Ethics and Health Communication in English: Tackling the Consequences of Colonial Era Linguicism and Racism

Abstract

Sri Lanka, once a colony of Britain, gained independence in 1948. However, especially the health sector continues to use English as its main medium of communication. Such language bias leads to marginalization of those less fluent in English, and hinders achieving a higher level of health literacy. Discrimination of people or social groups based on their language is termed linguicism. Tackling linguicism requires an understanding of its historic roots and an exploration of potential links to colonial racial prejudices. Published literature presents evidence that traces linguicism to language policies of the British colonial government (1815–1948). Though an exhaustive survey of historical records is not presented, there is reasonable evidence to suggest a close link. British colonial rule derived its justification from supremacist and racist ideology. As a result, English became the medium in all forms of official communications, a situation that persisted after independence. A similar situation exists in many parts of the worlds. We should recognize language-based discrimination and linguicism as public health issues. They are detrimental to health of vulnerable groups and have the potential to worsen health disparities.

Introduction

Recent events in the USA, Europe and Brazil have thrust racism onto the agenda of public debates, policymaking and academic research. The historic origins of racism and its implications on health have increasingly attracted the attention of public health researchers and policymakers and it is now considered a public health issue (Rivara and Fihn 2020). In contrast to racism, linguicism is discrimination of people or social groups due to their language and therefore is more an expression of racism. This paper describes the role of English in health communication in Sri Lanka and explores its impacts on health literacy, and links it to colonial era policies that promoted linguicism, based on a racist ideology.

This paper begins by assessing the current practices of language use in health communication, their potential impact on health literacy, the historical roots of these current practices and a global perspective on linguicism.

Current Language Use in the Health Sector

This section outlines the existing dominant position of English in the allopathic health sector and provides evidence of linguicism. To an outside observer, an overview of the functioning of the health sector would reveal that almost all the following aspects are conducted solely in English: hospital administrative notes, prescriptions by doctors, diagnostic summaries, labelling of drugs and health professional education.

Administration

Health institutions, such as hospitals and clinics, conduct their work in English. All administrative reports continue to be in English and so is most of the professional communication in the health sector. Internal circulars at the Ministry of Health aimed at medical officers are predominantly in English, while other communications are in Sinhala or Tamil. The websites of the Ministries of Health in the government and in the devolved provinces have trilingual content, though most technical reports are in English (Ministry of Health n.d.).

Hospital-Based Activities

All hospital-based activities, such as discussions during ward rounds, and official communication among colleagues are conducted in English (Perera et al. 2012a). Discussions during ward rounds are normally conducted in English, while a majority of patients are not engaged in the conversation, because they are not fluent in the language. Such encounters may be followed by a brief explanation or discussion with the patient in their native language.

Hospital Notes

The official forms used to request investigations as well as hospital notes are in English. Discharge summaries are written on the so-called diagnosis cards, used both in the public and in the private sector hospitals. All diagnosis cards are completed by the medical officer, invariably in English (Perera et al. 2012a, b; Senanayake and Dallas 2012). There is evidence that providing information in native languages in discharge summaries improves understanding and knowledge related to illness and drug compliance (Perera et al. 2012a, b).

Labelling of Drugs

Most of the drugs available in pharmacies are labelled only in English and do not provide patient information in the native languages Sinhala and Tamil (Mendis and Jayasinghe 2011).

Prescriptions

All prescriptions by doctors issued to pharmacies are in English. Consumers unable to read the prescription have no recourse because the labels of the drugs too are only in English (Perera et al. 2012a, b).

Medical and Health Professional Education

Undergraduate and postgraduate courses in health sciences are conducted in English. The situation is ironic because assessment of communication skills at the postgraduate level is confined to encounters in English.

Impact of English in Health Communication on Health Literacy

Hardly any studies in Sri Lanka have investigated the potential impact of the widespread use of English in health communication on health literacy. However, there is ample evidence that its impact is likely to be negative.

First, only 9% of students achieve a proficiency level in English beyond “Basic User level”, with urban children significantly out-performing their rural counterparts (Shepherd and Ainsworth 2018). As a result, using English as the only medium of health communication should adversely impact the achievement of health literacy. Second, there is a strong negative correlation between poor perceived and objectively measured English fluency and academic performance among first-year dental students and in medical students across several universities (Ariyasinghe and Pallegama 2012; Wijesundara et al. 2018; Hewage et al. 2011). One of the state universities found an improvement from the situation from 1999. A study at that time on 460 first-year dental students found English proficiency explained almost 60% of variance in predicting academic performance (Pallegama et al. 1999). This suggests the advantage available to learners who are fluent in English, when studying courses that are primarily in that language.

Third, there is evidence that provision of health information in native languages improves patients’ knowledge of diseases and medication, and leads to higher rates of drug compliance (Perera et al. 2012a, b). Similar observations have been reported from the USA that exclusive use of English restricts the acquisition of knowledge on medicines and illnesses by the lay public (Institute of Medicine 2004).

Finally, members of civil society less fluent in English have experienced a disadvantage when gaining health-related knowledge. This was expressed through a petition filed with the Human Rights Commission of Sri Lanka, alleging a violation of the Fundamental Human Rights due to the failure of the state to ensure drug labels in all three languages according to the Official Languages Act. The petition in the Supreme Courts (SCFR/102/16) alleged that the National Medicinal Regulatory Authority (NMRA) failed to implement the provisions of the Act. After preliminary hearings, the NMRA published its regulations in the gazette, but the pharmaceutical traders filed a counter case in the Court of Appeal against the practicality of some of its provisions (Centre for Policy Alternatives 2020). Thus, a majority of drugs continue to be sold with labels and patient information leaflets only in English.

Studies in several countries have shown poor health literacy to lead to errors in the dosage regimen by patients and healthcare workers, which in turn leads to an increase in mortality and morbidity (Pakenham-Walsh and Ana 2014). Furthermore, health literacy is essential to make an informed choice about healthcare, to access healthcare providers and to be active partners in one’s own care (WHO Regional Office for Europe 2020). On a wider scale and at a national level, health literacy is recognized as one of the key requirements to achieve the health-related targets of the Sustainable Development Goals (SDG) (World Health Organization 2017).

Reasons for Dominant Use of English in Health Communications: Historical Roots and Linguicism

English has continued to play a key role in the practice of allopathic medicine due to historical reasons and a system that gave it an advantageous position in society. The origins of the contemporary allopathic healthcare system were by colonial Englishmen. Its subsequent expansion was through English-educated local medical professionals, academics and health administrators. The textbooks and knowledge were in English and the further training was in the UK, until quite recently when other English-speaking nations such as Australia have become popular. The initial professional associations were established as branches of the British organizations. For example, the current Sri Lanka Medical Association was originally the Ceylon Branch of the British Medical Association (Uragoda 1987).

The dominant position given to English in society and in the health sector is due to the persisting linguicism or discrimination based on language competence. The overt widespread manifestations of linguicism in society are documented in surveys and interviews (Lim 2013; Kandiah 1984; Jayasinghe et al. 2011). The existence of implicit linguicism in the health sector is shown by the continuing resistance to the widespread use of native languages. More overt linguicism manifests as acts of discrimination or humiliation of students for their poor English competency (Jayasinghe et al. 2011). The condescending attitude seen in some teachers towards those less fluent in English has been described in a range of disciplines (Lim 2013; Kandiah 1984; Jayasinghe et al. 2011; Suntharesan 2013). The social norm of linguicism combined with a “teaching by humiliation” approach can have devastating consequences for student who wish to improve their competency in English (Jayasinghe et al. 2011; Jayasuriya-Illesinghe et al. 2016).

Tracing the Origins for Linguicism to Racism and White Supremacy

Sri Lanka, an island nation situated below India, has a population of 21.7 million and three major ethno-linguistic groups: Sinhala, mainly spoken by Sinhalese (75% of the population), Tamil spoken by Tamils and Muslims and an indigenous group (Vaddhas). For several centuries, parts of the country experienced invasions from southern India but its linguistic and cultural characteristics survived. European invasions began in 1505 by the Portuguese and later the Dutch. They installed brutal rule but that was confined to the coastal areas. Neither of their languages is spoken anymore, although Catholicism continues to be practiced by about 6% and surnames originating from this period (e.g. Perera, Fernando and De Silva) are relatively common in urban areas, especially in the western coastal belt.

In contrast, the invasion by Britain resulted in a dramatic shift in the linguistic and cultural characteristics, especially after 1815 when they gained control over the whole island. After crushing several uprisings and consolidating their power, they introduced long-lasting changes in 1832 through the Colebrooke Report (Gooneratne 1968; Coperehewa 2011). This Report defined the language policies and plans to administer the country and recommended that almost all functions of the state including administration, education and the judiciary should be conducted solely in English (Gooneratne 1968; Coperehewa 2011). The associated condescending attitudes of the colonizers were summarized by the comments made in the Colebrooke Report: “The education afforded by the native priesthood in their temples and colleges scarcely merits any note”, and by the Government Inspector of Schools: “I am of the opinion that Vernacular Sinhalese is a language on the wane, gradually decaying, and destined to die out […] If it be a decaying dialect, any attempt to revive it will only impart to it the vitality of a galvanized corpse” (Report on Education, 1867, Appendix: 56, in Coperehewa 2011).

Speaking in Sinhala and Tamil in schools was prohibited and inequities in education widened because English was taught mainly in elite urban schools. Employment favoured position given to English and fluency was used as a proxy for a higher social standing (Lim 2013; Gooneratne 1968). Discrimination faced by those not fluent in English followed and was noted for decades with little protests (Mendis and Jayasinghe 2011; Shepherd and Ainsworth 2018). Such discrimination has been normalized by people, the establishment and society. This is best illustrated by calling English “kaduva” (i.e. the Sinhala term for sword) because it “…divides society between the privileged and down-trodden” (Lim 2013; Kandiah 1984).

Linguicism was based on an ideology of supremacist racism, which was prevalent in the British Empire at the time. As noted in the Colebrooke Report, there was an attempt to link their mission to civilize natives through Christianity and the promotion of English: “Instruction in the English language should be promoted and encouraged as much as possible, when the people would be enabled to come more directly to the evidence of Christianity than they are through the tardy and scanty medium of translations” (Gooneratne 1968).

Initially, health services were administered by the military, but in 1858, they became a civilian department (Uragoda 1987). All medical communication and training were in English (Gooneratne 1968; Coperehewa 2011). The first medical school was established in 1848 by American missionaries in Jaffna and had English as its medium of instructions (Uragoda 1987). However, the medium of instructions was converted to Tamil, when it became clear that their graduates migrated to other areas for employment. The school subsequently closed, and the colonial government opened its first medical school in 1870; the medium of instructions was in English. There was no change in the status quo even after independence in 1948, and English continued to be the language of communication in all matters related to the allopathic health sector.

The Official Languages Act in 1956 introduced Sinhala to many of the administrative circulars. During 1970–1977, there was an attempt to introduce more Sinhala and Tamil texts in the undergraduate medical curriculum, but it was bitterly opposed by a segment of academia and soon the policy was reversed. A compromise was reached, and extra lectures were delivered in a combined format of English and Sinhala or English and Tamil. The position of English was boosted further, when it was recognized as a link language in the 13^th Amendment to the Constitution (1987). This gave a legal loophole for English to be used as the sole language of communication, irrespective of the language competency of citizens. English usage in the education sector advanced further with the establishment of several private international schools with overseas links in the 1990s. They functioned under the Board of Investment, “outside” the purview of the Ministry of Education, and educated students based on overseas syllabi, mainly of the UK. The educational reforms in 1997 consolidated the situation of English in the public sector schools when many schools were mandated to begin classes on English language from Grade 1 and a proportion were selected to offer English as a medium of instruction from Grade 5 (Walisundara and Hettiarachchi 2016). For several decades, all medical courses in the universities have been in the English medium and rely on extra language classes to improve English competency, especially at the beginning.

Linguicism: a Global Perspective

At a global level, the concept of linguicism is rarely raised as an issue in the literature on racism, social discrimination or human rights. It should rightly be considered a manifestation of institutionalized discrimination or even as a form of institutional racism (Bailey et al. 2017). It is prevalent in many other post-colonial nations such as India, Pakistan and Bangladesh that were one time under the British (Evans 2002). Linguicism based on favoured positions of Spanish and Portuguese are prevalent in parts of South America where almost all nations have marginalized their indigenous languages (Casma 2014). Similarly, discrimination of indigenous or native groups continues in the USA, Australia and Canada (Vass et al. 2011). As a result of social discrimination coupled with adverse policies, cultures, languages and indigenous knowledge systems are becoming extinct. We are probably facing a period of mass cultural extinction, never experienced before by human civilization. Movements against racism should therefore confront such hidden discrimination that has the potential to devastate the rich cultural and linguistic diversities that have evolved over millennia.

The reason for ignoring linguicism may be a lack of voice of those unempowered and affected. It could also be so because academia, human rights activists and civil society groups are often educated in English and conduct their own work only in English. Open discussions and a planned approach to dismantle such vestiges of colonialism are essential to develop more inclusive societies, and to improve health literacy and health outcomes.

Conclusion

English plays a dominant role in health communication in many countries. Studies from Sri Lanka show this is based on linguicism, and discriminatory and racist colonial policies of the past. Similar situations plague many nations, including indigenous groups in Latin America, the USA, Canada and Australia. This should be recognized as a manifestation of racism and tackled as a public health issue. The health sector has to identify situations of linguicism (e.g. a lack of communication and documentation in native languages) and rectify such instances. Health professionals should be educated on the adverse health impact and trained to change their behaviour during patient encounters to be more inclusive. Resources should be allocated to provide translations to relevant native languages. Similar interventions should be extended to other sectors that may be inadvertently practicing linguicism. International organizations dedicated to protecting culture, such as the UNESCO, should therefore be adequately resourced to dismantle overt racism and its less obvious forms such as linguicism. The time to act is now.

Funding

Personal funds were used.

Data Availability

Not applicable.

Declarations

Competing Interests

The author declares no competing interests.