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International Clinical Trials

Speaking the Language

Simon Andriesen at MediLingua investigates the critical shortage of translators for clinical trials conducted in Africa, and looks at the work being done to improve the situation

Africa is assumed to be the origin of humans, but so far this headstart has not given the continent many advantages. With a population of around 1 billion, Africa has about 15 per cent of the world’s population – unsurprising considering it has around 20 per cent of the world’s total land surface. However, research shows that it also has around 25 per cent of the world’s disease cases and, perhaps most tellingly, these have to be treated by less than three per cent of the world’s doctors and nurses.

In Africa, people suffer from diseases such as diarrhoea, pneumonia, AIDS and malaria, which often result in death. While this is a well-known fact, a less obvious cause of death is illiteracy, or rather, heath illiteracy. Children die because their parents cannot read health-related information – or at least not in the language in which it is available. Simple healthrelated instructions are not useable because they are not in a local language, sometimes with fatal consequences. In addition, in many small communities, the person with the highest level of medical ‘expertise’ may be a fairly inexperienced nurse, the nearest hospital may be a half-day trip away, and doctors are always busy as there are far too few in number for far too many patients.


Increasingly, CROs are deciding to organise clinical trials in African countries. This brings benefits for the local economy and is also good for the local healthcare system, as doctors are exposed to new medical development and know-how, as well as receiving money for their efforts. It is also valuable for the population; new medicines will eventually become available and, during the trials, participants receive check-ups and will potentially benefit from the study medication. Finally, it is also good for the healthcare translation sector, as more people will have the opportunity to build up translation expertise.

Conducting trials in Africa brings with it the need for translation of the patient-oriented study documents, at least into local languages. Under the Declaration of Helsinki, developed by the World Medical Association in 1964 (and since then updated frequently), trial participants must be fully informed and need to completely understand the information, including the risks associated with the study medication or study treatment. In most cases, this means that the information has to be available in their own language or dialect.

Typically in Africa, European languages are widely used in government and academia as a consequence of former colonial rule. Therefore, doctors will usually understand a European language; however, this is not the case for less well-educated people.

Most countries in the western world have a well-developed ‘translation infrastructure’ including: training for translators; efficient translation companies with enough work to sustain a population of translators; magazines for the translation sector (such as Multilingual); conferences and seminars on translation (such as Localization World); fast and relatively low-cost internet; access; and money to invest in translation support tools. However, in many parts of Africa this is not the case and there is no well-developed translation infrastructure. There are few training opportunities for translators, and the cost of a PC represents considerably more than the average monthly income for a translator, as well as low rates of internet access among the general population. Indeed, even when there is internet access, it is often very slow.

Medical translation is usually the work of people at the crossroads between medicine and linguistics. However, in a region where linguistics is a luxury and where doctors are struggling to do what they can, medical translators are hard to find.

The result is that humanitarian and international organisations, governments and CROs have difficulty finding people to translate crucial healthcare information. During a recent outbreak of cholera, a lack of available translators meant that a high-ranking official of the Ministry of Public Health and Sanitation translated crucial healthcare information himself. This happened in Nairobi, capital of Kenya – a city with three million people and two universities. The required target language was Swahili, which is a language spoken by around 100 million people in a dozen countries in East Africa.


According to Unesco, around 2,000 different languages are spoken in Africa (other estimates suggest a number of around 1,000). Of these, some 85 are considered ‘important’ languages. When only counting the official languages of the various countries, this number is reduced to around 30; meanwhile the African Union only has six working languages (see African Languages and African Language Families).

Reducing the estimated number of languages from 2,000 to 85, to 30, or even to six, does not help trial organisers who need to facilitate one-on-one contacts with participants who have to be addressed in their own language, and this is where the problem starts. Take Nigeria for example, which according to Wikipedia has over 250 different languages, making it a country with one of the greatest concentrations of linguistic diversity in the world. Organisers of trials in Nigeria would probably prefer to only include those participants who speak the country’s official language of English, or one of a very limited number of Nigerian languages. However, this excludes many parts of the population. Another example is South Africa, with 11 official languages (and to think that those of us in Europe consider Belgium and Switzerland as complex countries with four official languages).


So, how do CROs, NGOs, international organisations and local governments deal with a shortage of translators? It seems that European or US-based CROs usually find a solution, but this is not always the case for other organisations.

Compared to the total cost of a trial, translation is often a small item, and volumes are usually not large. Even paying a high rate per word is unlikely to matter if you only need, for example, 10,000 words translated. On a €250,000 budget, a translation fee of €1,000 or €2,500 seems negligible. Trial documents, such as the study protocol, and patient reported outcome documents, such as questionnaires, need to be well-translated, and with some additional financial input, this can be usually accomplished. When needed, local trial organisers can also approach university staff, who can provide such services.

For NGOs and governments, many healthcare texts are not translated, even into Swahili, which is one of the languages in Africa with the highest number of speakers (around 100 million); for ‘smaller’ languages the situation can be assumed to be worse. Healthcare workers generally do not have the time or career motivation to take on translation tasks; in poorer countries, studying a language is a privilege that few people can afford.

Professional African translators often work on commercial projects such as business software, or manuals for mobile phones. With a rapidly growing economy in several countries in Africa, these markets are increasingly important for local translators.

Experienced healthcare translators are few and far between, and as a result healthcare translations are often carried out by people without much translation experience and with little know-how of translation techniques and tools. Thus, the work they produce can vary in quality. According to Kenya government officials, due to a lack of translators only a small proportion of all official healthcare documents are available in Swahili, which in Kenya is one of the two official languages.

CROs have many more resources to hand; if translators are too busy, these organisations can seek help from their own staff, who as a result become more experienced. Translators Without Borders, an organisation facilitating the work that professional translators volunteer to do for humanitarian organisations, is planning to start a translation training centre in Kenya, offering free medical and translation training to aspiring healthcare translators. If they succeed, the local translation workforce will be increased drastically, and as a result more healthcare and clinical trial information will be translated.

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Simon Andriesen is CEO of MediLingua, a translation company based in the Netherlands. He is also a board member of the Life Sciences Roundtable at Localization World, a series of high-level conferences about translation and localisation. He has designed a course on medical-pharmaceutical translation and is currently designing a healthcare translation course for aspiring Swahili translators. He is a frequent speaker at conferences about language, medical translation, medical writing and readability testing. Email:
Simon Andriesen
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