Healthcare Access for the Deaf in Singapore: Overcoming Communication Barriers

Abstract

Good communication between healthcare providers and patients is vital to effective healthcare. In order to understand patients’ complaints, make accurate diagnoses, obtain informed consent and explain treatment regimens, clinicians must communicate well with their patients. This can be challenging when treating patients from unfamiliar cultural backgrounds, such as the Deaf. Not only are they a linguistic and cultural minority, they are also members of the world’s largest and oft-forgotten minority group: the disability community. Under Article 25 of the United Nations Convention on the Rights of Persons with Disabilities (“CRPD”), persons with disabilities have rights to the same range, quality and standard of free or affordable healthcare and programmes as provided to other people. Yet communication barriers and healthcare providers’ lack of familiarity with Deaf culture can impair the quality and accessibility of healthcare for the Deaf. This essay analyses the scope of this issue in Singapore: a state party to the CRPD which has a vibrant Deaf community, and yet no legislative or constitutional guarantees of the rights of persons with disabilities. In addition to exploring the communication barriers faced by Deaf patients in Singapore, this essay highlights ways in which healthcare providers and the state can support community-based initiatives to overcome these barriers.

The hospital was abuzz with a flurry of doctors and nurses who bustled in and out of the ward. No one had time to attend to the patient who sat in their midst, evidently waiting for something. Confusion was written upon his face. Who or what he was waiting for had been lost in the blur. “He’s deaf”, mentioned a senior nurse, “so why go through the trouble of asking him?” Four hours passed. The patient was still there; unmoved. Finally, a junior nurse who had learnt basic sign language plucked up the courage to walk over. “Hello. My name is… I am a nurse.” she signed. It was the patient’s first human interaction in hours. He burst into a tirade, signing frantically, but the nurse could not understand.

Article 25 of the United Nations Convention on the Rights of Persons with Disabilities (“CRPD”; UN Treaty Collection 2019; United Nations, n.d.) states that persons with disabilities (“PWDs”) have rights to the same range, quality and standard of free or affordable healthcare and programmes as provided to other people (UN General Assembly 2007). As the world’s largest and oft-forgotten minority group (UN Enable, n.d.), the disability community faces structural and attitudinal barriers in accessing healthcare, which can be overcome through targeted action (CRPD Preamble). In the case of signing Deaf patients, communication barriers in medical settings pose a great hurdle in access to effective healthcare (Kuenburg et al. 2016). This concern has been explored extensively in places such as the USA, Europe, Australia and New Zealand (Kuenburg et al. 2016). This essay examines the scope of this issue in Singapore: a country which ratified the CRPD, has a vibrant Deaf community and yet has no legislative or constitutional guarantees of the rights of PWDs (Yap 2013; Disabled People’s Association 2017; Wong et al. 2017). As such, non-state actors bear significant responsibility for upholding disability rights and preventing discrimination against PWDs through a “bottom-up” approach (Kuenburg et al. 2016). This essay highlights the communication barriers faced by Deaf patients in Singapore, and ways in which healthcare providers and the state can support existing, community-based initiatives in overcoming them. This essay aims to prompt further discussion and research into healthcare access for PWDs in Singapore, as there is a relative dearth of information on this important subject.

Deaf Culture and Communication in Singapore

In the medical world, deafness is mainly viewed as a disease to be studied and cured (Hedding and Kaufman 2012). However, many individuals with hearing loss see themselves as a cultural and linguistic minority that is affiliated with, yet separate from other disabled groups (McAleer 2006). This cultural identity is marked by the term “Deaf” with a capital “D” and is characterised by the use of sign language as one’s preferred language (The Singapore Association for the Deaf, n.d.). Healthcare providers may find it challenging to communicate with Deaf patients if they are unfamiliar with their culture and language. Since effective communication forms the basis of the therapeutic alliance, communication barriers can impair healthcare quality for the Deaf (Ha and Longnecker 2010; Kuenburg et al. 2016). This is because mutual trust and understanding is needed to elicit patients’ histories and complaints, make accurate diagnoses and explain treatment plans (Kuenburg et al. 2016). Furthermore, effective communication supports Deaf patients’ autonomy, by empowering them to be active and informed participants in caring for their own health (Stein et al. 2009). Therefore, it is important for healthcare providers to understand Deaf patients’ culture and language to care for them effectively.

In Singapore, the preferred language of the Deaf is Singapore Sign Language (“SgSL”), which has its own grammar and vocabulary (The Singapore Association for the Deaf, n.d.). To clarify a common misconception, sign language is not universal. Sign language can be readily understood by the Deaf, unlike the mentally taxing guesswork involved in lip reading and deciphering speech (Callis 2017). It is estimated that only 30–45% of spoken English can be understood through lip reading (Lieu et al. 2007). However, not all deaf and hard-of-hearing people know SgSL or identify as Deaf. This could happen if they are late-deafened or were raised by hearing parents and educated in schools which enforce “oralism,” i.e. making deaf students communicate via speech and lip reading, without the use of sign language (“Oralism noun.” 2004). Such people may also encounter communication barriers in accessing healthcare, but an analysis of these challenges is beyond the scope of this essay. In the years to come, Singaporean healthcare providers can expect to encounter more d/Deaf patients who use a combination of SgSL and lip reading to communicate, since this is the mode of instruction for deaf students enrolled in designated mainstream schools (Teng 2017). Although this essay focuses on the needs of the signing Deaf community, it will outline the various modes of communication used by deaf Singaporeans for completeness.

Late-deafened adults or deaf people who have never learnt SgSL may use a combination of assistive devices (e.g. hearing aids and cochlear implants), lip reading and writing to communicate (The Singapore Association for the Deaf, n.d.). They may also rely on note-takers who use technology like Communication Access Real-Time Translation (“CART”) to convert speech into text (The Singapore Association for the Deaf, n.d.). Additionally, older deaf people may use “home signs”, an invented system of signs that are only understood within their family (Walker 2012). Others may use SEE-II, a system which manually converts English sentences into signs (The Singapore Association for the Deaf, n.d.). Alternatively, they may learn SgSL as adults and profess various levels of signing proficiency. Notably, sign language dysfluency can cause its own communication pitfalls (Woodcock and Pole 2007; Kuenburg et al. 2016).

If a Deaf person needs to communicate with her doctor, she may engage an interpreter or note-taker from the Singapore Association of the Deaf (“SADeaf”). Among SADeaf’s professional interpreters (colloquially referred to as “terps”), there are five hearing interpreters who convert spoken language into sign and vice versa, and two Deaf relay interpreters who interpret between different sign systems (e.g. SEE-II ➔ SgSL) (Morgan and Adam 2012; The Singapore Association for the Deaf, n.d.). Relay interpreters work together with hearing terps when the latter does not know the client’s preferred sign system (Morgan and Adam 2012). SADeaf also recognises around twenty ad hoc community interpreters (The Singapore Association for the Deaf, n.d.). These numbers/estimates are accurate as of the date of this paper. Alternatively, Deaf people may ask family members to act as informal interpreters, such as hearing children of Deaf adults (“CODA”) (Disabled People’s Association 2017). The Deaf can also write or type conversations with their healthcare providers, but this is not an option for those who are illiterate. Importantly, interpretation requires more skill than translation, because it involves re-expressing a message in the target language and framing it appropriately for the relevant social and cultural context, in real time (Brenner et al. 2018).

According to SADeaf’s website, there are approximately 500,000 people with hearing loss in Singapore and more than 5,400 SADeaf-registered clients (The Singapore Association for the Deaf, n.d.). In a survey, one third of these clients stated that they knew sign language (The Singapore Association for the Deaf, n.d.). It is safe to say that many more Deaf Singaporeans were unaccounted for. Given that the five professional hearing terps interpret everything from theatre performances, to political speeches, to court hearings, there is a gross undersupply of sign language interpreters in Singapore, let alone terps that are trained in medical interpretation (Ling 2015; Wang 2018). This naturally limits Deaf patients’ ability to access accurate information in healthcare settings.

Singapore, the Right to Health and the CRPD

Singapore is a state party to the CRPD, which is an international treaty establishing the rights of PWDs. By ratifying the CRPD in July 2013, Singapore agreed to ensure PWDs’ equal enjoyment of human rights, and to prohibit discrimination based on disability (Disabled People’s Association 2015; CRPD Article 1). This includes the right to health (Stein et al. 2009; CRPD Article 25). However, Singapore has not enacted any domestic laws which codify disability rights or target disability discrimination (Wong et al. 2017). Article 12 of the Singapore Constitution prohibits discrimination against citizens on specified grounds, but “disability” is not one of them (Constitution of the Republic of Singapore 1965). Furthermore, Singapore did not sign the optional protocol to the CRPD, which would have granted an international committee the power to investigate Singaporean PWDs’ complaints of rights violations (Wong et al. 2017). Commentators note that this reflects Singapore’s political ethos, which eschews the emphasis on individual rights found in “Western” liberal democracies for “Asian” communitarianism and pragmatism (Wong et al. 2017). Nevertheless, Singapore is accountable to the United Nations (“UN”) for demonstrating compliance with the CRPD. In fact, in its initial report to the UN, Singapore affirmed its commitment to non-discrimination with regard to PWDs’ right to access healthcare (CRPD Article 35; UN Human Rights Office of the High Commissioner 2016).

Although the enactment of disability legislation would aid the progress of disability rights in Singapore (Yap 2013), this paper will not be arguing for this cause. Rather, this paper tackles a different question: what can be done to improve access to healthcare for the Deaf, in the context of Singapore’s current legal and policy landscape? In this regard, Article 25 of the CRPD and Singapore’s Enabling Masterplans establish foundational principles which solutions could be built upon.

First, Article 25 of the CRPD establishes PWDs’ rights to “the enjoyment of the highest attainable standard of health without discrimination on the basis of disability.” State parties are required to uphold this right by providing PWDs with “reasonable accommodations” which can allow them to access health services on an equal basis with others. PWDs should be given access to “the same range, quality and standard of free or affordable health care and programmes as provided to other persons.” Under Article 25(d) of the CRPD, healthcare providers must also provide “care of the same quality to [PWDs] as to others, including on the basis of free and informed consent.”

In order for Deaf patients to enjoy these rights, they must be able to communicate with and be understood by their healthcare providers. For example, through access to skilled sign language interpreters (Stein et al. 2009). In fact, Article 9 of the CRPD requires that the following measures be taken for PWDs to enjoy equal access to all aspects of healthcare: implement minimum standards and guidelines; train stakeholders on accessibility issues; provide professional sign language interpreters; and ensure PWDs’ access to information (Stein et al. 2009; CRPD Article 9; Brenner et al. 2018). Though these requirements may seem onerous, Article 5 of the CRPD makes it clear that state parties should take all appropriate steps to ensure the provision of “reasonable accommodation” to promote equality and eliminate discrimination against PWDs. “Reasonable accommodation” is defined in Article 2 of the CRPD as “necessary and appropriate modification and adjustments not imposing a disproportionate or undue burden” for PWDs’ to enjoy equal rights (CRPD Article 2). The measures specified in Article 9 are necessary minimum measures for Deaf patients to obtain equal access to healthcare, including on the basis of informed consent, and are arguably reasonable. For example, providing a Deaf patient with a sign language interpreter who can accurately convey the benefits and risks of an intended treatment to him is proportionate to the goal of ensuring his equal access to healthcare. Failing to provide reasonable accommodations such as these could be considered discrimination (Lord et al. 2010).

Second, as of 2007, the Singapore government launched a series of 5-year Enabling Masterplans to give effect to rights in the CRPD (Ministry of Social and Family Development, n.d.). These Masterplans contain national strategies for disability inclusion and were developed in consultation with stakeholders in the public sector and disability community (Ministry of Social and Family Development, n.d.). Singapore is presently working towards the goals of its third Enabling Masterplan for the years 2017 to 2021. I shall refer to this as “EM3”. Although the Masterplans have not tackled Deaf access to healthcare specifically, they establish principles which can indirectly support this goal. For example, EM3 has four key thrusts: “improving the quality of life of PWDs,” “supporting caregivers,” “building the community” and “building an inclusive society” (Ministry of Social and Family Development, 2016). In a later section, this paper will elaborate on how EM3 can be used to support Deaf access to healthcare.

Communication Barriers Affecting Access to Healthcare for the Deaf

Deaf Singaporeans are entitled to reasonable accommodations that will grant them access to healthcare on an equal basis with others. Therefore, healthcare providers and the state are legally and morally responsible for helping the Deaf overcome communication barriers faced within healthcare settings (Stein et al. 2009; Kuenburg et al. 2016). To understand what accommodations are needed, stakeholders should recognise that the problem is multifaceted. As shall be explored below, communication barriers can be attributed to four main issues.

Insufficient Professional Interpreters

The shortage of sign language interpreters in Singapore is problematic in multiple ways. First, it limits Deaf patients’ freedom to schedule medical appointments as and when they are needed. The Deaf may have to make appointments contingent on the availability of an interpreter, which may not be possible for emergency visits. Likewise, the frequency and timing of inpatient reviews by a doctor may be subject to an interpreter’s availability, which can diminish the quality of care that Deaf patients receive. Second, it can affect Deaf patients’ health privacy. The small pool of professional interpreters in Singapore means that each interpreter is well-known throughout the local Deaf community. Therefore, Deaf patients may be reluctant to hire an interpreter for sensitive consultations if they regard their interpreters as friends (Meador and Zazove 2005; McAleer 2006). If patients are especially cautious about their health privacy, they may even forgo their medical appointments.

If a Deaf patient turns to an alternative communication-aid, other problems are likely to arise. If he uses an informal interpreter such as a family member, this person may lack the necessary signing fluency or health literacy to interpret accurately (Brenner et al. 2018). This risks subjecting the Deaf patient to misdiagnoses or unnecessary tests and procedures (Brenner et al. 2018). Informal interpreters are also not bound by codes of professional ethics. As such, they may bring their personal agendas into the consultation. They might embellish, distort or restrict the flow of information between clinician and patient without either party’s knowledge (Kaufert and Putsch 1997). For example, they may withhold treatment options from the patient or make decisions on the patient’s behalf, thus undermining Deaf patients’ right to informed consent (Bezuidenhout and Borry 2009). Informal interpreters may also fail to respect patient privacy and confidentiality outside the clinic (Bezuidenhout and Borry 2009). Additionally, their presence may be inappropriate owing to their youth. For example, asking a CODA to interpret discussions about her parent’s reproductive health or diagnosis with a terminal illness.

Alternatively, if written communication is used, misunderstandings may ensue if the Deaf patient is not well-versed in English. The differences between SgSL and English syntax could be a cause of confusion (Meador and Zazove 2005). To quote an example from American Sign Language (“ASL”), a physician wrote “You may need surgery” to an American Deaf patient, who understood this to mean, “You need surgery in May”. This is because in ASL, the English sentence, “You may need surgery” would be signed, “You maybe need surgery” (Meador and Zazove 2005). Furthermore, written communication is not an option for the illiterate. Ultimately, the national undersupply of professional interpreters inhibits Singaporean Deaf patients’ ability to access timely medical care and make informed medical decisions. The unavailability of interpreters or suitable alternatives could lead to missed medical appointments and delayed treatment. This hinders Deaf access to healthcare on an equal basis with others, and pursuant to Articles 9 and 25 of the CRPD, this problem needs to be addressed.

Lack of Training in Medical Interpretation

Even if a Deaf patient can secure a professional interpreter for his/her health appointments, none of SADeaf’s interpreters have been trained in medical interpretation. To complicate matters, a dictionary of SgSL medical signs does not exist (Osman 2018). Therefore, interpreting unfamiliar medical jargon into sign language often requires impromptu innovation. Although SADeaf occasionally conducts teaching sessions for its interpreters on medical signs, this cannot substitute formal training in medical interpretation. As intermediaries, interpreters must have substantial health literacy, knowledge of medical terminology (in English and SgSL) and familiarity with hospital culture to work effectively in healthcare settings (Hedding and Kaufman 2012). The more integrated an interpreter is in a healthcare institution’s day-to-day operations, the better his ability to facilitate the seamless exchange of information between Deaf patients and healthcare professionals.

In a teaching session for interpreters on 1 December 2017, Deaf instructor James Ong presented a video about doctors misinterpreting Deaf patients (Osman 2018). He also taught signs for common diseases and symptoms (Osman 2018). Initiatives like this are necessary, but they scratch the surface of the training needed for effective medical interpretation. Take psychiatry, for example. Psychotherapy and psychiatric diagnosis depend heavily on nuanced doctor-patient communication (Crump 2012). Interpreters need to learn how to convey clinically relevant subtleties (e.g. unusual or repetitive phrasing) in their interpretations (Crump 2012). Medical interpreter training should also provide pre-emptive guidance on clinical ethics issues. Should an interpreter be present during an intimate physical examination (McAleer 2006)? When medical signs do not exist, is fingerspelling (i.e. using a hand alphabet to spell) terms like “colonoscopy” sufficient for Deaf patients to give informed consent? Or is a more creative description by pointing to a picture of the colon and miming the insertion of a colonoscope necessary for a Deaf patient to understand (Hedding and Kaufman 2012)? Uncertainty about how to deal with these issues, either from a lack of training or protocols, could lead to delayed treatment and reduced autonomy among Deaf patients. Once again, this is a barrier to equal access to healthcare, which calls for a solution.

Inadequate Deaf Cultural Competency Among Healthcare Providers

Many of the communication challenges faced by Deaf patients would be mitigated if their nurses and doctors were proficient in SgSL or familiar with Deaf culture. Unfortunately, that is not often the case. When clinicians have limited awareness of Deaf culture and communication, they may have misconceptions about Deaf patients that may affect the quality of care which they provide(Iezzoni et al. 2004; Kuenburg et al. 2016).

Some Singaporean universities and polytechnics have offered basic sign language training to medical and nursing students (Disabled People’s Association 2017). This is a positive step, but such training appears to be offered sporadically. Furthermore, cultural competency training is needed to educate clinicians about how to interact with Deaf patients. For example, Deaf patients whose first language is SgSL may not be well-versed in English. This could lead to misunderstandings when communicating in writing. Deaf patients may write in seemingly “broken” English, but this could in fact be the word-for-word rendering of SgSL (Hedding and Kaufman 2012). A doctor who assumes that it is the former may treat these patients as unintelligent, which would undermine trust (Hedding and Kaufman 2012). Furthermore, doctors who are pressed for time may write down medical abbreviations that are unfamiliar to Deaf patients, let alone hearing laypeople (Hedding and Kaufman 2012).

Without cultural competency training, clinicians may manifest a medicalised view of deafness in their attitudes and the use of language that Deaf patients may consider insensitive. Contrastingly, doctors and nurses who understand Deaf etiquette and identity can help to bridge the cultural and communication divide (Kuenburg et al. 2016). They would not cover their mouths while speaking, in order to facilitate lip reading. They would also be better equipped to work with interpreters, e.g. by courteously addressing the Deaf patient while speaking, rather than the interpreter. Healthcare administrators can also benefit from cultural competency training to meet the needs of patients from the disability community (Stein et al. 2009). For example, learning to ensure that auditory information in their institutions is also conveyed in visual form, and vice versa for the benefit of the blind (Disabled People’s Association 2017). This problem is apparent in the waiting rooms of departments in certain hospitals, where patient names or queue numbers are called out by members of staff or over an intercom, with no visual equivalent (Disabled People’s Association 2017).

Comparatively Low Health Literacy Among the Deaf

Health literacy has been defined as “the degree to which individuals can obtain, process and understand basic health information and services needed to make appropriate health decisions” (Nielson-Bohlman et al. 2004). Low health literacy affects patients’ ability to understand and adhere to treatment plans and medications, which can lead to poorer health outcomes (Choon 2011). As US studies have shown, this problem is likely to be exacerbated among Deaf patients (Hedding and Kaufman 2012). This is not due to unintelligence but lifelong exclusion from participating in an auditory world. Teri Hedding and Gary Kaufman give the example of a child accompanying a hearing parent to a medical appointment. A hearing child can incidentally learn medical terminology and how to interact with doctors by listening during the consultation. Contrastingly, a Deaf child would miss out on this information because it is unlikely to be translated for her benefit (Hedding and Kaufman 2012).

In the National Council of Social Services’ disability rights campaign, “See the True Me”, Deaf ambassador Roseanne shared her story about living among hearing relatives:

“Despite using a hearing aid in her left ear, Roseanne faces challenges in trying to communicate with people who can hear, including her own family. Occasionally, she finds it tiring to lip read and listen to the conversation. Sometimes she misinterprets what people are saying and often feels like the last person to know what is happening. Although people make the effort to repeat parts of the group conversation, she can feel left out and resorts to doing her own thing like playing games on her mobile [phone]” (National Council of Social Service 2018).

The experience of being left out of spoken conversations has been termed “dinner-table syndrome,” and is common among the Deaf (Hauser et al. 2010). This is why Deaf children who are born into hearing families are often described as having a “global-fund-of-information” deficit (Hedding and Kaufman 2012). Such lost opportunities to acquire knowledge about the medical world, through incidental learning, can contribute to lower health literacy (Hedding and Kaufman 2012).

Overcoming Communication Barriers

“Nothing about us, without us” was a slogan that informed the drafting of the CRPD, and it should also inform solutions to improve healthcare accessibility for the Deaf (Lord et al. 2010). It is a reminder that instead of imposing well-meaning ideas upon PWDs or inviting them to the table as an afterthought, solutions should be developed together with them (Lord et al. 2010). This demonstrates respect for the lived experience of PWDs as experts in navigating a world that was not designed with them in mind (Lewis 2019). Therefore, healthcare providers and state actors could consult Deaf Singaporeans (and their allies) in developing solutions for the issues identified above. Although a qualitative study was not conducted for the purposes of this paper, the following paragraphs will highlight recommendations by Deaf Singaporeans and sign language interpreters whom this author consulted informally. Existing initiatives by PWDs that solutions can be built upon will also be outlined.

First, building a larger cohort of professional SgSL interpreters is necessary. The statistic of five professional hearing terps in the whole of Singapore is worrying. It should be recalled that providing the Deaf with access to sign language interpreters is a reasonable accommodation, and an obligation under Article 9 of the CRPD. Perhaps a concrete goal to work towards is training one on-staff hearing terp for each public hospital in Singapore. For this to happen, there is a need to promote awareness of and incentivise entry into this profession. This task could be helped by the following measures. In terms of disability rights, the Singapore Disabled People’s Association (“DPA”) has suggested that government recognition of SgSL as an official language could raise public awareness of the language (Disabled People’s Association 2017). However, for this to happen, an ongoing debate about SgSL’s legitimacy as against the use of SEE-II needs to be resolved (Tay 2018). Additionally, SgSL is a relatively young language which continues to undergo standardisation through SADeaf-led consultation sessions with members of the Deaf community (Goy 2017). Government investment into these efforts and research into the d/Deaf’s perceptions of SgSL could elevate the status of the language and the work of interpreters. In terms of policy, two recommendations in EM3 are particularly relevant:

• 11—“To synergise partnerships within and across health, education and social service to better support persons with disabilities and their caregivers”; and

• 15—“To build the capacity and capability of disability service providers to enhance service quality” (Ministry of Social and Family Development 2016).

Although these recommendations were devised to curtail a national shortage of allied health professionals, they can also inform strategies to attract and retain sign language interpreters. To implement these two recommendations, the EM3 Steering Committee proposed harmonising the competency framework and professional standards for related services across the health, education and social service sectors to make these careers more attractive (Ministry of Social and Family Development 2016). This was intended to make opportunities for career progression more apparent (Ministry of Social and Family Development 2016). Analogously, creating a harmonised competency framework for sign language interpreters could attract more people to this profession. Funding could also be devoted to the SADeaf-led development of SgSL interpretation courses. These classes could be taught in local vocational and tertiary institutions to promote SgSL interpretation as a viable career option. Awareness-raising initiatives on the ground could support these efforts. For example, local Deaf entrepreneur, Lily Goh, offers sign language interpretation services and courses through her sole proprietorship, ExtraOrdinary Horizons, and promotes Deaf awareness through the arts (ExtraOrdinary Horizons, n.d.).

Second, building on the EM3 recommendations, evidence-based curricula, protocols and other resources could be developed to train terps in medical interpretation (Swabey and Malcolm 2012). Ideally, this would be a joint effort between SADeaf, the Ministry of Health and Singaporean medical schools and institutions. Hedding and Kaufman, an American Deaf patient advocate and hearing signing physician, respectively, have authored a useful list of recommendations for medical interpretation courses (Hedding and Kaufman 2012; Swabey and Malcolm 2012). This included: training interpreters in medical language competency; teaching anatomy to equip them with the necessary terminology and visual aids; offering medical shadowing opportunities to familiarise interpreters with hospital environments; and creating a “tool kit” of props, such as pictograms of common symptoms, to equip their work (Hedding and Kaufman 2012; Richler et al. 2012). Training in clinical ethics issues like patient privacy and confidentiality should also be mandatory (Disabled People’s Association 2017).

Additionally, a dictionary of SgSL medical signs could be developed (Osman 2018). The ‘Medical Signbank’ in Australia provides an example of how this could be done. This is an online platform which allows interpreters and Deaf users to share and evaluate sign language vocabulary for medical terms and also provides definitions for each entry, to educate users (Johnston and Napier 2010). An SgSL Signbank was recently launched in the International Week of the Deaf in September 2019, to document SgSL signs (Singapore Sign Language Bank 2019). Medical terminology in SgSL could eventually be developed or sourced from the local Deaf community and added to the SgSL Signbank. On the ground, steps to develop a mobile app featuring a library of medical visual aids could also help to facilitate communication (Hedding and Kaufman 2012).

Third, cultural competency training on how to interact with PWDs could be offered in medical and nursing schools, or in “continuing medical education” programmes. These modules could be developed by the DPA and other disability organisations, drawing from their existing public-education resources. Think tanks and research projects that develop innovative ways to communicate with Deaf patients could form part of the syllabus. For example, medical students could be encouraged to collaborate with members of the Deaf community to develop the mobile apps and toolkits mentioned above. Registration for sign language classes could be offered during these sessions. Additionally, the task of facilitating access to audio and visual information in healthcare settings for the d/Deaf and blind respectively, could be placed on the agenda of Singapore’s next Enabling Masterplan.

Finally, Article 24 of the CRPD calls for the provision of lifelong learning opportunities to PWDs. EM3 even recommends doing this to improve PWDs’ employability. To support Deaf patient autonomy and equal access to healthcare, basic health literacy courses could be provided to the Deaf community. Such courses have the added benefit of spurring the development of new SgSL signs for medical terminology.

Conclusion

Alongside fellow PWDs, Deaf Singaporeans have rights to “the same range, quality and standard of free or affordable health care and programmes as provided to other persons.” Effective communication is the basis of the therapeutic alliance, informed consent and Deaf access to healthcare. Therefore, healthcare providers and the state are morally and legally responsible for enabling the Deaf to overcome communication barriers in medical settings (Stein et al. 2009; Kuenburg et al. 2016). This is a matter of equality and non-discrimination. Since this issue has not received much prior attention in Singapore, this essay surveyed the laws and policies supporting Deaf Singaporeans’ rights of equal access to healthcare. This paper also identified four sources of healthcare communication barriers faced by the Deaf: (a) insufficient professional interpreters; (b) no specialised training in medical interpretation; (c) inadequate Deaf cultural competency among healthcare providers; and (d) comparatively low health literacy levels among the Deaf. In the spirit of “nothing about us, without us,” this essay has attempted to highlight existing initiatives and recommendations by PWDs and sign language interpreters for overcoming these barriers. It is hoped that the suggestions in this essay may prompt further discussion, research and action to promote equal healthcare access for the Deaf in Singapore.

Returning to the story at the beginning of this paper is a fitting way to end. The weekend after the event, my friend, the junior nurse, excitedly told me that she had encountered a Deaf patient at work for the first time. What was more, she had introduced herself in sign language. “Where did you learn?” I asked. She explained that a few weeks before, a Deaf person had taught her how to fingerspell her name. “I should really learn more,” she expressed, musing that besides her, none of her colleagues could communicate with the patient in his own language. In healthcare, efforts to effectively communicate with the Deaf are natural extensions of medical beneficence. For the Deaf, overcoming barriers to healthcare access is not just a matter of therapy but equality: as informed patients, unique individuals and full members of society.

Compliance with Ethical Standards

Conflict of Interest

The author declares that she has no conflict of interest.