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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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The German population largely appreciated the Turkish immigrants’ presence for their contribution towards the German industry, most notably since “this was a nondemanding, non-unionised, cheap and hard-working labour force, which was available where and when needed and which was ready to undertake the least desirable tasks that the host nation was reluctant to do“ (Kağucibaşi 1997: 44-45). This initial acceptance by Germans, however, turned into resentment after the OPEC crisis in 1973 heavily struck the German economy and unemployment hit the population. During this time of recession, recruitment of guest workers ceased (Anwerbestopp) and schemes developed to entice return to their respective home countries (Rückkehrförderung). Migrant labourers from Turkey, Italy, Yugoslavia, Spain, Portugal, Morocco etc. were offered enticement aids of 10,500 Deutsche Mark11 (plus DM 1500 per child) and the offer to cash in any retirement funds (Goldberg et al. 2004: 19). In 1983/84, about 250,000 people, mostly Turkish, returned while only 42,000 entered Germany through family reunion schemes. It seems that both those who decided to return and those staying in Germany were left holding the bag. The high financial enticements created much envy towards the “home comers” in Turkey. Reintegration schemes within Turkey largely failed due to its starkly expanding population size, high unemployment and rising inflation rate. Similarly, those migrant workers who decided to stay in Germany had to face social envy by the German population triggered by these high financial enticements and oddly directed towards those left in the country. Above all though, many Germans resented those thought-to-be “temporary” migrant workers who decided to stay in the country despite its bad economic situation.

In the early 1980s, Germany faced an initially unanticipated situation: the temporary guest workers became permanent residents, brought their families from Turkey and raised new children. As many migrants initially came to Germany without their family, schemes to reunite them with their families (Familiennachzug) needed to be in place in accordance to various international agreements such as the European Social Charter and the European Convention on Human Rights that stipulate the human right to live with one’s family (Goldberg et al. 2004: 15). Moreover, an educational system had to figure out how to take care of many children and especially teenagers who did not speak German and did not have German school education. New schemes aimed to integrate these teenagers in vocational training, however these were largely irrespective of their level of Turkish education (that might have favoured a university education) (ibid. 16).

While the young generation of migrants and those siblings born in Germany slowly started to grapple with an emerging Turkish German identity, the older Turkish migrants realised that their anticipated return to their home country became an increasingly distant prospect that should, nonetheless, not be given up. Migration literature tended to explain this “myth of return” with the unsettling feeling of not being welcome in the new country and the attempt to come to terms with it by imagining the 11DM 10,000 was a substantial amount of money in the early 1980s and would be worth about EUR 10,000 today.

eventual homecoming (Anwar 1979). These sentiments are quite understandable as Germany is evidently (as my informants insured me) a much greyer, colder and quite possibly less affectionate and neighbourly country than Turkey. Even more so, the Turkish migrant population was increasingly facing overt discrimination, exclusion and violence (Goldberg et al. 2002; Kağucibaşi 1997).

A second decisive period for Turkish migrants started after Germany’s reunification in 1990 with new xenophobic tendencies and violence towards migrants and asylum seekers (Horrocks and Kolinsky 1996; also see: Toelken 1985). Interestingly enough, White’s (1996: 25) ethnography explores a very different xenophobia in postreunification Berlin, where Turkish residents gained new status of recognition and were suddenly awarded trust and belonging to the “West-community” against the “more foreign” East Germans. Since 11 September 2001, a new element of general Islamophobia has been added to resentments against the Turkish population that is characterised by a much more widespread, above all, media attention to perceived threats to human rights and civic order in the form of youth crime, forced arranged marriages and honour killings. Interestingly though, a frequent ethnocentrism survey to test the population’s sentiments towards “foreigners’” rights and freedom attested a steady improvement of tolerance even post 11 September despite this scaremongering (Dietrich 2007: 239).

Social provision and self-help Despite this long history of Turkish settlement, Germany seems still at odds with accommodating this population group. It took until 1998 and a change in government to amend the German citizenship law to facilitate naturalisation of the migrant populations and their children born in Germany (Fücks 2002).12 The latest census of Germany’s population also included, for the first time, a category to “migrant background” in order to also subsume those migrants with German citizenship to the minority groups (Statistisches Bundesamt 2007). These latest statistics state that in 2005, 18.6 per cent of the German population are of migrant background.

12 German citizenship is still mainly allocated according to ius sanguinis (right of blood or parentage) rather than ius soli (right of the soil).

Significant for this thesis is, that, nonetheless, German society fails to acknowledge this diversity, as well as the deprivation and inequality large groups of the population are subjected to. Germany is a wealthy country and spends a lot of money funding its strong social welfare system (Sawicki and Bastian 2008). But it is also a conservative system that seems surprised by societal changes, and fails to adequately respond and address these. Revisiting the troubles of the Rütli-school, it is emblematic for the experience of a marginalised population group that faces complex challenges. Students join the school with little language skills, they live in deprivation and with bleak future prospects. The educational system is structurally overwhelmed by such demand, as education in Germany is a federal system and the relatively poor federal state Berlin lacks the financial means to employ more social workers or teacher aids. However, public and political debates tend to evoke images of “failed integration”, how such population groups create a problem for society, rather than discussing how parts of the population are let down by society.

Despite – or perhaps because of – such failed politics, social and political action is taken elsewhere. During my fieldwork I was living two blocks away from Rütli-school, and I took Turkish lessons at a Turkish club for education (Türkischer Bildungsverein). These language classes provide the club with extra funding, but its main objective is to offer homework help for local youth whose parents could not afford private lessons. This is the first example of local self-help I encountered.

Other clubs, for example, offer Muslim religious education in association with local mosques, or Turkish language courses for children who did not grow up bilingual. As the German constitution guarantees the right to religious education to their citizen – and as a consequence of the much revised citizenship and naturalisation laws – schools are finally also developing and implementing Muslim religious education, and Berlin’s schools increasingly also offer Turkish language classes. It was mainly the activism and lobbying of Turkish-origin political groups and the support of the increasing numbers of Turkish-origin politicians that led to these developments. The majority of this education is still organised privately or voluntarily, and there are also projects for private boarding schools that aim to provide Turkish-origin children with non-biased, non-discriminatory school education (although children of all backgrounds are welcome; Die Zeit 2007).

This thesis is mainly concerned with healthcare, which shows similar increasing political organisation and activism in clubs, NGOs and charities. The case of healthcare shares the same dilemma with education. Social deprivation not only creates ill-health but poverty and high illness rates also strain the services that should care for ill-health. And structural reforms that aim to alleviate the problem fail to acknowledge the complexity of the problem in everyday practice. For example, a society of medics with migrant backgrounds invited me to their talk on new insulin prescription regulations. The German Institute for Quality and Efficiency in Health Care (IQWiG), an equivalent of UK’s NICE, had recommended that human insulin was just as effective and less costly than the more refined insulin analogues. This way the healthcare system could better cope financially with its increasing numbers of diabetic patients. As a result of the recommendation, state health insurances would only pay for the prescription of human insulin, and patients on analogues should be switched back to human insulin as soon as possible. The doctors in the medics’ society were outraged as their resource strained practices in largely socially deprived areas with high percentages of diabetes patients could not possibly cope with this task. What was more, they believed that human insulin needs stricter monitoring to achieve as good diabetes control, which the doctors considered a difficult task for their migrant patients (from field notes 17.10.2006).

Berlin was a vibrant place for such activism and political activities. At the German-Turkish Congress of Medicine and Public Health a whole range of social workers, medics, politicians, NGOs, interest groups and private companies discussed how the healthcare system failed to provide for a population group in special need (from field notes 27.10.2006). Participants expressed their disapproval of national politics that framed problems in terms of duties of this population group in the interest of integration (learning German), rather than acknowledging that the state needs to make more adequate provision (translation services). They were appalled by the expectation that a sick and elderly person should learn German to converse with her doctor, or chose to be translated by her grandchild as the only other option.

Participants demanded funding for translation services, more Turkish-origin doctors in primary care and training of Turkish-origin practice nurses; they debated an already established migrant patient consultancy, and private businesses of Turkish nursing homes to provide adequate elderly care.

Last but not least, the congress was attended by representatives of Berlin’s Turkish diabetes self-help group. As German diabetes care has yet largely failed to acknowledge diversity or structural health inequalities, it was (mostly Turkishorigin) health professionals that initiated a self-help group that should fill this provision gap. This initiative of self-help aims to provide individual support to diabetics in their native language, access to education and resources. They also engage in community outreach work to raise awareness of diabetes and offer help to a patient group whose healthcare system makes no provision of native language care or education or cultural-specific dietary advice. As this thesis will explore, in this group Turkish-origin Berliners teach themselves to adopt a strict discipline of body maintenance into their lives that manages their illness better than any medication can.

Chapter 2: Research methodology

From September 2006 to August 2007 I conducted ethnographic fieldwork in Germany’s capital city Berlin. I had planned to trace common public health perceptions on the alleged vulnerability of migrant populations to chronic illness and explore the scarce accounts on unusually high type 2 diabetes rates among Turkish migrants in Germany (Laube et al. 2001). Initially, I expected to speak to (mostly German) health professionals about their perception, as to whether they experienced a local “public health challenge” in terms of above-average illness rates or inadequate health provision. Through these professionals, I had hoped for access to “the other side of the story” and explore actual patient experiences. In order to investigate illness management as an individual and community practice, I aimed to use the concept of “marginality” as a relational approach to both illness (susceptibility and care) and migrant status. It should be ethnographically investigated who and what is placed at the margins (by whom), and how centre and margins are constructed, connected and contested. Despite my analytical goal to overcome a dichotomy of “centre” and “margin”, “majority” and “minority”, and even the “healthy” and “ill”, the study design nonetheless envisioned two sets of research participants – the Turkish patient with diabetes and the (mostly) German health professional, or more generally the Turkish migrant and the German healthcare system. However, during fieldwork these dichotomies largely disintegrated. Instead I found a whole network of Turkish-language diabetes-related services, interest groups and individuals, which was difficult to sort into neat categories of lay-professional, formal-informal, Turkish-German, (non)citizen-state, and so on. Not only did I encounter this structural answer to diabetes within the Turkish migrant community but I also had to revise another preconception drawn from public health literature. My diabetic informants did struggle with their illness but, despite their disadvantaged demographics, had a firm grip on their illness management.

In this chapter, I will describe the methodology used in this research project. I will explain more about my initial research question, and then introduce my research setting and sample. Finally, this chapter describes important aspects of the study design and data analysis.

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