Bridges: The Journal Of Global Urban Lab Vol. 2

BRIDGES THE JOURNAL OF GLOBAL URBAN LAB VOL. II 2014 - 2015

Global Urban Lab Research Journal Copyright 2015 Rice University. All rights reserved. No parts of this publication may be reproduced, stored in or introduced to a retrieval system, or transmitted, in any form, or by any means, without the prior written permission of Rice University’s School of Social Sciences. Requests for permission should be directed to ipek@rice.edu.

Ipek Martinez, Associate Dean of Social Sciences, Director of Gateway Eugenia Georges, Ph.D., Professor of Anthropology, Global Urban Lab Istanbul Faculty Director Jeffrey Fleisher, Ph.D., Professor of Anthropology, Global Urban Lab London Faculty Director Alex Wyatt, Assistant Director of Gateway, Editor Courtney Stefancyk, Gateway Administrator, Contributing Editor

INTRODUCTION One of the best ways to engage with the world around you is through interacting with people in major global cities in order to solve today's challenges. In the Global Urban Lab we work to bridge the gap between the promise and challenges of our world's great cities. Students do so through a comprehensive program of study, research, interning, and experiences. This journal is a collection of the best papers from our 2014 2015 research cohort.

TABLE OF CONTENTS

NOT A SIMPLE ACT: COMPARISON OF WASTE MANAGEMENT PRACTICES IN INSTANBUL & HOUSTON

By Derek Brown

Pg. 3

AN ASSESSMENT OF WETLAND VALUATION IN OUTLYING AREAS OF HOUSTON & ISTANBUL

By Avantika Gori

Pg. 15

URBAN INTOXICATION: EVALUATING ALCOHOL CONTROL POLICIES IN LONDON AND ISTANBUL

By Benjamin Hamm Conard QUALITATIVE COMPARISON ON HEALTHCARE EXPERTS’ VIEWS ON THE BARRIERS OF DIABETES MANAGEMENT IN HOUSTON AND ISTANBUL

By Anisah Khan THE GLOBAL ISSUE OF WASTE: UNDERSTANDING AND ANALYZING THE SUSTAINABLE WASTE MANAGEMENT OF ISTANBUL AND LONDON

By Ryan Saathoff PROTECTING ARTISTS’ URBAN ROLE: AN EXAMINATION OF THE AFFORDABILITY OF STUDIO SPACE IN LONDON AND ISTANBUL

By Cydney Smith

Pg. 23

Pg. 31

Pg. 41

Pg. 53

ASSESSING PROFESSIONAL FOOTBALL PLAYER SALARIES THROUGH THE USE OF ANALYT- Pg. 61 ICS

By Enrique Walsh COMPARATIVE ANALYSIS OF ATTITUDES TOWARDS PREIMPLANTATION GENETIC DIAGNOSIS AND PRENATAL TESTING IN THE UNITED STATES AND TURKEY

By Pooja Yesantharao

Pg. 69

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NOT A SIMPLE ACT: COMPARISON OF WASTE MANAGEMENT PRACTICES IN INSTANBUL & HOUSTON

By Derek Brown EXECUTIVE SUMMARY The medical industry is one of the largest producers of waste annually, and much of this waste is unregulated by hospitals. Now more than ever there are organizations devoted to improving the care of medical waste produced by healthcare-providing institutions, a significant amount of waste remains funneled into landfills. In a large number of cases, these supplies and equipment are still usable material; they are simply thrown out. Additionally, a large and widening gap exists between developed nations, such as the U.S. and Turkey, and developing nations in the structure and prowess of medical systems. While developed countries often have access to and observe a surplus of supplies and equipment, developing countries face extreme deficits with even basic medical equipment. The goal of this project is to understand where wasted medical supplies go, and to examine whether unused supplies and underused equipment used in cities with developed health care centers, such as Houston and Istanbul, can be recycled and reused in developing nations without equal access to the same level of resources.

INTRODUCTION The medical industry has a huge garbage issue.

Hospitals, clinics, and private practices in developed cities with structured medical systems and facilities produce several million pounds of garbage each year. According to 2010 research performed by Practice Greenhealth, an organization collaborating with members within the health care community to increase acts of environmental guardianship, in the United States of America (U.S.) alone, nearly 5.9 million tons of waste is produced annually (Waste).

This estimation is conservative and has likely seen a significant increase in recent years. Most of this garbage is comprised of medical supplies and equipment, often times functional yet still thrown away and wasted.

Although there are several methods, policies, and regulations that health care providers can use to dispose these materials, still large portions of waste generated by hospitals include functional supplies; materials ranging from excess syringes and lightly worn bedding sheets, to surgical instruments and diagnostic machines remain.

Additionally, several protocols and measures have been taken to ensure materials and equipment remain sterile. This problem has been exacerbated by current shifts towards the use of easily disposable supplies and medical equipment “kits,� according to

a physician working at MD Anderson Cancer Center in Houston, Texas (Sahin 2015). This shift has encouraged practitioners to toss supplies that are found in excess, generating a large proportion of the waste hospitals produce. Currently, very few organizations and health care institutions track the purchase of supplies, quantity and quality of existing supplies, and the amount of medical waste produced annually. These inadequacies often lead to a large excess of supplies, and an unknown millions of pounds of waste created. Where do these supplies truly go after hospitals or health care providers throw them away? Landfills and beaches? Soil and water supply?

Or are they partly donated to developing nations whom lie at a significant deficit of supplies to treat patients. Better yet, can they be?

The goal of this project is twofold; first, to understand where wasted medical supplies go after they are considered waste and second, to examine whether these unused supplies and underused equipment used in cities with developed health care centers, such as Houston and Istanbul, can be recycled and reused in developing nations with unequal access to such resources.

METHODS Literature reviews were a main venue for gathering information and knowledge about the disposal of medical supplies and equipment in a general sense

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from both the U.S. and Turkey, specifically in Houston and Istanbul. Statistics on waste management policies and processes from each country were analyzed to determine major differences and similarities within each city, and then used in a comparative analysis. Additionally, online journals and articles were explored to elicit information concerning the impact current medical waste management protocol has on developing nations. Both recent and past research was analyzed to determine and describe the current practices of health care providers relating to the handling of medical waste. This research is important in addressing the serious issues surrounding the feasibility of delivering medical supplies and equipment to developing regions, and their effects on such nations.

observations were undertaken at Medical Bridges, including examination of the re-engineering facility, equipment storage, and processes taken to donate materials. These observations provided insights into

In both Istanbul and Houston, information was gathered mostly through fieldwork consisting of personal interviews and observations. Six 25-30 minute interviews were conducted to collect data and information. In Istanbul, professionals involved in health care from Koç University School of Nursing, Açibadem Hospital, and Sariyer Mayor’s Office were interviewed. Additionally, observations of the used medical equipment at Açibadem Hospital were recorded.

Figure 2: Re-sterilization machine in Açibadem surgical operating room (2015).

Figure 1 and Figure 2 illustrate some of the equipment used in this hospital, a private health care institution. Reaching out to professionals through personal interviews was a chosen method to obtain information not available in the published literature, and was also used to provide historical and cultural context for Istanbul. Personal interviews and observations were also conducted in Houston. Interviews in Houston also lasted between 25-30 minutes and were performed at Texas Medical Center Executive Offices, Medical Bridges, and Rice University. On-site

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Figure 1: MRI machine in Açibadem Kadikoy Hospital (2015).

RESEARCH Hospitals in the U.S. comprise merely 2% of all medical waste generators, yet they generate nearly 77% of the total annual volume of regulated medical waste, which comes to 8,400 lbs/month/hospital (Klangsin 517). Various factors affect the amount of medical waste that hospitals produce, such as: hospital size, geographic location, state and local waste social policies, hospital disposal policies (Klangsin 517). Clinics, laboratories, dentists’ offices, residential care facilities, and hospice care units are all producers of medical waste (Lichtvel 1990). Health-care waste is caused by several factors including a lack of awareness concerning the hazards surrounding improper disposal of health-care waste, inadequate training in waste management, meager financial and human resources, and absence of policies for environmentally-friendly waste plans ("Waste from Health-care Activities").

High-income countries, such as the U.S. and Turkey, generate about 0.5 kg/bed-day hazardous waste per bed per day according to the World Health Organization (WHO) ("Waste from Health-care Activities”).

These numbers are significantly lower than the average range of medical waste in developing countries, which are situated around 1.5-3.9 kg/bed-day (Mato 4). Nevertheless, mid and low-income countries oftentimes do not separate and record waste into hazardous or non-hazardous waste such that the real quantity of hazardous waste produced by these countries is likely much higher. Findings from a study performed in Turkey revealed an estimated quantity

of medical waste from hospitals of nearly 22 tons/ day, which is about 0.63 kg/bed-day (Birpınar 446).

Houston, having one of the largest and most advanced medical centers in the world, most likely produces waste coinciding with the 0.5 kg hazardous waste/bed/day calculated by WHO, and most likely even lower than that of waste produced per bed-day in Turkey.

The practices and habits within the health care industry are hard to influence and change. Environmentalists and government agencies have noticed the problem in medical waste over several decades and have advocated and created policies to reduce the detrimental environmental impact. However, awareness is only the first step. Hospitals must change their practices relating to producing waste.

Health-care related activities serve to protect lives and revitalize wellbeing, but the waste these activities produce may impose a vicious cycle that creates toxic environments and spreads disease. According to WHO, of the total amount of medical waste created by such health-care activities, 80% is considered general waste comparable to domestic, or household waste ("Waste from Health-care Activities”). The other 20% is considered hazardous waste material that can be infectious, toxic, or potentially radioactive ("Waste from Health-care Activities").

These wastes cover a spectrum of materials including: infectious waste (waste contaminated with blood, diagnostic samples, cultures and stocks, and equipment), sharps (syringes, needles, disposable scalpels), anatomical waste (removed body organs), chemicals, and pharmaceuticals ("Waste from Health-care Activities", “Medical Waste”). WHO has calculated that infectious and anatomic waste account for about 15% of total waste from the healthcare industry. Sharps, on the other hand, represent about 1% of medical waste, but largely contribute to disease transmission ("Waste from Health-care Activities"). The fraction of medical waste capable of producing and spreading infectious disease are considered infectious waste (Klangsin 517). Nomenclature and definitions applied to medical waste across countries and even hospitals are neither universal nor consistent. The Centers for Disease Control (CDC), The U.S. Environmental Protection Agency (EPA), Joint Commission, and the Agency for Toxic Substances and Disease Registry all have different interpretations and definitions of medical waste, specifically infectious medical waste (Klangsin 517).

The assortment and inconsistent definitions make it especially hard for hospitals, even policy makers

to develop protocols and procedures that are adequate. According to guidelines prescribed by the CDC, in order for waste to be considered infectious it must satisfy four conditions: virulent pathogens, portal of entry, host resistance, and present in sufficiently high dose (Lichtvel 1990). Anywhere between 3-15% of waste is considered infectious, for this percentage depends on the definitions, which illustrates the variability in protocol (Klangsin 517).

In recent years, treatment methods have been imposed to reduce the risk of improper disposal of health-care waste. For all states, using private haulers (61.5%), pouring into municipal sewage (46.6%), and depositing in landfills (41.6%) are the most frequently reported methods of treating medical waste; percentages add up to greater than 100% because hospitals reported more than one method (Klangsin 523). Incineration is a popular technique among hospitals and waste management companies (Lee 11). Although some incineration procedures of medical waste have proven to be successful at disposing volumes of material, this process releases vast quantities of toxic pollutants into the air that indirectly cause health risks. Medical incinerators can release significantly toxic pollutants to the atmosphere including: carbon monoxide, acid gases, particulate matter, and furans (Lee 17-21, Rutala 38-9, ”Waste from Health-care Activities"). Additionally, American health care facilities have continued to dispose of nearly four billion pounds into landfills annually, making it the second largest contributor to landfills following the food industry (Kwayke 398).

FINDINGS Specific government regulations and policies were researched to track what has lead to current acts of disposal, or misuse of disposal techniques. Additionally, analyses of policies, both current and past, were essential to analyze whether hospitals are abiding such regulations, or performing against such policies. In the following sections, findings from interviews and observations conducted in Turkey and the U.S. are presented in turn. ■

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ISTANBUL

Medical Waste Policy Background in Turkey As a rapidly developing country with an emerging economy, Turkey is undergoing massive cultural and population shifts that have large effects on the medical and healthcare industries. Turkey has seen increasing incomes and changing demographics in recent years that have resulted in increased access to healthcare services to a wider population of people (Deloitte 2014). Aging population, higher incidence of chronic disease, increased economic welfare, and wider health insurance coverage have all been driving factors behind this dramatic shift in the Turkish heath care system throughout the past decade (Deloitte 2014). Needless to say, the growing population, increased access to care, and the changing face of disease profiles have placed pressure on health care institutions and government officials to improve the overall infrastructure of healthcare in Turkey. According to data from the World Bank, as of 2013 the population of Turkey stood at 74.93 million people (World Bank Group 2015). Figure 3 depicts the population dynamics of Turkey as determined by Deloitte in a 2014 study (Deloitte 2014).

Deloitte projects that by the year 2023, the overall population of people in Turkey over the age of 65 to rise by 10%, and by 2075 to rise by 28%. Additionally, as Turkey’s population begins to resemble populations of developed countries, the change in disease profile will cause significant change to the healthcare system. Increased deaths from cardiovascular disease and cancer incidence have already been recorded, and are expected to increase in the future (Deloitte 2014). These driving forces will ultimately change the types of medical supplies and equipment used by health care providers, and most likely resemble the trends in the amounts and types of waste produced by higher developed countries such as the United States.

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There are 81 provinces in Turkey, consisting of 3125 municipalities, yet there are merely13 sanitary landfills (Tarhan 2004). Of these landfills, only three are composting plants, and three are incineration plants (Tarhan 2004). Incineration is a commonly used technique to dispose of medical waste in Istanbul; however disposal to landfills is more common (Baltaci 2013). In fact, according to the National Regulations of Waste Management in Turkey, the most common method of disposal of medical wastes is dumping wastes into preexisting municipal storage areas with other types of wastes and without any regulations (Köse 2007). Starting with the construction of the first incineration plant in Istanbul in 1995, medical wastes generated by hospitals are transported and disposed of in burning units (Birpınar 446). Since then, waste volume has decreased by 95% according to statistics from ISTAC, an environmental protection and waste management company (İSTAÇ Turkey n.d.). According to the national regulation, wastes generated by healthcare services are classified into four major groups, depicted in Table 1 (Birpınar 446). This regulation classifies how waste should be properly disposed by implementing a colored bag system (Table 1).

There are several efforts and policy structures in place in Turkey focused on proper disposal of medical waste, but the solid waste management systems in Turkey are quite different than those practiced in the United States. A candidate state for admission into the European Union (EU), Turkey must adopt EU Environmental Directives into national legislation (Alagöz 2006, Birpınar 445). Not until 1991, when the Solid Waste Control Regulation came into effect, were organization and enforcement applied to the management of municipal solid waste (MSW).

By definition of this regulation, MSW consists of all waste generated by human activity and categorized as unwanted material, including medical wastes generated from health-related activities (Berkun et. al, 2005, Turan, 2008). This regulation played an integral role in the development of practices for storage, collection, and disposal of solid waste. Additionally, the Medical Waste Control Regulation (TMWCR) of 1993 and the Hazardous Waste Control Regulation created action steps for waste generators based on such principles of reuse, transportation, collection, and disposal methods (Alagöz 2006, Deloitte 2014, Goren 2010). The TMWCR regulation was the basis for improving medical waste practices throughout Turkey with the aim of regulating and establishing legal controls concerning waste management (Alagöz 2006). Until 1994, there were only estimates of MSW

generation due to popular use of open dumping and lack of tracking and recording of waste management processes. Now, the Turkish Statistical Institute (TURKSTAT) analyzes and records data concerning MSW management.

According to Dr. Kahraman, a professor in the Department of Environmental Engineering at Middle East Technical University, however, Turkey’s enforcement of waste management legislation and handling of medical waste is not as productive as some studies and statistics might suggest. According to Kahraman, recycling and sanitary disposal practices are generally ignored in Turkey (Tarhan 2004). Furthermore, there is also widespread and inadequate landfill site selection and operation of such sites, which lead to increased environmental pollution, and added risk of explosions due to stored gases (Tarhan 2004). Financial woes caused by insufficient resources in municipalities, a need for a consistent and regular accounting system between municipalities, and a lack of superior legal institutional responsibility for supervising waste management services all contribute to recurring problems with medical waste management in Turkey (Tarhan 2004).

Moreover and perhaps just as important, there is a lack of awareness and information about regulations and policies the Turkish government has created to address these major environmental issues.

government to reinforce policies and framework around waste management (Alagöz 2006, Goren 2010). According to Turkish waste management policy, medical wastes are the infectious, pathological, and sharp wastes generated during hospital-related or other medical institutional activities (Köse 2007).

Currently, large portions of medical wastes are not collected separately, and are often mixed with other types of wastes and disposed in landfills. There are also inconsistent pricing systems imposed by the Local Government councils (Köse 2007). Only a small number of municipalities use shipment vehicles to transport medical wastes. Many medical institutions dispose of these wastes directly, or mix with household wastes (Köse 2007). 2012 TURKSTAT data suggests that out of about seventy thousand tons of medical wastes collected annually, 46% of medical waste collected was disposed of in controlled landfill sites following sterilization, 28% without sterilization; 16% waste disposed of in municipal dumping sites after sterilization, and 1% without; and 8% incinerated (Baltaci 2013, Köse 2007). Furthermore, out of the total medical waste collected from the largest metropolitan cities, only 22% was collected from health care institution in Istanbul, 11% in Ankara, and 8% from İzmir (Baltaci 2013). The remaining 51% of medical waste was not recorded as collected by these institutions; thus waste from these institutions could not be accurately tracked.

Turkey still faces major challenges since current regulation still lacks critical information on medical waste management that is required by EU Environmental Directives. In the meantime, overall consumption continues to increase and outstrip current attempts to change national legislation. This situation has inevitably led to an increase in solid waste production from past years (Birpınar 445-6). Although Turkey has historically faced many obstacles concerning the management of solid waste, the rise in population and its strong candidacy for membership in the European Union (EU) have spurred the

INTERVIEWS AND OBSERVATIONS

The structure of the healthcare system of Istanbul is quite different from that of Houston. Its healthcare industry is undergoing several transformations including a growing alignment with established European systems. In Istanbul, there is a notable difference between public and private hospitals and in the patients they treat. Private hospitals are more representative, and treat nearly 20% of the Istanbul population, making up 37% of all hospitals in Turkey, 30% (152 hospitals) of which are located in Istanbul alone (Deloitte 2014).

According to a Professor of Nursing at Koç University School of Nursing, public hospitals serve a majority of the Istanbul population due to costs of care, yet they are “crowded with people,” and resemble public hospitals in developing areas, such as India (Terzioğlu 2015). There have been difficulties gathering information about public hospitals in Istanbul, as well as statistics on the disposal of medical supplies and equipment. However, information about private hospitals was available through conversations with

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the Director of Equipment at and Açibadem hospital and with contacts at Koç. Research also found that medical equipment recycling processes are being carried out in Turkey, but there is little consistency between sources on this specific subject matter.

The Açibadem Hospitals group is a private Turkish healthcare institution comprised of 18 hospitals and 12 medical centers. Since 1991, this healthcare group has become one of the leading institutions in Turkey, and has received international attention for the standard and quality of care given to patients.

Açibadem Kadikoy Hospital (Figure 3) is the first and smallest hospital of the Açibadem Healthcare Group network, currently housing about 106 beds.

This hospital was visited and the Director of Equipment was interviewed about the processes and the flow of equipment that enters and exits this hospital.

This employee spoke only Turkish, and the teaching assistant for the lab translated from Turkish to English. During the tour of the Açibadem hospital, one of the most notable talking points and attractions for patients was the up-to-date diagnostic equipment, most of which was bought from Siemens. Figure 1 and Figure 2 are examples of equipment observed in Açibadem Kadikoy.

Figure 3: Exterior of Açibadem Kadikoy Hospital (2015).

Following a tour of the Açibadem Kadikoy facility, the Director of Equipment took some time to provide further information about what policies Açibadem follows concerning getting rid of medical equipment, whether old, dysfunctional, or simply not wanted. Interview questions were designed to gain insight into where exactly this material, equipment, and waste travel after discharge from hospital. For large medical equipment, such as MRI, X-Ray, and ultrasound machines, all with many components, Açibadem has an elaborate system for disposal (Bilici 2015). In order to request new equipment for purchase, a physician or department, with a specific machine in mind will propose this purchase to the hospital administrators, whom will then send a pro-

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posal to the sellers (Bilici 2015). Açibadem actually tracks all of its equipment, and prior to purchasing any new equipment, there is a team of people who research the productivity and quality of both the new and old equipment to weigh the benefits to the patients and to the overall improvement of the hospital (Bilici 2015). The Açibadem Hospital chains have in place a system of extensive and elaborate research prior to purchasing of equipment. When machines need to be disposed, Açibadem pays to have a company transport the material to a warehouse offsite, where it is compartmentalized (Bilici 2015). The usable parts are salvaged, stored, and either donated to other domestic hospitals or shipped abroad to developing countries. The director mentioned that Açibadem has connections with physicians and health-care providers in Niger, to whom they frequently donate parts. Dead parts are sold to a metal junkyard. For hazardous and potentially radioactive components, Açibadem pays for an outside company to dispose of that waste properly (Bilici 2015). For medical supplies and wastes that are on a smaller scale, for example bandages, sharps, and surgical instruments, Açibadem has a similar disposal system.

From the information obtained during the interview, virtually 0% of usable waste goes to landfills; it was mentioned that perhaps 2-3% of waste from Açibadem ends up in landfills (Bilici 2015). According to this interviewee, whatever supplies are still usable Açibadem donates to developing countries.

Similarly, Amerikan Hospital, an older hospital in Istanbul, has policies and practices that mimic Açibadem. Both Amerikan and Açibadem hospitals are private institutions, and according to the Professor at Koç School of Nursing, public hospitals follow very different protocols (Terzioğlu 2015). According to this interviewee, nearly all of the medical waste in private hospitals is properly disposed, however it could not be confirmed whether medical waste from public hospitals is handled according to national legislation (Terzioğlu 2015). According to statistics observed by TURKSTAT, many hospitals report proper collection and transfer of medical waste. However, a large number of hospitals fail to report and are likely not taking measures to properly dispose of medical waste (Baltaci 2013, Köse 2007). While these efforts seem environmentally friendly and beneficial for developing countries, Amerikan and the Açibadem Hospitals may be two anomalies.

While visiting the Mayor’s Office in Sariyer Municipality in northern Istanbul, the Minister of Healthcare was interviewed and able to provide insight on

practices in the municipality he oversees. He spoke only Turkish, and the translator, also a Turkish-native, may have lost some information during translation to English. Regardless, the Minister mentioned that nearly 97% of medical waste that is generated from the Sariyer municipality ends in landfills (Minister of Healthcare 2015). In contrast to information obtained from the literature review and Turkish national survey statistics, there appear to be areas within Istanbul that direct an overwhelming majority of medical waste to landfills along with common household wastes. Whether this waste was regulated or not could not be confirmed by the Minister during the interview.

Açibadem and Amerikan are private hospitals that draw in wealthy, or upper-middle and upper class patients, and have more resources than a government-run, or public hospitals. Public hospitals are often not as well endowed as private healthcare institutions and thus, do not take consistent measures to properly dispose of, or donate surplus materials to developing countries. In some areas within Turkey, the public hospitals are as ill-equipped and over-crowded as some developing countries. Unfortunately, private hospitals, and personnel from those facilities, were the only people interviewed for this project; public hospitals were contacted, but no responses were received. This was likely due to existing language barriers, time constraints, and limited use of internet, or many other outside factors.

Houston

Medical Waste Policy Background in the U.S.

In the U.S., there have been several policies formulated to enforce proper disposal of medical waste.

The Medical Waste Tracking Act passed in 1988 set short-term standards for federal government regulations of medical waste in four states and Puerto Rico (U.S. Congress 1988). Section 3 of this act actually defines medical waste as “any solid waste that is generated in the diagnosis, treatment, or immunization of human being or animals, in research pertaining thereto, to in the production or testing of biological,” (Lichtvel 1990). Medical waste, infectious waste, and regulated medical waste are each subsets of hospital waste (Klangsin 517). In 1991, when the Act expired, states were given autonomy over laws and regulations concerning the disposal of medical waste.

In Texas, statewide policies and regulations were considered in 2006 under the advocacy of the Texas

Commission on Environmental Quality. This is a regulatory guide to assist those generating medical waste, so health-care providers and facilities, as well as transporters of unwanted medical waste, and operators of medical waste treatment facilities (Texas 1-5). According to Texas policy, medical waste is defined as “regulated medical waste,” and “special waste,” which includes only untreated medical waste (Texas 1-2). Specifically, special waste would include any waste directly coming from animals that have been exposed to pathogens, blood contaminants, pathological waste, or sharps. Generators of medical waste, according to TCEQ policy, are required to properly package, label, and weigh equipment for off-site treatment. Additionally, generators are required to obtain a receipt as well as keep records of all shipments of untreated medical waste for at least three years following the date of shipment; these records must be kept available for potential inspection by the TCEQ (Texas 3). Mainly, Texas policy for generators of medical waste requires parties to notify the TCEQ of operations and maintain records of such efforts. Whether TCEQ are notified of operations, or if consistent records are indeed kept by health care administrators is unknown.

The Texas Administrative Code (tit. 30 §330.1207), lists rules for which generators of medical waste should be familiar with including methods used to classify medical waste, and requirements for shipment of untreated wastes when it leaves the hospital or health-care facility, and concerns proper marking and classifications of such waste. These policies lay out clear guidelines for facilities to abide by, but the enforcement and maintenance of such policies can only be measured by the percentage of medical waste improperly handled and disposed of; a problem that is very much still apparent within the scope of current health-care disposal practices.

INTERVIEWS AND OBSERVATIONS

It is estimated that nearly $200 million worth of prepared materials are disposed unused in the U.S. (Rosenblatt 400). Especially in the surgical field in the U.S., unused medical supplies are disposed a regulated medical wastes simply because there is a hospital surplus, and the supply has become unsterile. Nationwide, the disposal of usable materials results in being one of the most costly expenditures in the health care industry (Rosenblatt 400-401).

Yet, little action has been carried out to determine the true extent to how much medical supply loss is generated and what kinds of surgical supplies are

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most frequently wasted. Turkey is no stranger to this act of disposing usable medical supplies as well.

Specifically in private hospitals institutions, there are large surplus of medical supplies that are circulated into the process of improper disposal. With several millions of dollars of medical supplies wasted every year by developed countries, and viewed against nations facing severe deficits and shortages in the amount of medical supplies and resources available for treatment, it is unsettling and startling.

An interview with the Senior Vice President of Shared Services in the Texas Medical Center (TMC) supplied knowledge of medical waste generation and donation policies within the greater scope of the Texas Medical Center in Houston. He mentioned that even within the medical center, there are large and drastic differences existing on a spectrum between procedures, policies, and practices among different hospitals and on how they approach medical wastes (Stokes 2015). MD Anderson he said for example, is on the far positive side of the spectrum of potential practices; it is an anomaly much like what was seen within the practices in the Açibadem Kadikoy hospital. Currently, there are no consistent measures taken to track and monitor the amount or number of medical supplies at hospitals within the TMC, thus a hospital seeing a large surplus of supplies is a common occurrence (Stokes 2015). So what happens with the surplus supplies? The question, “When new supplies, for example, plastic tubing are ordered, where do the old ones go if there is not enough storage space?” was asked specifically during the interview. The interviewee’s response was that the surplus materials are likely sitting in a warehouse not being used, rather than most of the waste going to landfill. Although he himself could not confidently confirm, he had a strong assumption; it seemed “pretty likely,” (Stokes 2015). These warehouses are dotted around the Houston metropolitan area filled with equipment that is hardly regulated and hardly ever tapped into for supplies. These warehouse essentially serve as little more than hidden landfills and dumping sites for excess supplies and equipment found in surplus in hospitals and other health care facilities. Although he was not entirely confident on the percentage of waste filtering into landfills, he mentioned it being a low percentage (Stokes 2015). Secondly, he mentioned that donations were widely common among hospitals in Houston and in the TMC, Medical Bridges being a major recipient (Stokes 2015).

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Only in the last few decades has the medical industry in Houston begun grasping the core and the true repercussions of this medical waste problem. The amount of waste health-care facilities generate, and efforts made decrease amounts are aimed at understanding the potential resourcefulness and usability of materials, any materials, in developing nations several organizations and philanthropic efforts have arisen to help bridge the gap between the surplus in medical supplies.

Medical Bridges is a non-profit medical surplus recovery organization (MSRO) aimed to bridge this healthcare gap between developed and developing nations by gathering medical supplies and equipment and redistributing these materials to organizations in the developing world. The Director of Operations (D.O) at Medical Bridges focuses on the procurement of surplus medical supply product donations gave first-hand insight on what a non-profit such as Medical Bridges does. According to the D.O., in the U.S. alone, about nine billion pounds of medical surplus goes to waste every year (Judkins 2015). Although a large portion of that waste does end up in landfills, a portion of that is stored in warehouses, and a portion are donated to organizations such as Medical Bridges, or sold (Judkins 2015). In the scope of the MSRO, a major barrier to the flow of supplies and equipment through their service are these outsourced, second-hand sellers that operate much like eBay (Judkins 2015). Healthcare facilities sell companies their wasted, but still useful equipment, then these companies resell or auction those others whom repurpose or then resell the material.

An even bigger barrier for hospitals is that it takes time, resources, and connections to donate, whereas resale shops are often found online and have completely electronic processes. Needless to say, Medical Bridges have formed extensive connections with healthcare facilities within Houston, and receive thousands of pounds of equipment every fiscal year.

The interviewee argued that hospitals currently run and thrive off of a system of surplus. Hospitals, in normal operation tendencies, buy supplies that are found in abundance without knowing that such supplies already exist. This could partly be attributed to faulty communication between hospital staff and inadequate tracking and documentation of supplies across departments within hospital systems, or several other factors depending on the specific hospital and resources available. Currently medical equipment consumers are much more likely to buy additional equipment before checking to see what

already exists. The system of surplus that hospitals use to operate is particularly counterproductive in terms of generating medical waste (Judkins 2015).

Following the interview, the Medical Bridges facility was toured and observed. Currently, the facility holds over 3500 parts to review and donate to partner countries. They receive supplies (syringes, bandages, tubing), equipment (nebulizers, x-ray, incubators), and furniture (beds, tables, dressers). Medical Bridges is not a lone ranger in the medical industry; there are several similarly based non-profits spotted throughout the state of Texas, and nationwide. In Turkey even, there are similar efforts as well, such as the Turkish Red Crescent.

Similar differences between private and public hospitals were observed in Houston, although these differences are not as marked as those seen in Turkey. Private and well-resourced hospitals, such as MD Anderson Cancer Center, have elaborate and well-defined processes of disposing medical waste, larger machines and smaller medical supplies included, much like what was observed in the private hospitals in Istanbul. According to an interview conducted with a Pathologist at MD Anderson, employees recycle as many materials as possible, and that their equipment is properly disposed of by hiring an outside company to ensure safe and environmentally-friendly disposal (Sahin 2015). Needless to say, there are still venues for equipment to be wasted, most notably in the surgical and diagnostic setting. Although several healthcare facilities in the U.S. practice proper handling and disposal procedures for medical waste, many still do not. Even within hospitals that exhibit proper waste disposal behavior, such as MD Anderson, it is not simply the appropriate practice that affects the amount of waste generated, but also on the types of materials, supplies, and equipment purchased.

MEDICAL KITS: A CULPRIT OF THE PROBLEM

Some hospitals are seeing an increase in pre-packaged medical supplies, or “kits,” as they are called (Sahin 2015). Medical kits have proven to be quite useful in recent years. Many equipment and instruments often come in pre-packaged kits, which provides easier means of transportation, storage within facilities, and provide accurate aid for routine and emergency medical situations (Medical Kits & Equipment, Sahin 2015). However, the equipment or instruments in these kits is used for the precise procedure at-hand, whatever that procedure may be. After the kit is open however, the instruments

become unsterile. Thereafter, physicians are more likely to simply throw away perfectly good, yet unneeded medical supplies. It costs money to re-sterilize equipment and instruments, and it is seemingly less costly and timesaving to toss the extraneous material. However, a large proportion of materials in such kits are wasted due to several reasons. Even if such materials are re-sterilized, there are identical kits with the same materials present, which create a surplus of materials that continue to add up. Houston, housing one of the largest medical centers in the world, definitely makes a large footprint on this number. However, greater than 25% of U.S. hospitals are utilizing reprocessing as a mean for decreasing the tons of medical waste generated per year (Kwakye 2).

COMPARISON OF MEDICAL WASTE MANAGEMENT IN U.S. AND TURKEY

Both in the U.S. and Turkey, Houston and Istanbul, policies have framed detailed procedures for the proper disposal of medical wastes. However, several factors lead to improper placement of hazardous materials in landfills. Policies set rules for health-care providers to abide by when disposing wastes, yet there is little regulatory enforcement behind such policies for facilities in both Turkey and the U.S. Moreover, and perhaps a bigger problem, there is a miscommunication between policy makers and providers of health care concerning proper disposal.

Hospitals both in the U.S. and Turkey operate on a system of surplus, in which supplies and materials are continually purchased despite having an endowed stock of the exact or similar supplies. Simply, even though the policies are drafted, passed, and in effect, there is a lack of awareness of where and how to properly dispose of medical wastes. Whether a majority of material deemed medical waste is completely inoperative, or if the waste consist of usable materials (beddings, sharps, and instruments, etc.) simply found in surplus and in operable condition.

Within the masses of wastes generated by healthcare activities, facilities, and institutions, how much of that ‘waste’ are usable goods? What proportions of supplies are simply thrown out because new equipment has misplaced old, or because consumers over order bandages or bedding sheets?

MEDICAL EQUIPMENT IN DEVELOPING NATIONS: NOT A SIMPLE ACT

The title of a 2008 NBC News article, 10 million children die from a lack of health care, speaks clearly

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of the issue developing nations face. More than 200 million children under the age of 5 do not have access to basic medical care, leading to the daunting number of annual child mortality rates in developing regions. Fast forward seven years to the present, this number is likely much higher, and broadening this population to all age groups, an even higher estimation.

The act of donating medical equipment and supplies to developing countries is an act easier said than done. There are several barriers that may pose as hindrances for successful use in such regions.

Medical equipment donations, indeed, have the power to enable hospitals in developing countries to have access to advanced and much-needed technology (Jones 2013). However, there are legitimate and growing concerns that these donations are creating more impairments than benefits (Courage 2012). According to a published online report in 2012, an estimated 40% of medical equipment is out of service in developing countries (Howitt 3). Likewise, WHO has calculated that nearly 80% of medical equipment is donated or funded through foreign services, and only 10-30% of those donations are implemented to an operable state (Medical device donations 2011).

According to Howitt, there are three fundamental barriers that prevent technology from making a greater contribution to global health in developing countries: availability, accessibility, and acceptability (11). Technological equipment that is donated must be able for use in a resource-poor setting, one without sufficient supply of energy, human resources access, and usability (Howitt 11). Many resources and equipment used in developed countries are designed for environments with access to sufficient energy supply and large numbers of trained health care providers, and when these types of equipment are donated to countries without these fundamental resources, problems arise, and equipment virtually becomes trash (Courage 2012).

Needless to say, when large amounts of medical waste are produced annually by developed countries such as the U.S. and Turkey, in cities such as Houston and Istanbul, how can hospitals or healthcare-focused organizations better mobilize efforts to bridge gaps between access to medical care in developed and developing countries? Through research and interviews, observations and conclusions suggest that if regulations are upheld and organization such as Medical Bridges gain more support, hospitals in both locations can develop abilities to filter out usable yet unneeded supplies and equip-

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ment and better support implementation to developing countries.

CONCLUSIONS AND IMPLICATIONS OF RESEARCH

The inequalities existing in access to health care for populations in developing nations and populations in developed nations are wide and only increasing.

Several countries with established medical industries and resources are active in donating to developing regions, but the act of donating is not enough to supplement disparities.

The U.S. and Turkey, specifically Houston and Istanbul, were studied to determine how much medical supplies and equipment are generated as waste, and whether such wastes are supplies that are still usable. Additionally, research was aimed to determine whether organization and hospitals had incentives to support the donation of what are usable wastes into developing countries. The problem of waste generation within the health care industry has been long standing, yet perceived as stable.

Such that, health care providers are not considering the environmental footprint supplies leave once thrown away, especially when such supplies are usable. Usable or not, healthcare institutions fail to consistently monitor and report to environmental agencies where medical waste from facilities travels. With additional awareness of regulations and sufficient training of health care providers, this can be changed; amounts of medical wastes in landfills can be decreased, and amount of usable supplies filtered into developing countries increased.

The act of throwing away medical equipment improperly is a simple act, a seemingly unmeasurable operation. Yet, if health care providers are empowered to become more aware of their actions, develop and enforce proper disposal of medical waste, maybe, just maybe people would start to notice the large quantity of medical supplies and equipment that are being misused and underused. Change is not simple under any circumstance, but if hopes of decreasing the amount of usable medical material in landfills and increasing the amount of usable material sent and donated to developing countries are to be fulfilled, change must happen. The medical supplies and equipment we waste may save the lives of those who are denied such privilege and such resources; ambitious it might be, yet a simple realization. â–

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AN ASSESSMENT OF WETLAND VALUATION IN OUTLYING AREAS OF HOUSTON & ISTANBUL

By Avantika Gori

EXECUTIVE SUMMARY Across the world wetlands and other vital natural ecosystems are degraded more and more each year.

Given that wetlands provide a multitude of ecosystem services, such as carbon sequestration, fishery support, migratory bird habitat, recreational/cultural value, as well as many others, it is imperative that urban communities take actions to preserve these spaces. This paper aims to understand the value of wetlands in the outlying areas of Houston and Istanbul. Specifically, this paper explores the ecosystem functions that benefit each city, investigates how these services are valued, and seeks to discover the origins and actions of wetland protection initiatives. In Houston, coastal saltwater marshes are primarily valued for their ability to sequester large amounts of carbon each year, and provide nursery habitat for shrimp and other fish. Preservation actions in Houston have focused on restoring degraded wetlands, and been made possible due to funding from government agencies and local NGOs. On the other hand, in Istanbul freshwater wetlands surrounding the city provide key water purification services, and provide much-needed habitat space for migratory birds. Environmental activism in Istanbul has often started at the grassroots level, with local NGOs advocating greater protections for these important natural spaces. Both cities have begun to realize the great importance of wetland ecosystem services, and steps have been taken toward integrating the natural environment with the urban environment in a way that is mutually beneficial.

INTRODUCTION The United States Environmental Protection Agency defines wetlands as areas that “are inundated or saturated by surface or groundwater” and that support “a prevalence of vegetation typically adapted for life in saturated soil conditions” (Wetland Definitions, 2014). More generally, wetlands serve as a nexus between land and water, conveying sediments, nutrients, and energy between the two systems (Wetlands Overview, 2004). In addition to supporting the health of connected land and aquatic ecosystems, these transition zones also provide crucial habitat space for a wide range of plants and animals. Wetlands, marshes, and bogs provide nursery support for many juvenile fish and mammals, while also serving as important rest stops for migratory fowl.

Due in part to the ecological significance of these areas, and the trend in severe wetland degradation observed in the past century, there has been a push for wetland preservation and restoration among the global community. These sentiments were codified in the Ramsar Convention of 1971, which outlined wetland identification criteria, and encouraged nations to designate wetland sites of ecological/cultural importance as protected areas (U.S. Fish and Wildlife Service, 2014). This convention and international treaty catalyzed movements within many countries toward greater wetland protection and restoration.

As more attention has focused on protecting and enhancing degraded natural ecosystems, methods for quantifying the value of specific ecosystems have become more popular. The concept of ecosystem services aims to identify specific services that are provided by natural ecosystems and are utilized by humans. Wetlands in particular have the ability to sequester substantial amounts of carbon dioxide per year, provide nursery habitat for juvenile fish and crustaceans, store and purify freshwater inflows, and provide an aesthetically valuable recreational space for the public. These services are public goods their values not fully captured by commercial markets - and consequently are often undervalued by decision-makers (Costanza, 1997). Ecological economist Robert Costanza was one of the first to attempt broad-scale quantification of ecosystem value, and estimated that wetlands alone provided a value to humans of 140,000 USD per hectare of wetland per year (Costanza, 2014).

The outlying areas of both Houston and Istanbul are home to critically valuable wetlands. In Houston, these wetlands are found in Galveston Bay (figure 1), and consist mostly of coastal salt marshes. In Istanbul, freshwater wetlands surround several important lakes and streams on the outskirts of the city (figure 2). As urban expansion and development have continued in the 21st century, an alarming trend

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of wetland loss and degradation in these outlying urban areas has been observed. Along the Gulf Coast, wetlands have been lost at a rate of around 57,000 acres per year (Dahl & Stedman, 2013). Within Galveston Bay, this loss has primarily been due to increased coastal development and oil and gas related activities. In the outlying areas of Istanbul, wetland loss has occurred in large part because of the so-called “crazy projects” – large infrastructure endeavors – that are being pursued by the Turkish government. In both cases, the desire for urban development conflicts with the ecological need for these ecosystems. These trends in wetland loss provide the motivation for this research paper, and demonstrate the need for more thorough wetland valuation by policy makers.

ISSUE STATEMENT This paper seeks to understand the specific wetland functions and services that are valued by the public in Houston and Istanbul. Though wetlands provide a wide range of services such as nutrient cycling, animal habitat, and recreational space, different urban areas value and rely on these services to different degrees. In Houston, the specific ecosystem services that have been identified as important are carbon sequestration and fishery support. In Istanbul, freshwater purification and migratory bird habitat will be the two services discussed in this paper.

Wetland conservation and protection efforts will be evaluated in order to understand how the public views wetlands, and to understand the relationship between urban space and the natural environment. In addition, special attention will be given to initiatives that encourage recreational use of wetlands, such as bird-watching, hiking, biking, etc. Through studying the recreational use of wetland spaces, the cultural and heritage value of wetlands can be evaluated as well. These two services are often neglected in wetland studies, but are vitally important from a sociological standpoint.

Figure 1 – Satellite image of important wetland sites around Istanbul

Figure 2 – Satellite image of Galveston Bay

Thus, this paper aims to capture the ecological and social importance of wetlands to the urban spaces of Istanbul and Houston.

METHODS

In order to understand the ecological value placed on wetlands in Houston, studies conducted in the Gulf of Mexico, and specifically Galveston Bay, were collected, analyzed, and then reported upon in this paper.

Specific emphasis was placed on studies that quantify wetland functions, such as the amount of carbon sequestered per acre.

Similar research was conducted for outlying areas of Istanbul, focusing on specific lakes and water bodies that hold ecological significance in the area. Dr. Melek Alhan, Professor of Civil Engineering at Istanbul University, was interviewed about on-going research on Istanbul wetland services and about wetland sites that are under ecological threat.

Research on public awareness and social value placed on wetlands was more subjective and qualitative.

In Istanbul, this research came from interviews with

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several decision-makers including a Koc university professor, director of the Istanbul Policy Center Dr. Korel Goymen, and local municipality deputy mayor Sevgi Atalay. The purpose of these interviews was to shed light on the value the government places on wetlands, as well as the value perceived by the general public. In addition, research was done online to track actions and literature produced by Turkish environmental groups. In Houston, the research on social awareness and social action has relied on several case studies of wetland restoration along Galveston Bay. These restoration efforts have been undertaken by various federal agencies, such as the National Oceanic and Atmospheric Administration (NOAA), as well as non-profit organizations like the Galveston Bay Foundation. In both Houston and Istanbul, special attention has been given to initiatives that encourage public involvement in advocacy and restoration efforts.

Research Carbon Sequestration in Houston Wetlands Wetlands have the ability to sequester substantial amounts of atmospheric carbon, and store this carbon in their soil. Carbon dioxide in the air is trapped in wetland sediments, or stored in plant biomass.

Plants are able to sequester carbon dioxide in the air through photosynthesis and use this CO2 to grow leaves, roots, stems, etc. This process is called carbon “fixation”, and occurs over many years. When plants die, part of their biomass is buried under the soil, which effectively traps much of the carbon underground. Since wetland soils contain low oxygen levels, carbon dioxide can persist in the soil for many years without degradation (Lal et al, 2004).

Coastal marshes are unique because tidal flows cause sediments to accumulate on top of each other.

Via this mechanism, carbon is buried underneath the soils and prevented from escaping back into the atmosphere. Because coastal marshes are constantly vertically accreting, they are able to continuously sequester carbon from the atmosphere (Mcleod et al, 2011). Thus, coastal marshes have the potential to offset some of the carbon emissions resulting from urban activity in the Houston region.

Since carbon sequestration rates are heavily dependent on sedimentation rates and flooding/tidal patterns, it can be difficult to quantify the carbon offset potential of wetlands. A study conducted on coastal marshes in the Gulf of Mexico found that on average they can sequester around 2500 lbs of atmospheric carbon per acre of wetland per year (Engle 2011).

This represents a significant amount of carbon that

is removed from the atmosphere each year. Some studies find that coastal wetlands can sequester carbon at a rate ten times higher than other wetland types (Bridgham et al, 2006), making them uniquely valuable to the Texas coast. Furthermore, wetland sequestration potential may become increasingly important in the future. As the sea level continues to rise, marshes and wetlands are able to adapt and expand inward in order to accommodate the higher water surfaces. As marshes move landward, “high marsh” areas transition to “low marsh”, and are able to sequester more carbon per acre (Choi et al, 2001).

The expansion of marshland occurs naturally as long as undeveloped land is available at the coast.

Given the geography and topography of coastal wetlands in Galveston Bay, they are well-suited to provide carbon sequestration services to the Houston community. Though not a directly tangible service, this function is critically important on a macro-scale, and has the potential to provide long-term carbon offsets to compensate for emissions coming from the Houston area.

Fishery Support in Houston Wetlands Shrimping and fishing along the Gulf of Mexico, and the Texas coast specifically, are vitally important industries. In the Gulf alone, shrimping accounts for billions of dollars of economic activity, with around 30% of this value attributed to the Texas Coast (Commercial landings data, 2003). In 2001, over 77 million pounds of shrimp resided along the coast of Texas, making shrimping one of the most lucrative coastal economic activities (Commercial landings data, 2003). Specifically in Galveston Bay, recreational and commercial fishing and shrimping is valued at three billion dollars, and these activities support over 40,000 jobs in the Bay (Wetlands Restoration).

The vibrancy of the fishing industry in this area is due in part to the abundance of coastal marshes and wetlands that provide nursery support for juvenile shrimp and crustaceans. The vegetation and shallow water of coastal wetlands provide protective habitat for growing shrimp as they swim between the vegetated complex of the marsh and the open water. Extensive research has been done to quantify the value of coastal marshes for fishery support, and much of this research has been conducted within Galveston Bay. Minello et al (2008) found that the wetlands of Galveston Bay can support nearly 35,000 shrimp per hectare and over 15,000 blue crab per hectare.

These values are 2-4 times higher than shrimp and crab populations observed in open water. Wetland

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complexes not only support much higher numbers of crustaceans per hectare, they also decrease the risks of crustacean mortality. Haas et al (2004) found that juvenile shrimp survive best in regions of high marsh vegetation. The study also noted that densely vegetated marshes reduce shrimp mortality by reducing the distance of open water shrimp must traverse to move from marsh to marsh.

Water Treatment in Istanbul Wetlands Wetlands are efficient tools for remediating contaminated water because they are able to treat many types of contaminants and require little to no maintenance. Many countries in Europe have even started building wetlands for the purpose of water purification, as an environmentally friendly alternative to traditional wastewater purification plants (Chen et al, 2009). In Istanbul, research is being conducted on the ability of wetland soils and vegetation to remove both organic and heavy metal pollutants from wastewater and urban runoff.

Natural as well as constructed wetlands remove pollutants through several different mechanisms. Wetland soils are able to remove contaminant particles through the process of adsorption (whereby toxic molecules stick to the surface of soil particles), and this accounts for a large portion of heavy metal removal. Another mechanism involves wetland plants, whose root systems catch and hold toxic chemicals.

Many wetland reeds are able to hold large concentrations of toxins in their root system without harming the health of the plant. Different species of microorganisms present in the soils break down organic contaminants through degradation processes, constituting the third mechanism of pollutant removal. Chen et al (2009) conducted a study on heavy metal removal in wetland soils and determined that different wetland soils were able to remove between 95-99% of the lead (Pb) measured in the inflowing water.

During a visit to Dr. Melek Alhan’s hydrology lab at Istanbul University, first-hand observations of heavy metal adsorption in wetland soils were noted. Dr. Alhan gave a tour of her experiments in the lab, and explained how each experimental apparatus worked. Notably, Dr. Alhan described her research into the ability of soils from the wetland area of the Kucukcekmece Lake (refer to Figure 1) to remove arsenic (As) and lead (Pb) from urban runoff. Her research simulates urban stormwater runoff into a lake by setting up several different wetland cells

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at the research lab. Water was directed through these cells and incoming and outgoing levels of Pb and As were measured. This experimental set-up was observed during the visit to her lab. Dr. Alhan explained that her research was motivated by the increase in industrial facilities surrounding the Kucukcekmece Lake, which have produced water runoff with high concentrations of heavy metals. Her research aims to assess the degree to which wetlands can remediate urban runoff.

Research into runoff remediation by wetlands has also focused on organic pollutants. A study conducted by Ayaz (2008), and commissioned by Istanbul Water and Sewage Management, identifies the need for wastewater treatment for small settlements in the outlying areas of Istanbul. Specifically, the settlements around the Omerli dam (one of the main drinking water reservoirs for the city) do not have wastewater treatment systems, and end up dumping their wastewater into streams that feed into the Omerli reservoir. Researchers believe that the use of constructed wetlands in these areas could provide a low cost method of water treatment, and serve as an aesthetic improvement for the communities. Three types of wetlands were constructed at a site in Istanbul, and monitored over a period of three years. In this time biological oxygen demand (BOD), chemical oxygen demand (COD), total organic carbon (TOC), and coliform removal efficiencies were quantified.

Biological oxygen demand was significantly lowered by the constructed wetlands, with a removal efficiency of almost 77% in some cases. In all cases coliform removal was very high, with removal efficiencies greater than 90% in all cases, and up to 96% under certain conditions.

Migratory Bird Habitat in Istanbul Wetlands and marshes in the outlying areas of Istanbul support a wide array of migratory bird species.

These areas act as rest stops for birds that make long migration journeys, especially those species crossing the Bosporus Strait, or those coming from Europe.

This area covers an estimated 660 hectares, and without this critical habitat space, it is estimated that many birds would perish, and the rich biodiversity of this region would be lost.

Some research has been done to quantify the importance of these wetlands in relation to migratory bird habitat. Studies conducted near the site of the airport have identified many different species of storks, falcons, buzzards, and eagles that fly over the

region. It is estimated that at least 500,000 storks and 250,000 raptors fly through Turkey each year.

Istanbul is located along one of the main spring migratory routes, so large numbers of these birds pass through the outlying areas of the city. Another study conducted by Porter and Willis (1968) surveyed migration through the Bosporus and found that around 250,000 birds flew through the survey site in a single autumn season. In addition to numerical estimates of birds, researchers have also attempted to quantify species use of this migration route. Arslangundogdu (2011) monitored autumn migration patterns at a site around the southern tip of the Bosporus. It was found that 27 different species of birds from 4 different families and 3 orders utilized the strait as a migration pathway.

Government Policy and Public Awareness – Houston Given the importance of Houston wetlands to the fishing industry, and due to the significant cultural and heritage value these wetlands hold, there has been a large push in recent years to preserve natural marshland and restore degraded wetlands. Several marsh restoration projects have been successfully completed in Galveston Bay and several more are currently in progress. Minello et al (2012) documented nine different restoration projects, each occurring in a different region of the Bay. The study documented the specific restoration techniques employed, such re-planting vegetation and restoring sediments to the sites. Though the restored wetlands could not support the same amount of fish as natural wetland areas, the projects succeeded in greatly increasing fish populations relative to pre-restoration levels.

Funding for restoration projects of this nature comes from several different sources. Many non-governmental organizations (NGOs) raise money for restoration projects, and often work in conjunction with government agencies. For example, the Galveston Bay Foundation (an NGO committed to restoration of the Galveston coast) partnered with NOAA (the National Oceanic and Atmospheric Administration) to restore a marsh in the upper reach of the Houston Ship Channel. This project relied on over 100 volunteers to rebuild and restore thirty-three acres of a degraded marsh (Burnet Bay Habitat Restoration Project). Other projects conducted in the Bay have relied on private donors, such as the Snake Island Restoration Project. Two neighboring landowners, who were concerned about wetland loss in the Bay, funded this restoration project. (Snake Island Restoration Project).

However, recent actions toward wetland restoration do not completely make up for the losses in wetland area that have been observed since the 1950’s.

Between 1950 and 2002, over 1500 ha of salt marsh, 1600 ha of tidal flats, and 1000 ha of sea-grass beds were lost (White et al, 2004). The causes of wetland loss in this region are numerous, and can be directly traced to anthropogenic activities. Marshland loss occurred primarily due to subsidence, shoreline faulting, and local development. Subsidence in Galveston Bay became a major problem because of over-use of the underlying aquifer. In order to satisfy the water demands of a growing urban city, more and more water was pumped from under ground, causing the land to sink almost 3 meters (White et al, 2004). In addition, faults (or fractures in the earth’s crust) have also caused many wetlands to be wiped out. Many researchers believe faults in the Galveston region have become active due to increased oil and gas pumping (White et al, 2004). The increase in oil and gas activity outside Houston could explain part of the trend of wetland degradation that has been observed since the 1950’s.

Government Policy and Public Awareness – Istanbul In Istanbul, the relationship between the government and environmental groups is more complicated than in the Houston region. While visiting Istanbul, it was observed that the term “crazy projects” was frequently used to describe large infrastructure projects being spearheaded by the central government. These projects included a third bridge across the Bosporus (being constructed currently), a third airport for the city (early in construction period), and a second canal through the city (still in development phase). These projects in some way characterize the priorities of the central government, and represent a desire for continued urban expansion and development. This desire is by no means unwarranted, as the city of Istanbul continues to grow rapidly each year. Rapid population growth and economic development have resulted in a significant increase in car usage and reliance on Istanbul’s transportation infrastructure. Currently, more than 1.3 million vehicles drive through the city every day, placing strain on the two bridges that convey traffic across the Bosporus Strait. Projections estimate that 4.2 million vehicles will utilize the Istanbul transportation system by 2023 (Environmental and Social Impact Assessment, 2011), which demonstrates the need for an expansion of the transportation network.

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However, many of these infrastructure projects will cause detrimental environmental effects to wetlands in the outlying areas of the city. For example, the site of the third airport is currently home to many small lakes and ponds that make up nearly 660 hectares of wetland space (Bayradkar & Durmaz, 2014). These wetlands are vital resting stops for migratory birds that fly through this region from across the Bosporus. Without this critical habitat space, it is estimated that many birds will perish, and the rich biodiversity of this region will be lost. Furthermore, these wetlands and the streams emanating from them serve as important recharge sources for Lake Terkos, which provides 22% of drinking water for the city of Istanbul (Bayradkar & Durmaz, 2014). Draining of these wetlands could cause water shortage problems in the future. Another so called “crazy project” is the Canal Project, which would cut another sea route through the outside of the city to connect the Black Sea and the Sea of Marmara. While it is true that ship traffic has greatly increased through the Bosporus in the past several years, this canal would have irreversible negative impacts on the wetlands of the Istanbul region. The Kucukcekmece Lake and the Buyukcekmece Lake are located in the southern part of Istanbul and near the projected route of the canal.

These two lakes are important ecological assets, and had previously been designated as protected areas.

These two lakes would be completely destroyed during the construction of the canal. The wetlands along the banks of these lake not only serve ecological functions, but also hold significant heritage and cultural value. The Kucukcekmece Lake has several cave settlements and lighthouse ruins along its banks that date back several hundred years. These ruins hold important cultural significance.

In response to the announcement and construction of these “crazy projects” there has been a backlash by some members of the public. Notably, during a conference with several government officials from Sariyer, one of the northern municipalities of Istanbul, the deputy mayor (Sevgi Atalay) voiced concerns about the forested wetlands of Sariyer being destroyed by the third Bosporus Bridge. The deputy mayor stated that the forested areas of the municipality are considered valuable by the local government, and that the municipal government opposed the construction of the third bridge. According to the deputy mayor Sevgi Atalay, Sariyer has the largest forested area of any municipality, and the public utilizes this area for picnicking, jogging, and other recreational activities

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One professor at Koc University in Istanbul (who spoke on the condition of anonymity) explained that many environmental movements – especially in regards to wetland preservation – occur at the grassroots level since public officials often are hesitant to speak against the policies/actions of the central government. This theory was confirmed in some respects when one of the senior members of the Istanbul Policy Center, Dr. Korel Goymen, seemed hesitant to answer questions about the status of wetlands located at the site of the third Bosporus bridge. On the other hand, environmental groups have been vocal and active in their calls for wetland protection. In response to the siting of the third airport, BirdLife International (an environmental NGO) organized a meeting in Istanbul to protest the construction of the airport, re-iterating the devastating effects its construction will have on migratory birds (Bayradkar & Durmaz, 2014). Other opposition voices have been published in popular news sources in Istanbul. For example, the Turkish paper Today’s Zaman has published many opinion pieces, blogs, and reports advocating wetland protection in Istanbul. In one article the paper states that Turkey’s wetlands are “under an increasing threat from the destructive policies of the Justice and Development Party (AKP Party)” (Altintas, 2014).

FINDINGS In both Houston and Istanbul wetlands provide valuable services to the urban population. These services differ in each city and have been valued and utilized in different ways through the 20th and 21st centuries. The degradation of wetlands that occurred in Houston throughout the 20th century demonstrates that Houston policy-makers had been greatly under-valuing these wetland services. By encouraging development of the coast and increasing the oil and gas activities in the area, decision-makers effectively sacrificed wetland space in favor of greater urbanization. This phenomenon is not unique, and has occurred in many growing cities across the globe.

In many ways, the Houston urban space has been in conflict with the natural wetland space of the coast.

However, in the past couple decades the public and government have largely adopted a new mindset in regards to wetlands. Instead of viewing these natural spaces at odds with the urban environment, there has been a push to integrate the two spaces and allow each to benefit from the other. Restoration efforts of Galveston Bay marshes have aimed to revitalize the fishing industry of Houston, and have encouraged community involvement in wetland

protection. Government funding has been made available to educate the public on the value and importance of these ecosystems, and state parks on the Bay have allowed wetlands to be utilized for recreational purposes. The research efforts being conducted on carbon sequestration in Gulf Coast marshes demonstrates a desire to understand the macroscopic benefits of wetlands. As more attention has been focused on cutting carbon emissions in urban areas, this type of research signifies another way that Houston can rely on its outlying wetlands.

While Houston’s environmental movement in regards to wetlands has largely occurred through a top-down approach – whereby large amounts of government funding have been made available to restore wetland sites – Istanbul’s environmental advocacy has occurred at the grassroots level. Given the tremendous growth experienced by the city of Istanbul and the resulting strain on the transportation systems from this boom in population, it is justified that the government has made large infrastructure projects a top priority. In fact, many journalists and government officials have begun using the term “crazy projects” to describe these large infrastructure endeavors. However, many advocacy groups and academics are seeking ways to reconcile urban expansion and development with natural ecosystem preservation. The use of wetlands for water purification purposes has been extensively researched in Istanbul, and could provide a natural alternative to conventional wastewater treatment methods. This potential is starting to be realized by academics and government agencies – the wetland pilot study referred to above was funded by an Istanbul municipal agency. Recognizing the water treatment value of wetlands in Istanbul by academics and municipal policy-makers is the first step toward more comprehensive wetland protection.

Migratory bird habitat is another issue of importance in Istanbul. Many groups within the city are becoming more aware of the threat to migratory birds and the habitat value that freshwater wetlands have. The activities of BirdLife International aim to educate Istanbul residents about the rich biodiversity of the city, and many articles published in papers like Today’s Zaman call for the recognition of Turkey as a globally important biodiversity hotspot. Opponents to the third airport and Canal Project have placed large emphasis on the potential deaths of thousands of migratory birds. These efforts exemplify the nature of many grassroots movements that aim to preserve the natural landscape of Istanbul. In addition, the public interacts with wetlands in several different

ways. Bird tours of Turkey are popular, and Ms. Atalay of the Sariyer municipality explained that picnicking near wetlands and marshes is common among Istanbul residents. Viewed holistically, it can be seen that many groups within the city share a vision for Istanbul that encompasses both urban areas and outlying natural ecosystems.

CONCLUSIONS

This paper has investigated the wetland ecosystem services potential in outlying areas of Houston and Istanbul. This research has aimed to understand what functions these wetlands serve and investigate on-going preservation initiatives in both cities. In Houston, wetlands provide a multitude of services including carbon sequestration benefits, and nursery habitat for juvenile shrimp and crab. In Istanbul, wetlands are able to treat polluted urban storm runoff, and serve as vital resting stops for traveling migratory birds. The analysis of academic literature conducted in this paper has demonstrated the high value of these services to both cities, and has explained the need for conservation actions. Specific environmental initiatives in both city have been investigated, and it has been found that while Houston environmental remediation often occurs in a top-down manner, in Istanbul the bulk of the environmental advocacy starts at the grassroots level. By characterizing the nature of environmental action in each city, one can understand how the public in each respective city values wetlands. This research is important for the future of wetland conservation since it investigates not only the progress that as already been made, but also highlights areas in which both cities can continue to make progress in subsequent years.

WORK CITED Altintas, Baris. “Turkey on verge of ecological disaster on Environment Day”, Todays Zaman, Jun 5 2014, Web. 1 April 2015.

An Overview of the Commercial Shrimp Harvesting Industry in the Gulf of Mexico and South Atlantic Region (2003). US Department of Commerce, National Marine Fisheries Service, 2-26.

Arslangundogdu, Z. (2011). Autumn-2007 Migration of Soaring Birds Across the Bosphorus, Turkey. Journal of the Faculty of Forestry, Istanbul University, Vol 61, No 2, 39-44.

Ayaz, S. C. (2008). “Post-treatment and reuse of tertiary treated wastewater by constructed wetlands,” Desalination 226, 249255.

Bayradkar, M., & Durmaz, V. (2014). Environmental Impacts of Airports” A Research on The Istanbul 3rd Airport, Eskisehir Anadolu University.

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Burnet Bay Habitat Restoration Project, Galveston Bay Foundation, 2010. Web. 1 April 2015. http://galvbay.org/how-we-protect-the-bay/on-the-ground/burnet-bay-habitat-restoration-project/ Chen, M., Tang, Y., Li, X., & Yu, Z. (2009). Study on thee Heavy Metals Removal Efficiencies of Constructed Wetlands with Different Substrates, Journal of Water Resource and Protection, Vol 1, 1-57.

Costanza, R., d’Arge, R., de Groot, R., Farber, S., Grasso, M., Hannon, B., van den Belt, M. (1997). The value of the world’s ecosystem services and natural capital. Nature, Vol 387, 253-260.

Costanza, R., de Groot, R., Sutton, P., van der Ploeg, S., Anderson, S. J., Kubiszewski, I., …Turner, R. K. (2014). Changes in the global value of ecosystem services. Global Environmental Change, Vol 26, 152-158.

Choi, Y., Wang, Y., Hsieh, Y., Robinson, L. (2001) Vegetation succession and carbon sequestration in a coastal wetland in northwest Florida: Evidence from carbon isotopes, Global Biogeochemical Cycles, Vol 15, No. 2 Dahl, T. E., & Stedman, S. M. (2013). Status and trends of wetlands in the coastal watersheds of the Conterminous United States 2004 to 2009. U.S. Department of the Interior, Fish and Wildlife Service and National Oceanic and Atmospheric Administration, National Marine Fisheries Service, 46 Engle, V. D. (2011). Estimating the Provision of Ecosystem Services by Gulf of Mexico Coastal Wetlands. US Government.

Environmental and Social Impact Assessment for the Eurasia Tunnel Project Istanbul, Turkey, (2011) Environmental Resources Management Group, Germany, and ELC Group, Istanbul.

Haas, H. L., Rose, K. A., Fry, B., Minello, & T. J., Rozas, L. P. (2004).

Brown Shrimp on the Edge: Linking Habitat to Survival Using an Individual-Based Simulation Model. Ecological Applications, Vol 14, 1232-1247.

Lal, R., Griffin, M., Apt, J., Lave, L., & Morgan, M. G. (2004). Managing Soil Carbon, Science, Vol 304, 393.

Mcleod, E., Chmura, G. L., Bouillon, S., Salm, R., Bjork, M., Duarte, C. M., … Silliman, B. R. (2011). A blueprint for blue carbon: toward an understanding of the role of vegetated coastal habitat in sequestering CO2. Front Ecol Environ, Vol 9, 552-560.

Minello, T. J., Matthews, G. A., Caldwell, P. A., & Rozas, L. P. (2008). Population and Production Estimates for Decapod Crustaceans in Wetlands of Galveston Bay, Texas. Transactions of the American Fisheries Society, Vol 137, 129-146.

Minello, T. J. Rozas, L. P., Caldwell, & P. A., Liese, C. (2012). A Comparison of Salt Marsh Construction Costs with the Value of Exported Shrimp Production. Wetlands, Vol 32, 791-799.

Porter, R. and Willis, I. (1968), THE AUTUMN MIGRATION OF SOARING BIRDS AT THE BOSPHORUS. Ibis, Vol 110, 520–536.

Ramsar Convention. U.S. Fish and Wildlife Service, International Conservation, Aug 2014. Web. April 1 2015. http://www.fws.gov/ international/pdf/factsheet-ramsar.pdf Snake Island Restoration Project, Galveston Bay Foundation, 2012. Web. 1 April 2015. http://galvbay.org/how-we-protectthe-bay/on-the-ground/snake-island-restoration-project/ Wetlands Definitions. U.S. EPA, Office of Water, n.d. Web. April 1 2015. http://water.epa.gov/lawsregs/guidance/wetlands/definitions.cfm Wetlands Overview: What is a Wetland? U.S. EPA, Office of Water, Dec 2004. Web. 1 April 2015. http://water.epa.gov/type/ wetlands/upload/2005_01_12_wetlands_overview.pdf .

Wetlands Restoration, Galveston Bay Foundation, n.d. Web. 1 April 2015. http://galvbay.org/how-we-protect-the-bay/on-theground/wetlands-restoration/

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White, W. A., Tremblay, T. A., Waldinger, R. L., & Calnan, T. R. (2004). Status and Trends of Wetland and Aquatic Habitats on Barrier Islands, Upper Texas Coast, Galveston and Christmas Bays, Coastal Coordination Council, National Oceanic and Atmospheric Administration.

URBAN INTOXICATION: EVALUATING ALCOHOL CONTROL POLICIES IN LONDON AND ISTANBUL

By Benjamin Hamm Conard EXECUTIVE SUMMARY Recent years have seen significant changes in the alcohol control policies of both the United Kingdom and Turkey. This paper explores the different effects of these policies, specifically those implemented by the Licensing Act 2003 in the United Kingdom and the laws passed by the Justice and Development Party in Turkey. As microcosms of their respective countries, London and Istanbul will be examined as spaces in which policy that regulates alcohol is controversial and, at times, volatile. Due to their dense populations, the prevalence of bars and other alcohol-serving venues, and the atmosphere of “work hard, play hard” found in both these cities prove to be excellent studies for the regulation of alcohol. The paper will find that culture and history play important roles in determining intent, implementation, and the subsequent consequences of alcohol control policies. The paper will seek to explore the relationship between the increase in alcohol control policies in both countries and alcohol consumption, as it is manifested in Istanbul and London. Finally, it will find that the manifestation of alcohol control policies in both cities is highly affected by the desire of the countries to curb the negative health and safety effects of alcohol consumption.

INTRODUCTION Alcohol is one of the few drugs largely accepted in society. While it has been celebrated for its social benefits and has played a significant role in the development of civilization, it also has considerable health risks, and is associated with a variety of anti-social behaviors (West et al, 2006). Governmental regulation of alcohol has been instrumental in limiting the negative impacts that alcohol can have on an individual and a societal level.

Cities have played a significant role in this regulation, as they function as densely populated spaces wherein nightlife is one of the key attractions. The high concentration of people and quarters in urban centers as well as the prevalence of bars, pubs, and other establishments focused on serving alcohol means that alcohol consumption affects a wide variety of people, not just those who drink. As a result, alcohol control policies must take into account both the public and private consumption of alcohol, and the effects that these policies might have on both drinkers and non-drinkers.

London and Istanbul, two cities of immense international stature, stand in stark contrast to one another both in their historical and cultural relationships with alcohol, and their alcohol policies. In London, drinking has long been a socially accepted and often encouraged activity; this is evidenced by the fact that there are over 7,000 pubs in London alone, and the United Kingdom is widely perceived as a “drinking

nation” (Ricciardi). This has led to a comprehensive set of alcohol control policies, as the regulation of alcohol has been a key part of the United Kingdom’s Department of Health and Safety for well over a century. This is not to say, however, that policy has been made without controversy, as alcohol is an inherently controversial topic.

Conversely, alcohol was banned in Istanbul until the advent of the modern Republic in the last century. As a predominantly Muslim nation, alcohol was forbidden under the Ottoman Empire, and is still forbidden in the Islamic faith. To say that this has played a significant role in the construction and implementation of alcohol policy in both the city and the nation as a whole would be a drastic understatement (Göymen). Istanbul proves to be an interesting subject in this regard due to its geographic and social position as a crossroads between Eastern and Western culture. With recent changes in governance, Turkey is currently facing an identity crisis of sorts. Controversy in Istanbul has centered on the conservative government, headed by the Justice and Development Party, which came to power in 2002. Secular groups have protested that the new alcohol control policies are a step back to the prohibition endured by the country under the Ottomans. Istanbul, a major hub of nightlife and alcohol consumption in Turkey, has played a significant role in these contestations.

In examining the alcohol control policies implemented by the governments of both Turkey and the United Kingdom, this paper aims to shed light on the key differences found therein. As two cities

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that have almost opposite cultures when it comes to the acceptance, prevalence, and impact of alcohol consumption, London and Istanbul will serve as the basis for these comparisons.

ISSUE STATEMENT Alcohol consumption has always been a contentious part of urban policy decision-making and through the examples of Istanbul and London this paper will explore how these policy decisions have played out.

Both through statistical and ethnographic research, the two cities will be contrasted with each other with the express intent to determine the differences and similarities of their respective alcohol control policies. It is not the intent of this paper to provide policy recommendations. Rather, this paper aims to evaluate the intent, execution, and the subsequent consequences of alcohol control policies in both London and Istanbul.

RESEARCH For both London and Istanbul this paper will draw on a combination of ethnographic research, conducted by the author, and a variety of news sources and statistical databases referring to consumption levels and changes in alcohol policy in both countries. Statistics will primarily draw from the World Health Organization’s data on worldwide consumption. Additional data will be taken from a variety of sources, including a study on alcohol control policies, as well as reports issued by the governments of both Turkey and the United Kingdom. In some cases, these data will refer to the broader populations of the United Kingdom and Turkey, as information for specific cities is not always available. In these cases, the data will be analyzed through the lens of both the conducted ethnographic research and through broader statistics relating the cities to their respective countries.

Ethnographic research was conducted in both cities.

The author lived in London between January 19 and April 25, and while residing in the city conducted formal and informal interviews with experts in the general field of alcohol as well as members of the public. Subjects of interviews included Gianmaria Ricciardi, the head brewer at the Howling Hops Brewery, bartenders at the Riding House Café, conversations with local councilors, accessed through the author’s internship with the Local Government Association in London, and students encountered at the Imperial College Student Union. Additional sup-

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porting evidence will be given in the form of personal experience, although this evidence will be purely supplementary to the statistical data.

Gianmaria Ricciardi emphasized the familial nature of the pub. He is an Italian immigrant in his early 30s who moved to London to pursue a career in brewing beer. His insight on the difference between beer in London and beer in the rest of Europe was helpful in understanding the nature of London’s alcohol culture. It was made clear through discussion that beer is an item that unites people in London, and is a substance that invites conversation. While other nations in Europe are known for their wine or spirits, in many ways Gianmaria believes that the United Kingdom, and London specifically as its capital, centers its drinking culture on beer. This helps to explain the social aspect of pub life and the importance of the pub in the UK as an establishment that welcomes large groups and predominantly serves beer.

From March 2 through March 8, the author traveled to Istanbul to conduct in person interviews with experts in Istanbul, as well as ground the data collected in experiential learning. Formal interviews were conducted with policy expert Korel Göymen at the Istanbul Policy Centre and with Huseyin Öztürk, the head brewer of the Bosphorous Brewing Company. An additional interview with an American living in Istanbul for 15 years will be omitted due to the subject’s request for anonymity. These interviews will be supported by informal interviews conducted with locals during time spent at bars in Istanbul, as well as by the ethnographic research obtained from experiences in Istanbul during the week of travel.

Korel Göymen, a policy expert and resident of Istanbul was able to provide information on how the government and the residents of the city treat alcohol. He spoke to the history of Turkey as a smoking culture, further shown through the multitude of hookah bars. He emphasized that this was due in large part to the fact that drinking is forbidden in Islam, whereas smoking is not.

Huseyin Öztürk, the head brewer at the Bosphorus Brewing Company, spoke to the difficulties faced by establishments serving alcohol as well as to the hardships faced by local brewers. Chief amongst these troubles is the tax on alcohol and alcohol-related imports in Turkey. Many of the beers brewed at the Bosphorus Brewing Company require ingredients not found in Turkey (hop varieties are specific to the location they are grown in, such as Germany or the Cascade Mountains in the U.S.). The tax imposed

by the government on these ingredients makes it difficult for brewpubs wishing to brew their own beers, and near impossible for home brewers hoping to brew beer as a hobby.

than just a harmful substance to be regulated: it is an important part of English culture.

Alcohol Consumption Levels, Problem-drinking, and Other Statistics

Finally, newspaper articles as well as journalistic resources exploring the history of alcohol consumption and the related policies will be used. In some instances, these articles will take contrarian positions against the government, and, where appropriate, these biases will either be stated or removed.

Statistically, the U.K. records higher yearly alcohol consumption levels than the European average, at 11.6 liters of pure alcohol per capita (averaged over the years from 2008-2010), compared to the European average of 10.9. Overall, however, alcohol consumption in the U.K. is down since the 2003-2005 average of 13.2 liters of pure alcohol per capita (World Health Organization). When compared to other regions in the U.K., alcohol consumption levels per capita in London are significantly lower, especially when measured against higher drinking areas such as the North East. Rates of dangerous drinking are also lower in London. “The average units consumed on the heaviest drinking day exceeded twice the recommended limits for drinkers in the North East (9.3 for men and 6.5 for women), while the average number of units was lowest in London (6.4 for men, 4.2 for women)” (Eastwood, 20). Similarly, school pupils in London were found much less likely to have ever drunk alcohol than pupils in other regions, and London had the lowest amount of prescriptions for alcohol dependency per capita in England (Eastwood, 20). In London, bingeing is less common, students are less likely to drink, and alcohol dependency is lower than the rest of England. While the U.K. drinks more than the European average, the effects are not as apparent in London as they are in the rest of the country.

FINDINGS Past and Present: Alcohol in London and the United Kingdom In 1751, the English artist William Hogarth issued two prints—of the fictitious London streets ‘Beer Street’ and ‘Gin Lane’—intended to portray the benefits of drinking beer and the detriments of drinking gin. The prints were made in support of the Gin Act, a statute imposed by the government to combat the so-called ‘Gin Craze’ of the early 1700s (Gately, 171). This was a time during which the prevalence and cheapness of gin caused Londoners to consume alcohol at an incredible rate and drunkenness among the working class was a common state of being. In fact, the source of the Gin Craze was legislation passed by the government encouraging the practice of grain distilling, which was intended to prop up the faltering agricultural economy (Dillon, 15). London has long had a cultural acceptance of alcohol, which is evident today in the prevalence of pubs that occupy street corners like Starbucks coffee shops in New York City. Only by spending time in England can one truly experience the deep-seated cultural significance of the British pub. The pub is a place to meet friends, bring family, socialize with colleagues after work, and enjoy the company of others. Pubs typically have outdoor standing areas, and it is common to see rows of people packed tightly together in front of the windows, sipping beer and sometimes obstructing the pedestrians walking by. As a social construct, the pub plays an important role in understanding British alcohol policy. In an alcohol strategy report issued by the U.K. government, Prime Minister David Cameron made clear that new regulations “will not hurt pubs.” The report additionally commented that, “in moderation, alcohol consumption can have a positive impact on adults’ wellbeing, especially where this encourages sociability” (the Government’s Alcohol Strategy, 3).

In the U.K., alcohol is treated as something different

United Kingdom Alcohol Control Policies: The Licensing Act 2003 In the United Kingdom, the most significant law in recent history to be passed was the Licensing Act 2003. The act, which was implemented in 2005 updated laws that had not been altered since 1964 (O’Brien). These laws largely concerned the distribution and sale of alcohol by licensed premises, and allowed licensed premises to apply for extended hours. Responsibility for issuing liquor licenses, thereby allowing establishments to serve alcohol, was given to local councils. Reaction to the law at the time can be divided into two opposing categories.

The first position was that with extended hours and more businesses able to sell alcohol, consumption would increase, and with it drinking-related incidents such as public intoxication and health complications as a result of ‘binge drinking’. The second opined that with extended hours patrons would no longer

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feel the need to consume as much as possible before the early closing time, and therefore consumption and its negative effects would decrease (Roberts et al, 6). The more general purpose of the law, however, was to streamline the bureaucratic licensing process and devolve power to local councils who would be better able to regulate the sale of alcohol.

Additionally, the act stipulated that local residents would be able to determine the opening hours of their local bars and pubs by collective agreement. If patrons of a pub or bar were perceived to be disturbing the peace, local residents could petition for a restriction on the operating hours of the establishment (Department for Culture, Media and Sport, 33).

London has fairly permissive laws when it comes to public consumption. Drinking in public is legal in England, with very little restrictions in place. There are certain areas that local councils may have declared “Controlled Drinking Zones” in which police officers may ask people to cease drinking and can confiscate open or closed containers of alcohol (Morris). The current Mayor of London, Boris Johnson, banned drinking on public transport, which until 2008 had been legal (BBC England). Drinking on non-public transportation, such as the National Rail, is still legal.

Alcohol advertising has been strictly regulated in the United Kingdom. It is illegal for alcohol advertisements to target those under the age of 18, and ads are restricted from appealing in any way to youth demographics, “by linking alcohol with irresponsible behavior, social success or sexual attractiveness” (Advertising Standards Authority). Ads for alcohol are also restricted from being played during or near programming that targets people under the age of 18 or that may appeal to a youth demographic (Advertising Standards Authority).

Past and Present: Alcohol in Istanbul and Turkey Turkey is a historically Islamic nation. In the practice of Islam, alcohol is forbidden, and during the reign of the Ottoman Empire, consumption of alcohol was banned. Following the advent of the Republic of Turkey in 1923, a new, secular ideology that ran counter to that of the Sultanates that had ruled for over 600 years found its place in Turkish politics. Led

by Mustafa Attatürk, the new government did away with many of the laws that had been established under the old Islamic government. This included the ban on alcohol. Today, the culture of alcohol use in Istanbul is tenuous. The majority of the population identifies with the Islamic faith, and as such does not drink. More common is the use of pipe tobacco and shisha, which is widely accepted and practiced both

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in the home and at the many shisha bars in Istanbul (Göymen). Since alcohol is not a fully integrated part of the Turkish culture, casual drinking is not as widespread as in other European cities. This does not mean that there is no alcohol culture to speak of.

Bars in Istanbul are open until the early hours of the morning and serve a combination of beer, wine, and spirits. Istiklal Avenue, which leads from the Galata Tower to Taksim Square, is full of side alleys with an array of bars offering plenty of nightlife. There is also a prevalence of ‘shot bars’—bars that specialize in serving shots (typical measurement for spirits, constitutes 1 unit of alcohol) of hard alcohol in large quantities at cheap prices. Predominantly it is younger generations going to these bars and dominating Istanbul’s nightlife.

Alcohol Abstinence, Abuse, and Other Statistics The high rates of abstention in Turkey prove that the large majority of the population does not consume alcohol in any context—neither casual consumption nor binging. In 2010, 79.6% of Turkey’s population abstained from drinking. These statistics were higher amongst women, with 92.4% of females abstaining and 65.9% of males abstaining (World Health Organization). Rates of alcohol abuse and other negative consequences associated with alcohol use are, as a result, relatively low in Turkey. The World Health Organization survey measured an incredibly low rate of heavy episodic drinking (measured as having “consumed at least 60 grams of pure alcohol on at least one occasion in the past 30 days”) at 1.6% of the drinking population and just 0.3% of the overall population (World Health Organization). Additionally, consumption from 2008 to 2010 was recorded at 1.4 liters of pure alcohol per capita. This has not changed from the 2003-2005 average (World Health Organization). In Istanbul, a study conducted in 2003 indicated that 25.6% of residents used alcohol, again with fewer women using than men (15.9% and 34.5% respectively) (Akvardar et al, 1081). Rates of use in the 2014 World Health Organization study show similar data for the population of Turkey as a whole, at 20.4% of the population using alcohol. It is difficult to extrapolate on this comparison, however, as urban versus rural differences as well as time could explain the difference. The 2003 study reported that the rate of alcohol use was highest among those aged 40-49 years old, while the onset of alcohol consumption was most common for 16-19 year olds (Akvardar et al, 1081). Evidence of “risky drinking” was found in 6.8% of those surveyed (Akvardar et al, 1081). Statistics are admittedly hard to come

by for Istanbul and the associated rates of alcohol consumption. This can be attributed to the language difference, amongst other factors, given that scholarly articles examining alcohol use in Turkey will likely be published in Turkish.

Turkish Alcohol Control Policies: Recent Developments and Youth Focus Much of the discussion surrounding alcohol use in Turkey has centered on the younger generations, as they are perceived as being more likely to be drinking and drinking in larger quantities. Additionally, it has been well established that there is a known link between alcohol advertisements and the increased consumption of alcohol, particularly for those under the age of 18 (Booth et al, 142). The Turkish government has made it clear that their policies are targeted towards youths. The government has drawn heavily on Article 58 in the Turkish Constitution mandating that the state should “protect the youth from addiction to alcohol” amongst other substances (Turkey Constitution, Art. 58). Additionally, public drunkenness is illegal and is penalized by a fine and a minimum 15-day jail sentence for “disturbing others and violating public order” (Buker, 4). Given the stated motive of the government that these regulations were engineered with Article 58 in mind, this explains the ban on advertising and public intoxication. From a night out in Istanbul, it is clear that just as with most hubs of nightlife, bars cater to a younger crowd. As referenced in a report by the USDA on exports to Turkey, “the relatively young average age in Turkey is expected to support continued growth in [the alcoholic beverage] sector as the younger Turks account for the major part of alcohol consumption.

This growth is despite increased prices as a result of frequent increases in Turkey’s Special Consumption Tax” (USDA, 2). The Special Consumption Tax refers to the tax placed by the Turkish government on, amongst other things, alcohol. Despite the government’s intention to curtail alcohol use by younger generations, it seems inevitable that younger generations will be those drinking the most. In this way, the intention and measured results of Turkish alcohol policy do not align. While statistics are not readily available regarding rates of alcohol addiction in Turkey, alcohol consumption continues to rise, especially amongst younger generations of Turks (World Health Organization).

In Turkey, recent years have brought about significant changes in national laws that regulate alcohol and alcohol consumption. These changes were

the focus of many news articles at the time of their implementation and are still the topic of contention to this day. Laws included an increase in sales tax on alcoholic beverages, a ban on advertisements for alcohol, and a restriction on the hours during which alcohol sales are permitted. In response to criticism by secular groups in Turkey, the government cited the need to bring Turkey’s alcohol policy up to par with existing policies in European nations (Asalioğlu).

Indeed, most of these laws, passed by the Justice and Development Party (JDP), were equivalent to laws that had been in place in the European Union (EU) for decades. In the comparative analysis of alcohol control policies on the 30 countries comprising the Organization for Economic Cooperation and Development (OECD), Turkey was ranked in the middle for its policy strength (12 out of 30) (Brand et al). The study measured alcohol control policies based on the strength of policies relating to the physical availability of alcohol, community programs designed to prevent alcohol problems, alcohol prices, alcohol advertising, and motor vehicle use under the influence. Undoubtedly with new regulations on sales times and an increase tax on alcoholic beverages, Turkey’s rating for alcohol control policies would be even higher today.

EVALUATION One of the key differences explored above between the alcohol policies of Istanbul and London is the level on which these policy decisions are being made. In Turkey, policy is constructed at the national level to regulate alcohol use and curb public disorder and other such anti-social behavior that can result. It is difficult to study alcohol policy in Istanbul specifically because policy is the same across the country. While broad policy, such as that that affects advertising and mandates the drinking age is universal in both countries, the United Kingdom differs in its devolution of alcohol control policy to local groups and councils. This means that London, and the individual districts therein have significant control over alcohol regulation. Locals are capable of controlling the hours during which bars are open as well as areas where public consumption is not permitted. In Istanbul, these decisions are controlled by the national government. Factors that affect these different styles of policy-making certainly include the lack of a ‘pub culture’ in Istanbul, due in large part to the historical shunning of alcoholic beverages. With the extent that alcohol has pervaded British culture,

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and the established consideration of the social benefits provided by pubs, the government can afford to let locals control their respective environments. On the contrary, as alcohol has never been a pervasive part of Turkish culture, the social aspect of drinking has not been ingrained and there are no pub equivalents to be regulated locally.

In this regard, U.K. alcohol policy has been well established since the 1700s meaning that policy changes today are predominantly concerned with amending laws that are already on the books. As the nature of alcohol consumption evolves and as new data emerge regarding the health risks and social benefits, U.K. law has evolved more or less in pace (the Licensing Act 2003 being the most recent example of this evolution). Istanbul and Turkey, however, have been thrust into a position of creating and editing alcohol policy in a relatively short period of time. Given the ban on alcohol consumption under the Ottoman government and the rapid reversal of prohibition following the emergence of the Turkish Republic in 1923, alcohol policy has been a volatile part of Turkish law. This trend has continued in the 21st century. The amendments made to Turkish alcohol policy by the conservative JDP Party have proven much less permissive than the laws they are amending, though just two decades ago Turkish alcohol policy was considered more liberal than many countries in the European Union. This volatility is the result of the short period of time that the Turkish government has been regulating alcohol and possibly merely a symptom of the relative youth of the Republic of Turkey. While the U.K. has developed its alcohol policy over the course of hundreds of years, the government of Turkey has only had to regulate alcohol on a more granular level since 1923.

Not surprising is the emphasis that both governments place on health and safety, and specifically the health and safety of the younger generations.

The express intent of laws affecting the consumption, provision, or distribution of alcohol is to provide safety for alcohol users and to limit the potential negative effects associated with drinking alcohol (including binge drinking, alcohol related injuries, crime related to alcohol, and others, generally categorized as anti-social effects). With the drinking age set at 18 years old, the governments of both countries have made it clear that their focus is to curtail the negative effects of drinking amongst the youth. In London, advertisers are not allowed to target youth with advertisements promoting alcohol consumption, and in Istanbul advertisements

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are banned altogether. Additionally, recent laws in Turkey have mandated that alcohol consumption as well as smoking be censored from television. Both countries also place an emphasis on reducing problematic episodic drinking, and focus on lowering the rates of alcohol dependency and alcohol related health issues. London has seen success in this endeavor, especially when compared to the rest of the United Kingdom. The statistics are less clear for Istanbul specifically, however alcohol dependence in Turkey dropped from 1.3% of the population in 2000 to 0.8% of the population in 2010 (World Health Organization). Controversy has affected both cities, though perhaps Istanbul on a grander scale.

The regulation of alcohol, as a drug with significant health and safety risks such as overconsumption and addiction is naturally a controversial topic. The controversy in Istanbul is due to the fact that many in the Western world—and indeed many secular Turkish groups—view the recent increase of alcohol control policies as religiously based. The reality of the matter, however, is that many countries have similarly strict controls of alcohol consumption, licensing and sale, and that from the policies alone, there is no indication that religion was involved directly in the policy-making. That being said, it is impossible to ignore the country’s history as a Muslim nation and the fact that the majority of the population abstains from alcohol use entirely. Controversy in London is largely broken into two groups, those that believe policies are too permissive and those who believe they are too restrictive. Following the implementation of the Licensing Act 2003 (though the U.K. was still ranked on the lower end of the alcohol control policy survey conducted on OECD nations) critics decried the later hours of operation for pubs stating that it gave more time for drinkers to consume more alcohol. In fact, it prevented the prevalence of ‘binge drinking’ associated with early closing hours forcing patrons to drink as much as possible before being sent home. Compared to the Turkish controversy, this is relatively minimal, however it is important to note that with the regulation of a substance such as alcohol, there will always be controversy to some degree.

The goal of this paper is not to serve as a policy recommendation for either city—there are simply too many contrasting factors to control for to issue a recommendation based on the policies of one or the other. Likewise, as alcohol policy is largely a function of the people it is made for, policies that fit in Istanbul would not fit in London, and vice versa. It is not the purpose of this paper to criticize or recommend,

rather to compare and shed light on differing alcohol policies and their intended and realized effects.

WORKS CITED West, Robert, Colin Drummond, and Kate Eames. "Alcohol Consumption, Problem Drinking and Antisocial Behaviour in a Sample of College Students." British Journal of Addiction 85.4 (2006): 479-86. Web. 24 Apr. 2015.

Gately, Iain. Drink: A Cultural History of Alcohol. New York: Gotham, 2008. 171. Print.

Dillon, Patrick. Gin: The Much Lamented Death of Madam Geneva the Eighteenth Century Gin Craze. London: Thistle, 2013. 15.

Print.

Turkey Constitution. Article 58.

Asalioğlu, Ibrahim. "Parliament Passes Bill Limiting Sale of Alcohol, Banning Ads." Today's Zaman 24 May 2013. Print.

Brand, Donald A, Michaela Saisana, Lisa A Rynn, Fulvia Pennoni, and Albert B Lowenfels. "Comparative Analysis of Alcohol Control Policies in 30 Countries." PLOS Medicine (2007). Web. 25 Apr. 2015. <http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.0040151>.

Ricciardi, Gianmaria. "Brewing and Pubs in London." Personal interview. 20 Feb. 2015.

Göymen, Korel. "Alcohol Policy in Istanbul." Personal interview. 3 Mar. 2015. Öztürk, Huseyin. “The Bosphorus Brewing Company.” Personal interview. 6 Mar. 2015

The Government's Alcohol Strategy. London, 2012. 3. Print.

"Country Profiles." World Health Organization Global Status Report on Alcohol and Health 2014 (2014): 243, 246. Web. 24 Apr. 2015. <http://www.who.int/substance_abuse/publications/ global_alcohol_report/msb_gsr_2014_2.pdf?ua=1>.

Eastwood, Paul. "Statistics on Alcohol: England, 2013." Health and Social Care Information Centre (2013): 20. Web. 24 Apr. 2015. <http://www.hscic.gov.uk/catalogue/PUB10932/alc-eng2013-rep.pdf>.

O'Brien, Mike. "The Idiot's Guide to Licensing Laws." BBC 31 Jan. 2006. Web. 24 Apr. 2015. <http://www.bbc.co.uk/northyorkshire/content/articles/2005/11/21/drinking_laws_intro_feature.shtml>.

Roberts, Marion, and Adam Eldridge. "Expecting ‘Great Things’?

The Impact of TheLicensing Act 2003 on Democratic Involvement, Dispersal and Drinking Cultures." (2007): 6. University of Westminster. Web. 24 Apr. 2015.

"Evaluation of the Impact of the Licensing Act 2003." BBC Department for Culture, Media and Sport (2008): 33. Web. 24 Apr. 2015. <http://news.bbc.co.uk/1/shared/bsp/hi/pdfs/04_03_08_ Licensingevaluation.pdf>.

Morris, James. "Councils May Use Bye-laws for 'no Alcohol Zones'" Alcohol Policy UK 4 Oct. 2009. Web. 24 Apr. 2015. <http://www.alcoholpolicy.net/2009/10/councils-may-use-bylaws-for-no-alcohol-zones.html>.

"Johnson Bans Drink on Transport." BBC England 7 May 2008.

Web. 24 Apr. 2015. <http://news.bbc.co.uk/1/hi/uk_politics/7387113.stm>.

"Alcohol Advertising." Advertising Standards Authority. 2015.

Web. 24 Apr. 2015. <http://asa.org.uk/News-resources/Hot-Topics/Alcohol.aspx#.VTaKpq3BzGc>.

Akvardar, Yildiz, Ahmet Turkcan, Umit Yazman, Sema Aytaclar, Gul Ergor, and Duran Cakmak. "Prevalence of Alcohol Use in Istanbul." Psychological Reports 92.3c (2003): 1081-088. Web. 24 Apr. 2015.

Booth, Andrew, Petra Meier, Tim Stockwell, Anthea Sutton, Anna Wilkinson, and Ruth Wong. "Independent Review of the Effects of Alcohol Pricing and Promotion." Project Report for the Department of Health (2008): 142. University of Sheffield. Web. 24 Apr. 2015. <https://www.sheffield.ac.uk/polopoly_fs/1.95617!/file/ PartA.pdf>.

Buker, Hasan. "Substance Abuse in Turkey: A Critical Review."

Crime & Justice International 22.91 (2006): 4-13. Web. 24 Apr. 2015.

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“Alcoholic Beverages Sector Report: Turkey.” By Meliha Atalaysun. 2013. Web. 24 Apr. 2015.

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QUALITATIVE COMPARISON ON HEALTHCARE EXPERTSâ&#x20AC;&#x2122; VIEWS ON THE BARRIERS OF DIABETES MANAGEMENT IN HOUSTON AND ISTANBUL

By Anisah Khan

EXECUTIVE SUMMARY Type 2 Diabetes Mellitus, a chronic condition where blood glucose levels are high due to insulin resistance, has been increasing at a rapid rate for the past twenty years. As type 2 diabetes contributes to high mortality rates across the globe, it is important to understand the barriers in managing such uncontrolled elevated blood sugar levels. To further explore this issue, a qualitative study was conducted to identify what health experts regard as the major barriers in diabetes management in Houston and Istanbul.

When studying two global urban centers, which vary in healthcare models and cultural values, it is important to highlight noticeable similarities and differences in the diabetes management processes. Ultimately the diagnosis, treatment, and follow-up procedures for patients with type 2 diabetes are similar in Houston and Istanbul; however, factors such as access to healthcare, socio-cultural background, and level of diabetes education all pose barriers in the diabetes management processes.

INTRODUCTION As type-2 diabetes becomes more prevalent in populations around the world, there has been an increase in awareness and guidelines set in place for treating the chronic condition. Houston and Istanbul are two global cities with especially high rates of patients living with type 2 diabetes. According to the International Diabetes Federation Diabetes Atlas, Turkey had 7,227,450 diabetes cases in the year 2014 (International). In comparison the United States had a total of 25,779,340 diabetes cases in the year 2014 (International). Type 2 diabetes is in an upward climb in both countries, and the projected increase of diabetes at a global scale has made diabetes

management a major concern for the United States and Turkey.

In order to make diabetes management effective for patients, healthcare providers in Houston and Istanbul follow guidelines structured by accredited organizations. Most healthcare providers in Istanbul adhere to guidelines set-up by The Society of Endocrinology and Metabolism of Turkey (SEMT).

Similarly a majority of healthcare providers in the United States follow the Standard of Medical Care In Diabetes outlined by the America Diabetes Association (ADA) (Standard). The guidelines are written to improve the diabetes management processes, which include diagnosis, treatment, and follow-up

Map 1: Prevalence of Diabetes mellitus in adults (20-79 years), 2013 http://healthintelligence.drupalgardens.com/content/prevalence-diabetes-world-2013

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methods. While such guidelines provide healthcare providers with standards for patient care, external factors beyond the scope of medicine cause barriers in the adherence to such procedures.

Dr.Satman, corresponding author at the Division of Endocrinology and Metabolism, did a retrospective study on the adherence to the guidelines set by the SEMT. Through his research it can be found that the Clinical Practice Guidelines set by the SEMT are not properly adhered to since “age, gender, diabetes duration, history and number of chronic complications and body mass index (BMI) of patients, physician’s specialty and type of healthcare institution were tested as possible factors affecting guideline adherence”(Satman). The barriers identified in the study are just a few that affect the diabetes management processes and contribute to the increased prevalence of diabetes.

When analyzing the rate at which patients with type 2 diabetes is increasing, it can be seen that Turkey is growing faster than the United States. In more than a decade the prevalence of diabetes in Turkey has increased from 7.2% to 14.84% (Satman). In comparison the United States has a 9.3% prevalence of diabetes as of 2014 (International). As captured by Map 1, Turkey is one of the few nations with over a 12% prevalence of diabetes mellitus in adults from the ages of 20-79 years old (Prevalence).

With such varying and overall rising prevalence of diabetes at a global scale, it is vital to understand what healthcare experts’ view as barriers in the diabetes management processes in Houston and Istanbul. When analyzing the information gathered during the qualitative interviews there were both common and unique barriers that emerged in Houston and Istanbul. Before analyzing the data, however, it is important to understand the methods and limitations that apply to such a broad scope research topic.

RESEARCH METHODOLOGY “A Patient-based Study on the Adherence of Physicians to Guidelines for the Management of Type 2 Diabetes in Turkey” authored by Satman et al, was the basis for this particular study. Exploring a similar topic on type 2 diabetes, this research study focuses on healthcare experts’ perceptions on the barriers of diabetes management in Houston and Istanbul.

Once the research topic was established a Master Document was created to keep track of multiple

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literature reviews, agenda items, local contacts, appointments, and qualitative interview questions.

The next crucial step was to identify a local champion, an advocate and contact point for the study, in Houston and Istanbul. Dr.Bulent Ozseker, a radiologist with Acibadem Healthcare Group, was the local champion in Istanbul. Dr.Ozseker helped coordinate qualitative interviews with healthcare providers at Acibadem Hospital. Dr.LeChauncy Woodard, a primary care physician at the Michael E. DeBakey VA Medical Center, was the local champion in Houston.

In addition to coordinating with the local champions, it was important to reach out to other healthcare experts in order to gage a broad range of viewpoints during the qualitative interviews.

To prepare for the qualitative interviews a 24 question-query was designed to address the barriers of diagnosis, treatment, and follow-up methods in Houston and Istanbul. The query included questions regarding clinical practices, the healthcare system in each of the respective cities, socio-economic backgrounds of patients with diabetes, and the influence of culture in healthcare. A total of ten healthcare experts were interviewed for this study. The qualitative interviews in Houston were conducted with an internal-medicine physician, two family medicine physicians, and a public health expert. The interviews in Istanbul were conducted with an endocrinologist, nephrologist, diabetes nurse, two professors at the Koc University Nursing School, and the Dean of the Koc University Medical School. To maintain consistency, all of the qualitative interviews were conducted in person, but due to time constraints two of the Houston interviews were conducted over the phone.

The qualitative interview questionnaire can be found below.

Once the initial contacts were established and the appointments were scheduled, the next step was to conduct the qualitative interviews in Istanbul and Houston. The qualitative interviews lasted approximately 20 minutes, and all the interviews were recorded for reference and accuracy. Once all of the qualitative interviews were complete in Istanbul and Houston, the next step was to analyze and compare the data collected.

Once a patient is diagnosed with diabetes, what are the initial steps taken to treat the chronic disease? a. Medication b.

Life-style change c.

Education on what diabetes is and how to live with it Describe the compliancy of the diabetes patients to the recommended treatment methods.

Are patients able to afford treatment methods and medication?

Describe the diabetes education programs available to patients.

What are some barriers in treating patients with diabetes?

How do these barriers affect patients with diabetes?

How often do healthcare providers follow up with patients with diabetes?

Describe how healthcare providers follow up with diabetes patients. a.

Via phone or clinic b.

What types of labs/tests are performed during follow up appointments Describe the blood glucose levels in most diabetic patients during follow up appointments.

How do diabetes patients manage their diabetes care?

What are some barriers faced when following up with diabetes patients?

How do these barriers affect patients with diabetes?

22.

23.

24.

How effectiveis the healthcare system in Houston, in helping patientsâ&#x20AC;&#x2122; control/manage their diabetes?

Are there any socio-economic or cultural barriers that make the diabetes management process difficult?

What role do you think genetics and the social environment play in diabetes management?

General Feedback:

16.

17.

18.

19.

20.

21.

Follow-Up:

10.

11.

12.

13.

14.

15.

1.

Describe the general type 2 diabetes populations in Houston.

a.

What age range do most pre/diabetes patients fall in?

b.

Is there an overwhelming trend in gender or ethnicity?

c.

Is there an increase in the prevalence of diabetes in a certain group of people?

2.

Do most undiagnosed/diagnosed type 2 diabetic patients have access to health insurance in Houston?

3.

What are the initial steps taken before a patient is seen by the physician (paper work, checking blood pressure, weight, height, etc.)?

4.

How you as the healthcare provider determine whether or not a patient is pre-diabetic or diabetic?

a.

HbA1c levels, fasting blood glucose, and postprandial blood glucose-is there sufficient equipment to perform these tests, and can patients afford such labs?

b.

Medical history

c.

Physical examination 5.

What is the root cause of diabetes in Houston?

6.

Do you as physician follow any specific guidelines when diagnosing patients? Are such guidelines practical/ useful in application?

7.

On average, how long does each appointment generally last? Are multiple health issues addressed at the same time?

8.

Are there any barriers in diagnosing diabetes patients?

9.

How do these barriers affect patients with diabetes?

Treatment:

Diagnosis:

1. Name: 2. Specialty: 3. Workplace: 4.

How long have you been working there?

Background on the healthcare expert:

Qualitative Interview on the Barriers of Diabetes Management:

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FINDINGS The findings from this comparative study can be described by evaluating what healthcare experts in Istanbul and Houston view as barriers in the diabetes management processes.

A. B. C.

Barriers in Diagnosis Barriers in Treatment Barriers in Follow-up

A. Barriers in Diagnosis Istanbul

Diabetes management begins once healthcare providers diagnose patients with diabetes mellitus.

After going over family history, running A1C blood glucose tests, and conducting other laboratory evaluations, healthcare providers can determine whether or not patients have type 2 diabetes. While there are patients who have access to healthcare services and can receive a proper diabetes diagnosis, there are still 46.3% of the worlds population living with undiagnosed diabetes (International). Of the 7,227,450 people living with diabetes in Turkey, 2,191,360 of them are unaware of their condition (International).

The barriers in diagnosing type 2 diabetes can be

Figure 1: The International Diabetes Atlas depicts the percentage of undiagnosed diabetes patients worldwide (International).

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Since 2003 “Turkey has successfully introduced health system changes and provided its citizens with the right to health to achieve universal health coverage, which helped to address inequities in financing, health service access, and health outcomes”(Atun).

With the new health care system “there are family clinics available, and everybody is assigned to a physician” according to Dr.Sevket Raucan, Dean of the Koc University School of Medicine. While modern Turkey has made efforts to transform healthcare, there are still many individuals who cannot access the help they need. In more rural areas of Turkey, specifically rural areas of Istanbul, there is a “shortage of medical and nursing labor” making access to the universal health system more difficult. (Carter).

Dr.Aysecan Terzioglu, Professor at the Koc Univeristy Nursing School, explained that some individuals who have questions about their diabetes “have very limited access to doctors unless they visit hospitals, which is always a hassle” when trying to address immediate concerns.

In addition to the limitations in accessing healthcare services, another barrier in diagnosing patients with type 2 diabetes is the cultural taboo surrounding chronic conditions. Many individuals living in Istanbul with undiagnosed type 2 diabetes may be aware of their symptoms, but they are too afraid to go into the doctor’s office to confirm their fears. Dr.Aysecan Terzioglu believes that “any chronic illness limits social life”. She continues on to explain “Turkish people have issues with talking about their problems… they sometimes hide their condition and hospital visits from their closest friends”. Dr.Terziolgu also references the book Illness as a Metaphor by Susan Sontag. In the book Susan Sontag talks about how “illness is the night side of life” and describes “illness as being a citizen of another country” (Sontag). In order to maintain a healthy and fit appearance, many individuals with undiagnosed type 2 diabetes avoid receiving the life changing diagnosis.

Another barrier healthcare providers face when diagnosing patients with type 2 diabetes is the patient’s lack of understanding of the condition. Dr. Ayse Ferda Ocakci, Professor at the Koc University Nursing School, believes that patient education is one of the major barriers in diagnosing patients with the chronic condition. Patients correlated with low socio-economic backgrounds tend to have lower literacy rates, and a substantial portion of the individuals who are obese and have type 2 diabetes are a part of this low literacy and low socio-economic background (Dijkshoorn). Four out of the six

healthcare experts that were interviewed in Istanbul identified low literacy and a lack of diabetes knowledge as issues when diagnosing new patients. Low literacy, “in addition to inadequate public awareness and knowledge of diabetes symptoms may explain the failure of early diagnosis” in Istanbul (Shafaee).

Since there are many newly diagnosed patients that are unaware of what type 2 diabetes is, there are a few facilities in Istanbul that have diabetes education nurses answer any questions the patients may have.

Nurse Gulin Cevik, the diabetes education nurse at Acibadem Hospital, informs diabetes patients on how to check their blood glucose levels, how to inject insulin, and how to adjust their lifestyle according to their condition.

Houston

Houston, like Istanbul, is a global center that has barriers in terms of diagnosing patients with type 2 diabetes. One of the major barriers in properly diagnosing individuals with type 2 diabetes in Houston is a lack of health insurance. With the passing of the Affordable Care Act (ACA) in 2009, there have been major changes to the quality and access of healthcare in Houston and across the United States.

The ACA has helped over 10 million people gain access to healthcare across the United States, but Texas is one of the states with the highest number of individuals that remain uninsured. Lea Kiefer, public health expert at the Michael E. Debakey VA, explains that “with the roll out of the ACA, there was a portion of the law that was suppose to pick up the uninsured population with the expansion of Medicaid. The elected officials in Texas refused to accept that help from the federal government, and that has left a certain percentage of the people without access to healthcare. They make too much to qualify for Medicaid prior to the expansion, but they make too little to qualify for any of the health insurance premiums on the healthcare exchange. That leaves a lot of people stranded without access to healthcare”.

Dr.Brian Reed, a family medicine physician with the Harris Health System, confirms that a majority of his patients do not have health insurance. He describes that in Harris Health “there is a sliding scale classification program that is dependent on household income and determines the type of discount patients receive...the patients rather pay out of pocket occasionally than pay a premium”. Many individuals that are uninsured try to avoid the doctor’s office and the cost associated with each visit; therefore, a majority of individuals with type 2 diabetes are unaware of their condition.

For the Houston population that is insured, there are still other barriers to diagnosing patients with type 2 diabetes. Dr.Jahangir Kabir, a family medicine physician with Cy-Fair Medical Parnters, views a lack of diabetes education as a major barrier in diagnosing patients with the chronic condition. A study done on Implementing Diabetes Self-Management Education in Primary Care has found that a “lack of access to education has been proposed as a potential barrier to reaching people with diabetes” (Emerson). When individuals are unaware of the basic symptoms of type 2 diabetes, they are less likely to recognize these signs as a concern for their health. Most family medicine appointments last about 20 minutes, so patients that are dealing with multiple conditions may fail to mention their symptoms of diabetes to the physician. Dr.Reed states “it is rare to have patients come in with only one complaint”, so it not unlikely that patients and physicians alike may overlook symptoms of emerging type 2 diabetes. Most patients who are unable to recognize the symptoms of type 2 diabetes get diagnosed at a later stage. If patients were able to recognize and address their diabetes at an earlier stage, then preventative measures could have been taken to stop the progression of the chronic condition.

B. Barriers in Treatment Istanbul Once patients are aware of their diagnosis, their physician outlines a treatment plan for them. In Istanbul most of the treatment plans are followed from the guidelines set by the SEMT. All of the healthcare experts that were interviewed in Istanbul agreed that the SEMT guidelines, which are adapted from the guidelines set by the ADA, are useful in both diagnosing and treating type 2 diabetes patients. Unfortunately healthcare experts also believe there are barriers in treating type 2 diabetes patients, which are not addressed in the guidelines. The most common barrier that was brought up during the qualitative interviews was the patient’s psychological resistance to change. Turkey is “well known as the land of kebabs, sweet lokum, baklava and now, for an expanding waistline” so it is difficult for patients with type 2 diabetes to adjust their long lasting habits for the sake of their health (Laher). Dr.Ozlem Sezgin Mericliler, an endocrinologist at Acibadem Hospital, believes that “there is a very specific psychological problem in diabetic patients that disables them from accepting the condition and organizing their life according it. I think this is the most important barrier.” Patients with type 2 diabetes have a hard time

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accepting the fact that they have a life long chronic disease, but they also find it difficult to integrate the treatment plan into their daily life. Dr. Terzioglu speaks on her experience with diabetic patients and describes, “It is very hard for them (type 2 diabetes patients) to manage their daily lives and to find time to inject their insulin. They have to have a strict control of their daily lives because their lives are not supervised by the medical staff.” Earlier Dr. Terzioglu explained that the cultural taboo surrounding chronic conditions is one of the barriers in diagnosing patients with type 2 diabetes, but the psychological acceptance of this cultural taboo makes following medication and insulin plans difficult for patients as well. Dr. Mericliler speaks more to the psychological barriers in treating diabetic patients by explaining how “some of the patients reject using oral medications and insulin. They think they can change their diabetes with diet and exercise. If the blood glucose is not very high, then I sometimes give patients that chance to see what happens.”

A more common barrier in treating type 2 diabetes, which is essentially found worldwide, is the patient’s lack of understanding of the treatment plan. Most newly diagnosed type 2 diabetes patients are unfamiliar with the medical terminology surrounding diabetes, and Dr.Cukran strongly believes that “time is very important…if you spend the time and explain to them what all these changes are about, on a level that they can understand, then patients comply to treatment plans”. In reality physicians do not always have the time to give a thorough explanation on how to deal with diabetes, so many patients are referred to other healthcare provides. While Acibadem Hospital, a private healthcare group, does have a diabetes education nurse, there are many public hospitals in Istanbul that do not have such resources.

Therefore patients, who have questions about their treatment plan but do not have a diabetes education center near them, must travel a great distance to get the help they need. In addition, patients that require guidance on their diet are often required to pay out of pocket to consult with a dietician. Not all patients in Istanbul have access to diabetes education, so they are often left uneducated on how to use their insulin or follow their medication routine.

In a study done on diabetes education in the Turkish population it was found that, “a 1-day diabetes education program has a positive impact on improving well-being of Turkish people with type 2 diabetes in short term. According to this study, having not attended a diabetes education program, insulin treatment, poor metabolic control, and being female are

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main factors related to lower well-being in subjects with type 2 diabetes in Turkey” (Ozer). Istanbul is slowly making strides towards improving the quality of life through increased education, but there is still a large portion of the population who is unable to reach such education due to external factors beyond their control (Shafaee).

Houston

Similar to the psychological barrier patients in Istanbul face in accepting the diabetes diagnosis, patients in Houston have a difficult time understanding the long-term effects of diabetes. The shortsighted view on the chronic condition is a major barrier in patient’s adherence to treatment methods. Dr. Woodard expands on the issue by saying “diabetes is one of those conditions where you see the effects much later, after you have had diabetes for a long time. Not readily being able to see that connection (between diabetes and future complications) can be difficult.” When diabetic patients do not realize the importance of keeping up with the diabetes treatment plan, they are often faced with adverse effects in the future. Dr. Kabir adds to this topic by describing how “some patients who do not realize the reality of neuropathy or amputation continue on with their sedentary lifestyle, unhealthy diet, and incompliancy with treatment methods.” There are many reasons behind why type 2 diabetes patients lack adherence to treatment methods, including the lack of perceived seriousness of diabetes and future complications. A study done on Improving Patient Adherence states that “diabetes health care providers know that if only their patients adhered to their treatment recommendations, they could do well and avoid diabetes-related complications. The fact that so many patients do not can be very frustrating” (Delamater).

The misguided view on the implications of diabetes is a major barrier in treating patients with type 2 diabetes, but the inability of diabetes patients to afford treatment methods proves to be an equally important barrier. It has been established that not all patients with type 2 diabetes have health insurance, so this makes medication and other treatment methods very expensive. Public health expert Lea Kiefer expands on the issue by saying “diabetes is not limited to medication. There are also management supplies needed like the testing strips, the insulin syringes, glucose tablets, hard candies-all those have a cost as well.” While there are places, like Wal-Mart and Kroger, where individuals can purchase $4 generic

prescriptions, it does not cover insulin or any other supplies diabetes patients may need. According to a study done on problems paying out-of-pocket medication costs among older adults with diabetes, “Out-of-pocket medication costs pose a significant burden to many adults with diabetes and contribute to decreased treatment adherence”(Piette). In an article in the New York Times, it can be found that “ Diabetes patients spend an average of $6,000 annually on costs for treating their disease, according to a recent survey conducted by “Consumer Reports Health”(Parker). In addition to not being able to afford the medication and insulin, some type 2 diabetes patients are also unable to eat healthy on a regular basis. The basic treatment recommendation made by most healthcare providers is to eat healthy. Dr. Reed recognizes that “eating healthy is expensive…Filling up on bread is a lot cheaper than buying vegetables. Even eating leaner meats would cost more”. There are many costs associated with having type 2 diabetes, and many patients are just not able to afford the direct and indirect costs with their limited income.

Figure 2: Represents the increased costs patients with diabetes incur. http://latestnewslink.com/2015/02/cost-ofhaving-diabetes-has-doubled-in-two-decades/

C. Barriers in Follow-Up Istanbul

Throughout my qualitative interviews in Istanbul, the healthcare experts did not identify any substantial barriers in following-up with diabetes patients. Dr. Mericliler went over their protocol of “following-up with diabetes patients every three months in an in person appointment. Diabetes nurses occasionally follow-up via the phone.” The healthcare experts identified many barriers in the diagnosis and treat-

ment aspects of diabetes, but they did not find any major barriers in following-up with patients.

A minor barrier in following-up with type 2 diabetes patients is their inability to take on a lifestyle change.

According to Dr.Ocakci, “the barrier to following-up is the lifestyle, because it is too difficult to change.”

Often times when type 2 diabetes patients’ return to see their healthcare provider, they have a higher risk of complications if they have not made positive modifications to their lifestyle. According to Dr. Terzioglu, patients may not return for follow-up visits because “they lack knowledge about the condition, or they have a poor attitude towards the disease and treatment plan.”

Houston

It is essential for patients with type 2 diabetes to follow-up with their physicians on a regular basis, but that is often difficult when there is such limited time.

One of the main barriers to following-up with diabetes patients is the lack of appointment availability.

Dr. Woodard and Dr. Reed identified appointment availability as being a major concern when scheduling follow-up appointments with their patients.

Due to the busy schedules of many primary care physicians, type 2 diabetes patients may be referred to other family physicians or specialists. This rising issue of appointment availability can be attributed to the fact “the United States faces a shortage of as many as 90,000 physicians by 2025, including a critical need for specialist to treat an aging population that will increasingly live with chronic disease”(Bernstein). With a shortage of physicians and an influx of diabetes patients, it has become increasingly more difficult to follow-up on a regular basis. Map 2 reflects the increasing struggle patients face when trying to schedule an appointment with family physicians. When patients with type 2 diabetes are unable to discuss their progress or difficulties in dealing with their condition, it can lead to a lack of adherence to their treatment plan and other complications (Wiwanitkit).

Appointment availability is one of the main barriers in following-up with type 2 diabetes patients, but patient education on the topic of diabetes is another barrier in follow-up appointments. Diabetes patients who are uninformed on the importance of following-up with healthcare providers often skip their appointments. Dr. Reed identifies that the diabetes patient education level is important because it empowers them to come in for follow-up visits.

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Map 2: Increasing wait time in days to schedule an appointment with a family physician.

http://www.bustle.com/articles/25845-the-average-wait-time-to-see-a-doctor-in-these-us-cities-is-a-little-bit/image/25845

IMPLICATIONS & CONCLUSION Houston and Istanbul are both urban centers with a high prevalence of patients with type 2 diabetes.

Through the qualitative interviews with health experts in Houston and Istanbul, there were important barriers identified in the diabetes management processes. After evaluating the findings above, there were a few themes that emerged within each city.

The general themes found in the diabetes management processes reflect the views of healthcare experts interviewed for this study.

Istanbul Healthcare experts in Istanbul identified many barriers in diagnosing, treating, and following-up with patients with type 2 diabetes. From the healthcare experts viewpoint, the barriers have attributed to the increased prevalence of type 2 diabetes patients in the last twenty-years. After analyzing the barriers, there are three overall themes that can be identified as the root problems in diabetes management.

1.

Difficulty in accessing healthcare 2.

Cultural taboo towards type 2 diabetes 3.

Lack of diabetes education

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Individuals living with type 2 diabetes require accessibility to healthcare providers because of the nature of their condition. Although the universal healthcare system has brought about substantial changes within Turkey, many individuals in areas of Istanbul are still unable to access healthcare. This issue arises form the fact that there are simply not enough primary care physicians evenly distributed around the city. Due to the uneven distribution of physicians and barriers surrounding transportation, many patients are unable to visit healthcare providers and get diagnosed with diabetes at a latter stage. In addition, many type 2 diabetes patients who cannot easily access healthcare facilities are left uneducated on how to take their medications and maintain a healthy diet. Without a nearby hospital or clinic, patients may miss their follow-up appointments leading to major complications like neuropathy and kidney disease.

Another major theme found in the barriers of diabetes management is the cultural taboo surrounding type 2 diabetes. In order to avoid any social stigma, individuals with symptoms of diabetes avoid the doctor for as long as possible. Even after receiving their diagnosis, many diabetes patients refuse to

comply with the treatment plan because it interferes with their social life. With the cultural taboo surrounding diabetes, some patients refuse to speak about their condition and make little efforts to adjust their lifestyle. This form of denial causes an increase in blood glucose levels, but more importantly it continues to reinforce the detrimental cultural taboo.

The final theme established during the qualitative interviews is the lack of diabetes education among diabetic patients and the general public. While preventative campaigns have started emerging in Istanbul, they are not as far reaching as they should be. The lack of diabetes education prevents individuals from identifying their symptoms, following their treatment plans, and reducing any risk of complications during follow-up appointments. Education is one of the main factors in not only diagnosing patients but also making sure that their blood-glucose levels remain steady.

Houston

Healthcare experts in Houston also identified many barriers in diagnosing, treating, and following-up with patients with type 2 diabetes. The barriers in diabetes management in Houston are driving forces in the increased prevalence of type 2 diabetes patients. After analyzing the barriers, there are two overall themes that can be identified as the root problems in diabetes management.

1.

Difficulty in Accessing Healthcare a.

High costs of healthcare 2.

Lack of diabetes education

Unlike Turkey, the United States does not have universal health care. It is due to the difficulty in accessing healthcare that may individuals with type 2 diabetes never get a proper diagnosis. A significant number of patients with type 2 diabetes fall under a low socio-economic bracket, and without health insurance many of these diabetic patients cannot afford the healthcare they need. Without a consistent primary care physician, type 2 diabetes patients cannot receive guidance on how to treat their condition or on what medications to take.

In addition, if the diabetic patient has high blood glucose levels, the patient most likely needs insulin.

Insulin, test strips, blood glucose meters, and other tools required to manage diabetes are often pricey and unaffordable for the patients that require them.

For the patients that do have health insurance and a primary care doctor, there is often difficulty in sched-

uling an appointment to see the healthcare provider.

The difficulty in accessing healthcare for diabetes patients is a concern of both time and money.

A lack of diabetes education is another major theme that contributes to the increased prevalence of diabetes in Houston. Individuals that are unable to recognize diabetes symptoms can often times remain undiagnosed until the condition has reached a detrimental state. On a similar notion, patients that do not understand what diabetes is or how to follow their treatment plan may also end up with some sort of complication. The lack of education seen among many diabetic patients reduces any sense of urgency or seriousness in treating and controlling the chronic condition.

CONCLUDING THOUGHTS Istanbul and Houston are two cities with different demographics, but they both have very similar themes that prove to be barriers in diabetes management. While Istanbul has Universal healthcare, many patients in Istanbul are unable to access this care due to transportation and geographic issues.

On a similar note, most patients with type 2 diabetes in Houston are unable to access healthcare because they cannot afford it. The theme may be the same, but the cause behind the lack of healthcare access is very different. The concept of viewing diabetes as a cultural taboo is something that is unique to Istanbul. With that being said, Houston has a culture of obesity, which normalizes the idea of diabetes.

The major barrier and theme that most healthcare experts view as the source of increased prevalence of diabetes in both Istanbul and Houston, is the lack of patient education. Diabetes populations, in Houston and Istanbul, are often unaware of the symptoms of diabetes, how to follow treatment methods, and the importance of follow-up appointments. The lack of diabetes education is almost like a pandemic, which has decreased the seriousness of the chronic condition.

Istanbul and Houston share similar themes surrounding the barriers of diabetes management, and both of the urban centers need to realign their healthcare focus towards helping type 2 diabetes patients. The themes found in both cities are pressing issues that need to be addressed immediately, because the coming years project an increase of type 2 diabetes patients world-wide.

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Satman MD, Ilham. "Clinical Practice Guidelines for Diagnosis, Treatment and Follow-Up of Diabetes Mellitus and Its Complications." Turkish Journal of Endocrinology and Metabolism 14 (2010): 1-140. Print.

Shafaee, Mohammed A Al, and Sulaiman Al-Shukaili. "Knowlege and Perceptions of Diabetes in a Semi-urban Omani Population." BMC Public Health (2008). BioMed Central. Web. 29 Apr. 2015.

Sontag, Susan. Illness as Metaphor. New York: Farrar, Straus and Giroux, 1978. Print.

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Wiwanitkit, Viroj. "Loss of Follow-up of diabetic Patients: What Are the Reasons?" Indian Journal of Endocrinology and metabolism: 144. Web. 1 May 2015.

THE GLOBAL ISSUE OF WASTE: UNDERSTANDING AND ANALYZING THE SUSTAINABLE WASTE MANAGEMENT OF ISTANBUL AND LONDON

By Ryan Saathoff

EXECUTIVE SUMMARY This paper will evaluate the sustainable waste management practices implemented by Istanbul, its Municipality of Sarıyer, London, and its Royal Borough of Kensington and Chelsea. This is accomplished by first introducing municipal solid waste (MSW) as an urban and global issue, and then exploring the general polices of the overarching central governments of the global cities of London and Istanbul, as well as explaining the organizational structure of waste management within the cities. After providing such context, this paper discovers and analyzes specific policies being utilized by the respective neighborhoods in their pursuit of greater recyclable recovery and waste minimization tactics. More so, this paper explores the role of non-governmental actors, specifically how they augment the waste management infrastructure and promote “greener” living. Finally, this paper offers recommendations in the form of greater global cooperation, increased local government funding, and community outreach to combat the rising urban issue of solid waste management.

Introduction One of the greatest hindrances to urban sustainability lies in waste management. In fact, almost all city managers report that solid waste management is among their top five challenging problems (UN-Habitat 2010). One reason is clear: managing waste is not a glamorous profession in both appearance and practice. Nonetheless, government effectiveness is often interpreted by the cleanliness of the city streets, so efficacious policies for the removal of waste is paramount for happy citizens. It is also largely thrust upon local and municipal governments to manage waste “in the most economically, socially, and environmentally optimal manner possible” (World Bank 2013). More so, the management of municipal solid waste (MSW) is often the largest budgeted expense for most local governments, creating the most city-employed jobs. Globally, it is estimated we now spend $205.4 billion annually on solid waste management, with this number expected to rise an additional $100 billion in the next ten years. Therefore, the arguably least publicized urban management issue demands the greatest resources, both in capital and time, from local urban governments.

The impending effects of climate change have also created new pressures for these local governments.

No longer is it acceptable for the world’s cities to simply put their waste in a landfill or burn it in an incinerator. Instead, more national governments are

encouraging their local governments to invest in biomass collection (for fuel or compost), intensive recycling practices, and close-loop-consumer-good production. However, this relies on greater investment in infrastructure, citizen education, and new processing facilities. In a post-2008 financial crisis world, where austerity has dominated global economic policy, there is great hesitancy to invest in such projects. This, coupled with the mass exodus from rural to urban settings — more than 50% of humanity now lives in cities, with this percentage only rising — threatens the future of sustainability for all cities. In fact by 2050, it is projected that 70% of the world’s population will reside in cities (Mayor of London 2011). Additionally, it is expected that by 2025, 4.3 billion urban residents will be generating about 1.42 kg/capita/day of municipal solid waste, equaling about 2.2 billion tons per year. By these calculations, municipal solid waste rates are even surpassing urbanization rates throughout the world (World Bank 2013).

Surveys conducted by UN-Habitat show that in areas where waste is not collected frequently, the incidence of diarrhea is twice as high and acute respiratory infections six times higher than in areas where collection is frequent (UN-Habitat 2010). That statistic simply highlights the importance of collection in general; however, the health of people is just another reason the “greening” of waste management is necessary, as solid waste is a major producer of methane, a greenhouse gas (GHG) (UN-Habitat

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2010) (World Bank 2013). Common global environmental and climate problems associated with open and unsustainable dumping include: air pollution and release of particulates, specifically from carbon dioxide and fine particles incurred from the burning of waste; the release of methane from anaerobic decomposition of organic materials under surface; and, the pollution of surface water from exposure to waste, or resulting from anaerobic decomposition under water (UN-Habitat 2010). All of these instances jeopardize the health of our planet, our people, and the sustainability of urban life.

Thus, the implementation of sustainable MSW practices will be paramount in the years to come. It is not, however, the simple answer of merely improving reclamation rates; waste minimization strategies will also become the focus of municipal policy as more and more landfills reach capacity (UN-Habitat 2010).

Waste, due to the increasing population of cities, is largely an urban issue. While rural areas will clearly need to improve sustainable practices in the following years, they lack the issue that is the sheer volume of waste that challenges the sustainability of urban futures. Therefore, that is what this paper aims to do: understand the sustainable policies implemented by municipal governments in the global cities of London and Istanbul. Global cities, by definition, are the forefront of the urban experiment, as the international community is constantly watching and criticizing their strategies. Due to this global publicity and importance, cities such as London and Istanbul have a responsibility to promote sustainable images, and in this case, sustainable municipal solid waste management.

In summation, waste is an ever-growing urban issue, and there is a dire need for effective waste management practices that benefit the sustainability of an urbanized world. This necessity is rooted not only in the increased economic costs that waste management will incur (as discussed in earlier paragraphs), but also in the necessity of maintaining the public global health. London and Istanbul both have significant challenges in their own pursuit for sustainable waste management, which this paper will explore; but, they are not problems particular to these global cities alone. Instead, the cities are experiencing challenges that many cities around the world are facing currently or will face in the future. With that said, studying Istanbul and London’s sustainable waste management practices offers insight for policymakers across the globe, which this paper hopes to provide.

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ISSUE STATEMENT As touched on in the previous sections, this paper has three main aims: to understand the challenges that London and Istanbul are facing in their attempts to make their MSW practices more sustainable, to examine what policies are being implemented by the larger cities and their municipal subsets of the Royal Borough of Kensington & Chelsea and the Municipality of Sarıyer respectively, and to establish what can be learned from these findings in terms of policy prescriptions. This paper will evaluate waste management at a local and city level, and assess its global implications under the theme of urban sustainability. Urban sustainability is defined in this paper as the idea that a city can be organized without excessive reliance on the surrounding countryside and environment, and without jeopardizing the future of the ecological health of our planet and the well being of future generations of humanity (Allen 2009). In the context of waste management, this translates into strategies that minimize waste, increase recycling rates, and promote conscious public consumption. This paper will focus on these strategies, and which policies the global cities of Istanbul and London create to realize them.

To define municipal solid waste, this paper utilizes the definition offered by the Organization for Economic Co-operation and Development (OECD): “municipal waste is collected and treated by, or for municipalities. It covers waste from households, including bulky waste, similar waste from commerce and trade, office buildings, institutions and small businesses, yard and garden, street sweepings, contents of litter containers, and market cleansing.”

In essence, it is everyday waste. This definition offers a degree of flexibility in its use, as it allows this paper to look at MSW in the context of both commercial and residential waste. Nonetheless, the foremost interest of this paper’s focus lies in sustainable residential MSW strategies implemented by the municipal governments of Istanbul and London. Both of these cities have vastly different backgrounds, yet their organizational structure for MSW is relatively similar, allowing for comparisons and contrasts between the two. Still, the motivations behind sustainability in Istanbul and London (necessity and responsibility, respectively) are largely different, and this paper also attempts to uncover the implications of these motives on policy and practices.

While some of the questions this paper proposes can be interpreted as quite broad, the goal is not to

uncover the finite details that challenge the fabric of urban sustainability. Rather, this paper’s goals are oriented in a way that give both local and international policymakers a general understanding of the barriers at hand and a foundation of potential policy solutions to build upon for greater research for sustainable waste management in global cities.

In the end, the reader should be able to fully realize the broader situation at hand for both Istanbul and London, and what can be done to alleviate the problems that plague local governments in their pursuits of urban sustainability in the context of waste management.

RESEARCH To understand the sustainable policies and practices of MSW for Istanbul and London, and more specifically the policies of the local governments of the Sarıyer municipality and the Royal Borough of Chelsea and Kensington, this paper utilizes a broad array of sources, ranging from field observations and interviews to academic journals and data sets.

Through this range of sources, this paper aims to offer a diversified perspective of MSW sustainability through different analytical lenses. More so, analyzing the policies of both the larger city and its municipal subsets allows for both macro- and micro-analysis of the issues at hand, resulting in more apt policy prescriptions.

Nonetheless, due to information access hindrances and the language barrier, the Istanbul research is largely qualitative, based on two interviews and field observations. An abundance of online resources (such as waste databases and articles) exist for London, so quantitative analysis is overwhelming used to understand the London context. Still, similar information is obtained for both cities (with Istanbul being slightly less in depth), so a comparative framework is still very accomplishable. Even still, it is prudent to understand that London and Istanbul, while both definitive global cities, are very different cities in terms of both economics and perspectives on sustainability. These differences in the cities will be highlighted in their respective sections, but it is important to note these differences before proceeding further. The affluence of London results in a more responsibility-oriented approach to society, while Istanbul makes sustainability decisions through necessity, as resources, both material and financial, are more limited (Türkay 2015). This fundamental difference in approach will be an underlying theme throughout this paper.

In terms of methodology, the information obtained, as touched upon in earlier paragraphs, is through interviews with a local authority for environmental concerns for Sarıyer, and a mechanical engineering professor from Koç University specializing in sustainability. The field observations are obtained from walking around İnstinye in Sarıyer, whereas the field observations for Kensington & Chelsea are obtained from living in Earl’s Court. Finally, government databases are utilized for London, whereas a research paper summarizing the waste management of Istanbul is the main provider of quantitative information for the Turkish context. Through these means, this paper uncovers the current state of sustainable waste management practices in both cities.

For simplicity in understanding, this section is divided into four sub-sections: London, the Royal Borough of Kensington and Chelsea, Istanbul, and the Municipality of Sarıyer. Breaking it down in this manner allows the broader context of the city-at-large to be given for the local governments before delving into their own analyses; thus, the research hopes to be clear and digestible.

London

As mentioned above, due to the vast amount of quantitative resources available from the London and British governments, the majority of the research for understanding London, as a whole, is based on data sets provided by the Greater London Authority and GOV.UK, specifically the London DataStore. Moreover, datasets retrieved from the Department for Environment, Food, and Rural Affairs (also accessible through the data store) are also utilized to understand London comparatively to the rest of England. Using these data sets, this paper aims to paint a picture with numbers of the state of London’s MSW in the context of sustainability. Therefore, this section aims to: (1) explain the sustainability of waste management in the context of England, (2) explain the structure by which London is organized to handle and process waste, and (3) provide insight into what the centralized authorities, specifically the Mayor of London’s Office has done to encourage sustainable waste management.

Despite London being ranked 2nd in the Sustainable Cities Index, its performance in recycling rates lag behind the rest of English regions, placing last with only 34% of Greater London waste being recycled (GOV.UK 2014). Nonetheless, when viewed in a five-year change, rates in all of England, including

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London, has seen an increase (2008/09-2013/14).

(See Figure 1). However, the last few years (20122014) have shown stagnation in rates as a national phenomenon, and this is most apparent in London.

In fact, “out of thirty-three London councils, fifteen recycled/composted less in 2012/13 compared to the previous year,” roughly 50% of all councils (LONDON.GOV.UK 2013). The root of this decline is difficult to pinpoint due to the structure of London’s collection of MSW. As mentioned in the previous quote, the collection of MSW is left to the 31 borough councils (plus the councils of the City of London and the City of Westminster) that London is divided into for local governance.

Because of this localized level of control of management of MSW, there are local factors highly specific to each local council that could not be feasibly teased out for the purpose of the paper. While the local councils perform collection, regional waste authorities (South London Waste Partnership, West London Waste Authority, North London Waste Authority and the East London Waste Authority) process the waste collected, whether that be through recycling center or disposal in landfills. These authorities handle approximately two-thirds of all waste produced by London; however, the Greater London Authority (GLA) aims to make this figure 100% by 2026 (Mayor of London 2015).

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Due to the relatively low diversion rate of MSW, “The municipal waste that London sends to landfill generates approximately 460,000 tons of greenhouse gas emissions each year” (Mayor of London 2011).

To combat this figure, Boris Johnson, the Mayor of London, published the Mayor’s Municipal Waste Management Strategy in November 2011. This publication set forth the goals for the future of sustainable waste management in London. In this manifesto for MSW practices, the Mayor aimed to: • achieve zero municipal waste direct to landfill by 2025; • achieve a 20% decrease in household waste by 2031; • increase London’s capacity to reuse or repair municipal waste from approximately 6,000 tons a year in 2008 to 20,000 tons a year in 2015 and 30,000 tons a year in 2031; • and recycle or compost at least 45 per cent of municipal waste by 2015, 50 per cent by 2020 and 60 per cent by 2031. (Mayor of London 2011) Interestingly though, the stagnation of the reclamation of MSW began the year the strategy was published, thus highlighting the difficulties that the waste management goals imposed on the local governments. The 2015 goals set by this strategy are also not on track to meet their target, with the recycling/composting rate looking to fall short by around

10%, as the rate has remained at 34% since 2011/12 (GOV.UK 2015).

Despite these policy challenges, when the Mayor’s office iterated their targets in The London Plan published in March of this year, the goals of London largely remained the same. The only difference was the pushing back of total waste diversion from landfills to 2026, a mere one-year difference (Mayor of London 2015). More so, no new policies were set forth by The London Plan, again emphasizing the desire to manage and process all waste internally, educate citizens, reduce waste in general, and promote re-use (Mayor of London 2015). To meet these expectations, a hierarchy of waste management has been established by the Mayor’s office. The hierarchy is ordered as follows: (1) prevention or reduction, (2) re-use and repairing for re-use, (3) recycling, (4) other recovery such as gasification or anaerobic digestion that produce fuels for heat and power, and (5) disposal (Mayor of London 2011) (Mayor of London 2015). See Figure 2.

The GLA and Boris Johnson are not the only actors attempting to combat unsustainable waste management. Other entities such as non-profit organization and NGOs are attempting to provide resources, information, and promote sustainability for MSW management. One of the most prolific of these entities is the London Re-Use Network, which is comprised of “charities, social enterprises and non-profit organisations” that work in tandem to increase the practice of re-use throughout in London (London ReUse Network 2014). Often partnering with the local boroughs, the London Re-Use Network collects unwanted furniture, appliances and household items, which they then quality/safety-check, refurbish, and then pass on to new homes. They can pick up items from peoples’ homes upon request, or items can

be dropped off at a local re-use shop within the network. Organizations such as the London Re-Use Network are becoming the backbone of the Mayor’s waste management initiatives, as they have seen greater success in their goals, with the Re-Use Network exceeding their targets for recycling and re-use by 49% in 2013 (London Re-Use Network 2013).

Therefore, the current state of London’s waste can be summarized as: while there might be stagnation in the composting/recycling rate, the centralized authorities, the Mayor of London and the Greater London Authority, have made clear goals for the local councils to not only improve landfill diversion, but minimize waste in general. The presence of other outside active participants, such as NGOs and non-profits who aim to “green” waste management and foster a culture of re-use, also bolster the policies put forth, and official partnerships between them and local governments will continue to amplify their importance in the years to come.

The Royal Borough of Kensington and Chelsea It is noted earlier in previous section that 15 of the the 33 councils have seen decreases in their recycling and composting rates in the past few years. One such council is that of the Royal Borough of Kensington and Chelsea. In fact, from the 2013/14 data, Kensington and Chelsea ranks only 25th out of the 33 councils in composting and recycling rates at 25.45%. (See Figure 3). Seeing a steady rise in this rate from 2008 to 2012, it fell sharply in 2013 and continued to fall in 2014.

To understand this situation, this section aims to: (1) explain how the Royal Borough Kensington and Chelsea subvert expectations in terms of sustainability in solid waste management, and (2) explain their polices for recycling and composting.

Kensington and Chelsea contains some of the most high-skilled workers in all of London, with the second highest proportion working in the finance sector (22%), the highest proportion in real estate (3.4%), and the sixth highest proportion in ‘Professional, Scientific and Technical industries’ in all of England and Wales (17%). Even more so, nearly 75% of employed residents work in senior occupations, with “23 percent ‘Manager, Directors and Senior Officials’ (e.g. chief executives, financial managers), 23 percent in

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tinted recycling bags to clear transparent bags in 2014. (See Image 1). Using the tagline “let’s be clear about recycling,” the council aims to encourage people to recycle responsibly and allow residents and recycling collectors to spot items that cannot be recycled. Reportedly, the Council has to pay seven times as much for a contaminated load of recycling as it does for a clean load; therefore, the new bags allow the waste management workers to easily recognize if the contents are clean and dry (RBKC. GOV.UK 2015). Kensington and Chelsea utilize a single-stream recycling system — paper, glass, cartons, metal containers, and plastic are all bagged together — which theoretically creates ease for the consumer. However, the increases in contamination that drove the borough council to transition to the clear bags highlights the challenges that a single stream system can encounter.

‘Professional Occupations’ (e.g. scientists, engineers) and 25 per cent ‘Associate and Technical Occupations’ (e.g. town planners, laboratory technicians, civil engineering technicians)” (RBKC.GOV.UK 2011).

With the incomes and required education that are associated with these professions, it comes at no surprise that 58 percent of all residents describe their health as “very good”, the highest proportion in all of England and Wales. In these regards, it is fair to call Kensington and Chelsea a center of affluence in London, and possibly the most affluent of all boroughs.

This affluence is important to note, because research on environmental consciousness in consumer behavior has shown that affluence and education correlate strongly to greater environmental concern, and therefore higher recycling rates (Barnett et al.

1997). Therefore, it would be expected that the borough of Kensington and Chelsea would have some of the highest recycling rates in London, if not all of England. To further subvert expectations, Kensington and Chelsea is the only borough to decrease in population in the past census, thus only creating less of a burden for the local council in terms of waste management. “Waste experts said the drop — after years of progress — was the result of the Coalition [Government of Liberal Democrats and Liberal Democrats] scrapping its own statutory target in 2010 and local government devoting less resources to the recycling drive due to budget cuts” (Prynn 2014).

Despite these budget cuts, the borough council has actually taken many steps forward to revitalize the recycling culture in Kensington and Chelsea.

One such innovation is the transition form orange

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To encourage re-use, Kensington and Chelsea is one of the boroughs that has partnered with the aforementioned London Re-Use Network. In this partnership, similar to the information booklet included with the recycling bags that are shown in Image 1, some recycling bag packages also have included booklets detailing the re-use network resources available to all Kensington and Chelsea residents. A local dropoff area is available, as well as training opportunities for retail skills, business administration, and waste management. Thus, the London Re-Use Network not only offers an infrastructure for waste minimization, but also educates and trains the populace to expand a supporting culture for the borough.

Waste minimization is a priority for Kensington and Chelsea, as their website recognizes that while “it is generally accepted that recycling is one of the best ways of dealing with waste, a much better way is by producing less waste in the first place” (RBKC.GOV. UK 2015).

To foster this statement they encourage their residents to: • “buy loose fruit and vegetables rather than packaged varieties, or choose products packaged in recyclable material; • buy products like washing up liquid in large quantities; • use a milk delivery service or vegetable box delivery service; • have their name removed from most mailing lists in the country; as well as thinking twice about: • buying bottled water when chilled tap water might do just as well; • using disposable products such as tissues, face wipes, razors, paper and plastic cups, plates and cutlery; • throwing away your garden waste (composting instead); • sing cling film and aluminum foil to wrap food and use boxes with lids instead;”

among other things. (RBKC.GOV.UK 2015).

Therefore, while the borough residents subvert sustainability expectations, it perhaps cannot be attributed to a lack of messaging from the council.

As the experts mentioned earlier, the falling rate might have more to with a lack of funding for waste management generally, again highlighting the challenges of austerity packages in a post-2008 financial crisis world.

Istanbul Istanbul lacks the vast digital resources that are so readily available in the United Kingdom; so, as mentioned previously, my information of Istanbul is derived from two sources: an interview with Metin Türkay of Koç University, a mechanical engineering professor who studies in sustainability, a 2011 paper

by Cevat Yaman of the Istanbul Metropolitan Municipality titled Evaluation of the current condition of packaging wastes throughout Istanbul. These two sources offered quite differing perspectives of the sustainable waste management practices at hand, which highlights the challenge that is analyzing sustainability in Istanbul, a sprawling global city of over 14 million people (compared to London’s 8.6 million). Nevertheless, this section aims to: (1) explain

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how waste management practices are structured in Istanbul, and (2) what sustainable waste management looks like at a broader scale for Istanbul.

In the interview with Professor Türkay, he provided an overview of Istanbul practices, in regard to both general waste management and recycling more specifically. For general waste management, he talked about the desire for more landfill diversion by the government, following explosions caused by built up methane gas in covered landfills. This has resulted in both greater pushes by the metropolitan government to encourage recycling, as well as investment in utilizing the methane gas produced from the anaerobic digestion of landfills for power.

While not the cleanest source of power, this is still considered a step in the right direction. In terms of diversion, Professor Türkay said that around 90% of all glass, paper, plastic, and metal is recovered. This is driven largely by the worth of these products in Istanbul. Further, their value in the Turkish context highlights the necessity of sustainability in Istanbul, as it is far too costly for the Turkish economy to only import or create these goods from raw materials and natural resources.

bul. Nonetheless, the metropolitan authority has stated the goal that 60% of all paper, plastic, glass, and metals will be recovered by 2020. These goals rely heavily upon the 74 county municipalities that Istanbul is broken up into for local governance and solid waste management. Each municipality sets its own policy. Figure 5 visually shows the relationship in MSW policymaking.

This also encourages one of the unique facets of the waste management system in Istanbul: the street collectors who dig through street waste to recover recyclables to sell to the junkman or direct to the collection/separation facilities. According to Yaman (2011), street collectors account for nearly “10% of total urban waste and 25-30% of recyclable solid waste is collected” by the near 100,000 street collectors in Istanbul, “who are generally from immigrant, minority or other radical groups.” In fact, Professor Türkay (2015) called the street collectors “one of the most important parts of Istanbul recycling.” This informal sector of recycling comes at no cost to the formal waste management center, and UN-Habitat (2010) lauds that “this form of inclusion in solid waste management shows how spectacular results can be achieved where the involvement of the informal sector is promoted.” The relationship of the street collector to the general structure of waste management is shown below in Figure 4.

However, the rates of recovery proposed by Professor Türkay are challenged by the data provided by the Yaman paper. In the paper, Yaman (2011) finds that recovery rates are more around 20-25% for all of solid waste in Istanbul. Incredibly different than Türkay’s estimates, this figure paints a much more difficult obstacle for urban sustainability in Istan-

Professor Türkay believes that one of the greatest challenges Istanbul will face in the years to come will be in the form of e-waste and battery waste. While some municipalities do collect these forms of waste, it is not the collection that poses the issue. Rather, it is what can be done with it afterward. Turkey, as a whole, does not have any electronic or battery manufacturing, importing the majority from China.

Therefore, this requires Istanbul to export its waste to countries that have this manufacturing infrastructure. The exportation of “waste” carries stigma, and many countries that manufacture e-goods and batteries have regulations put in place to ban such imports. This leaves countries such as Istanbul in a severe predicament for urban sustainability (Türkay 2015).

In general, Istanbul, due to its massive sprawl and vast number of municipalities, is hard to generalize in terms of sustainable waste management. That said, it would seem that Istanbul’s reclamation rate stands somewhere in 30% range when taking into account both Professor Türkay’s and Cevat Yaman’s estimates. A great deal of this recovery is thanks to the informal sector of street collectors; however, advancement in the formal sector is needed to achieve the 2020 goal rates set by the Metropolitan Municipality. Finally, the necessity of sustainability in waste

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management will surely be a factor that influences Istanbul in the years to come.

The Municipality of Sarıyer The Municipality of Sarıyer is offering an abundance of services to its residents to encourage sustainable waste management. For this section, this insight is gathered from an interview with Oğuz Abacan, the Environment Protection Manager of Sarıyer, and from field observations in Intinye of Sarıyer. This section aims to (1) explain the options provided to residents of Sarıyer to be sustainable with their waste, and (2) describe the presence of recycling within the municipality jurisdiction. Through these means, this paper hopes to adequately define sustainable waste management in Sarıyer.

In the interview, Oğuz Abacan (2015) provided polices set by the municipality, which is actually rather diverse in its applications to different forms of waste.

For residential pick-up, Sarıyer collects plastics, metals, paper/cartons, and glass. Residents must separate these items; however, the municipality offers receptacles for all residents. Bulk items, cooking oils, e-waste, and batteries are also collected by the municipality; however, residents need to either phone for pick-up or deliver the items personally. Abacan has said these methods have been largely successful with “many residents taking part in the program.”

Once the waste has been collected, it is then transferred to private waste-processing centers. Abacan prided the municipality in its beauty and says that the polices put in place would sustain such beauty.

When walking around Sarıyer, recycling is well publicized via bottle shaped receptacles with the municipality logo (see Image 2). These receptacles, seen throughout Instinye, offer clear iconicity to recycling.

More so, the clear messaging of these receptacles allow residents, immigrants, visitors, and tourists to

clearly understand where they can recycle. These receptacles will surely be useful in the Metropolitan’s pursuit of increased recovery rates for recyclables.

Finite recovery figures for Sarıyer were not available, so the successes of the sustainability policies are mostly conjectures. Nonetheless, the principles guiding the sustainable waste management practices of the municipality are sound, and should buttress the recovery rate in the years to come.

FINDINGS With recovery rates both around 30%, Istanbul and London seem fairly similar in their waste management at a distance; however, both are utilizing fairly different policies. More so, the motivations are quite different. Economic pressures on Istanbul cause greater need to be sustainable, whereas London’s sustainability is more of response to expectations and responsibilities as a city of a fully developed country within the European Union. Nonetheless, the similarity in recovery rates emphasizes that no matter the motives at hand, global cities are finding it increasingly difficult to keep up with growing populations and their waste in sustainable fashion.

This paper also finds that central governments are responding to this issue, with both the Metropolitan Municipality of Istanbul and the Greater London Authority (specifically the Mayor of London) creating clear goals for recovery rates in the years to come.

Responding to these goals however proves difficult for local governments, this paper finds, as sustainable rhetoric by central governments does not mean sustainability in practice. Therefore, greater financial resources are probably needed for local governments, municipalities, and councils in years to come.

Waste grows as population does, so increased investment is a clear necessity for the urban future.

Of course, this also highlights another finding of this paper: waste minimization is just as important (if not more) as the increase of recovery rates. Decreasing waste will relieve both local councils and central governments of the economic burden of collecting and processing waste.

Additionally, both Istanbul and London exemplify the fact that outside players in the network of sustainability are also vital players. In Istanbul, the street collectors are an invaluable resource who collect nearly one third of all recyclables, while London’s NGOs and non-profits (such as the London Re-Use Network) are going beyond this own expectations in

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terms of sustainability and outreach. These successes also highlight the fact that London and Istanbul can learn from each other. An integration of NGOs and non-profits into the waste management of Istanbul and a support system that encourage street collecting in London could result in both waste minimization and recovery being bolstered in both of the global cities.

Another key finding in this paper is that simplicity in policy and effective imaging are key practices by local governments in both London and Istanbul, highlighted by the clear bags in Kensington and Chelsea, and by the bottle-shaped receptacle in Sarıyer. Both of these examples are engineered to make sustainability in consumer practice simple yet effective. Thus, designing other sustainable innovations should be the focus of local governments’ time, energy, and resources.

With similar recovery rates in both cities, this paper finds that neither single-stream recycling nor separated goods is superior to the other, and each has their own challenges. While single-stream recycling is simpler for the consumer, contamination risk is greater and separation of the recyclables incurs greater costs. That said, the requirement of residents to separate their own waste might be hindering higher recovery rates for materials. Finally, due to the similarity of recovery rates, this paper challenges the assumption of affluence and its correlation to “greener” lifestyles, as the arguably most affluent area in all of the United Kingdom has seen less than stellar recycling/composting rates.

RECOMMENDATION & CONCULSIONS

The implications of the findings are quite broad, but responding to them can be done simply: investment in education for waste minimization and infrastructure for greater recyclable recovery is paramount in the years to come for global cities. Austerity-driven economic policy and its reverberations in local council budgets only harm the chance at sustainable urban futures. Therefore, even if local government budgets need to be downsized, this paper recommends that the waste management section of the budget remain untouched (if not be expanded).

Only then can sustainable waste management goals established by central governing bodies can be fully realized and attained.

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More so, acknowledging that non-governmental actors can supplement the waste management infrastructure, assist in establishing a re-use culture, and help the image of sustainability should be another priority for urban governments who are economically stressed. This will require learning from unconventional practices from countries in all stages of development, such as street collecting, but will better exemplify the definition of a global city who learns from itself and the international community. Therefore, providing frameworks and support systems for these outside actors should guide waste management policymakers in local and central governments.

At a global scale, greater partnerships and networks need to be established to tackle the issue of e-waste.

Both producers and consumers should be held responsible, and therefore trade agreements should be established that allow for the ease of exportation and importation of these materials. If not, e-waste, which consists of rare, precious, and semi-precious metals, (and of which extraction is financially and environmentally intensive) will be lost to landfills. In a globalized world, waste of all kinds is not a national or local issue; rather, this problem belongs to the world and its pursuit of sustainability.

Finally, this paper concludes with and recommends emphasizing the importance of consumer/resident engagement. The problems of faulty and unsustainable waste management are incredibly important for the future of our society, people, planet, and health; yet, many urbanites are not aware of the stakes and risks at play. Therefore, policymakers would be wise to focus on community outreach and messaging that clearly and simply explains the financial, ecological, and societal burdens that the perpetuation of unsustainable waste management will incur. This interaction with the public will hopefully bolster recycling practices and promote waste minimization tactics, thus finally defeating the global issue of waste.

WORKS CITED Abacan, Oğuz. “Interview with Oğuz Abacan.” Personal interview. 1 Mar. 2015.

Allen, Adriana. “Sustainable Cities or Sustainable Urbanisation?”

Journal of Sustainable Cities (2009). Web. <https://www.ucl. ac.uk/sustainable-cities/results/gcsc-reports/allen.pdf>.

Baker, Dominic. Census 2011: Kensington and Chelsea. Rep. The Royal Borough of Kensington and Chelsea, 11 Dec. 2012. Web. Greater London Authority. Media. Recycling Rates Drop in Almost Half of London Boroughs as Incineration Soars. LONDON. ORG.UK. Greater London Authority, 15 Nov. 2013. Web.

Jonathon, Prynn. “Recycling in London Has Fallen for the First Time.” The Evening Standard. The Evening Standard, 21 Nov. 2014. Web. Let’s Be Clear About Recycling. London: Royal Borough of Kensington and Chelsea, 2014. Pamphlet. Print.

Local authority collected waste management - annual results. 18 Nov. 2014. Raw data. Https://www.gov.uk/government/statistics/ local-authority-collected-waste-management-annual-results, London.

“London Re-use Network: About Us.” London Reuse. The London Re-Use Network, 2014. Web. London Re-Use Network. NETWORK EXCEEDS RE-USE TARGETS AGAIN. Londonreuse.org. The London Re-Use Network, 1 July 2013. Web. LONDON’S RESPONSE TO CLIMATE CHANGE. Rep. no. Chapter 5. THE LONDON PLAN (Mayor of London), Mar. 2015. Web. Mainieri, Tina, Elaine G. Barnett, Trisha R. Valdero, John B. Unipan, and Stuart Oskamp. “Green Buying: The Influence of Environmental Concern on Consumer Behavior.” The Journal of Social Psychology 137.2 (1997): 189-204. Web. Solid Waste Management in the World’s Cities. Rep. no. 3.

United Nations Human Settlements Programme (UN-HABITAT), 2010. Web. “The Mayor’s Waste Management Strategies.” LONDON.ORG. UK. The Mayor of London, 18 Nov. 2011. Web. Türkay, Metin. “Interview with Metin Türkay.” Personal interview. 3 Mar. 2015.

“Waste Minimisation.” RBKC.GOV.UK. The Royal Borough of Chelsea and Kensington, 2015. Web. World Bank. “What a Waste: A Global Review of Solid Waste Management.” The World Bank: Urban Development. The Work Bank, 2013. Web. Yaman, Cevat. “Evaluation of the Current Condition of Packaging Wastes throughout Istanbul.” Scientific Research and Essays 6.16 (2011): 3378-388. Web.

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PROTECTING ARTISTS’ URBAN ROLE: AN EXAMINATION OF THE AFFORDABILITY OF STUDIO SPACE IN LONDON AND ISTANBUL

By Cydney Smith

EXECUTIVE SUMMARY This study examines the ability of artists to live and work in two global cities, London and Istanbul, using the affordability of studio space as a measure. Due to the stark difference between London and Istanbul, the report uses the successes of and challenges facing London’s more established art community and applies it to Istanbul, which lacks significant governmental policy surrounding artists.

This report finds that London is failing at providing enough low-cost studio space for artists in the city, representing a larger issue of affordable housing in the city. The report calls for a critical examination of planning laws surrounding the redevelopment of industrial areas, among other solutions. Istanbul currently lacks affordable studio space due to the absence of governmental funding and awareness of the issue. This report determines that the elite support of Istanbul’s art community has the biggest influence in developing affordable places for artists to work and live. Although artists in both cities are significantly struggling at obtaining low-cost workplaces, this report offers viable solutions to mitigate studio cost.

INTRODUCTION Artists have played a key role in continual geographical and social shaping of cities around the world. Due to the unstable nature of their work, many artists occupy spaces that others would not, such as condemned buildings, abandoned industrial sites, and short-term spaces (Phillips et al. 145).

They place capital and build a sense of community in these spaces, ultimately increasing land value in urban places originally deemed unsafe and cast aside. These communities of artists and creatives then fall prey to interested developers keen to build on cheap land. Although artists play a significant role in rebuilding abandoned and run-down places in cities, they are often the first people to lose their homes and workspaces because of rising rent. In a globalized city, artists are increasingly pushed farther and farther from the geographical center, and in a way, from the center of the city’s cultural and social realms.

London prides itself on its commitment to both culture and arts. However, due to foreign investment and urban migration, the city has become unaffordable for most residents, including artists. As the Greater London Authority writes in a recent report, finding affordable workspace will become increasingly difficult for artists: “With London’s population due to reach nearly 10 million in the next decade, affordable workspace has become a key issue, put-

ting particular pressure on creative small businesses, which includes artists” (Greater London Authority 5). Due to the continual growth in population, London artists are pressured financially to compete for space with newcomers. According to the Design and Artists Copyright Society, photographers made an average of £15,000 and typical fine artists earned £10,000 in 2010 in the UK (“Artist Salary Research”).

The precarious financial nature of a career in visual arts, combined with the ephemerality of affordable studio space, endangers artists’ ability to work and live in a city internationally known for its art.

Istanbul, pronounced a European Capital of Culture in 2010, has recently grown into a larger player in the global contemporary art scene. With a current population of more than 13 million people, the city will face a large influx of people in the coming years (“IFCC WorldLab Istanbul 2014”). Since it has yet to establish itself as a prominent global city like London, Istanbul lacks comprehensive governmental policies aimed at protecting and encouraging culture. Artists in Istanbul do not have a public support system in place. As people continue to flock to the city, Istanbul will face a similar issue of keeping artists, and thus cultural innovation, in the city.

ISSUE STATEMENT The following paper will focus on government and community efforts to aid artists in their livelihood. It

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will use affordability of studio space in London and Istanbul as an indicator of artists’ ability to live in the two cities. Due to the stark difference between London and Istanbul, this report does not compare the two cities on equal terms. Instead, it will use London’s challenges and successes as potential insights into how Istanbul may encourage artists to work in the city while it continues to rapidly grow. This paper will suggest policy changes for both Istanbul and London by examining the successes and challenges of an established urban art community in London.

RESEARCH The research conducted in this report includes literature review, structured interviews, and unstructured interviews. Greater London Authority’s 2014 reports, Artists’ Workspace Study and Creating Artists’ Workspace, serve as the foundation for initial research.

The two studies document organizations that provide a significant amount of affordable studio space for London artists. Additionally, online news articles, journals, and websites were utilized.

The report makes references to both structured and unstructured interviews. One informal interview was with a London street artist, Ben Slow, during a street art tour in Shoreditch, a neighborhood in East London internationally known as a street art destination. In addition, Duncan Smith, Creative Director of the Association for Cultural Advancement through Visual Art, and Shona MacPherson, a practicing artist and artist correspondent for Art Map London, shared their opinions on the affordability of studio space in London during formal interviews. In Istanbul, formal interviews consisted of two people: Ilgim Veryeri Alaca, a professor in Koç University’s Department of Media and Visual Arts, and her graduate student, Bilge Merve. Görkem Dikel, an artist based in Istanbul, provided her insights through email correspondence as well.

Gathering information and data on the affordability of studio space in Istanbul was difficult. The largest challenge was the language barrier, as many of the sites and journals that focused on artists’ ability to live in Istanbul were written in Turkish. Furthermore, both the national and city governments have yet to collect data on artists. Unlike the London government, the City of Istanbul has not conducted research on studio space prices in the city.

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London Funding Public funding for the arts goes through Arts Council England, the national body for arts. Arts Council England invests money from the government and National Lottery into both arts and culture. For instance, the council plans to use £210 of funding for its open-access funding program, Grants for the arts, over the next three years. (Arts Council England, “Grants for the arts, 2015-2018). Public monies dedicated to the arts were invested in 59 library projects, 227 museums, and 5370 art commissions (Arts Council England, Great Art and Culture for Everyone 11). The Arts Council England has used more than £1.4 billion of capital grant money to create and renovate 1000+ buildings (Arts Council England, Great Art and Culture for Everyone 5). In its 10-year framework, the Council promises to “invest in the arts sector’s buildings and infrastructure though capital investment” through 2020 (Arts Council England, Great Art and Culture for Everyone 53).

The UK government has used a portion of National Lottery earnings to fund arts since 1995. In the 20102011 fiscal year, Arts Council England received £151 million for arts funding. In April 2012, the government increased the share of National Lottery funding for the arts from 16.67% to 20%. This increase results in total Arts Council England funding, from the National Lottery funding and direct government funding, to jump from £569 million in 2011-2012 to an estimated £605 million (Javid and Vaizey).

Studios/Workspaces

According to Greater London Authority’s Artists’ Workspace Study’s Initial Audit, there are 298 separate studio space sites, serving more than 11,500 artists in London (Greater London Authority 5). Of which, 82% are explicitly intended to supply affordable studio space (Greater London Authority 15).

Workspace providers normally achieve this low cost studio space through charitable or not-for-profit standing.

However, studio rents in London have significantly risen in recent years. Over the past decade, over half of studio space rent in London has increased by more than 68%: “In 2004 the average studio rent was £7.52 per sq. ft per annum, in 2010 this average was identified as £9.72... more than half (56%) now have average studio rent of more than £11 per sq. ft per annum” (Greater London Authority 15). The ma-

jority of artists, 36.8%, that responded to the study’s audit, pay between £11 and £19 per square foot each year. An astonishing 19.3% pay more than £19 (17). With fine artists making on average £10,000 per year, this increase in studio rent is detrimental to artists’ ability to live in London. Due to future development of buildings, 28% of artists’ studio providers are unsure of their ability to renew leasehold agreements in the next five years (Greater London Authority 7). This translates into around 3500 artists expected to lose their workspaces during the same time period (Greater London Authority 5).

Organizations working for studio space

There are many organizations in London currently dedicated to affordable studio space. Artists’ Workspace Study lists 53 different workspace providers.

The largest 20 providers account for 4330 studios, hosting more than 6000 artists (Greater London Authority 31). Acme Studios is the second largest studio provider in London (Greater London Authority 31). Founded in 1972, Acme Studios aims to provide “affordable studio space and residencies and awards for non-commercial fine artists. Through this provision it continues to make a vital contribution to the development of art and artists’ careers” (“Affordable Artists’ Studios in London”). Currently, Acme Studios runs 15 buildings in Greater London, which translates into 570 studios for 650 artists. According to Acme Studios’ website, the average cost of a 300ft2 studio is £10.85/ft2, equating to £271/month (“Affordable Artists’ Studios in London”).

One of Acme Studios’ buildings, the Galleria, is specifically built to house artists’ studio space. It forms a part of a mixed-use development, which includes 149 affordable residential flats. The site was primarily funded by an Arts Council capital grant, and Acme Studios covered the rest through a bank loan. The Galleria provides 50 studios for 61 artists, with a rent rate of £11.54/ft2 per year. One artist, Rebecca Stevenson, rents out a 209 ft2 studio for £297 per month. Stevenson believes that the Galleria’s purpose-built artists’ studio building provides a safe place for her to practice her craft: “When she comes to work late at night, she knows there are people around, unlike in more normal locations in industrial areas…There is a misconception that [artists] don’t need professional [workspaces]” (Dunne et al. 22).

The Galleria not only provides space for artists, but supplies well-designed and safe studios for people to work.

Duncan Smith, the Artistic Director of the Association for Cultural Advancement through Visual Art (ACAVA), criticizes the lack of studio space for artists.

Smith states that the number one problem facing London artists is “the increasing problem of affordability of workspace.” He started ACAVA in 1983 as a solution to his personal inability to find suitable studio space. Now, ACAVA has grown into one of the largest workspace providers in the UK, offering 20 buildings mostly in London for over 500 artists (“What we do”). ACAVA is an educational charity, meaning that they aim to promote “the development of visual skills in relation to school and university curricula and beyond, to provide work experience and promote career development” (“What we do”). In order to achieve its mission, ACAVA provides numerous services for artists, such as studios and facilities for professional artists, community educational projects, and consultation.

Smith stresses that ACAVA can only offer studio space to artists who can help meet the organization’s charitable mission. The application process to rent a studio includes proving what kind of public benefit the artists have provided through their art. As an associate member of ACAVA, an artist can apply for available studio space listed on the organization’s website. Depending on the desirability of the studio space, the process could take as short as a week or up to a year. Artists that have been associate members for the longest have priority for the spots.

Currently, ACAVA is working to establish studio buildings not only in London, but in Kent, Stoke-OnTrent, Hamley, Harlow and other places in Essex as well (Smith).

Smith cites planning policies as large contributors to studio space difficulties in central London. The local government recently relaxed planning laws, easing the process of converting unused industrial buildings into residential developments. In a response to a growing housing crisis in the city, the Department for Communities and Local Government crafted a document addressing the issue, “Relaxation of planning rules for change of use from commercial to residential.” In the study, the Department explains that derelict or abandoned industrial buildings offer a unique solution to the housing crisis: “… there are industrial buildings which are no longer suitable for manufacturing which have struggled to find new uses but which offer good opportunities for conversion” (Department for Communities and Local Government 2). However, these same buildings are suitable for conversion into studio space

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for artists as well. The relaxation of development of industrial buildings to residential has led to competition between residential and studio space projects.

According to Smith, authorities are beginning to realize the severity of the problem: “The problem in central London is getting so serious that some of the local authorities are beginning to respond to the fact that artists are disappearing from the middle of the city. But the responses are too little and possibly too late.”

Most artists have a hard time securing affordable studio spaces run by organizations like ACAVA and Acme Studios. Ben Slow, a street artist and painter based in East London, holds a pessimistic view on working in London. Many of his friends have left London in the last decade due to rising rents. Slow signed a contract three years ago to rent a studio for £370 per month. His friend, two months ago, secured a rental agreement for £900 per month in the same neighborhood. As a result of his contract ending, Slow is moving to West London this month after securing a studio for £600 per month. He stated that he was only able to bargain down the rent to £600 per month because of his relationship with the building owner. When asked about applying for low-cost studios at places such as Acme Studios or ACAVA, he mentioned that the competitiveness and demand has greatly hindered many artists’ ability to secure these organizations’ studio space. For him and many other artists, it is impossible to find lowcost studio spaces in London. Slow indicated that he would have left London years ago, if it were not for his fiancé’s inability to relocate her job.

Shona MacPherson, both a practicing artist and artist correspondent for Art Map London, works and lives in the East London neighborhood of Hackney Wick.

Art Map London is an English company that aims to “demystify the art world” through sharing information about events, galleries, fairs, and businesses (Art Map London). The organization has an online directory, called Free Spaces, which lists venues where artists can show their creations for free. MacPherson serves as an artist correspondent, for which she interviews practicing artists in the region to compile an up-to-date database surrounding artists’ experiences living and working in England. In comparison to Slow, she pays £130 per month for her studio space, which has “gone up from £116 when I moved in a year and a half ago” (“Interview with Shona MacPherson”). MacPherson has interviewed many artists in London, Manchester, Glasgow and Liverpool.

She found that in London, in particular, studio rent

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differs dramatically according to a space’s location, facilities, and size. MacPherson believes that living in London can be very challenging for artists, especially those creating more community-based, rather than commercial, works of art (“Interview with Shona MacPherson”).

Istanbul Istanbul is home to a relatively new art scene and its art community has experienced rapid growth in the past years. There are several internationally renowned events based in the city, including the Istanbul Biennial, Contemporary Istanbul and Istanbul Art Fair (Davies). The Istanbul Biennial brings more than 100,000 visitors to the city to view both local and international art ("İstanbul Biennial Draws Record Number of Visitors"). In addition to events, Istanbul is home to a burgeoning number of artist-run initiatives, such as SAHA, SPOT, and SALT (Davies).

Although these initiatives do not specifically provide low cost studio space to artists in Istanbul, they represent a growing interest in cultivating the city into an artistic hub.

According to the 2013 World Cities Report, commissioned by the Mayor of London, there are 774 students enrolled in “Art &Design degree courses at generalist universities” alone, 7 national museums and 267 art galleries (44). Compared to 15,745 students, 7 national museums and 857 galleries in London, these numbers seem low for a European Capital of Culture (Owens et al. 44-45). The lack of established art infrastructure is due to Turkey’s recent turbulent history. As Tan, author of “Self-Initiated Collectivity: Artist-Run Spaces + Artists' Collectives in Istanbul,” describes, the 1980s Turkish regime still influences modern life: “The legacy of Turkey’s 1980s military regime lives on in the state’s institutions, policies, procedures, and in its bureaucrats who remain both nationalistic and conservative” (21). Therefore, artists and curators oftentimes hesitate to ask for public funding, instead turning to private support and funding for studio space and commissions. This hesitation applies to international funding as well because artists believe that “internationally funded projects yield multicultural exoticism while they conform to socio-cultural populism and that, ultimately, they are instruments of cultural normalization whose sole purpose is to shape contemporary art policies” (Tan, “Self-Initiated Collectivity” 21). Although international funding remains an option, Tan asserts that Turkish artists would prefer to pursue different methods of funding.

Furthermore, according to Donadio, the secular and religious tensions of Turkish leadership have resulted in the self-censorship of artists and cultural institutions: “Artists say they are increasingly subject to state pressure or intervention, or withdrawal of funding by the government… conservative Muslim sensibility has shifted the national tone after decades in which a secular elite ran the country.”

Donadio further assigns the “climate of anxiety and self-censorship” to shifting government standards for offensive artwork. Due to the many transitions in government rule, artists are not comfortable producing art that may offend the Turkish government. An art graduate student at Koç University, Bilge Merve, believes that the government’s understanding of art is “totally different than ours because… they tend to support the traditional arts and … more religious works” (Merve). There is no government-run space for contemporary art.

Studios/Workspaces and Arts Funding

Currently, private collectors and investors play a large role in the development of contemporary art in Istanbul because there is a significant lack of public funding. Furthermore, unlike in London, Istanbul lacks data and literature on the affordability of studio space for artists. However, Yaqoob writes in “Burgeoning art scene in Istanbul despite little state funding,” private funding has become a driving force for Istanbul’s art scene: “There are now more than 200 privately sponsored initiatives in the city and the number is growing” (2). Garanti Bank, for instance, invested $30 million into SALT, one of the most prominent art organizations in Istanbul. SALT Galata, one of the two buildings SALT owns in the city, occupies the former luxurious headquarters of the Ottoman Bank (Yaqoob 1). In large part due to Garanti Bank’s investment, SALT provides a fully stocked art research center and exhibition and event spaces.

It is becoming increasingly common for banks to place large sums of money into the Istanbul art scene. Akbank, a premier sponsor of Contemporary Istanbul, has been “ploughing money into cultural institutions while setting up initiatives for new collectors to buy art in installments and on credit” (Yaqoob 2). Istanbul banks realize the possible profit in building an innovative and rich network of art organizations. More and more Istanbul residents are beginning to build collections of art, as they are indicators of individual wealth. As of September 2013, there were around 25 serious collectors, each spending more than $200 thousand annually on art in Turkey.

In addition to 500 other residents buying art on a smaller scale, these wealthy Turks have greatly contributed to the nation’s, and Istanbul’s, art economy and community (Davies).

At the moment, Istanbul’s art scene, primarily driven by private investment, lacks structure regarding the distribution and use of public funding. November Paynter, a local curator, highlights the effect: “the system for channeling private philanthropy transparently, and with a clear channel of application and grant giving overseen by a board, has not been formalized in Turkey. This leads to a dilution of funds between many difference spaces, people, and potentials” (“To Participate or Follow?” 311). Although private donations and investments are crucial to the viability of Istanbul’s art community, the lack of guidelines has led to misguided and uninformed public investment into the art scene. More threatening, however, is that educational art departments have yet to significantly invest in studio space. At the moment, many universities, whether private or public, do not have the capacity to offer studio spaces to practicing students. Many young artists work and live in their parents’ houses (“To Participate or Follow?”

311).

Görkem Dikel, Content Manager at Mixer Arts, states that a studio costs at least 700 Turkish Liras, or £170, per month in Istanbul. For a young artist like Merve, this figure is oftentimes unrealistic. Mixer Arts, an art gallery in Istanbul, aims to support young emerging artists by providing “educational processes on art and art writing…, [involvement in] international platforms, [and representation] in art fairs both national and international” (“Interview with Görkem Dikel”).

Although Mixer Arts and other art organizations around Istanbul do not specifically aim at providing affordable studio space, they represent a growing desire in the city to aid artists in their profession.

FINDINGS London

The average London artist makes £10,000 per year. With studios currently costing around £11 per square foot per annum, artists spend a large part of their income on their workspaces. For a 300ft2 studio, the cost per year would be on average around £3,300. With an income of £10,000, the average artist dedicates 33% on studio space alone. Studio space prices have increased more than 68% in the past decade. In the next ten years, artists will dedi-

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cate more and more of their meager income to their workspace. For this reason, London has already seen many artists leave the city in search for cheaper, more affordable studio space.

The London art world is facing a key transition as artists are beginning to disappear from Central London. According to both Ben Slow and Duncan Smith, London will no longer function as a viable workplace for artists. In the next ten years, more and more artists will have fled from the city. Smith states, “The future of London as a major culture venue is in question. I think that unless a city has facilities where people can create culture that it ceases to be a place where people come to consume culture.” ACAVA is beginning to expand into other places in the country, such as Kent and Stoke-on-Trent, to address the unaffordability of studio space in London. To Smith, London’s dynamism will disappear as artists turn to other UK cities because “[London’s dynamism] is brought about by people coming from all over the country, or indeed all over the world, to share ideas and to create in an atmosphere of mutual interest.”

London’s trend of embracing foreign investment and ignoring housing costs will lead to a city void of practicing artists, and therefore a city vacant of organic culture.

Istanbul Istanbul’s lack of governmental policies will allow for the opportunity for the city to grow with and accommodate artists. As a rising global city, it is just beginning to establish an approach towards the arts. Unlike London, Istanbul lacks significant public funding for arts and culture. However, the city’s contemporary art scene is uniquely driven by private investment. Banks have embraced the business of a thriving art community. If approached in the correct manner, private investment may be able to turn Istanbul into an affordable place for artists in the next decade.

However, at this point, most researchers and artists agree that affordable studio space will not available in the next ten years in Istanbul. According to Professor Alaca, Istanbul in general is “very expensive and getting more and more expensive… Some institutions will support further artists. But on the other hand, this may not fulfill all the artists’ needs” (Veryeri Alaca). As Alaca alludes to, private institutions, such as banks, are beginning to address artists’ needs. However, without public funding and aggressive private investment into studio space and artist

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resources, practicing artists will have an increasingly difficult time living and working in the city. Currently, due to the lack of data relating to studio prices in Istanbul, it is impossible to say if studio space is affordable.

RECOMMENDATIONS London Although people within London’s art community, such as Slow and Smith, are pessimistic about its ability to retain artists, there are some solutions that the City could implement now in order to stall a complete migration of artists out of London.

In order to both protect existing artists and promote development of studio space in London, the City should consider the following options: • Working with developers and art organizations to incentivize development projects and partnership opportunities.

• Building a platform for the local community to rent out studio space to artists.

• Offering subsidies for practicing artists.

Working with developers and artist organizations to incentivize development projects and partnership opportunities: To promote stability in artists’ lives, the City should pair developers with organizations that provide low-cost studio options to increase investment in long-term and permanent workspaces. As the Greater London Authority describes, by working with workspace providers, property owners can ensure that their investment pays off: “The high levels of demand, coupled with the significant experience of many workspace providers mean that the risk of void periods is very low. This ensures a reliable income stream for property owners even at the moment a new development is launched” (Dunne et al. 37). The City can facilitate partnerships between organizations and developers to create a win-win situation for all parties involved.

To further encourage workspace development projects, the City should address its recent relaxation of zoning laws pertaining to the redevelopment of industrial buildings into residential projects (Smith).

These zoning laws could be altered to encourage mix-use projects that have both residential housing and designated studio spaces. By including subsidies for developers that include studio space in their projects, the City could greatly incentivize private development of more studio spaces. Acme Studios’ site, the Galleria, is a good example of such a development. The Galleria addresses both the housing crisis and artists’ need for studio space.

Building a platform for the local community to rent out studio space to artists: A more temporary, quick solution to artists’ problem could be modeled off of Art Map London. As MacPherson suggests, “If empty spaces could be more easily used by artists in the city” artists could find at least temporary studio spaces (“Interview with Shona MacPherson”). The website would serve as a platform for art supporters to list their unused spaces as studio spaces. Artists could then utilize the spaces for a discounted rent. However, for a platform of this nature to work at a substantial level, community involvement and partnership development must be key goals. Studios such as Acme Studios and ACAVA are only able to offer relatively low-cost studios because they have built close partnerships with parties involved in planning, development and art (Dunne et al. 7).

Offering subsidies for practicing artists: In order to directly help artists, the local and national government should provide subsidies on studio space.

These should target artists that are not fortunate enough to rent studio space from low-cost providers, such as ACAVA and Acme Studios. Artists paying more than the London average of £11/ft2 per year, could receive the difference between their rent and the average cost from the City. If this subsidy is too lofty to obtain, the City should, at the minimum, provide tax breaks for non-commercial artists.

Istanbul Taking into account London’s crisis for studio space, Istanbul must take action to save its small, but rapidly growing, art community. The head of TOKi, Ergün Turan, describes Istanbul’s increasing redevelopment of buildings as a commitment to profit. The regeneration and redevelopment agenda, which includes “sites to accommodate the demands of the city’s newly expanding wealth,” turns city spaces into money-making assets (Aksoy). Due to the demands of Istanbul’s newly increasing wealth, industrialized areas are being converted into profit-making commercial and residential spaces. Moving forward, the art community must fight for the rights to develop on these industrial spaces. In order to facilitate such a campaign, the City should consider the following recommendations: • Collecting data on studio spaces in Istanbul in order to create a ten-year plan.

• Allocating dedicated funding to artists’ workspaces.

• Backing organizations and supporters in their

endeavors to educate citizens, promote participation, and protect studio space.

Collecting data on studio spaces in Istanbul in order to create a ten-year plan: The government should start collecting data as soon as possible in order to create a plan laying out policies toward the treatment of current and future studio space. This plan should address the challenges and opportunities for artists as well as policy gaps in Istanbul. The creation of a plan addressing the affordability of studio space will help the government identify key measures it, along with private investors and art organizations, can take to ensure that artists continue to have a place in the city.

Allocating dedicated funding to artists’ workspaces: Istanbul should look towards London’s experience with public funding of the arts. London does not have a specific fund laid out in its budget that contributes directly to the maintenance and creation of affordable studio space. For this reason, the issue has not received as much attention or funding necessary to solve it in London, especially with the development of the housing crisis. Istanbul, instead, should lay out plans for funding future workspace development projects in order to avoid the crisis that London now faces.

Backing organizations and supporters in their endeavors to educate citizens, promote participation, and protect studio space: At the very least, the City should place effort in encouraging and backing art-focused organizations, such as SALT and Mixer Arts, and supporters. Davies states that a strong art community has emerged as a direct result of the government’s inaction: “Wealthy private investors, banks, art funds, collectors, holdings, institutions, and galleries have provided the local art scene with the capital needed for it to blossom because there is little in the way of government funding.” Although the lack of government funding has created a “certain degree of freedom,” it points to a larger problem of the popular understanding of the arts.

Most residents do not understand the importance of contemporary art in establishing Istanbul as a global hub for culture. Thus, this study recommends that the local government work to assist art-centered organizations and educate city residents on the importance of artists in society and the economy.

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CONCLUSIONS As this report demonstrates, artists’ workspaces are becoming increasingly endangered in both London and Istanbul. As London continues to see a flight of artists away from the urban core, it will become evident to city officials that they must prioritize the affordability of studio space. However, when taking the city’s unfolding housing crisis into account, it becomes questionable whether or not any efforts attempting to solve the increasing cost of studio space will slow down the migration of artists out of London.

Istanbul, at the other hand, has time to address the lack of urban studio space. Due to the strong support of local banks and elites, Istanbul continues to grow as a hub and incubator for local artists. In order to avoid the crisis that London now faces, the city government must establish preemptive measures to protect artists’ workspaces in Istanbul.

Affordable studio space is crucial in cities’ efforts to encourage cultural exchange and interaction. To ensure that London and Istanbul remain capitals of culture, their respective governments must reconsider the popular belief that artists can successfully work in temporary studio spaces. The reality is that the majority of the two cities’ populations would not voluntarily live in the endless cycle of unstable workspace so common to artists (Phillips et al. 147).

Without artists’ occupation of industrial and rundown spaces, urban regeneration would likely take a very different and less organic form. For this reason, local governments must work to establish long-term studio options for artists, thus acknowledging and supporting the crucial role artists play in shaping global cities.

WORKS CITED "Affordable Artists' Studios in London." Acme Studios. Acme Studios, n.d. Web. 20 Apr. 2015."

Artist Salary Research." DACS. DACS, n.d. Web. 20 Apr. 2015.

Aksoy, Asu. "Istanbul's Choice: Openness." LSE Cities. London School of Economics, Nov. 2009. Web. 17 Apr. 2015.

Art Map London. “Art Map Manifesto.” Art Map London. 2015.

Web. 19 Apr. 2015.

Arts Council England. "Grants for the arts, 2015-18." Arts Council England. Arts Council England, n.d. Web. 27 Jan. 2015.

Arts Council England. Great Art and Culture for Everyone. Manchester: Arts Council England, 2013. Print.

Davies, Rhiannon. “The Rise of Istanbul’s Contemporary Art Scene.” The Guide Istanbul. The Guide Istanbul. 30 Sept. 2013.

Web. 24 Apr. 2015.

Department for Communities and Local Government. Relaxation of planning rules for change of use from commercial to residential. London: Crown Copyright, 2012. Print.

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Dunne, Kirsten, Tobias Goevert, Levent Kerimol, and Katherine Spence. Creating Artists' Workspace. Publication. London: Greater London Authority, 2014. Print.

Donadio, Rachel. "In Turkey, the Arts Flourish, but Warily." The New York Times. The New York Times, 18 Nov. 2014. Web. 3 Mar. 2015.

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Greater London Authority. Artists' Workspace Study. London, UK: Greater London Authority, 2014. Print.

"IFCC WorldLab Istanbul 2014." IFCC WorldLab Istanbul 2014.

IFCC, 2014. Web. 20 Apr. 2015.

“Interview with Görkem Dikel.” E-mail interview. 2 Apr. 2015.

"Interview with Shona MacPherson." E-mail interview. 15 Mar. 2015. "İstanbul Biennial Draws Record Number of Visitors." Today's Zaman. Feza Gazetecilik A.Ş, 12 Nov. 2007. Web. 13 Apr. 2015.

Javid, Sajid, and Ed Vaizey. "Arts and Culture." Policy. Department for Culture, Media & Sport, 27 Jan. 2013. Web. 02 Feb. 2015.

Merve, Bilge. “Interview with Bilge Merve.” Personal Interview. 04 Mar. 2015.

Owens, Paul, Chris Gibbon, Ulrike Chouguley, Matthieu Prin, Richard Naylor, Cecilia Dinardi, and Yan Woon Yvonne Lo. World Cities Culture Report 2013. London: Mayor of London, 2013.

Print.

Phillips, Andrea, and Fulya Erdemci. “Social Housing--Housing the Social: Art, Property and Spatial Justice.” Amsterdam: SKOR, Foundation for Art and Public Domain, 2012. Print.

Slow, Ben. “Interview with Ben Slow.” Personal Interview. 26 Mar. 2015.

Smith, Duncan. “Interview with Duncan Smith.” Telephone interview. 15 Mar. 2015.

Tan, Pelin. "Self-Initiated Collectivity: Artist-Run Spaces + Artists' Collectives in Istanbul." ArtPapers (2006): 20-23. Web. 23 Jan. 2015. <https://www.academia.edu/202522/Artist_run_spaces_and_collective_in_Istanbul>.

Tan, Pelin. "The Question of Autonomy in the Practice of Commons: Present and Future of Artist Run Practices." Publication by Rajataide Association (2012): 5-15. Web. 23 Jan. 2015.<http://issuu.com/mariakaroliinapaappa/docs/publication_by_rajataide_ association>.

“To Participate or Follow? (Views on the Current Situation of the Istanbul Art Scene).” The Arab Studies Journal 18.1, Visual Arts and Art Practices in the Middle East (2010): 300-15. JSTOR. Web. 1 Mar. 2015.

Veryeri Alaca, Ilgim. "Interview with Ilgim Veryeri Alaca." Personal interview. 04 Mar. 2015.

"What We Do." ACAVA. Association for Cultural Advancement through Visual Art, 2010. Web. 14 Feb. 2015.

Yaqoob, Tahira. "Burgeoning Art Scene in Istanbul despite Little State Funding." The National. N.p., 4 Jan. 2013. Web. 24 Mar. 2015 Zeynep Eksiolglu, S., and Özlem Ece, eds. Istanbul Foundation for Culture and Arts Economic Impact Research. Rep. Istanbul: Istanbul Foundation for Culture and Arts, 2012. Print.

ASSESSING PROFESSIONAL FOOTBALL PLAYER SALARIES THROUGH THE USE OF ANALYTICS

By Enrique Walsh

EXECUTIVE SUMMARY From basketball to baseball and even horse racing, the use of data and analytics software has reshaped the modern sports world. Where teams had previously relied heavily on scouts and other traditional ways of evaluating players, general managers, team executives and head coaches are now making decisions based on statistical evaluations, revolutionary algorithms and complicated rankings. This paper focuses on football and explores the use of analytics in the sport at a professional level. It presents arguments that support and oppose professional football players earning massive salaries. To have a quantifiable way to solve the debate of overpaying football players, this paper statistically assesses whether England’s Chelsea Football Club and Turkey’s Fenerbahçe Sports Club are overpaying or underpaying their players, according to onfield data. Furthermore, it will evaluate the correlation between having high quality players and team performance.

INTRODUCTION Sports Analytics is the use of techniques from academic areas such as statistics, mathematics, game theory, biomechanics, and kinesiology to model, rank and predict professional sports performances. Sports analytics was first successfully applied in baseball, when the methods of pioneer Bill James revolutionized Major League Baseball in the United States. The book written by Michael Lewis (and the movie based on that book), Moneyball, depicts James’ strategies with Sabermetrics, the use of sport analytics specifically in baseball, and how a ball club with a restricted budget and limited resources used analytics to build a championship caliber team.

Sports Analytics has also made a smooth transition into professional basketball. According to NBA Basketball Research, 26 out of the 30 NBA teams either employ basketball analytics professionals or work with statistical consultants to enhance their decision-making and playing style (“NBA Teams that have…”). Ironically, sports analytics has failed to grasp as much traction in football, the most popular sport on the planet.

Football has underutilized the application of analytics due to three main reasons. The first is the lack of publicly available data. The second is the complexity of the sport; the game cannot be systematically broken down as easily as baseball for example, as the results in football are “products of complex and intriguing interactions between performances of individual players and also uncertainties pertinent to specific citations” (Kumar, 1). Football is a very fluid sport, and the scarcity of discrete events makes

it very difficult to quantify player performance. The third reason is the culture and effect of a “star player.” Whereby Bill James would not be afraid to hire an athlete no one had heard of but had good onfield production, football clubs tend to go for the players that are red-hot at the moment, often times ignoring past underachievement, injury history and other red flags. However, analytics in football are becoming increasingly more popular. According to an article by Sports Illustrated, United States Men’s National Team head coach Jürgen Klinsmann advocates the use of analytics. “Let’s say, how quickly you release the ball, how quickly you get into transition, how quickly you transition into your defensive shape.

How you connect your back line right away with your midfielders. There’s a lot of good data to use,” said Klinsmann (Qtd. in Whal). As a result, the United States Soccer Federation is establishing a data analysis center based at the StubHub Center in Carson, California. Evidently, statistics can be used to model player performance. This paper adapts a method of measuring statistical performance developed by Michael Fotopoulos and Andrew Opatkiewicz, and will creatively rank players for two of the biggest, wealthiest and most popular teams in England and Turkey: Chelsea FC and Fenerbahçe SC, respectively. The aim of this is to apply sports analytics to football, and try to answer a question that is of much debate: do football players really deserve to get paid as much as they do?

ISSUE STATEMENT There is much controversy as to whether professional football players truly deserve to be paid astro-

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nomical salaries. The proponents of players being overpaid argue that they get paid too much for what they do. A football player’s week consists of daily two-hour training sessions, a weekly press conference and one or two 90-minute matches. For this, the average Premier League player earns £ 2.3 million - around $ 3.4 million. Conversely, a paramedic’s week is full of emotional stress, traumatic situations, brutally long shifts and life saving opportunities. In 2013, the average annual salary for EMTs and paramedics in the United States was $31,270 (Parademic: Salary). To put these figures in perspective, it would take the average Premier League player 47 minutes to earn the average paramedic’s weekly salary (“How long would it take…”). In other words, it would take the average paramedic 216 years of work to earn the average Premier League player’s annual salary. If the average paramedic had started working in 1799, he’d almost be even with what the average Premier League player makes in one year. The work – to – earnings ratio in professional football is extremely high, making a lot of people question whether players deserve what they earn.

On the other hand, those that say that football players are not overpaid argue that football is just a business, plain and simple. They say that to keep the business running, teams must invest in capital, which in this business happens to be players. According to Chelsea’s website, the club officially reported a total revenue of over $ 486 million coming from TV rights, ticket day sales, merchandise and others sources.

At the epicenter of this revenue are the footballer players themselves, as they are the responsible for the club making the majority of this money. Advocates of players not being overpaid say that since the players are responsible for all the money being generated, shouldn’t they not benefit significantly from it? Furthermore, they argue that being a professional player requires an enormous amount of talent, hard work and an even bigger amount of sacrifices.

Take Lionel Messi for example. When he was only 13 years old, he left his hometown of Rosario, Argentina and moved to Barcelona’s youth academy, often times crying at night due to homesickness.

In an effort to see what local Londoners had to say on the topic, a die-hard Chelsea fan was interviewed.

Mr. Jacob Baldwin was asked “Do you think professional football players are being overpaid?” and he said: “Yeah, I think so. If you think about it, Wayne Rooney earns 300,000 pounds a week. I might never earn that in my lifetime. But football is now a business,

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and like in any business, you have to pay a premium to get the best quality. The bigger the business, the bigger salaries you can afford. If Wayne Rooney played for Crawley (a third division team) he’d earn 2K a week, because the business isn’t that big. But since Manchester United is a massive business, they can afford to keep him. It’s just a business.” (Baldwin, Jacob).

He was then asked, “Staying in line with football being a business, based on the amount of money Manchester United makes out of their players, do you still think they are being overpaid?” He responded with, “Well in that case, no, they are not. They are not overpaying them because they are making more money off them than they are losing. If they were overpaying them, they would run out of business.

But for what they do, I think they get too much money. If computing was as big as football, and they earned billions of pounds a year for what they do, computer technicians would be on a 300K a week salary, but it’s the fact that football is such an enormous industry that players get these ridiculous wages.” (Bladwin, Jacob).

Evidently, it is very hard to say whether football players deserve to be paid a lot of money, exemplified by Mr. Baldwin’s mixed thoughts. This paper attempts to solve this argument in a statistically manner, by statistically analyzing whether professional football players in Chelsea FC and Fenerbahçe SC are being underpaid or overpaid. This analysis is based on data tracked during each of the player’s performances during the current 2014/15 season.

It uses statistical data to determine what wage each player truly deserves. The study focuses on Chelsea and Fenerbahçe because they are among the teams in their national leagues that spend the most money on players, thus offering good examples of whether teams are overpaying or underpaying players.

RESEARCH Companies such as Prozone Sports and WhoScored. com have transformed football statistics. Gone are the days when only rudimentary statistics like goals, saves and shots were recorded. These companies employ people to watch matches and document every single occurrence. Information such as headers won, types of through balls and amount of shots taken from inside the box are now available. Figure 1.1 in the appendix is an example of what an

analyst’s computer screen looks like after an entire game of logging in statistics. For the purpose of the study, 14 statistics were extrapolated for each player of England’s Premier League and Turkey’s Süper Lig. Table 1.2 in the appendix is an excerpt of the entire data set, showing Chelsea FC players’ statistics for each of the 14 categories recorded for each player.

Next, a ranking system was created to show which players perform best. This ranking was based on a method developed by Michael Fotopoulos and Andrew Opatkiewicz used to assist salary allocation strategies in Major League Soccer.

In contrast to European Leagues, the United State’s Major League Soccer has a salary structure unique to the football world. With the league constructed as a single entity, clubs receive a share of a common pool of salary cap dollars to spend on their rosters each season (Fotopoulos & Opatkiewicz, 1). While European teams have enormous spending disparities between top, middle and lower tier teams, MLS salary disparities are kept to a minimal.

For the 2013/14 season, every MLS team received a salary budget of 3.1 million dollars to be used to build their rosters. The maximum budget charge for a single player is $387,500. However, the Designated Player Rule allows clubs to acquire up to three players whose salaries exceed their budget charges, with the club bearing financial responsibility for the amount of compensation above each player’s budget charge (“Roster Rules and Regulations”). As a result, MLS teams don’t have 100% identical payrolls, but the inequality is astronomically smaller than in Europe.

To put it in perspective, the Premier League’s biggest spender for the 2013/14 season, Manchester City, spent approximately $ 350 million on their roster (Arshad, “Man City…”). Conversely, Cardiff City spent the least amount of money, totaling a payroll of 45 million dollars (Arshad, “Cardiff City…”).

That is a difference of 305 million dollars. In contrast, MLS’s biggest spender, Toronto FC, spent $15 million while New England Revolution spent only $2.9 million, a difference of around $12.1 million (Rodriguez). While a salary cap promotes league parity, it introduces a new element to teambuilding, and gives clubs with more effective resource allocation benefits over others. (Fotopoulos & Opatkiewicz, 1). Teams that maximize the utility of each salary cap dollar spent will perform better than those who don’t. For this reason, Fotopoulos and Opatkiewicz

designed a way to identify player production in three phases of the game (offense, defense, and possession) and to provide a comprehensive view of the individual events that contribute to a player’s on the field performance. By statistically ranking players, MLS teams can make better salary allocation decisions and spend their limited resources more effectively. The ranking system they developed works as follows.

A player’s ability to convert offensive events such as goals, assists and shots on target was condensed into a single measure, Offensive Production (OFF).

The weights for each variable were obtained by observing the frequencies of offensive events and the corresponding ratios between events. For example, shots on target were 5 times as frequent as goals, so the individual weightings of these events reflect the 1:5 ratio. Fotopoulos and Opatkiewicz used the following equation to calculate a player’s Offensive Production raw score: OFF = 5.000*Goals + 1.003*Shots On Target + 5.784*Assists – 2.482*Offsides Using the same linear weighting approach, this paper came up with its own Offensive Production equations, reflecting on the ratios and total observed frequencies for both the Premier League and the Süper Lig. PL OFF = 3.220*Goals + 0.990*Shots On Target + 4.465*Assists – 2.047*Offsides SL OFF = 3.677*Goals + 1.000*Shots On Target + 5.637*Assists – 2.487*Offsides For example, Chelsea’s Eden Hazard scored 6 goals, had 24 shots on target, gave 6 assists and was caught offside 3 times, so his Offensive Production is equivalent to: PL OFF = 3.220*6 + 0.990*24 + 4.465*6 – 2.047*3 = 76.609 These raw scores were then ranked as a percentile among all of the players in their respective leagues, with the final Offensive Production score for a player recorded as his percentile rank. However, since a player’s value is not limited to his offensive skills, two more measurements were created. Using Prozone and WhoScored.com to isolate player production in the defensive and possession phases of the game, the Defensive Production (DEF) and Possession Production (POSS) measurements were created in a similar way the Offensive Production statistic was

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developed. These values add to the overall concept that every player contributes to each phase of play over the course of a match. However, for more internal consistency, some adjustments were made to the model to account for infrequent events skewing a player’s raw score. For example, the frequency of possessions gained to total possessions was observed roughly 2.8 to 1 over a much larger sample size than successful headers. A similar ratio to the 2.8 to 1 ratio was also used for the less frequent events such as successful headers as both events led to a similar result, the active taking of possession from an opponent. (Fotopoulos & Opatkiewicz, 2).

This paper used the following equations to calculate each player’s DEF and POSS raw scores: PL DEF = Possessions + 2.015*Possessions Gained – 2.015*Fouls + 2.512*Crosses Defended SL DEF = Possessions + 1.998 * Possessions Gained – 2.023 * Fouls + 2.574 * Crosses Defended PL POSS = 1.002*Successful Short Passes + 1.007*Clearances + 2.018*Successful Long Passes – 1.994*Possessions Lost + 2.593*Shots Blocked + 2.802*Successful Header SL POSS = 0.999*Successful Short Passes + 1.041*Clearances + 2.053*Successful Long Passes – 2.124*Possessions Lost + 2.456*Shots Blocked + 2.705*Successful Header Once again, these raw scores are then ranked as a percentile among all of the players in their respective league. With each phase of the game scored as a percentile rank, a summary metric that considers the total output of a player was derived. Former Italian football star and manager Gianluca Vialli provides a simple way to evaluate players geometrically (Qtd. in Fotopoulos & Opatkiewicz, 2), taking each phase of the game and plotting it on an x,y plane. In this case, the 3 rankings create a triangle: AREA = 0.5 * (OFF) * (DEF + POSS)

For example, if a player scores 61.0 OFF, 63.0 DEF, 82.0 POSS, his AREA score would be: AREA = 0.5 * 61.0 * (63.0 + 82.0) = 4422.5 Once every single AREA score was calculated, they were also ranked as a percentile. Table 2.1 and Table 2.2 shows players with the top 10 highest AREA’s in each league, along with their OFF, DEF and POSS percentile rank scores.

Building out from Fotopoulos and Opatkiewicz’s work, this paper used their ranking system to illustrate trends in professional football player salaries.

With each player ranked in terms of an AREA percentile rank score, it is possible to determine whether they are being overpaid or underpaid. To do this, each Premier League player’s salary was extrapolated from CelebritiesMoney.com. Table 3.1 shows the ten highest paid players in the Premier League. In theory, the best player should be getting paid the most; the second best player should be getting the second highest salary and so forth. According to Christina Settimi from Forbes magazine, Manchester United’s Radamel Falcao is the highest paid player in the Premier League, making $ 469,775 a week, or $ 24,428,300 a year.

After the best players were ranked in terms of their AREA score, they were assigned a Theoretical Weekly Salary, equivalent to the salary of the player corresponding to their AREA rank. For example, Chelsea’s Cesc Fàbregas ranked #1 in AREA score, so he was assigned the #1 salary, which belongs to Radamel Falcao. Arsenal’s Santi Cazorla came in with the second highest AREA score, so he was assigned the second highest salary, which belongs to Manchester City’s Sergio Agüero. Chelsea’s Eden Hazard ranked #6 in AREA score, so he was assigned a Theoretical Weekly Salary equivalent to the 6th highest paid player, which is Manchester City’s Yaya Touré at $300,000 a week. This was done for all Premier League players. Table 3.2 illustrates Chelsea FC player’s weekly and yearly salaries, as well as their Theoretical Weekly Salary and also where they rank in terms of AREA score.

The same process of cross-referencing AREA scores to a Theoretical Weekly Salaries was attempted to be done with the Süper Lig. However, due to the lack of publicly available data, it was not possible to find every single Süper Lig salary. For this reason, instead of comparing salaries and AREA scores across the entire league, scores and salaries were compared

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internally within the club. For example, Dirk Kuyt has the second highest AREA score in the Süper Lig, which ranks first among Fenerbahçe players. As a result, he should be getting the highest salary within the club, which belongs to Moussa Sow. Table 3.3 illustrates Fenerbahçe player’s weekly and yearly salaries, as well as their Theoretical Weekly Salary and also where they rank in terms of AREA score within their club and the Süper Lig. Since it was not possible to cross-reference Fenerbahçe AREA scores with the entire league’s salaries, Chelsea’s internal comparison is illustrated in Table 3.4. This was done in order to conduct an “apples to apples” comparison, as it was not fair to compare Chelsea’s players to 438 other players while only comparing Fenerbahçe players to their own team.

Findings Having conducted the previous research, it is now possible to answer the issue statement: are players being underpaid or overpaid for their efforts? To do this, the following scale between the actual weekly salary and Theoretical Weekly Salary discrepancy was developed: Discrepancy + or - $ 0 - $50,000 + or - $ 50,000 - $ 100,000 + or - $ 100,000 - $150,000 + or - $ 150,000 +

Category Slightly Under / Overpaid Under / Overpaid Heavily Under / Overpaid Severely Under / Overpaid

Table 4.1 and Table 4.2 summarizes under which category each player fell into. The following tallies represent each team’s verdict: Chelsea FC Fenerbahçe SC Severely Underpaid 1 Severely Underpaid Heavily Underpaid - Heavily Underpaid Underpaid 2 Underpaid Slightly Underpaid 3 Slightly Underpaid Just Right 5 Just Right Slightly Overpaid 5 Slightly Overpaid Overpaid 1 Overpaid Heavily Overpaid - Heavily Overpaid Severely Overpaid 1 Severely Overpaid

3 4 5 4 2 -

When comparing the two teams at a glance, Chelsea seems to overpay more players than Fenerbahçe.

Chelsea has a total of 7 players categorized as being slightly overpaid or worse, while Fenerbahçe only has 6. Although these figures are pretty similar, it is necessary to compare how much each team is overpaying or underpaying their players. When summing everything up, Chelsea is underpaying its players by a total of $408,000 every week, while overpaying its players by exactly the same amount.

This means that they have a net “overpaying” of $0, indicating that although they are overpaying 7 of their players, they are underpaying 6 to balance it out. Fenerbahçe is underpaying its players by a total of $204,488 every week, while overpaying its players by exactly the same amount as well. Although both teams have a net “overpaying” of $0, amount by which Fenerbahçe overpays and underpays its players is half of Chelsea’s, indicating that they do a better job at valuating players and salary allocation.

Another interesting observation is that Fenerbahçe stays away from the extremes, as none of its players are being severely nor heavily underpaid / overpaid.

Conversely, four Chelsea players are being severely or heavily underpaid / overpaid. What do these numbers indicate? They indicate that Fenerbahçe’s decision makers are evaluating and pricing talent fairly accurately, much more effectively than Chelsea.

Now that comparisons have been drawn between Chelsea’s and Fenerbahçe’s spending tendencies, it is noteworthy to highlight spending discrepancies between the England and Turkey. Provided by Nick Harris from the Daily Mail, Table 5.1 shows the average salaries in the world’s major football leagues (Harris). As previously stated, Premier League footballers earn an average of £ 2.3 million a year, giving them wages 56% larger than their next competitor, Germany's Bundesliga. When compared to the Turkish Süper Lig, the Premier League average wages are 410% higher. What’s even more surprising is that England's second division, the Championship League, is ranked 8th globally, with its players earning more than most first divisions around the world. The astronomical salaries in England are attributed to its massive television deals. Nick Harris from the Daily Mail reports that the Premier League signed a 5 year domestic TV deal with Sky and BT worth £ 1 billion (roughly $ 1.5 billion) each year, overseas TV deals in 212 countries bringing in £ 733 million (roughly $ 1.1 billion) a year and assorted other highlights, near-live and clip deals bringing in hundreds of millions more. To put the incredible money-making in perspective, the Premier League now earns a similar amount from selling goal clip rights to the UK mobile market alone as Scottish domestic football does combined from all its live television rights - about £ 15 million ($ 23 million) a year (Harris). Clearly, the football business in England is unparalleled anywhere else.

Some people would argue that it doesn’t matter if all of the players are being severely overpaid; if the team is winning games, who cares? For this rea-

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son, this paper went an even further step and tried to conclude to what extent having higher quality players translates to winning more points . In other words, to what extent is it justifiable, based on team wins, to overpay players? In theory, the higher the quality of a team’s players, measures in AREA score, the more points a team will win. To do this, the Average AREA of each team was calculated, as well as the number of points each team has won. This can be seen in Table 6.1 and Table 6.2 in the appendix. Total points as a function of average Area was plotted and a linear regression line was ran through these data points – shown in Figure 6.3 and Figure 6.4 – to asses the correlation and develop R and R2 statistics. The Premier League had an R statistic of 0.8324 and the Süper Lig had an R of 0.8105. This means that there is a strong, positive correlation between the Average AREA and points won. R2 statistics of 0.69289 for the Premier League and 0.64946 for the Süper Lig mean that 69.289% and 64.946% of the variation in a team’s performance, measured in points won, can be explained by the scores of the teams’ players, measured in Average AREA. As a result, in general, the higher quality players a team has, the more points the team should win. This does not mean, however, that teams should go ahead and severely overpay every player since there seems to be a positive a correlation between having better players and winning more. Linear regression analysis simply states that likelihood of two events happening; it does not suggest that one event causes the other to occur.

leverage contracts and visit team executives and say, “According to his statistics, this is how my player is performing. This is what he is getting paid in relation to his fellow teammates and competitors. There seems to be a discrepancy here that needs to be addressed. If it isn’t, he might just walk out on the club.”

Equally, this argument can be reversed, as team executives can show this analysis to the players and restructure their contracts. Another application this study has is that a team executive can see a player’s AREA score before buying him, taking any hype or emotions attached to the player out of the equation.

CONCLUSION

Arhsad, Sameer. “Cardiff City Players Salary List 2014.” TSM Plug.

6 Aug. 2013. Web. 16 Apr. 2015.

In conclusion, this study tackled the much-heated question as to whether football players are being overpaid. It presented arguments for both sides of the debate, and subsequently answered this question through the use of a statistical analysis. Based on 14 different statistics and a creative way to rank each player, it was found that relative to the performance of their teammates, Chelsea and Fenerbahçe both underpay and overpay players. The paper also shows spending differences among the different leagues in the world, showing the power England’s Premier League has over the rest of the world. Furthermore, it showed the there is a strong, positive correlation between having better quality players and winning more points.

Baldwin, Jacob. Personal Interview. 9 Feb. 2015.

This study has numerous applications. Agents can reach out to a statistician and pay them to come up with a similar analysis. Afterwards, the agent can

“Paramedic: Salary.” US News. Web. 24 Apr. 2015.

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Evidently, football is a business, and like Mr. Baldwin said, “if they were overpaying them, they would run out of business.” In the case of the two specific clubs that were tested in this study, the numbers say that Chelsea tends to overpay its players, while Fenerbahçe has a more balanced payroll. Additionally, the wage of an average American was compared to that of the average Premier League player, and the results were breath taking. Finally, the paper explored the correlation between player quality and points won, showing there is a strong, positive correlation.

Do football players truly deserve their salaries? It’s very hard to say. What is known is that the industry is only going to get bigger, as it does so will the wages.

WORKS CITED Arhsad, Sameer. “Man City Players Salary List 2014.” TSM Plug. 6 Aug. 2013. Web. 16 Apr. 2015.

“Chelsea FC announces annual profit.” Chelsea FC. 13 Nov. 2014. Web. 24 Apr. 2015.

“Chelsea Players Salaries 2015 (Hazard The Highest Paid).” Total Sportek. 3 Jan. 2015. Web. 27 Feb. 2015.

Fotopoulos, Michael; Opatkiewicz, Andrew. “Salary Allocation Strategies for Major League Soccer.” MIT Sloan Sports Analytics Conference. 2-3 Mar. 2012. Web. 3 Mar. 2015.

Kumar, Gunhan. “Machine Learning for Soccer Analytics.” KU Leuven. 2012-2013: 1. Web. 3 Mar. 2015 Harris, Nick. “Premier League wages dwarf those around Europe.” Daily Mail. 14 Nov. 2014. Web. 30 Mar. 30, 2015.

“How long would it take you to earn a top footballer’s salary?”

BBC. 4 Feb. 2015. Web. 30 Mar. 2015.

“NBA Teams that have Analytics Department.” NBA Basketball Research. 29 Oct. 2014. Web. 3 Apr. 2015.

“Premier League Player Statistics.” WhoScored.com. Web. 9-23 March 2015.

Rodriguez, Alicia. “Comparing 2014 MLS team spending - teams largely stay in similar positions year to year.” SB Nation. 11 Apr. 2014. Web. 16 Apr. 2015.

“Roster Rules and Regulations.” MLS Soccer. Web. 17 Apr. 2015.

Settimi, Christina. “The World’s Highest-Paid Soccer Players.”

Forbes. 5 Jul. 2014. Web. Mar. 23, 2015.

“Super Lig Player Statistics.” WhoScored.com. Web. 9-23 Mar. 2015.

Wahl, Grant. “Jurgen Klinsmann on use of analytics, fitness demands, more dual-nationals.” Sports Ilustrated. 12 Mar. 2015.

Web. 23 Mar. 2015.

“X Player Salary, Net Worth.” Celebrities Money. Web. 28 February 2015.

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Comparative Analysis of Attitudes towards Preimplantation Genetic Diagnosis and Prenatal Genetic Testing in the United States and Turkey

By Pooja Yesantharao EXECUTIVE SUMMARY Prenatal genetic testing and preimplantation genetic diagnosis allow geneticists to assess a fetus or an embryo, respectively, during pregnancy. These procedures are controversial, however, because although they can reduce the incidence of various genetic diseases, they are also seen as promoting eugenic selection of embryos or as causing increased rates of abortion. Thalassemia is an autosomal-recessive hemoglobin disorder, which is of growing global concern because of its increasing incidence worldwide. Thalassemia is prevalent in Turkey as it is commonly found in those of Mediterranean ancestry, and its prevalence has increased due to the Islamic practice of consanguineous marriage. Thalassemia has also been found to be more common in the United States than previously thought, especially in populations not traditionally defined to be at-risk. This study looks at the availability of, attitudes towards, and government as well as insurance policies regarding prenatal genetic testing and preimplantation genetic diagnosis in the United States and Turkey, specifically with regards to thalassemia. In doing so, this project also studies how religious bioethics respective to each country can impact the provision of genetic services. Given different conceptions of personhood in Islam as compared to Christianity, preimplantation genetic diagnosis for thalassemia is less controversial in Turkey than in the US. Also, because thalassemia has historically been viewed as a public health risk in Turkey, the Turkish governmentâ&#x20AC;&#x2122;s public healthcare system promotes thalassemia health campaigns and provides full coverage of genetic tests, unlike in the US where public awareness of the risk of thalassemia is much lower. Such findings can inform future policies in both countries, especially given that thalassemia is currently on the rise in the United States.

INTRODUCTION Prenatal genetic testing and preimplantation genetic diagnosis are relatively new fields of medicine that have developed in the last few decades. They allow geneticists to assess the physical status of a fetus or an embryo (respectively) during pregnancy or even before implantation. Preimplantation genetic diagnosis, more specifically, is an early method of prenatal diagnosis in which embryos that are created in-vitro are analyzed for defined genetic defects, and only those which are free of defects are returned to the womb for implantation (Sermon, Steirteghem and Liebaers). This genetic technique is mainly used in two indication groups: individuals who are at high risk of having a child with a genetic disease or individuals who are undergoing in-vitro fertilization (IVF) treatments, in order to improve the success rate of IVF (Braude, Pickering and Flinter). The first published use of preimplantation genetic diagnosis in a clinical setting was reported in UK in 1990, which led to much change in the healthcare legislation of the UK and other countries with regards to research surrounding embryos (Appold). Prenatal genetic

testing is a means by which certain genetic disorders can be detected and diagnosed during pregnancy, using procedures such as blood counts, amniocentesis and chorionic villi sampling (Han and Ryu).

Such methods can be used to identify pregnancies that are at risk for certain diseases in order to allow for early treatment, which is often associated with higher quality of life for the patient (Han and Ryu).

Though the use of preimplantation genetic diagnosis and prenatal genetic testing is growing, there is much debate surrounding the ethicality and use of such genetic procedures. Some people argue for the promise that such genetic technology offers in advancing human health by providing information about and preventing the incidence of genetic diseases, while others believe that such testing could lead to harmful consequences, especially in the context of religious bioethics (Allyse, Minear and Berson).

Specifically with regards to preimplantation genetic diagnosis, there are concerns that it will be used for purposes other than the prevention of genetic disease through the selection of a healthy embryo,

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such as screening for susceptibility conditions, screening for late-onset diseases, HLA matching for existing children in the family, and sex selection (Shenfield). These uses are typically not considered to be valid reasons that necessitate the preimplantation genetic diagnosis procedure. For instance, allowing parents to use IVF procedures in order to obtain HLA-matched embryos that could serve as a tissue match for an older sibling who is seriously ill creates the ethical dilemma of “possible instrumentalisation of the future child,” leading to the use of a person as a “mere means for a specific end,” leading to “concerns about the welfare of the future child” (Shenfield 313). Similarly, preimplantation genetic diagnosis could be used to select an embryo with a particular sex, thus bringing up “the general question of eugenic practices,” or the selection of specific genetic traits in embryos in order to produce certain desired characteristics in progeny, which is frowned upon in most societies (Shenfield 312). Preimplantation genetic diagnosis used in the context of preventing the incidence of genetic disease is especially troublesome because this technique involves two ethically-charged processes: creation and selection of embryos based on genetics, and the discarding of embryos that are deselected (Allyse, Minear and Berson). There are concerns that the genetic screening allowed by preimplantation genetic diagnosis could eventually encourage a trend towards the creation of a eugenic world, with designer children created through the routine use of genetic selection techniques. The ethical objections brought up about this genetic technique parallel those used in debates on abortion and embryonic stem cell research, and they are generally grounded in cultural and religious conceptions of the personhood and consequent rights of an embryo, in the sense that certain embryos must be deselected in order to select for one without the genetic disease in question (Allyse, Minear and Berson). The concerns regarding embryonic selection can also stem from religious views about the nature of human reproduction, such as the view that human reproduction is a “gift” that should not be tampered with (Robertson). On the other side of the debate, those who are in support of preimplantation genetic diagnosis argue that preimplantation genetic diagnosis is ethically acceptable when done for valid reasons, such as preventing serious genetic disease in progeny. This, they argue, also brings the added benefit of preventing selective abortions due to such diseases because preimplantation genetic diagnosis allow for a viable and healthy embryo to be selected even before implantation (Shenfield).

The use of preimplantation genetic diagnosis is

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also supported by the argument that it allows couples who are at serious risk for producing offspring that have genetic diseases to still have children, by preemptively screening embryos (Allyse, Minear and Berson). Studies have shown that preimplantation genetic diagnosis may reduce the risk of passing a particular genetic disease onto a child by up to 50% (Appold).

One of the main ethical concerns with prenatal genetic testing is that it may increase the frequency of abortions, because it allows for the diagnosis of genetic disorders during pregnancy and thus introduces the issue of whether or not to terminate a pregnancy if the offspring is known to have a particular genetic disease (Han and Ryu). This again brings up the debate of eugenics, as those fetuses that are shown to have or be at risk for certain genetic conditions that are not seen as ideal or favorable could be aborted (Parens and Asch). However, those who support of prenatal genetic testing cite studies, as previously mentioned, which show that early diagnosis of certain genetic conditions can lead to early treatment efforts that typically have better clinical outcomes, and the results of the test can lead to greater preparedness on part of the parents with regards to any special needs that the baby could have due to a particular genetic condition (Remennick).

With regards to both prenatal genetic testing and preimplantation genetic diagnosis, a few other important ethical considerations include the fact that both genetic procedures could be connected to a larger disability movement, where couples’ choices can impact people living with disabilities or genetic diseases by maintaining the conception that genetic diseases or conditions are negative and should be selected against (Rapp). Also, with regards to a more anthropological critique of prenatal genetic testing and preimplantation genetic diagnosis, such procedures can be seen as leading to the overmedicalization of the female body and pregnancy, which encourages the use of invasive biomedical interventions (Rapp). When considering both preimplantation genetic diagnosis and prenatal genetic testing, it is generally agreed that all such genetic procedures require informed consent in the United States, though this practice varies between countries based on cultural context and public health situations (Parens and Asch).

Currently, in the United States, there are no specific federal or state provisions that address particularly the conditions surrounding application of preimplantation genetic diagnosis, and the decision is

largely left to the treating physician and the parents (Appold). It is legal in most countries, especially in conjunction with assisted reproductive technology, except in a few cases such as Switzerland and Australia (Appold). With regards to prenatal genetic testing, the US has allowed for routine prenatal screening and testing during pregnancy, through methods such as amniocentesis and maternal serum alpha fetoprotein screening, since 1970 (Appold).

Though it has seen a rise in private healthcare, Turkey largely provides public healthcare for its population under the Ministry of Health, with two tiers based in the central and local governments (Agartan). Under this system, there is a government mandate for premarital screening, where couples must present evidence of health certificates in order to be married. In this way, the government can identify couples who are carriers for certain diseases and thus who have higher risks of conceiving offspring with those diseases. This premarital screening process was passed into law in 1993 under the Ministry of Health (Balci, Ergin and Polat). The Turkish law has special regulations that allow the use of IVF and preimplantation genetic diagnosis in order to avoid congenital disease, especially in high-risk situations, listed under the title “Assisted Reproductive Treatment and Assisted Reproductive Treatment Centers Regulation” (Balci, Ergin and Polat).

Thalassemia is a disease that involves a disruption of either the alpha or the beta chain of hemoglobin (Figure 1), which is a protein in erythrocytes that transports oxygen (Cunningham, Macklin and Neufeld). The disease leads to anemia in the patient, and can lead to stillbirth or major health complications if very severe.

Figure 1. A close-up view of erythrocytes in a patient affected by thalassemia. The disease is manifested through the irregular morphology of the erythrocytes, which hinders their oxygen-carrying capacity.

There are two main types of thalassemia, which are called “alpha” and “beta,” and are categorized based on which part of the hemoglobin is defective (Cunningham, Macklin and Neufeld). Both forms of thalassemia are inherited in the same manner, through an autosomal recessive pattern (Figure 2).

Figure 2. Pattern of inheritance of hemoglobin genes from parents with the thalassemia trait. As shown, the couple has a one in four chance of inheriting two thalassemia genes and thus having a severe form of thalassemia (also known as thalassemia major).

Carriers of the disease are said to have thalassemia minor, and they generally do not display symptoms.

Those people who receive copies of the faulty gene from both parents have thalassemia major, and they have the disease (Center for Disease Control and Prevention). Generally, individuals who have alpha thalassemia have milder versions of the disease in comparison to those who have beta thalassemia.

Treatments for thalassemia include blood transfusions, and those individuals who have thalassemia major require antibiotics, regular blood transfusions and extensive hospitalization and medical care.

Symptoms of the disease are often seen early in life, if not diagnosed through prenatal genetic testing, and include listlessness, fatigue, delayed growth, jaundice, and poor appetites. If untreated, thalassemia can lead to brittle bones and enlarged spleen, liver, and heart. Infection and heart failure are the leading causes of death if children remain untreated, based on the severity of the particular case (Center for Disease Control and Prevention). Thalassemia is one of the most common monogenic diseases seen around the world, though historically it has been localized largely to tropical and subtropical regions of the world (such as Southeast Asia, the Indian subcontinent, and the Middle East), as well as in the Mediterranean countries. Population migra-

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tion has contributed largely to the global spread of this disease to Europe, North and South America, as well as Australia, such that now it is thought to have a much larger global burden than ever before (Luo, Boudreaux and Steinberg). Published statistics state that at least 1.5% of the world’s population is reported to be a heterozygote or carrier of β-thalassemia, though this statistic may be much higher given that many cases, especially in Asian countries, often go unreported due to the lack of a proper healthcare infrastructure that could provide surveillance or monitoring functions (Colah, Gorakshakar and Nadkarni).

Turkey, a Mediterranean country, has a high rate of thalassemia and abnormal hemoglobin disorders that is typical for countries in this region (including Greece, Italy, West Asia, and North Africa) (Center for Disease Control and Prevention). As a largely Islamic country, Turkey has a high rate of consanguinity, which has remained at 20-25% for the past 25 years. This has been shown in various studies to also be linked to the abnormally high incidence of various rare autosomal recessive diseases, such as thalassemia, in the Turkish population (Tuncbilek; Balci, Ergin and Polat). The United States, whose population is not largely of Mediterranean ancestry, on the other hand, has a much lower rate of thalassemia, though it is still a common monogenic disease encountered in various parts of the country. Additionally, as a largely Christian country, the US does not report to have any increased rates of transmission of genetic disorders due to practices of consanguinity, unlike in Turkey as described above.

However, studies from the United States have shown that thalassemia is more common and diverse in this country than generally thought of, and only four out of the forty participants who had clinically significant cases of the disease were of Mediterranean ancestry (Luo, Boudreaux and Steinberg). The epidemiology of thalassemia in North America had been reported to reflect a very heterogeneous group of diseases manifested in people of different ethnicities and showing altered genotypes in comparison to what is typically reported (Luo, Boudreaux and Steinberg).

This increases the danger of the disease as well as its potential to be found in nontraditional populations, since new genotypic versions of the disease have been discovered that are different from the commonly-known genotypes (Vichinsky, MacKlin and Waye). Therefore, in addition to the global spread of the disease through migration as mentioned previously, thalassemia is also spreading in terms of its genetic manifestation, as it is now shown to impact populations that are not traditionally considered to

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be at-risk (Colah, Gorakshakar and Nadkarni; Luo, Boudreaux and Steinberg).

Given the information above, there is a great need for the study of thalassemia with regards to prenatal genetic testing and preimplantation genetic diagnosis, because this disease is rising in prevalence worldwide both in its traditional form and in new genetic manifestations. This project studies the availability of, attitudes towards, and government policies regarding genetic testing and preimplantation genetic diagnosis in the United States and Turkey, specifically with regards to thalassemia. In doing so, this project also looks to study how the influence of religion, Islam as compared to Christianity, can impact the provision of genetic services with regards to this disease. Such analysis is aimed at understanding how the intersection of religion, culture, and law can impact health outcomes in countries as diverse as the United States and Turkey.

RESEARCH This investigation uses various research methods in order to provide a comprehensive analysis of the study as described above. Through a multimodal approach, this investigation aims to provide an insightful discussion regarding perceptions of preimplantation genetic diagnosis and prenatal genetic testing in Turkey and the United States.

Ethnography was used in order to understand the disease and perceptions of the disease from an academic or physician’s perspective, through formal interviews with physicians from Koc University School of Medicine, Koc University School of Nursing, Acibadem, and Texas Children’s Hospital. Koc University School of Medicine is a relatively new institution which has an associated training hospital, and is housed partly on the Koc University campus. Koc University School of Nursing is part of the Koc University system, and it works closely with the American Hospital in Istanbul. Acibadem is a private health facility in Istanbul which is part of the Acibadem Healthcare Group of Turkey. It is known to be one of the leading institutions in Turkey in the field of private healthcare, and has a partnership with IHH Healthcare Berhad which has made it the world’s second largest healthcare chain. Texas Children’s Hospital is one of the most highly-ranked pediatrics hospitals located in Houston, Texas in the Texas Medical Center. Site visits were conducted to the Koc University School of Medicine as well as the Koc University School of Nursing, Texas Children’s Hospital, and Acibadem. These interviews were

meant to provide context into understanding the perceptions of geneticists or other healthcare professionals with regards to general social attitudes towards prenatal genetic testing or preimplantation genetic diagnosis for thalassemia. These interviews were also designed to provide information with regards to how religion impacts expecting parents’ views on preimplantation genetic diagnosis or prenatal genetic testing for thalassemia. Much of the substantial research came from such in-person, open-ended interviews conducted with faculty from both medical institutions. All interviews were recorded. Two physicians from Koc University Medical School were also interviewed through online correspondence. These interviews were especially useful because the healthcare professionals and geneticists frequently come into contact with and interact with expecting parents, so they directly work with the target population and can make statements with regards to major trends or patterns that they see amongst this population.

Participant observation was also used in this study in order to provide more information on patient perceptions of genetic testing and preimplantation genetic diagnosis in the United States. Clinical rounds under the direction of two physicians in the Pediatric Genetics Department of Texas Children’s Hospital were observed. These physicians, Dr. Amber M. Yates and Dr. Lakshmi L. Srivaths, work directly with thalassemia patients, so the clinical rounds provided substantial information regarding the types of decision models used and the types of factors that are taken into consideration by expecting parents when determining the need or desire for the abovementioned genetic procedures. Direct participation in clinical situations where expecting parents were informed about and counseled with regards to thalassemia in their children elucidated the various concerns, questions and issues that the parents are seen to express during this process. However, since only a small sample of 10 families was observed, these observations may not be completely representative of the general population.

The third major research method implemented in this study is more quantitative, and is derived from literature reviews of data collected from hospitals in Turkey and the United States. Analyzing statistics regarding the prevalence of thalassemia in both the United States and Turkey, and comparing this data to the reimbursement policies surrounding prenatal genetic testing and preimplantation genetic diagnosis in both countries, can provide more information

regarding public perceptions of these procedures.

This also provides context into how the healthcare system in each country responds to the relative prevalence and threat of thalassemia in its respective population, with a focus on prenatal genetic testing and preimplantation genetic diagnosis.

FINDINGS Government and Insurance Policies Key findings from formal interviews in Istanbul and literature reviews of Turkish and US healthcare policy include the following: the Turkish government has a publicly-funded healthcare system that completely covers the cost of prenatal genetic testing and substantially covers the cost of preimplantation genetic diagnosis, especially in cases where the risk is high (Balci, Ergin and Polat; Seven). The government has established a national program to reduce the incidence of hemoglobinopathies, by eliminating risky pregnancies through genetic screening and counseling. The first bill to address genetically transmitted hematological diseases was passed in 1993 (called “Fight Against Hereditary Blood Disease”), and in 2000 a council was established through a collaboration between the Ministry of Health, NGOs, and academic institutions in order to put forth a more serious effort in reducing the incidence of diseases such as thalassemia (Orer). Thalassemia screening centers were also established around the country starting in 1994 (Alanay). As mentioned earlier in the paper, couples in Turkey are required (especially in the 33 “high-risk” provinces) to get a health screening (Thalassemia Premarital Screening Program) before receiving their marriage license, which informs them of whether or not they are carriers of thalassemia (Seven). The general reasoning behind such government-mandated screening is that it facilitates informed reproductive decision-making in the preconceptional period, and it is thought to increase equity and reduce stigmatization that getting such tests could have if they were not mandated and instead were elective (Teeuw, Loukili and Bartels; Alanay). Turkey allows for gender selection only in cases where the child is at high risk for thalassemia, in which case parents are allowed to select for an embryo without the disease through IVF (Orer; Alanay). Turkey also has other government-led education initiatives, such as the National Thalassemia Prevention Campaign (Ruacan; Canatan, Aydinok and Kihnc).

The United States, on the other hand, does not have any government policies or public health campaigns

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regarding thalassemia (Srivaths; Yates). This is starkly in contrast to the Turkish government policies as outlined above. Also, in the United States, the cost of procedures such as preimplantation genetic diagnosis can be prohibitively high (Russell). This is because preimplantation genetic diagnosis requires in-vitro fertilization, which is not covered by many health insurances (National Conference of State Legislatures). Since the 1980s, there are 15 states in the U.S. that mandate coverage for infertility diagnosis and treatment, but in the other 35 states most insurance plans do not provide much assistance with payment for in-vitro fertilization services, which are often very costly (National Conference of State Legislatures).

The Perceived Risk of Thalassemia In Turkey, premarital screening is done in about 81% of all marriages, as reported in 2008 (Canatan, Aydinok and Kihnc). Though 91% of the couples interviewed in one study agreed with the importance of the premarital screening program, in terms of reducing the prevalence of genetic diseases, only half of the couples had heard about thalassemia, mostly from television programs, the Internet, and newspapers (Balci, Ergin and Polat). Furthermore, according to the study, 82.5% of the participants in the study did not know how thalassemia is passed down, and only 41.6% of the participants believed that thalassemia is a preventable disease (Balci, Ergin and Polat). This study also found that knowledge of thalassemia positively correlated with the age and education level of the participants (Balci, Ergin and Polat). Awareness is increasing in urban areas of Turkey, but those of lower socioeconomic status and disadvantaged backgrounds often are less informed about the disease (Orer). Thus, there is a need for an increased awareness of thalassemia and its risks amongst the Turkish population, which the current government is actively trying to promote through national education programs and campaigns in schools. This is especially important given the fact that the prevalence of the β-thalassemia carrier gene can reach 8-10% in certain focal areas such as the Thrace, Mugla, and Antalya regions, where it is a major public health problem (Orer). Though people may know about the disease, they do not know what it does or how it is transmitted, which is crucial information. However, according to practicing physicians in Turkey, those who do know of thalassemia view it as causing as much of a disability as diabetes or heart disease are seen to cause in the United States population – it reduces quality of life, especially

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given that rates of unemployment are higher among thalassemia patients – but it does not preclude the affected individual from working or getting married and building a family (Orer; Alanay).

In the United States, there is a significant lack of public awareness regarding thalassemia and screening for thalassemia, because traditionally this disease has been seen as localized to the Mediterranean countries and those people who have Mediterranean ancestry (Srivaths). Based on information from literature reviews, pregnant women in the United States are generally found to have a lack of awareness regarding genetic testing (Cousens, Gaff and Metcalfe). In a study evaluating public awareness of thalassemia amongst those Americans who are most at-risk to have or be carriers of the disease (due to Mediterranean ancestry), only 19% had heard of thalassemia (Cousens, Gaff and Metcalfe). This number is starkly lower than those cited above for Turkey, because of the lack of governmental education programs for the general public and the lack of training of health professionals. Also, Americans are not required to have premarital screening in order to receive marriage licenses, so they are often not aware if they could be carriers for the disease. More often than not, the perceived risk of thalassemia is most acutely understood in American families that have a familial history of thalassemia (Yates; Srivaths). Based on interviews with hematologists at Texas Children’s Hospital, patients often do not know much about prenatal genetic testing or preimplantation genetic diagnosis other than the standard triple or quad screen that is offered to all women who are pregnant, to detect trisomy 21 and neural tube defects (Russell; Srivaths; Yates).

One interesting point of comparison between the two countries stems from their cultural practices with regards to marriage. The fact that Turkish and Islamic cultural practices generally make it uncommon to have children before marriage, combined with the fact that the Turkish government requires couples to have premarital screening for genetic diseases such as thalassemia, means that most couples who are going to have children already are aware of whether or not they carry the gene for thalassemia, and thus already understand the risks (Seven). This may influence parents to be more proactive in seeking genetic testing or preimplantation genetic diagnosis. In the United States, however, there is a higher rate of having children before or outside of marriage, and even if married, couples are not required to undergo genetic screening. This may lead to a lower knowl-

edge about thalassemia risk and influence public perceptions regarding prenatal genetic testing and preimplantation genetic diagnosis for the disease.

However, though premarital screening is mandatory in Turkey, it is often done with a blanketed consent and individuals who are tested are often not aware that they are being screened for thalassemia unless they are found to be a carrier for the disease. This is in conflict with dominant views in the United States regarding informed consent, where the predominant opinion is that informed consent is necessary before any type of procedure can be carried out (Rapp). Despite this view, surveys done in the United States have shown that faced with numerous options of genetic tests offered to them and no set requirement or standard to rely on, pregnant women often are overwhelmed and do not have a clear understanding about what the tests offered are designed to detect (Cousens, Gaff and Metcalfe).

Public and Physician Perceptions on Prenatal Genetic Testing and Preimplantation Genetic Diagnosis Overall, Turkey seems to have a greater public acceptance for and use of prenatal genetic testing and preimplantation genetic diagnosis with regards to thalassemia than the United States. This may be due to a combination of factors, including the higher prevalence and perceived risk of thalassemia in Turkey than in the United States, as well as the existence of many government campaigns promoting screening for thalassemia. Also, Islamic bioethics invalidate some of the arguments that are popular in the United States to prevent the use of preimplantation genetic diagnosis from an ethical standpoint, because the Islamic religion does not see the embryo as being a person, and sees personhood as starting at the point of implantation (Karahuseyinoglu). Therefore, deselection of embryos before implantation is not ethically troublesome because they are not considered to have personhood yet (Seven). Also, as previously mentioned, there is a generally higher awareness of thalassemia in Turkey than in the United States. Furthermore, given that the Islamic culture promotes consanguineous marriage, it is fitting that this population is more aware of and willing to use such techniques in order to prevent the spread of genetic disease that accompanies their cultural practices. However, one cultural factor stemming from the Islamic religion that would prevent the use of prenatal genetic testing and preimplantation genetic diagnosis would be the â&#x20AC;&#x153;fatalistâ&#x20AC;? attitude that promotes a mindset of accepting whatever hardships a person must face in life, even if they are

entirely by chance (such as genetic disorders), because it is a way in which people repent past sins or transgressions (Orer; Seven). However, this attitude is only common in low socioeconomic classes that are not highly educated, and it is overcome by the government-mandated policy for genetic screening before marriage (Alanay).

In the United States, the predominant religion is Christianity, so Christian bioethics often can be seen to shape public perceptions (Yates). Certain branches of Christianity see personhood as beginning at the point of fertilization (Yates; NPR). This is a very different view from that predominant in Islam as described above, in which personhood is seen at the point of implantation. Therefore, one factor driving the lower rate of use of prenatal genetic testing and preimplantation genetic diagnosis (besides the fact that these are not supported by the government or completely covered by insurance, as described previously) is the fact that deselection of embryos can be viewed as ethically wrong since the embryos are considered to be persons.

In both Islamic and Christian faiths, abortion is discouraged and is not commonly practiced. After speaking with faculty and physicians from Koc University School of Medicine, Koc University School of Nursing, and Acibadem Hospital, the common messages seems to be that though abortion is legal in Turkey, it is highly discouraged by the current government, and thus it is very difficult to find clinics that will actually carry out abortions (Karahuseyinoglu). In the United States, based on the 1973 landmark Supreme Court decision in Roe v. Wade, the current policy regarding abortion is that it is legal, but may be restricted by individual states to varying degrees (United Nations Department of Economic and Social Affairs). Based on interviews with physicians in both countries, there is an attitude in the general populations of both countries that abortion should be regulated to at least a certain extent (Srivaths; Seven). Though thalassemia is not typically a cause for parents to elect for an abortion, given that it can be treated and managed even in severe cases, the desire to avoid abortion could be an additional factor contributing to the acceptance and use of preimplantation genetic diagnosis for thalassemia in Turkey (Ruacan).

In both nations, the perceptions on prenatal genetic testing and preimplantation genetic diagnosis are also highly influenced by familial history of the disease. According to physicians in both countries,

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if a particular family has had multiple members who have thalassemia and have done well with measures such as transfusion therapy, they may have a lower perceived need for prenatal genetic testing or preimplantation genetic diagnosis (Yates; Srivaths).

This is because to them, such measures would be deemed as an unnecessary financial undertaking and ethical dilemma given that they have seen the disease be completely and successfully treated via other measures after the child is born (Yates). Additionally, in both countries, more people know about prenatal genetic testing in comparison to preimplantation genetic diagnosis, and parents in both countries are known to express concern regarding the medical risks that prenatal genetic testing or preimplantation genetic diagnosis can cause to the pregnancy or to the mother, which is a major factor they take into consideration when making their decision of whether or not to have the procedure done (Srivaths; Alanay).

The perceptions of the physicians interviewed in both nations seem to align as well, because all hold a positive view of prenatal genetic testing. However, most physicians were neutral with regards to preimplantation genetic diagnosis, and preferred to allow parents to make the decision (Alanay; Srivaths). Hematologists at Texas Childrenâ&#x20AC;&#x2122;s Hospital are reported to work with the Prenatal Genetic Counseling Group at Baylor College of Medicine, encouraging patients to seek more information about their pregnancy, especially if they have a family history of thalassemia (Yates). All doctors interviewed mentioned that they review both preimplantation genetic diagnosis and prenatal genetic testing with expecting parents who have a familial history of thalassemia, but allow the family to make the ultimate decision (Yates; Alanay; Srivaths). However, the average practitioner in both countries is reported as not being completely knowledgeable about these genetic procedures, mostly because a large proportion of currently-practicing generalist physicians went to medical school before the sequencing of the human genome and the advent of such technologies, so they were not trained to give such a large consideration to genetic factors (Alanay).

CONCLUSIONS AND IMPLICATIONS In conclusion, information synthesized from an extensive literature review and from formal interviews of professors and medical professionals in both the US and Turkey has demonstrated that in comparison to the United States, Turkey has more population

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and governmental support for prenatal genetic testing and preimplantation genetic diagnosis with regards to thalassemia. This can be attributed to the interplay of multiple factors, including the higher prevalence and perceived risk of thalassemia in Turkey than in the United States, as well as the presence of more government policies and campaigns supporting genetic screening and thalassemia education. There is also more insurance coverage for such genetic procedures in Turkey. Islamic bioethics invalidates some of the ethical arguments that are used in the United States to prevent the use of preimplantation genetic diagnosis, and Islamic practices of consanguineous marriage put the Turkish population at a higher risk for the spread of genetic disorders, making it increasingly important to foster public awareness of such preventative genetic measures in Turkey. Therefore, people in Turkey more frequently utilize genetic testing and preimplantation genetic diagnosis for thalassemia than people in the United States, especially because the Turkish government allows people who are at high risk for having children with thalassemia to choose the sex of their child through in-vitro fertilization so that the embryo with the least chance of having the disorder will be implanted. However, a higher acceptance or rate of abortion is not seen Turkey in comparison to the US, even though there is a higher use of prenatal genetic testing for thalassemia, due to Islamic views and governmental policies that look negatively upon abortion.

RECOMMENDATIONS AND FUTURE WORK Future work in this area of research should involve more extensive population surveys with regards to attitudes on and awareness of prenatal genetic testing and preimplantation genetic diagnosis when dealing with thalassemia, given that the conclusions in this study are based on interviews and observations of very small data sets.

Given the growing risk and incidence of thalassemia in the United States, especially with the discovery of new genotypes that affect people who are not of Mediterranean ancestry, it is important that the United States provide increased public education about genetic diseases such as thalassemia, in line with the campaigns promoted by the Turkish government.

Though the use of preimplantation genetic diagnosis and prenatal genetic testing has not definitively proven to be beneficial, because these techniques are still very new and require much ethical consideration, it is still important for the public to be aware

of diseases such as thalassemia and how they are transmitted, as well as what genetic procedures are available with regards to prevention or treatment.

This is not necessarily to increase the rate of preimplantation genetic diagnosis or prenatal genetic testing, but just to promote population awareness.

Increasing health literacy in this way will improve the general health of the population as a whole.

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