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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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2.1 Researching marginality: the initial research question My original research proposal had outlined to investigate “Chronic Illness at the Margin” and positioned itself within an “anthropology of the margins” (Das and Poole 2004). “Marginality” in its connection to ill-health was borrowed from Ecks and Sax’s (2005) paper on the “ills of marginality. “Marginality” served those scholars as new ways of conceptualising health inequalities. They referred to both illness as the reason for being marginalised within a society as well as the marginal status within a society leading to illness.

The notion of “marginality” is nothing particularly new within social theory, for example see the sociologist Edward Shils’ (1975) distinction of centre and periphery in his investigation of authority in society. Eickelman and Piscatori (1990) borrowed Shils’ approach when looking at “centrality” in the study of Muslim societies. Although acknowledging its utility, they considered Shils’ framework of centre and periphery problematic. They argued that “centrality” should be understood in more complex ways insofar as there is more than one centre or that one can find more than one hierarchy within the centre (referring in this case to the pluralism of Islam). I found their approach very useful and could see that in the study of “marginality” (or “centrality” respectively), one should account for these pluralities (also see Ecks and Sax 2005). The “centre” in my research, for example, was not envisioned as a single entity; the German state is not necessarily the same as German healthcare politics or provision, and there are hierarchies (centres and margins) within that.

At first sight, “marginality” refers to the spatial position of many marginal subjects. It includes those groups or individuals living in “developing” countries rather than their adjacent wealthier neighbours, in rural areas rather than the cities, or in inner cities’ ghettoes rather than their trimmed suburbs. The latter clearly shows that the centre and its margins do not always own clearly assigned status. Most importantly though, “marginality” does not turn out to be a solely spatial concept but serves as a way of describing marginal positions in hierarchical systems, stratified societies with unequally divided opportunities or access to services or participation.

However, concepts such as inequality could also accommodate such meaning.

Instead, “marginality” was chosen to be understood as “a radically relational concept” which recognises the connectivity of centre and margins (Ecks and Sax 2005: 199).

Moreover, “marginality” should be understood as social process, social practice and transitive action (Ecks and Sax 2005: 208). Nijhawan argued in his account on Sikh asylum seekers in Germany “that the migrants’ marginality in everyday life does not mean that they are at the margins of public discourse” (Ecks and Sax 2005: 207). He thus suggested moving beyond simplistic conceptualisation of marginality and exploring its complexities and relations, and how “marginality” is not just a status but a performance or technology. In his contribution, different facets of marginality were explored, including how marginality can also be a position of power. Marginality here becomes the subject of documentation. Both the German state and the asylum seekers document “evidence” of the trauma of violence and political prosecution. Marginalisation is a means of governmentality and state control as much as performance and activism.

Accordingly, my research project aimed to employ “marginality” as a starting point to explore Turkish migrant experiences with diabetes in Germany. In doing so its design included possible agency, power or more concrete ways of actively handling healthcare, illness management or encounters with the state that affect the body as much as notions of residency or citizenship. Above all, these Turkish migrants should not be regarded as a bounded group without relation to other Berliners.

Current emphasis on “health inequalities” in Euro-American migrant health studies seemed to offer limited and over-simplified understandings of the processes at play. There, both migrant status and chronic illness are described in their debilitating mode and static and discriminatory position (e.g. Marmot 2006). In my proposal I suggested that investigating migrant experiences with chronic illness in their relation to the “centre” – may that be the state or its representation as healthcare (practice) – allowed for social practice and agency. This could ultimately not only shed light on the understanding of migrant illness experiences but also on the understanding of German healthcare (the state) and biomedical knowledge production and practice. Das and Poole (2004: 4), after all, argue that “the anthropology of the margins offers a unique perspective to the understanding of the state, not because it captures exotic practices, but because it suggests that such margins are a necessary entailment of the state, much as the exception is a necessary component of the rule”.

I originally stated in my research proposal that it should not be “the other” or the “pathological” at the centre of investigation but the social processes that define the margins, how boundaries are set and contested. I anticipated that research of people’s experiences of marginality should therefore not solely include these people at the margins as main research participants; that it was not distinct communities but rather their embeddedness in wider societal networks that should serve as the research setting. Having said that the research design should accommodate a fluent and multi-layered conceptualisation of centres and margins, the actual fieldwork soon uncovered misconceptions. For example, I still (if reluctantly) expected a dichotomy of (Turkish) patient versus (German) doctor, a (Turkish) migrant minority community interacting within wider (German) society. Most of my research participants, however, turned out to be – with very few exceptions – Turkish-origin, mostly first generation immigrants, of various backgrounds, doctors, nurses, patients, patient consultants, drug company representatives, active group members and group leaders and assistants, those considering themselves activists, involved in NGOs, but also researchers – family doctors researching and giving talks, and clinical researchers guiding German public health rhetoric in this field and NGO agendas. I also shared the “observer’s seat” at a self-help group for a while with a Turkishorigin nurse writing her Master’s dissertation. This quickly faltered any attempts to identify “minority group” vs. majority society, disadvantaged vs. elite, or probably most obviously lay knowledge vs. expertise. Marginality, indeed, turned out to be a truly relational concept: a self-help group member could assume a “central”, privileged position as an expert; the German healthcare system can be rendered marginal to the experience of my research participants that move in more informal care settings.

2.2 Research setting and participants Setting: Berlin For my fieldwork I settled in Germany’s capital city Berlin, which is often described as the ultimate “postmodern” city and offers a unique research setting for a study of marginality. The city has been defined and shaped by its boundaries which were at times salient and deadly, the Berlin wall, later silent and invisible as the borders of East and West are still drawn in the imagination of its residents (Borneman 1992).

Berlin’s boundaries though were never absolute, often permeable or at least challenged by its residents. They shared a historic memory of social ties across borders; questions of belonging, being marginalised and yet at the centre of world politics are intrinsically tied to a Berliner’s identity (Borneman 1992). Berlin seemed thus the ideal setting for exploring marginality, questioning the static and unrelational character of marginalised people.

Berlin is also a diverse European metropolis, with 13.4 per cent of Berlin’s almost 3.4 million residents without German citizenship (Statistisches Bundesamt 2007). It has been chosen as the setting for this research as it has, with around six per cent, one of the highest percentages of Turkish-origin residents of all German towns and cities (Statistisches Landesamt Berlin 2006). Many Turkish residents live in city districts such as Neukölln and Kreuzberg where the immigrants constitute up to one third of the population. Kreuzberg is known among Germans as “Little Istanbul” – much to the offence of Istanbullus who regard their modern, metropolitan lifestyles to be in stark contrast to the migrant lives in Berlin. The Istanbullu author Aykol (2002), for example, suggests calling it “Little Anatolia” in order to more accurately describe the migrants’ often rural backgrounds from Turkish Anatolian hinterland. In Turkey, Germany is nonetheless humorously called Turkey’s sixty-eighth province (Mandel 1990).

I specifically chose the district Neukölln as my major research setting, as it received much media attention lately that depicted Neukölln as Berlin’s “new Bronx”, a “ghetto” of ethnic segregation where schools have an overwhelmingly “non-German” student population, unemployment is high, and stories of violence and crime are frequently reported in national newspapers. A local family doctor told me that Neukölln’s benefit office hands out the largest social benefit and unemployment payments in Germany. It used to be infamous for regularly running out of money by December and leaving benefit recipients not able to pay their bills at the end of the year. Neukölln has become the centre of debates on multiculturalism and integration, an idiom of the “foreigner” in German society, and an example how the “marginalised” can enter “central” public debates.

I also chose this research setting for its large population of Turks (Sunni, Shi’a Alevi, Kurds), who share their neighbourhood with an eclectic community of Arabs (Palestinians, Lebanese, Syrians, Iraqis), Persians (Iranians, Afghans), East Europeans (Russians, Polish), Africans (mostly from North- and West-African states), and Germans (those born in Berlin, growing up in the East or West, and those who moved to Berlin more recently)13. Walking down the streets of my neighbourhood gave little evidence of media tales of ghetto culture, crime and poverty.14 On the contrary, day-to-day street life resonated Neukölln’s multiethnic character of vibrant social interaction and relaxed co-habitation. I would share a UBahn carriage with groups of teenage girls from various ethnic backgrounds in the latest fashions of skinny jeans or mini-shorts who discussed celebrity gossip with their friends in long sleeved coats with colourful headscarves. Elderly couples in traditional Eastern-Turkish clothing were strolling down the street back from their shop at one of the many big Turkish supermarkets, the woman pulling a shopping trolley behind her, and at my local discount-bakery Backfactory tables would be This list is only exemplary but attempts to highlight the community’s diversity. Defining ethnic or migrant groups in Berlin seems an unpromising endeavour. National census, e.g., register nationalities but subsume second or third generation immigrants as “migrant background” without specifying their origin. The term Turkish in this thesis should include religious and ‘ethnic’ distinctions such as Sunni, Shi’a Alevi and Kurdish Turks. For a longer discussion see On terminology: Turkish Berliners further on in this chapter.

14This is perhaps because I avoided unsafe situations, e.g. walking at night in certain neighbourhoods.

Crime rates are high in this area, there is a gang culture; however, my everyday life was not affected by this.

shared by the international students of the adjacent language school and elderly Muslim men who prefer the cheap coffee to the pricier Turkish men’s tea-house around the corner. Shops, supermarkets, hairdressers, mobile phone shops, etc., were locally owned by Neukölln’s ambitious businessmen, and the names of the many doctors, lawyers, insurance agencies, etc. sign-posting their services in multiple languages gave me a first hint that the multiethnic neighbourhood expands into all social classes. It turned out, however, that my Turkish-origin informants lived spread all across Berlin, as they were all first generation immigrants who had been subject to initial migrant policies of “anti-ghetto” urban planning (Mandel 2002: 369).

Participants: family doctors What I could achieve locally in my district Neukölln was to visit family doctor surgeries that either attended to a large patient group with migrant backgrounds or whose doctors were Turkish, Arab, Persian, etc. themselves. Interviews proved hard to get, as I had to by-pass the surgeries’ receptionists who enjoyed their power of turning down requests to speak to the doctors with their on-the-spot assessment of whether their bosses would be interested in my research at all. Those doctors who I managed to get through in the first place, and who then would give a time slot of 20 or 30 minutes for an interview, were often reluctant to talk about “migrant health”.

Some seemed nervous about the quite politically incorrect exercise of singling out their Turkish patients, others finally highlighted the difficulties of working in a socially deprived area and with “high-maintenance” patients with poorer health and little language knowledge. I formally interviewed 5 German doctors and 7 Turkishorigin doctors.

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