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«Tactics of Diabetes Control Turkish immigrant experiences with chronic illness in Berlin, Germany. Cornelia Guell PhD by Research The University of ...»

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Before I explore diabetes as a communal problem for Turkish Berliners, let me make a short excursion to a related research question that I did not ask but that always lingers in the background. A commonly asked question by most people I tell about my research is: so, why do Turkish Germans have so much diabetes? First of all, as mentioned before, this is not a proven statement. As a starting point to this research I used the study of Laube et al. (2001) that states that Turks are almost twice as likely to have diabetes as Germans or Turks in Turkey. But I have also highlighted earlier that the research is considered a poor study with a convenient sample that required to be controlled for age and sex. However, much epidemiological research indicates that migrant and ethnic minority population groups indeed show more diabetes prevalence (Qiao 2004; Unwin and Zimmet 2009). So, could my 12-month-long research contribute to this research question? I did not set out to answer this question, and would lack the methodology and training to do so. Nonetheless, I spoke to many health professionals and patients, and their common agreement was that diabetes is perceived as a current and severe problem of this population group. Relying both on the scarce medical statistics, which had been – in turn – produced by mostly Turkishorigin academics, and their own personal experience of everyday diabetes prevalence among their patients, Turkish-origin doctors identified diabetes as a communal problem that needed addressing. Narratives varied but the concern was widely shared and backed with the ever-cited Laube (et al. 2001) study. Some doctors would also refer to a local council study on high obesity rates among Turkish-origin school children (Delekat 2005) in order to back their own observation and experiential knowledge with more “hard facts”. Cautioning me at all times that “this is only anecdotal evidence”, they explored the reasons for the indeed high occurrence of diabetes in their practices. That it is perceived as a burden might not necessarily reflect the relative or absolute numbers of diabetes but the challenges to provide healthcare and other support systems. The immense efforts of health insurance companies, I witnessed, to sign up Turkish-origin diabetes patients to their management programmes, and of drug companies to target this newly discovered consumer group with “ethno-marketing”, indicates that this patient group is increasingly moving into focus, irrespective of reliable prevalence data.

Could I then shed more light on the question as to why Turkish Germans might be vulnerable to developing diabetes? There are three hypotheses about diabetes risk to certain ethnic minorities: their lifestyles, their genes, or foetal/childhood deprivation (also see Mol 2008: 64ff). While, again, I did not set out to explore these issues, research participants did frequently comment on all three aspects. First, as frequently mentioned before, type 2 diabetes is associated with unhealthy eating habits and sedentary lifestyles (Zimmet, Alberti and Shaw 2001).

Some doctors I spoke to highlighted that Turkish diet, contrary to the myth of the Mediterranean diet, can be very fatty and sugary. Anatolian cooking, especially, many women also explained to me, uses a lot of butter fat instead of olive oil, and fried and baked stews are more common than grilled dishes.

Why then would their diet be worse in Germany than it used to be in Turkey?

Some health professionals pointed out social deprivation. A doctor explained how

people were altering their diet to save money (interview transcript 02.11.2006, p.2):

“Everybody talks about the healthy Mediterranean diet. As if! They don’t use olive oil anymore. Butter is much cheaper. Turkish cooking is abused here, really.” Taking the environment into account he went on to complain that the streets of Berlin’s Turkish districts were lined with cheap Turkish fast-food eateries: “Just walk down Hermannstraße and you’ll see all these discount shops. Fantasy prices!

It’s insane, really. You can eat so cheap nowadays that you wonder how they can still make a profit. These shops – huge Turkish supermarkets where you can buy anything – and these take-away places weren’t here ten years ago.” Indeed, while public health professionals would often point out that fast food is actually much more expensive than home-cooked food, Berlin’s extremely cheap Turkish fast food begs to differ.

This cheap food at every street corner also helped to change eating habits. Talking to Turkish Berliners about childhood obesity, many parents shared their frustration with me that while Turkish-origin children still have sit-down meals with their families, they also snack on burgers, pizzas and kebabs on the way to the family meal. Doctors would also point the finger at the parents: “People living here in Neukölln are still very traditional. They still raise their children like decades ago. You’ve got to spoil your child.” (Interview transcript 02.11.2006, p.1). For these elderly Turks obesity would still be a sign of prosperity.

Several doctors also mentioned that stress was an important factor in diabetes – in terms of causation and management. Many older Turkish Berliners suffered from complex health problems; for example, my research participants with diabetes were almost always also chronic pain patients or suffered from mental health problems. Another frequently mentioned illness was eating disorders (especially over-eating) in connection to high depression rates, especially among women of all ages. This, finally, leads to sedentary lifestyles as a behavioural cause of diabetes.

Again social factors might play a role, for example a population group that suffers from high unemployment and early retirement is perhaps less likely to lead active lives. This is, as mentioned earlier, linked to high rates of skeletal illness that also restricts movement. The doctor that pointed out the plight of fast food venues also mentioned that Turkish Berliners can now enjoy an abundance of Turkish TV channels with their satellite receivers. He suggested that many people were less physically active after migrating to Germany. In recent years, he added, this problem had worsened, as tens of Turkish TV programmes were available in Turkishspeaking households in Berlin by then. Some decades ago people had to leave their houses to meet friends to socialise. Now, “they can sit on their sofa all day and be entertained” (interview transcript 02.11.2006, p.4).

The second possible explanation why Turkish Germans may be at risk of diabetes is biological: genes. As mentioned in Chapter 1, the so-called “thrifty gene hypothesis” says, that insulin resistance used to be a useful evolutionary trait for people that lived between periods of fasting and feasting (McDermott 1998). If food is scarce, the rare moments of feasting require a slow metabolism that would not process the energy source glucose too quickly. With industrialisation and increasing wealth, people (the implication is, in the Western world) slowly adapted to changing food availability and eating habits. People in the developing world (e.g. Asia, with increasingly high diabetes rates, Zimmet, Alberti and Shaw 2001), undergo such changes too rapidly for their metabolism to cope. Population groups that made this change even more abruptly, namely migrants, this thrifty gene effect is even more significant, especially when keeping above mentioned lifestyle and environmental factors in mind. Less controversial are other gene-related theories of illness causation. Scientists seem to agree that type 2 diabetes has a definite genetic element in its aetiology (Hedgecoe 2002). Genetic research suggests multiple gene defects at play and is currently focussed on unravelling these complex workings (Rock 2005).36 The anthropologist Melanie Rock (2005: 117) explores this recent genetic research on diabetes onset and quotes a genetisist who linked a Mexican-American population to a certain gene that “reduced the desire to exercise” in laboratory mice.

Third, Turkish Berliners might not only share habits, environment or genes, but similar childhoods. Research also points to a connection between risk of diabetes and deprivation during pregnancy and early childhood; in this theory, the environment can have an impact on biochemistry. Hales and Barker (1992) called this the “thrifty phenotype hypothesis”, in which (in accordance to the thrifty genotype hypothesis), deprivation is said to be able to alter the biochemistry of a foetus and baby, to prepare the young person for a life in poverty and scarce food supply. This is often explored in birth weights (Harding 2001). Although there is no data on the birth weights of my research participants with diabetes, some shared biographical stories of great poverty in early life with me. While labour migrants tend to have lived in relatively poor circumstances before making the brave move to try their luck in a wealthier environment that offers more opportunities, it has to be pointed out that patients’ childhood memories are subjective and are not appropriate as the basis of epidemiological evidence.

The above explorations of possible causes for diabetes are, of course, speculations that are fleshed out by observations, perceptions and experiences of my research participants. The only possible answer to the question why the Turkish Berliners may be at risk of diabetes is shared by most researchers in the field of diabetes. Diabetes causation is complex and research would have the task to disentangle the multifaceted factors of lifestyle, psychology, environment, genes and biochemistry (Zimmet, Alberti and Shaw 2001; Unwin and Zimmet 2009).

Diagnosing a communal health problem: the medics’ society The above interview excerpts show that it was particularly Turkish-origin doctors who voiced their concerns about diabetes as a problem of “our community”, and much of Berlin’s activity around “Turkish diabetes” was instigated by them. Berlin with its large Turkish-origin population (around 200,000 of the 3.4 million inhabitants; Statistisches Landesamt Berlin 2006) has by now over a hundred Turkish-origin doctors whose practices mainly accommodate migrant patients who appreciate the offer of native language healthcare. The number of doctors of Turkish migrant backgrounds used to be much smaller and still is relatively small (compared to, for example, South-Asian origin doctors in the UK context, as many Turkishorigin doctors would highlight). Social mobility is made difficult in German society and the for-profit, entrepreneurial system of medical practices is a financially risky and trying business. Doctors therefore organised themselves in medics’ societies that functioned as both support and lobby networks. They also felt strongly about the politics involved in their patients’ care. While the doctors in the above interview excerpts often expressed their evaluation of the roots of diabetes in personal choices and failings, they were also keen to point out environmental and social constraints, and structural and political disadvantages of their patients. For example, many felt that it was important to raise awareness among healthcare professionals and bureaucrats to have the necessary language skills to talk to migrant patients. “In some hospitals, they let the cleaning lady do the preoperative informed consent procedures,” a doctor complained (interview transcript 02.11.2006, p.4).

I suggest understanding how these doctors identify the social and political dimension of diabetes in terms of symptoms, diagnosis and treatment of a communal problem. Drawing parallels to the clinical way of diagnosing the physical illness diabetes, the social problem of diabetes appears to be explored in similar ways.

While the individual, physical experience of diabetes often begins with symptoms such as thirst and fatigue, these also metaphorically frame the local discourse of Berlin’s migrant population group as deprived and drained. The diagnosis of diabetes, then, is clinically done with a glucose test in form of a blood test or sometimes, although outdated, urine test. Biomedicine narrows general problems and complaints down to a particular place or seat of illness. In accordance, this marginalised population is, in general terms, burdened by deprivation and marginalisation, while the medics’ society aims to investigate more specifically the burden of this group, in particular diabetes (and high rates of obesity, sedentary lifestyles, unhealthy diets and depression as contributors to diabetes). While for national politics the problem of this marginalised population group is lack of societal “integration”, activists and academics consider challenges in lacking acceptance and provision in terms of education, employment and social welfare. Local medics, of course, identify much more specific needs of their particular patient group, in particular obesity and chronic illnesses such as diabetes, but see such ill-health as closely linked to, shaped by and in turn shaping deprivation and marginality.

In short, diabetes could be regarded as a symptom of social hardship or social disadvantage and diagnosed by diabetes “activists”, here involved medics, as a social challenge, burden or demand. Such diagnosis of diabetes as an ultimately social problem remains largely undetected by national and local mainstream politics.

Combining their own everyday experience of illness prevalence with more “scientific”, “factual” data of the scarce statistics produced by their (prominently Turkish-origin) academic colleagues in research, Turkish-origin doctors produced a certain political agenda. In their interviews the local medics positioned themselves in these “tales of diagnosis” at times as the scientist or professional who identifies someone else’s problem, bad habits and uncertain futures, and at times as members of the “community”, doing something for “your own”, threatened and burdened all the same by such illness, or at least acting as spokespersons. Similar to such shifting positions, their stories (of causation) were also variant, evoking both patients at fault of such bad practices and backward beliefs, and a population victim to structural disadvantages and economic market forces that determine bad eating habits and sedentary lifestyles.

Community self-management: the self-help group Subsequent to the analytical device of symptoms and diagnosis, what follows is the question of treatment. Central to diabetes care is self-managed diabetes control.

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