full imperative sentences: “Do not take Viagra”, “If you are allergic (hypersensitive)”. Also, the medical term “hypersensitive” is retained but in parenthesis after the popular term “allergic”: Example 4 [SPC] 4.3 Contraindications Hypersensitivity to the active substance or to any of the excipients.

[PL] Do not take VIAGRA – If you are allergic (hypersensitive) to sildenafil or any of the other ingredients of VIAGRA.

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To achieve a more personalized communication, the tenor is adjusted in PLs, the language is more personal and the passive is less frequent. In Example 5, we can notice that the degree of formality decreases (e.g., “penile erection” translated as “to get or keep a hard, erect penis”, “satisfactory sexual performance” translated as “sexual activity”). Also, the personal pronoun “you” is introduced in the passive form: “sexual stimulation” is translated as “you are sexually stimulated”. Example 5 [SPC] 4. CLINICAL PARTICULARS 4.1 Therapeutic indications Treatment of men with erectile dysfunction, which is the inability to achieve or maintain a penile erection sufficient for satisfactory sexual performance. In order for VIAGRA to be effective, sexual stimulation is required.

[PL] 1. WHAT VIAGRA IS AND WHAT IT IS USED FOR VIAGRA is a treatment for men with erectile dysfunction, sometimes known as impotence. This is when a man cannot get, or keep a hard, erect penis suitable for sexual activity. VIAGRA will only help you to get an erection if you are sexually stimulated.

As we have mentioned, when the context of communication of medical knowledge moves from specialists to the general public, terminology, which is a quick, clear and precise way of transmitting information for the specialist, may hinder comprehension for the lay reader. Determinologization is therefore a requirement. Montalt Resurrecció and González Davis (2007, pp. 252–253) state that the determinologization procedures that can be used by translators and medical writers when, for example, producing press releases from medical research articles, include the following: • • • •

Scientific terms are retained and followed by explanations. Scientific terms are retained in parentheses after the explanations. Scientific terms are followed by popular terms. Scientific terms are completely avoided and replaced by explanations.

In the process of genre shifting from SPCs into PLs a comprehensive operation of determinologizing the original text is also required of the linguistic mediators. In our example of VIAGRA 25 mg film-coated tablets

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(Pfizer Limited, 2009–2010) we can find instances of the following determinologization procedures: •

• •

•

Scientific terms retained and followed by explanations and/or popular terms: the phrase “patients who have conditions which may predispose them to priapism (such as sickle cell anaemia, multiple myeloma or leukaemia)” in the SPC is translated as “If you have sickle cell anaemia (an abnormality of red blood cells), leukaemia (cancer of blood cells), multiple myeloma (cancer of bone marrow)” in the PL. Scientific terms retained after the explanations in the PL, as in “If you are allergic (hypersensitive)” or “If you have a deformity of your penis or Peyronie’s Disease”. Scientific terms followed and/or accompanied by popular terms in the PL, as in “angina pectoris (or ‘chest pain’)”, “the drugs known as nitric oxide donors such as amyl nitrite (‘poppers’)”, or “If you have a deformity of your penis or Peyronie’s Disease”. Scientific terms completely avoided and replaced by popular terms: for example, “Impaired renal function” in the SPC becomes “kidney problems” in the PL; and “Impaired hepatic function” in the SPC is determinologized as “liver problems” in the PL.

As a summary, we can state that the different shifts observed when genre shifting from SPCs into PLs are: • • •

Shifts that are intended to facilitate the PL’s readability for patients. Shifts that are intended to exercise control over patients’ actions and that have power implications. Shifts that personalize communication and try to get closer to readers.

6. Conclusions In this study, I propose that the notion of genre systems can be a valuable analytic device for studying the roles played by the context and the different agents involved in complex communicative actions such as the medicinal product information, and a means to provide medical writers and translators with the contextual and textual information that their task requires. Our purpose here is to help to illustrate how genre systems description can be used to adress the multifaceted issue of medicinal product information. I have described the medicinal product information genre system, focusing on how metagenres interact with the genre system, how they regulate the interrelations and sequence of the constituent genres, and how they contribute to stabilizing the content and form of communicative

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product information practices, paying special attention to two of the salient and more closely related genres, the SPC and the PL. The system as a whole, as well as the individual genres, can be said to have a socially recognized purpose and common formal characteristics. It is suggested that the contextual knowledge of these dimensions and of the institutional operations of metagenres can benefit and play an important role in the socialization of medical writers and linguistic mediators as communicative agents of the pharmaceutical sector. To approach the way in which textual competence should be acquired and applied by linguistic mediators, the intertextual operations that take place between the specialized genre and the lay-friendly genre have been explored. Our method here is not corpus-based; we have rather illustrated the genre shift or intralinguistic transgeneric translation process from the SPC into the PL, both genres belonging to the medicinal product information genre system, taking the example of a particular medicinal product (VIAGRA 25 mg film-coated tablets). Although the mediator’s decisions in the process of genre shifting from SPCs into PLs are restricted by norms and rules, there are certain areas that offer scope for rhetorical composition, which are governed in turn by the communicative needs and purposes of PLs. I have identified different types of shift; and genre-shifting strategies and determinologization procedures have been illustrated. It is suggested that they may be used by (prospective) professional medical writers and translators to work more efficiently and to achieve the intended communicative function of the texts produced. However, further corpusbased analysis will be needed to consolidate (or extend) the list of strategies and procedures identified. Also, the power implications that we have just pointed out and that may underlie the shift from the specialized into the layfriendly genre will require a more careful consideration. This study may also contribute to the development of conceptual and cognitive resources for researchers interested in medical communication processes, and to the improvement of tools for the teaching and acquisition of medical writing and translation competence, in its formal, social and cognitive aspects.

References Bhatia, V. K. (1997). Translating legal genres. In A. Trosborg (Ed.), Text typology and translation (pp. 203–214). Amsterdam: John Benjamins. Bakhtin, M. (1986). The problem of speech genres. V.W. McGee (Translated into English. Russian original). In C. Emerson & M. Holquist (Eds.), Speech genres and other late essays (pp. 60–102). Austin: University of Texas Press. Bazerman, C. (1994). Systems of genres and the enactment of social intentions. In A. Freedman & P. Medway (Eds.), Genre and the new rhetoric (pp. 79–101). London: Taylor and Francis.

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Berkenkotter, C. (2001). Genre systems at work: DSM-IV and rhetorical recontextualization in psychotherapy paperwork. Written Communication, 18, 326–349. Devitt, A. J. (2000). Integrating rhetorical and literary theories of genre. College English, 62(6), 696–718. Directorate General for Health and Consumers (DGHC). (1986–2012a). Volume 1: Pharmaceutical legislation medicinal products for human use. In The rules governing medicinal products in the European Union. Retrieved July 20, 2012, from http://ec.europa.eu/health/documents/eudralex/vol-1/index_en.htm Directorate General for Health and Consumers (DGHC). (1986–2012b). Volume 2: Pharmaceutical legislation notice to applicants and regulatory guidelines medicinal products for human use. In The rules governing medicinal products in the European Union. Retrieved July 20, 2012, from http://ec.europa.eu/ health/documents/eudralex/vol-2/index_en.htm Directorate General for Health and Consumers (DGHC). (2008). Guideline on the packaging information of medicinal products for human use authorised by the community. In The rules governing medicinal products in the European Union (Vol. 2C). Retrieved January, 20 2012, from http://ec.europa.eu/health/files/ eudralex/vol-2/c/bluebox_02_2008_en.pdf Directorate General for Health and Consumers (DGHC). (2009a). A guideline on summary of product characteristics. In The rules governing medicinal products in the european union (Vol. 2C). Retrieved January 20, 2012, from http://ec.europa.eu/health/files/eudralex/vol-2/c/smpc_guideline_rev2_en.pdf Directorate General for Health and Consumers (DGHC). (2009b). Guideline on the readability of the labelling and package leaflet of medicinal products for human use. In The rules governing medicinal products in the European Union (Vol. 2C). Retrieved January 20, 2012, from http://ec.europa.eu/health/files/ eudralex/vol-2/c/2009_01_12_readability_guideline_final_en.pdf European Directorate for the Quality of Medicines and Healthcare (EDQM). (2008). Standard terms database. Retrieved December 12, 2011, from http://www. edqm.eu/en/Standard_Terms-590.html European Directorate for the Quality of Medicines and Healthcare (EDQM). (2010). European pharmacopoeia. Retrieved January 12, 2012, from http://www. edqm.eu/en/European-Pharmacopoeia-1401.html European Medicines Agency (EMA). (1995–2012). Product information requirements. In European Medicines Agency: Science, medicines, health. Retrieved July 20, 2012, from http://www.ema.europa.eu/ema/index.jsp?curl=pages/regulation/ general/general_content_000199.jsp&mid=WC0b01ac0580022bb3 European Medicines Agency. (2011). Operational procedure on the linguistic review process of product information in the centralised procedure—human. Retrieved January 22, 2012, from http://www.ema.europa.eu/docs/en_GB/document_ library/Regulatory_and_procedural_guideline/2009/10/WC500004182.pdf Ezpeleta Piorno, P., & Gamero Pérez, S. (2004). Los géneros técnicos y la investigación basada en corpus: proyecto GENTT. In R. Gaser, C. Guirado, & J. Rey (Eds.),

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Insights into scientific and technical translation (pp. 147–156). Barcelona: PPUUniversitat Pompeu Fabra. Fahnestock, J. (1998). Accommodating science: The rhetorical life of scientific facts. Written Communication, 15, 330–350. Freedman, A., & Medway, P. (Eds.). (1994). Genre and the new rhetoric. London: Taylor and Francis. García Izquierdo, I. (Ed.). (2005). El género textual y la traducción. Bern: Peter Lang. García Izquierdo, I., & Montalt Resurrecció, V. (2002). Translating into textual genres. Linguistica Antverpiensia New Series – Themes in Translation Studies, 1, 135– 143. Giltrow, J. (2001). Meta-genre. In R. M. Coe, L. Lingard, & T. Teslenko (Eds.), The rhetoric and ideology of genre: Strategies for stability and change (pp. 187– 206). Cresskill, NJ: Hampton. Medical Dictionary for Regulatory Activities (MedDRA). (2012). Retrieved February 10, 2011, from http://meddramsso.com/ Miller, C. (1984). Genre as social action. Quarterly Journal of Speech, 70, 151–167. Montalt Resurrecció, V., Ezpeleta Piorno, P., & García Izquierdo, I. (2008). The acquisition of translation competence through textual genre. Translation Journal, 12(4). Retrieved November 10, 2011, from http://translationjournal.net/journal/46competence. htm. Montalt Resurreció, V., & González Davis, M. (2007). Medical translation step by step. Manchester: St Jerome. Pfizer Limited (2009–2010). Viagra: EPAR product information. Retrieved January 20, 2012, from http://www.ema.europa.eu/docs/en_GB/document_library/EPAR__Product_Information/human/000202/WC500049830.pdf Quality Review of Documents Group (QRD). (2012). Draft quality review of documents human product information annotated template: Revision of the product information. Retrieved July 28, 2012, from http://www.ema.europa.eu/ docs/en_GB/document_library/Template_or_form/2012/07/WC500130008.pdf Russell, D. (2001). The kind-ness of genre: An activity theory analysis of high school teachers’ perception of genre in portfolio assessment across the curriculum. In R. M. Coe, L. Lingard, & T. Teslenko (Eds.), The rhetoric and ideology of genre: Strategies for stability and change (pp. 225–242). Cresskill, NJ: Hampton. Schryer, C. F. (2001). Genre and power: A chrontopic analysis. In R. M. Coe, L. Lingard, & T. Teslenko (Eds.), The rhetoric and ideology of genre (pp. 73–102). Cresskill, NJ: Hampton. Schryer, C. F., & Spoel, P. (2005). Genre theory, health care discourse, and professional identity formation. Journal of Business and Technical Communication, 19, 249– 278. Spinuzzi, C. (2003). Tracing genres through organizations: A sociocultural approach to information design. Cambridge, MA: MIT Press. Trosborg, A. (Ed.) (1997). Text typology and translation. Amsterdam: John Benjamins.

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Yates, J., & Orlikowski, W. (2001). Genre systems: Chronos and kairos in communicative interaction. In R. M. Coe, L. Lingard, & T. Teslenko (Eds.), The rhetoric and ideology of genre: Strategies for stability and change (pp. 103– 122). Cresskill, NJ: Hampton. Yates, J., & Orlikowski, W. (2002). Genre systems: Structuring interaction through communicative norms. Journal of Business Communication, 39(1), 13–35.

Appendix Table 2: Summary of product characteristics template (QRD, 2012, pp. 4-8)

SUMMARY OF PRODUCT CHARACTERISTICS 1. Name of the medicinal product 2. Qualitative and quantitative composition 3. Pharmaceutical form 4. Clinical particulars 4.1. Therapeutic indications 4.2. Posology and method of administration 4.3. Contraindications 4.4. Special warnings and precautions for use 4.5. Interaction with other medicinal products and other forms of interaction 4.6. Fertility, pregnancy and lactation 4.7. Effects on ability to drive and use machines 4.8. Undesirable effects 4.9. Overdose 5. Pharmacological properties 5.1. Pharmacodynamic properties 5.2. Pharmacokinetic properties 5.3. Preclinical safety data 6. Pharmaceutical particulars 6.1. List of excipients 6.2. Incompatibilities 6.3. Shelf life 6.4. Special precautions for storage 6.5. Nature and contents of container 6.6. Special precautions for disposal 7. Marketing authorization holder 8. Marketing authorization number(s) 9. Date of first authorization/renewal of the authorization 10. Date of the revision of the text

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Table 3: Package leaflet template (QRD, 2012, pp. 10-15) Package leaflet: Information for the {(Invented) name strength pharmaceutical form} What is in this leaflet 1. What X [the medicine] is and what it is used for 2. What you need to know before you X Do not X Warnings and precautions Children Other medicines and X X with Pregnancy breast-feeding Driving and using machines

3. How to X



4. Possible side effects

5. How to store X 6. Contents of the pack and other information What X contains What X looks like and contents of the pack Marketing Authorization Holder and Manufacturer This leaflet was last revised in

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This article is part of the research project: 2010-2012 (FFI2009-08531/FILO), funded by the Spanish Ministry of Science and Innovation (MICINN).

From the original article to the summary for patients: Reformulation procedures in intralingual translation 1

Ana Muñoz-Miquel Universitat Jaume I

The wider access to information and the tendency toward patient education have increased the demand for medical texts aimed at a wide, nonspecialized, heterogeneous audience. In this context, it is essential to know what procedures are required to make specialized knowledge accessible to non-experts. This paper presents a corpus-based exploratory study that describes the procedures employed to reformulate, intralingually, medical knowledge from a highly specialized genre, the original article (OA), into a genre derived directly from it but addressed to laymen, namely, the summary for patients (SP). The linguistic and textual changes that take place when translating an OA into an SP are taken as the basis for explaining the reformulation procedures used. The results of the study contribute to the characterization of the SP from a text genre perspective, and provide keys to writing and reformulating for both medical translators and experts in the field, who are often called upon to carry out these intralingual translations.

1. Introduction Nowadays, the more widespread access to information has kindled people’s interest in knowing “what scientists are up to” (García Palacios, 2001, p. 159, my translation). In the field of medicine, these aspects, together with the current tendency toward educating the patient, who is assuming a more active role when making decisions about his/her health, have increased the demand for texts that facilitate the transfer of medical knowledge to a wide, non-specialized, heterogeneous audience. A growing number of publications written by and for specialists (such as the journal Annals of Internal Medicine) now include simplified versions of original research works that are reformulated and recontextualized (Ciapuscio, 2003, p. 210) intralingually to meet the needs of a lay audience. These expert-to-layman reformulations, called intralingual translations or rewordings in Jakobson’s classification of the types of translation (1959/2000), have thus become an important practice today. Intralingual translations do not conform with what translation theory traditionally calls translation proper (Zethsen, 2007, p. 281), that is, translation between different languages. Although these kinds of translation are governed by functional (Nord, 1997; Reiss & Vermer, 1984/1991) rather than linguistic factors, they may well be part of the multifaceted activity carried out by translators, “as most experts find it difficult to write

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about their field in layman terms” (Zethsen, 2009, p. 809). In view of this situation and given the growing demand for texts aimed at a lay audience, it is important to know what procedures are required to reword specialized medical knowledge in order to reach the non-expert reader. This is especially relevant for those who carry out this activity, whether they are translators, editors or experts in the field. This paper presents a corpus-based exploratory study that describes the procedures employed to reformulate medical knowledge from a highly specialized and conventionalized genre, that is, the original article (henceforth, OA), into a genre aimed at laymen that is “intergenerically derived” (Askehave & Kastberg, 2001, p. 491) from the OA, that is, the summary for patients (henceforth, SP). These genres share the same subject matter but differ mainly in terms of communicative purpose and target reader. The OA, also known as a research article, journal article, original investigation or original contribution, has been widely studied in the literature (Bhatia, 1993; Nwogu, 1997; Swales, 1990). It is a primary information genre, the communicative purpose of which is to make known the results of a research study in a rigorous manner and convince the reader of their validity. This demand for rigour implies the use of a fixed macrostructure (IMRD: Introduction, Methods, Results, Discussion) and a specialized jargon that is shared by the sender and the receiver, as both belong to the same community of specialists. The SP, nevertheless, is a relatively new popularizing genre exclusive to the biomedical field, given that in other disciplines there is no need for this communicative mediation (Montalt, 2005, p. 73). Usually following a question-and-answer structure, its main communicative purpose is to reformulate specialized medical studies 2 for laymen. Though it is increasingly used in medical journals, 3 associations, 4 or research institutes, 5 it has received very little attention in the academic literature. The corpus of OAs and their corresponding SPs compiled for this study was analysed taking into consideration the concept of text genre (Bhatia, 1993; Swales, 1990) with its communicative, formal, and cognitive aspects (Montalt, Ezpeleta Piorno, & García Izquierdo, 2008). This approach allows us to identify a prototypical series of aspects such as participants, purpose, communicative situation, text conventions or readers’ needs, which may govern the translator’s decisions regarding the reformulation procedures to be used. Thus, comparing the characteristics of the source and the target genres may enable us to better understand and describe the linguistic and textual changes that take place when translating an OA into an SP intralingually, that is, when performing an intergeneric translation (Askehave & Zethsen, 2001), expert-to-layman translation (Zethsen, 2007, p. 301) or genre shift (Montalt & González Davies, 2007, p. 163). The article is organized as follows: Section 1.1 reviews some of the most common popularization and reformulation procedures found in the

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literature; Section 2 explains the characteristics of the corpus and the method of analysis; Section 3 describes the reformulation procedures from a macro and microtextual point of view; and, finally, Section 4 discusses the procedures analysed and presents some concluding remarks.

1.1. Popularization and reformulation procedures The procedures for popularizing or reformulating scientific knowledge have been addressed by disciplines such as translation studies, linguistics, discourse studies or scientific journalism, among others. Either from an intralingual perspective (Adams Smith, 1987; Askehave & Kastberg, 2001; Ciapuscio, 2003; Gutiérrez Rodilla; 1998) or from an interlingual point of view (Albin, 1998; Askehave & Zethsen, 2001, 2002; Mayor Serrano, 2005; Montalt & González Davies, 2007), these contributions describe or prescribe the reformulation procedures in expert-to-layman communication or the characteristics of popularizing genres by taking different genres (popular articles, patient package inserts, patient information leaflets, etc.) as a reference. Though none of these works focus on the SP (given the lack of studies centred on this genre), they can serve as a reference since those genres share the same reader and overall social function as the SP. A review of the abovementioned contributions reveals that the reformulation procedures to be applied either intralingually or interlingually are varied and affect the text on both the macrotextual (content, structure and organization of information) and the microtextual (morphosyntactic and lexical mechanisms) levels. Most authors agree on putting the emphasis on the procedures used in order to clarify the terminology, which is “the most obvious barrier” (Ciapuscio, 2003, p. 222) and, at the same time, the most characteristic trait of specialized scientific genres. In Table 1 below we classify the most commonly mentioned procedures according to the macrotextual and microtextual aspects that may be subject to modification: Table 1. Reformulation procedures found in the literature reviewed Level Macrotextual

Aspect affected Title

General structure

Procedures to be used • Rewording the title to make it more attractive, revealing and definite, and less descriptive. • Restructuring the overall text. • Shortening the length of paragraphs.

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Content

Typography, layout and visual support

Microtextual Morphosyntax

Microtextual Lexis

Sentence length and structure Verbs

• Selecting the most relevant information. • Eliminating information considered not relevant (e.g., statistical data). • Adding topics not found in the original. • Making the applications of the study and social consequences prevail over the scientific environment. • Incorporating visual elements (figures, illustrations and tables). • Using vertical numbered or bulleted lists for listing elements. • Avoiding capital letters. • Emphasizing keywords. • Avoiding justification, hyphenation and footnotes. • Shortening sentences. • Simplifying complex syntactic structures.

Voice

• Giving preference to transitive verbs and simple tenses. • Increasing the use of the active voice.

Noun phrases

• Replacing noun phrases by verbal clauses.

Tenor

• Addressing the reader directly.

Punctuation marks Technical terms or concepts

• Increasing the number of punctuation marks to introduce explanations, definitions, etc. • Keeping the technical term and adding explanations/metaphors/comparisons/exemp lifications. • Eliminating the technical term and replacing it with: pseudoequivalents/explanations/paraphrases. • Rewording abstract concepts in a nonabstract manner. • Using redundancy techniques (repetitions, synonyms) for complex concepts.

This brief review will be used as the basis for the analysis of the changes observed in our corpus. This may allow us to detect whether there are characteristics or reformulation procedures that are prototypical of the SP genre.

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2. Materials and methods For the analysis, ten OAs and their corresponding SPs were selected. 6 All of them were taken from Annals of Internal Medicine (http://www.annals. org/), a leading internal medicine journal and one of the most cited worldwide. This journal, established by the American College of Physicians, publishes a wide variety of information on internal medicine and related topics, among which OAs are the most frequent publication. These OAs obey the general IMRD structure, are preceded by an abstract, and include acknowledgements, references, figures and, if necessary, appendices. As previously mentioned, the journal also includes information aimed at laymen. The preparation of the SPs and the Patient Information Pages, 7 which provide general information about common health conditions, constitutes the journal’s initiative to publish specialized information for non-experts. On the Annals of Internal Medicine’s website, SPs are described as: “brief, non-technical summaries of studies and clinical guidelines [...]. The Summaries aim to explain these published articles to people who are not health care providers”. 8 The overall social function of SPs is thus to make medical knowledge more widely known, and their rhetorical purpose is to explain information about a specific study on internal medicine. They are addressed to a non-expert reader who, as happens with scientific magazines, may be interested in medicine but has no medical background. These SPs include bibliographic information about the OA on which they are based and a message informing the reader of the purpose of the summary. The ten OAs were chosen according to the following criteria: • • •

Having open access (the most recent OAs are not available); Having an SP, because many do not; Being fairly recent (from 2005 to 2011).

Additionally, efforts were made to include OAs covering diverse areas within internal medicine. Once the OAs and their SPs had been chosen, a qualitative analysis of the linguistic and textual changes that take place when translating an OA into an SP was carried out. These changes are viewed as the results of the author’s strategic choices about the procedures to be used to reformulate specialized knowledge. The summary of the main procedures found in the literature (Table 1) was used as a basis to carry out the analysis. The procedures were thus approached according to the textual levels that could be modified: on a macrotextual level, aspects such as title, structure, length, content and typographical variations were taken into account. On a microtextual level, sentence length and structure, verbs, voice, noun phrases, tenor, modality and management of specialized terms were

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analysed. To illustrate the analysis, examples taken from the OAs are compared with their SPs.

3. Analysis and results In this section, the linguistic and textual changes found in our corpus will be described from a macro and microtextual point of view.

3.1. Macrotextual level On a macrotextual level, we will focus on the main changes concerning title, structure, length, content, and typography and layout.

3.1.1. Title The main aim of an OA title is to provide as much information as possible about the content and objective of the study. This is the reason why it is usually “long, precise and informative” (Busch-Lauer, 2000, p. 92). In the case of the SPs analysed, eight of the ten titles are shortened as well as simplified. They retain the same descriptive nature but are less dense in content, tend to omit details on the methods applied, and contain fewer technical terms: (1)

[OA] The Risk for Myocardial Infarction with Cyclooxygenase-2 Inhibitors: A Population Study of Elderly Adults. [SP] Risk for Heart Attacks with Different NSAIDs.

3.1.2. Structure The standard IMRD structure of the OA is transformed into a series of questions and answers that respond, in essence, to the questions posed in a research study, albeit in a highly simplified manner. Each SP section has the same rhetorical purpose as the sections of the OA. Table 2 below shows the sections that form the SP and how they relate to the OA.

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Table 2. Structure of the OA and the SP Structure of the OA

Structure of the SP

Rhetorical purpose

Introduction

What is the problem and what is known about it so far?

Define the problem, prove it is interesting, and establish the hypothesis and objective.

Why did the researchers do this particular study? Methods

What was studied? How was the study done?

Explain what was studied and how.

Results

What did the researchers find?

Provide information about the results obtained.

Discussion

What were the limitations of the study?

Explain the results in the context of the study.

What are the implications of the study?

3.1.3. Length The OAs analysed have an average of 7665 words, whereas the SPs only have 492 words, so the original content is reduced by more than 90%. Apart from this reduction, there are certain contents of the OA that are always omitted in the SP, namely: the abstract that precedes the article, the references, the appendices, and the visual elements (figures, tables and graphs).

3.1.4. Content As a considerable reduction of information has been carried out, we shall examine what information remains in each section and what was omitted. The section What is the problem and what is known about it so far? is the longest (about 40% of the total). Here, the content originating directly from the OA is minimal, since most of it is not explicitly stated in the OA. This is contextual information that is assumed to be known by a reader belonging to the research community, but that is made explicit for a reader without such background knowledge. Let us examine an example of the first few lines from an OA and its corresponding SP:

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(2)

[OA] Rapid ascent to altitudes greater than 2500 m may cause acute mountain sickness (AMS) and high-altitude pulmonary edema (HAPE). In nonacclimatized mountaineers, the prevalences of AMS and HAPE at 4559 m are approximately 50% and 4%, respectively. [SP] There is less oxygen in the air at high altitude than at sea level. Many people who live at sea level travel to high altitude for recreational purposes. Some people become ill shortly after arriving at high altitude. Illness at high altitude is caused by the effects of low oxygen levels on the blood vessels, lungs, and brain. About 50% of people who ascend rapidly to high altitude develop acute mountain sickness (AMS), characterized by headache, nausea, fatigue, lightheadedness, and insomnia. Four percent of people develop a lifethreatening illness, high-altitude pulmonary edema (HAPE), characterized by fluid accumulation in the lungs that blocks oxygen uptake, causing shortness of breath and even death if effective therapy is not provided. Doctors treat both AMS and HAPE with extra oxygen to breathe.

As we can observe, the amount of contextual information added is significant. The two diseases and the reasons why they occur are explained, as well as their symptoms and how they are treated. In contrast with this, very detailed information, such as the specific altitudes, is omitted and conveyed to the reader with the adjective “high” only. The section Why did the researchers do this particular study? clearly corresponds to the purpose of the study, which in the OA is usually expressed in the last lines of the introduction: (3)

[OA] In our study, we examined whether initial treatment for early breast cancer differed between women who qualified for Social Security Disability Insurance (SSDI) and Medicare at diagnosis and other women younger than 65 years of age and the extent to which observed differences in breast cancer treatment relate to survival. [SP] To see whether women with localized breast cancer and disabilities are treated differently from and live as long as those without disabilities.

As we can see, the purpose of the study is explained more simply, and the amount of detail (e.g., information concerning the age or the insurance) is reduced. The sections of the SP that correspond to the OA methodology, Who was studied? and How was the study done?, only provide information relevant to the design of the study and its participants. The section Who was

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studied? is the shortest (70% of the cases are summarized in a single sentence). As we can see in the example to follow, the SP only includes information about the total number of participants and their main characteristics with regard to the purpose of the study. The OA provides more detailed and complex information (such as participants’ inclusion and exclusion criteria, state of health, origin), which has not been included in this paper due to space limitations: (4)

[SP] 216 adults who still needed a breathing machine 4 days after heart surgery.

The section How was the study done? is more extensive than the previous one, although the simplification and the selection of information are also dominant procedures. Statistical data are completely eliminated and technical terms avoided, such as those defining the type of study (randomized, prospective, single-blinded, controlled, etc.). As the example shows, these terms are replaced by paraphrases, a procedure that will be explained in Section 3.2.2.2.: (5)

[OA] Participants and study personnel responsible for follow-up assessments were blinded to treatment assignment. [SP] […] neither the patients nor the researchers who assessed adverse events were told which patients received vaccine or placebo.

Despite this tendency to simplify and reduce information, we also find additions with the aim of making contents easier to understand. In the example below, the equivalent unit of measurement in the target culture is provided along with the international one: (6)

[SP] […] an altitude of 4559 meters (14,000 feet) 9

With regard to What did the researchers find? the main results of the study are explained by giving only general information, thus avoiding the use of statistical analysis data (medians, IQR, probabilities, test results, etc.): (7)

[OA] The 3-month Kaplan-Meier estimates of pneumonia in the nectar-thick and honey-thick liquid groups were 0.084 (10 events) and 0.150 (18 events), respectively (HR, 0.50 [CI, 0.23 to 1.09]; P _ 0.083). [SP] About 15% of the patients who drank honey-thick liquid and about 8% who drank nectar-thick liquid developed pneumonia.

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There are even cases where the reasons that could cause such results are specified, although this information is not included in the original: (8)

[OA] The median time taken to administer epinephrine for the mass concentration group was 35.5 seconds (IQR, 27.0 to 65.0 seconds) compared with 130.0 seconds (IQR, 112.0 to 171.0 seconds) for the ratio group (p ≤ 0.001). The adjusted mean time was 91.0 seconds (CI, 61.0 to 122.1 seconds) (Table) greater in the group using a ratio rather than mass concentration label. [SP] Because they had to figure out how much drug to give, the doctors using ampules labeled with a ratio also took about 1.5 minutes longer to give it.

As we can see, another procedure used to simplify the results is the conversion of seconds into minutes, which may be easier for the reader to understand at first sight. Finally, the sections What were the limitations of the study? and What are the implications of the study? focus on explaining its main limitations and implications. As the example shows, generally only some of these limitations/implications are mentioned—possibly the most relevant ones. Moreover, these are not usually explained in the order in which they appear in the OA: (9)

[OA] Our study had some limitations. First, while we did not observe any increased risk with the use of meloxicam, traditional NSAIDs, or naproxen, our power to detect meaningful differences was limited by the unexpectedly low use of these agents. Second, only case-patients admitted to the hospital were included in our analysis. […] Third, we did not have information on smoking status, obesity, physical activity, family history, and socioeconomic status. […]. While a major strength of this study has been our accounting of the riskmodifying effects of aspirin, concern may exist about the possibility of misclassification due to missing information on over-the-counter use of aspirin, as well as ibuprofen […]

[SP] The researchers did not assess over-the-counter use of aspirin and ibuprofen and whether people took prescribed amounts of NSAIDs [fourth limitation]. The researchers had limited ability to detect risks of meloxicam, naproxen, and traditional NSAIDs because most NSAID prescriptions were for rofecoxib and celecoxib [first limitation]. The researchers may have missed some heart attacks since the study databases recorded only heart attacks that led to hospitalization [second limitation].

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In this example one can also observe that other procedures affecting terms and concepts are used: abstract and technical notions are specified (“low use of these agents” becomes “most NSAID prescriptions were for rofecoxib and celecoxib” and “case-patients admitted to the hospital” is conveyed as “heart attacks that led to hospitalization”). We will focus on these kinds of procedure in Section 3.2.2.

3.1.5. Typography and layout Several typographical variations are introduced into the SPs: • • •

The columns showing the content of the OAs are eliminated; The text is aligned to the left as opposed to justified; In contrast to the OA, hyphenation is avoided.

3.2. Microtextual level Now that the changes on a macrotextual level have been described, in this section the procedures that lead to lexical and morphosyntactical modifications will be analysed.

3.2.1. Morphosyntax Regarding morphosyntax, procedures affecting sentence length and structure, verbs, voice, noun phrases, tenor, modality, and punctuation marks will be analysed.

3.2.1.1. Sentence length and structure The sentence structure is simplified considerably. This simplification becomes apparent in terms of both the length (sentences tend to be shorter) and the morphosyntactical and lexical structure: (10) [OA] Study personnel who reconstituted the vials and inoculated the participants […]. [SP] Staff injecting the solution under the skin […]. (11) [OA] The patient simulator was programmed to mimic development of acute anaphylaxis with hypotension profound enough to warrant 0.12 mg of intramuscular epinephrine, according to the protocol.

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[SP] The researchers programmed a medical mannequin to look like it was having a life-threatening allergic reaction. As we can see, specific details (such as the characteristics of the allergic reaction) are omitted; the ideas conveyed are reworded with a more accessible language (“to mimic development of acute anaphylaxis” becomes “look like it was having a life-threatening allergic reaction”); words of a Latin or Greek origin (inoculate, mimic) are avoided (on the subject of these last two points see Examples 26 and 27), and the logical sentence structure (subject/verb/object) is followed. Paradoxically, in many cases the process of simplifying concepts leads to the use of a larger number of words, as abstract concepts need to be clarified (in the example below, “immediate early tracheotomy” and “prolonged intubation”): (12) [OA] patients […] were randomly assigned to immediate early tracheotomy or prolonged intubation with tracheotomy only when mechanical ventilation exceeded day 15 after randomization. [SP] Patients were randomly assigned to have an early tracheotomy done in the intensive care unit within 1 day or breathing support continued through a tube already inserted into the mouth for up to 2 weeks, at which time tracheotomy was considered.

3.2.1.2. Verbs and voice Preference is given to the active voice. Many passive sentences are replaced by active transitive ones for the sake of simplification: (13) [OA] In the tadalafil group, 2 participants developed severe AMS on the evening of arrival at 4559 m and were withdrawn from the study. [SP] Two participants taking tadalafil dropped out after developing severe AMS on the evening of arrival at altitude. In this example, again other procedures are also used: omission of specific details (4559 m), and shortening and simplification of sentences (preference for verbal clauses, that is,, “Two participants taking tadalafil” to noun phrases, that is, “In the tadalafil group, 2 participants”).

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3.2.1.3. Noun phrases As already shown in the above example, there is a clear preference for using verbal clauses as opposed to noun phrases. We can find more examples in the following extract: (14) [OA] A general recommendation for use of dexamethasone in prophylaxis against HAPE and AMS in adults who are susceptible to HAPE cannot be made on the basis of our findings because of the limited number of highly selected participants, the participants’ short exposure to high altitude, the single-center nature of this study, and the lack of assessment of adverse side effects. [SP] The researchers were not able to recruit as many participants as they had planned. The study did not evaluate the adverse side effects of each medication.

3.2.1.4. Tenor Tenor is adjusted to achieve a more personalized communication. The impersonality of scientific discourse is reduced in the SPs by giving more visibility to the authors of the study. This is also achieved by increasing the number of sentences written in the active voice: (15) [OA] Participants were enrolled in this 3-month follow-up study […]. [SP] Researchers followed patients for 3 months […].

3.2.1.5. Modality Scientific uncertainty is made apparent in the OAs by the frequent use of modal verbs and adverbs of doubt. The SPs are more conclusive when presenting the results, and there is a clear tendency to avoid modal verbs and replace them with more definite assertions. The declarative modality prevails over the hypothetical one: (16) [OA] Third, our findings may not generalize to persons with disabilities who, for whatever reason, do not apply or qualify for SSDI and Medicare.

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[SP] Also, the findings apply only to women with disabilities who received disability benefits from the federal government. 3.2.1.6. Punctuation marks Finally, the increased number of determinologization procedures such as definitions, explanations, and examples increase the usage of punctuation marks with a metalinguistic function, especially parenthesis: (17) [SP] Complications of colonoscopy include perforation (a hole in the wall of the colon) […]. These determinologization procedures will be analysed in detail in the next section.

3.2.2. Lexis The procedures for determinologizing technical terms and concepts usually take place at the beginning of the SP, in the section What is the problem and what is known about it so far? In the rest of the SP it is less common to find these kinds of procedure, maybe because key concepts have already been clarified. Let us now analyse all these procedures in detail.

3.2.2.1. Technical terms that are kept The most common practice is to keep the technical term but to accompany it with an explanation or definition that is placed either before or after the term itself. Normally the explanation precedes the medical term, which generally appears in parenthesis and sometimes after a reformulator such as this is called: (18) [SP] Some persons with dementia, Parkinson disease, stroke, or other neurologic conditions have difficulty with swallowing (dysphagia). […] During coughing or choking, they may inhale liquid or food through their windpipes into their lungs; this is called aspiration. In other cases, it is the specialized term that precedes the explanation, definition or specification of the word (see also Nisbeth Jensen & Zethsen in this issue):

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(19) [SP] More recently, researchers have suggested using tadalafil (a medicine often used to treat erectile dysfunction). .

Although it is not the standard practice, we also find examples where both variants (explanation before and after the technical term) are used in the same paragraph: (20) [SP] Sometimes doctors use colonoscopy to look for the cause of a patient’s symptoms (diagnostic colonoscopy). Another use of colonoscopy is to look for polyps (growths that can become cancer) […]. At times, the term is followed by a lay synonym. This is usually put in quotation marks to highlight the fact that it is a colloquial term: (21) [SP] Herpes zoster (also called “shingles”) is a condition in which painful blisters develop on the skin along the path of a nerve. Occasionally examples that do not appear in the OA or comparisons that help the reader associate complex concepts with daily life are provided: (22) [SP] People commonly use nonsteroidal anti-inflammatory drugs (NSAIDs) to relieve pain. Examples of NSAIDs include aspirin, etodolac (Lodine), ibuprofen (Advil or Motrin), and naproxen (Aleve). (23) [SP] Patients given thickened liquids were randomly assigned to drink either a very thick liquid (the consistency of honey) or a less thick liquid (the consistency of nectar—for example, tomato juice). The comparison can also be expressed with the use of words that have “-like” added to them: (24) cortisone-like drug known as dexamethasone.

3.2.2.2. Technical terms that are omitted In very few cases, technical terms are eliminated and replaced by more colloquial pseudo-equivalents (i.e., of a non Greek or Latin origin). This procedure is most frequently used for terms that may not be so relevant to the SP: (25) [OA] Myocardial infarction.

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[SP] Heart attack. (26) [OA] […] exacerbations of pre-existing diseases; new local or systemic illnesses. [SP] […] worsening or new illnesses. Other cases where Latin-Greek terms are avoided or substituted by everyday English words are found in Examples 10 and 11 (see Section 3.2.1.1.). Finally, paraphrases are sometimes used to substitute technical terms or abstract concepts (see also Example 5 in Section 3.1.4.): (27) [OA] second-line treatment options […] [SP] […] options for other drugs they could take.

4. Discussion and conclusions As we have seen, the intralingual translation of an OA into an SP involves the use of various reformulation procedures that affect both content and form. Our analyses show that many of them coincide with those used in other popularizing genres, as reviewed in Table 1. The selection of the key original content is fundamental to the SP, since this genre must be much shorter than the OA. For this, it is essential that the writer determine the main ideas properly and then choose the most relevant and interesting ones for the reader. This strategy requires both having substantial knowledge of the original contents and taking readers’ needs into account. This selection procedure leads to the elimination of the content considered irrelevant or too complicated for the new target reader. This is especially apparent on the macrotextual level (elimination of the abstract, references, visual elements, and other “irrelevant” content such as statistical analyses), but also on the sentence level (very specific details are omitted or transmitted in a more general way). This procedure, common in other popularizing genres, helps the non-expert understand the core of the study and not get lost. The emphasis is thus more on the general results than on the basic scientific and methodological content. Although the selection and elimination of content is significant, the addition of completely new information is one of the most distinctive procedures used. It plays a fundamental role, despite the fact that the ability to summarize is essential to the SP. Relevant specific information about key concepts is added or made explicit for a reader who does not have the same knowledge about the subject as the writer. This contextual information is

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usually presented at the beginning of the text, when the reader might feel displaced. This serves to capture the reader’s interest, and to make the topic more attractive and akin to his/her own experience. This procedure is more obvious in the SP than in other genres addressed to a lay audience, in which new information seems to be only occasionally added (see Askehave & Kastberg, 2001). The reorganization of the structure in questions and answers could also be considered a genre-specific procedure. The discourse is organized within a pre-established super-structure, parallel to that of the OA, yet adapted to the new communicative situation and to the knowledge and expectations of the receiver, who may be unaware of what the IMRD sections imply. The questions contribute to the involvement of the reader (Mayor Serrano, 2005, p. 135), and help him/her “build a mental picture of the facts he/she is reading” (Gutiérrez Rodilla, 1998, p. 325, my translation). On the sentence level, morphosyntactic simplification is another key procedure in this genre. It is achieved by making sentences shorter in most cases (with the consequent omission of details), and by carrying out different kinds of substitution that usually coincide with those mentioned for other popularizing genres: noun phrases are replaced by verbal clauses, modal expressions by more definitive assertions, and passive sentences by active ones. The change of passive to active is also due to a change in tenor, which gives researchers more visibility. Readers, however, are not addressed directly (as the work by Askehave & Kastberg 2001, shows), a fact that could be explained by the rhetorical purpose: SPs are meant to be descriptive and informative rather than instructive (as patient package inserts or patient information leaflets would be). Another element that is also simplified is the main title, which is made shorter, less dense in content, and easier to understand. Its characteristics, however, do not coincide with those stated by the authors reviewed, since SP titles are not attractive and revealing. This aspect could be justified by the medium in which SPs are published. They are not published in the mass media but are made available on a highly specialized medical journal’s website. Hence their titles conserve the more formal and objective quality of the journal. The handling of terminology favours the use of a large number of determinologization procedures: explanation and definition of technical terms, specification of abstract concepts, comparison of complex notions to aspects of daily life, paraphrasing of specialized concepts, and addition of lay synonyms, among others. Metaphors, however, are not used to explain specialized concepts, despite being widely referred to in the contributions reviewed. All these procedures increase the use of punctuation marks with a metalinguistic function. On the other hand, the preference to conserve specialized terms (they are rarely eliminated from the text) supports the didactic, albeit secondary, role of the SP genre.

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Finally, regarding typography and layout, there is no addition of visual elements, despite being a procedure mentioned in the literature. This could also be considered a characteristic feature of the SP. Furthermore, key concepts are not visually highlighted with the intention of aiding readability. This could be explained by the fact that the didactic function in this genre is secondary. If the genre were primarily didactic, stressing the key concepts would be more justified. However, other kinds of procedure, such as elimination of hyphenation and of text justification, are used to enhance readability. As we can see, although the SP shares traits in common with other popularizing genres, it has characteristics and requires procedures that could be considered prototypical of the genre, such as: adding a large amount of contextual information that does not appear in the original; reorganizing the information following a question-and-answer structure that answers the questions posed in a research study; keeping and explaining technical terms rather than eliminating them or replacing them with pseudoequivalents or paraphrases; rewording titles to make them shorter and simpler yet not very attractive, or avoiding visual elements. The results help to define the SP from a text genre perspective, and show the relevance of taking into account genre characteristics when carrying out a genre shift, since these determine the selection of the reformulation procedures to be used. Furthermore, these findings provide keys to writing and reformulating for medical translators, who need to be increasingly more versatile, and for experts in the field, who are often called upon to carry out these intralingual translations. Regardless of the limitations of the study (the size of the corpus and the fact that the SPs were taken from only one source), this work shows the importance of describing the reformulation procedures needed to popularize the results of medical studies within an “authentic healthcare culture” (Salvador, 2011, pp. 96-97, my translation) such as the one we currently find ourselves in, which is increasingly more interested in patient education. We should take into account the fact that the procedures described in this paper are those used in this specific context. This does not imply, however, that they are the only ones or even the most suitable. Further research should be carried out with patients and the general public in order to evaluate the readability of the SPs. Such studies would shed light on the effectiveness of the procedures used.

References Adams Smith, D. E. (1987). The process of popularization-rewriting medical research papers for the laymen: Discussion paper. Journal of the Royal Society of Medicine, 80, 634–636.

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Albin, V. (1998). Translating and formatting medical texts for patients with low literacy skills. In H. Fischbach (Ed.), Translation and medicine (pp. 117–129). Amsterdam: John Benjamins. Askehave, I., & Kastberg, P. (2001). Intergeneric derivation: On the genealogy of an LSP text. Text, 21(4), 489–513. Askehave, I., & Zethsen, K. K. (2001). Inter-generic and inter-linguistic translation of patient package inserts. In F. Mayer (Ed.), Language for special purposes: Perspectives for the new millennium (pp. 882–887). Tübingen: Gunter Narr. Askehave, I., & Zethsen, K. K. (2002). Translating for laymen. Perspectives: Studies in Translatology, 10(1), 15–29. Bhatia, V. K., (1993). Analysing genre: Language use in professional settings. London: Longman. Busch-Lauer, I.-A. (2000). Titles of English and German research papers in medicine and linguistics theses and research articles. In A. Trosborg (Ed.), Analysing professional genres (pp. 77–94). Amsterdam: John Benjamins. Ciapuscio, G. E. (2003). Formulation and reformulation procedures in verbal interactions between experts and (semi)laypersons. Discourse Studies, 5(2), 207–233. García Palacios, J. (2001). En los límites de la especialidad: Los textos de divulgación científica. In M. Bargalló, E. Forgas, C. Garriga, A. Rubio, & J. Schnitzer (Eds.), Las lenguas de especialidad y su didáctica (pp. 157–168). Tarragona: Rovira i Virgili University. Gutiérrez Rodilla, B. M. (1998). La ciencia empieza en la Palabra: Análisis e historia del lenguaje científico. Barcelona: Ediciones Península. Jakobson, R. (1959/2000). On linguistic aspects of translation. In L. Venuti (Ed.) (2000), The translation studies reader (pp. 113–118). London: Routledge. Mayor Serrano, M. B. (2005). Análisis contrastivo (inglés-español) de la clase de texto “folleto de salud” e implicaciones didácticas para la formación de traductores médicos. Panace@, 6(20), 132–141. Montalt, V. (2005). Manual de traducció cientificotècnica. Vic: Eumo Editoral. Montalt, V., Ezpeleta Piorno, P., & García Izquierdo, I. (2008). The acquisition of translation competence through textual genre. Translation Journal, 12(4). Retrieved from http://translationjournal.net/journal/46competence.htm Montalt Resurreció, V., & González Davis, M. (2007). Medical translation step by step. Manchester: St Jerome. Nord, C. (1997). Translating as a purposeful activity: Functionalist approaches explained. Manchester: St. Jerome. Nwogu, K. N. (1997). The medical research paper: Structure and functions. English for Specific Purposes, 16(2), 119–138. Reiss, K., & Vermeer, H. (1984/1991). Grundlegung einer allgemeinen Translationstheorie. Tübingen: Niemeyer. Salvador, V. (2011). Paraula i cultura de la salut: Indagacions de lingüística mèdica. Caplletra, 50, 89–106. Swales, J. M. (1990). Genre analysis: English in academic and research settings. Cambridge: Cambridge University Press.

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Zethsen, K. K. (2007). Beyond translation proper: Extending the field of translation studies. TTR: Traduction, Terminologie, Redaction, 20(1), 281–308. Zethsen, K. K. (2009). Intralingual translation: An attempt at description. Meta, 54(4), 795–812.

_____________________________ 1

This work has been partially supported by Universitat Jaume I under grant PREDOC/2009/43.

2

Similar initiatives to publish summaries for patients from other genres such as guidelines (http://www.eastonad.ucla.edu/guidelines/AAN_Guideline.pdf) or conferences/symposiums (http://www.aamds.org/sites/default/files/SymposiumPatientSummary.pdf) have also been undertaken.

3

Such as Annals of Internal Medicine (http://www.annals.org/).

4

Such as the European Association for the Study of Diabetes (http://www.easd.org/).

5

Such as the Pediatric Brain Tumor Consortium from the National Cancer Institute (http://www.pbtc.org/public/protocol_summaries.htm).

6

The corpus is available at: http://www.tradmed.uji.es/documents/Corpus.zip.

7

http://www.annals.org/site/patientinformation/patientinformation.xhtml.

8

http://annals.org/SS/PatientInformation.aspx.

9

Italics in the examples indicate my emphasis.

Interpreting and knowledge mediation in the healthcare setting: What do we really mean by “accuracy”?

George Major & Jemina Napier Macquarie University, Sydney

This paper explores the concept of “accuracy” in the context of interpretermediated healthcare interaction by reporting on a study of simulated doctor-patient consultations involving professional Australian Sign Language (Auslan)/English interpreters. Wadensjö’s (1998) taxonomy of renditions is used to analyse the ways interpreters convey health information. Our data reveals that interpreters frequently produce reduced and expanded renditions that are not detrimental to the message or the interaction. There has previously been little discussion of how qualified interpreters make these decisions, and we suggest that achieving accuracy in the healthcare setting may be a more dynamic and context-dependent process than previously suggested. While the use of role-plays can on the one hand can be considered a delimiting factor (due to their artificial nature), they also allow a systematic comparison of different interpreters, thus providing more robust evidence for healthcare interpreter training.

1. Introduction and contextual overview The success of interpreter-mediated healthcare interaction depends to a significant extent on the linguistic choices made by interpreters (Tebble, 1999) and the ethical tenet of accuracy is considered important, given that real health outcomes are on the line (Hale, 2007). Accuracy is defined as the requirement for an interpreter to deliver information within a message “in the same spirit, intent and manner of the speaker, with no additions, deletions or alterations to the meaning” (Napier, McKee, & Goswell, 2010, p. 74). But what does this actually look like in practice? And what are the implications for healthcare? Studies have shown that untrained interpreters in healthcare settings may not convey information accurately (e.g., Dubslaff & Martinsen, 2005; Valero Garcés, 2005), but few studies have systematically explored how qualified interpreters perform in this regard, and even fewer have described how healthcare interpreters can add or omit information and still achieve accuracy. This paper explores the concept of accuracy in the context of interpreter-mediated healthcare interaction involving Australian Sign Language (Auslan)/English interpreters. In Australia, interpreters receive their accreditation from the National Authority for the Accreditation of Translators and Interpreters (NAATI) by either passing a NAATI test or completing a NAATI-approved course of study. Accreditation is available at Paraprofessional or Professional level. Paraprofessional level accreditation is an entry-level qualification that assesses interpreters as

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being “safe to practise”, although the Professional level is regarded as the ideal minimum level of competence. An accredited interpreter, however, is not necessarily a trained interpreter. Approximately 300 Auslan/English interpreters are active and regularly available for work (Napier, Major, & Ferrara, 2011), 70% of whom are accredited at the Paraprofessional level (Bontempo & Napier, 2007). Auslan/English interpreters serve a sign language-using deaf population of approximately 6,500 (Johnston, 2006, p. 152). Auslan interpreters are provided for private healthcare appointments through the federally funded National Auslan Interpreter Booking and Payment Service (NABS). NABS only employs interpreters who have NAATI accreditation. The motivation for this study was the relative lack of research into healthcare interpreting in Australia in general, and in particular into signed language healthcare interpreting.

1.1. Accuracy One of the seminal studies on accuracy in signed language interpreting was conducted by Cokely (1992). He conducted analyses on the output of interpreters working between English and American Sign Language, and developed a miscue taxonomy, identifying five types of shifts within the texts. These included additions, omissions, substitutions, intrusions and anomalies. Cokely’s taxonomy focused on the search for inaccuracy or errors made by interpreters. Error analysis is also a popular approach in evaluating accuracy in simultaneous spoken language interpreting (e.g., Barik, 1994). Alternatively, Napier’s (2004) omission taxonomy for the analysis of interpreting between English and Auslan accounts for interpreters’ strategic decision-making. The taxonomy was developed by analysing the output of ten interpreters working from a university lecture, and then eliciting metalinguistic reflections from the interpreters in retrospective interviews where they were shown the data and asked to comment on why omissions were produced. The taxonomy includes five omission types: conscious strategic, conscious intentional, conscious unintentional, conscious receptive, and unconscious1. Napier (2004) proposes that every interpretation has an “omission potential” and depending on the number and types of omissions produced, accuracy can still be achieved. Nevertheless, measurements of accuracy are complex and should consider not only factual information, but also style (Hatim & Mason, 1990). In a study of seventeen English-Spanish interpreted courtroom interactions, Hale (2002) observed that witnesses’ utterances were often interpreted accurately in terms of content, but that the style of the source text was modified in the target text, for example through use of a different register and adding or omitting affective elements of the message (such as

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hesitations and hedges). Hale suggests that interpreters’ failure to convey these stylistic features can potentially weaken the credibility of witnesses, and consequently alter the outcomes of cases. Thus any measurement of accuracy should take into account not only the interpretation of factual information, but also affective information.

1.2. Wadensjö’s measurement of accuracy Wadensjö’s (1998) work is based on authentic spoken language interpreted interactions in Sweden, and reveals that interpreters frequently use deliberate strategies in order to achieve message equivalence. Wadensjö asserts that the level of strategic decision-making depends on contextual factors within the interaction, as also noted by Napier (2004) in a monologic setting. Wadensjö’s (1998) approach involves the categorisation of utterances as “originals” or “renditions”. Essentially, an interpreter’s utterance is a “rendition”, which relates in some way to the immediately preceding “original” utterance (e.g., by a doctor or patient). Wadensjö’s taxonomy includes eight sub-categories of renditions: close renditions, expanded renditions, reduced renditions, substituted renditions, summarised renditions, multi-part renditions, non-renditions and zero renditions. Details of each category can be seen in Table 1. These sub-categories enable the analyst to explore the adequacy of an interpretation by looking at the appropriateness of a rendition within the interactional context.

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Table 1: Wadensjö’s rendition sub-categories Rendition type

Definition

Close

Propositional content of original explicitly expressed in the rendition, style approximately the same.

Expanded

More explicitly expressed information in the rendition than the original.

Reduced

Less explicitly expressed information in the rendition than the original.

Substituted

A combination of expanded and reduced.

Multi-part

Two interpreter utterances correspond to one original, which is split into parts by the interjection of another original.

Summarised

Text that corresponds to two or more prior originals.

Non

Interpreter-initiated.

Zero

Original not translated.

(see Wadensjö, 1998, pp. 107–108) Through her analysis of interpreter-mediated police interviews and healthcare consultations, Wadensjö (1998) judges rendition types based not only on the closeness or divergence of renditions, but also on the context immediately preceding them and the wider context of the whole interaction. She notes that interpreters produce contextually, linguistically and culturally appropriate utterances that meet the communicative goals of the original statements. For example, reduced renditions are produced to place emphasis on the more recently articulated of two communicative goals in the original utterance; and close and expanded renditions are also produced in order to emphasise certain parts of the information. Angelelli (2004) and Bolden (2000) also note similar strategies in healthcare interpreting, which is the context for our study.

1.3. Healthcare interpreting The majority of studies of healthcare interpreting have involved error analysis, with discussion of inappropriate omissions, additions and alterations of factual information produced by (untrained) interpreters (e.g., Aranguri, Davidson, & Ramirez, 2006; Laws, Heckscher, Mayo, Li, & Wilson, 2004). In her discussion of healthcare interpreting, Hale (2007) acknowledges that achieving accuracy can be a challenge, and promotes a

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“direct” approach, in which “the interpreter interprets every turn, and the doctor and the patient address each other through the interpreter” (p. 41). This direct approach could be considered as being equivalent to Wadensjö’s close rendition category, whereby the propositional content of the original is explicitly expressed in the rendition, and the style is considered to be the same. Taking a similar stance, Tebble (1999) analysed a corpus of authentic interpreted healthcare interactions to examine the interpersonal, affective features of the discourse. Tebble (1999) notes that “all turns at talk should be interpreted” (p. 44), which mirrors Hale’s (2007) call for a “direct” approach. A limitation of this type of analysis is that potential strategic reasons for reduced renditions are not discussed. For example, some of the original utterances in Tebble’s data may not have been interpreted due to overlap, time-constraints, the interpreter’s prior knowledge of the patient’s understanding of English, or other factors. We believe that judgments of accuracy should be made based on wider contextual evidence. Studies based on authentic spoken and signed language interpreting data have provided evidence that strategic decisionmaking, based on contextual factors, is a key component in healthcare interpreting (e.g., Angelelli, 2004; Bolden, 2000; Major, 2012; Metzger, 1999). Shlesinger (2009) calls for more replication of existing interpreting studies in order to test findings and applicability across different languages and contexts. Thus for our study, we felt it was appropriate to adopt the model proposed by Wadensjö (1998) as aspects of her taxonomy have been replicated by other spoken language interpreting researchers in their examination of healthcare interpreted events. Amato (2007) focuses on zero and non-renditions to gain insight into what interpreters choose not to render, and Cirillo (2012) also analyses these same categories to explore how interpreters’ initiatives may either promote or inhibit affective communication in doctor-patient talk. Until the current study, Wadensjö’s taxonomy had not been applied to the analysis of signed language interpreting. In our study, we provide further evidence that the error-based models of accuracy are inadequate for explaining the decisions made by interpreters, and that accuracy in the healthcare setting can only be fully understood with regard to interactional context.

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2. Research method

2.1. Participants and data collection Using network sampling, a flyer seeking expressions of interest to participate in the study was sent to NAATI accredited Auslan/English interpreters registered with various interpreting agencies, and who were members of the Australian Sign Language Interpreters Association. Ten interpreters from the Sydney area were recruited to participate in a simulation of doctor-patient interaction between a real GP and a deaf patient (both female). The role-play was repeated ten times, and each interpreter participated only once. As it was not a quantitative study, there was no attempt to balance demographic characteristics, although the ten interpreters varied in age, gender, educational background, and interpreting experience. Six interpreters were female and four were male. Three held NAATI Professional accreditation and seven had Paraprofessional accreditation. The most experienced had been interpreting for eighteen years, and the least experienced for one year. Eight interpreters had completed formal interpreter training, while two had gained accreditation without completing a training programme. The role-play was designed to be as naturalistic as possible. It was developed in consultation with the GP and the deaf person, and the scenario was built upon an injury that the deaf person had sustained in real life. It involved the patient visiting her GP after fracturing her ankle (having first had this treated in hospital) in order to request more pain medication. The GP then addressed a potential risk of osteoporosis, questioning the patient about her diet, describing the causes of bone weakness, and recommending further tests. Interpreter participants commented that they quickly forgot that the interaction was simulated, particularly because there was a real GP involved, and thus we are confident that the role-play resembled a realistic interaction as much as possible. Two digital video cameras were used to record each role-play, and the researcher was not present in the room during recording. Each role-play ran for between 13 and 16 minutes, and the GP and patient followed the same brief for each scenario.

2.2. Transcription and analysis The role-play video footage was transcribed and analysed in ELAN, a computer programme that allows the precise alignment of transcription with video data (Wittenburg, Brugman, Russel, Klassmann, & Sloetjes, 2006). Auslan signs were represented in written form using standard signed

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language research conventions, such as CAPITAL LETTERS, to ‘gloss’ the main content of the signer’s talk (Johnston & Schembri, 2007). In order to prevent identification of the interpreter participants, each interpreter was allocated a letter code. For the analysis presented in the current paper, we focused on one excerpt that occurred with particular consistency across each of the ten roleplays. This excerpt begins approximately 4-5 minutes into each role-play, and starts when the GP briefly questions the patient about her diet and lifestyle. After establishing that the patient is likely to be deficient in calcium and vitamin D, the GP explains that tests are needed in order to either diagnose or rule out osteoporosis as a cause of bone weakness. Due to the amount of data and the space limitations of this paper, here we report only on the analysis of the Auslan renditions produced by the interpreters. The excerpts varied in length, with the average duration being 6 minutes, 13 seconds. For the purposes of this study, units of analysis (“originals”) were defined based on the GP’s utterances. In order to draw boundaries between utterances, we considered pausing and intonation, and also relied on our intuition as native speakers of English. The GP (who had previously worked with interpreters in real life) spoke at a measured pace and often paused between utterances. Interpreter renditions tended to follow the GP’s utterances in terms of her prosodic utterance boundaries (i.e. when she paused), so it was ideal to analyse the interpreter utterances following the same boundaries. In total, there were 412 renditions, averaging 41 per excerpt. All renditions were categorised according to Wadensjö’s taxonomy, and this process was conducted separately by both researchers to ensure reliability (Burns, 1997). Our judgments were based both on interactional evidence within the video data and on our intuitions derived from our professional experience as interpreters and researchers. Complicated or unclear examples were discussed until an agreement was reached. The process of categorising thus was an important part of the analysis itself, and more detailed analysis was conducted on the most frequent rendition types. In section 3 we describe patterns identified in our analysis, and discuss two of the rendition types in detail—expanded and reduced—with reference to representative examples from the data.

3. Findings and discussion We begin by giving a general overview of the renditions produced. Initially we had anticipated that the process of categorising all renditions might reveal some patterns based on demographic factors; however, this was not the case and no such patterns could easily be extracted. Table 2 provides a summary of the overall rendition frequency, with the exception of “multipart” renditions, which did not occur in our dataset.

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Table 2: Summary of rendition types Rendition type

Frequency

Close

123

Expanded

97

Reduced

81

Substituted

69

Zero

24

Non

11

Summarised

7

TOTAL

412

Overall, the main types of rendition that were produced were close renditions, expanded renditions, reduced renditions, and substituted renditions. There were far fewer instances of summarised renditions, zero renditions and non-renditions, which may have been because the data chosen for analysis had many monological characteristics and interpreters did not need to engage in much discourse management during that particular excerpt. Close renditions, which were the most frequent, were judged to mainly convey the core meanings of the original utterances appropriately. This does not mean that close renditions are always the most appropriate approach, however, as we believe that many concepts require alternative strategies in order to be conveyed accurately in the context. We encountered some challenges in identifying patterns in the category of substituted renditions as we were unable to ask the interpreters themselves whether certain substitutions had been conscious strategies or unconscious miscues. Thus, we focus our discussion in the remainder of this paper on our analysis of the reduced and expanded rendition types, as these revealed particularly interesting patterns.

3.1. Reduced and expanded renditions In conducting a more detailed analysis of reduced and expanded renditions, examples of both successful and less successful (sometimes even problematic) renditions were identified. It must be stressed, however, that problematic renditions could not be attributed to any one interpreter, or to any group of interpreters based on demographic factors. Additionally, the

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deaf actor reported that all ten interpreters performed adequately, so individual miscues highlighted by our analysis were not perceived to be detrimental to her ability to access health information overall.

3.1.1. Reduced renditions A substantial proportion of the 412 renditions (81, or 19.66%) included some type of reduction in comparison with the original utterances. In order to identify exactly what interpreters were reducing, a second and more detailed analysis of this subset of data was conducted. It was established that while some reductions were strategic in nature (as per Napier’s [2004] identification of conscious strategic omissions), many did involve apparent miscues, although rarely was the core message negatively affected (with the exception of 12 out of 81 reduced renditions). Interpreters tended to make minor reductions to content (usually not core content), cohesion, and/or affective elements such as mitigation or hedging. The types of reduction identified in the data are outlined in Table 3 below. Table 3: Analysis of reduced renditions Type of reduction

Frequency

Strategic reduction

20

Reduction of affective or cohesive elements

11

Reduction of content (not core content)

34

Reduction of both content and affective elements

4

Core message missing or altered

12

TOTAL

81

For reasons of space, we cannot provide examples of all categories, although we will discuss a rendition in which content and affective elements are reduced, followed by a strategic reduction. We begin with Example 1, which occurs as the GP is explaining how vitamin D levels can be improved. A back translation of the glossed Auslan rendition is provided in italics. Example 1: Reduction of content and affective elements GP:

If you don’t have enough vitamin d then probably what we would do is get you to take a tablet that’s got vitamin d that’s the easiest way to get your cal- your vitamin d level up

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IntE:

IF NOT ENOUGH VITAMIN D: (.) WELL GIVE TABLETS (.) IMPROVE YOUR VITAMIN D =[If you don’t have enough vitamin d (.) well we have to give you tablets to improve your vitamin d]

In this example, the core message is conveyed with accuracy by the interpreter. That is, he clearly conveys the GP’s statement that if the patient has low vitamin D she can be given tablets to improve it. Some content is slightly reduced, however, specifically that tablets are the easiest way to improve the problem. Additionally, the GP’s original utterance includes softening devices and hedging around the need to take a tablet (“probably what we would do is get you to take a tablet”), which is rendered much more direct in the interpretation: “well we have to give you tablets”. As noted by Tebble (1999) and Hale (2002), the reduction or modification of affective elements of talk can potentially be just as significant as the reduction or modification of content, and therefore should inform our understanding of accuracy. In Example 1, the interpreter’s rendition could affect how the patient judges the GP (for example, she may form an impression that the GP is very direct or even bossy). This example is one of many from our data that supports calls in the literature for interpreters to pay attention not only to the content but also to the style of talk. It is important to stress that we do not mean affective markers should necessarily be conveyed literally; we also identified many instances in which affective markers in English originals were successfully conveyed in Auslan renditions, and this was almost always achieved through nonlinguistic features such as body movement and facial expressions (see Hoza, 2007; Major, 2012). It is also revealing to investigate reduced renditions categorised as “strategic”. We identified twenty of these, representing 24.69% of the total number of reduced renditions. Strategic reductions were reductions—and sometimes even complete omissions—that were judged to be strategic moves rather than miscues (see Napier, 2004). In some cases, a reduction occurred because the interpreter needed to stop and clarify. In other instances, information was already clear from context and did not need to be repeated by the interpreter. Example 2 illustrates this, and some additional interactional context has been provided. The original utterance that is the focus of this example is underlined. Example 2: A strategic reduced rendition GP:

…that’s called osteoporosis

IntB:

…O-S-T-E-O-P-O-R-O-S-I-S THAT NAME THAT =[the name of that is osteoporosis]

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PT:

((smiles and shakes head))

GP:

Have you ever come across that word?

IntB:

No what- sorry what’s osteoporosis?

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In this example, the GP has been explaining about the condition called osteoporosis, and the patient (PT) immediately responds by smiling and shaking her head. This indicates a lack of understanding and is a cue often perceived by interpreters to be a clarification request, even though it is completely non-linguistic (Major, 2012). Thus, when the GP asks “have you ever come across that word?”, a strategic reduction occurs: IntB does not convey this, because to do so would be redundant. Instead, he conveys the patient’s implied request for clarification: “no what- sorry what’s osteoporosis?”, responding directly to the GP’s question in a manner that might be more typical of monolingual question-answer pairs. This example illustrates the need to conduct message equivalence analyses giving consideration to context; if we had only considered the original utterance, and the interpreter’s lack of a corresponding rendition, we might have judged this to be a miscue, rather than a strategic move designed to maintain the flow of talk. We now turn to the other end of the spectrum and examine the nature of expanded renditions.

3.1.2. Expanded renditions Ninety-seven renditions were expanded (23.54% of the total dataset). Table 4 below provides a comprehensive list of all the expansion types, although it should be noted that some renditions included more than one type of expansion, making the total number of expanded features (122) greater than the number of renditions (97).

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Table 4: Analysis of expanded renditions Type of expansion

How many occurred

Implicit information made explicit

54

Repetition or cohesive elements added

33

Expansion with visual encoding for clarity

20

Evaluative comment added

5

Problematic expansion (wrong information added)

5

Meta-comment added

2

Elicitation of patient feedback added

2

Mitigation added

1

TOTAL

122

As opposed to reductions, very few expansions involved miscues, minimal or otherwise. Certainly, there were some problematic expansions, but these represented only 5 out of 97 expanded renditions, or 5.15%. Thus, in the interests of space, problematic expansions are not addressed further here. Overwhelmingly, it was our judgment that the expansions found in this dataset were strategic and were used to convey a clearer message than might have been achieved with a close rendition. In this section, we describe and illustrate the three most frequent types of expansion. The first type of expanded rendition to be addressed is when information implied by the GP in the original is expanded and made explicit in the rendition. This was the most frequent type of expansion, occurring in 54 out of the 97 expanded renditions (55.67%), and it is illustrated in Example 3 below. Example 3: Making implicit information explicit GP:

Do you: have much dairy products in your: diet?

IntG:

WHAT YOU HAVE TAB- DRINK (.) MILK FIRST CHEESE SECOND YOGHURT YOU EAT+ PLENTY WHAT FEW+ WHAT? =[Do you have tab- do you drink milk or do you eat cheese and yoghurt a lot or only occasionally?]

Different languages encode concepts in different ways, and the concept of “dairy” is a good example of this, as Auslan does not have one sign that corresponds directly to this superordinate term. To convey this concept in

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Auslan, one can borrow directly from English and fingerspell “dairy”, or one can expand and give examples of foods implied by the English term. Both strategies are considered to be legitimate language contact strategies used by deaf people and interpreters (Davis, 2003; Napier, 2006). In Example 3, IntG chooses to expand the concept by specifying milk, cheese, and yoghurt. An additional expansion is “a lot or only occasionally”, as the interpreter makes explicit what the GP had implied by “do you have much”. Thirty-three expanded renditions included the addition of cohesive elements, typically linking the rendition back to previous statements or topics of talk, as illustrated in Example 4: Example 4: Adding cohesive elements GP:

Okay it sounds to me like you have a calcium deficient diet

IntB:

((nods head)) YOU FROM MY (MAYBE) ME ASSESS ALREADY YOU-EXPLAIN (ME) FEEL MAYBE YOU (HAVE) NOT-ENOUGH C-A-L-C-I-U-M IN (YOUR) FOOD EAT =[So from my assessment of your explanation I feel that you may not have enough calcium in your diet]

In this example, IntB adds referential cohesion by referring more explicitly back to previous talk: “so from my assessment of your explanation”, before conveying a close (albeit slightly more hedged) rendition of the original utterance. Referential cohesion is considered an important aspect of signed language discourse (Cresdee, 2006), thus it can be considered that this interpreter employed this strategy appropriately. We found that interpreters also expanded utterances in a bid to make the message clearer by encoding information visually: a strategy that is regarded as typical in signed languages (Brennan, 1992; Brennan & Brown, 1997). This occurred in twenty of the expanded renditions, as illustrated in Example 5 below. Prior to this extract, the GP has explained that the patient will not need to pay for tests if she goes to a place that “bulk bills” (that is, a medical service that does not directly charge fees to the patient and instead claims them from the Australian Government’s publically funded universal health system). This meaning was conveyed (with a close rendition) by the interpreter, but the patient nonetheless sought clarification: “MEAN ME STILL PAY?” =[does that mean I still have to pay?]. Example 5 occurs after this question has been interpreted to the GP. Example 5: Expansion with visual encoding for clarity GP:

No no no I will send you to a place (.) that you just sign

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IntF:

NOTHING B-U-L-K B-I-L-L MEAN ME REFER FORM SHE TELL-THEM SIGN SWIPE-CARD =[No bulk bill means I will refer you with a form to a place where you can easily just sign and swipe your card]

It seems reasonable to assume that the interpreter’s expanded rendition in this instance may relate to the patient’s prior request for clarification. She first mirrors the GP’s original utterance (“no”) and then adds an explanatory link “bulk bill means”. She then specifies exactly how this will happen “I will refer you with a form to a place”, and expands on “you just sign” to describe how patients actually use their Medicare cards: “you can easily just sign and swipe your card”. Another example that was used by almost all the interpreters was when the doctor was discussing the need for an x-ray, they depicted visually how one might hold up an x-ray against a light to look at it. This way of visually and systematically describing an action or series of events is a typical Auslan strategy; it would be unlikely to be used when interpreting from Auslan into English as English does not usually encode this level of visual detail. A post-recording interview with the deaf actor revealed that she preferred a style of interpreting that included a lot of visual expansion, rather than too much fingerspelling. Although it is important to remember that individual patients will have different preferences, our data shows that expanded renditions are an important part of the healthcare interpreter’s repertoire. Interpreters should always expand with caution, however, particularly when relying on a lay understanding to expand upon technical medical concepts, as lay and professional use of medical terminology may differ (Thompson & Pledger, 1993). Even interpreters who have had rudimentary healthcare interpreter training may not necessarily grasp medical concepts to the same degree as healthcare practitioners who have received substantially more training. In sum, analysis of the renditions produced by Auslan/English interpreters in the healthcare context, and detailed discussion of two rendition types, reveal that interpreters do make strategic decisions about their interpretation choices based on the context within an interaction. The findings from this data support Wadensjo’s (1998) research with spoken language interpreters.

4. Limitations of the study Before drawing this paper to a close, there are various limitations of the study that we would like to acknowledge: • Our findings may be skewed by the fact that we only analysed Auslan renditions, and it seems reasonable to assume that renditions in English and other languages may give rise to other strategies.

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•

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More research is needed to gain a fuller picture of the rendition types used by signed language interpreters in various contexts and in both language directions. As noted earlier, the use of simulated data always presents limitations as participants can be influenced by the artificial nature of the experience. The kind of comparison presented in this study, however, would not have been possible with authentic data. While the use of role-plays can on the one hand be considered a delimiting factor, they also allow a systematic comparison of different interpreters, thus providing more robust evidence for healthcare interpreter training. The judgments made in the analysis were based on our intuitions as experienced professional interpreter practitioners, educators and researchers. We were not able to verify our allocation of strategies through interviews with interpreters, which was how Napier (2004) categorised levels of consciousness and strategy in her analysis of interpreting omissions. Targeted interviews with interpreters would have shed light on the strategies employed, which may have shifted the numbers of renditions placed within each category.

5. Conclusion This paper has explored the concept of “accuracy” in the context of interpreter-mediated healthcare interactions involving professional Auslan/English interpreters. Close renditions made up the largest category (but still represented less than one third of all renditions), and the majority of close renditions were judged to be adequate. There appeared to be many substituted renditions, but clear categorisation was difficult without being able to ask the interpreters themselves whether these substitutions had been conscious strategies or unconscious miscues. The two categories of most interest were reduced and expanded renditions. Although there were some problematic reductions, for the most part, reduced renditions were not judged to alter the core message. It is important for interpreters to be mindful, however, of the reduction of affective elements and we agree with Hale’s (2007) and Tebble’s (1999) assertions that the style of talk is important. Many different features of the talk were expanded, principally to make implied information explicit, to add cohesion, or to clarify the message by encoding visual information. Expansions were generally judged to be successful renditions that ensured message equivalence, and promoted accuracy. In the light of these research findings, therefore, we claim that accuracy is achieved not only through close renditions. Often, alternative strategies such as expanded renditions are required, and these judgments are made by interpreters based on interactional context.

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Wadensjö’s (1998) typology of renditions provides a basis for better understanding the context-bound process of decision-making in interpreting, and our examples have illustrated the application of this typology to signed language interpreting. Students could also usefully apply this analytical technique to the examination of their own interpreting practice, through participation in role-plays and retrospective analysis (Metzger, 2000). Furthermore, the provision of comparative samples from studies such as ours will offer students the opportunity to compare their own renditions with those produced by accredited interpreters. Although our findings are specific to Auslan/English interpreting (specifically English into Auslan), we have identified some interesting patterns that could be followed up in future studies. Further research is needed to explore notions of context-bound accuracy in more depth, and we would like to reiterate Shlesinger’s (2009) call for more replication of existing interpreting studies. This study is the first to apply Wadensjo’s (1998) taxonomy to the analysis of signed language interpreting, and we would like to see greater comparison—across spoken and signed language interpreting in different settings—of what “accuracy” really means in context.

6. Acknowledgments Data for this study was originally collected in 2010 as part of a doctoral study (Major, 2012), although the current study adopts a different analytical approach. The researchers would like to thank Dr Linda Mann, Katrina Lancaster, and all the interpreter participants.

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Transcription conventions NOT-ENOUGH

Represents one sign in Auslan

M-I-N-E-R-A-L

Fingerspelled word

EAT+

Sign is repeated once

((smiles and shakes head))

Description of non-linguistic features

((nods head)) YOU

Non-linguistic feature that carries on over talk

you:

Word/sign is held

(.)

One second pause or less

(HAVE)

Transcriber’s best guess at an unclear utterance

References Amato, A. (2007). The interpreter in multi-party medical encounters. In C. Wadensjö, B. Englund Dimitrova, & A. Nilsson (Eds.), The Critical Link 4: Professionalisation of interpreting in the community (pp. 27–38). Amsterdam: John Benjamins. Angelelli, C. (2004). Medical interpreting and cross-cultural communication. Cambridge: Cambridge University Press. Aranguri, C., Davidson, B., & Ramirez, R. (2006). Patterns of communication through interpreters: A detailed sociolinguistic analysis. Journal of General Internal Medicine, 21(6), 623–629. Barik, H. (1994). A description of various types of omissions, additions ands errors of translation encountered in simultaneous interpretation. In S. Lambert & B. Moser-Mercer (Eds.), Bridging the gap: Empirical research in simultaneous interpretation (pp. 121–138). Amsterdam: John Benjamins. Bolden, G. B. (2000). Toward understanding practices of medical interpreting: Interpreters’ involvement in history taking. Discourse Studies, 2(4), 387–419. Bontempo, K., & Napier, J. (2007). Mind the gap!: A skills analysis of sign language interpreters. The Sign Language Translator & Interpreter, 1(2), 275–299. Brennan, M. (1992). The visual world of BSL: An introduction. In D. Brien (Ed.), Dictionary of British Sign Language/English (pp. 1–133). London: Faber & Faber. Brennan, M., & Brown, R. (1997). Equality before the law: Deaf people’s access to justice. Durham: Deaf Studies Research Unit, University of Durham, United Kingdom. Burns, R. B. (1997). Introduction to research methods. Melbourne: Addison Wesley Longman.

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Cirillo, L. (2012). Managing affective communication in triadic exchanges: Interpreters’ zero-renditions and non-renditions in doctor-patient talk. In C. J. K. Bidoli (Ed.), Interpreting across genres: Multiple research perspectives (pp. 102–124). Trieste: EUT Edizioni Universtà di Trieste. Cokely, D. (1992). Interpretation: A sociolinguistic model. Burtonsville, MD: Linstok. Cresdee, D. (2006). A study of the way(s) to teach signed discourse cohesion, particularly reference, within a story context. (Unpublished doctoral dissertation). Charles Darwin University, Australia. Davis, J. (2003). Cross-linguistic strategies used by interpreters. Journal of Interpretation, 18(1), 95–128. Dubslaff, F., & Martinsen, B. (2005). Exploring untrained interpreters’ use of direct versus indirect speech. Interpreting, 7(2), 211–236. Hale, S. (2002). How faithfully do court interpreters render the style of non-English speaking witnesses’ testimonies?: A data-based study of Spanish-English bilingual proceedings. Discourse Studies, 4(1), 25–47. Hale, S. (2007). Community interpreting. Hampshire: Palgrave Macmillan. Hatim, B., & Mason, I. (1990). Discourse and the translator. London: Longman. Hoza, J. (2007). It’s not what you sign, it’s how you sign it: Politeness in American Sign Language. Washington, DC: Gallaudet University Press. Johnston, T. (2006). W(h)ither the Deaf community?: Population, genetics and the future of Auslan (Australian Sign Language). Sign Language Studies, 6(2), 137– 173. Johnston, T., & Schembri, A. (2007). Australian Sign Language: An introduction to sign language linguistics. Cambridge: Cambridge University Press. Laws, M. B., Heckscher, R., Mayo, S., Li, W., & Wilson, I. B. (2004). A new method for evaluating the quality of medical interpretation. Medical Care, 42, 71–80. Major, G. (2012). Not just ‘how the doctor talks’: Healthcare interpreting as relational practice (Unpublished doctoral dissertation). Macquarie University, Australia. Metzger, M. (1999). Sign language interpreting: Deconstructing the myth of neutrality. Washington, DC: Gallaudet University Press. Metzger, M. (2000). Interactive role-plays as a teaching strategy. In C. Roy (Ed.), Innovative practices for teaching sign language interpreters (pp. 83–107). Washington, DC: Gallaudet University Press. Napier, J. (2004). Interpreting omissions: A new perspective. Interpreting, 6(2), 117– 142. Napier, J. (2006). Comparing language contact phenomena between Auslan/English interpreters and deaf Australians: A preliminary study. In C. Lucas (Ed.), Multilingualism and sign languages: From the Great Plains to Australia (pp. 39–78). Washington, DC: Gallaudet University Press. Napier, J., Major, G., & Ferrara, L. (2011). Medical Signbank: A cure-all for the aches and pains of medical sign language interpreting? In L. Leeson, M. Vermeerbergen, & S. Wurm (Eds.), Signed language interpreting: Preparation, practice and performance (pp. 110–137). Manchester: St Jerome. Napier, J., McKee, R., & Goswell, D. (2010). Sign language interpreting: Theory and practice in Australia and New Zealand (2nd Ed.). Sydney: Federation.

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Shlesinger, M. (2009). Crossing the divide: What researchers and practitioners can learn from one another. The International Journal for Translation and Interpreting Research, 1, 1–16. Tebble, H. (1999). The tenor of consultant physicians: Implications for medical interpreting. The Translator, 5(2), 179–200. Thompson, C. L., & Pledger, L. M. (1993). Doctor-patient communication: Is patient knowledge of medical terminology improving? Health Communication, 5(2), 89–97. Valero Garcés, C. (2005). Doctor-patient consultations in dyadic and triadic exchanges. Interpreting, 7(2), 193–210. Wadensjö, C. (1998). Interpreting as interaction. London: Addison Wesley Longman. Wittenburg, P., Brugman, H., Russel, A., Klassmann, A., & Sloetjes, H. (2006). ELAN: A professional framework for multimodality research. Retrieved from the Language Archiving Technology website: http://www.lat-mpi.eu/papers/papers2006/elan-paper-final.pdf

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Due to the word limit of this paper we are not able to provide more detailed definitions, so readers are encouraged to refer to the original Napier (2004) paper for more detail on the omission types.

Les modes de conceptualisation des unités d'hérédité au XIXe siècle : Spencer, Haeckel et Elsberg

Sylvie Vandaele & Marie-Claude Béland Université de Montréal Ever since the end of the 19th century, the biological sciences have been preoccupied with the elucidation of the complex mechanisms underlying heredity. They were faced with a fundamental problem: how does a given phenotypic trait (e.g., skin or fur color) correspond to a physical entity, more often than not putative, responsible for its transmission from one generation to the next. The discovery and subsequent characterization of the unit of inheritance (unité d’hérédité) is thus the central focus of research on heredity in many fields, namely genetics, population genetics, molecular biology, and, more recently, genomics. What we now call gene since Johanssen coined the term, however, has a long and troubled past characterized by various successive conceptualizations. These have left sometimes confusing and even contradictory features in modern scientific discourse, of which we intend to understand the origins. The present article aims to examine the different embodiments of the concept unit of inheritance in the works of two key 19th century authors: Spencer and Haeckel. Elsberg, a rival of Haeckel, will also be considered. Using an analysis of indices of conceptualization in discourse, we show the various metaphorical conceptualization modes active in their respective theories and examine how they manifest themselves in English and in French.

1. Introduction La génétique et ses cousines, de la biologie moléculaire à la génomique, tiennent une place prépondérante non seulement dans les sciences biomédicales fondamentales, mais aussi dans le grand public et dans les relations entre patients et professionnels de la santé, et ceci depuis déjà un certain nombre d'années (voir par exemple Kahn, 1996 ; Le Douarin et Puigelier, 2007 ; Parker, 2012). Les discours relatifs aux maladies génétiques, à la procréation assistée ou aux thérapies géniques ne se limitent pas à la communication entre spécialistes au sein d'articles savants ou dans le cadre de conférences, ils ont envahi également la sphère publique (médias, internet), notamment en raison des questions éthiques, philosophiques, voire spirituelles ou religieuses, que ces sujets soulèvent. Resurgissent souvent des débats mettant en jeu le darwinisme, débats assez souvent malsains dans la mesure où ils se veulent sensationnalistes car fondés sur des perceptions erronées qui remontent à des contemporains mêmes de Darwin (voir par exemple Tort, 2000). De plus, comme le souligne Hedgecoe (2000), la vision de la génétique présentée au public est souvent simpliste et elle évacue les analyses sociales complexes. Ce

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processus de simplification outrancière, nommé en anglais geneticization par différents auteurs critiques de cet état de fait (Abby Lippman, Hubbard et Wald ; cités dans Hedgecoe, 2000, p. 183) est d'autant plus regrettable que le fonctionnement du génome se révèle, en fin de compte, bien plus plastique que prévu (Séralini, 2005) et qu’il serait loin d'être déterministe comme on le présente souvent (Kupiec et Sonigo, 2003). Or, maintenant que le traducteur autant que l'interprète sont confrontés à leur « invisibilité » et, conséquemment, invités à agir comme médiateur actif au sein du processus de communication (Angelleli, 2004Venuti, 1995), il leur est impossible d'ignorer ces difficultés, d'autant que dans les contextes où ils doivent intervenir, ils auront à tenir compte de différences culturelles, idéologiques, voire religieuses, interférant profondément avec les décisions que les patients ou les soignants auront à prendre. Les enjeux économiques et juridiques liés à la brevetabilité des gènes (Cassier et Stoppa-Lyonnet, 2012) et à la commercialisation parfois discutable de tests génétiques (Jordan, 2012) forment des lieux de controverse dans lesquels les langagiers impliqués doivent faire preuve de prudence autant que de compétences. Les imprécisions langagières et conceptuelles qui affectent la communication se trouvent au cœur de ce qui peut sembler parfaitement familier. Ainsi, le mot gène (gene en anglais, Gen en allemand) est bien connu, mais le fait que la notion sous-jacente soit encore source de controverse chez les chercheurs (Chevassus-au-Louis, 2001 ; Gerstein, 2007 ; Pichot, 1999) l'est beaucoup moins. Par ailleurs, certaines formulations, comme le gène de telle maladie (par exemple, de la mucoviscidose, du cancer), ou le gène de tel comportement (de l'alcoolisme, de la violence, de l'homosexualité, etc.), si elles semblent courantes et donc admises, sont discutables : aucune maladie n'est, à proprement parler, encodée génétiquement. Ce qui est transmis, c'est la défectuosité d'un gène, qui n'est plus « décodé » correctement par la cellule, laquelle produit une (ou plusieurs) protéine(s) imparfaite(s), ou n'en produit même plus. Le dysfonctionnement qui en résulte entraîne un état pathologique, mais dans bien des cas, le rôle d'un gène putatif reste impossible à cerner (le cas du « gène de l'autisme », Gilgenkranz, 2012) et les interactions complexes entre génome et environnement (l'épigénétique) brouillent les cartes, tout particulièrement dans le cas des comportements. On peut avancer sans trop de craintes de se tromper que nombre de formulations entérinées par l'usage mais obsolètes ou peu transparentes rendent la communication touchant à la génétique et à l'hérédité souvent biaisée à la base. Le problème dépasse de loin une simple question de terminologie ou de phraséologie examinées en synchronie. Or, les enjeux sociétaux, sinon philosophiques, sont énormes. Il se trouve que le gène est le fruit d'une longue histoire ponctuée par les avancées technologiques qui permettent d'en préciser la nature et par une succession de constructions théoriques qui ne manquent jamais de mobiliser non seulement la science,

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mais aussi la philosophie et des idéologies contradictoires. Par conséquent, il nous semble important de remonter le temps et l'évolution de la pensée scientifique pour mieux comprendre comment le discours moderne se construit en empruntant aux théories qui se sont succédé, et comment les métaphores qui les ont nourries s'agencent, pour le meilleur et pour le pire.

2. Contextualisation historique Jusqu'à la fin du XIXe siècle, les théories qui tentent d'expliquer les ressemblances entre générations sont fort peu corrélées à l'expérimentation. C'est, selon Rostand (1942), la période pré-expérimentale, durant laquelle prévaut la recherche de la synthèse de nombreuses données d'observations. Parmi les figures marquantes de cette fin du XIXe siècle, on relève Spencer, Darwin, Galton, Haeckel et Elsberg. Weissman clot cette période en réfutant de manière définitive la pangenèse de Darwin, avant la reconnaissance par De Vries, en 1900, des travaux de Mendel (1865). À partir de ce moment, et avec la création de l’acception moderne de genetics, par Bateson qui nomme ainsi la toute nouvelle science de l’hérédité (Bateson 1905 ; le mot est attesté avant, au moins en 1872, par l’Oxford English Dictionary, avec le sens de « principe or laws of generation ») et du mot Gen par Johanssen en 1909 à partir de Pangen, utilisé par De Vries (1889 ; terme sans rapport avec la pangenèse de Darwin), le coup d'envoi à la génétique moderne est donné. Comme le souligne Gayon (2004, p. 250), à partir de Johannsen, le gène est entendu comme une unité de calcul et de fonction (au sens de la combinatoire mendélienne) et non plus comme une particule ou une unité morphologique – ce qui est plutôt la problématique du XIXe siècle. Mais même avec la progression des techniques et les avancées expérimentales qui en découlent au XXe siècle, les modélisations successives de la biologie se sont construites, par nécessité, sur des raisonnements tenus à partir de données, certes maintenant expérimentales, mais néanmoins indirectes (personne n'a jamais observé directement un gène « en action », malgré ce que laissent croire les magnifiques animations en trois dimensions sur YouTube...) et sur des conceptualisations métaphoriques successives qui se sont surajoutées les unes aux autres (Fox-Keller, 2002, 2003 ; Vandaele, 2009). Mais un peu à la manière des couches rocheuses témoignant de la succession des périodes géologiques, les théorisations et leurs métaphorisations laissent des traces dans le discours jusqu'à nos jours. Pour comprendre les problématiques notionnelles et discursives actuelles qui affectent profondément et de façon occulte la communication biomédicale dans ses différents contextes, il nous faut donc examiner, de manière diachronique, comment les notions de gène et d'hérédité, ainsi que les discours s'y rapportant, se sont construites. Notre hypothèse de travail est que certaines métaphores, bien implantées dans le discours, sont dépassées

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ou menacent de l'être, mais qu'elles continuent d'être employées soit naïvement, soit à des fins rhétoriques qu'il importe de repérer. Ainsi, bien que l'humain s'interroge depuis l'Antiquité sur les causes de la ressemblance entre humains de générations successives, c'est au XIXe siècle que se prépare la « révolution scientifique » (Kuhn, 1962) du début du XXe siècle qui va fonder la conception moderne de l'hérédité. La transmission des caractéristiques des êtres vivants, les traits ou caractères, dont l'ensemble, pour un organisme donné, constitue le phénotype, sont l'une des préoccupations majeures des scientifiques de l'époque (pour des synthèses sur la question, voir par exemple Pichot, 1999 ; Heams et coll., 2011). La manière dont s'opère la correspondance entre un trait (la couleur de la peau ou du pelage, par exemple) et des entités biologiques hypothétiques, transmissibles de génération en génération, est au cœur des réflexions. Ceci rejoignait une autre des questions les plus saillantes, à savoir identifier et caractériser les particules constitutives de la matière vivante (Pichot, 1993). Au centre des recherches portant sur l'hérédité, la génétique des individus et des populations, puis à partir du milieu du XXe siècle, de la biologie moléculaire et, plus récemment, de la génomique, se trouve ainsi la caractérisation de l'unité d'hérédité (unit of inheritance). Ce couple d'équivalents passe du XIXe siècle au XXIe siècle sans qu'il ne paraisse jamais être rattaché à aucune théorie spécifique, ce qui lui confère un statut fortement générique (voir par exemple, Vignais et Vignais, 2006, p. 405). C'est donc à dessein que nous utiliserons ce terme et que nous abandonnerons, dans la suite de l'article, celui de gène, puisque nous nous intéresserons à la période qui précède l'apparition de ce dernier. Les multiples avatars de l'unité d'hérédité ont fait l'objet de nombreux écrits analytiques et critiques qui en soulignent les similitudes et les différences et qui les situent dans le contexte scientifique de leurs époques de création et d'emploi respectives. Mais si un certain nombre d'auteurs se sont intéressés aux métaphores en sciences, et plus particulièrement de la génétique ou de la théorie de l'évolution (par exemple Pramling, 2008 ; Ruse, 2000), ce qui est presque toujours laissé dans l'ombre, c'est la manière dont ces notions ont été ou sont encore conceptualisées métaphoriquement via le discours. Notre étude se situe dans un projet plus vaste embrassant des auteurs marquants du XIXe au XXIe siècle. Le sujet est d'une telle ampleur – ainsi qu'en témoignent les nombreux écrits et synthèses, comme celles de Pichot (1999), et l'imposant Dictionnaire du darwinisme et de l'évolution dirigé par Patrick Tort (1996) – que nous nous devons de restreindre notre propos dans le présent article. Nous nous concentrerons sur la manière dont la notion d'unité d'hérédité est nommée, décrite et conceptualisée chez trois auteurs de la fin du XIXe siècle, c'est-à-dire de la période pré-expérimentale évoquée plus haut : Spencer (l'unité physiologique), ainsi que Elsberg et Haeckel (les plastides et les plastidules).

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Pourquoi ces auteurs ? Contemporains de Darwin (1809–1882), mais un peu plus jeunes, Herbert Spencer (1820–1903) et Ernst Haeckel (1834– 1919) comptent parmi les penseurs qui ont le plus contribué à étendre le darwinisme à l’intérieur et hors du champ scientifique – même au prix de certaines déformations réfutées par Darwin lui-même. L'un est anglais, l'autre, allemand, ils représentent les deux pays scientifiquement dominants, du moins dans ce domaine, de l'époque. Louis Elsberg (1836–1885), lui, est américain. Beaucoup moins connu – il n’a même pas d’entrée qui lui soit consacrée dans le Dictionnaire du darwinisme et de l’évolution (Tort, 1996) – ses écrits manifestent cependant une concurrence sans merci avec Haeckel au sujet des unités d'hérédité. On peut penser qu'il est l’un des représentants de l'émergence de la science nord-américaine sur l'échiquier mondial, laquelle deviendra prédominante au cours du XXe siècle, tandis que celle de l'Europe va décliner en raison des deux guerres mondiales dévastatrices.

3. Les modes de conceptualisation scientifique Avant de poursuivre, revenons sur notion et conceptualisation, car la posture que nous adoptons conditionne la suite. C'est à dessein que nous les distinguons. Nous préfèrerons notion à concept pour exprimer le contenu encyclopédique auquel un terme renvoie, ce que nous appelons également signification notionnelle (par opposition à la signification lexicale ; voir Vandaele et Raffo, 2008a). La conceptualisation – le plus souvent métaphorique – renvoie aux projections opérées depuis des cadres conceptuels sources sur un cadre cible (une notion) (Lakoff, 1980/2003, 1993), ce qui peut s'exprimer également par le biais des représentations factives et fictives de Talmy (2000). Depuis quelques années, nous nous attachons à la caractérisation des modes de conceptualisation métaphorique dans les sciences biologiques (voir, pour une synthèse, Vandaele, 2009 ; voir par exemple, pour les métaphores en sciences, Boyd, 1993 ; FoxKeller, 2003 ; Kuhn, 1993). Nous avons montré, dans notre équipe, que ces modes de conceptualisation sont véhiculés par des indices de conceptualisation (IC) selon deux mécanismes. Le premier est un mécanisme de projection opérant via les actants d'IC prédicatifs (Vandaele et Lubin, 2005) : ainsi, dans l'artère court le long du muscle, l'artère est soumise à une représentation fictive de mouvement à cause de l'IC verbal représenté par le verbe courir (Lubin, 2006). Le second est un mécanisme d'analogie de traits chez les IC non prédicatifs : les structures musculaires dites piliers du coeur sont ainsi nommées par analogie de traits avec des piliers en architecture (Labelle, 2009). Le premier mécanisme ne peut fonctionner qu'en discours, tandis que le deuxième est plutôt le fait de dénominations ou de désignations et fonctionne donc également hors

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discours. Nous avons par ailleurs montré que les IC formaient des réseaux lexicaux qui rendent compte de la puissance, en quantité (densité) et en qualité (variété), des conceptualisations métaphoriques (Vandaele et coll., 2006). Examiner la conceptualisation métaphorique à partir des marques laissées dans le discours permet d'éclairer d'un jour nouveau les problématiques soulevées quant au contenu notionnel per se. Les conceptualisations métaphoriques, une fois intégrées sur le plan cognitif et participant à l'intersubjectivité partagée, opèrent certes en arrière-plan, mais en sont d'autant plus puissantes. Elles constituent un problème essentiel non seulement de la traduction scientifique, mais aussi de la pédagogie et de la vulgarisation (Vandaele et Raffo, 2008b). En traduction, les modes de conceptualisation métaphoriques véhiculés par des IC prédicatifs sont particulièrement importants pour l'idiomaticité de la phraséologie et constituent une difficulté bien plus importante que la terminologie (voir, par exemple dans Vandaele, 2005 et Vandaele et coll., 2006, le cas de la conceptualisation des molécules biologiques et des cellules). Nous nous efforcerons donc, dans le présent travail, de cerner les modes de conceptualisation relatifs aux unités d'hérédité tels qu'ils manifestent, sous l'une ou l'autre forme, chez les auteurs retenus, et nous commencerons par présenter la méthodologie adoptée. Nous exposerons le contenu des notions retenues et la terminologie correspondante, en relation avec le corpus étudié. Ce faisant, nous situerons les théories de chacun des auteurs. Nous présenterons les résultats de l'analyse des modes de conceptualisations métaphoriques correspondant à ces notions. Enfin, le recours aux bitextes, lorsque cela était possible, a permis d'appréhender la problématique reliée à la traduction de ces textes certes scientifiques, mais dont l'aspect spéculatif ne doit pas être négligé, et qui posent donc des problèmes bien particuliers.

4. Méthodologie Nous avons recherché les termes renvoyant à la notion générique d'unité d'hérédité chez les auteurs marquants à partir du XIXe siècle – étant entendu que cette notion prend différentes formes et différents noms selon les auteurs jusqu'à ce que le terme gène (gene, ou Gen) s'impose définitivement (Vandaele, à venir). Nous nous sommes, pour cela, appuyées notamment sur Rostand (1949), Pichot (1993, 1999), Tort (1996, 2000), Vignais et Vignais (2006) ainsi que sur Loison (2008). Nous avons ensuite sélectionné les principaux auteurs de langues anglaise (A) ou française (F), avec les traductions éventuelles, ainsi que ceux de langue allemande dont les textes traduits étaient accessibles en anglais ou en français. Nous avons laissé de côté les auteurs mineurs tels que Béchamp, Beale ou Foster, ainsi que, malheureusement, les nombreux auteurs de langue allemande pour lesquels

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nous ne disposons pas de traduction (Brucke, Jäger, Nägeli, De Vries, Altmann, Hertwig, Wiesner, Haacke, Verworn), pour retenir Spencer, Darwin, Galton, Elsberg, ainsi que Haeckel et Weismann. Comme nous l'avons annoncé plus haut, nous présentons ici les résultats de l'analyse des textes de Spencer, Elsberg et Haeckel. Les textes ont été préparés pour l'annotation grâce au logiciel Oxygen (v. 11 et 12) en format XML. Il a donc fallu, au préalable, les convertir en format .txt et, dans certains cas, avoir recours à un logiciel de reconnaissance de caractères (ReadIris Pro, v. 11). Les éléments de balisage XML contenaient différents attributs nécessaires à la caractérisation des indices de conceptualisation et de leurs actants. Nous avons également repéré les analogies et les comparaisons introduites comme telles par certains auteurs. L'extraction des données a été réalisée à l'aide de requêtes rédigées en langage Xquery (Vandaele et Boudreau, 2006).

5. Les unités d'hérédité

5.1. Les théories pré-expérimentales de l'hérédité en bref Le questionnement autour de l'hérédité et donc de la variation ou de la fixité des espèces n'a certes pas commencé avec Darwin. Depuis Hippocrate et Démocrite, il est possible de retracer des dizaines de théories (Zirkle, 1946). Les principales positions pré-darwiniennes peuvent se résumer ainsi : la théologie de la nature, prévalente dans l'Angleterre victorienne, de type créationniste, représentée par Paley (1804), qui fut au rang des auteurs que le jeune Darwin se devait de maîtriser durant ses études (voir Tort, 1996, p. 3336) ; le fixisme, représenté par Cuvier (1825), en France; sa théorie rivale, le transformisme, représentée tout d'abord par Lamarck (1809), puis par les différents auteurs, dont Darwin bien entendu, qui acceptèrent le concept de l'évolution des espèces et qui finit par s'imposer comme seule position scientifiquement valable. Ce qui distingue les lamarckiens est leur adhésion à une hérédité dite organiciste, globale, c'est-à-dire relevant du monisme (Loison, 2008), contrairement aux autres, qui admettaient une hérédité dite micromériste (Delage, 1903), c'est-à-dire liée à l'existence de particules. Cette idée remonte à l'Antiquité (Rostand, 1949 ; Zirkle, 1946), mais elle émerge sérieusement, avec Maupertuis (1745), puis Buffon (1749) – lequel s'oppose violemment aux théologies de la nature. Ce dernier courant se fixe pour objectif de découvrir le support physique de l'hérédité et, partant, d'expliquer le mécanisme de l'évolution des espèces. De 1861 à 1909, une vingtaine d'auteurs de nationalités diverses, essentiellement de langue allemande (11) ou anglaise (6 ; seulement 2 Français), tentent de se distinguer en proposant des théories et des néologismes distincts, cherchant

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à nommer et à décrire la particule support de l'hérédité : parmi eux, Spencer, Haeckel et Elsberg (tableau 1). Tableau 1 : Les termes dénotant les unités d'hérédité chez Spencer, Haeckel et Elsberg Auteur introduisant le terme

Année de référence

Terme allemand anglais français Herbert Spencer (1820–1903) 1864 physiologischen Einheiten Philosophe et sociologue anglais. °physiological units unités physiologiques Ernst Heinrich Philipp August Haeckel 1873 °Plastiden (1834–1919) plastids Biologiste et philosophe allemand plastides (molécules vitales) Louis Elsberg (1836–1885) 1874 Plastidulen Médecin américain °plastidules plastidules ° Symbole repérant le néologisme véritable, les autres termes étant la traduction dans les autres langues.

5.2. Spencer : les unités physiologiques (physiological units) Spencer, célèbre pour son expression survival of the fittest (survivance du plus apte ; Tort, 1996, p. 4173), est un ardent défenseur du principe d'évolution, mais nombre de ses idées concernant l'extension du darwinisme hors du champ de la biologie, notamment le « darwinisme social », sont souvent attribuées faussement à Darwin (Tort, 2000, pp. 131–132). Le premier tome de Principles of Biology (1864), écrit après la parution de la première version de On the Origin of Species (1859) de Darwin, s’attache à expliquer les fondements chimiques et physiques de la vie, de l’hérédité et de l’évolution. Darwin reprendra l'expression dans la 5e édition de On the Origin of Species (1869). Le deuxième tome de Principles of Biology paraît en 1867. Avant de poursuivre, il est important de signaler que nous avons eu accès aux deux volumes par des rééditions américaines dont la numérotation n’est pas précisée, celle de 1884 pour le premier tome, et celle de 1871 pour le deuxième tome. Les traductions en français datent, respectivement, de 1877 et de 1878. Pour les éditions de langue anglaise aussi bien que pour celles qui sont traduites, nous indiquons aussi la date de la première édition anglaise de manière à éviter une incohérence apparente dans la datation. Les indices de conceptualisation sont en italiques dans les citations (les mises en relief éventuelles des auteurs n’ont pas été conservées pour éviter toute confusion).

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Pour Spencer, la vie s’organise selon des forces fondamentales. Comparant les êtres vivants à des cristaux formés d'atomes, il les conceptualise selon un modèle chimique : We must infer that a plant or animal of any species, is made up of special units, in all of which there dwells the intrinsic aptitude to aggregate into the form of that species: just as in the atoms of a salt, there dwells the intrinsic aptitude to crystallize in a particular way. (Spencer, 1864/1884, p. 181 ; nous soulignons) Nous devons conclure qu'une plante ou un animal d'une espèce quelconque se compose d'unités spéciales dans chacune desquelles réside une aptitude intrinsèque à s'agréger dans la forme de cette espèce: c'est ainsi que dans les atomes d'un sel réside une aptitude intrinsèque à cristalliser d'une façon particulière. (Spencer, 1864/1877, p. 218 ; nous soulignons) C'est ce que relève Weismann lorsqu'il évoque la théorie de Spencer : « [...] the 'polarity' of the 'units' leads to their arrangement in such a way that the whole 'crystal' - the organism - is restored, or even formed anew » (Weismann, 1892/1893, p. 1). Toutefois, constatant l'impossibilité de concevoir autant les cellules (morphological units) que les atomes ou les molécules (chemical units) comment étant les unités à l'origine de la formation des organismes vivants, Spencer postule l'existence d'unités « intermédiaires » (l’étoile indique un problème de traduction évoqué plus bas) : If, then, this organic polarity can be possessed neither by the chemical units nor the morphological units, we must conceive it as possessed by certain intermediate units, which we may term physiological. [...] in each organism, the physiological units produced by this further compounding of highly compound atoms*, have a more or less distinctive character. We must conclude that in each case, some slight difference of composition in these units, leading to some slight difference in their mutual play of forces, produces a difference in the form which the aggregate of them assumes. (Spencer, 1864/1884, p. 183 ; nous soulignons) Si donc cette polarité organique ne saurait être possédée par les unités chimiques, ni par les unités morphologiques, nous devons croire qu'elle est possédée par certaines unités intermédiaires que nous appellerions physiologiques. [...] dans chaque organisme, les unités physiologiques produites par cette combinaison d'atomes d'une composition avancée*, ont un caractère plus ou moins distinctif. Nous devons conclure que dans chaque cas, une légère

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différence de composition dans ces unités amenant une légère différence dans le jeu réciproque de leurs forces, produit une différence dans la forme que prend alors leur agrégat. (Spencer, 1864/1877, pp. 221–222 ; nous soulignons) Ainsi les unités physiologiques sont-elles postulées par déduction et non sur la base d'observations empiriques ou d'expérimentation mettant à l'épreuve une hypothèse. Ces unités se distinguent de celles de Maupertuis ou de Buffon : elles ne sont pas « des germes d'organes, mais des "éléments caractéristiques de l'espèce", des "corpuscules spéciaux", dont chacun possède une aptitude intrinsèque à s'agréger aux autres pour reproduire la forme propre à l'espèce » (Rostand, 1949, p. 249). Les cellules sexuelles contiennent les unités physiologiques de la mère et du père, qui sont transmises aux descendants chez lesquels se mélangent et s’affrontent les unités des deux parents. Les individus varient sous l’influence des forces environnementales et de l’habitude ou de manière spontanée. Ces deux sortes de variations sont transmises à la descendance et sont soumises à la sélection naturelle, ce qui explique l’évolution. En ce qui concerne les modes de conceptualisation, les unités physiologiques se voient attribuer une certaine agentivité, mais ce n'est pas la métaphore la plus saillante, elle est même sous-représentée par comparaison aux textes modernes de biologie (Vandaele, 2009) : Throughout the process of evolution, the two kinds of units, mainly agreeing in their polarities and in the form which they tend to build themselves into, but having minor differences, work in unison to produce an organism of the species from which they were derived, but work in antagonism to produce copies of their respective parentorganisms. (Spencer, 1864/1884, p. 254 ; nous soulignons) Tout le temps de l'évolution, les deux espèces d'unités se ressemblent principalement dans leur polarité et dans la forme sous laquelle elles tendent à se construire, seulement, comme elles ont aussi des différences secondaires, elles travaillent à l'unisson pour produire un organisme de l'espèce d'où elles sont dérivées, mais elles travaillent en opposition l'une avec l'autre pour produire des exemplaires des organismes-parents d'où elles sortent respectivement. (Spencer, 1864/1877, p. 308 ; nous soulignons) Les représentations fictives les plus saillantes évoquent plutôt un monde physicochimique de matériaux plus ou moins plastiques et soumis à des forces, de nature inconnue, qui les modèlent : [...] each organism is built of certain of these highly-plastic units peculiar to its species - physiological units which slowly work

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towards an equilibrium of their complex polarities, in producing an aggregate of the specific structure, and which, are at the same time slowly modifiable by the reactions of this aggregate [...]. (Spencer, 1864/1884, p. 287 ; nous soulignons) [...] chaque organisme est construit avec certaines de ces unités extrêmement plastiques, particulières à son espèce, unités qui travaillent lentement à mettre en équilibre leurs propriétés polaires complexes, en produisant un agrégat de la structure spécifique, et qui en même temps sont susceptibles de se modifier lentement sous l'influence des réactions de cet agrégat [...]. (Spencer, 1864/1877, p. 350 ; nous soulignons) Equally certain is it that the special molecules having a special organic structure as their form of equilibrium, must be reacted upon by the total forces of this organic structure ; and that, if environing actions lead to any change in this organic structure, these special molecules, or physiological units, subject to a changed distribution of the total forces acting upon them will undergo modification modification which their extreme plasticity will render easy. (Spencer, 1864/1884, p. 487 ; nous soulignons) Il est également certain que les molécules spéciales, ayant une structure organique spéciale comme leur forme d'équilibre, doivent subir la réaction des forces totales de cette structure ; et que si des actions environnantes conduisent à des changements dans cette structure organique, ces molécules spéciales, ou unités physiologiques, soumises à une distribution modifiée des forces totales agissant sur elles, subissent une modification que leur extrême plasticité rendra active. (Spencer, 1864/1877, p. 592 ; nous soulignons) Selon Rostand, la théorie de Spencer reste relativement obscure, mais elle est la première évoquant l'existence « d'unités intracellulaires, douées de propriétés héréditaires définies, et ne représentant pas des germes d'organes ou de parties » (Rostand, 1949, p. 252). Outre que cela la distingue de la pangenèse de Darwin, dans laquelle les gemmules représentent des parties d'organes qui se rassemblent dans les organes sexuels, elle est donc, sur la question de ces unités intracellulaires, précurseur du gène, ou plutôt du chromosome porteur du génome. L'évocation de forces appliquées à des éléments physiques n'est pas sans rappeler le système de forces « motrices » opposées qu'Empédocle d'Agrigente, considéré comme un des précurseurs antiques des chimistes, applique aux quatre éléments et qu'il nomme amour et haine :

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Ainsi l'amour et la haine chez Empédocle ne sont nullement des forces abstraites ; ce sont simplement des milieux doués de propriétés spéciales et pouvant se déplacer l'un l'autre, milieux au sein desquels sont plongées les molécules corporelles [...]. Quant aux noms poétiques qu'Empédocle a choisis pour désigner ces milieux, ils ne doivent point faire illusion [...] il n'y a nullement là des personnifications mythologiques véritables [...]. (Tannery, 1887, p. 306 ; nous soulignons) Au delà de Spencer, cette métaphore de l'attraction et de l'opposition semble avoir nourri la pensée de la chimie et, partant, la pensée biologique qui se réclame de cette dernière. Elle se retrouve de nos jours en pharmacologie dans la terminologie des interactions ligand-récepteur, décrites en termes d'affinité, d'agonisme ou d'antagonisme (Beaulieu et Lambert, 2010, pp. 21–25). L'idée d'affinité se trouve déjà chez Maupertuis (1745), elle est empruntée aux chimistes qui commencent à l'appliquer aux « combinaisons de substances » (Rostand, 1949, p. 243). Elle se retrouve également chez Buffon (1749), lorsqu'il tente d'expliquer la constitution de l'embryon par « l'affinité » des molécules organiques en excès chez les adultes formés et qui se sont localisées dans les semences féminines et masculines. Et nous allons également la retrouver chez Darwin. Cette convergence n'est pas étonnante, puisque, comme le souligne Pichot, les travaux de Spencer, avec ceux de Haeckel et de Weisman s'inscrivent dans la vision résolument « physico-chimio-biologique » de la fin du XIXe siècle (Pichot, 1999, p. 211). Et la filiation de pensée passe par Newton, connu de Spencer, et dont on sait qu’il influença Maupertuis et Buffon (Ruse, 2009, p. 21 ; Tort, 1996, pp. 459–471 et pp. 2837–2842). Du point de vue de la traduction, on remarque que le traducteur, Émile Cazelles, suit de très près la formulation du texte anglais. Le texte traduit suit l'original phrase par phrase, sans d'autres reformulations que celles qui sont requises par l'idiomaticité de la langue. Les réseaux lexicaux témoignant des modes de conceptualisation sont fidèlement rendus. On sent quelques hésitations à l'occasion : par exemple, parmi les extraits présentés, la traduction de « the physiological units produced by this further compounding of highly compound atoms* » (Spencer 1864/1884, p. 183 – nous soulignons) par « les unités physiologiques produites par cette combinaison d'atomes d'une composition avancée* » (Spencer, 1864/1877, pp. 221–222 ; nous soulignons). Il nous semble que Spencer fait allusion ici à différents degrés de complexité (auxquelles il fait référence par ailleurs, en termes d'« atomes simples » et d'« atomes complexes ») et d'agrégation. Nous aurions plutôt traduit ce passage de la façon suivante : « les unités physiologiques produites par une combinaison d'atomes déjà complexes eux-mêmes ».

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5.3 Haeckel et Elsberg : plastides et plastidules (plastides, plastidules) Elsberg, dans un article faisant état d'une communication de 1874 présentée devant la American Association for the Advancement of Science et publié en 1875, introduit le terme, en anglais, de plastidule (la forme française homographe plastidule est retrouvée dans divers textes français de l’époque évoquant Elsberg). Les plastidules seraient des particules vivantes porteuses d’hérédité, infiniment petites et non encore observables, provenant de tous les ancêtres et contenues dans le germe de chaque être vivant. À chaque génération, les plastidules des parents se mélangent, menant à une différentiation graduelle qui se module en fonction de l'environnement. Nous ne disposons pas, à notre connaissance, de traductions en français des textes d'Elsberg. Certains auteurs attribuent le terme plastidule à Elsberg, d'autres à Haeckel. Les textes de Haeckel publiés en allemand en 1868 font état du terme Plastid (Plastiden au pluriel). La traduction française (1874) fait état de plastide et la version anglaise (1880 et 1887 aux États-Unis pour les tomes 1 et 2), de plastide (ici aussi, la mise en relief en italiques de l’auteur n’a pas été conservée) : As has already been mentioned, our whole understanding of an organism rests upon the cell theory established thirty years ago by Schleiden and Schwann. According to it, every organism is either a simple cell or a cell-community, a republic of closely connected cells. All the forms and vital phenomena of every organism are the collective result of the forms and vital phenomena of all the single cells of which it is composed. By the recent progress of the cell theory it has become necessary to give the elementary organisms, that is, the "organic" individuals of the first order, which are usually designated as cells, the more general and more suitable name of form-units, or plastids. Among these form-units we distinguish two main groups, namely, the cytods and the genuine cells. The cytods are, like the Monera, pieces of plasma without a kernel (p. 186, Fig. 1). Cells, on the other hand, are pieces of plasma containing a kernel or nucleus (p. 188, Fig. 2). Each of these two main groups of plastids is again divided into two subordinate groups, according as they possess or do not possess an external covering (skin, shell, or membrane). We may accordingly distinguish the following four grades or species of plastids, namely: 1. Simple cytods [...] ; 2. Encased cytods ; 3. Simple cells [...] ; 4. Encased cells [...]. (Haeckel, 1868/1880, p. 346 ; nous soulignons) Dans son article de 1875, Elsberg écrit : « [...] in other words, that the germ of this new being contains actual particles, plastid-molecules or plastidules,1 of its grandparents » (Elsberg, 1875, pp. 89–90 ; nous

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soulignons). La note 1 en bas de la page 90 indique : « Haeckel has given the name Plastid, meaning forming or formative matter, to the units or ultimate form-elements to which organic bodies are reducible. » La note, fort longue, se poursuit à la page 91 : « The smallest partition-particles, or molecules, of a plastid I have called plastidules ; which I define to be the smallest particles in which the qualities of a plastid reside : the really "elementary factors of plastid life," as Haeckel [...] expresses it. » Et la référence à Haeckel date de 1873 ("Zur Morphologie der Infusorien" Jenaische Zeitschrift für Medicin und Naturwissenschaft, vol. vii, No. 4, 1873, p. 22). Le terme plastid (plastide) est en fait, d'après le raisonnement de Elsberg, un générique subsumant quatre types d'éléments-formes (formelement) : sans noyau (une forme primitive d'après les descriptions de l'époque : les cytodes), avec (Lepocytodes) ou sans membrane (Gymnocytodes) ; avec noyau (les cellules), avec (Lepocytes) ou sans membrane (Gymnocytes). Il appelle les plus petites parties des plastides plastidules (en français, plastidules), mot-valise créé avec plastide et molecule (Elsberg, 1875, pp. 89–90). Elsberg attribue aux plastidules, situées dans le noyau, un rôle essentiel dans les processus de multiplication des cellules. Mais dans le même temps, il hésite à définir les plastidules comme un « centre ou un faisceau de forces » ou des « particules matérielles » : To those who can more readily conceive the idea of force being transmitted than matter, it may make the subject clearer to state that I regard a "plastidule" quite as much a centre or bundle of force as of matter. [...] Nevertheless actual material transmission appears to me the most probable. [...] With the assumption of transmitted plastidules, the fact of the resemblances in features of children to grandparents, other inheritances good and evil, predisposition to disease, atavism, etc., are quite naturally explained. (Elsberg, 1875, pp. 89–90 ; nous soulignons) The assumption made, and we shall not find it difficult to believe that the germ of a child contains molecules or plastidules or bundles of force derived through its parents from grandparents, greatgrandparents, and in fact from a long line of ancestors. (Elsberg, 1875, p. 92 ; nous soulignons) En 1877, Elsberg publie un court article qui réitère la position prise dans l'article de 1875 et qui vise à différencier sa théorie de celles de Haeckel, de Spencer et de Darwin. (Elsberg, 1877, p. 181). Il insiste sur ceci : « a plastidule is a centre of force quite as much as a centre of matter, and that force or molecular motion is preserved and transmitted quite as much as molecular substance » (Elsberg, 1877, p. 179 ; nous soulignons). Il

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mentionne qu'il n'avait pas eu le temps d'approfondir la question de la transmission des forces, quand sont parus les travaux de Haeckel sur la périgenèse (perigenesis) dans lesquels la théorie d'Elsberg, dite regeneration hypothesis, aurait été mal comprise. Haeckel affirme que, dans sa théorie, seul le mouvement périodique des plastidules est transmis, mais Elsberg affirme que sa propre théorie en contenait le principe: "[...] only the particular form of periodic motion ; and it is only this continuing 'wave-motion of the plastidules' which, by virtue of their memory, causes the qualities of the older ancestors to reappear in the later progeny." (Haeckel, cité par Elsberg, 1877, p. 180) Mais Elsberg affirme que sa théorie de regeneration hypothesis contient l'idée de la transmission de l'hérédité par le biais de la transmission du mouvement des plastidules (Elsberg, 1877, p. 181). L'article de Elsberg paraît donc faire état d'une querelle portant sur la paternité du concept de transmission héréditaire par les plastidules, et plus particulièrement sur l'idée du mouvement à l'origine de cette transmission. Avec la périgenèse de Haeckel et les positions parallèles de Elsberg – bien qu'un peu hésitantes dans un premier temps –, c'est un nouveau mode de conceptualisation qui apparaît : l'unité d'hérédité n'est plus véritablement liée à l'existence d'une particule matérielle, mais à un phénomène de nature ondulatoire. Un peu plus tôt, Lamarck (1809), dont on caricature trop souvent la position en la résumant à une transmission simpliste des caractères acquis (voir Corsi et coll., 2006), admet la variabilité des espèces et propose une hypothèse de complexification graduelle des espèces sous l’effet de deux facteurs : le mouvement des fluides [sic] dans les corps vivants, qui amène le développement de nouveaux organes, et l’influence extérieure de l’environnement, qui amène un développement de ces organes par un usage plus ou moins grand. Il est intéressant de relever que Lamarck imagine une interaction entre le milieu externe au corps et le milieu interne. L'idée de mouvement se retrouve plus tard chez d'autres auteurs, pour tenter d'expliquer comment ce qui forme les organes se retrouve dans les organes reproducteurs (chez Darwin, dans le mouvement des gemmules), ou comment un caractère peut être transmis à la descendance (et donc, chez Elsberg et Haeckel, dans le mouvement ondulatoire des plastidules). Faut-il y voir une inspiration liée aux théories de la dualité onde-particule (ou onde-corpuscule) qui se sont épanouies au XIXe siècle, mais dont les prémisses remontaient au XVIIe, avec la querelle entre Huyghens et Newton ?

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6. Conclusion L'examen des principaux auteurs du XIXe siècle qui se sont penchés sur la nature des unités d'hérédité montre que chacun d'entre eux s’est positionné sur des axes distincts. Les théories microméristes se révèlent plus fructueuses que les théories organicistes néolamarckiennes, la vision globale de ses derniers bloquant l'accès à la conceptualisation des unités d'hérédité. Au sein des théories microméristes, un tournant décisif survient lorsqu'est abandonnée la vieille idée, remontant à l'Antiquité, des particules émises par le corps et se concentrant dans la semence, mais cet abandon se fait par étape. Spencer l'a déjà abandonnée quand Darwin y adhère encore (ce qui en fait le dernier représentant de la pangenèse), et Elsberg et Haeckel l'ont complètement laissée de côté. Weismann, ultérieurement, y portera le coup de grâce. Si Darwin est fortement influencé par son activité de naturaliste, chez Spencer, qui paraît être fortement influencé par des concepts de physique et de chimie, la métaphorisation est conforme au discours chimique de l'époque et elle ne témoigne pas de mode spécifique qui lui soit particulièrement original. Il est néanmoins obligé de postuler l'existence d'une forme intermédiaire entre les cellules et les atomes ou les molécules, ce qui évoque, même très imparfaitement, ce qui sera le génome porté par les chromosomes. L'absence de données concrètes limite cependant la théorie. Quant à Haeckel et Elsberg, ils apportent un mode de conceptualisation « désincarné » (quoiqu'avec une certaine prudence) dans lequel ce qui serait transmis ne serait plus une entité concrète, mais un mouvement, autrement dit, une quantité d'énergie. Mais là aussi, une fois ceci posé, l'imaginaire scientifique est limité par le manque de données venant appuyer l'hypothèse. En fait, chez ces auteurs, les réseaux lexicaux sont loin d'être aussi riches que ceux que l'on pourra observer au XXe siècle en biologie cellulaire et moléculaire ou en génétique, domaines qui se verront enrichis par les recherches menées tout au long de ce siècle (voir Vandaele 2009). Notre analyse met en relief la limitation de la métaphorisation quand manquent les données issues de l'expérience : autrement dit, les modes de conceptualisation restent relativement pauvres, faute de pouvoir discriminer, à ce stade de la formation de l'hypothèse, des phénomènes spécifiques. Il se pourrait même que la volonté unifiante qui se révèle dans les théories du XIXe siècle (vouloir trouver un mécanisme unique rendant compte de toutes les observations, aussi bien chez les végétaux que chez les animaux) constitue un frein à la métaphorisation. Au fond, en l'absence de la métaphore de l'encodage ou de l'information qui va prévaloir au XXe siècle (Fox-Keller, 2002, 2003) dans l'histoire de la notion de gène, les savants de l'époque n'ont pas d'autre manière de raisonner sur les relations entre les unités d'hérédité et l'organisme qu'en termes de constituants, de déplacement et de génération.

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En ce qui concerne la traduction, les textes révèlent, chez les différents traducteurs, un souci de la fidélité à l'auteur. Sauf quelques écarts ponctuels, on n'observe pas les errances d'une Clémence Royer traduisant On the Origin of Species (Brisset, 2006). Les traducteurs sont en fait euxmêmes des scientifiques sinon toujours de profession, tout au moins de formation : Charles Jean Marie Létourneau (1831–1902), traducteur de Haeckel vers le français, détient un titre de docteur, et il est l’auteur de La biologie (1876). Sir Edwin Ray Lankester (1847–1929), traducteur de Haeckel vers l'anglais, est un zoologiste britannique réputé, membre de la Royal Society. Émile Cazelles (1831–1907 ou 1908 selon les sources), traducteur de Spencer, est médecin, mais il est surtout connu comme philosophe et homme politique. Les conceptualisations se retrouvent fidèlement, de façon générale, dans les traductions. Pour terminer, il est frappant que les théories scientifiques de Spencer et de Haeckel aient été réfutées, mais que les concepts de nature non scientifiques aient perduré au point qu'ils ont constitué un terreau idéologique fertile au cours du XXe siècle. Ils ont contribué certes à ancrer le transformisme, mais ils ont été, comme le dit Tort, des « partisans impurs » du darwinisme d'origine (tous deux étaient en fait plutôt lamarckiens à la base), le premier « s'en servant pour justifier la relation compétitive des individus entre eux, aboutissant à la disqualification nécessaire des moins aptes » (Tort, 2000, p. 131), et le second, « imprégné d'eugénisme spartiate et d'euthanasie [...] » (Tort, 2000, p. 133), allant nourrir l'idéologie nazie. La suite de nos recherches, outre l'étude des auteurs qui ont suivi, et notamment Weismann, qui inaugure la période expérimentale, visera sans nul doute à repérer les traces empruntée à ces deux auteurs dans les travaux ultérieurs, non pas sur le plan des notions elles-mêmes invalidées, mais sur celui des métaphores qui continueront ou non de s'imposer.

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Access to health in an intercultural setting: the role of corpora and images in grasping term variation

Maribel Tercedor-Sánchez & Clara I. López-Rodríguez Department of Translation and Interpreting, University of Granada, Spain

Medical concepts can often be lexicalized in several ways depending on aspects such as the facet of the concept being underlined or the particular communicative setting in which the concept is being used. This feature of terminology is known as terminological variation. In this paper we consider terminological variation as a tool to improve interlinguistic and intercultural communication, a key issue in the provision of universal access to health care. To facilitate the identification and analysis of terminological variation, the paper also proposes some search strategies to highlight this phenomenon in corpora, the main source of terminological information. Finally, images are proposed as a key issue in the localization process needed to bridge communication gaps between health care providers and lay audiences. The data used in the paper are taken from an international cooperation project aimed at providing health providers in Yucatan, Mexico, with materials and training in intercultural communication for healthcare mainly in Spanish and Mayan, and from a research project on lexical variation 1.

1. Introduction Universal health access is a basic right that however is far from being accomplished due to economic, language and cultural barriers 2 which lead to difficult access to health care and poor communication between patients and health professionals. In many places, such as the Yucatan peninsula in Mexico, it is often the case that mainstream health care based on Western medicine coexists with traditional culture-based practices and this means that interculturality is a key issue in succeeding in the provision of healthcare. Interculturality within health care is defined as the explicit incorporation of the collective cultural load of the patient into his/her relationship with the healthcare provider, who is in turn source, generator and transmitter of a different form of culture (Campos, 2011). In addition, culture encompasses not only the products of a society as embodied in its institutions and objects, be they traditional or Western, but also world views, experiences and behaviour schemata (López-Rodríguez, 2003, p. 152). Furthermore, low health literacy is often an obstacle reflected in the difficulties the patient faces to understand the medical concepts used by the provider (Brooke Lerner, Jehle, Janicke, & Moscati, 2000). As a result, health authorities and providers are increasingly concerned with health literacy, defined by the American Medical Association (n.d.) as the “ability

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to obtain, process and understand basic health information and services needed to make appropriate health decisions and follow instructions for treatment”. In this context, translators are essential in the crosslinguistic and crosscultural mediation that often takes place in medical settings where there may be asymmetries of medical knowledge between health professionals and patients, as well as cultural and linguistic differences due to different national identities. According to Angelelli (2008, p. 130) in cross-cultural medical encounters interpreters (and hence translators) occupy the unique position of understanding both interlocutors’ points of view and points of reference. The literature on health interpreting includes studies assessing translational accuracy and mistranslations (omissions, substitutions, etc), and their effect in clinical practice (Pöchhacker & Shlesinger, 2007, pp. 2–4). Many of these mistranslations are related to cultural differences between the participants in healthcare communication, patients’ low health literacy, and terminological variation. Thus, maintaining accuracy in meaning and promoting intercultural understanding should be a priority for translators and interpreters in medical and health settings, a priority shared by translators in general: “Translators mediate between cultures (including ideologies, moral systems and socio-political structures), seeking to overcome those incompatibilities which stand in the way of transfer of meaning” (Hatim & Mason, 1990, p. 223). The aim of this paper is to present different forms of terminological variation (register-based and dialectal variation) in medical settings and their relevance in intercultural and interlinguistic communication. We will illustrate ways in which terminological variation can be a useful tool to bring medical knowledge closer to different audiences. Our methodology for retrieving and analysing different forms of denominative variation is based on the use of electronic corpora and search strategies. Finally, images are proposed as a key issue in the localization process needed to bridge communication gaps between health care providers and lay audiences, and we illustrate this with examples from our cooperation project in the Yucatan peninsula. Our data are extracted from the methods and results of research in this cooperation project entailing the production of Mayan and Spanish audiovisual materials for the promotion of health care in the Yucatan peninsula, and in the context of a research project on terminological variation aimed at the study of this phenomenon from a communicative as well as a cognitive perspective.

2. Culture and medical knowledge in healthcare communication In interlinguistic healthcare communication there are cultural elements whose understanding is essential for health decisions and treatment. Therefore, the use of translation procedures helping to bridge the gap

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between source language and target language, while maintaining accuracy, are key. Montalt & González Davies (2007, pp. 180–181) mention the following translation strategies: exoticism, cultural borrowing, calque, transliteration, communicative translation and cultural transplantation. While these are useful strategies at the microtextual level, translating in an intercultural setting requires going beyond the textual level. Consequently, Montalt & González Davies (2007, p. 184), following Katan (1999) indicate that mutual understanding between different linguistic communities may be hindered by the relevance given by these communities to context vs. text in communication. In this regard, Latin American cultures are closer to so-called High Context Cultures, for which “communication takes place through context rather than through texts” (Katan, 1999). Cultures where text is more important than context in communication are referred to as Low Context Cultures. 3 As part of our cooperation project, we became familiar with the health situation and the reasons for hospital admission of the indigenous populations in the Yucatan peninsula from 2010 to 2012. In this setting, communication takes place between two high context cultures (Mexican and Spanish), however, health information and practices are based on two different medical systems (Western medicine and Traditional medicine 4), which are not always successfully integrated. Health resources provided by international organizations such as Unicef and PAHO are neither assimilated nor accepted by the local population. The Yucatan peoples do not accept these resources because they do not represent their physical features and local identities as reflected in customs, clothes, houses, and everyday artifacts. Traditional medicine in Mexico, as in many Latin American countries is based on humoral medicine, defined by Foster (1987, p. 355) as “an ethnomedical system in which local foods and medicines are labeled with “hot” and “cold” markers, and illness is believed to be a disturbance to the temperature equilibrium in the body that is treated through the principle of opposites” (as cited in Worley, 2011, p. 5). Such folk medicine and practice pose a communication problem for doctors prescribing Western medicine to indigenous peoples since their world views and cognitive frame for understanding disease and healing are different. Smith (2003, p. 3) mentions that in Mexican traditional medicine vitamin C is considered a “cold food”, and therefore an inappropriate treatment for a “cold disease” like an upper respiratory tract infection. These cultural differences also pose translation and terminological challenges since there are medical conditions that are endemic to certain geographical areas due to environmental circumstances and/or cultural practices. Such conditions are known as “culture bound syndromes”, “culture specific diseases” (O'Neil, 2010) or “syndromes of cultural filiation” (Fagetti, 2004). Culture specific diseases are usually referred to with local names (e.g., ku ben ba, mal viento, tip’ te) because of their cultural and environmental specificity, and they are recognized in

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Traditional medicine but not always in Western medicine. Some of the most reported culture bound syndromes in the area of scope of our project are mal de ojo/ ojo (evil eye or strong eye), aire (group of diseases caused by leaving a hot environment and entering a very cold one), and susto (fright sickness) 5. Considering the distance between these two medical systems and the need to acknowledge the cultural idiosyncrasies of the indigenous peoples, it was necessary to find a common framework for communication between doctors and patients in which basic concepts related to disease and their basic conceptual relations (cause, effect, location, etc.) are integrated. In fact, all cultures have systems for classifying diseases on the basis of etiology, signs/symptoms and treatments (Neff, 1996). The first such common framework is the MEDICAL EVENT proposed by Faber (2002, p. 8) (Figure 1). It constituted the backbone for connecting medical terminology in English and Spanish of varying degrees of specialization in an information resource on cancer called OncoTerm6 (Faber, López-Rodríguez, & Tercedor, 2001; López-Rodríguez, Faber, & Tercedor, 2006). In the MEDICAL EVENT, the main conceptual categories in a prototypical medical process were identified: RISK FACTOR, BODY_PART, CONDITION, SYMPTOM, DIAGNOSTIC PROCEDURE, INSTRUMENT, TREATMENT, THERAPEUTIC OR HEALING AGENT, SIDE EFFECT, SPECIALISTS and HOSPITAL. It was ascertained that all these categories were valid and applicable to different medical domains (Faber, 1999, p. 99; Faber & Mairal, 1999). AGENT-1

CONDITION

LOC-1

PROCESS

RESULT

PATIENT

AGENT-2

TREATMENT

LOC-2

INSTRUMENT

Figure 1: Medical event (Faber, 2002, p. 8) This figure permits us to relate, define and paraphrase specialized terms on the basis of general language vocabulary. For example, the concept radiation therapy was represented in relation to basic concepts such as TREATMENT, INSTRUMENT, THERAPEUTIC AGENT, RESULT and LOCATION, as

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shown in Figure 2. This template was the foundation for terminographic definitions.

radiation therapy IS-A USES-[AGENT-2

[TREATMENT] = THERAPEUTIC AGENT]

USES-[INSTRUMENT]

high-energy rays linear accelerator tomotherapy machine

HAS-[RESULT]

elimination of cancer cells

AFFECTS

body part [LOCATION-2]

Definition treatment involving the use of high-energy rays to damage cancer cells and stop them from growing and dividing.

Figure 2: Representation of the concept RADIATION THERAPY To our mind, this framework can help bridge the gap between the medical knowledge and vocabulary of experts and those of patients, and between users and providers of health services who use different lexicalizations of concepts according to different situations and communication needs because it breaks down concepts into meaning units (see Section 3, Figure 4). As a result, this framework can be applied to integrate the knowledge and practices of different medical traditions, and to explain and define medical conditions to different audiences as in the following example:

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Language

Terms

Definition

Mayan

Tip 'te, Tip ‘te tuch

Spanish

cirro, pasmo del cirro, latido umbilical, cirro ladeado

English

There is not an equivalent in English. The translator can use the words in Mayan or Spanish (exoticism: cirro, Tip ‘te…) or adapt the reference to the target language (cultural transplantation: belly button ache, stomach ache).

A disease [CONDITION] affecting the digestive system [BODY PART AFFECTED] caused by mixing hot and cold food, eating in excess or making heavy efforts [AGENTS OF DISEASE]. The treatment for this disease is a therapeutic massage called sobada [TREATMENT] carried out by a partera (midwife) [SPECIALIST].

Figure 3: Conceptual categories to promote understanding of medical terminology The second framework that can help patients and interpreters come to grips with specialized medical objects, entities and procedures, is a better understanding of the Greek and Latin basis of medical terms. In our cooperation project, the population who spoke Mayan and Spanish obtained a better understanding of medical terminology after their etymology had been explained. In this regard, Peckham (1994), studying reactions in 180 orthopedic patients reported that 80% of them thought that there was a difference between a fractured bone and a broken bone. Montalt & González Davies (2007, p. 267) include an appendix of Latin and Greek roots for medical terminology, which are organized thematically. Greek and Latin roots in medical terminology can facilitate classification of terms into main conceptual categories such as these. The above classification constitutes again a framework for the organization of medical knowledge in the same vein as Faber's medical event.

3. Terminological variation in corpora as a key for use in intercultural communication The multiple ways to designate a concept through different expressions is often referred to as terminological variation 7. Thus, term variants are the different lexical manifestations of a term designating a particular concept. Researchers in both translation and terminology have long acknowledged the cognitive and communicative motivation of terminological variation. Although variation has been approached mostly from the cognitive

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perspective recently (Fernández, 2010; Fernández & Kerremans, 2011; Tercedor, 2011), its communicative aspects have been tackled in many studies as well (Freixa, 2006; Freixa, Fernández, & Cabré , 2008; Tercedor & Méndez, 2000). Medical concepts can be lexicalized in several ways depending on the facet of the concept being underlined, given a particular domain or a particular interest in the sender, something which brings about the multidimensional character of medical terminology, a feature it shares with other specialized domains. Furthermore, a particular term choice can be made on the grounds of the communicative setting in which it is going to be used, entailing geographic features, a marked register, or both. This feature of terminology is key in succeeding in health promotion in an intercultural setting. In this paper, we will therefore concentrate on the communicative motivation of terminological variation and how this feature can be incorporated in corpus linguistics for terminological purposes. One of the most influential approaches to linguistic variation was the one by Halliday, McIntosh and Strevens (1964, p. 77), who distinguished between linguistic variety according to the use to which language is put (register), and variety according to the characteristics of the users engaged in communication (dialect). This approach to language variation was applied to Translation Studies by many authors (Baker, 1992; Hatim & Mason, 1990; inter alia), and can be applied to terminological variation. The communicative reasons for choosing one term or another are the focus of Sections 3.1 and 3.2. Language enables us to construe items of world knowledge in different ways (Wierzbicka, 1995) and the way in which it is done depends on many factors intrinsic to the concept and its features or to the way it is perceived. Thus, the distinction between what the word means “objectively” and what it means to its user is not always obvious. In this regard, the cognitive paradigm challenges the objectivist view that distinguishes between the semantics and pragmatics of concepts, the distinction between what the word means and all the encyclopaedic knowledge that you happen to have about the things the word refers to (Lakoff, 1987, p. 138). This consideration of semantics and pragmatics as a continuum is key in the understanding of lexical instances of concepts as equally relevant, their relevance being dependant upon the particular context in which the term is going to be used. For a long time corpora have proved useful in the identification of terminological variation in medicine (López-Rodríguez, 2001; Tercedor, 1999). The different types of terminological variants, whether registerdependent or not, require different types of corpora. In order to compile register-dependent terminological variants a corpus of texts for a lay audience or a corpus of texts with different levels of specialization is needed, whereas to identify variations within the same level, a corpus containing texts of the same level of expertise can be used (Tercedor & Méndez, 2000).

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In a corpus of semi-specialized medical texts, the use of what has been called knowledge probes (Ahmad & Fulford, 1992) and knowledgerich contexts (Meyer, 1994) can help translators detect register variation in texts: one of the variants is the specialized term and the other is a hypernym, which is followed by a paraphrase of the specialized term. Meyer et al. (1999 cited in L’Homme & Marshman, 2007, p. 70) identify three main types of knowledge patterns: • • •

Lexical patterns: is the, is a, such as, and other, known as […] Grammatical patterns: for example, NOUN + VERB to explain the function of the specialized term Paralinguistic patterns such as the use of parenthesis or commas.1

The use of these patterns to detect terminological variants that can be of use in contexts such as the one in Yucatan described above, will be shown in examples taken from the 32 million corpus of the OncoTerm project. 8 We will also search the CREA corpus (Reference Corpus for Contemporary Spanish), 9 and Sketch Engine, 10 a Corpus Query System providing access to large corpora and producing concordances, and word sketches (a corpusderived summary of a word’s grammatical and collocational behavior). In this paper we exploit these resources either offline (with WordSmith Tools 11) or online to extract concordances and word sketches as a way to grasp conceptual relations and term variants (López-Rodríguez, 2007; Tercedor & López, 2008).

3.1. Register-based variation Register is understood as a combination of three variables: field, tenor and mode (Halliday et al., 1964). Halliday (1993, p. 25) defines these variables as follows: (a) field is the social action in which the text is embedded; it includes the subject-matter, as one special manifestation; (b) tenor is the set of role relationships among the relevant participants; it includes level of formality as one particular instance; (c) mode is the channel of communication selected, it includes the medium (spoken or written). Tenor is normally associated to the personal relation in terms of social distance or formality between the user and his/her audience. This notion has been called “formal tenor” (Hatim, 1997, p. 18) and “personal tenor” (Hatim & Munday, 2004, p. 190). In any case, tenor is a particular privileged category (Hatim, 1997, p. 26) because it interacts with field and mode. The interaction between tenor and field gives rise to technicality: the more formal the occasion, the more technical the use of language (Hatim & Munday, 2004, p. 81). When tenor interacts with mode, tenor determines the purpose for which language is used such as to persuade, to inform, to

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exhort or to discipline. Hatim and Mason (1990, p. 51) call it functional tenor. Drawing on this approach, terminological variation due to register mainly encompasses variation reflecting the social relation between the participants (formal register) as well as the knowledge shared by participants (technicality or degree of specialization). For example, a doctor can use the expression chemo in an informal situation with a colleague, low-dose chemotherapy in a research journal, and medication to communicate with his/her patient. The increasing number of standardized medical vocabularies, such as SNOMED CT®, ICD, CPT®, MeSH, or UMLS—to mention a few—show the complexity and nuances of communication in medical settings, and of variation according to use (register) as shown in the following example involving different types of users such as patients, companies, health organizations, clinicians and information management professionals.

Figure 4: Different terms and standards for one concept and different users (Source: IMO ® Interface Terminology: http://www.e-imo.com/ One of the ways of acting interculturally when providing health information is through the selection of paraphrases to better target the particular ways of

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conceiving health by a given cultural and linguistic community. That is why, when recording medical terminology for different purposes, different communicative settings should be considered and marked. For the purpose of corpus analysis and its use in the improvement of intercultural communication in health settings such as the one described above, the classification of texts according to communicative settings is essential. This can be achieved in two ways: (a) grouping texts in folders according to technicality/degree of specialization (specialized, semispecialized, text for the general public) and formality (formal, neutral, informal); (b) adding in each text a header with tags relating to the pertinent communicative setting(s). The first approach was followed in OncoTerm, where the texts included only basic tags (for example, author, title, journal and pages in the case of research articles), and the files division into folders was the basis for searches to retrieve terminological variants. For example, the introduction of the knowledge probe called served to generate concordances where the words to the left of called were an explanation or paraphrase of the meaning of the specialized term to the right (bronchi, epidermoid carcinoma, bronchoscopy, and so on). These paraphrases were very indicative of the kind of information to be included in the definition of terms for a lay audience (Pearson, 1998; López-Rodríguez, 2001). Other useful expressions were: is known as / is referred to as / is called / means / is defined as. 1

e product of the body's cells. Tubes called bronchi make up the

2

ancer: squamous cell carcinoma (also called epidermoid carcinoma),

3

oat and into the bronchi. This test, called bronchoscopy, is

4

e chest between two ribs. This test, called thoracoscopy, is

5

also may be removed in an operation called a pneumonectomy.

6

the vein or muscle. Chemotherapy is called a systemic treatment

7

One new type of radiation therapy is called radiosurgery. In

8

out only a small part of the lung is called a wedge resection.

9 11 12 13

the vein or muscle. Chemotherapy is called a systemic treatment . Like surgery, radiation therapy is called local treatment lung is taken out, the operation is called a lobectomy. When one n one whole lung is taken out, it is called a pneumonectomy.

Figure 5: Concordance lines around called (López-Rodríguez, 2001, p. 513) As to the second approach to classify texts with a view to detect register variation, in the framework of the two research projects described in this paper, a corpus of medical texts for different contexts has been compiled and is now being tagged following the following schema in order to filter

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texts by keywords, medical domain, audience, and so on. We have used an adaptation of the tags proposed by the Lexicon research group (http://lexicon.ugr.es) for the corpus of EcoLexicon, a terminological knowledge base on the Environment (http://ecolexicon.ugr.es/en/). The annotation is based on XML language, and is the result of selecting from the Dublin Core metadata 12 the most relevant for translation purposes. The domain and keywords tags ensure the comparability of the texts so that the texts under study share similar terminology. These tags also illustrate the overlapping between field, tenor and mode.

Tag

Meaning of the tag

Values for tags

Register variation

Language

ISO code for languages

Not applicable

Domain

Areas of International Classification Diseases (ICD)

Field

keywords

the

Keywords in Medline

of Technicality (interaction fieldtenor) The synonyms used in the text for the Medline keywords indicate formal tenor and/or technicality.



Audience

Genre

expert semi-expert

Technicality (interaction fieldtenor)

lay

Formal tenor

abstract

Functional tenor tenor-mode)

research article thesis patent advertisement […]

Figure 6: Tags to filter register variation

(interaction

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Even when the corpus has not been tagged, when translating medical terms in intercultural contexts it is possible to obtain good examples by consulting on-line corpora such as the CREA (Corpus de Referencia del Español Actual) or the ones available from Sketch Engine (López-Rodríguez & Buendía, 2011) as will be seen in the following section.

3.2. Dialectal variation In terminology, studies on medical variation normally focus on variation according to register. However, in real medical encounters in an intercultural context, health providers and translators should also consider medical variation according to dialect (diatopic, diastratic, and chronolectal variation). All these have an impact on the strategies chosen to adapt the message to particular groups of receivers in a specific geographical, social and temporal context. Within diatopic or geographical variation, corpora are valuable tools to confirm intuitions about the geographical uses of words. The use of tools such as Diatopix 13 or Sketch Engine and its available corpora can provide dialectal variants and confirm “terminological hunches”. In the case of the Spanish TenTen corpus of Sketch Engine, only examples of European Spanish can be obtained, although the enormous size of the corpus (more than 2100 million words) constitutes a real advantage. And so, a Google search may indicate that, if we encounter the acronym ETV in Mexico, it is likely to refer to the term Enfermedades Transmitidas por Vector while in Spain, it stands for Enfermedad Tromboembólica Venosa. This can be confirmed by searching the expression ETV in the context of venosa and then, in the context of vector within a collocational span of 15 words in the Spanish TenTen corpus. No results for ETV referring to Enfermedades Transmitidas por Vector were found in the corpus of European Spanish (Figure 7).

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Figure 7: The acronym ETV in the Spanish TenTen corpus of Sketch Engine In any case, if we want to use a corpus including texts in Mexican and European Spanish, the CREA should be the best choice, although it often needs to be complemented with other sources of information and a thorough collocational analysis. If the corpus is compiled for a special purpose, as in our case, tags referring to geographical variation such as the ones below should be used. Tag

Meaning of the tag

Values for tags

Language

ISO code for languages

Country of publication

ISO codes for countries

Geographical variation

For example: Es-es (European Spanish) Es-mx (Mexican Spanish)

Figure 8: Tags to filter dialectal variation

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In our corpus the selection of the tag Es-mx in combination with a syndrome of cultural filiation such as “cirro” has allowed us to retrieve instances of dialectal use not only of the searched term but also of its linguistic and cultural context, thus improving our knowledge of Mexican traditional medicine. The concordances show the most frequent cooccurring words, synonyms and related terms.

Figure 9: Using the corpus to search for instances of dialectal use: the case of cirro Dealing with terminological variation in a multicultural setting also means being aware of variation due to social (diastratic) and geographical (diatopic) differences on the part of speakers. A doctor in Spain or Mexico may use the term metanfetamina (methamphetamine) to refer to an extremely addictive drug. However his/her patients can refer to this drug with one of the street names used in their respective countries, which may not be familiar terms for the doctor. Regarding chronolectal variation, there are not many corpus data shedding some light on either the language of children in clinical settings or the use of child language (i.e., language used by the child and controlled actively by her: Jakobson, 1969) by paediatricians examining them. Expanding previous corpora on child language such as the ones contained in the CHILDES database (http://childes.psy.cmu.edu/) to include healthcare situations in different countries and different dialects could be a promising research area. Such a corpus would be helpful in finding the Mexican equivalent of the children expression pupa found in this example from the Spanish component of the CHILDES project (Figure 10).

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Figure 10: A mother and child talking about pain in the CHILDES database 14 To facilitate the understanding of medical concepts and their different terminological variants in intercultural and interlinguistic health settings, images can be used as a link between concepts and their lexicalizations. Therefore, we propose that visually representing medical conditions is a basic step into a better intercultural and interlinguistic communication, as well as an important tool for the generation of texts based on controlled languages. Following is an example of a visual representation of a medical symptom for kids (tummy ache / dolor de tripa) and the geographical distribution of the terminological variant chosen. This issue is considered in greater depth under 4.

Figure 11: Visual representation of the concept STOMACH PAIN for children (left) and presence of the terminological variant “dolor de tripa” as retrieved by Diatopix

4. Images triggering term variation in patient-health provider communication Images can help bridge communication obstacles in health settings provided they are chosen on the grounds of a particular degree of

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specialization or a focus on a particular aspect of a medical concept. The use of images to represent general medical concepts is a common communicative tool in hospital and other health facilities. Projects such as the Hablamos Juntos program (http://www.hablamosjuntos.org) have long been working in studying universal signs and icons to direct patients within hospital settings. Images can be used to bridge communication obstacles and to improve patients’ knowledge about disease and health, as in the following information leaflet:

Figure 12: Symptoms of diabetes (Servicio de Salud de Yucatán, 2010, p. 2) The leaflet describes the symptoms of diabetes in plain language and with visual support so that low literacy patients can understand. “Necesidad de orinar con frecuencia”, is a paraphrase that would rarely be included as a term entry in traditional terminology settings. However, it is a better option to ensure comprehension by lay persons than the medical term polyuria. By the same token, “sed excesiva” is used instead of the medical term polidipsia, and “falta de energía” instead of astenia. This register-based form of variation is key in bringing closer concepts to lay audiences or audiences with limited language proficiency. Such strategy is further enhanced by the use of images that facilitate understanding of medical concepts. Images in this context serve as a sort of interlingua between medical concepts and their lexicalizations, but the interpretation of images, icons and body language by different individuals and cultures is also an important issue to consider, as revealed by our cooperation experience in Yucatan. Images are thus a thorny issue in any process entailing cultural and linguistic adaptation (localization) for health promotion. In our cooperation project, patients did not have confidence in existing healthcare materials

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(mainly in printed form) due to the fact that they had been designed with a focus on global use (written in majority languages and lacking cultural referents) and therefore, patients’ identities were not reflected. Consequently, we addressed this challenge by designing and developing audiovisual and printed materials in Mayan and Spanish and by assessing the cultural, technical and linguistic aspects that should be considered with a focus on localization, reflected both in language and images. As for language, local cultural concepts were chosen to empower the language and culture. For example, analogies using local concepts such as "me pondré grande como una ceiba" (I will grow tall as a ceiba) were used to illustrate eating habits for children. Images were chosen on the basis of cultural adequacy after anthropologic consultation and field studies to ensure local acceptance.

Figure 13: Local features in the design of printed materials (left) and cartoons (right). Source: Animated videos and education materials from the University of Granada cooperation project Procuración de justicia y acceso a la salud por parte de la población indígena de Yucatán: mediación interlingüística e intercultural

We have briefly illustrated how in multimodal scenarios images play an important role in the access to health serving as a bridge between the concept and its lexicalizations. In this context, their motivated choice relates to the textual configuration and the terminological variants chosen.

6. Conclusions In this paper we have illustrated how terminological variation reflects different communicative and social context-bound motivations in designating concepts. The nature of the concept and its salient features are a basic aspect to study terminological variation, although register can

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determine the choice of one or another lexicalization. Furthermore, the suitability of a particular term choice in a geographical setting can enhance communication between health care providers and patients. In an interlinguistic and intercultural setting, the awareness of these forms of variation is fundamental in succeeding in providing access to health for all. The corpus-based examples and visual resources provided indicate new ways to improve patient-doctor communication and health literacy. Some issues such as the cognitive motivation for a particular terminological choice in a medical encounter or the relation between term variants and images remain to be researched, and experimental methods such as those searching for spontaneous production are a promising venue for researching terminological variation.

References Ahmad, K., & Fulford, H. (1992). Knowledge processing 4: Semantic relations and their use in the elaboration of terminology. Computing Sciences Report. Guildford: University of Surrey. American Medical Association. (n.d.). Health Literacy. Retrieved from http://www. ama-assn.org/ama/pub/about-ama/ama-foundation/our-programs/public-health/h ealth-literacy-program.page Angelelli, C. (2008). Medical interpreting and cross-cultural communication. Cambridge: Cambridge University Press. Baker, M. (1992). In other words: A coursebook on translation. London: Routledge. Brooke L., E., Jehle, D. V.K., Janicke, D. M., & Moscati, R. M. (2000). Medical communication: Do our patients understand? American Journal of Emergency Medicine, 18(7), 764–766. Campos, R. (2011). Interculturalidad, cosmovisión y practicas médicas mayas de la Peninsula de Yucatán: Una aproximación antropológica. Universidad Nacional Autónoma de México. Retrieved from http://www.mayas.uady.mx/articulos/ interculturalidad.html Faber, P. (1999). Conceptual analysis and knowledge acquisition in scientific translation. Terminologie & Ttraduction, 1999(2), 97–123. Faber, P. (2002). Investigar en terminología. In P. Faber & C. Jiménez (Eds.), Investigar en terminología (pp. 3–23). Granada: Comares. Faber, P., López-Rodríguez, C. I., & Tercedor-Sánchez, M. (2001). La utilización de técnicas de corpus en la representación del conocimiento médico. Terminology, 7(2), 167–197. Faber, P., & Mairal Usón, R. (1999). Constructing a lexicon of English verbs. Berlin: Mouton de Gruyter. Fagetti, A. (2004). Síndromes y filiación cultural: Conocimientos y prácticas de los médicos tradicionales en cinco hospitales integrales con medicina tradicional del estado de Puebla. Puebla: Servicios de Salud del Estado de Puebla.

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Fernández Silva, S. (2010). Variación terminológica y cognición: Factores cognitivos en la denominación del concepto especializado. PhD Thesis. Universitat Pompeu Fabra. Fernández Silva, S., & Kerremans K. (2011). Terminological variation in source texts and translations: A pilot study. Meta: Translators’ Journal, 56(2), 318–335. Foster, G. M. (1987). On the origin of humoral medicine in Latin America. Medical Anthropology Quarterly, 1(4), 355–393. Freixa, J. (2006). Causes of denominative variation in terminology: A typology proposal. Terminology, 12(1), 51–57. Freixa, J., Fernández, S., & Cabré, M. T.. (2008). La multiplicité des chemins dénominatifs. Meta: Translators’ Journal, 53(4), 731–747. Geeraerts, D., Grondelaers, S., & Speelman, D. (1999). Convergentie en divergentie in de Nederlandse woordenshat: Een onderzoek naar kleding- en voetbaltermen. Amsterdam: Meertensinstituut. Halliday, M. A. K., McIntosh, A., & Strevens, P. (1964). The linguistic sciences and language teaching. London: Longman. Halliday, M. A. K.. (1993). Language as social semiotic. In J. Maybin (Ed.), Language and literacy in social practice (pp. 23–42). Clevedon: Multilingual Matters. Hatim, B., & Mason, I. (1990). Discourse and the translator. New York: Longman. Hatim, B. (1997). Communication across cultures: Translation theory and constrastive text linguistics. Exeter: University of Exeter Press. Hatim, B., & Munday, J. (2004). Translation: An advanced resource book. London: Routledge. Jakobson, R. (1969). Kindersprache, Aphasie und allgemeine Lautgesetze. Frankfurt am Main: Suhrkamp. Kangwa, C. (2010). Traditional healing and Western medicine: Segregation or integration? Retrieved from www.milligan.edu/academics/writing/pdfs/ Kangwa.pdf Lakoff, G. (1987). Women, fire, and dangerous things: What categories reveal about the mind. Chicago: University of Chicago. L’Homme, M.-C., & Marshman, E. (2007). Terminological relationships and corpusbased methods for discovering them: An assessment for terminographers. In L. Bowker (Ed.), Lexicography, terminology, and translation: Text-based studies in honour of Ingrid Meyer (pp. 67–80). Ottawa: University of Ottawa Press. López-Rodríguez, C. I. (2001). Tipologías textuales y cohesión en la traducción biomédica inglés-español: Un estudio de corpus. Granada: Editorial Universidad de Granada. Retrieved from http://www.webcitation.org/5u2exEiZC López-Rodríguez, C. I. (2003). Electronic resources and lexical cohesion in the construction of intercultural competence. Lebende Sprachen, 4, 152–156. López-Rodríguez, C. I. (2007). Understanding scientific communication through the extraction of the conceptual and rhetorical information codified by verbs. Terminology, 13(1), 61–84. López-Rodríguez, C. I., Faber, P., & Tercedor-Sánchez, M. (2006). Terminología basada en el conocimiento para la traducción y la divulgación médicas: El caso de

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Oncoterm. Panace@, 7(24). Retrieved from http://www.medtrad. org/panacea/IndiceGeneral/n24_tradyterm-l.rodriguez.etal.pdf López-Rodríguez, C. I., & Buendía-Castro, M. (2011). En busca de corpus online a la carta en el aula de traducción científica y técnica. Trans-Kom (Journal for Translation and Technical Communication Research), 4(1). 1–22. Retrieved from http://www.trans-kom.eu/bd04nr01/trans-kom_04_01_01_Lopez _Buendia_Corpus.20110614.pdf Meyer, I. (1994). Linguistic strategies and computer aids for knowledge engineering in terminology. L’Actualité Terminologique/Terminology Update, 27(4), 6–10. Meyer, I. (2001). Extracting knowledge-rich contexts for terminography: A conceptual and methodological framework. In D. Bourigault, C. Jacquemin, & M.-C. L’Homme (Eds.), Recent advances in computational terminology (pp. 279–302). Amsterdam: John Benjamins. Montalt Resurrecció, V., & González Davies, M. (2007). Medical translation step by step (Translation practices explained). Manchester: St. Jerome. Neff, N. (1996). Folk medicine in Hispanics in the Southwestern United States. Retrieved from Rice University, Baylor College of Medicine website: http://www.rice.edu/projects/HispanicHealth/Courses/mod7/mod7.html O’Neil, D. (2010). Culture Specific Diseases. Retrieved from http://anthro. palomar.edu/medical/med_4.htm Pearson, J. (1998). Terms in context: Studies in Corpus Linguistics (Vol. 1). Amsterdam: John Benjamins. Peckham, T. J. (1994). Doctor, have I got a fracture or a break? Injury, 25(4), 221–222. Servicio de Salud de Yucatán. (2010). InfoSalud, 4(33) (September–December). Retrieved from http://www.salud.yucatan.gob.mx/boletin/10_12/10_12.pdf Smith, A. B. (2003). Mexican cultural profile. Retrieved from http://www.son. washington.edu/portals/idc/cases/hepC/rc9/JohnPDFs/PDFs/%28D14%29%20Et hnoMed,%20Hispanic.pdf Tercedor, M. (2011). The cognitive dynamics of terminological variation. Terminology, 17(2), 181–197. Tercedor, M. (1999). La fraseología en el lenguaje biomédico: Análisis desde las necesidades del traductor. Madrid: CSIC / Elies, vol 6. Retrieved from http://elies.rediris.es/elies6/. Tercedor, M., & Méndez Cendón, B. (2000). Fraseología y variación terminológica: Estudio descriptivo en corpora biomédicos. Terminologie & Traduction, 2, 82– 100. Tercedor, M., López-Rodríguez, C. I., & Robinson, B. (2005). Textual and visual aids for e-learning translation courses. Meta: Translators’ Journal, 50(4). Retrieved from http://www.erudit.org/revue/meta/2005/v50/n4/019904ar. pdf Tercedor, M., & López-Rodríguez, C. I. (2008). Integrating corpus data in dynamic knowledge bases: The puertoterm project. Terminology, 14(2), 159–182. doi: 10.1075/term.14.2.03ter

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Wierzbicka, A. (1995). Dictionaries vs. encyclopaedias: How to draw the line. In P. W. Davis (Ed.), Alternative linguistics: Descriptive and theoretical modes (pp. 289– 315). Amsterdam: John Benjamins. Worley, J. L. (2011). The blend of traditional and modern medicine: Case studies from Latin America as lessons for the United States. Honors Thesis, University of Arkansas. Retrieved from https://uarkive.uark.edu:8443/xmlui/handle/10826/ ETD-2011-12-64 Zografi, M. (2009). Relevance of intercultural communication for human resources management. Management & Marketing, 4(4), 133–140.

Lexicographic and Terminographic resources GRUPO LEXICON. EcoLexicon, terminological knowledge base on the environment. Available at: http://ecolexicon.ugr.es/en GRUPO ONCOTERM. OncoTerm: Sistema bilingüe de información y recursos oncológicos. Available at: http://www.ugr.es/~oncoterm LEXICAL COMPUTING LTD. Sketch engine. Available at: http://www.sketchengine. co.uk REAL ACADEMIA ESPAÑOLA: Banco de datos (CREA). Corpus de referencia del español actual. Available at: http://www.rae.es Universidad Nacional Autónoma de México (2009). Biblioteca digital de la medicina tradicional mexicana. Retrieved from http://www.medicinatradicionalmexicana. unam.mx/index.php

_____________________________

1

This research has been carried out within the framework of two projects. (1) Procuración de justicia y acceso a la salud por parte de la población indígena en México: mediación interlingüística e intercultural is a Joint Project of the University of Granada and the Higher Education Institute of Translation and Interpreting, Mexico DF, funded by the Center of Cooperation Initiatives of the University of Granada (CICODE). (2) VariMed: Denominative variation in medicine: Multilingual multimodal tool for research and knowledge dissemination (FFI2011-23120), a three year (2012-2014) research project funded by the Spanish Ministry of Economy and Competitiveness, with the participation of researchers from the University of Granada, University Pablo de Olavide, and University of Valladolid (Spain), Rutgers University (USA) and Carleton University (Canada), aimed at the study of denominative variation from a cognitive and communicative perspective.

268

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Medical journals such as the Journal of General Internal Medicine are devoting whole issues to language barriers in health care.

3

The cline representing the role of context in various cultures was proposed by Copeland & Griggs (1986 cited in Zografi 2009, p. 136) and it goes from High Context Cultures to Low Context Cultures as follows: Japanese – Chinese – Arab – Greek – Mexican – Spanish – Italian – French – French Canadian – English – English Canadian – American – Scandinavian – German – Swiss-German.

4

Kangwa (2010) discusses the differences between Traditional Medicine and Western Medicine.

5

Biblioteca digital de la Medicina Tradicional Mexicana: http://www.medicinatradicionalmexicana.unam.mx/index.php

6

http://www.ugr.es/~oncoterm

7

The concept has been refeered to as onomasiological variation in the cognitive linguistics paradigm (Geeraerts, Grondelaers and Speelman (1999), distinguishing between formal variation (use of synonyms) and conceptual onomasiological variation (use of the hyperonym and hyponym alternatively). However in the field of terminology this form is rarely used and full synonymy is rare.

8

http://www.ugr.es/~oncoterm/

9

http://corpus.rae.es/creanet.html

10

http://www.sketchengine.co.uk/

11

http://www.lexically.net/wordsmith/index.html

12

http://dublincore.org/

13

http://olst.ling.umontreal.ca/~drouinp/diatopix/index_en.html

14

http://childes.psy.cmu.edu/browser/index.php?url=Romance/Spanish/Irene/52.cha

BOOK REVIEWS

Gambier, Y., & van Doorslaer, L. (Eds.). (2011). Handbook of translation studies (Volume 2). Amsterdam: John Benjamins. Printed edition, 197 p. Gambier, Y., & van Doorslaer, L. (Eds.). (2011). Handbook of translation studies online (2nd ed.). Available online at: http://www.benjamins.nl/online/hts/ Luc van Doorslaer writes in “Bibliographies of translations studies” published in volume 2 of the Handbook of translation studies (HTS) (pp. 13–16) that the maturing discipline of Translation Studies is sufficiently institutionalized to warrant the confection of “knowledge-structuring academic ‘tools’” (p. 13) to organize and systemize the somewhat fragmented knowledge published in bibliographies, dictionaries, encyclopaedias, textbooks and elsewhere. Examples of books that publish overlapping and often complementary knowledge are volumes 1 (2010) and 2 (2011) of the HTS, edited by Yves Gambier and Luc Van Doorslaer and published by John Benjamins, the second edition of the Routledge encyclopedia of translation studies (Baker & Saldanha, 2011), the fourvolume Translation studies (Baker, 2009), Übersetzung: ein internationales Handbuch zur Übersetzungsforschung = Translation: an international encyclopedia of translation studies = Traduction : encyclopédie internationale de la recherche sur la traduction (Kittel, House & Schultze, 2004), and the Oxford handbook of translation studies (Malmkjær & Windle, 2011). However, as Gambier and van Doorslaer explain, what sets their reference book apart are the “two major contributions [that it makes] to the field” (p. ix): 1) “both a print edition and an online version”, where articles are “regularly revised and updated” and 2) “the interconnection with the online Translation studies bibliography (TSB)” (p. ix), an example par excellence of a “knowledge-structuring academic ‘too[l]’” (p. 13). Selected concepts from the TSB (Gambier & van Doorslaer, 2012) are the subject of HTS print and online articles. Key terms and concepts in the HTS’s online articles are hyperlinked to the TBS in order to facilitate research by key word and related fields. In addition, the student, researcher and general reader can “find an abstract of the publication” (p. ix) in the TSB to determine the potential pertinence and usefulness of articles, chapters and books. The HTS clearly aims to make translation and interpreting knowledge available to a broad public thanks to the online edition. Thankfully, Benjamins also publishes a print version for those of us who still prefer the tactile pleasure of a quality bound book. The second volume of the print edition adds 35 articles to the 70odd articles published in the first volume. The articles vary in length from 500 to 6,000 words, “based on relevance” (p. ix) and the depth to which the subject matter is treated. They are organized by alphabetical order and interrelated thanks to asterisks that highlight subjects dealt with in other articles published in volumes 1 (one asterisk) and 2 (two asterisks). For

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example, in Cristina Valdés’ “Advertising translation” (pp. 1–5), “Turns of Translation Studies” (p. 1), “translation strategies” (p. 2), “Semiotics and translation” and “localization” (p. 3), and “the Web” (p. 4) are highlighted with one asterisk, while “wordplay” (p. 1) is highlighted with two asterisks – a link to Jeroen Vandaele’s “Wordplay in Translation” (pp. 180–183). A list of references and, in most cases, suggestions for further reading complete the articles. A detailed subject index at the end of volume 2 lists entries – in bold – that “lead directly to an article (either in HTS vol. 1 or vol. 2)” (p. 184), as well as key words. The cumulative index is more extensive in the second print volume, but is the most complete in the online version of the HTS, where it is possible to use the “Search” function to access very quickly pertinent articles by article, author or subject. International Translation Studies scholars with an expertise in the subject field are generally the authors of articles. While 29 of the contributors to volume 2 are recognized names in European TS scholarship (e.g., Dirk Delabastita on literary translation, pp. 69–78, and Kirsten Malmkjaer on linguistics and translation, pp. 61–68), four Canadian researchers (Paul Bandia, “Orality and translation”, pp. 108–112; Hélène Buzelin, “Agents of translation”, pp. 6–12; Brian Mossop, “Revision”, pp. 135–139; Sherry Simon, “Hybridity and translation”, pp. 49–53), a US researcher (Sonia Colina, “Evaluation/Assessment”, pp. 43–48) and a Turkish researcher (Şehnaz Tahir Gürçağlar, “Paratexts”, pp. 113–116) have also contributed to the volume. Inevitably, some shortcomings are to be noted in a publication of this type. A sensitive issue – from a Canadian perspective at least – is the Eurocentrism of articles such as Albert Branchadell’s “Minority languages and translation” (pp. 97–101) that makes but passing reference to a few non-European languages (Ghaya, Khasi, Oriya) in its discussion. Branchadell’s reliance on the research of Michael Cronin, while beyond reproach in terms of the quality of the research referenced, could be questioned in terms of variety. This reviewer would have expected that reference be made as well to non-European classics such as the seminal work that has inspired research on theatre translation and minority in Québec, Canada and abroad, most notably Scotland: Annie Brisset’s (1990) brilliant Sociocritique de la traduction: Théâtre et altérité au Québec (1968-1988), to give just one possible example. Not surprisingly, given that the HTS is only at its second volume, the absence of articles on several specific concepts is to be noted, for example, equivalence, modulation, interculturality. We are nevertheless confident that these concepts, among numerous others, will be the subject of future articles. Translation Studies is a rapidly evolving discipline that is progressing relatively quickly through a series of “turns” (pragmatic, cultural, global, iconic, ideological, empirical, sociological, creative, ethical, power) (see, for example, “The turns of Translation Studies” by Snell-Hornby (2010) in the HTS, volume 1). The HTS could arguably prove highly useful by being not only a resource that deals with the most

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current topics in the discipline, but also one to which readers can refer to find answers to fundamental Translation Studies questions, a “back to basics” if you will. An effort is clearly being made in this area. Volume 2 boasts an article on “Institutional translation” by Kaisa Koskinen (pp. 54–60), “Translation problem” by Gideon Toury (pp. 169–174) and “Translation universals” by Andrew Chesterman (pp. 175–179). These articles provide an introductory review of the literature on the respective concepts as well as an historical overview of their development. The articles are followed by a highly useful list of references (Koskinen), or by a list of references and a list of suggested further reading (Toury, Chesterman), both of which identify key researchers and their publications. On the whole, volume 2 of the Handbook of translation studies gives a broad audience of students, researchers and the general public an excellent idea of the progress of ideas in the dynamic discipline of Translation Studies with, for example, articles on “Metaphors for translation” by James St. André (pp. 84–87), “Methodology in Translation Studies” by Peter Flynn & Yves Gambier (pp. 88–96) and “Pseudotranslation” by Carol O’Sullivan (pp. 123–125). The greatest strength of the HTS (volumes 1 and 2) lies in its providing, structuring and simplifying access to various sub-fields in Translation Studies; the HTS not only provides access to the subject of interest, but it also offers the undeniable advantage of identifying leading thinkers in the sub-fields and their publications. Furthermore, thanks to the links between the online Handbook of translation studies and the Translation studies bibliography, researchers can access more rapidly readings that are pertinent to their research projects. Volume 2 of the HTS will certainly add new users to the loyal group who eagerly awaits the publication in book form and in electronic format of new volumes, in addition to updated editions of existing volumes of the Handbook of translation studies. Bibliography Baker, M. (Ed.). (2009). Translation studies. 4 volumes. Abingdon: Routledge. Baker, M., & Saldanha, G. (Eds.). (2011). Routledge encyclopedia of translation (2nd ed.). London: Routledge. Brisset, A. (1990). Sociocritique de la traduction: Théâtre et altérité au Québec (1968-1988). Longueuil: Le Préambule. Gambier, Y., & van Doorslaer, L. (Eds.). (2012, first release October 2004). Translation studies bibliography. Available online at: http://www.benjamins.nl/online/tsb/ Kittel, H., House, J., & Schultze, B. (Eds.). (2004). Übersetzung: ein internationales Handbuch zur Übersetzungsforschung = Translation: an international encyclopedia of translation studies = Traduction : encyclopédie internationale de la recherche sur la traduction. Berlin: W. de Gruyter.

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Malmkjær, K., & Windle, K. (Eds.). (2011). The Oxford handbook of translation studies. Oxford: Oxford University Press. Snell-Hornby, M. (2010). The turns of Translation Studies. In Y. Gambier, & L. van Doorslaer (Eds.). Handbook of translation studies (Volume 1) (pp. 366–370). Amsterdam: John Benjamins. Denise Merkle, Département de traduction et des langues, Université de Moncton, Canada

Pedersen, J. (2011). Subtitling norms for television: An extrapolation focussing on extralinguistic cultural references. Amsterdam: John Benjamins. 240 p. The treatment of culture in translation has been the topic of scholarly discourse for quite some time. However, empirical studies of in the field of Audiovisual Translation (AVT) are not common. In this carefully researched and exceptionally well-structured book, Jan Pedersen takes the reader on a journey through the ways in which Extralinguistic Cultural References (ECRs), a term that the author has coined, are treated in Scandinavian subtitles. The book contains concrete examples from subtitling practice. One of its biggest strengths is a clear link that Pedersen makes between translation theory; between Descriptive Translation Studies (DTS), the writings of Toury and Chesterman in particular, and the practice of interlingual subtitling in Scandinavia. Thus, descriptive in nature, the book aims at eliciting subtitling norms that exist in Scandinavian countries and does so by means of extensive empirical research. Subtitling Norms for Television is divided into seven chapters. In Chapter 1, entitled “Subtitling as Audiovisual Translation”, Pedersen explains for instance that although countries are traditionally divided into subtitling and dubbing countries with respect to their preferred mode of AVT, this division is no longer applicable because of the “dynamics of the mediaspace” (p. 4). The reader is acquainted with interesting AVT practices such as the one in Ukraine, where the subtitling or non-subtitling of Russian films depends on whether the government is pro-Russian or not. Chapter 1 also explains the nature of subtitling (p. 8), of the subtitling process (p. 13) and of the constraints of subtitling (p. 18). This chapter also introduces the practicalities of subtitling to those not aware of the process, and further explains it to those who are. Chapter 2 is entitled “Norms in General and Particular” and it forms an important theoretical background for Pedersen’s empirical study. This chapter is a good reminder of what DTS is based on. Section 2.3, “The Potency of Norms”, helps the reader to better understand the sometimes confusing terminology related to norms, which does not prevent the author from giving the reader a clear overview of the concepts of laws, rules, norms, conventions, regularities and idiosyncrasies. The difference between

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Toury’s and Chesterman’s norms is also explained. In this section, the difference between norms, strategies and solutions is presented and an important claim is made, which states “[t]hat strategies are not norms, instead norms tell translators which strategy is appropriate given the circumstances” (p. 37). Chapter 3 introduces the central point of the model on which the empirical research is based, and those are ECRs. The definition of ECRs is provided (p. 43) and the differences between ECRs and realia are explained since Pedersen claims that the term realia is vague (p. 44). Chapter 3 establishes that “referents of ECRs are not found within language, but rather in extralinguistic reality, i.e. in the world” (p. 56) and this claim is key to understanding ECRs. The Scandinavian Subtitles Corpus is the author’s source of ECRs, which is the corpus of AVT materials (50 films and 50 episodes of TV series) that Pedersen has compiled. Chapter 3 is concluded with interesting findings, such as the findings that genre influences the distribution of ECRs (p. 63) and that the genre of comedy, for instance, shows much more variation than could be expected (p. 64). Chapter 4 bears the title “Translation Strategies: How It’s Done” and investigates “what translation strategies are used to make ECRs accessible to the TT audience” (p. 69), while discussing taxonomies proposed by other translation scholars, such as Katan and Chesterman. In order to make his taxonomy absolutely clear, Pedersen presents the reader with a graphic layout of ECR transfer strategies (p. 75) and in so doing, the reader is made aware of Pedersen’s view that retention, specification and direct translation are source-oriented strategies, while generalization, substitution and omission are target-oriented strategies. The remainder of Chapter 4 clarifies the strategies in detail and concludes with a simplified process-oriented taxonomy of ECR transfer strategies (p. 102). Chapter 5, “Influencing Parameters: Why It’s Done Like That” introduces the classification of ECRs into transcultural, monocultural and infracultural, since “before rendering an ECR, the subtitler has to try to decide whether or not the TT audience has knowledge about the ECR” (p. 106). Transcultural ECRs are those which are not bound to the source culture, while infracultural ECRs are. This chapter (p. 107) reveals that monocultural ECRs partly overlap with transcultural and infracultural ECRs. Chapter 5 also discusses the importance of ECRs, and the polysemiotics, which consist of the interplay between channels and mediaspecific constraints. The effects of the subtitling situation raise important questions as to what the skopos of the text is and whether the TT audience has special knowledge, which may be instrumental in the subtitler’s treatment of ECRs. Chapter 6 is the most extensive chapter in Pedersen’s monograph since the model presented in previous chapters is applied to empirical data. This chapter also reveals the amount of work that Pedersen has devoted to the empirical research of norms. Pedersen explains the reasons for focusing his study on 100 AVT materials and he also points out that the corpus is

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“mainstream in character” (p. 125). The criteria for the compilation of the corpus are explained in detail (p. 126) and the corpus is broken down by genre in the form of a table (p. 128). Pedersen introduces technical concepts such as expected reading speed, subtitle density and condensation rate, which were studied in the corpus. Chapter 6 reports interesting finding with regard to exposure time and the expected reading speed of subtitles in Denmark and Sweden and does to in the form of a diachronic study, in which Pedersen concludes that “expected reading speeds are rising everywhere” (p. 135). Topics such as subtitle density and condensation rate are studied in detail. The second part of Chapter 6 offers insights into how cultural references are rendered as regards subtitling strategies, especially as regards monocultural ECRs. The author also discusses the use of master templates and the consequences that this practice has on rendering ECRs, since it shows “how alike these texts become” (p. 176). Pedersen also recognizes that “subtitlers are more likely to adhere to the norms inherent in template files” than to the “appropriate subtitling style of each country” (p. 179). Chapter 6 concludes with the formulation of subtitling norms, based on the empirical study of Danish and Swedish subtitles. One of the most interesting conclusions is that “[w]e can see a general trend of sourceorientation in subtitles of Anglophone audiovisual material” (p. 196). Chapter 7 is entitled “Prototypical Subtitling” and although it is brief, it presents some interesting views. Pedersen’s conclusion of his study is that the most striking findings are that “very few significant differences were found between Swedish and Danish subtitling norms”, that one can talk about “pan-Scandinavian subtitling norms”, as well as the “general conclusion of this investigation: that the Scandinavian subtitling norms are converging or have converged” (p. 209). Pedersen concludes by stating that subtitling is a “[t]ransient and transcultural, polysemiotic, if not prototypic, form of translation, which is the most visible and the most vulnerable, the most common and most constrained of all modes of translation” (p. 216). The style of the book is accessible to anyone, and it is set firmly in academic discourse; Pedersen demonstrates full awareness of academic rigour. This monograph is therefore a sound basis for further scholarly investigations into norms and the treatment of culture in subtitling. Its extensive bibliography also provides a treasure trove of useful entries that may be exploited by other scholars. Witty at times, this monograph is a must-read for those interested in Audiovisual Translation, interlingual subtitling and the treatment of culture in translation in general. It is also of great interest those interested in the study of norms. Kristijan Nikolić, Department of English, Faculty of Humanities and Social Sciences, Zagreb University, Croatia

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Remael, A., Orero, P., & Carroll, M. (2012). Audiovisual translation and media accessibility at the crossroads: Media for all 3. Amsterdam: Rodopi. 439 p. The twin disciplines of Audiovisual Translation (AVT) and Media Accessibility have grown rapidly in size and importance over the last two decades, and there can no longer be any doubt that they have grown into disciplines on their own right, as the editors claim (p. 13). This book, however, begs the question of whether these disciplines are to be considered sister disciples of the mother discipline of Translation Studies, or whether they are two separate fields of study, or if one could be said to contain the other. As Media Accessibility is arguably the broader field, semantically speaking, as its object of study is semiotic transfer, which could be said to include the linguistic transfer which is the object of study within AVT. However, AVT is the older and more established discipline, and many of the scholars working in Media Accessibility started out in AVT (or indeed in Translation Studies). This book shrewdly avoids the question of disciplinary organization (just talking about a strong link between the two fields; p. 14), and makes no distinction between contributions from the two fields, but presents them thematically instead (which could arguably be said to indicate an inclusive stand). This volume contains the proceedings of the third Media for All conference, which is a conference series which has grown dramatically both in size and importance for the two (or one) disciplines, and the contributions presented in this volume indeed reflect both the high quality as well as the multifaceted nature of the series. The greatest strength of this volume comes from the many high-quality contributions that really let the reader sample some of the best state-of-the-art research in the fields. The greatest weakness of the book is that the many and varied topics, approaches, perspectives, objects of study and sub-disciplines that are represented in the contributions makes it something of a fragmented reading experience. This is probably due to the inclusive nature of the conference series and of its proceedings, which actually could be seen as a genuine strength, and which truly reflects the plurality of the disciplines. The volume contains 19 contributions about topics as varying as crowdsourcing, publishing, pictograms, video games, live subtitling, speech reception, audio description, eye tracking, sign language, voice-over, surtitling, Anglicisms, reception studies, multilingualism, corpus studies, and many other aspects of semiotic transfer in various audiovisual settings. It goes without saying that it is no small challenge to bring these diverse topics into some sort of thematic order. The editors have chosen to organize the articles into three different sections. The first is entitled “Extending the borders of AVT”, the second “Interpreting sight and sound” and the third “The discourses of audiovisual translation”, which is further subdivided. With the possible exception of the second section, these titles are vague enough to include just about anything

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within the field(s), and they indeed do that. The title of the volume claims that the disciplines are at a crossroads, and that metaphor is explored in the foreword: it refers to the impact of the many new technologies (including Web 2.0, corpora and eye tracking) in the field as well as in academia, and also the threat from “the index society” (p. 16) and not least from the multidisciplinary approaches in the field. The metaphor is an apt one, as it also hints the many various sources of the contributions in the volume, from practitioners and scholars alike. It could, however, be said that in the rapidly and continuously changing world of AVT and Media Accessibility, the metaphor could be used at any time in the past decades and in all possibility also in the coming ones. The first section is the most controversial, mainly because it contains a brilliant and somewhat polemic article by Lucile Desblanche, who explores the stepmotherly fashion in which AVT is treated by academia, in the form of the marginalization of the discipline in bibliometrics and publishing, and she also discusses open access, e-journals and other hot publication topics. These are important issues, and the more importance that can be drawn to them the better, not least when considering recent changes in the ranking and classifying of TS journals in general, and AVT in particular. The section also contains a very interesting article on the rise of Web 2.0 and the use of crowdsourcing in subtitling, by Minako O’Hagan, who explores “the wisdom of the crowd”(p. 33), which sees fansubbing enthusiasts as an organic organism which is self-adjusting. Professional subtitlers need perhaps not worry too much about this yet, however, as the crowd does not yet seem to be quite wise enough to replace the quality of their work. Carmen Mangiron’s contribution about accessibility in video games could work as an eye-opener for the business, as it points out that most creators of video games do not consider disabled gamers at all, or if they do, it generally comes as an afterthought. The perhaps most fascinating article in this section was the futuristic article by Junichi Azuma, who looked at how emoticons and other pictograms are currently used, which is really interesting. The author then goes on to suggest that a whole new universal language with both grammar and lexis can be constructed by pictograms. This is indeed an article that extends the border of AVT. The idea is arguably somewhat utopian, however, as it ignores or downplays the different connotations that different images have in different cultures, as well as the effort that would go into learning this language, which is not quite as intuitive as the author appears to think. The article is also somewhat contradictory, as it first (rightly) extols emoticons and pictograms as adding extra paralinguistic and interpersonal information to verbal messages, but then, as the pictograms get to replace the verbal message, the article does not seem to consider the fact that the result is less information. The section on interpreting sight and sound is the most homogeneous one, as it mainly explores various aspects of Audio Description (AD) and subtitling for the Deaf and hard of Hearing (SDH). There are two articles on

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AD. Iwona Mazur and Agnieszka Chmiel reflect on the pioneering Pear Tree Project, and use its finding to destabilize the old objectivity/subjectivity dichotomy in AD. Nazaret Fresno uses questionnaires to ascertain what seeing people consider to be the most salient features about the characters in Charlie and the Chocolate Factory (2005), which could be very useful for helping audio describers decide what to describe. There are more articles about aids for the hearing-impaired. One of the most important findings of this volume is that not one but two articles (by Pablo Romero-Fresco and Juan Martinez Pérez) through independent studies both come to the conclusion that block subtitles are clearly superior to scrolling ones in live subtitling. It is thus established beyond doubt that the comprehension of live subtitles is much greater when using block subtitles - now we just need to convince the policy makers. The section ends with a very interesting piece by Alex McDonald, who has found that in-vision sign language interpreters in UK television seem to disregard the fact that they are in a polysemiotic setting. The bulk of the contributions is housed in the third section, which is entitled “The discourses of Audiovisual Translation”. It is further subdivided into three subsections, the first of which is called “AVT classics revisited”, which contains one article about voice-over and one about surtitling. Why these should be more classical than other topics is not immediately clear. Monika Woźniak’s article on voice-over in Poland is very insightful and points to the future with a new approach to the topic that shows all the advantages of this oft-neglected mode of AVT. She claims that voice-over can be (and is, to some degree) made much more unobtrusive by placing the translations between the original utterances (“voice-in-between”, as she puts it; p. 209). She convincingly proves this by using extracts from Star Trek; had she been equally convincing using a Woody Allen film is perhaps a more open question. Anika Vervecken describes the process of surtitling for the stage in illuminating detail. She then goes on to stress the fact that directors need to take surtitling into account early on in the production process. This is clearly true, and symptomatic of the lack of awareness of semiotic transfer issues that many producers of audiovisual material in general seem to have. This was also stressed by Mangiron in her article, and something of a standing issue in AVT. The second subsection deals with “Bilingualism, multilingualism and its consequences”. It begins with Henrik Gottlieb’s article on Anglicisms in subtitles. He conducted something as rare as a longitudinal subtitling study, where he compared old and new Danish subtitles of Anglophone films, looking for an increase in Anglicisms in the new subtitles. To his surprise, this turned out not to be the case. Dominique Bairstow and Jean-Marc Lavaur present an abridged version of their study on the use of inter- and intralingual subtitles. Their findings show that subtitles help those that have little or no knowledge of the foreign language, but, more surprisingly, distract from the comprehension of the film by bilinguals. Beginners in a

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language were helped by intralingual and reverse subtitles. Reverse subtitles (i.e., audio in L1 and subtitles in L2) seems best for comprehension and language learning. The section ends with two articles (by Anna Vermeulen and Vincenza Minutella, respectively) about multilingual films, which could be seen as a token of how much contemporary attention is being paid to this area. They found that in some aspects, the dubbed versions of the films were more domesticating than the subtitled ones, but, perhaps surprisingly, that ethnolects tended to be magnified in dubbing. The overall generalization that might be made from these two articles is that the main language tends to be domesticated in translation, whereas minority languages tend to be exoticized, as tokens of foreignness. The final section in the book is centred on corpus studies and it is very gratifying to see that AVT now makes use of corpora in a serious and effective way, not least because it adds credence to our discipline in the eyes of older disciplines, notably linguistics. Here we find descriptions of the AD film corpus in the TRACCE project (described by Catalina Jiménez and Claudia Sibel), and the Pavia film corpus, which is described by Maria Freddi, who found that film language is more formulaic than natural speech. The Pavia corpus was also used by Maria Pavesi, who studied the intricacies of cross-linguistic pronoun use, and found that shifts in pronoun use in translations can be triggered by linguistics cues in the source texts, but also from paralinguistics, the action and other aspects of the audiovisual context. Another article based on a linguistic corpus study is written by Veronica Bonsignori, Silvia Bruti and Silvia Masi. The findings from their study on greetings and leave-takings confirms the work of others (e.g. Freddi in this volume, but also more generally speaking, the work of e.g. Pablo Romero Fresco and Frederic Chaume Varela) that dubbese, i.e. the language use particular to dubbing, is quite different from natural speech. All in all, it is very good news that our discipline now seems to have overcome the technical difficulties involved and is now applying corpuslinguistic methods to the entire polysemiotic package which makes up our audiovisual reality. Summing up, this volume is a very valuable addition to our knowledge of AVT and Media Accessibility, and it is the most up-to-date volume on the state of the art of the discipline(s). Its somewhat discontinuous content is just a reflection on the inclusive stance of the editors and of the Media for All conference series, and of the multifaceted and truly fascinating nature of our fields of research, regardless if one considers AVT and Media Accessibility to be one or two disciplines. I for one cannot wait for the next volume in the series to appear. Jan Pedersen, the Institute for Interpretation and Translation Studies, Stockholm University, Sweden

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Flotow, L. von (Ed.). (2011). Translating women. Ottawa, ON: University of Ottawa Press. 341 p. This collection of 15 essays by scholars from different European and American countries offers a fresh insight into women’s translation research, which first appeared in North America in the 1970s. According to the editor, Luise von Flotow, twenty years ago the interest in women’s translation produced many studies that focused on historical research, on women translators or women authors, and on women's translation (p. 2). At that stage, the concept of gender and translation was mainly centred on women who were not recognized as dominant players in culture and writing. However, as the editor states in her introduction, considerable changes have taken place from that first period up to the present. Firstly, many new translation projects have been undertaken and brought to completion, especially the compilations of anthologies of women’s writing, which have been rendered in western languages and many of the world's other languages. Secondly, women’s writing has been promoted by female researchers, translators and editors, who have given visibility to these works from different countries and disciplines. Good examples to support the editor’s assertion are the anthology recently edited by Taillefer de Haya (2008) with its collection of translations from the sixteenth to eighteenth centuries, and a second volume also edited by Taillefer de Haya (forthcoming), which includes another collection of translated works published in the nineteenth and twentieth centuries. Thirdly, new paradigms may provide promising paths to further research in the domain of women and translation. Von Flotow mentions the usefulness of certain aspects of performance theory for translations since they “allow various performances of a text, they foment differences in these performances and [...] most importantly they take up ‘interlocutory space’” (p.8). The volume edited by Von Flotow is not only a collection of articles by well-known scholars but also a well-founded publication that offers a critical view of most of the major topics in the field of Translation Studies. This makes the volume absolutely pertinent for the discipline at the present moment. It is apparent that the editor has been deeply involved in the elaboration of the volume. In addition to the introduction, she is also responsible for Chapter 7 and the translation of two essays. Chapter 7 is dedicated to Ulrike Meinhof and to several recent translation projects and the ways in which these projects have contributed to rehabilitating the reputation of the bright intellectual and political activist from the 1960s, who fought for social justice and was opposed to war and any form of militarism. Von Flotow highlights that, paradoxically, the projects designed to cast light on Meinhof's role as a humanitarian and brilliant journalist “should come into being largely because of her reputation as a terrorist” (p. 148). The other chapters in the volume may be grouped according to the eight issues that they tackle. These issues will be discussed below.

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1. Affinity with women writers. The need for an affinity with and among women writers is brilliantly outlined in Chapter 6 by Pilar Godayol, who introduces five Catalan women writers and translators whose works provided the Catalan language with canonical women’s writings in the 1980s and 1990s. These five translators were interested in the same topics that were of concern to the writers whose works that they translated (e.g., the body, maternity, lesbianism). In addition, they paid attention to more general concepts, such as love, lack of affection, loneliness and pain, seen from the point of view of women. 2. The visibility of women translators. This issue is present in the first chapter by Alison E. Martin, which deals with the translation of botany by British women at the beginning of the nineteenth century. The author highlights the active presence of these women translators in the texts that they rendered from French into English by means of annotations. These women not only showed their skills and scientific knowledge to the British reading public, but they also considered how to reach a broader audience by making the contents of their translations inclusive for both amateurs and professional readers. 3. Women’s poetry. Chapters 2 and 5 are dedicated to women’s poetry. Both chapters are centred on authors who by means of their art sought excellence and freedom. The second chapter by Tom Dolack examines the work of Karolina Pavlova, a 19th-century female Russian poet who translated poetic German texts that portrayed women who – unhappy in their society at that time – gained access “to a higher realm” through the translation of poetry (p. 52). Therefore, translation became not only a means of social commentary but also a vehicle for transcendence. In Chapter 5, Sandra Bermann raises the topics of 're-vision' and 'translation' inAdrienne Rich’s poetry. Rich refuses to domesticate but offers the opportunity of using a multiplicity of languages and messages. Her idea of revision starts a cultural tradition of renaming and exploiting the potential fast-changing role of language within a global context. This vision is quite innovative and fresh, even in the twenty-first century. She foresees a change in the politics of languages. 4. The intervention of the translator to adapt the message to the target audience or target culture. This issue constitutes a crucial point in the discipline closely related to culture (Katan, 2009). In Chapter 3, Anna Barker reflects on the work by the poet Helen Maria Williams, who was also a novelist, translator, abolitionist and political activist in favor of the French Revolution. Barker examines Williams’s translation of the novel Paul and Virginia by Bernardin St. Pierre, which constitutes an example of mediating otherness. Williams omits several passages in the translation and instead introduces a few sonnets more likely to be accepted by the English-reading public. For Williams, it is a reconstructive process and although she does not claim to have improved the original, she hopes not to have deformed the beauty of

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the original. Madeleine Stratford’s contribution, which appears in Chapter 4, is dedicated to Susan Bassnett’s translation of Alejandra Pizarnik’s work Exchanging lives: Poems and translations (2002). The author concludes that Bassnett translates the book not for an English-speaking audience, but for her own pleasure, eventually becoming emotionally involved with the texts and the author. Stratford highlights that Bassnett’s translations pursue fluency and she constantly puts an emphasis on Bassnett´s subjective intervention. Stratford claims that this interventionist approach has had an influence on how Pizarnik’s work is received and that it perhaps fosters the suspicion that the role of translation in ’regenerating literature’ has gone beyond its purpose. 5. Ethnography and translation. As the discipline of Translation Studies is becoming increasingly international and multicultural, so is the need for discussing how to deal not only with the rendering of texts in another language, but also with accomplishing an intellectual activity which is not at all ideologically neutral (Herman, 2009). Kate Sturge’s contribution (Chapter 9) deals with translation and ethnography in Ruth Behar’s Translated Woman (1993). This work constitutes an ethnographic study of rural Mexican life, based on a life-story format, telling the story of the heroine, Esperanza, as narrated to Behar by means of recorded interviews and “supplemented by Behar’s own background research on history and habits of the region” (p. 167). The language of the heroine Esperanza’s translated words is not similar to the original language – the actual language that Esperanza produces. The narrative expresses the layers of historical identity hidden in the identities of the Indian-descended Mexican-Spanish, English and indigenous languages across the Mexican and US borders and the translator’s instability between those languages. 6. The reception of texts in different cultures. This major topic is superbly exemplified in three significant contributions which are rich with debate: Chapters 8, 10 and 12. The aforementioned analysis by Flotow of Ulrike Meinhof‘s work in recent translation projects (Chapter 7) may also be included in this group. In Chapter 8, Anna Bogic analyzes the renewed interest in the life and work of Simone de Beauvoir at the beginning of the 1990s and in the centennial of the author’s birth in 2008. Bogic focuses on the translations of Beauvoir’s philosophical work into English, especially Le deuxième sexe, and the reception of this work by the English readership. New English translations are now appearing after the 1953 English version, whose contents, although respected for the broad scope and psychological insight, were criticized in reviews. These recent projects are contributing and will continue to contribute to re-discovering the author and to re-establishing her value as an important philosopher and founder of feminist philosophy. What is more, translations may contribute to keeping ideas alive and strongly influence the disciplines involved. This is also reflected in Chapter 10, in which Anne-Lise Feral discusses translated chick texts. She analyzes translations from English into French,

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finding that the transfer of those texts can alter the notion of new female sexuality, since the popular ideology and constructed knowledge of femininity and sexuality in French culture are linked to the images of the courtesan and prostitute. The British audience received translations of French sex-related literature as evidence that women had reached sexual equality. On the contrary, female heroines in books such as Sex and the City were considered guilty of depravation and prostitution by French readers. In Chapter 12, the translations of the Japanese writer Sei Shônagon over the last 150 years are thoroughly analyzed by Valerie Henitiuk, as well as the prefaces to and comments on these translations regarding sexuality, competitiveness with both men and women in the imperial world. Henitiuk finds that the writings of Shônagon can cause a different impact on western readers, depending on the different translations of her work they may come across. 7. The concept of gender. This central topic has been discussed in important academic works in the discipline, such as Santaemilia (2005), von Flotow (2008) or Yu (2011). Von Flotow (2008) states that the concept of gender must be carefully used in the context of translation: “Gender as a category of informing macroanalysis of translated texts is largely revisionist exposing the fact that women and other gender minorities have essentially been excluded from presented negatively in the linguistic and literary histories of the world’s cultures” (p. 123). In this volume, the concept of gender is addressed in Chapters 11 and 13. In Chapter 11, James W. Underhill surprisingly states that the concept of gender is not pertinent in the case of the French translations of Emily Dickinson’s work. Dickinson is a pillar of American poetry simply because she is not “a damsel in distress or a radical feminist who needs no defenders” (p. 236). On the contrary, she has an authoritative poetic voice and fine vision of reality. Moreover, male translators were the ones who promoted Dickinson’s work to a French audience. Therefore, gender is more a political question, whereas “in the domain of poetry, what counts is the poem and the ability to hear it” (p. 236). In Chapter 13, Bella Brodzki focuses on the cross-cultural, geopolitical transfer of theoretical terms and concepts. She analyzes what happens to theories when they travel across time and space, zeroing in on the role of translation in the American importation of structuralism and semiotics, and in the transfer of French feminism into English. In this analysis, Brodzki pays particular attention to the concept of gender in translation. 8. Intervention of the translator to improve or censor the source texts. This topic is dealt with in Chapters 14 and 15. Carolyn Shread discusses in Chapter 14 the translation of The Rapaces from Haitian French into English by Marie Vieux Chauvet. Shread clearly states the attitude and method she is in favor of, which is not only a mimetic replication of the signals in the source text but also of the subtext and context “that the rational might not pick up” (p. 300). Shread challenges some of the conventions and limiting

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expectations from female activism in Translation Studies. The last contribution in this volume is one by Pascale Sardine. It is devoted to Tahar Ben Jelloun, one of the most translated francophone authors in the world, and more specifically to his book L’Enfant de sable. This is a disturbing story of a woman who must pretend to be a man since her Moroccan family has no boys and therefore the father has forced her to become a man. She reclaims her identity with turning points that are mainly linguistic. Ben Jelloun intends to show that the concept of gender is performative and arbitrary, since it is a mere act of enunciation followed by practice (p. 306). When the book was translated into English, American translations failed to capture the double meaning and complex writing, which were present in French and which the author used to talk about women’s submission in a phallogocentric society. Instead, the text was reorganized in English and numerous passages censored and cut. The reason might hint at the state of American culture in the late 1980s, when the US market, for practical reasons, aimed to please neo-liberal conservatism and was not prepared to assume risks in the translation of this work. Summing up, the outcome of Translating Women is a joint effort by well-known researchers and a comprehensive and critical work that will be extremely useful not only for scholars and researchers but also for novice researchers and students of translation. The editor has gathered many powerful, well-grounded and serious contributions which deal with topics that are being currently investigated and questioned in the field of Translation Studies. Moreover, the vast number of examples provided by all the contributions makes this piece of work a valuable tool for study and research. It constitutes a must-have in graduate and undergraduate programs in the discipline. Regarding the editing of the volume, it must be mentioned that it is carefully outlined and that the index provided at the end of the manuscript is extremely helpful for the reader. Nevertheless, readers may object to the lack of further insight into 21st century literature by women which is, by all means, very prolific worldwide. Bibliography Flotow, L. von. (2008). Gender and sexuality. In M. Baker & G. Saldanha (Eds.). Routledge encyclopedia of translation studies (pp. 122–126). London: Routledge. Hermans, T. (2009). Translation, ethics, politics. In J. Munday, (Ed.). The Routledge companion to translation studies (pp. 93–105). London: Routledge. Katan, D. (2009). Translation as intercultural communication. In J. Munday, (Ed.). The Routledge companion to translation studies (2nd ed.) (pp. 74–92). London: Routledge. Munday, J. (2009). The Routledge companion to translation studies (2nd ed.).London: Routledge. Santaemilia, J. (2005). Gender, sex and translation: The manipulation of identities. Manchester: St. Jerome.

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Taillefer, L. (2008). Orígenes del feminismo: Textos ingleses de los siglos XVI-XVIII. Madrid: Narcea Ediciones. E-book http://www.todoebook.com/ORIGENES-DEL-FEMINISMOLIDIA-TAILLEFER-DE-HAYA-NARCEA-ebook9788427716131.html Taillefer, L. (forthcoming). La causa de las mujeres en Gran Bretaña a través de los textos (ss. XIX y XX). Madrid: Narcea Ediciones. Yu, Z. (2011). Gender in translating lesbianism in The Second Sex. In J. Santaemilia & L. von Flotow (Eds.), Woman and translation: Geographies, voices and identities (pp. 421–445). MonTI 3. http://www.ua.es/dpto/trad.int/publicaciones/index.html Encarnación Postigo Pinazo, Departamento Interpretación, Universidad de Málaga, Spain

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Mus, F. & Vandemeulebroucke, K. (ass. d’Hulst, L. & Meylaerts, R.) (Eds.) (2011). La traduction dans les cultures plurilingues. Artois Presses Université : Arras 256 p. Si la traduction est couramment conçue comme un pont reliant différentes cultures, ce qui lui confère une fonction de passeur et de médiateur, voire de pacificateur (« qui diffuse la traduction cueille la paix », Guidère, M. (22010). Introduction à la traductologie. De Boeck : Bruxelles, p. 7), elle peut également se penser en termes de frontière, de démarcation et de séparation (Wilfert-Portal, B. (2007). « Des bâtisseurs de frontières, Traduction et nationalisme culturel en France, 1880-1930 », in : Lombez, C./von Kulessa, R. (Eds.). De la traduction et des transferts culturels. L’Harmattan : Paris, pp. 231–253). Le dénominateur commun de ces deux perspectives consiste en ce qu’elles s’appuient toutes les deux sur une conception fortement territorialisée des langues et cultures, la traduction opérant entre deux entités (source et cible) géographiquement et linguistiquement séparées. Or, à l’heure de la mondialisation, la généralisation de configurations non territoriales et post-nationales met à mal l’unité supposée entre nation, langue et culture érigée en norme absolue par une certaine idéologie romantique. La décolonisation et la condition « postmonolinguale » (Yildiz, Y. (2012). Beyond the Mother Tongue. The postmonolingual condition. Fordham University Press: New York) de la plupart des Etats nécessitent désormais une prise en compte de la diversité linguistique à l’intérieur même des frontières, frontières qu’une conception binaire de la traduction risque de renforcer sans les questionner ou analyser. Comme l’écrivent Lieven d’Hulst et Reine Meylaerts dans leur introduction substantielle au présent ouvrage (les deux éditeurs principaux n’ayant pas joint d’avant-propos ou de présentation), « c’est depuis une décennie seulement que les relations complexes entre plurilinguisme et traduction ont retenu l’attention des traductologues » (p. 8). Les études

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réunies dans ce volume édité à l’Université de Louvain apportent ainsi quelques nouvelles pierres à l’édifice d’une reconsidération de la traduction (littéraire) à partir de la question du plurilinguisme, reconsidération entamée notamment par quelques études récentes sur l’autotraduction (voir Hokenson, J. W. & Munson, M. (2007). The Bilingual Text. History and Theory of Literary Self-Translation. St. Jerome : Manchester). L’ouvrage entend également apporter un correctif à une certaine conception de la traductologie qui « a emboîté le pas aux histoires littéraires nationales en identifiant les écrivains comme des instances nationales monolingues et en acceptant le simple partage des rôles de l’écrivain et du traducteur. » (p. 12). Venant d’une dizaine de pays différents, les contributeurs du volume abordent un grand éventail de langues et cultures, les aires examinées allant de l’Amérique du Sud jusqu’en Israël, en passant par l’Amérique du Nord, l’Afrique du Sud et l’Europe occidentale et centrale. On remarque une légère dominance, aisément compréhensible, des thématiques belges et canadiennes, ces deux cultures plurilingues exemplaires. La vingtaine d’études de cas présentées concernent aussi bien la période historique des XIXe et XXe siècles que l’époque actuelle. Le volume est partagé en trois sections : médiateurs, espaces plurilingues et écrivains plurilingues. Aurélia Klimkiewizc (York University, Canada) ouvre la première partie, consacrée aux « médiateurs » avec des réflexions « à propos du commentaire métalangagier dans la littérature migrante », en préconisant de cibler davantage la subjectivité du locuteur multilingue. Lieven D’hulst et Karen Vandemeulebroucke (tous deux de l’Université de Louvain) examinent chacun quelques usages plurilingues relevés dans des revues littéraires françaises et belges du XIXe siècle. Reine Meylaerts (Université de Louvain) présente le cas de Stijn Streuvels et Camille Melloy, deux auteurs bilingues belges qui se sont mutuellement traduits. A partir du concept d’hétérolinguisme, Myriam Suchet (Université de LilleIII/Concordia University, Canada) analyse le roman Triomf de Marle van Niekerk et ses traductions. Erika Mihálycsa (Université de Cluj, Roumanie) entreprend l’analyse de sa propre traduction en hongrois de la pièce Translations de l’auteur irlandais Brian Fiel. La deuxième partie, consacrée aux « espaces plurilingues », s’ouvre avec une contribution de Michaela Wolf (Université de Graz, Autriche) portant sur le multilinguisme et la traduction culturelle dans l’espace de la monarchie austro-hongroise. Denise Merkle (Université de Moncton, Canada) présente la ville de Londres à la fin de l’époque victorienne comme une « Mecque plurilingue et multiculturelle » à l’intérieur d’un espace national. Les deux articles suivants se penchent sur la littérature produite en Israël. Rachel Weissbrod (Université Bar Illa, Israël) présente une analyse systémique des trois littératures qu’elle distingue dans ce pays : hébraïque, israélienne et juive. Nitsa Ben-Ari (Université de Tel-Aviv) étudie l’influence de la littérature populaire étrangère sur l’évolution de la littérature hébraïque. Dans leurs contributions respectives, Gillian Lane-

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Book reviews

Mercier et Nicole Nolette (toutes deux de l’Université McGill, Montréal) abordent ensuite l’espace plurilingue canadien, la première en s’interrogeant sur les rapports entre la traductologie et la littérature comparée au Canada, la deuxième en analysant le théâtre bilingue de l’ouest canadien. Francesca Blockeel (Université de Louvain) ferme cette deuxième partie avec une contribution sur « la traduction de la littérature de la jeunesse dans les langues officielles de l’Espagne ». Analysant le cas de l’écrivain alsacien trilingue Tomi Ungerer, Britta Benert (Université de Strasbourg) ouvre la dernière partie consacrée aux « écrivains plurilingues ». An Van Hecke (Université de Louvain) présente le roman Waiting to happen d’Alejandro Morales, écrivain chicano. Lisa Bradford (Université de Mar del Plata, Argentine) présente son travail sur l’établissement d’une anthologie bilingue anglais-espagnol de onze « Latino poets » mêlant ces deux langues à l’intérieur de leurs œuvres. K. Alfons Knauth (Université McGill, Montréal) clôt le volume avec une contribution sur le poète brésilien Haraldo de Campos, en examinant la relation particulière entre traduction et création plurilingue chez cet écrivain. Hormis la première contribution, à forte teneur théorique, toutes les autres partent de l’analyse d’un texte, d’un auteur ou d’un corpus restreint, ce qui aboutit à une grande diversité de genres étudiés (roman, théâtre, poésie). Le niveau d’analyse et de réflexion est toujours à la hauteur de la problématique complexe et exigeante, en impliquant des méthodes issues notamment de l’analyse littéraire, de la linguistique (psycho-, sociolinguistique, analyse du discours) et des descriptive translation studies (même si certains résultats mettent en cause certains postulats de cette théorie). A certains endroits apparaissent également les jalons d’une théorie propre aux rapports entre plurilinguisme et traduction. Ainsi, certains auteurs du volume portent la réflexion sur le plan éthique, ce qui ouvre des perspectives fort intéressantes. En outre, plusieurs contributions rappellent que la thématique de la traduction dans les cultures plurilingues ne concerne pas uniquement l’ère postcoloniale, mais également des périodes antérieures, y compris le XIXe siècle. On pourrait sans doute reprocher au volume un certain manque de cohérence, voire un éparpillement dans le choix des cultures, langues, auteurs et textes étudiés, en même temps que quelques lacunes regrettables (l’absence du cas suisse notamment). Toutefois, l’étendue et la richesse du champ d’investigation peuvent amplement justifier une telle approche hétéroclite, d’autant que les études sont réunies par une problématique commune forte de la plus grande importance, problématique magistralement exposée dans l’introduction au volume. Somme toute, on ne peut que saluer la parution de cet ouvrage qui vient renforcer une nouvelle perspective importante des études traductologiques. Dirk Weissmann, Institut des Mondes Anglophone, Germanique et Roman (IMAGER), Université Paris-Est Créteil, France

Alphabetical list of authors & titles with keywords Ezpeleta Piorno, Pilar An example of genre shift in the medicinal product information genre system Keywords: medicinal product information, genre systems, genre shift, metagenres, medical translation 167 Felberg, Tatjana R. & Skaaden, Hanne The (de)construction of culture in interpreter-mediated medical discourse Keywords: culture, othering, interpreting in Norwegian health care 95 Krystallidou, Demi On mediating agents’ moves and how they might affect patient-centredness in mediated medical consultations Keywords: patient-centredness, interpreter, roles, participation framework, Goffman 75 Major, George & Napier, Jemina Interpreting and knowledge mediation in the healthcare setting: What do we really mean by “accuracy”? Keywords: healthcare interpreting, signed language interpreting, accuracy, reduced/expanded renditions, decision-making 207 Montalt-Resurrecció, Vicent & Shuttleworth, Mark Research in translation and knowledge mediation in medical and healthcare settings Keywords: translation, medical, healthcare, knowledge, mediation, recontextualization 9 Muñoz-Miquel, Ana From the original article to the summary for patients: Reformulation procedures in intralingual translation Keywords: intralingual translation, reformulation, original article, summary for patients, genre shift. 187 Nisbeth Jensen, Matilde & Korning Zethsen, Karen Translation of patient information leaflets: Trained translators and pharmacists-cum-translators – a comparison Keywords: medical translators, expert-to-lay translation, patient information leaflets, Latin-Greek terms, nominalization 31 Pedro Ricoy, Raquel de Reading minds: A study of deictic shifts in translated written interaction between mental-health professionals and their readers

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Alphabetical list of authors & titles with keywords

Keywords: deictic shifts, expert-lay communication, mental health, nonprofessional translators, writer-reader interaction 51 Pittarello, Sara Medical terminology circulation and interactional organization in interpreter-mediated medical encounters Keywords: medical terminology circulation, interactional organisation, mediated medical encounters (in Italy), interlocutors’ active participation, translation structure 113 Pritzker, Sonya Translating the essence of healing: Inscription, interdiscursivity, and intertextuality in U.S. translations of Chinese Medicine Keywords: Chinese medicine, textual translation, education, acupuncture, CAM (complementary/alternative medicine) 151 Ross, Dolores & Magris, Marella The role of communication and knowledge management as evidenced by HCP vaccination programs in the Netherlands, Germany and Italy: Possible suggestions for medical translators Keywords: health communication, mediation, Netherlands, Germany, Italy 133 Tercedor Sánchez, Maribel & López Rodríguez, Clara Inés Access to health in an intercultural setting: The role of corpora and images in grasping term variation Keywords: access to health, interculturality, terminological variation, corpora, images 247 Vandaele, Sylvie & Béland, Marie-Claude Les modes de conceptualisation des unités d'hérédité au XIXe siècle : Spencer, Haeckel et Elsberg Keywords: mode de conceptualisation, unité d'hérédité, gène, unité physiologique, plastide 227

Alphabetical list of contributors & contact addresses Béland, Marie-Claude Département de linguistique et de traduction Université de Montréal 3150, rue Jean-Brillant Montréal, QC, H3T1N8 Canada e-mail: [email protected] Ezpeleta Piorno, Pilar Department of Translation and Communication Universitat Jaume I Av. Sos Banyat, s/n 12071 Castelló de la Plana Spain e-mail: [email protected] Felberg, Tatjana R. Department of International Studies and Interpreting Oslo and Akershus University College of Applied Sciences P.O. Box 4 St Olavs plass 0130 Oslo Norway e-mail: [email protected] Korning Zethsen, Karen Department of Business Communication Aarhus University Jens Chr. Skous Vej 4 8000 Aarhus C Denmark e-mail: [email protected] Krystallidou, Demi Faculty of Applied Language Studies University College Ghent /Ghent University Groot-Brittanniëlaan 45 9000 Ghent Belgium e-mail: [email protected]

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Alphabetical list of contributors & contact addresses

López Rodríguez, Clara Inés Facultad de Traducción e Interpretación Universidad de Granada C/ Buensuceso 11 18071 Granada Spain http://lexicon.ugr.es/lopezrodriguez e-mail: [email protected] Magris, Marella Department of Legal, Language, Interpreting and Translation Studies (IUSLIT) SSLMIT Via Filzi 14 34132 Trieste Italy e-mail: [email protected] Major, George Department of Linguistics Macquarie University Sydney NSW 2109 Australia e-mail: [email protected] Merkle, Denise Département de traduction et des langues Université de Moncton 18, ave Antonine-Maillet Moncton, NB, E1A 3E9 Canada e-mail: [email protected] Montalt-Resurrecció, Vicent Department of Translation and Communication Universitat Jaume I Av. Sos Banyat, s/n 12071 Castelló de la Plana Spain e-mail: [email protected]

Alphabetical list of contributors & contact addresses

Muñoz-Miquel, Ana Departament de Traducció i Comunicació Universitat Jaume I Campus de Riu Sec s/n 12071 Castelló de la Plana Spain e-mail: [email protected] Napier, Jemina Department of Linguistics Macquarie University Sydney NSW 2109 Australia e-mail: [email protected] Nikolic, Kristijan Department of English University of Zagreb Ivana Lucica 3 10000 Zagreb Croatia e-mail: [email protected] Nisbeth Jensen, Matilde Department of Business Communication Aarhus University Jens Chr. Skous Vej 4 8000 Aarhus C Denmark Department of Linguistics Macquarie University Sydney NSW 2109 Australia e-mail: [email protected] Pedersen, Jan The Institute for Interpretation and Translation Studies Stockholm University S-106 91 Stockholm Sweden e-mail: [email protected]

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Alphabetical list of contributors & contact addresses

Pedro Ricoy, Raquel de Department of Languages and Intercultural Studies Heriot-Watt University Edinburgh EH14 4AS United Kingdom e-mail: [email protected] Pittarello, Sara International Relations Office University of Padova Via VIII Febbraio 2 35122 Padova Italy e-mail: [email protected] Conference Interpreter & Translator Via Rossini 41 35020 Legnaro, Padova Italy e-mail: [email protected] Postigo Pinazo, Encarnación Departamento de Traducción e Interpretación Campus de Teatinos Universidad de Málaga Avda. Cervantes 2 29071 Málaga Spain e-mail: [email protected] Pritzker, Sonya UCLA Center for East-West Medicine & UCLA Department of Anthropology 1033 Gayley Ave., Ste. 111 Los Angeles, CA 90024 U.S.A. e-mail: [email protected] Ross, Dolores Department of Legal, Language, Interpreting and Translation Studies (IUSLIT) SSLMIT Via Filzi 14 34132 Trieste Italy e-mail: [email protected]

Alphabetical list of contributors & contact addresses

Shuttleworth, Mark Translation Studies Unit Imperial College London Sherfield Building, Room S312B South Kensington Campus London SW7 2AZ United Kingdom e-mail: [email protected] Skaaden, Hanne Department of Internationals Studies and Interpreting Oslo and Akershus University College of Applied Sciences P.O. Box 4 St Olavs plass 0130 Oslo Norway e-mail: [email protected] Tercedor Sánchez, Maribel Facultad de Traducción e Interpretación Universidad de Granada C/ Buensuceso 11 18071 Granada Spain http://lexicon.ugr.es/tercedor e-mail: [email protected] Vandaele, Sylvie Département de linguistique et de traduction Université de Montréal 3150, rue Jean-Brillant Montréal, QC, H3T1N8 Canada e-mail: [email protected] Weissmann, Dirk Faculté des lettres, langues et sciences humaines Université Paris-Est Créteil 61, avenue du Général de Gaulle 94010 Créteil France e-mail: [email protected]

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