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 C O M M U N I C AT I N G I N P R O F E S S I O N S A N D O R G A N I Z AT I O N S

series editor: Jonathan Crichton

Communicating Across
Cultures and Languages in
the Health Care Setting

Claire Penn and Jennifer Watermeyer

Communicating in Professions and Organizations

Series Editor
Jonathan Crichton
University of South Australia
Adelaide, SA, Australia
This ground-breaking series is edited by Jonathan Crichton, Senior Lecturer
in Applied Linguistics at the University of South Australia. It provides a
venue for research on issues of language and communication that matter to
professionals, their clients and stakeholders. Books in the series explore the
relevance and real world impact of communication research in professional
practice and forge reciprocal links between researchers in applied linguis-
tics/discourse analysis and practitioners from numerous professions,
including healthcare, education, business and trade, law, media, science
and technology. Central to this agenda, the series responds to contempo-
rary challenges to professional practice that are bringing issues of language
and communication to the fore. These include:

• The growing importance of communication as a form of professional

expertise that needs to be made visible and developed as a resource for
the professionals
• Political, economic, technological and social changes that are trans-
forming communicative practices in professions and organisations
• Increasing mobility and diversity (geographical, technological, cul-
tural, linguistic) of organisations, professionals and clients

Books in the series combine up to date overviews of issues of language

and communication relevant to the particular professional domain with
original research that addresses these issues at relevant sites.
The authors also explore the practical implications of this research for
the professions/organisations in question. We are actively commissioning
projects for this series and welcome proposals from authors whose experi-
ence combines linguistic and professional expertise, from those who have
long-standing knowledge of the professional and organisational settings in
which their books are located and joint editing/authorship by language
researchers and professional practitioners. The series is designed for both
academic and professional readers, for scholars and students in Applied
Linguistics, Communication Studies and related fields, and for members of
the professions and organisations whose practice is the focus of the series.

More information about this series at

http://www.palgrave.com/series/14904
Claire Penn • Jennifer Watermeyer

Communicating
Across Cultures and
Languages in the
Health Care Setting
Voices of Care
Claire Penn
Health Communication Research Unit,
School of Human and Community
Development
University of the Witwatersrand
Johannesburg, Gauteng, South Africa
Jennifer Watermeyer
Health Communication Research Unit,
School of Human and Community
Development
University of the Witwatersrand
Johannesburg, Gauteng, South Africa

Communicating in Professions and Organizations

ISBN 978-1-137-58099-3    ISBN 978-1-137-58100-6 (eBook)
https://doi.org/10.1057/978-1-137-58100-6

Library of Congress Control Number: 2017954943

© The Editor(s) (if applicable) and The Author(s) 2018

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with the Copyright, Designs and Patents Act 1988.
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We dedicate this book to those who do what matters in real time and space
 Acknowledgements

The Researchers The work and insights described in this book reflect the
efforts, vision and energy of a wonderful team of researchers and research
assistants whose ‘lived’ experience with qualitative research methods in
some very demanding contexts has added great texture and understand-
ing to this field. Our deep thanks go to Victor de Andrade, Paula Diab,
Melanie Evans, Berna Gerber, Carol Legg, Motlatso Mlambo, Joanne
Neille, Lesley Nkosi, Dale Ogilvy, Jai Seedat, Samantha Smith, Gabi
Solomon and Tina Wessels, for their pioneering work in health commu-
nication across cultures in South Africa.

The Research Assistance Team at the Health Communication

Research Unit Bianca Burkett, Johanni du Toit, Harriet Etheredge,
Victoria Hume, Caitlin Longman, Sonia Mbowa, Rhona Nattrass, Sheryl
Neel, Megan Scott, Tshegofatso Seabi and others.

The Healers Carol Baker, Astrid Berg, Edwin Cameron, Ashraf

Coovadia, Paul Farmer, Bernard Gaede, Mike Levin, Aldo Morrone,
James Nuttall, Bruno Pauly, Neil Prose, Paul Roux and others.

The Funders South African National Research Foundation (NRF),

South African Netherlands Research Program on Alternatives in
Development (SANPAD), South African Medical Research Council
vii
viii Acknowledgements

(MRC), Fogarty International, American Speech-Language-Hearing

Association, Mellon mentorship funding, Friedel Sellschop funding,
University of the Witwatersrand Faculty Research Committee grants,
Swedish Research Council, The Wellcome Trust, MRC HIV/TB Initiative
Funding (in collaboration with the Aurum Institute), Carnegie
Foundation and KidzPositive.

The Enablers Large portions of this manuscript were written while CP

was in residence at the Rockefeller Foundation in Bellagio and at the
Stellenbosch Institute for Advanced Studies (STIAS). These contexts pro-
vided peace, space and companionship, which enabled creativity and
consolidation of a body of research. PATA is acknowledged for its huge
role and continuing efforts. Drama for Life at the University of the
Witwatersrand has been a constant companion in many of our projects.

The Advisers and Mentors Srikant Sarangi, Neil Prose, Tom Koole,
Leslie Swartz, the late Chris Candlin, Brett Bowman, Garth Stevens,
Hanna Ulatowska, Audrey Holland, Elisabeth Ahlsén, Jens Allwood.

The Voices The opinions, experiences, narratives and perceptions of all

who have taken part in our research. Their precious stories have yielded
deep insights.

Thanks go to Caroline Kennard for her efficient editorial assistance.

We thank our families for their forbearance and support of a vision.
 Contents

Part I Background and Central Constructs    1

1 Prologue   3

2 The Context of Health Communication: Global, Local

and Theoretical  25

Part II Research Methods and Challenges   59

3 Methodological Issues: Approaches, Pitfalls and Solutions  61

Part III The Evidence 117

4 Islands of Good Practice 119

5 Language Diversity in the Clinic: Promoting and

Exploring Cultural Brokerage 171

ix
x Contents

6 Verbal and Non-Verbal Dimensions of the Intercultural

Health Setting 207

Part IV Implementation 263

7 Putting It All into Practice: Some Examples and Advice 265

8 Conclusions and Implications: Paradoxes and Principles 313

Appendix 347

Index 359
 List of Abbreviations or Acronyms

AIDS Acquired Immune Deficiency Syndrome

ART Antiretroviral Therapy
ARV Antiretroviral
CA Conversation Analysis
CAM Complementary and Alternative Medicine
CARM Conversation Analytic Roleplay Method
CD Communicable Disease
CHW Community Health Worker
CP Claire Penn
CVA Cerebrovascular Accident
DA Discourse Analysis
DM Diabetes Mellitus
DGs Disability Grants
DVD Digital Versatile Disk
EMS Emergency Medical Service
HAART Highly Active Antiretroviral Therapy
HCRU Health Communication Research Unit
HIV Human Immunodeficiency Virus
ICF International Classification of Functioning, Disability and Health
IRB Institutional Review Boards
JW Jennifer Watermeyer
MDR-TB Multiple Drug-Resistant Tuberculosis
MRC Medical Research Council

xi
xii List of Abbreviations or Acronyms

NCD Non-communicable Disease

NGO Non-governmental Organization
NHI National Health Insurance
PATA Paediatric Aids Treatment of Africa
PMTCT Prevention of Mother-to-Child Transmission
RA Rheumatoid Arthritis
TB Tuberculosis
UNAIDS The Joint United Nations Programme on HIV and AIDS
VCT Voluntary Counselling and Testing
WHO World Health Organization
XDR-TB Extremely Drug-Resistant Tuberculosis
 List of Figures

Fig. 1.1 Map of South Africa indicating our sites of research 6

Fig. 1.2 The voice of medicine and the voice of the lifeworld
(Photographs by Yeshiel Panchia) 12
Fig. 2.1 The pill burden associated with treatment of drug-resistant TB 33
Fig. 2.2 The chain of communication in TB care contexts 36
Fig. 2.3 Ecological model of potential influences on pharmacist-patient
communication (After Watermeyer 2008) 38
Fig. 2.4 Ecological model of micro and macro influences on
communication in emergency care settings 40
Fig. 3.1 The three Rs (After Penn 2013) 63
Fig. 3.2 Participatory action research as incorporated into our research 65
Fig. 3.3 Example of a multidimensional polyphonic notation system
(Smith 2009) 101
Fig. 3.4 Our research ‘lab’ in Mpumalanga 104
Fig. 4.1 Site 1, an HIV/AIDS clinic at a tertiary hospital in the
Western Cape (psychiatry.uct.ac.za) 122
Fig. 4.2 Site 2, a child psychiatry clinic in Khayelitsha (vocfm.com) 130
Fig. 4.3 Site 3, an HIV/AIDS clinic in Mpumalanga 138
Fig. 4.4 The deck, above and below 141
Fig. 4.5 Ethnographic notes from observations of the patient
support group 142
Fig. 4.6 Site 4, an HIV/AIDS clinic in rural Eastern Cape 146

xiii
xiv List of Figures

Fig. 4.7 The Keiskamma Guernica, based on the painting by Pablo

Picasso, depicting HIV’s slow destruction of a community 146
Fig. 6.1 Metaphor themes and examples 219
Fig. 6.2 Example of a visual illustration of the battle metaphor
such as found in an HIV/AIDS counselling manual 220
Fig. 6.3 Mount Legogote in Mpumalanga 225
Fig. 7.1 The communication bus 281
Fig. 7.2 The DRIVE model 282
Fig. 7.3 Example of a transcribed call used in the training workshop 287
Fig. 7.4 Training workshop methods 292
Fig. 7.5 Examples of team ideas of the ideal clinic space 305
Fig. 8.1 Intersecting narratives on Prevention of Mother-To-Child
Transmission male non-involvement (Mlambo 2014) 320
Fig. 8.2 The entrance to the Chris Hani Baragwanath Academic
Hospital in Soweto (Photo: AFP) 330
 List of Tables

Table 3.1 Arthur Kleinman’s eight questions 75

Table 3.2 Some useful methods and ideas for intercultural research
in the clinical setting (After Penn 2013; Penn and
Armstrong 2017) 107
Table 4.1 Features of relevance emerging from sites 121
Table 4.2 Completed research on language in the HIV/AIDS clinic 123
Table 4.3 Patient perceptions of care at Site 1 126
Table 4.4 Patient perceptions of care at Site 2 136
Table 4.5 Patient perceptions of care at Site 3 140
Table 4.6 Patients’ comments about the qualities of a good doctor
at Site 4 149
Table 4.7 Caregiver and staff perceptions of care at Site 5
(Watermeyer 2012) 153
Table 4.8 Eight qualities of care identified at the islands of good
practice154
Table 4.9 Patient perceptions about quality of care at other sites 161
Table 5.1 Examples of the content of asides (uninterpreted sections)
emerging in 17 mediated interactions (After Penn and
Watermeyer 2012b) 186
Table 6.1 Comparison of priorities for information exchange during
the consent process 245
Table 6.2 Reported barriers to enrolment in trials 246

xv
xvi List of Tables

Table 7.1 Structure and content of the two informed consent

protocols270
Table 7.2 Enrollers’ perspectives on ‘challenging’ participants 273
Table 7.3 Strategies for improving communication in informed
consent processes (After Penn and Evans 2009, 2010) 275
Table 7.4 Examples of participant feedback from communication
training278
Table 7.5 Strategies that reportedly facilitated communication
during the consent process 280
Table 7.6 Verbal and non-verbal communication strategies presented
to participants 283
Table 7.7 Communication behaviours pre- and post-training 285
Table 7.8 Feedback from workshop participants 288
Table 7.9 A comparison of recommendations across two sites 301
Table 8.1 Elements of the ‘Communication in Health’ course 324
Table 8.2 Guidelines for teaching culturally safe communication skills 334
 Part I
Background and Central Constructs
 1
Prologue

Introduction
Communication has been identified as the single biggest barrier to health
care in a global world, and the provision of culturally and linguistically
appropriate services is a top priority, particularly in the light of the
increased migration patterns and complex illness burden imposed by dis-
eases such as HIV/AIDS.
Responding to such complex challenges of communication, within the
past decade, the Health Communication Research Unit at the University
of the Witwatersrand in South Africa has produced a body of research
which has had a significant influence on ways in which intercultural
health interactions can be viewed.
Using methods from the social sciences and linguistics, this project has
explored, in detail, same- and cross-language interactions in the health-
care setting, the role of the mediator in such settings and ways in which
interactions can be modified to improve communication.

© The Author(s) 2018 3

C. Penn, J. Watermeyer, Communicating Across Cultures and
Languages in the Health Care Setting, Communicating in Professions
and Organizations, https://doi.org/10.1057/978-1-137-58100-6_1
4 1 Prologue

Our research goals have been:

1. To describe and analyse cross-language and intercultural interactions

between health professionals and patients and to understand the role
of the interpreter in this process.
2. To establish the perceptions of the different participants (patients,
health professionals and interpreters) regarding the role of the inter-
preter and the language dynamics of medical interviews.
3. To assess the influence of different sites of service delivery on the
process.
4. To develop and implement appropriate guidelines for training health
professionals who work in cross-cultural and cross-linguistic contexts.

The research to date has examined cross-linguistic communication

and interpreting practices in the areas of HIV/AIDS, TB, genetic coun-
selling, psychiatry, respiratory illness, stroke, disability, audiology, phar-
macy, antiretroviral (ARV) treatment, paediatrics, diabetes, emergency
care and general health issues. Our research has also focused on cultural
beliefs regarding illness and causality as well as the impact of healthcare
systems on rural communities. The findings of some of these studies
have shown an urgent need for revision of current practices, as well as
linguistic and cultural tailoring of information for the patient, to ensure
successful transfer of information and concordance. The research has led
to the formulation of recommendations for policy and practice as well
as the development of communication skills training programmes for
health professionals. Efficacy studies on training programmes suggest
that the communication behaviours of health personnel can be modified
effectively and demonstrably after appropriate context-specific
training.
This book represents the consolidation of this decade of experience
into a text which will hopefully significantly influence ways in which
communication practices in all intercultural health settings are managed
and understood. The culturally diverse context in which this research has
taken place has obvious and immediate application in a wider interna-
tional context, given globalization and increased patterns of migration.
 Introduction 5

Four lines of research have emerged from the research:

1. The first body of evidence stems from an investigation of intercultural

healthcare interactions in various settings and the examination of a
range of verbal and non-verbal features in such settings which facili-
tate and inhibit such interactions.
2. The second line of research has been concerned with the impact of a
third party (interpreter or cultural broker) on the dynamics of such
settings and the perceptions of the participants around this process.
3. The third body of research (including the new field of genetic counsel-
ling) has explored cultural explanations of illness and how these may
interface with the medical model.
4. The fourth line of research focused on the understanding of how this
knowledge can be transferred into training and development models
for individuals and institutions.

Having had the opportunity to work at numerous sites, across numer-

ous diseases with multiple participants and across multiple languages,
this book offers us a chance to stand back, take stock and take a bird’s-eye
view—in other words a perspective about the whole. We have worked in
seven of the nine provinces of South Africa and across six of its official
languages. Figure 1.1 shows some of our sites of research.
Much of our work has been published, and we do not want to make
the mistake here of repeating that work and its findings. Indeed, our own
perspective on that work has often changed with time and with hindsight
and with the emergence of new evidence. Rather we use this book as an
opportunity to begin to compare and contrast the evidence and to inter-
face the collective experiences with our growing insights and the global
literature, and our experience at sites with patients and doctors.
Thus, while part of the book is very much about making sense of the
real evidence (and we now have a lot of that) and highlighting useful
methods and recurrent themes, the other part is very much forward-­
looking and drawing connections where none existed, making recom-
mendations or observations which are novel and which will hopefully
influence new ways of addressing practice.
6 1 Prologue

Fig. 1.1 Map of South Africa indicating our sites of research

This text presents these findings and shows how the methods we have
developed are unique and have wide potential application. The text is
intended for health professionals, language specialists, medical educators,
researchers and practitioners, and includes a range of theoretical, meth-
odological and empirical considerations. We have developed a set of rec-
ommendations for reframing the notion of ‘cultural safety’ in health care.
This will hopefully influence both individual and systemic practices for
managing diversity.
There is a clear relationship between effective communication practices
and outcomes which can be measured in tangible benefits for patients,
the health professional and the institution. Among documented benefits
for the patients are increased accuracy of diagnosis, understanding of
treatment, improved adherence to treatment and research protocols,
 Introduction 7

greater satisfaction and greater likelihood of returning for follow-up treat-

ment. Potential benefits for the health professional include increased
speed and efficiency, more accurate diagnosis, less stress and burnout and,
in turn, greater job satisfaction and, because of the improved use of the
diagnostic power of the interaction, less dependence on costly diagnostic
tests. Institutions benefit from effective communication, as they are likely
to experience decreased turnover of staff and financial savings, and argu-
ably, most importantly, they comply with the legal and ethical obligation
of providing equitable services to all patients.
To date much of the research on such factors has not been done in the
context of the multi-lingual clinic, and where it has, some of the methods
of measurement have been unidimensional. The complexities introduced,
for example in the mediated healthcare interaction in a situation of lin-
guistic and cultural diversity, are not well understood and require meth-
ods which capture such interactional complexity. Further, little is known
about the effect of disease on the process. The work of our project has
thus been deliberately framed within a multi-dimensional perspective of
the problem. In addition to the direct evidence we have of recorded inter-
actions, we have the perceptions of the participants, as well as narrative
and ethnographic perspectives on sites of practice and from particular
illness and communication experiences. It also seems important to con-
sider the impact of the broader ‘macro’ context in health care and to
understand the socio-political and institutional context of the
interaction.
Many South African patients continue to experience numerous poten-
tial barriers to accessing the healthcare system, interacting with health
professionals or adhering to treatment regimens. These barriers are linked
to factors such as stigma and discrimination, poverty, unemployment,
gender, education, religion, literacy, access to treatment and health care,
financial resources, and trust of the healthcare system or health profes-
sional. In other words, the separate world views of the participants in
healthcare interactions have a very real impact on the process and often
cause breakdowns, which have marked consequences in terms of effi-
ciency of diagnosis and treatment.
Fascinating material has emerged from the project. As reflected in the
dissertations and publications produced, we have a body of unique material
8 1 Prologue

which spans a range of healthcare settings, a range of diseases and a number

of health professionals (see the table in the Appendix for details of each
study). We have patient narratives and health professionals’ perspectives,
and we have delved into the verbal and non-verbal minutiae of clinical inter-
actions. We have discovered multiple barriers to care and glowing islands of
good practice. We have seen how things can be demonstrably changed and
the impact that these changes have on the process of communication and on
the participants’ attitudes and behaviours. We have found that an examina-
tion of the micro-content of health interactions frequently provides insight
into broader societal issues. This suggests that many of the solutions to cur-
rent global healthcare challenges may lie in the voices of these ordinary
people and how communication takes place across this intercultural space.
We begin in this text to coalesce this material and offer some explana-
tions, solutions and methods for reframing these challenges based on
some remarkable and exciting evidence.
The following are considered some central values to this project.

F ocus on Everyday Practice and Authentic

Methods
Based on the belief that the study of everyday, local and particular is espe-
cially valuable, the emphasis in this book is a close examination of everyday
practice in a range of settings. Our research has enabled us to bear witness
to the stories and experiences of ordinary patients and health professionals.
As Jonny Steinberg (2010) has indicated in relation to effective implemen-
tation of new health policy and universal coverage of ARVs in South Africa,
“A great deal will depend on what ordinary people think and do.”
Our focus has been on just that. Methods of data collection, tran-
scription, translation and analysis have been developed with an empha-
sis on capturing accurate and nuanced language use. We have examined
interactional aspects such as openings and introductions, length, cou-
pling, symmetry and the search for collaborative moments (moments
in the interviews where participants and observers endorse mutual
understanding). Our methods also include participant observation, and
the exploration of the everyday life, experiences, events and problems
 Focus on Everyday Practice and Authentic Methods 9

of our participants through interviews and narrative methods. Some of

our methods have encouraged self-reflection —health professionals
reviewing videotapes and transcripts of their own practice— and hear-
ing their explanations for their behaviours.
In this text we also wish to highlight and illustrate the methodological
challenges of such research and to discuss in detail some lessons learned
and some mistakes made and to develop some recommendations about
these tools and their potential future use. These methods also have
enabled a certain way of presenting evidence from the project. We also
want to ensure that there is a depth and richness of illustration in this
text. As one of the health workers interviewed in this project observed,
“Sometimes the direct voice of the patient is more powerful and beautiful
than any secondary analysis or interpretation of what was said.”
Some of the evidence that we have is embedded in the narratives— sto-
ries of patients about their disease. As Rita Charon (2008) has indicated,
such narratives provide a remarkable perspective on the patient’s world
and form an important diagnostic and therapeutic function. This is par-
ticularly the case in contexts where a strong oral tradition exists. We have
stories about disability, about diseases such as HIV/AIDS and of health-
seeking paths. There are stories of resilience and adaptation to illness.
We also have the stories of doctors— doctors disillusioned with the
system, and some developing methods of communicating which are par-
ticularly unique and powerful.
We present some of these narratives in the text to provide the reader
with an opportunity to blend and merge voices of the health professional,
the patient and the mediator or third person who is so frequently present
in such interactions.
Similarly, the technique of conversation analysis, which we have used
for analysis in some of our studies, allows for the illustration of very detailed
interactional material, and the text includes a number of verbatim extracts
between health practitioners and patients which provide the reader with a
detailed understanding of both verbal and non-verbal components.
We are acutely aware of the ethical complexities of research of this
nature. By definition, this book deals with vulnerable populations of peo-
ple who are often sick, poor or uneducated. These are the very people who
have been marginalized by society, and their voice is often ­misrepresented
10 1 Prologue

and silenced. Our qualitative methods seek to directly represent their

voices, and we believe it is our ethical obligation to do so. Both of us have
been active members of our university’s ethics committees for a number
of years. All our research has received ethical clearance from the relevant
Institutional Review Boards and informed consent was obtained from all
participants. We have taken care to anonymize the people involved and to
use pseudonyms where necessary. In some instances however, and partic-
ularly where we highlight excellence of settings, we have chosen not to
completely anonymize all of the clinic details. Similarly, finding and using
the appropriate terminology within clinic spaces has proven an important
but challenging aspect of our research endeavours. As will be described in
more detail in Chapter 3, the words we use to refer to those who work in
clinics and with patients have direct links with our own approach to
research, our views of participants and our perceptions of ourselves as
researchers in the clinic space. In our research we have seen that when
issues around team membership, acknowledgement of role and the use of
inclusive terminology have been actively considered and addressed, there
have been positive consequences.
While this book reflects the products and efforts of a long-term partner-
ship, at times we discuss our own experiences and perspectives on particu-
lar projects, and we have taken care to label these perspectives as particular
to one author. We have also on occasion included ‘small stories’ (Bamberg
and Georgakopoulou 2008) to illustrate our research experiences.

Emergent Themes
In this text we highlight some of the themes which have emerged from
the research and which have a cohesive potential, in terms of both theory
and practical import.
Some examples link to:

• A consideration of the interface between a Western biomedical health-

care framework, which operates alongside established systems of tradi-
tional medicine.
• The powerful influence of gender on the health communication pro-
cess. What factors help women to express themselves and enable their
 Emergent Themes 11

voice to be heard? What barriers to care exist for women, and how can
the clinical relationship assist in resolution of these issues?
• The interaction between disease, poverty and communication. We are
interested in exploring what Paul Farmer et al. (2006, 2013) refer to as
“structural violence” imposed in a context of poverty and how tempo-
ral and spatial factors interface with health communication.
• Why do community structures of support sometimes have limits?
• How do the voices of different generations interface in the health con-
text? Our body of research on grandmothers, for example, has high-
lighted a number of differing models of illness causation.
• The delicate tension between the emergence of established organiza-
tional routines in healthcare interactions, in a context of fluidity and
uncertainty and scarce resources.

Just as many of the problems in health delivery link to communication

issues, so too do many of the solutions. Some of these are surprisingly
practical and simple and are described and illustrated in the text. For
example, asking the right questions, changing the seating in the interview
or the tea room arrangements in a clinic, negotiation of language rules,
the conscious deployment of non-verbal strategies (e.g., the use of ges-
ture, facial expression and using props) are some mechanisms that have
been explored. Similarly, ways in which vocabulary and terminology can
be clarified and understood have been a feature of our research.
The essence of our research endeavour is, in short, to blend the voice
of the lifeworld with the voice of medicine (Mishler 1984) and to use
communication as that bridge.
This is beautifully illustrated by the following pair of photographs
(Fig. 1.2), taken (with permission of all participants) in a diabetes clinic
in a large hospital in which one of our projects was sited.
In the one picture we see the messages of the clinic (in this case about
foot care) and the standard mediator for that message (the nurse ­educator)
whose primary role is to educate patients coming to the clinic about the
­complexities of diabetes management. In the other picture we see part of
our drama intervention involving actors, patients, nurses and facilitators,
the use of a cell phone and a snapshot of a group interaction whose goals
were entirely similar. The images complement each other and indicate the
potential role of communication strategies in helping to bridge the gap.
12 1 Prologue

Fig. 1.2 The voice of medicine and the voice of the lifeworld (Photographs by
Yeshiel Panchia)
 Emergent Themes 13

We have some really pleasing evidence for how such factors enhance
communication, reduce barriers to mutual understanding and promote
concordance even in the most challenging intercultural contexts. It is in
the initial and subsequent interface between the health system and the
patient that lives can be changed or that paths are set. We have begun to
see the emergence of what we call ‘magic moments’ in clinical settings—
points at which the participants collaborate and show evidence of mutual
understanding and intention. Such moments mostly occur around non-­
medical topics and are characterized as having greater interaction, being
more informal and personalized, demonstrating more coupling and mir-
roring behaviours, facial animation, increased eye gaze, forward body
posture and increased gesture. Such findings have major implications for
medical education.
Interwoven into this discussion is a consideration of biomedical ethics
and the role that communication factors play in this field. We consider,
for example, how communication variables are central to determining
and enhancing autonomy, self-efficacy and decision-making capacity and
can be actively enhanced in cross-linguistic research trial settings.
Other questions and solutions are more complex. How, for example,
can communication dimensions interface with the barriers to care which
continue to exist in the context of HIV/AIDS? What are the language
dimensions of the process of disclosure? Why do fewer than 30% of
women take up counselling services and why is there no apparent decline
in new infections in pregnant women? The fact that staying alive depends
on maintaining high adherence rates to ARV regimens in order to pro-
mote treatment success requires a detailed understanding of the language
of the pharmacy which is considered in depth in this text. Similarly, com-
munication is implicated in the complex treatment regimens and in rec-
ommended nutritional practice for patients.
How can some of our findings influence confidence and effectiveness
of young doctors working in contexts of cultural and linguistic diversity?
What mechanisms will best aid and assist systems and settings to cope
with what has been termed ‘organizational shock’ brought about by the
rapid and profound demographic changes and the complexity and sever-
ity of the diseases encountered?
14 1 Prologue

Emerging Solutions
This text aims to address some of the above issues and offer some concep-
tual and some practical proposals for individuals, institutions and policy.
Amongst some of the issues we explore (and which inform the last section
of the book) are the following:

 he Move Towards a Revised Model of Cultural

T
Brokerage

Our findings have strengthened the notion that in an intercultural set-

ting, a traditional conduit model of interpreting (where interpreters are
expected to remain neutral and merely transfer information verbatim
between patient and health professional), is ineffective and a cultural
brokerage model of interpreting is most effective for the transmission of
meaning in intercultural contexts. In this model the cultural broker acts
as a mediator between the health professional and patient, offers a cul-
tural framework in which the message can be interpreted and assists
both parties to negotiate cultural and linguistic barriers in order to
achieve a specific communicative goal. The text presents the discrete
profiles of cultural brokerage interpreting which have emerged in differ-
ent settings.

Islands of Good Practice: Characteristics of a Caring

Clinic

In our setting, because systems of health care are often underdeveloped or

even malfunctional, because the monitoring of such systems may be
erratic and because of profound resource limitations imposed by the
needs of a developing country, such difficulties are mapped daily onto the
clinic and its people. Ironically, this has created a space or vacuum which
has enabled an opportunity to exercise creativity, resourcefulness and
adaptation, and this has enabled the emergence of unique organizational
routines. A fascinating picture emerges in some cases about not only how
the role players have made do in a context of scarce resources, but also
 Emerging Solutions 15

how they have flourished, retained integrity and dealt with the challenges
in meaningful ways.
The intention here is not to harp on the bad-luck stories, the global
pattern of health inequities, the overwhelming disease profile, and the
health budget and mismanagement that beset clinical practice. These are
well described and acknowledged and hopefully will be systematically
addressed in the future on a global level. Rather, what we hope to do is
show humanization within such systems and show that despite, or
­perhaps because of, these systems, interpersonal and systemic evidence
emerges which point the way for us all. There is space for care and it
emerges when suffering is recognized and responded to.
Thus, a focus of this text is about the discovery and analysis of such
islands of good practice—settings or individuals where intercultural
communication is demonstrably effective, where patients are satisfied
and where indices of success (such as adherence to treatment and return
to the clinic) are remarkable. An examination of these interactions has
considerable promise: understanding the features characterizing such
interactions has the potential to yield a number of important directions
for future clinicians. We highlight eight features of good care common to
them all.
Five such examples of islands of good practice are described in detail in
the text:

• The first is the interactions between patients and one particular doctor
in the context of a paediatric HIV/AIDS clinic in the Western Cape.
We observed a number of his sessions and were able to interview him
about his perceptions of his practice and the individual sessions
observed. He worked both with and without interpreters and his par-
ticular style seemed to facilitate a number of positive interactions. His
management of disclosure (in the case of an adolescent girl) is a ­keynote
exemplar. A detailed description of this session is used in the text to
focus on this complex issue.
• The second context in which exceptional practice has been observed is
in a small rural village in the Eastern Cape. We spent some time at the
Keiskamma health programme (linked to the internationally recog-
nized art programme of this area), interviewing members of the
16 1 Prologue

c­ommunity, patients in the hospice and some of the village health

workers while assessing the impact of this programme.
• A third focus of good practice is a project in the primary healthcare
setting of Khayelitsha in the Western Cape, in which a diagnostic
method for determining mother-child dyads in need of intervention
has been established (infant-led psychotherapy). This method relies
entirely on the collaborative intervention between a child psychiatrist
and an individual who serves as her assistant or cultural broker. Their
collaborative partnership has developed over 13 years and has resulted
in a highly effective service measured in relatively high compliance
rates and high infant survival rates. We provide examples of the unique
linguistic features which characterize the success of the interaction.
• The fourth context of good practice is an HIV/AIDS clinic in
Mpumalanga. This study documented the impact of a patient support
group in a rural clinic and the informal development of an organiza-
tional routine which had a marked impact on patient adherence and
satisfaction.
• The fifth site is a paediatric HIV/AIDS clinic in Gauteng. The study
involved six months of ethnographic observations and interviews at
the site with the aims of unpacking the components of good care and
understanding why caregivers choose to attend this clinic, sometimes
travelling hundreds of kilometres to get there.

Place, Space and Time

Through our methods, we begin to interrogate what it is about features

of the context which influence communication. Illness and its experience
are located in spatial and temporal dimensions. We are interested in the
influence, for example, of the setting: whether this is an urban or rural
context, whether this is in the context of a community clinic, a teaching
hospital, a hospice or the patient’s home. We are interested in who is
present in the interaction and the perceived roles of those present
­
(for example, family members).
For example, some of our studies have taken place in Khayelitsha with
isiXhosa-speaking patients. One of the studies (referred to above) was
 Emerging Solutions 17

conducted in a child psychiatry clinic and explores the long-term part-

nership between a psychiatrist and a cultural broker. Another study in
this setting explored the beliefs and perceptions of a group of caregivers
of patients with haemophilia who regularly attend a support group in this
context. A third study (which was conducted longitudinally) explored
the treatment-seeking paths of five persons living with stroke. In this
peri-urban context of extreme poverty, uncertainty, vulnerability and flu-
idity, certain themes emerge and frame the health experience of its
residents.
Another setting in which research was conducted was in a rural area
described as a ‘pocket of poverty’ between the Swaziland and Mozambican
borders. In an ongoing study on disability involving narrative methods,
we interrogate the impact of poverty on access to health care and beliefs
about causation and the structural barriers to treatment which exist. We
explore how some of the methods provide potential access to patients’
concerns.

Spatial Aspects

Spatial aspects of the clinical setting also seem important for communica-
tion goals. They incorporate seating, privacy and comfort levels. We have
studied what organizational routines occur in different health settings—
when these occur spontaneously and when they are imposed by the sys-
tem. We are also interested in the use of props—how they are used in
multiple ways to help in getting the message across, as gifts and dona-
tions, in dispensing pills, and in the organization of clinics.
In one of our studies, for example, which involved an analysis of the
communication between pharmacists and patients, we examined in
detail the use of props (pills, pill containers, pictures, brown-paper
bags) in the interactions and the role that they played in facilitating
the interactions. This study demonstrated the various functions of
such props—to differentiate ARV from non-ARV drugs, to reinforce
and supplement verbal instructions, to verify the understanding of
dosage instructions, to facilitate communication across barriers and to
facilitate closings.
18 1 Prologue

Time

Time has been described as a pivotal axis of the medical encounter. It is a

feature commented on by a number of our participants as a factor which
can both enhance and inhibit communication processes. It has been
interesting to examine what aspects influence perceptions of time par-
ticularly when a third party is present in the medical interview. Some
doctors felt, for example, that the presence of an interpreter tended to
lengthen the session and place pressure on an already pressured day.
Other perceptions, however, suggested that there was no length differ-
ence between interpreted and non-interpreted sessions. In fact in a con-
text of multi-lingualism an interpreted session also affords the opportunity
of repetition of information—something which clearly helps the process-
ing and comprehension of important messages. One doctor referred to
the cultural distinctions in time which affect the communication in a
session as follows: “The Western European psyche does not have a ‘sense of
process.’ Our way is that A leads to B then to C. Here [in Africa] you have A
then wait until the next thing happens.”

Implementation Research

Typically the work described in this book involves a participatory action

research framework which includes entering a clinic space and through
ecologically valid qualitative methods evaluating systems and communi-
cation effectiveness and making recommendations around shifts in prac-
tice and organizational routines. Interestingly over this period and work
in a number of domains the focus of our work has gradually shifted. We
feel we have reached a crossroads in our research which is best described
as one driven by an implementation research paradigm (Peters et al.
2013). We believe that implementation research in a context like ours is
an ethical imperative. It is not enough to describe a set of circumstances
and to offer explanations for their emergence. South African healthcare
barriers include a high burden of disease, language and cultural barriers,
emigration of healthcare professionals, social and geographic isolation in
rural areas, staff shortages, staff attitudes, resource constraints, high
 Emerging Solutions 19

­ overty and violent crimes (Daviaud and Chopra 2008; Mayosi and
p
Benatar 2014). Once such inequities and imbalance are recognized, there
is an ethical imperative to step over the line and to effect some meaning-
ful change. How to do that of course is a dangerous minefield especially
in a complex context marked by its unique history, cultural and linguistic
diversity and persistently two-tiered health system. As with any qualita-
tive research paradigm, the rules of engagement are different. There is a
risk to both researchers and participants in this research and the need for
recognizing constantly the thin line between paternalism and authentic-
ity, between researcher and practitioner, between participant and specta-
tor and between balancing one’s own ignorance and supposed expertise.
Perhaps this is best reflected in the concept of ‘entanglement’ described
by Fitzgerald and Callard (2016), who argue that Medical Humanities
needs to address the shifting boundaries that constitute moments of ill-
ness and healing and to actively engage in the realism of the interface
between medicine and the humanities.

Linking with Global Trends

Our research aligns with some international trends in medical education

and in system management. In the final section of the book, we propose
some suggestions for embedding communication and cultural issues
more firmly into medical education approaches and into institutional
practices and policy. This section includes a consideration of harnessing
community resources, the recognition of cultural brokers and effecting
changes in organizational routines. This approach aligns with global
imperatives highlighted by the World Health Organization (2008) for
task shifting in underresourced countries, which suggest that “we ­must…
seek innovative ways of harnessing and focusing both the financial and
the human resources that already exist.” This approach also links to vari-
ous existing models, for example the “accompagnateur” model or expert
patient model (Behforouz et al. 2004). By identifying and training suit-
able community informants who can act as cultural brokers in healthcare
contexts, we can implement this notion of task shifting and formalize
some existing community resources.
20 1 Prologue

New models of training and partnership emerge from this work.

Returning to relevant intercultural theory (e.g., the anxiety and uncer-
tainty theory of Gudykunst and Nishida 2001), we consider the import
of this body of work in a broader context and how trust develops in the
individual relationship between healthcare practitioners and patients and
within the whole institution. This has a powerful resonance for the con-
tent of training programmes, and implies particularly the relevance of
good communication at the level of institutions and community.
Importantly, in line with a philosophy of cultural safety, these changes
should extend beyond a mere understanding of barriers to care, to a level
of fluent and committed implementation of suitable methods as well as
the development of relevant sustainable policies.
The Lancet of November 2014 produced a special publication by the
Commission on Culture in Health (Napier et al. 2014) which calls for
the reversal of systematic neglect of culture in health and highlights the
need for addressing the single biggest barrier to advancement of health
worldwide.
In reflecting on this publication (UCL News 2014), David Napier sets
a challenge reflecting the need for a broader perspective:

“Only if health professionals, researchers, and health managers begin to appre-

ciate the central role of culture in how we perceive and understand health, will
we begin to be able to move towards a system in which health is as much about
caring as it is about curing”, and

“Continuing to ignore the effects of culture on health is not an option: not only
will we fail to address the biggest health problems faced by the world today, but
the resulting waste of public and private resources will continue to cripple
health care delivery worldwide.”

We believe this book addresses this challenge.

The notion of cultural safety is a central theme of the text which
implies a move beyond simply cultural awareness but to a situation where
“a client feels that their cultural social and human values are respected
and that an organization providing service to that client reorients its
institutional practices, values, resource and governance arrangements
accordingly” (Phillips 2007).
 Conclusions 21

We argue that cultural safety is a human rights issue and will depend
on health professionals continuing to feel culturally incompetent (Daniels
and Swartz 2007) and actively striving to address that feeling through
reflexivity and openness. Some principles might include the adoption of
culturally attuned methods, the recognition that patients are experts of
their own lifeworld and that cultural beliefs regarding illness have a per-
vasive impact on medical interactions and outcomes. The research sug-
gests that facilitators and barriers to care are identifiable and can be
addressed effectively through a focus on communication and process
aspects and the adoption of new methods for deriving information and
checking understanding. New models of training and partnership linked
to principles of social advocacy hence emerge.

Conclusions
We believe this text offers a unique approach to understanding the com-
plexities of communication in the context of health care. Many prior
approaches to the issue of communication appear to have been predi-
cated within a so-called cross cultural framework in which beliefs and
practices of different cultural and ethnic groups are contrasted. This ter-
minology implies an ‘othering’ of clinical and cultural groups rather than
an awareness both that cultural factors impinge on all clients regardless of
language or ethnicity (Daniels and Swartz 2007), and that both health
professionals and clients bring their own values, beliefs and experiences
to an interaction. Rather than examining such difference, our focus is on
the space of interaction between individuals which implies a move
towards a more culturally embedded model of communication. We argue
that South Africa with its very diverse cultural and linguistic heritage
provides an exceptionally fruitful testing ground for the study of such
issues and the development of local rather than universal models of prac-
tice is both conceptually desirable and achievable.
Although most of the research has been conducted in South Africa, we
feel that this text has a much broader appeal and application. The discus-
sion of the methods and the approach has wide potential resonance, as do
the multiple case examples. We will suggest that in the context of the
22 1 Prologue

Global South, fruitful conceptions may emerge in the international

debate on interdisciplinarity in this field. Indeed in the presentation of
our results (in Europe, Australia, the United States and the Far East), our
methods have evoked keen international interest and have resulted in a
number of invitations and collaborations. Our involvement in the
Paediatric AIDS Treatment for Africa (PATA) network has also demon-
strated the powerful potential of some of our tools in improving health
practices and interactions at different sites across the continent.
The implications for how we train and support health practitioners on
site are many, and we present evidence of successful interventions that we
have made. Similarly implications arise for the health practitioner in
training for models of medical education and for in-service training of
health practitioners at different sites and working with different illnesses
in different countries. Finally, and very importantly, the evidence and
explanations offered in this book will hopefully contribute to an under-
standing of intercultural theory and provide a framework for enhancing
and addressing global barriers to communication.

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in narrative and identity analysis. Text & Talk, 28(3), 377–396.
Behforouz, H. L., Farmer, P. E., & Mukherjee, J. S. (2004). From directly
observed therapy to accompagnateurs: Enhancing AIDS treatment outcomes
in Haiti and in Boston. Clinical Infectious Diseases, 38(5), S429–S436.
Charon, R. (2008). Narrative medicine: Honoring the stories of illness. London:
Oxford University Press.
Daniels, K., & Swartz, L. (2007). Understanding health care workers’ anxieties
in a diversifying world. PLoS Medicine, 4(11), e319.
Daviaud, E., & Chopra, M. (2008). How much is not enough? Human resources
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and clinical medicine. PLoS Medicine, 3(10), e449.
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global health. Los Angeles: University of California Press.
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 2
The Context of Health Communication:
Global, Local and Theoretical

Introduction
No account of illness or health would be complete without what Paul
Farmer et al. (2013) refer to as ‘historically deep’ and ‘geographically
broad’ understanding of political realities, social forces and global eco-
nomic conditions. “Social justice is a matter of life and death…inequi-
ties in health arise because of the circumstances in which people grow,
live, work and age and the systems that in place to deal with illness. The
conditions in which people live and die are in turn shaped by political,
social and economic forces. Achieving health equity within a generation
is achievable. It is the right thing to do” (Commission on Social
Determinants of Health 2008). This chapter will discuss culture and
health in the global sense and highlight some of the central constructs
which frame the methods and evidence of the next section. Some chal-
lenges of communication in health will be considered.

© The Author(s) 2018 25

C. Penn, J. Watermeyer, Communicating Across Cultures and
Languages in the Health Care Setting, Communicating in Professions
and Organizations, https://doi.org/10.1057/978-1-137-58100-6_2
26 2 The Context of Health Communication: Global, Local...

General Global Issues

Global inequality continues to escalate, with the divide between rich and
poor ever widening. Almost half a billion people around the world live on
less than $2 a day (Lakner et al. 2014; Oxfam 2016). More recently, the
world has witnessed unprecedented numbers of migrants, asylum seekers
and refugees on the move, and migration is considered by some to be one
of the defining issues of the twenty-first century.
Within this global context, inequities in health persist and have been
documented by bodies such as the World Health Organization (WHO).
Even in relatively developed countries there is an uneven distribution of
health services between subpopulation groups and marked differences
between urban and rural areas. Barriers to care exist not just in factors like
relative infrastructure and geography but also in a range of social deter-
minants, including education, employment status, income level, gender
and ethnicity, and in historical factors such as colonization, attitudes,
constructs of family and community, all of which have a marked influ-
ence on how healthy a person is, on how life events are perceived, and on
their treatment-seeking paths, and will determine the resilience that such
individuals and their communities have to deal with illness (Barnett et al.
2012; McEwen and Getz 2013; Napier et al. 2014; Farmer et al. 2013).
As Charon (2008, p. 6) reminds us, “Health professionals and patients
are at a crossroads. Together we have to discover means of sustaining the
tremendous capabilities of our biomedical science.”
Health is centrally positioned within the 2030 development agenda
adopted by the United Nations General Assembly in September 2015
with one comprehensive goal—that of sustainable development. This
agenda comprises 17 Sustainable Development Goals and includes 13
targets covering all major health priorities. Such a global debate now rec-
ognizes the centrality of social determinants of health—the conditions in
which people are born, grow, live, work and age, including the health
system-which are mostly responsible for current health inequities. These
forces and systems include economic policies and systems, development
agendas, social norms, social policies and political systems that favour the
interests of some over those of others. The presence of preventable ­diseases
especially in poverty contexts is viewed as essentially a violation of human
rights policy and the cause of a vicious cycle of poverty and exclusion.
 A Backdrop to Health Care in South Africa 27

For example, within the context of Global Health Risks (as defined by
the WHO) the two main leading causes of death in the world currently
are ischemic heart diseases and cardiovascular disease and will remain so
by 2030. The disability-adjusted life years also reflect these figures. Clear
differentiation is noted between income level and 19 leading global risk
factors for disability. In contexts of extreme poverty, the issue of multi-­
morbidity is a particularly interesting one (Sambo and Kirigia 2014;
Barnett et al. 2012). Most chronic diseases are associated with major risk
factors such as tobacco use, unhealthy diets, physical inactivity and alco-
hol abuse. Often cultural accounts of illness point out the disproportion-
ate representation of such issues among minority groups, but such
cultural taxonomies are unsafe and pejorative as they may cause labelling
and stereotyping, and clearly mask the real social determinants of these
issues such as power imbalances, poverty and access.
Probably the most comprehensive current perspective of culture and
health comes from the recent Lancet Commission published in November
2014 (Napier et al. 2014). This important piece highlights the relative
neglect, yet the centrality of culture, in health and promotion. It makes
far-reaching suggestions which are imperative to the achievement of
health worldwide—and which “constitute an agenda for the reversal of a
systematic neglect of culture in health, the single biggest barrier to
advancement of the highest attainable standard of health worldwide”
(p. 1608). As a culturally and linguistically diverse country with a unique
disease profile, South Africa provides a fertile space for illustration and
realization of some of these suggestions.

A Backdrop to Health Care in South Africa

South Africa presents a fascinating juxtaposition of contexts, cultures and
lifestyles, a contrast which accounts for many of the current challenges in
health care: the country is advanced industrially and financially, yet dis-
advantaged and underdeveloped areas remain. The impact of apartheid
processes, and specifically the discriminative allocation of resources and
denial of access to health care, has meant that the health needs of many
South Africans are often neglected. Many disparities continue to exist for
individuals and groups in terms of the availability of and access to
28 2 The Context of Health Communication: Global, Local...

healthcare services. For example, approximately 71% of the country’s

population is dependent on public healthcare services (Statistics South
Africa General Household Survey 2016). There is a chronic shortage of
health professionals, particularly in rural areas, and the situation is exac-
erbated by high levels of emigration of such professionals. High rates of
unemployment, poverty and migrant labour practices have compounded
these disparities (Mayosi and Benatar 2014).
Despite the government’s sound healthcare policies, implementation
of these has been poor. The public healthcare system has come under
much criticism over the last decades particularly relating to ill-equipped
and crumbling facilities: weak governance, ineptitude, poor coordina-
tion, corruption and negative healthcare professional attitudes (Coovadia
et al. 2009; McIntyre and Ataguba 2012; Rispel et al. 2016). Staff short-
ages, particularly in the rural districts, remain problematic even though
60% of the health budget is spent on human resources. Disempowered
patients, inequality, poverty and inadequate household resources further
exacerbate the difficulties in the state system (Mayosi et al. 2012; Scorgie
et al. 2015).
As a developing middle-income country, it also carries an exceptionally
high disease burden. The epidemic of HIV/AIDS is highest in sub-­
Saharan Africa and affects many individuals (UNAIDS 2016a). With this
disease (and with the development and rollout of antiretrovirals (ARVs))
has come a huge necessity for outreach of medical services, community
education and intervention and regular interface between the commu-
nity and the healthcare sector. This is a complex, serious and stigmatizing
disease often affecting people from vulnerable populations. Current epi-
demics also include TB, a growing burden of non-communicable diseases
(NCDs) (such as cardiovascular disease, diabetes, kidney disease, chronic
respiratory illnesses and cancer); poverty-related illnesses (e.g., neonatal,
perinatal, childhood and maternal diseases such as diarrhoea and malnu-
trition); as well as premature death and disability due to violence and
injury (Coovadia et al. 2009; Mayosi et al. 2012; Rispel et al. 2016).
Even though South Africa has the highest health expenditure of all the
developing countries, its healthcare outcomes are considered to be worse
than some lower-income countries (Global Health Initiative Strategy
2011). These current realities suggest that existing models of care are not
 A Backdrop to Health Care in South Africa 29

effectively addressing healthcare burdens, and a state of what might be

described as ‘organizational shock’ has emerged (to use Van de Ven et al.’s
(1999) term) resulting from the rapid and profound changes in the sys-
tem, including demographic diversity, political instability and the chal-
lenges of implementing new health policy. Others have described public
hospitals in South Africa as ‘stressed institutions’ (von Holdt and Murphy
2007) where there is lack of continuity of care and a huge loss to follow
up, particularly in chronic illness.
In an attempt to address past imbalances, the government has initiated
various health reforms with the goal of achieving equitable access to
health care. However, much work remains in addressing the ‘two-class’
nature of the health system comprising “a weak public sector that caters
‘second-class’ services to that majority of the population dependent upon
the state, and a strong private health sector providing ‘first-class’ services
for the wealthy and insured minority” (van Rensburg and Ngwena 2001,
p. 378). A response to the two-tiered South African health system is a
National Health Insurance (NHI) system which aims to promote more
equitable and effective healthcare services—a goal yet to be achieved.
Many South African patients thus continue to experience numerous
potential barriers to accessing the healthcare system, interacting with
health professionals or even adhering to treatment regimens.
Documented too are a general lack of agency in individuals, and a lack
of assertiveness and knowledge about patient rights. As noted by Ellis
(2004, p. 44), “in the past many patients’ initiative was taken away from
them by the apartheid regime which invaded communication in all
aspects of South African life, including the health care worker-patient
relationship.” Cultural norms of politeness and deference to the authority
of the health professional also mean that patients are often passive partici-
pants in healthcare interactions. For many individuals, the Western
biomedical healthcare framework operates alongside an established
centuries-old system of traditional medicine (Herselman 2007). Some
patients may utilize traditional medicine or western biomedicine only,
while others may seek treatment from both systems (a practice known as
dual consultation). Healers have great status, authority and influence
within communities and patients may thus refrain from explicitly ques-
tioning a health professional.
30 2 The Context of Health Communication: Global, Local...

Disease Profile
Communicable diseases (CDs) (e.g., HIV and TB) and NCDs (e.g., dia-
betes mellitus (DM) and hypertension) have been identified by the
Department of Health in South Africa as key areas of focus (Mayosi and
Benatar 2014). Further, more attention is being paid to the rise of NCD
and CD co-infection. Co-morbidities burden the healthcare system and
have adverse effects on clinical manifestations, treatment complexity and
patient prognosis (Bates et al. 2015).

HIV/AIDS in South Africa

Over the past few decades, HIV/AIDS has spread with astounding rapid-
ity. The impact of this epidemic has been particularly high in Eastern and
Southern Africa where there are approximately 19 million people living
with HIV and AIDS. This disease has become one of the most important
public health problems in South Africa and has created more challenges
to science and medicine than any other single disease. South Africa has
the largest HIV/AIDS epidemic in the world with an estimated seven
million people living with HIV. As of 2015, the adult prevalence rate is
19.2% and about 29% of all pregnant women in the country have HIV/
AIDS. Thus, while the country is home to 1% of world population, it
carries 19% of the global health burden. More than half of all HIV cases
involve children and it has become a disease of women living in poverty.
The majority of new infections are in women, with a female to male
prevalence ratio of 1:5. The life expectancy for women in the country is
now 64.3 years. It is estimated that four million women aged 15 and
older are living with the disease, and that there are now over 240,000
children younger than 15 years living with HIV in South Africa. Globally,
there are about 5700 new cases of HIV infections per day in both adults
and children, 400 of which are among children. Of these new cases of
HIV infections per day, 66% are in sub-Saharan Africa (Statistics South
Africa 2016; UNAIDS 2016a).
As a consequence of government policy, there was a delay in the intro-
duction of ARV drugs in South Africa in the public sector. The rollout
 Disease Profile 31

was finally approved in April 2004, amidst much controversy and a strug-
gle for accessibility (Nattrass 2006), and South Africa currently has the
largest ARV treatment programme globally. Since then, there have been
decreased mortality rates, a significant increase in adult life expectancy, a
huge reduction in mother-to-child transmission and hope for many.
Voluntary counselling and testing (VCT) and ARV treatment pro-
grammes are now freely available (UNAIDS 2016b).
Importantly, however, these programmes are not necessarily accessed
by people living with HIV/AIDS (Plazy et al. 2015). There remain barri-
ers to care which are felt to link mainly to psychosocial variables. The
demographic profile, the complexities of treatment and the envelope of
stigma which surround the disease present a particular challenge to the
health practitioner (Castro and Farmer 2005). Issues of disclosure, gen-
der inequalities, gender-based violence, poverty, culture and tradition all
impinge on access to ARVs. Uptake of VCT is low in some contexts;
there is often a significant drop-out rate from Prevention of Mother-To-
Child Transmission (PMTCT) services and no apparent decline in new
infections in pregnant women, although the epidemic has stabilized
(Meyers et al. 2007; Woldesenbet et al. 2015). Staying alive depends on
maintaining high adherence rates to antiretroviral therapy (ART)
(75–95%) in order to promote treatment success. Treatment regimens
are sometimes complex (especially in the case of combination therapy or
highly active antiretroviral therapy (HAART)) and patients are burdened
by the cost of transport, food, supplemental medicines, herbal remedies
and hospital fees associated with the disease (Rosen et al. 2007).
There are a number of things about this epidemic that we still don’t
understand well. Despite huge campaigns about prevention, there seems
to be limited efficacy to these programmes. Prevention works, but only a
little. There is also a mystery as to why some patients achieve poor adher-
ence, but this issue is clearly a complex one and linked to a number of
variables. Some of these may include the influence of poverty, poor
­literacy levels, stigma, discrimination and the discourse of silence that
surrounds this disease, access to treatment, migration, suspicion around
efficacy of ARVs, intergenerational conflicts, marginalization, sex prac-
tices, the role of disability grants, the role of traditional healers in these
issues, and religion and its interface with both biomedical and traditional
Another random document with
no related content on Scribd:
 CHRISTOPHE

était bien le peuple qui se dévoue, qui

se bat, et qui se laisse tromper.
CATHERINE DE MÉDICIS.

L’inconnu, assis sur un banc et enveloppé dans sa cape,

appartenait évidemment à la classe la plus élevée de la société. La
finesse de son linge, la coupe, l’étoffe et l’odeur de ses vêtements, la
façon et la peau de ses gants indiquaient un homme de cour, de
même que sa pose, sa fierté, son calme et son coup d’œil
indiquaient l’homme de guerre. Son aspect inquiétait d’abord et
disposait au respect. On respecte un homme qui se respecte lui-
même. Petit et bossu, ses manières réparaient en un moment les
désavantages de sa taille. Une fois la glace rompue, il avait la gaieté
de la décision, et un entrain indéfinissable qui le rendait aimable. Il
avait les yeux bleus, le nez courbe de la maison de Navarre, et la
coupe espagnole de cette figure si accentuée, qui devait être le type
des rois Bourbons.
En trois mots, la scène prit un intérêt immense.
—Eh! bien, dit Chaudieu au moment où le jeune Lecamus
acheva sa phrase, ce batelier est la Renaudie, et voici monseigneur
le prince de Condé, ajouta-t-il en montrant le petit bossu.
Ainsi ces quatre hommes représentaient la foi du Peuple,
l’intelligence de la Parole, la Main du soldat et la Royauté cachée
dans l’ombre.
—Vous allez savoir ce que nous attendons de vous, reprit le
ministre après une pause laissée à l’étonnement du jeune Lecamus.
Afin que vous ne commettiez point d’erreur, nous sommes forcés de
vous initier aux plus importants secrets de la Réformation.
Le prince et la Renaudie continuèrent la parole du ministre par un
geste, après qu’il se fut tu pour laisser le prince parler lui-même, s’il
le voulait. Comme tous les grands engagés en des complots, et qui
ont pour système de ne se montrer qu’au moment décisif, le prince
garda le silence, non par couardise: dans ces conjonctures, il fut
l’âme de la conspiration, ne recula devant aucun danger et risqua sa
tête; mais par une sorte de dignité royale, il abandonna l’explication
de cette entreprise au ministre, et se contenta d’étudier le nouvel
instrument dont il fallait se servir.
—Mon enfant, dit Chaudieu, dans le langage des Huguenots,
nous allons livrer à la Prostituée romaine une première bataille.
Dans quelques jours, nos milices mourront sur des échafauds, ou
les Guise seront morts. Bientôt donc le roi et les deux reines seront
en notre pouvoir. Voici la première prise d’armes de notre Religion
en France, et la France ne les déposera qu’après avoir tout conquis:
il s’agit de la Nation, voyez-vous, et non du Royaume. La plupart des
grands du royaume voient où veulent en venir le cardinal de Lorraine
et le duc son frère. Sous le prétexte de défendre la Religion
Catholique, la maison de Lorraine veut réclamer la couronne de
France comme son patrimoine. Appuyée sur l’Église, elle s’en est
fait une alliée formidable, elle a les moines pour soutiens, pour
acolytes, pour espions. Elle s’érige en tutrice du trône qu’elle veut
usurper, en protectrice de la maison de Valois qu’elle veut anéantir.
Si nous nous décidons à nous lever en armes, c’est qu’il s’agit à la
fois des libertés du peuple et des intérêts de la noblesse également
menacés. Étouffons à son début une faction aussi odieuse que celle
des Bourguignons qui jadis ont mis Paris et la France à feu et à
sang. Il a fallu un Louis XI pour finir la querelle des Bourguignons et
de la Couronne; mais aujourd’hui un prince de Condé saura
empêcher les Lorrains de recommencer. Ce n’est pas une guerre
civile, mais un duel entre les Guise et la Réformation, un duel à
mort: nous ferons tomber leurs têtes, ou ils feront tomber les nôtres.
—Bien dit! s’écria le prince.
—Dans ces conjonctures, Christophe, reprit la Renaudie, nous
ne voulons rien négliger pour grossir notre parti, car il y a un parti
dans la Réformation, le parti des intérêts froissés, des nobles
sacrifiés aux Lorrains, des vieux capitaines indignement joués à
Fontainebleau d’où le cardinal les a bannis en faisant planter des
potences pour y accrocher ceux qui demandaient au roi l’argent de
leurs montres et les payes arriérées.
—Voilà, mon enfant, reprit Chaudieu remarquant une sorte
d’effroi chez Christophe, voilà ce qui nous oblige à triompher par les
armes au lieu de triompher par la conviction et par le martyre. La
reine-mère est sur le point d’entrer dans nos vues, non qu’elle veuille
abjurer, elle n’en est pas là, mais elle y sera peut-être forcée par
notre triomphe. Quoi qu’il en soit, humiliée et désespérée de voir
passer entre les mains des Guise la puissance qu’elle espérait
exercer après la mort du roi, effrayée de l’empire que prend la jeune
reine Marie, nièce des Lorrains et leur auxiliaire, la reine Catherine
doit être disposée à prêter son appui aux princes et aux seigneurs
qui vont tenter un coup de main pour la délivrer. En ce moment,
quoique dévouée aux Guise en apparence, elle les hait, elle
souhaite leur perte et se servira de nous contre eux; mais
Monseigneur se servira d’elle contre tous. La reine-mère donnera
son consentement à nos plans. Nous aurons pour nous le
connétable, que Monseigneur vient d’aller voir à Chantilly, mais qui
ne veut bouger que sur un ordre de ses maîtres. Oncle de
Monseigneur, il ne le laissera jamais dans l’embarras, et ce
généreux prince n’hésite pas à se jeter dans le danger pour décider
Anne de Montmorency. Tout est prêt, et nous avons jeté les yeux sur
vous pour communiquer à la reine Catherine notre traité d’alliance,
les projets d’édits et les bases du nouveau gouvernement. La cour
est à Blois. Beaucoup des nôtres y sont; mais ceux-là sont nos
futurs chefs... Et, comme Monseigneur, dit-il en montrant le prince,
ils ne doivent jamais être soupçonnés: nous devons nous sacrifier
tous pour eux. La reine-mère et nos amis sont l’objet d’une
surveillance si minutieuse, qu’il est impossible d’employer pour
intermédiaire une personne connue ou de quelque importance, elle
serait incontinent soupçonnée et ne pourrait communiquer avec
madame Catherine. Dieu nous doit en ce moment le berger David et
sa fronde pour attaquer Goliath de Guise. Votre père,
malheureusement pour lui bon catholique, est le pelletier des deux
reines, il a toujours à leur fournir quelque ajustement, obtenez qu’il
vous envoie à la cour. Vous n’éveillerez point les soupçons et ne
compromettrez en rien la reine Catherine. Tous nos chefs peuvent
payer de leur tête une imprudence qui laisserait croire à la
connivence de la reine-mère avec eux. Là où les grands, une fois
pris, donnent l’éveil, un petit comme vous est sans conséquence.
Voyez! les Guise ont tant d’espions que nous n’avons eu que la
rivière pour pouvoir causer sans crainte. Vous voilà, mon fils, comme
la sentinelle obligée de mourir à son poste. Sachez-le! si vous êtes
surpris, nous vous abandonnons tous, nous jetterons sur vous, s’il le
faut, l’opprobre et l’infamie. Nous dirons au besoin que vous êtes
une créature des Guise à laquelle ils font jouer ce rôle pour nous
perdre. Ainsi nous vous demandons un sacrifice entier.
—Si vous périssez, dit le prince de Condé, je vous engage ma foi
de gentilhomme que votre famille sera sacrée pour la maison de
Navarre: je la porterai dans mon cœur et la servirai en toute chose.
 —Cette parole, mon prince, suffit déjà, reprit Christophe sans
songer que ce factieux était un Gascon. Nous sommes dans un
temps où chacun, prince ou bourgeois, doit faire son devoir.
—Voilà un vrai Huguenot! Si tous nos hommes étaient ainsi, dit la
Renaudie en posant une main sur l’épaule de Christophe, nous
serions demain les maîtres.
—Jeune homme, reprit le prince, j’ai voulu vous montrer que si
Chaudieu prêche, si le gentilhomme est armé, le prince se bat. Ainsi
dans cette chaude partie tous les enjeux se valent.
—Écoutez, dit la Renaudie, je ne vous remettrai les papiers qu’à
Beaugency, car il ne faut pas les compromettre pendant tout le
voyage. Vous me trouverez sur le port: ma figure, ma voix, mes
vêtements seront si changés, que vous ne pourrez me reconnaître.
Mais je vous dirai: Vous êtes un guêpin? et vous me répondrez: Prêt
à servir. Quant à l’exécution, voici les moyens. Vous trouverez un
cheval à la Pinte-Fleurie, proche Saint-Germain-l’Auxerrois. Vous y
demanderez Jean-le-Breton, qui vous mènera à l’écurie, et vous
donnera l’un de mes bidets connu pour faire ses trente lieues en huit
heures. Sortez par la porte de Bussy, Breton a une passe pour moi,
prenez-la pour vous, et filez en faisant le tour des villes. Vous
pourrez ainsi arriver au petit jour à Orléans.
—Et le cheval? dit le jeune Lecamus.
—Il ne crèvera pas avant Orléans, reprit la Renaudie. Laissez-le
avant l’entrée du faubourg Bannier, car les portes sont bien gardées,
il ne faut pas éveiller les soupçons. A vous, l’ami, à bien jouer votre
rôle. Vous inventerez la fable qui vous paraîtra la meilleure pour
arriver à la troisième maison à gauche en entrant dans Orléans; elle
appartient à un certain Tourillon, gantier. Vous frapperez trois coups
à la porte en criant:—Service de messieurs de Guise! L’homme est
en apparence un guisard enragé, mais il n’y a que nous quatre qui le
sachions des nôtres; il vous donnera un batelier dévoué, un autre
guisard de sa trempe, bien entendu. Descendez incontinent au port,
vous vous y embarquerez sur un bateau peint en vert et bordé de
blanc. Vous aborderez sans doute à Beaugency demain matin à
midi. Là, je vous ferai trouver une barque sur laquelle vous
descendrez à Blois sans courir de dangers. Nos ennemis les Guise
ne gardent pas la Loire, mais seulement les ports. Ainsi, vous
pourrez voir la reine dans la journée ou le lendemain.
—Vos paroles sont gravées là, dit Christophe en montrant son
front.
Chaudieu embrassa son enfant avec une singulière effusion
religieuse, il en était fier.
—Dieu veille sur toi! dit-il en montrant le couchant qui rougissait
les vieux toits couverts en bardeau et qui glissait ses lueurs à travers
la forêt de poutres où bouillonnaient les eaux.
—Vous êtes de la race du vieux Jacques Bonhomme! dit la
Renaudie à Christophe en lui serrant la main.
—Nous nous reverrons, monsieur, lui dit le prince en faisant un
geste d’une grâce infinie et où il y avait presque de l’amitié.
D’un coup de rame, la Renaudie mit le jeune conspirateur sur
une marche de l’escalier qui conduisait dans la maison, et la barque
disparut aussitôt sous les arches du Pont-au-Change.
Christophe secoua la grille en fer qui fermait l’escalier sur la
rivière et cria; mademoiselle Lecamus l’entendit, ouvrit une des
croisées de l’arrière-boutique et lui demanda comment il se trouvait
là. Christophe répondit qu’il gelait et qu’il fallait d’abord le faire
entrer.
—Notre maître, dit la Bourguignonne, vous êtes sorti par la porte
de la rue, et vous revenez par celle de l’eau? Votre père va joliment
se fâcher.
Christophe, étourdi par une confidence qui venait de le mettre en
rapport avec le prince de Condé, la Renaudie, Chaudieu, et encore
plus ému du spectacle anticipé d’une guerre civile imminente, ne
répondit rien, il monta précipitamment de la cuisine à l’arrière-
boutique; mais en le voyant, sa mère, vieille catholique enragée, ne
put retenir sa colère.
—Je gage que les trois hommes avec lesquels tu causais là sont
des Réf... demanda-t-elle.
 —Tais-toi, ma femme, dit aussitôt le prudent vieillard en cheveux
blancs qui feuilletait un gros livre.—Grands fainéants, reprit-il en
s’adressant à trois jeunes garçons qui depuis longtemps avaient fini
leur souper, qu’attendez-vous pour aller dormir? Il est huit heures, il
faudra vous lever à cinq heures du matin. Vous avez d’ailleurs à
porter chez le président de Thou son mortier et sa robe. Allez-y tous
trois en prenant vos bâtons et vos rapières. Si vous rencontrez des
vauriens comme vous, au moins serez-vous en force.
—Faut-il aussi porter le surcot d’hermine que la jeune reine a
demandé, et qui doit être remis à l’hôtel de Soissons où il y a un
exprès pour Blois et pour la reine-mère? demanda l’un des commis.
—Non, dit le syndic, le compte de la reine Catherine se monte à
trois mille écus, il faudrait bien finir par les avoir, je compte aller à
Blois.
—Mon père, je ne souffrirai pas qu’à votre âge et par le temps
qui court, vous vous exposiez par les chemins. J’ai vingt-deux ans,
vous pouvez m’employer à ceci, dit Christophe en lorgnant une boîte
où devait être le surcot.
—Êtes-vous soudés au banc? cria le vieillard aux apprentis qui
soudain prirent leurs rapières, leurs manteaux et la fourrure de
monsieur de Thou.
Le lendemain, le Parlement recevait au palais, comme président,
cet homme illustre qui, après avoir signé l’arrêt de mort du conseiller
du Bourg, devait, avant la fin de l’année, avoir à juger le prince de
Condé.
—La Bourguignonne, dit le vieillard, allez demander à mon
compère Lallier s’il veut venir souper avec nous en fournissant le vin,
nous donnerons la fripe, dites-lui surtout d’amener sa fille.
Le syndic du corps des pelletiers était un beau vieillard de
soixante ans, à cheveux blancs, à front large et découvert. Fourreur
de la cour depuis quarante ans, il avait vu toutes les révolutions du
règne de François Ier, et s’était tenu dans sa patente royale malgré
les rivalités de femmes. Il avait été témoin de l’arrivée à la cour de la
jeune Catherine de Médicis à peine âgée de quinze ans; il l’avait
observée pliant sous la duchesse d’Étampes, la maîtresse de son
beau-père, pliant sous la duchesse de Valentinois, maîtresse de son
mari, le feu roi. Mais le pelletier s’était bien tiré de ces phases
étranges, où les marchands de la cour avaient été si souvent
enveloppés dans la disgrâce des maîtresses. Sa prudence égalait sa
fortune. Il demeurait dans une excessive humilité. Jamais l’orgueil ne
l’avait pris en ses piéges. Ce marchand se faisait si petit, si doux, si
complaisant, si pauvre à la cour, devant les princesses, les reines et
les favorites, que cette modestie et sa bonhomie avaient conservé
l’enseigne de sa maison. Une semblable politique annonçait
nécessairement un homme fin et perspicace. Autant il paraissait
humble au dehors, autant il devenait despote au logis; il était absolu
chez lui. Très-honoré par ses confrères, il devait à la longue
possession de la première place dans son commerce une immense
considération. Il rendait d’ailleurs volontiers service, et parmi ceux
qu’il avait rendus, un des plus éclatants était certes l’assistance qu’il
prêta longtemps au plus fameux chirurgien du seizième siècle,
Ambroise Paré, qui lui devait d’avoir pu se livrer à ses études. Dans
toutes les difficultés qui survenaient entre marchands, Lecamus se
montrait conciliant. Aussi l’estime générale consolidait-elle sa
position parmi ses égaux, comme son caractère d’emprunt le
maintenait en faveur à la cour. Après avoir brigué par politique dans
sa paroisse les honneurs de la fabrique, il faisait le nécessaire pour
se conserver en bonne odeur de sainteté près du curé de Saint-
Pierre-aux-Bœufs, qui le regardait comme un des hommes de Paris
les plus dévoués à la religion catholique. Aussi, lors de la
convocation des États-généraux, fut-il nommé tout d’une voix pour
représenter le tiers-état par l’influence des curés de Paris qui dans
ce temps était immense. Ce vieillard était un de ces sourds et
profonds ambitieux qui se courbent pendant cinquante ans devant
chacun, en se glissant de poste en poste, sans qu’on sache
comment ils sont arrivés, mais qui se trouvent assis et au repos là
où jamais personne, même parmi les plus audacieux, n’aurait osé
s’avouer un pareil but au commencement de la vie: tant était forte la
distance, tant d’abîmes étaient à franchir et où l’on devait rouler!
Lecamus, qui avait une immense fortune cachée, ne voulait courir
aucun péril et préparait un brillant avenir à son fils. Au lieu d’avoir
cette ambition personnelle qui souvent sacrifie l’avenir au présent, il
avait l’ambition de famille, sentiment perdu de nos jours, étouffé par
la sotte disposition de nos lois sur les successions. Lecamus se
voyait premier président au parlement de Paris dans la personne de
son petit-fils.
Christophe, filleul du fameux de Thou l’historien, avait reçu la
plus solide éducation; mais elle l’avait conduit au doute et à
l’examen qui gagnait les étudiants et les Facultés de l’Université.
Christophe faisait en ce moment ses études pour débuter au
barreau, ce premier degré de la magistrature. Le vieux pelletier
jouait l’hésitation à propos de son fils: il paraissait tantôt vouloir faire
de Christophe son successeur, tantôt en faire un avocat; mais
sérieusement il ambitionnait pour ce fils une place de conseiller au
parlement. Ce marchand voulait mettre la famille Lecamus au rang
de ces vieilles et célèbres familles de bourgeoisie parisienne d’où
sortirent les Pasquier, les Molé, les Miron, les Séguier, Lamoignon,
du Tillet, Lecoigneux, Lescalopier, les Goix, les Arnauld, les fameux
échevins et les grands prévôts des marchands parmi lesquels le
trône trouva tant de défenseurs. Aussi, pour que Christophe pût
soutenir un jour son rang, voulait-il le marier à la fille du plus riche
orfévre de la Cité, son compère Lallier, dont le neveu devait
présenter à Henri IV les clefs de Paris. Le dessein le plus
profondément enfoncé dans le cœur de ce bourgeois était
d’employer la moitié de sa fortune et la moitié de celle de l’orfévre à
l’acquisition d’une grande et belle terre seigneuriale, affaire longue et
difficile en ce temps. Mais ce profond politique connaissait trop bien
son temps pour ignorer les grands mouvements qui se préparaient: il
voyait bien et voyait juste, en prévoyant la division du royaume en
deux camps. Les supplices inutiles de la place de l’Estrapade,
l’exécution du couturier de Henri II, celle plus récente du conseiller
Anne du Bourg, la connivence actuelle des grands seigneurs, celle
d’une favorite, sous le règne de François Ier, avec les Réformés,
étaient de terribles indices. Le pelletier avait résolu de rester, quoi
qu’il arrivât, catholique, royaliste et parlementaire; mais il lui
convenait, in petto, que son fils appartînt à la Réformation. Il se
savait assez riche pour racheter Christophe s’il était par trop
compromis; puis si la France devenait calviniste, son fils pouvait
sauver sa famille, dans une de ces furieuses émeutes parisiennes
dont le souvenir vivait dans la bourgeoisie, et qu’elle devait
recommencer pendant quatre règnes. Mais ces pensées, de même
que Louis XI, le vieux pelletier ne se les disait pas à lui-même, sa
profondeur allait jusqu’à tromper sa femme et son fils. Ce grave
personnage était depuis longtemps le chef du plus riche, du plus
populeux quartier de Paris, celui du centre, sous le titre de
quartenier qui devait devenir si célèbre quinze ans plus tard. Vêtu de
drap comme tous les bourgeois prudents qui obéissaient aux
ordonnances somptuaires, le sieur Lecamus (il tenait à ce titre
accordé par Charles V aux bourgeois de Paris, et qui leur permettait
d’acheter des seigneuries et d’appeler leurs femmes du beau nom
de Demoiselle), n’avait ni chaîne d’or, ni soie, mais un bon pourpoint
à gros boutons d’argent noircis, des chausses drapées montant au-
dessus du genou, et des souliers de cuirs agrafés. Sa chemise de
fine toile sortait en gros bouillons, selon la mode du temps, par sa
veste entr’ouverte et son haut-de-chausses. Quoique la belle et
large figure de ce vieillard reçût toute la clarté de la lampe, il fut alors
impossible à Christophe de deviner les pensées ensevelies sous la
riche carnation hollandaise de son vieux père; mais il comprit
néanmoins tout le parti que le vieillard voulait tirer de son affection
pour la jolie Babette Lallier. Aussi, en homme qui avait pris sa
résolution, Christophe sourit-il amèrement en entendant inviter sa
future.
Quand la Bourguignonne fut partie avec les apprentis, le vieux
Lecamus regarda sa femme en laissant voir alors tout son caractère
ferme et absolu.
—Tu ne seras pas contente que tu n’aies fait pendre cet enfant,
avec ta damnée langue? lui dit-il d’une voix sévère.
—Je l’aimerais mieux justicié mais sauvé, que vivant et
Huguenot, dit-elle d’un air sombre. Penser qu’un enfant qui a logé
neuf mois dans mes entrailles n’est pas bon catholique et mange de
la vache à Colas, qu’il ira en enfer pour l’éternité!
Elle se mit à pleurer.
 —Vieille bête, lui dit le pelletier, laisse-le donc vivre, quand ce ne
serait que pour le convertir! Tu as dit, devant nos apprentis, un mot
qui peut faire bouter le feu à notre maison et nous faire cuire tous
comme des puces dans les paillasses.
La mère se signa, s’assit et resta muette.
—Or çà, toi, dit le bonhomme en jetant un regard de juge à son
fils, explique-moi ce que tu faisais là sur l’eau avec... Viens ici que je
te parle, dit-il en empoignant son fils par le bras et l’attirant à lui...
avec le prince de Condé, souffla-t-il dans l’oreille de Christophe qui
tressaillit.—Crois-tu que le pelletier de la cour n’en connaisse pas
toutes les figures? Et crois-tu que j’ignore ce qui se passe?
Monseigneur le Grand-Maître a donné l’ordre d’amener des troupes
à Amboise. Retirer des troupes de Paris et les envoyer à Amboise,
quand la cour est à Blois, les faire aller par Chartres et Vendôme, au
lieu de prendre la route d’Orléans, est-ce clair? il va y avoir des
troubles. Si les reines veulent leurs surcots, elles les enverront
chercher. Le prince de Condé a peut-être résolu de tuer messieurs
de Guise qui, de leur côté, pensent peut-être à se défaire de lui. Le
prince se servira des Huguenots pour se défendre. A quoi servirait le
fils d’un pelletier dans cette bagarre? Quand tu seras marié, quand
tu seras avocat en parlement, tu seras tout aussi prudent que ton
père. Pour être de la nouvelle religion, le fils d’un pelletier doit
attendre que tout le monde en soit. Je ne condamne pas les
réformateurs, ce n’est pas mon métier; mais la cour est catholique,
les deux reines sont catholiques, le Parlement est catholique; nous
les fournissons, nous devons être catholiques. Tu ne sortiras pas
d’ici, Christophe, ou je te mets chez le président de Thou, ton
parrain, qui te gardera près de lui nuit et jour et te fera noircir du
papier au lieu de te laisser noircir l’âme en la cuisine de ces damnés
Genevois.
—Mon père, dit Christophe en s’appuyant sur le dos de la chaise
où était le vieillard, envoyez-moi donc à Blois porter le surcot à la
reine Marie et réclamer notre argent de la reine-mère, sans cela, je
suis perdu! et vous tenez à moi.
 —Perdu? reprit le vieillard sans manifester le moindre
étonnement. Si tu restes ici, tu ne seras point perdu, je te retrouverai
toujours.
—On m’y tuera.
—Comment?
—Les plus ardents des Huguenots ont jeté les yeux sur moi pour
les servir en quelque chose, et si je manque à faire ce que je viens
de promettre, ils me tueront en plein jour, dans la rue, ici, comme on
a tué Minard. Mais si vous m’envoyez à la cour pour vos affaires,
peut-être pourrai-je me justifier également bien des deux côtés. Ou
je réussirai sans avoir couru aucun danger et saurai conquérir ainsi
une belle place dans le parti, ou si le danger est trop grand, je ne
ferai que vos affaires.
Le père se leva comme si son fauteuil eût été de fer rougi.
—Ma femme, dit-il, laisse-nous, et veille à ce que nous soyons
bien seuls, Christophe et moi.
Quand mademoiselle Lecamus fut sortie, le pelletier prit son fils
par un bouton et l’emmena dans le coin de la salle qui faisait
l’encoignure du pont.
—Christophe, lui dit-il dans le tuyau de l’oreille comme quand il
venait de lui parler du prince de Condé, sois Huguenot, si tu as ce
vice-là, mais sois-le avec prudence, au fond du cœur et non de
manière à te faire montrer au doigt dans le quartier. Ce que tu viens
de m’avouer me prouve combien les chefs ont confiance en toi. Que
vas-tu donc faire à la cour?
—Je ne saurais vous le dire, répondit Christophe, je ne le sais
pas encore bien moi-même.
—Hum! hum! fit le vieillard en regardant son fils, le drôle veut
trupher son père, il ira loin.—Or çà, reprit-il à voix basse, tu ne vas
pas à la cour pour porter des avances à messieurs de Guise ni au
petit roi notre maître, ni à la petite reine Marie. Tous ces cœurs-là
sont catholiques; mais je jurerais bien que l’Italienne a quelque
chose contre l’Écossaise et contre les Lorrains, je la connais: elle
avait une furieuse envie de mettre la main à la pâte! le feu roi la
craignait si bien qu’il a fait comme les orfévres, il a usé le diamant
par le diamant, une femme par une autre. De là, cette haine de la
reine Catherine contre la pauvre duchesse de Valentinois, à qui elle
a pris le beau château de Chenonceaux. Sans monsieur le
connétable, la duchesse était pour le moins étranglée... Arrière, mon
fils, ne te mets pas entre les mains de cette Italienne qui n’a de
passion que dans la cervelle: mauvaise espèce de femme! Oui, ce
qu’on t’envoie faire à la cour te causera peut-être un grand mal de
tête, s’écria le père en voyant Christophe prêt à répondre. Mon
enfant, j’ai des projets pour ton avenir, tu ne les dérangerais pas en
te rendant utile à la reine Catherine; mais, Jésus! ne risque point ta
tête! et ces messieurs de Guise la couperaient comme la
Bourguignonne coupe un navet, car les gens qui t’emploient te
désavoueront entièrement.
—Je le sais, mon père, dit Christophe.
—Es-tu donc aussi fort que cela? Tu le sais et tu te risques!
—Oui, mon père.
—Ventre de loup-cervier, s’écria le père qui serra son fils dans
ses bras, nous pourrons nous entendre: tu es digne de ton père.
Mon enfant, tu seras l’honneur de la famille, et je vois que ton vieux
père peut s’expliquer avec toi. Mais ne sois pas plus Huguenot que
messieurs de Coligny. Ne tire pas l’épée, tu seras homme de plume,
reste dans ton futur rôle de robin. Allons, ne me dis rien qu’après la
réussite. Si tu ne m’as rien fait savoir quatre jours après ton arrivée à
Blois, ce silence me dira que tu seras en danger. Le vieillard ira
sauver le jeune homme. Je n’ai pas vendu pendant trente-deux ans
des fourrures sans connaître l’envers des robes de cour. J’aurai de
quoi me faire ouvrir les portes.
Christophe ouvrait de grands yeux en entendant son père parler
ainsi, mais il craignit quelque piége paternel et garda le silence.
—Eh! bien, faites le compte, écrivez une lettre à la reine, je veux
partir à l’instant, sans quoi les plus grands malheurs arriveraient.
—Partir! Mais comment?
 —J’achèterai un cheval. Écrivez, au nom de Dieu!
—Hé! la mère? de l’argent à ton fils, cria le pelletier à sa femme.
La mère rentra, courut à son bahut et donna une bourse à
Christophe, qui, tout ému, l’embrassa.
—Le compte était tout prêt, dit son père, le voici. Je vais écrire la
lettre.
Christophe prit le compte et le mit dans sa poche.
—Mais tu souperas au moins avec nous, dit le bonhomme. Dans
ces extrémités, il faut échanger vos anneaux, la fille à Lallier et toi.
—Eh! bien, je vais l’aller querir, s’écria Christophe.
Le jeune homme se défia des incertitudes de son père dont le
caractère ne lui était pas encore assez connu; il monta dans sa
chambre, s’habilla, prit une valise, descendit à pas de loup, la posa
sur un comptoir de la boutique, ainsi que sa rapière et son manteau.
—Que diable fais-tu? lui dit son père en l’entendant.
Christophe vint baiser le vieillard sur les deux joues.
—Je ne veux pas qu’on voie mes apprêts de départ, j’ai tout mis
sous un comptoir, lui répondit-il à l’oreille.
—Voici la lettre, dit le père.
Christophe prit le papier et sortit comme pour aller chercher la
jeune voisine.
Quelques instants après le départ de Christophe, le compère
Lallier et sa fille arrivèrent, précédés d’une servante qui apportait
trois bouteilles de vin vieux.
—Hé! bien, où est Christophe? dirent les deux vieilles gens.
—Christophe? s’écria Babette, nous ne l’avons pas vu.
—Mon fils est un fier drôle! il me trompe comme si je n’avais pas
de barbe. Mon compère, que va-t-il arriver? Nous vivons dans un
temps où les enfants ont plus d’esprit que les pères.
 —Mais il y a longtemps que tout le quartier en fait un mangeur de
vache à Colas, dit Lallier.
—Défendez-le sur ce point, compère, dit le pelletier à l’orfévre, la
jeunesse est folle, elle court après les choses neuves; mais Babette
le fera tenir tranquille, elle est encore plus neuve que Calvin.
Babette sourit; elle aimait Christophe et s’offensait de tout ce que
l’on disait contre lui. C’était une de ces filles de la vieille bourgeoisie,
élevée sous les yeux de sa mère qui ne l’avait pas quittée: son
maintien était doux, correct comme son visage; elle était vêtue en
étoffes de laine de couleurs grises et harmonieuses; sa gorgerette,
simplement plissée, tranchait par sa blancheur sur ses vêtements;
elle avait un bonnet de velours brun qui ressemblait beaucoup à un
béguin d’enfant; mais il était orné de ruches et de barbes en gaze
tannée, ou autrement couleur de tan, qui descendaient de chaque
côté de sa figure. Quoique blonde et blanche comme une blonde,
elle paraissait rusée, fine, tout en essayant de cacher sa malice sous
l’air d’une fille honnêtement éduquée. Tant que les deux servantes
allèrent et vinrent en mettant la nappe, les brocs, les grands plats
d’étain et les couverts, l’orfévre et sa fille, le pelletier et sa femme,
restèrent devant la haute cheminée à lambrequins de serge rouge
bordée de franges noires, disant des riens. Babette avait beau
demander où pouvait être Christophe, la mère et le père du jeune
Huguenot donnaient des réponses évasives; mais quand les deux
familles furent attablées, et que les deux servantes furent à la
cuisine, Lecamus dit à sa future belle-fille:—Christophe est parti pour
la cour.
—A Blois! faire un pareil voyage sans m’avoir dit adieu! dit-elle.
—L’affaire était pressée, dit la vieille mère.
—Mon compère, dit le pelletier en reprenant la conversation
abandonnée, nous allons avoir du grabuge en France: les Réformés
se remuent.
—S’ils triomphent, ce ne sera qu’après de grosses guerres
pendant lesquelles le commerce ira mal, dit Lallier incapable de
s’élever plus haut que la sphère commerciale.
 —Mon père, qui a vu la fin des guerres entre les Bourguignons et
les Armagnacs, m’a dit que notre famille ne s’en serait pas sauvée si
l’un de ses grands-pères, le père de sa mère, n’avait pas été un
Goix, l’un de ces fameux bouchers de la Halle qui tenaient pour les
Bourguignons, tandis que l’autre, un Lecamus, était du parti des
Armagnacs; ils paraissaient vouloir s’arracher la peau devant le
monde, mais ils s’entendaient en famille. Ainsi, tâchons de sauver
Christophe, peut-être dans l’occasion nous sauvera-t-il.
—Vous êtes un fin matois, compère, dit l’orfévre.
—Non! répondit Lecamus. La bourgeoisie doit penser à elle, le
peuple et la noblesse lui en veulent également. La bourgeoisie
parisienne donne des craintes à tout le monde, excepté au roi qui la
sait son amie.
—Vous qui êtes si savant et qui avez tant vu de choses,
demanda timidement Babette, expliquez-moi donc ce que veulent
les Réformés.
—Dites-nous ça, compère, s’écria l’orfévre. Je connaissais le
couturier du feu roi et le tenais pour un homme de mœurs simples,
sans grand génie; il était quasi comme vous, on lui eût baillé Dieu
sans confession, et cependant il trempait au fond de cette religion
nouvelle, lui! un homme dont les deux oreilles valaient quelque cent
mille écus. Il devait donc avoir des secrets à révéler pour que le roi
et la duchesse de Valentinois aient assisté à sa torture.
—Et de terribles! dit le pelletier. La Réformation, mes amis, reprit-
il à voix basse, ferait rentrer dans la bourgeoisie les terres de
l’Église. Après les priviléges ecclésiastiques supprimés, les
Réformés comptent demander que les nobles et bourgeois soient
égaux pour les tailles, qu’il n’y ait que le roi au-dessus de tout le
monde, si toutefois on laisse un roi dans l’État.
—Supprimer le trône! s’écria Lallier.
—Hé! compère, dit Lecamus, dans les Pays-Bas, les bourgeois
se gouvernent eux-mêmes par des échevins à eux, lesquels élisent
eux-mêmes un chef temporaire.
 —Vive Dieu! compère, on devrait faire ces belles choses et rester
Catholiques, s’écria l’orfévre.
—Nous sommes trop vieux pour voir le triomphe de la
bourgeoisie de Paris, mais elle triomphera, compère! dans le temps
comme dans le temps! Ah! il faudra bien que le roi s’appuie sur elle
pour résister, et nous avons toujours bien vendu notre appui. Enfin la
dernière fois, tous les bourgeois ont été anoblis, il leur a été permis
d’acheter des terres seigneuriales et d’en porter les noms sans qu’il
soit besoin de lettres expresses du roi. Vous comme moi le petit-fils
des Goix par les femmes, ne valons-nous pas bien des seigneurs?
Cette parole effraya tant l’orfévre et les deux femmes, qu’elle fut
suivie d’un profond silence. Les ferments de 1789 piquaient déjà le
sang de Lecamus qui n’était pas encore si vieux qu’il ne pût voir les
audaces bourgeoises de la Ligue.
—Vendez-vous bien, malgré ce remue-ménage? demanda Lallier
à la Lecamus.
—Cela fait toujours du tort, répondit-elle.
—Aussi ai-je bien fort l’envie de faire un avocat de mon fils, dit
Lecamus, car la chicane va toujours.
La conversation resta dès lors sur un terrain de lieux communs,
au grand contentement de l’orfévre qui n’aimait ni les troubles
politiques, ni les hardiesses de pensée.
Maintenant, suivons Christophe.
Les rives de la Loire, depuis Blois jusqu’à Angers, ont été l’objet
de la prédilection des deux dernières branches de la race royale qui
occupèrent le trône avant la maison de Bourbon. Ce beau bassin
mérite si bien les honneurs que lui ont faits les rois, que voici ce
qu’en disait naguère l’un de nos plus élégants écrivains:
 «Il existe en France une province qu’on n’admire jamais
assez. Parfumée comme l’Italie, fleurie comme les rives du
Guadalquivir, et belle, en outre, de sa physionomie
particulière, toute Française, ayant toujours été Française,
contrairement à nos provinces du Nord abâtardies par le
contact allemand, et à nos provinces du Midi qui ont vécu en
concubinage avec les Maures, les Espagnols et tous les
peuples qui en ont voulu; cette province pure, chaste, brave
et loyale, c’est la Touraine! La France historique est là!
L’Auvergne est l’Auvergne, le Languedoc n’est que le
Languedoc; mais la Touraine est la France, et le fleuve le plus
national pour nous est la Loire qui arrose la Touraine. On doit
dès lors moins s’étonner de la quantité de monuments
enfermés dans les départements qui ont pris le nom et les
dérivations du nom de la Loire. A chaque pas qu’on fait dans
ce pays d’enchantements, on découvre un tableau dont la
bordure est une rivière ou un ovale tranquille qui réfléchit
dans ses profondeurs liquides un château, ses tourelles, ses
bois, ses eaux jaillissantes. Il était naturel que là où vivait de
préférence la Royauté, où elle établit si longtemps sa cour,
vinssent se grouper les hautes fortunes, les distinctions de
race et de mérite, et qu’elles s’y élevassent des palais grands
comme elles.»

N’est-il pas incompréhensible que la Royauté n’ait point suivi

l’avis indirectement donné par Louis XI de placer à Tours la capitale
du royaume. Là, sans de grandes dépenses, la Loire pouvait être
rendue accessible aux vaisseaux de commerce et aux bâtiments de
guerre légers. Là, le siége du gouvernement eût été à l’abri des
coups de main d’une invasion. Les places du Nord n’eussent pas
alors demandé tant d’argent pour leurs fortifications aussi coûteuses
à elles seules que l’ont été les somptuosités de Versailles. Si Louis
XIV avait écouté le conseil de Vauban, qui voulait lui bâtir sa
résidence à Mont-Louis, entre la Loire et le Cher, peut-être la
révolution de 1789 n’aurait-elle pas eu lieu. Ces belles rives portent
donc, de place en place, les marques de la tendresse royale. Les
châteaux de Chambord, de Blois, d’Amboise, de Chenonceaux, de
Chaumont, du Plessis-lez-Tours, tous ceux que les maîtresses de
nos rois, que les financiers et les seigneurs se bâtirent à Véretz,
Azay-le-Rideau, Ussé, Villandri, Valençay, Chanteloup, Duretal, dont
quelques-uns ont disparu, mais dont la plupart vivent encore, sont
d’admirables monuments où respirent les merveilles de cette époque
si mal comprise par la secte littéraire des moyen-âgistes. Entre tous
ces châteaux, celui de Blois, où se trouvait alors la cour, est un de
ceux où la magnificence des d’Orléans et des Valois a mis son plus
brillant cachet, et le plus curieux pour les historiens, pour les
archéologues, pour les Catholiques. Il était alors complétement isolé.
La ville, enceinte de fortes murailles garnies de tours, s’étalait au
bas de la forteresse, car ce château servait en effet tout à la fois de
fort et de maison de plaisance. Au-dessus de la ville, dont les
maisons pressées et les toits bleus s’étendaient, alors comme
aujourd’hui, de la Loire jusqu’à la crête de la colline qui règne sur la
rive droite du fleuve, se trouve un plateau triangulaire, coupé de
l’ouest par un ruisseau sans importance aujourd’hui, car il coule
sous la ville; mais qui, au quinzième siècle, disent les historiens,
formait un ravin assez considérable, et duquel il reste un profond
chemin creux, presque un abîme entre le faubourg et le château.
Ce fut sur ce plateau, à la double exposition du nord et du midi,
que les comtes de Blois se bâtirent, dans le goût de l’architecture du
douzième siècle, un castel où les fameux Thibault le Tricheur,
Thibault le Vieux et autres, tinrent une cour célèbre. Dans ces temps
de féodalité pure où le roi n’était que primus inter pares, selon la
belle expression d’un roi de Pologne, les comtes de Champagne, les
comtes de Blois, ceux d’Anjou, les simples barons de Normandie,
les ducs de Bretagne menaient un train de souverains et donnaient
des rois aux plus fiers royaumes. Les Plantagenet d’Anjou, les
Lusignan de Poitou, les Robert de Normandie alimentaient par leur
audace les races royales, et quelquefois, comme du Glaicquin, de
simples chevaliers refusaient la pourpre, en préférant l’épée de
connétable. Quand la Couronne eut réuni le comté de Blois à son
domaine, Louis XII, qui affectionna ce site peut-être pour s’éloigner
du Plessis, de sinistre mémoire, construisit en retour, à la double
exposition du levant et du couchant, un corps de logis qui joignit le
château des comtes de Blois aux restes de vieilles constructions
desquelles il ne subsiste aujourd’hui que l’immense salle où se
tinrent les États-Généraux sous Henri III. Avant de s’amouracher de
Chambord, François Ier voulut achever le château en y ajoutant deux
autres ailes, ainsi le carré eût été parfait; mais Chambord le
détourna de Blois, où il ne fit qu’un corps de logis qui, de son temps
et pour ses petits-enfants, devint tout le château. Ce troisième
château bâti par François Ier est beaucoup plus vaste et plus orné
que le Louvre, appelé de Henri II. Il est ce que l’architecture dite de
la Renaissance a élevé de plus fantastique. Aussi, dans un temps où
régnait une architecture jalouse et où de moyen-âge on ne se
souciait guère, dans une époque où la littérature ne se mariait pas
aussi étroitement que de nos jours avec l’art, La Fontaine a-t-il dit du
château de Blois, dans sa langue pleine de bonhomie: «Ce qu’a fait
faire François Ier, à le regarder du dehors, me contenta plus que tout
le reste: il y a force petites galeries, petites fenêtres, petits balcons,
petits ornements sans régularité et sans ordre, cela fait quelque
chose de grand qui me plaît assez.»
Le château de Blois avait donc alors le mérite de représenter
trois genres d’architecture différents, trois époques, trois systèmes,
trois dominations. Aussi, peut-être n’existe-t-il aucune demeure
royale qui soit sous ce rapport comparable au château de Blois.
Cette immense construction offre dans la même enceinte, dans la
même cour, un tableau complet, exact de cette grande
représentation des mœurs et de la vie des nations qui s’appelle
l’Architecture. Au moment où Christophe allait voir la cour, la partie
du château qui, de nos jours, est occupée par le quatrième palais
que s’y bâtit soixante-dix ans plus tard, pendant son exil, Gaston, le
factieux frère de Louis XIII, offrait un ensemble de parterres et de
jardins aériens pittoresquement mêlés aux pierres d’attente et aux
tours inachevées du château de François Ier. Ces jardins
communiquaient par un pont d’une belle hardiesse, et que les
vieillards du Blésois peuvent encore se souvenir d’avoir vu démolir, à
un parterre qui s’élevait de l’autre côté du château et qui, par la
disposition du sol, se trouvait au même niveau. Les gentilshommes
attachés à la reine Anne de Bretagne, ou ceux qui de cette province
venaient la solliciter, conférer avec elle ou l’éclairer sur le sort de la