BRIDGES THE JOURNAL OF GLOBAL URBAN LAB
VOL. III 2015 - 2016
Global Urban Lab Research Journal Copyright 2016 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 Alexander Wyatt, Assistant Director of Gateway, Editor Cover, “The Demolition of Old London Bridge, 1832, Guidhall Gallery, London” Courtesy, Wikiepedia Commons
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 immersive experiences. This journal is a collection of the best papers from our 2015 - 2016 research cohort.
TABLE OF CONTENTS The Global Issue of Unemployment: Analyzing Compensation Systems in the United Kingdom and Turkey By Amber Lo
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Singularly Tricky: Traffic Challenges in the Ports of Houston and Istanbul By Benjamin Jones
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Too Many Emergencies:Comparing Inappropriate Emergency Care Usage in Turkey and the United Kingdom By Alex Alexander
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Comparative Study of Recent Health Policy Changes in Turkey and the United States: Health Transformation Program and The Patient Protection and Affordable Care Act By Hannah Crowe
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Comparative Analysis of Approaches to and Treatments of Schizophrenia: Houston and Istanbul By Rishi Suresh
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Factors Leading to Childhood Dental Decay: A Comparative Analysis of Turkey and the United States By Tim Wang
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The Typical and the Unconventional: The Influence of Campus Design on Student Behavior By Madeleine Pelzel
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Comparative Cultural Heritage Policy and Conversation in Istanbul and Houston By Matthew Proffitt
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A Comparative Analysis of Asylum Policies and Responses to Syrian Refugees in Turkey and United Kingdom By Mishi Jain
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The Global Issue of Unemployment: Analyzing Compensation Systems in the United Kingdom and Turkey By Amber Lo Executive Summary
the government through decreases in income tax revenue; for society as a whole through rising inequality and indirect effects on the community; and for the individual, a decrease in spending power (which leads to decreased consumer demand), and loss of marketable skills due to longterm unemployment (Anderton 2008).
High unemployment in major economies causes long-term ripple effects felt in countries around the world, with wide-ranging causes stemming from structural and frictional unemployment. It is imperative for government to take proper action in order to adequately assist the unemployed in their transition back into the labor market. This study examines the features and obstacles of effective implementation of unemployment benefit systems in the United Kingdom and Turkey in order to alleviate poverty and increase the standards of living for the unemployed, through evaluation of previous systems and accompanying policies. Due to the stark differences between the two countries, this report utilizes the UK’s past challenges and successes with its advanced economy in order to provide insights for Turkey, whose developing system is fiscally unsustainable in comparison. Although both countries struggle to fairly compensate all unemployed groups, and are attempting to solve markedly different scales of problems, there are several viable solutions for future growth. This study especially calls for a critical examination of design elements in policy planning, consideration of claimant feedback, and review of administration inefficiencies. These changes would create a sustainable support system which would be better prepared to address the diverse challenges of the contemporary labor market and could consequently boost economic growth. Introduction
According to the United Kingdom’s Office of National Statistics, unemployed people are defined as those who have been out of work for four weeks and are readily available for work for one hour per week (Clegg 2015). In comparison, Turkey’s State Institute of Statistics specifies that the unemployed category includes underutilized workers, involuntary part-time workers, and employed job seekers whose current job provides insufficient income or does not utilize their skills properly (Tunali 2003). People who are unwilling or unable to work are considered economically inactive and do not count towards unemployment figures. Analysis of monthly data from the Office of National Statistics reveals that predominant unemployment causes include that the person is a student (25.7% of economically inactive), looking after family or home (25.1%), or has a long term illness (23.3%) (2016). Specifically in Turkey, high unemployment rates are mostly a result of labor movement from agricultural activity to urban areas, a shift to capital-intensive activity, and an increase in the working age population (Nabli 2011). In the UK, the manufacturing industry has lost its cost advantage in manufacturing goods as production shifted east, causing structural unemployment.
In the context of global urban change, the most prominent issue facing developing and developed areas today is a long-standing problem: the complexities of poverty and income disparity. In both the United Kingdom and Turkey, the key goal of government economic policy has consistently been minimizing unemployment. Rising unemployment creates economic costs for
The need to fully address the issue of unemployment is critical as the labor market is a fundamental component of the economy, and longterm trends have major implications for both the economy and society. This market involves the interaction of labor demand and supply, and when an economy has high unemployment, it is not optimally using its economic resources. 3
Unemployment benefits, therefore, can ensure income during temporary unemployment and provide assistance during longer unemployment spells in order to prevent poverty. According to Mulheirn, a former Treasury economist, “Unemployment benefits play a crucial role in allowing people time to search, not just for any job, but for the right job: one that puts their skills and experience to best use” (Merry 2013). The UK government formulates specific targets for their welfare policies which include strengthening incentives to work for those who have the weakest incentives. These benefits are typically means-tested and based on welfare principle (Stovicek and Turrini 2012), and from a macroeconomic perspective, provide important automatic stabilization to level aggregate shocks.
ployed. The United Kingdom has a long history of relatively successful reforms that combined with other factors have stabilized the unemployment rate, while Turkey is struggling to distribute the insurance fund amounts efficiently and keep up with fast-rising unemployment rates due to structural changes in the economy. As a result of the stark political, economic, and social differences between the two countries, this report presents London’s challenges and successes in creating an effective policy system as insights for Istanbul’s rapidly growing unemployed population. However, both countries can make significant strides in improving the process of bringing the unemployed into work through addressing their distinct, pressing labor market issues, while maximizing government benefit funds in order to bring their economies to full employment.
The most effective unemployment benefits system should be able to smooth income reduction as a result of job loss and reduce long-term inequality. However, in Turkey, unemployment insurance reduces earnings by about 2% and long-term inequality by about 0.5% (“OECD Employment Outlook” 2015). Over the past few decades, the UK has grown in the size of its labor force as population increased, but similarly, the current benefits system decreases income by approximately 1.06% (Brewer, Browne, and Jin 2011). According to economists, however, the trend of falling value of benefits relative to earnings has improved both affordability and work incentives, as Jobseeker’s Allowance (JSA) has been indexed to inflation. For both the UK and Turkey, increasing employment and developing active labor market policies are identified as current policy priorities in government. Especially as the UK approaches its general election, welfare reform is positioned at the center of political debate (Taylor-Gooby and Taylor).
Methods In order to understand the effects and structure of the benefits system in both the United Kingdom and Istanbul, academic papers, government data, policy papers, surveys, online news articles, and interviews were collected, analyzed, and compared. This quantitative and qualitative research provided context on labor market conditions, as well as a framework for evaluating various policy options. Dr. Insan Tunali, a policy expert and Associate Professor of Economics at Koc University, was interviewed on current policy measures in Turkey targeting the jobless. Dr. David Etherington, Principal Researcher and Professor at Middlesex University, was interviewed on the role of neoliberalism and austerity in the United Kingdom’s policies. Professor Gristwood, Faculty Chair at CAPA International Education, was interviewed on the implications of the welfare state, and specifically the effects of recent trends in the United Kingdom. Furthermore, the paper brief, Do the UK Government’s Welfare Reforms Make Work Pay? by Adam, Stuart, and Brown, and the report National Employment Strategy by Sayin and Tümer served as the initial foundation for research. Relevant publications were evaluated and their contents were summarized, which made it possible to identify what could be learned from existing data sources. The largest challenge faced was the lack of data and research completed in Turkey, coupled with the language barrier, which prevented several groundbreaking policy papers to be explored. Furthermore, unlike the UK, Turkey does
Issue Statement This paper seeks to understand the implications of various features of unemployment benefit systems. The goal is to understand the radically different challenges the United Kingdom and Turkey face in implementing an effective benefits system, examine previously implemented policies, and recommend possible solutions as a foundation for policymakers to draw upon. The government has historically assumed responsibility for doling out benefits to alleviate poverty and increase the standards of living for the unem4
not have extensive information on the effects and consequences of national benefit systems, as its first unemployment insurance program was implemented merely 15 years ago.
sistance and job-search training can have large, longer-term impacts and deliver net benefits when outcomes are followed up for two or more years (“Labour Market Programmes”).
Research
In the UK, the dominant thinking of the role of state is expressed through neoliberalism, an increasing reliance on private debt as a growth model (Crouch 2009). There is also emphasis on distributional policy that favors capital over labor, including labor market flexibility, which combined, can result in growing debt and instability. As a result, the model sets firm constraints on the types of policy responses available. The New Labour government had somewhat modified the neoliberal approach by strengthening the commitment to public services through increased government expenditure and a new national minimum wage, both of which were essential to the development of a flexible labor market (Grimshaw and Rubery).
United Kingdom Background Currently, the United Kingdom maintains the lowest unemployment rate in 5 years at 6.5%, also one of the lowest rates in Europe (ONS 2010). However, the number of unemployed people per vacancy more than doubled from 2.3 people in March 2008 to 5.1 in March 2011 (ONS 2011). The Office of National Statistics publishes the claimant count, which shows the number of people receiving Jobseeker’s Allowance (JSA) in a particular month. The claimant count is consistently lower than unemployment numbers, as some people may have stopped claiming due to their claim spell length. Furthermore, while the number of people claiming unemployment benefits has decreased, the gap between that and the number of unemployed has increased (see Fig. 1). In January 2016, the number of claimants fell to 760,200, which was not only a 22.6% decrease from the previous year, but also the lowest level since 1975 (“Labour Market Statistics” 2016). However, JSA claimants were more likely to find employment compared with those who were not, holding other factors constant. It may be that certain conditions linked with claiming JSA, such as participating in interviews with coaches, encourage those individuals to become active in the labor market. Case study examples such as Canada’s SSP Plus provide evidence that voluntary programs delivering as-
Development of unemployment benefit system The first unemployment benefit system was introduced in the United Kingdom with the National Insurance Act of 1911, which provided a more limited coverage and unemployment insurance. Workers in certain trades such as building and shipbuilding who frequently had periods of unemployment all contributed to a fund, and if unemployed they could claim a small amount of money for a maximum of 15 weeks in any year (Field 2011). In the 1940s, the benefit system expanded ten times after implementation of the popular Beveridge report, which introduced flat-rate contribution and quickly became the model for the modern British welfare state. While this policy protected the jobless and established an acceptable minimum standard of living, the initiative also led to price distortions and related adverse economic effects (Hemerijck 2013). State intervention was firmly established through the National Insurance Act in 1946, which created a comprehensive system of unemployment, sickness, maternity and pension benefits funded by employers, employees and the government (Department for Work and Pensions 2005). According to the Office of National Statistics, unemployment benefit rates comprised 19.2% of average weekly earnings (about £26.10) in 1970 (2011). The Tories chose to raise benefits in line with prices after 1980, resulting in a low 16.6% replacement rate (Field 2011). 5
For the next 2 decades, the government utilized an orthodox market-liberal approach to welfare reform. Thatcher moved from the Keynesian commitment to full employment to decreasing most welfare programs in an effort to control rising costs of benefits (Kavanagh 2011). The Restart program was especially significant in emphasizing work-focused interviews, which was integrated into modern unemployment systems and has been shown to decrease rates of long-term unemployment (“Labour Market Programmes”). As a result of these changes, the economy grew rapidly, but also became burdened by greater income polarization between households and skill deficits. The successor Blair government introduced a series of New Deals after 1997 that targeted moving workers into employment and emphasized compulsory job search. Their policy aimed to offer the unemployed efficient job centers, more personalized support services, and core skills training such as literacy and self-presentation. The government left a strong legacy of fiscalization of British social security.
economy, rapid technological change and globalization has also reduced the demand for low-skill labor that many jobless could provide. The current unemployment benefit system The UK benefits system is constantly adapting to national needs. A series of social security reviews conducted by the Conservative Government (1979–1997) led to the introduction of Job Seeker’s Allowance (JSA), which intensified monitoring of claimants’ job-seeking behavior (Watts, Fitzpatrick, and Bramley 2014). Today, JSA is worth only 10.9% of average weekly earnings (“Jobseeker’s Allowance” 2016). According to Fig. 2, if JSA had risen in line with earnings, it would now be worth around £120, compared to the current figure of £65.45 a week (for a single person aged 25 or over). Within Jobseeker’s Allowance, benefits can either be contribution-based or income-based. The contribution-based amount depends upon the record of payments for National Insurance Contributions, as well as the level of pension and other earnings the claimant receives. Typical payments depend on age, and could range from up to £57.90 for 18-24 year olds to £73.10 per week for aged 25 and up, and are capped at 6 months (“Jobseeker’s Allowance” 2016). The number of individuals claiming contribution-based JSA has remained constant over the last two years at around 250,000. Income-based entitlement, however, is means-tested, which allows money to target those who need it most, and is cheaper than universal benefits, reducing taxpayer burden. The amount received depends on how much the claimant already has in savings and other earnings for the entire household, and amount ranges are nearly identical to what an individual would receive in a contribution-based system. Currently, there are almost 1.2 million claimants (Browne and Hood 2012). There are certain qualifications in order to claim Jobseeker’s Allowance, which includes specifications on age (at least 18 years old), education (cannot be a full-time student), and current work status (must be available for and actively seeking work, or work less than 16 hours per week). At the Jobcentre, the claimant must complete an interview with a work coach who would outline an action plan to find work and qualifications necessary to claim JSA. Afterwards, claimants must visit a Jobcentre office every two weeks to show proof of job seeking progress. Once the
Today in early 21st century Britain, the debate on welfare spending has shifted from Beveridge’s “cradle to grave” principle to provision of cost-effective social care. Furthermore, demographic aging and labor market changes, associated with the shift towards the knowledge-based service economy, pose challenges to the welfare state’s sustainability (Herden, Power, and Provan 2015). In the UK’s advanced
Fig. 2. Jobseeker’s allowance compared to weekly earnings
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ignoring other more challenging cases. In order to incentivize longer-term outcomes, the Work Program extends payment based on sustained job outcomes of at least three or six months. As seen in Fig. 3, job outcome performance is now exceeding the Department for Work and Pension’s minimum expectations, based on percentage of monthly cohorts achieving a job outcome after one year on the program.
claimant has found a job, the office would continue to provide support by offering to help with specific problems and assist in job preparation after coming off benefits. In 2010, the Coalition Government introduced a stringent workfare regime as part of major changes to the welfare and benefits system. Welfare spending cuts in order to reduce government borrowing and the total public sector debt resulted in claimants’ access to benefits becoming conditional on more difficult work requirements, and the use of benefit sanctions dramatically increased (Etherington and Daguerre 2015). The government also established its flagship welfare to work program via the Work Program, designed to help long-term unemployed people find work and come off unemployment benefits (Brewer, Browne, and Jin 2011). The Work Program receives referrals from those claiming JSA, with about 27% of participants finding a job (Newton, Meager, and Bertram 2012). The Work Program pays private and voluntary sector providers on a payments-by-results basis as a way of incentivizing them to assist the claimants to sustain work. These schemes provide valuable support such as help with interview techniques and job searching (“Welfare-to-work” 2015). However, data indicates that while participants often move off benefits for short periods of time under the program, finding sustained employment remains a much greater challenge.
Finally, the most recent policy, Universal Credit, assists those who are already claiming unemployment benefits and plans to eventually replace Jobseeker’s Allowance, as well as other benefits including housing benefits and working tax credit. This program is only being introduced in stages across various boroughs, and features single monthly payments. The structure is similar to means-tested benefits as payment amounts reflect differences in basic living costs, and subsequently the government devised a test to determine which benefit recipients would be subject to the conditionality regime (“Universal Credit” 2010). The central idea is to gradually decrease benefits as claimants begin working and their income increases, in order to allow them to come off benefits. This new program also appeals to hiring companies, as people aren’t limited by the hours they can work; previously the 16-hour a week rule may have led employees to restrict their working to avoid losing benefits (Judge). The resulting flexible and responsive workforce would benefit businesses with the challenge of filling vacancies.
Most notably, this program features a differential payment model in order to combat a recurring phenomenon in historic programs in which providers often chose to invest additional resources in claimants with higher probability of success (“Welfare-to-work” 2015). This strategy would allow the provider to collect large payments, while
In the context of the welfare state, the rollout of Universal Credit further extends the scope of the conditionality regime. Claimant Commitments, with the requirement that claimants must treat looking for work as their full-time job, increase
Fig. 3. Work Program performance against minimum expectations
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2006). The structural reforms that Turkey implemented during the 1980s and 1990s failed to deliver predicted labor market outcomes, especially moderate employment and wage growth (Kasapoglu 2015). One professor at Koc University explained that the number of job vacancies reflects the health of the labor market, and therefore the country Fig. 4. Average impact on disposable income by family type and employment status has a slack labor market. Turkey Background This theory was supplemented by Auer and PopAccording to March 2016 data by the Turkish ova, who proved that the employment to workStatistical Institute (TUIK), the country’s uneming age population has been steadily declining ployment rate has risen to 10.3%, the highest in since the 1970s, with supply-driven explanations 5 years (note that this rate does not include the including growing numbers of early retirees and unregistered unemployed), although rates have those who stay longer in school (2003). been fluctuating for the past decade (see Fig. 5). On a regional basis, unemployment is highest in In 2002, the number of benefit claimants was the eastern and southeastern provinces, which 5,710 (Tunali 2003), and the latest figures rehave been affected by mass destruction and ceived by the World Bank indicate that this has terrorist attacks. This is a critical issue as rampant risen to just over 90,000 (see Fig. 6). Only 550,000 unemployment in the region, along with ethnic unemployed are registered with ISKUR, the Turkish and political factors, becomes an important Employment Agency, although the total unemelement driving recruitment to the PKK and IS. In ployed population stands at 2.4 million people particular, the region’s youth, who have been (“Turkey” 2016). According to William Jackson, greatly affected by poverty and unemployment, senior emerging markets economist at Capital are attracted to high potential salaries of up to Economics, “What Turkey has in common with a $1,200 (Dogan 2016). lot of the major emerging markets is that growth weakened in recent years and this is reflective The largest driver behind the phenomenon of of structural problems in the economy” (Akkoc increasing unemployment is that population 2015). Turkey uniquely has a dual economy growth has consistently outpaced employment in which fairly developed sectors coexist with growth. Although the working age population underdevelopment. Furthermore, growth is exrose by 23 million from 1980 to 2004, only 6 million tremely volatile, and coupled with an unstable jobs were created (“Turkey Labor Market Study” Fig. 5. Turkey Unemployment 1988-2002
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a result, the employment package that was released by the Grand National Assembly of Turkey involved many modifications that were funded by the Unemployment Insurance Fund, the most notable of which were that the registered unemployed were entitled to vocational education and employment planning services (Kanik, Sunel, and Taskin 2013). On the structural front, these reforms aimed to reduce the payroll tax burden on the employers (presumably in order to fight the hidden economy), and on the cyclical front, the reforms aimed to create buffers that could respond to future business cycles. The total cost of these and other employment related measures amounted to 8.2 billion Turkish Liras in the 2008-2010 periods (Sayin and Tumer 2014). These measures helped early recovery of the economy compared to the government’s pessimistic expectations, with 8.8% growth in 2011 (Kanik et Fig. 6. Number of UI recipients and amount of benefits 2002-2004 al 2013). Development of unemployment benefit system The current unemployment benefit system In 1936, the first comprehensive work law, which Turkey’s passive labor market policy is centered included provisions for the establishment of a on Unemployment Insurance, which serves regsocial security system, was put into effect. Turkey istered workers to the Social Insurance Institution was also affected by the crisis of global capital(SSK). Although the program has been criticized ism and was pushed into a neoliberal period by for low benefits and strict eligibility requirements, international financial organizations such as the which in practice only benefits formal sector IMF beginning in the 1980s (Stovicek and Turrini workers, the number of claimants has been rising 2012). Active labor market policies began in since 2002 (“OECD Employment Outlook” 2015). 1988 through vocational training course and othThe benefit is paid for 180 days to an insured er measures aimed at increasing employment, worker with at least 600 days of contributions; for but these only benefitted a small fraction of un240 days with at least 900 days of contributions; employed (Hirshleifer et al 2014). The next major and 300 days with at least 1,080 days of contrireform came in 1999 with the establishment of butions. In order to collect benefits, the claimant the Unemployment Insurance (UI) system, as well must hand in an Unemployment Declaration to as the first benefit payments made in 2002. This the Turkish Employment Agency within 30 days of was the first program to partially compensate losing his job. Payment duration depends on the the income of workers when they were unemlength of employment and the premiums paid, ployed. Since then, the number of beneficiaries with a cap at 9 months (“OECD Economic Surincreased ten times, and public works and intern- veys” 2001). The system was designed as a group ship programs were introduced (Auer and Popoinsurance policy for workers who lost their jobs va 2003). involuntarily. Similar to other countries’ systems, a fraction of the gross wage is used for premium After the global crisis in 2008, the unemployment contribution. The amount of unemployment benrate grew to nearly 14% (“Turkey” 2016), and the efit is usually 50% of the last four months’ salary, government began launching comprehensive while not exceeding the minimum wage (“Social employment reforms in order to restrain the negSecurity Systems” 2014). If the claimant becomes ative effects. The rigidity of the labor market and employed or rejects training opportunities, he high non-wage labor cost posed significant chal- loses his benefit. For the UI system to function as a lenges in creating jobs for economic growth. As proper policy tool, however, the duration of ben9 financial system, these uncertainties impact employment expectations. Turkey is also characterized by having a prominent informal economy, with about one in three workers in urban areas unregistered with social security institutions (Reis, Angel-Urdinola, and Torres 2009). These workers cannot receive benefits, as unemployment insurance is based on institutional membership. Additionally, increasingly large numbers of young graduates are unable to find work, with nearly 1 million jobless university graduates in Turkey (Dogan 2016).
Findings
efits must be adjusted using labor market and macroeconomic indicators. This requires information on unemployment experiences of the unemployed as well as the recently employed workers, but presently this information is unavailable. In addition to these payments, job search help, training, and career counseling are provided to the unemployed by ISKUR, the state agency responsible for protecting employment and countering unemployment. Temporary Public Works Programs were originally initiated after the August 1999 earthquakes, and are designed to ease the consequences of natural disasters, as well as economic crises and dislocation due to privatization by providing temporary employment (Ural 2010). The program creates jobs that serve the directly affected community, with funding from foreign resources such as the World Bank, and may guarantee jobs for those who finish certain training programs.
Problems with UK benefits The priority for the welfare state is to reduce poverty and inequality while preserving the competitiveness of their economies, without raising tax burdens. Currently, the UK’s unemployment insurance benefits are meager and of short duration, and labor markets are largely deregulated. Out of 2.8 million workless households of working age, 2.5 million will see their entitlements reduced by an average of about £215 a year in 2015-16 (“Benefits in Britain” 2013). As these major welfare reforms are reducing claimants’ budgets, the unemployed still suffer from lower standards of living, and resort to getting into debt to pay large bills, or borrowing from family and friends. The issue of distribution of benefits is part of a broader debate on how poverty is seen in society, as an arbitrary classification of poor to the deserving and undeserving poor arises. The largest challenge to policy changes is resistance from the general public to paying higher taxes, with only 27% of surveyed British agreeing that the government should spend more on welfare in 2009 (Taylor-Gooby and Taylor). Over the past decades, policymakers have tried to solve this issue by finding indirect methods of spending and taxing. Through these efforts, Britain has been able to improve the goodness of fit between activating employability measures in support of “making work pay”.
Another crucial active labor market policy (ALMP) has been vocational education and training programs, implemented by ISKUR, NGOs and businesses, the widest of which is the Turkish Confederation of Trades and Craftsmen’s network (Dinler 2012). Apprenticeship-training programs are the largest training programs and seek to help alleviate youth unemployment, which involves theoretical and practical training for those who would begin working after completing compulsory education. Between 1997 and 2001, 620,000 young people received training in these courses (“Turkey Managing Labor” 2013). In addition to building skills, the program also provided a daily stipend of 15 Turkish liras to trainees (around half of the minimum wage in 2009).
Inadequate Work Program The government’s Work Program specifically has underperformed in terms of meeting its own targets, as a result of insufficient levels of resources allocated to deal with disadvantaged groups. The objective was to bring claimants into sustainable employment through assistance throughout the entirety of the job searching process (see Fig. 7), but benefit cycling still persists, with 4.6% of the UK workforce at risk of cycling between benefits and work (Wilson et al 2013). The rationale for this single program was to achieve economies of scale through simplification, while an outcome based payment model shifted risk from the government to the provider. However, a lack of capacity in contracted providers to join up with other services has contributed to poor performance for those participants with complex needs.
Fig. 7. Incentives for sustained work for a participant
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Complex Jobcentre Resources Additionally, survey data among claimants revealed that there generally was a lack of communication about what help was available at the Jobcentre, and as a result, many people were either reluctant to claim benefits or were improperly sanctioned. In a specific case study, Raja, a long time claimant, explained that he experienced a lack of empathy and support at the Jobcentre, which had led him to miss out on benefits he was entitled to, such as transport assistance (Perry, Williams, and Sefton 2014). Upon further investigation, most Jobcentre Plus staff similarly revealed that increased contact would be beneficial in order to smooth the participant experience and provide improved insight into advice for claimants.
ber countries in terms of number of unemployment per staff member is 62, compared to 917 in Turkey (Sayin and Tumer 2014). ISKUR’s services continue to expand as a result of additional active and passive policies conducted since 2009, which place large burdens on staff (Auer 2007). As a result, the benefits system cannot cover the optimal number of unemployed. Comparative analysis In comparison with the UK, Turkey has limited experience and capacity for active labor market programs, with more emphasis on vocational training programs through the establishment of ISKUR. Secondly, while the UK’s successful Universal Credit combines several benefits into a streamlined package, there is a need to consolidate Turkey’s benefit separately aimed at the elderly, disabled and unemployed to develop a comprehensive and more uniform social assistance program that adequately serves the poor. These differences arise partly as a result of the context in which the countries are operating in, with responses to the global recession of 2008 as a defining event. The employment creation capability of the Turkish economy did not improve after restructuring, due to the volatility in the macroeconomic environment. Specifically, Turkey’s inflation and exchange rate were major factors that hurt its export-oriented policy (Ercel 2006). Another distinct difference is the UK’s flatrate unemployment benefit regime, which is designed to ensure minimum income standards. This is rare among developed countries and contrasts with Turkey, which provide benefits that relate directly to people’s prior earnings. This structure creates a link between what people pay in and what they can expect to get out of the system, and decreases benefit dependency risk (Nabli 2011). By decoupling the entitlements of those who have paid in from those who have not, such systems have proven much more politically resilient over time.
Problems with Turkish benefits Turkey’s benefit system is frequently criticized for inefficiencies and inconsistencies regarding service and eligibility, and the overall social security system struggles under growing debt. At the height of the 2008 crisis, only 15% of unemployed could collect benefits (Macovei 2009). Other factors leading to this include jobless that didn’t meet the qualification period or may not have enough incentive to register as they’re working in the informal sector. A major weakness is low level of general welfare benefits, which are also biased towards certain segments of the population (the unemployed are consistently the worst covered group). As discussed previously, the system works well for those holding a formal-sector job and future policy initiatives may continue to channel through social insurance mechanisms, and as a result benefits will fail to reach the extremely poor. Another criticism is that the government lacks a countercyclical policy, in which benefits adjust to business cycles. Instead, they remain stable through recessions instead of expanding. From the government’s perspective, the current system is fiscally unsustainable, and is generating large deficits that need to be covered by the state budget, which consequently contributes to rising inflation. ISKUR receives unstable levels of monetary inflows from foreign funding and support, which result in fluctuations in the services they can provide. Limited personnel also contribute to limiting the number of claimants the organization can effectively serve. Through analyzing Eurostat 2009 data, the average of 21 EU mem-
However, both systems emphasize brief claims. Nine out of ten JSA claimants in the UK are back in work within the year (Merry 2013), and the average UI claimant in Turkey only receives benefits for around 6 - 9 months (Tunali 2003). This design is effective because by keeping welfare benefits to a minimum there is an incentive to retrain and look for paid work. The theory behind this, according to the Centre for Social Justice, is that if claims were longer, people would be11
come dependent on benefits, which would not only trap them in poverty but also prevent them from achieving economic independence, and increased labor immobility would lead to wider structural unemployment (2013). Opponents may argue, however, that decreased benefits cause the unemployed to stop claiming (the “spillover effect”), but not necessarily go to work. European studies show that “the use of sanctions is likely to lead to worse employment outcomes (lower pay and more likely to be back on benefits) than if sanctions are not used, as the threat or use of sanctions makes people take lower-quality jobs than if they had been allowed to wait for a better opportunity” (“Benefits in Britain” 2013), which creates unfavorable effects in the long run.
everyday response to austerity indicates lower motivation for policymakers to create alternatives. Growth of Informal Sector in Turkey In Turkey, on the other hand, the informal sector has expanded as a result of weakened benefits. As seen in Fig. 8, the unregistered employment rate is estimated to be 40%, which indicates that a large portion of workers do not benefit from the protection stipulated in labor law and trades are unregulated. This cushion for job losers and new entrants has also brought into prominence the concepts of traditional family and agricultural society. However, newcomers who cannot meet the market’s demands for skilled labor and who lack past social networks have resulted in new forms of poverty in large metropolitan cities such as Istanbul.
Use of Food Banks in the UK A major sign of failure of the welfare system in the UK is the use of emergency food aid, particularly in the form of food banks, which has dramatically increased over the last decade. In a case study by Perry, Williams, and Sefton, this demographic group, which included a single mom with three sons, commented along the lines of, “I thought the system would protect me. My benefits are my safety net – if they’re removed, how are families like ours meant to survive?” (2014). The unemployed typically turn to food banks as a last resort when other coping strategies are overstretched, and some are not aware of the various emergency payments available to them. Further analysis also revealed that there extensive waiting periods can occur between benefit claim and decision, and around 30% of food bank users were waiting for a benefit claim to be processed or paid. There is a distinct danger that the normalization of charitable food banks as an
Policy considerations and challenges Both the UK and Turkey have reformed their benefits system in line with neoliberal principles of financial sustainability, which are seen as major economic goals. In order to accelerate growth, the government should focus on how the welfare bill is spent, specifically what sort of incentives does it give to people to work and become trained or educated. According to the UK’s Prime Minister, “Work is the best route out of poverty” (Newman 2010). Reforms should involve the design of activating benefit systems which reward the unemployed returning to work, as well as systems that adequately adapt to economic conditions. Making these policies cost-effective requires making jobseekers more responsible, as well as getting the right services to the right people.
Fig. 8. Informal employment in Turkey
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Turkey: Empower Local Managers to Provide Local Solutions Job centers in Turkey should focus heavily on partnerships with local authorities and charities and provide greater autonomy on how to allocate their resources and design their services, such as childcare and financial advice to deal with specific problems (Newman 2010). Evidence from London Council’s report reveals that “councils – with their knowledge of their communities – are very well-placed to provide the support those further from the labor market need - both to find work and to stay in work” (2015). Local job centers can also identify potential job opportunities through their supply chains and as a major employer themselves. National programs can be less flexible at the local level, for example, in responding to large scale redundancy from a single local employer (Gugushvili and Hirsch 2014). This system would bring accountability for decision-making closer to the people who require support, and the economic and political influence of centers can bring stakeholders together and convene partnerships. Additionally, there would be less scope for benefits fraud.
Additionally, a major challenge to their government is determining levels of benefits, as it is well known that unemployment benefits raise unemployment durations. This result has been interpreted by orthodox labor economists as a substitution effect caused by a distortion in the price of leisure relative to consumption, leading to a reduced incentive to work, and a resulting moral hazard (Chetty 2005). The analysis is supported by recent studies which give strong evidence that many unemployed individuals face liquidity constraints. Gruber finds that benefit increases reduce the consumption drop during unemployment, indicating the inability to smooth consumption relative to permanent income (1997). Therefore, estimating the magnitude of the substitution effect is necessary in order to properly assess the relevance of moral hazard in unemployment insurance. However, economic models have also shown that where unemployment insurance is too low, the labor market does not function effectively, damaging the economy and reducing prosperity. Daron Acemoglu of the Massachusetts Institute of Technology argues that a moderate level of unemployment insurance can improve the functioning of the economy and the level of output (2009). The Centre for Social Justice Research similarly concludes that low benefits can act as a barrier to finding work, as problems with funds can make it difficult to afford the essential necessary when searching for employment including transport and appropriate clothes (2013).
Implement Flexible Work Arrangements Currently, Turkey’s active labor market policies are relatively insufficient in terms of flexibility and security indicators compared to EU countries. The government should therefore combine generous benefits with stringent job search conditions and time limits. Research by Auer (2007) suggests that this hybrid approach can achieve low levels of unemployment while avoiding the negative aspects of the United Kingdom’s model. Necessary regulations can be adapted for flexible work arrangements such as work sharing, flexible work time, homeworking and distant work. Part-time employees would have the possibility to work overtime proportionate to their work durations, and legal arrangements for private employment agencies to establish temporary work relations would be adapted. Flexible labor market aims at improving the adaptation capacity of enterprises to competition and changing conditions and also aims at the employment and income security of those in the labor market (Eichhorst and Konle-Seidl 2005). Main challenges that prevent widespread practice of the flexible work types in Turkey include a high level of unregistered employment and illegal overtime work. Unregistered employment in the agriculture sector is as great as 52.7%, according to Turkstat 2015 data.
Recommendations Turkey can draw from the United Kingdom’s successes and challenges in its own reform considerations, as the difficulties faced by Turkish government to improve its social insurance system are nearly universal. Currently, the government’s major aims include: to cut back on government spending; to give unemployed people greater incentives to move into work; to protect vulnerable citizens in need of support; and to simplify the system. Conclusions from statistical data comparing 1987 and 1994 indicate that an increasing number of households rely on wages as their sole source of household income (“Turkey: Economic Reforms” 2015). This is an expected result of economic growth and modernization. Major recommendations for Turkey as well as small structural reforms for the United Kingdom that policymakers should consider are detailed in this section. 13
Furthermore, the lack of legislation for temporary work through private employment centers is a major gap for meeting the short term labor demand of businesses.
develop skills needed for full-time work (“Labour Market Programmes� 2005). United Kingdom: Avoid Benefit Sanctioning without Notice Unemployed people who face sanctions are not able to replace income from benefits with income from work, and unfavorable long-term outcomes for earnings, job quality and employment retention emerge as a result. Evidence from Jobcentre Plus offices suggests that the majority of sanctions referrals actually result from failure to attend initial meetings, rather than from lack of compliance with required activities within programs such as the Work Program (Oakley 2014). According to earlier studies, some claimants were unwilling or unable to comply regardless of the consequences of sanctioning, and the sanctions instead generated hostility towards provided services and more negative views about work (Dorsett 2013). In cases of extreme abuse, how-
Strengthen Youth Unemployment Program Design In the growing Turkish economy, youth are a key asset. Policy should focus on equipping this demographic with the skills needed in the labor market and give them opportunities to become well-integrated into the world of work. These efforts would contribute to the productive potential of the economy and to social cohesion more generally. Furthermore, employers in many Arab-Mediterranean countries indicate that skills mismatches create prominent constraints to business development (Angel-Urdinola, Semlali, Brodmann 2010). Turkey can benefit from improving the apprenticeship system, and especially by implementing higher quality off-the-job training and mentoring in order to assist more
Fig. 9. Youth employed in temporary or informal jobs
young people. Partnerships could be achieved by designing provider contracts based on performance and intermediation (for example, pay performance bonuses to those who achieve higher placement rates), and developing community service and volunteer work that provides credits towards students’ graduation. For these programs, monitoring should be integrated in the design and interventions in order to provide immediate feedback. Previously, temporary contracts were considered vital for youth with limited skills and were increasingly widespread (see Fig. 9), but in reality, many low-skilled youth would remain in these jobs in the long-term. This is supported by evidence from the OECD Employment Outlook which similarly suggests that temporary jobs do not provide the necessary opportunity to
ever, a sanction decision may be acceptable if the letters sent clearly communicate the reason that a sanction is being imposed (including dates and specifically what the failure was), the period for which the sanction will apply, and whether a hardship payment has been granted, and if not, set out the process for obtaining one (Watts, Fitzpatrick, and Bramley 2014). However, this is a highly contentious area and there is a need for additional evidence on the impacts of benefit conditionality and sanctions in the longer term.
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Conclusion This paper has investigated the unemployment benefits structure and possible policy options in the United Kingdom and Turkey. This research has aimed to understand the purpose of these
benefits and resulting implications for government planning and spending. In Turkey, labor market policies only target a small section of the population and effects of these measures have been limited. However, efforts have been made to increase vocational training, which ensures improvements in the quality of the new entrants to the labor force. In the United Kingdom, a stricter benefit regime and efforts to streamline bureaucratic processes have had mixed results, but provide examples to Turkey in terms of work accountability strategies. There is a growing importance for Turkey to continue labor market reforms, with a focus on flexibility and job creation, as well as improve the social safety net for the most vulnerable. In the United Kingdom, monitoring sanctioning will increase efficiency of the benefit distribution process. The analysis of academic literature and national statistics conducted in this paper demonstrate the need of both national governments to constantly examine and assess challenges and successes in moving the unemployed into the labor force. This research is integral to guiding future decision making, as it investigates past progress as well as future prospects for growth.
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Singularly Tricky: Traffic Challenges in the Ports of Houston and Istanbul By Benjamin Jones Executive Summary
2015 alone, the metropolitan area added more than 159,000 residents (United States Census Bureau). Istanbul has grown even more rapidly. The city has experienced double-digit population growth in recent years, and today contains more than 14 million people (Daily Sabah). Expanding economies and populations pose increasingly complex problems in urban areas. As emergent global cities, Houston and Istanbul serve as fascinating laboratories for the creative management of these challenges.
Ports are integral elements of global cities because they facilitate the movement of people, goods, and ideas. Yet the immense volumes of ships, cargo, and people moving through ports can pose significant challenges to the urban landscape, and cities must be prepared to respond to these threats. This study compares the ports of Houston and Istanbul across three measures: interactions with other infrastructure, organization, and traffic management. In Houston, strong regulations and a centralized government authority allow for efficient port management. Port activity is concentrated along the Houston Ship Channel so as to minimize risk and maximize profits. The ports of Istanbul, in contrast, are saddled with a complex history with which they must vie in order to operate effectively. The legacies of colonialism and imperialism hamper the effective provision of safety and navigation services in the Bosporus. At the same time, neoliberal processes have created an increasingly dispersed and decentralized network of port facilities. Both Houston and Istanbul are poised to experience huge population and economic growth in the 21st, and this growth will undoubtedly be accompanied by increasing demands on port infrastructure. Port officials and policy makers must be given the power to efficiently and effectively respond to these changes.
As sites of commercial interaction, ports play a vital role in global cities. Ports facilitate the movement of people, goods, and ideas which have major impacts on both local and global scales. Moreover, as pieces of physical infrastructure situated in busy urban contexts, ports pose unique challenges to leaders and planners. In Istanbul, an increasingly large volume of commercial traffic must share valuable water space with local commuters. In Houston, the port poses threats to local environmental health. Because of all of these concentrated energies and challenges, ports offer a unique lens through which to study wider patterns of commerce, governance, and history in emerging global cities. Houston and Istanbul are both emergent global cities engaging in ocean-bound commerce. Yet these superficial similarities obscure deep differences that pose challenges to effective comparison. When I told one professor, a Turkish architect and urban planner, that I was conducting a research project comparing Houston and Istanbul, she jokingly wished me good luck (Ozkan). Numerous geographic, social, commercial, and political factors constrain the two cities in different ways. A brief historical review will serve to illustrate the problem of comparison between Istanbul and Houston.
Introduction Houston and Istanbul are posed, at the beginning of the 21st century, to join the ranks of an emerging group of global cities where burgeoning populations and rapidly improving information technologies have allowed for the increasing concentration of human, social, and economic capital. Both Houston and Istanbul have experienced rapid population growth and accompanying physical expansion in recent decades. The population of Harris County exploded by more than 2.5 million people between 1960 and 2006 (Klineberg). Between 2014 and
Istanbul, a city located where the Anatolian peninsula meets the European continent, has been inhabited since at least 6000 BCE. Maritime commerce has played an important role in the 19
city since ancient times, when it was colonized by the Greeks and given the name Byzantium. The city’s strategic position along the Bosporus, a strait linking the Black and Mediterranean seas, has made it a vital point in the flow of goods between Asia, the Middle East, and Europe. Indeed, the city’s long and successful history of maritime commerce actually poses challenges to its continued expansion, as new construction projects threaten to bulldoze over artifacts of the city’s ancient past (Batuman). Istanbul’s history easily lends itself to romanticism and nostalgia, and many prefer to think of it as a city favored by geography, culture, and commerce. Indeed, one recent publication says of Istanbul’s unique geographic position: “it is impossible to tell where the city and the sea meet and where they separate” (Biennale). Yet such flowery language obscures the very real problems which the city faces as it continues to expand and compete in the global market. Ports continue to play a vital role in Istanbul, yet problems of traffic management and the danger of accidents continue to multiply.
environmental disadvantages, while Istanbul appears to have been privileged by its natural location. But even the Bosporus’s natural contours have proven inadequate for modern demands. The two cities face different challenges in governance and organization yet continue to derive significant benefits from the operation of port facilities. Houston and Istanbul’s management of ports, assumption of costs, and continued drive for profit reveal the enduring role of ports in urban development. Issue Statement This paper has three central aims: (1) to assess the various challenges and benefits which traffic management in the ports pose to Houston and Istanbul, (2) to understand how the cities respond to these challenges, and (3) to suggest the policy implications of this comparison. Because the numerous differences between the two cities defy easy comparisons or explanations, this paper takes a broad view. Ports are taken to include not only bulk and container cargo ports, but also passenger vessels and cruise terminals. Utilizing elements of history, geography, economics, and anthropology, this paper attempts to paint a holistic and compelling portrait of two global port cities. This paper breaks the problem of port management into three distinct yet mutually influential categories: interactions with other infrastructures, organization, and traffic management. These categories allow for a more powerful and meaningful study of the role of ports in the global cities of Istanbul and Houston.
In contrast, Houston possesses neither a storied history nor a particularly advantaged geographic location. What the city does share with Istanbul is an early and consistent reliance on port activities for economic survival. When John and August Allen founded Houston in 1836, they knew that the bayou’s connection to the ocean-going trade of the Gulf of Mexico would be key for the city’s future prosperity, but they did not foresee the massive costs Houston would incur to connect itself to these networks. More than fifty miles separated Houston from the open ocean, most of it along muddy, shallow, and sluggish Buffalo Bayou. The Allen brothers’ fantastic claim that “vessels from New Orleans and New York can sail without obstacle” to Houston (Fisher) did not become a reality until federal intervention at the beginning of the 20th century. A sum of more than $5 million dollars was required to dredge the initial stretch of waterway and to create the Turning Basin which continues to anchor the Port of Houston (Morris). This artificial channel has required continued maintenance and expansion as commercial ships have increased in size and natural processes have silted up the channel. Divergent historical processes and geographic circumstances have produced different ports in Houston and Istanbul. Houston has had to invest significant resources into overcoming the city’s
Research Methods This paper draws from multiple sources, including historical studies, government issued reports, and interviews with academics and port officials. Quantitative data on Istanbul’s ports are relatively paltry. The dearth of accessible numerical data is compensated for in a series of interviews conducted with academics at Koc University and port management practitioners at the Turkish Directorate General of Coastal Safety, obtained during a site visit to Istanbul in the spring of 2016. Such qualitative sources are necessarily limited in their specificity, but shed unique light on the complex inner workings of the port of Istanbul. The findings of the research begin with separate 20
Galveston Bay, and into the Gulf of Mexico. As container ships continue to grow larger, the port has been forced to expand the channel in order to attract this traffic. The latest improvements to the channel were implemented in 1989. Today, more than $1 billion in future infrastructure improvements are planned; in 2014 alone, the Port Authority spent $80 million to dredge and expand the Barbours Cut and Bayport channels by an additional five feet (Port of Houston Authority). Ironically, early advocates and advertisements for the ship channel advertised Houston’s “strategic natural location” (Port of Houston Authority) while ignoring the vast sums of capital required to overcome the geographic disadvantages which necessitated the creation of the Ship Channel. The legacy of those decisions has resulted in a continual need for infrastructure improvement in order to keep the port of Houston operational.
overviews of the economies and geographies of the ports of Istanbul and Houston. Next, three points of comparison are drawn: interactions with other infrastructures, organization, and traffic management. Following these separate portraits, a final section draws conclusions and suggests future developments. Findings Houston Port activities in Houston are concentrated along the Houston Ship Channel, which runs along the course of Buffalo Bayou. Houston’s bayous are small and shallow—Buffalo Bayou can only function as a port because it is continually dredged and expanded. The Port of Houston Authority (PHA) is charged with the upkeep of the Houston Ship Channel, which stretches more than fifty miles from downtown Houston, through
The narrow course of the Houston Ship Channel is delineated in dark blue on this map. Ships must stay within this narrow passage, or risk running aground in the shallow waters of Buffalo Bayou and Galveston Bay. (Port of Houston Authority)
21
Istanbul
Despite these geographic obstacles, human ingenuity has transformed America’s “largest landlocked port” (Houston Pilots) into an engine of economic growth. Economic data on the port is easily accessible because the PHA eagerly advertises the port’s extraordinary capacity for economic output. The port handles 37 million tons of cargo annually, including more than 2 million Twenty foot Equivalent Units (TEU) of container cargo. In 2014 the Port of Houston was the second largest in the United States in terms of total tonnage, and the largest in terms of foreign tonnage (Port of Houston Authority). The port’s leading trade partners, in terms of dollar value, are China, Mexico, Germany, and Brazil, exhibiting a truly global reach. The PHA boasts that the port directly or indirectly creates more than 2.7 million jobs and fuels over $600 billion in economic activity (Martin Associates). Although the port’s containerized traffic, usually carrying consumer goods and other manufactured products, has been growing steadily in recent years, the majority of goods coming through Houston are raw and industrial materials. The port handles a staggering 100 million tons of oil and related petroleum products each year, worth almost $40 billion dollars. This trade makes Houston the energy capital of the world, and many oil companies including Shell and Exxon operate massive petroleum refineries along the ship channel.
The Istanbul Strait, commonly known as the Bosporus, is a naturally deep waterway which cuts through the heart of the city of Istanbul. The Bosporus does not require dredging as the Houston Ship Channel does. However, the Strait is plagued by a number of sharp turns and geographic peculiarities which make it a “singularly tricky strip of water” to navigate, according to Turkish port officials (Akten 2002). The Bosporus contains twelve turns that require passing ships to make course alterations. The largest turn, at Yenikoy, requires a correction of 80 degrees. The narrowest point of the straits, directly south of the Sultan Mehmet Bridge at Kandili, is less than 700 meters in width; this is especially concerning considering that modern tanker ships can exceed 300 meters in length (The Turkish Straits Vessel Traffic Service). On top of these physical constraints, the water in the straits is pulled by four different currents: (1) a southward flowing surface current due to differences in altitude between the Black and Marmara seas, (2) a deep current which flows in the opposite direction due to salinity differences between the two seas, (3) counter currents and eddies produced from the interaction of the surface current and the bends of the strait, and (4) the unpredictable Orkoz current, which can be triggered by strong southerly winds and leads to increased navigational
This table shows data only for bulk cargo, Houston’s largest trade category. (Port of Houston Authority)
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hazards (Akar). These unique factors combine to create a particularly dangerous waterway. The Bosporus’s hazards necessitate extensive safety and security measures, to be elaborated on later in this paper. Istanbul’s port activities are not concentrated in any one area, but rather distributed across numerous facilities operated by different interests. As such, there is a paucity of data related to the size of port operations. What can be gathered is that, on the whole, Istanbul is a larger port and proportionally handles more container cargo than does Houston. Ambarli port, the biggest port facility in the Istanbul region, handles more container traffic on its own (greater than 3 million TEUs) than all of Houston. In all, 43,000 ships carrying more than 500 million tons of cargo passed through the Bosporus in 2015 (Deniz Ticareti Genel Mudurlugu).However, because Istanbul is located along a throughway to other destinations in the Mediterranean, as many as one-third of ships passing through the Bosporus do not stop in Istanbul (Gurdeniz).
This map of the Bosporus diagrams the various currents at work in the straits, revealing the difficulty of passage. (The Turkish Straits Vessel Traffic Service)
Interactions with Other Infrastructures Ports in the two cities must contend with other forms of infrastructure. After all, ports are just one element of vibrant and crowded global cities. In Istanbul, passenger ferries clog the Bosporus and impede ship travel. As many as 350,000 people cross the Bosporus by sea every day on their way to work or home (Gurdeniz), amounting to more than 2,500 ferry crossings every day (Oil Companies International Marine Forum). These smaller ferries add to the already immense navigational difficulties of moving large container ships through the Straits. Regulations stipulate that ferries must yield right of way and give a wide berth to cargo ships, but in practice ferry captains must weave their way through the container traffic in order to meet the city’s immense transportation demands (Ayodogdu). The movement of passengers east to west across the Bosporus opposes the movement of cargo north to south, and puts immense strain on the capacity of Istanbul’s waterways.
Ambarli Port, the largest port in Istanbul, handles a greater volume of containers than Houston, but far less bulk cargo. (Atlas Ambali Port)
Houston currently does not face such pressures. Yet new environmental movements which see Buffalo Bayou as key to the city’s economic development may soon lay claim to the waterway currently occupied by the port. Buffalo Bayou Partnership is in the process of acquiring stretch23
es of the bayou between downtown Houston and the port’s Turning Basin, in order to transform these postindustrial waterfront properties into vibrant green spaces (Thompson Design Group). Kayakers and pleasure seekers may soon share the bayou with the port’s massive cargo ships. Both ports also face the problem of intermodal transportation: shifting goods between maritime and land-based transportation systems. In Houston, the government-operated Port Terminal Railroad Association (PTRA) guarantees equal and efficient access to railroad services which link maritime cargoes to rail networks that extend across the country. PTRA serves the port’s terminals through an extensive series of rail connections comprising 154 miles of track.
trucks, which are less efficient both for moving the goods off the ship and for moving them to overland. The trucks also clog Istanbul’s highways, placing further strain on an already overloaded roadway system. The lack of railroad infrastructure is a legacy of Turkey’s hurried and uneven industrialization in the 20th century. The United States is covered by over 200,000 kilometers of railway; Turkey, by contrast, possesses barely 10,000 km (The World Bank). This lack of infrastructural resources hampers the effective operation of the ports of Istanbul. Organization The port infrastructure is organized in different ways in both cities. Houston’s port activity is concentrated along the Houston Ship Channel, all regulated by a government agency called the Port of Houston Authority (PHA). The board members of the PHA are jointly appointed by Harris
In Istanbul, by contrast, access to land transportation is a serious problem. Only about one-third of containers moving through Istanbul make it onto railcars (Gurdeniz). The rest end up on
The government owned and operated PTRA railways connect all terminals along the Houston Ship Channel with commercial overland rail systems which transport goods across the country (Port Terminal Railroad Association).
24
Traffic Management
County and the surrounding city governments, with greatest influence being given to the cities of Houston and Pasadena. Although many companies operate private facilities along the Ship Channel, PHA maintains eight public terminals and also dictates common policy and regulatory structures. Among other things, the PHA oversees the port’s pilots and advocates for the ports interest on local, state, and national stages (Port of Houston Authority). The centralization of power in the PHA allows for efficient control and coordination of the many complex factors necessary to maintain the port as an engine of economic growth.
The problems of organization and interactions with other infrastructures both contribute to the difficulty of traffic management in the ports of Houston and Istanbul. In Houston, pilotage is mandatory; every ship entering the port must be guided by a select group of pilots who know the ins and outs of the narrow Ship Channel. These pilots, who only number about 150 individuals, are essential to the operation of the port. Once the pilot steps onboard a vessel entering the Ship Channel, they assume absolute control over ship and its cargo, which combined represent a multi-million dollar investment. PHA regulations stipulate that “nothing in these safety guidelines shall be construed to limit in any way the individual discretion of the Pilot” (Houston Port Authority). Such concentration of power is only possible because of the centralized management of the PHA and the monopoly which it holds on navigation and pilotage services.
In contrast, Istanbul has a number of port facilities widely distributed across the metropolitan region. The four largest ports in the Marmara region are: Asyaport, Ambarli, Haydarpasa, and Gebze. A few port facilities, such as Haydarpasa in the central city, are government-run and operate similarly to the PHA. Others are owned by private companies, not accountable to the public. There is not a strong precedent of government control of maritime infrastructure in Turkey. In fact, dating back to the 18th century, the Ottoman Empire was forced to enter into treaties with European nations known as capitulations, which allowed Europeans to trade and operate ports in Turkey free from taxes and domestic regulations (Gurdeniz). The capitulation system ended following World War One, and ports were brought under total state control. Then, beginning in the 1990s, the Turkish government began to divest itself from a variety of public industries, including ports, in accordance with popular neoliberal economic ideals. This policy continues to be pursued by the Justice and Development Party (AKP), which currently holds power in Turkey. Privatization may have boosted productivity and eliminated government inefficiencies, but it has also produced uneven and poorly managed growth distributed in a patchwork of facilities across the Istanbul region. In describing the reprioritization of private profit over smart management, Admiral Cem Gurdeniz said “everything is becoming privatized and everyone insists on making investments instead of protecting the environment or long term planning” (Gurdeniz). A renewed focus on centralized planning and regulation is necessary to coordinate Istanbul’s increasingly complex port infrastructures.
Istanbul faces comparable and perhaps even greater navigation and traffic control problems than does Houston. The city has constructed a substantial infrastructure system of coast guard stations, lighthouses, and traffic controllers in order to ensure safe and efficient passage through the Bosporus, all under the management of the Directorate General of Coastal Safety (DGCS). Pilotage services are provided to passing ships by Vessel Traffic Services (VTS), an arm of the DGCS. However, despite the peculiar difficulties of navigation through the strait, pilotage is not mandatory, and many ships choose not to take on a pilot and pay the associated fee. Most ships that choose not to take pilots are small Turkish or Russian vessels which do not have the necessary capital to invest in pilotage (Ayodogdu). Many officials within the DGCS strongly discourage this practice, because the only way “to keep [risk] minimum is by making pilotage compulsory for the vessels” (Gurel). Recent pushes by the DGCS have increased the proportion of vessels taking on pilots, but almost half continue to pass through the Bosporus unaided. This is especially concerning as the straits become more crowded with traffic and accidents become more likely. One study found that, as a result of increased petroleum production in Central Asia and the Caucasus, more than 220 million barrels of oil may be moving through the straits every year in the near future (Alkan). By 2015, that number 25
had already reached 140 million barrels (Gurdeniz). Oil tankers are especially dangerous because their volatile cargo has the potential to cause environmental harm, physical damage, and loss of life. Fortunately, regulations set by the Oil Companies International Marine Forum (OCIMF) require that its licensed vessels take pilotage and thus pilotage through the Bosporus is “kind of compulsory” for petroleum tankers (Ayodogdu). Yet these guidelines lack the force of government regulations, and cannot be very reassuring to the millions of people who live along the Bosporus. Istanbul has experienced several devastating accidents in the Straits in last fifty years (Akar), and can expect to encounter more as the traffic through the Bosporus increases. The date on the next page reveals that even as the proportion of ships taking pilots has increased in recent years, so too have the number of accidents.
cial access to the Turkish Straits, including the Bosporus, and placed them under the control of the League of Nations (Howard). The Turks protested, and under the leadership of Ataturk, fought a war against foreign intervention. The modern Turkish state emerged out of this war, but so too did vestiges of the old colonial arrangements. The Montreux Convention, signed in 1936 to replace the Lausanne Treaty, returned military control of the straits to Turkey but mandated that passage of commercial vessels through the straits must be free and that “pilotage and towage remain optional” (Convention Regarding the Regime of the Straits). The Turkish government is permitted to charge for the navigation services it provides, but cannot make those services mandatory and cannot charge tariffs on goods passing through the straits. Such circumstances reflected the unequal colonial relationships of the early 20th century; they should not remain the basis of policy today. To be fair, the Montreux Convention provides Turkey with strategic control over the Straits in wartime. This is of significant “geopolitical interest” to the Turkish state, and it is for this reason that Turkey faithfully adheres to the terms of the treaty (Gurdeniz). But such considerations matter far more to politicians and armchair generals than to the coastguardsmen,
The lack of navigation regulation, and Turkey’s lack of sovereignty in this critical region, is a vestige of post-colonial power politics. Following the First World War, the Western powers imposed the Treaty of Lausanne upon the vanquished Ottoman Empire. Among other things, this treaty guaranteed unrestricted military and commer-
Statistics on pilotage through the Istanbul Straits compiled from the VTS (The Turkish Straits Vessel Traffic Service) and the DTGM (Deniz Ticareti Genel Mudurlugu). Accident data not available after 2005.
26
hazards. The Bosporus is fundamentally limited in space, and as passenger and cargo traffic places increasing demand on the strait in the 21st century, accidents become more likely. As both cities look to expand in terms of population and port operations, they must manage growth so as to ensure safety and equal opportunity for all. The Port of Houston cannot serve as a model for Istanbul, because of the wildly different circumstances of the two cities. But Houston does demonstrate the advantages which strong government commitment and active regulation can achieve for port management. The Montreux Convention, and the restrictions it places on Turkish sovereignty in the Straits, are not likely to change any time soon. But Istanbul can work through other channels, like the OCIMF, to ensure that as many international bodies as possible recognize and affirm the importance of safe pilotage through the Bosporus. At the same time, alternative measures should be explored to divert traffic away from the already cramped waterways of Istanbul. The Marmaray, a passenger rail tunnel under the Bosporus, is an important step in reducing ferry traffic across the strait. Equally important is the need to limit commercial traffic in the Bosporus. The Turkish government of President Recep Erdogan has proposed digging a second channel dubbed Kanal Istanbul to augment the capacity of the Bosporus. Such a plan would be massive and costly, and is unlikely to be implemented in the near future. Nonetheless, other avenues of diversion, such as oil pipelines connecting Central Asian petroleum to Europe and thereby bypassing the Turkish Straits, can provide needed relief to Istanbul’s strained maritime infrastructure. Of supreme importance is building a culture in which private companies and government officials can work with the public to achieve the most safe and stable solutions. Until such an environment is created, traffic flow will continue to be a “singularly tricky” problem in the remarkable global ports of Houston and Istanbul.
pilots, and passengers which must navigate the terms of the treaty in their daily lives. Recommendations and Conclusions Ports continue to provide strong economic and cultural benefits to the global cities of Houston and Istanbul as they facilitate the movement of people, goods, and ideas. Yet, because of variations in history, geography, and government, ports in these two cities show remarkable differences across the three dimensions which this paper has explored: interactions with other infrastructures, organization, and traffic management. In Istanbul, port-going cargo traffic must share the Bosporus with other forms of passenger transportation that Houston, for the present, lacks. The high volume of passenger ferries moving between the Asian and European sides of Istanbul clog the Bosporus and make navigation for container ships and oil tankers bound for the city’s ports that much harder. The Port of Houston has avoided this problem because the city does not use Buffalo Bayou for passenger transportation. Organizationally, strong regulations and centralized government authority allow for efficient management of the Port of Houston, while the lack of these structures in Turkey leads to wide distribution and insecurity. The Port of Houston Authority is a centralized body which regulates the port, sets effective traffic laws, and advocates for the port on the national and international stages. The power of the PHA allows for millions of dollars to be invested into port improvements. In Istanbul, however, neoliberal processes have created an increasing dispersed and decentralized network of port facilities. Because the city’s ports are not concentrated or centrally governed, management is much more difficult. These various differences coalesce in the problem of traffic management, which Houston tackles through a system of mandatory pilotage. In Istanbul, however, the legacies of colonialism and imperialism have left international agreements which hamper the effective provision of safety services. The 1936 Montreux Convetion governing the Turkish Straits prohibits mandatory pilotage, which means that some vessels may be steered through the strait by someone who is not familiar with the area’s many navigational
Works Cited
Akar, Tuba. Interview. Benjamin Jones. 1 March 2016. Alkan, Guler Bien. “Impact of Caspian Crude Oil on Turkish Straits.” Asian Journal of Chemistry 18.3 (2006): 2047–60. Atlas Ambali Port. 16 April 2016 <http://www.altasliman.com/en/sirket_profili_istatistikler.php>.
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Ayodogdu, Vulkan. Interview. Benjamin Jones. 16 March 2016.
Ozkan, Evrim. Interview. Benjamin Jones. 29 February 2016.
Batuman, Elif. “The Big Dig.” 31 August 2015. The New Yorker. 16 April 2016.
Port of Houston Authority. 2014 Annual Report. Houston, 2015. —. “Advertising for Port of Houston.” 1936–1943. —. “Port Map.” Port of Houston Authority. 16 April 2016 <http://www.portofhouston.com/about-us/houstonship-channel-map/>. —. “Trade Statistics.” 2015. Port of Houston Authority. 16 April 2016 <http://www.portofhouston.com/business-development/trade-development-and-marketing/trade-statistics/>.
Biennale, Venice. The Ports of Istanbul Through the Ages. Venice, 2007. “Convention Regarding the Regime of the Straits.” 20 July 1936. Directorate General of Coastal Safety. 16 April 2016 <https://kiyiemniyeti.gov.tr/userfiles/editor/ pdf/montreux-convention.pdf>. Daily Sabah. “Turkey’s population expanding, Istnabul still most crowded.” 28 January 2016. Daily Sabah. 16 April 2016 <www.dailysabah.com/nation/2016/01/28/turkeys-population-expanding-istanbul-still-most-crowded-city>.
Port Terminal Railroad Association. “PTRA Rail Network Map.” PTRA. 2016 April 2016 <: http://www.ptra.com/ index.php/about-us/ptra-rail-network-map.html>. The Turkish Straits Vessel Traffic Service. “Nautical characteristics of the Turkish straits .” AFCAN. 16 April 2016 <Nautical characteristics of the Turkish straits >.
Deniz Ticareti Genel Mudurlugu. “2015 Turkish Straits.” 2006–20015. 16 April 2016 <https:/atlantis.udhb.gov/tr/ istatistik/gemi_gecis.aspx>.
The World Bank. “Rail lines (total route-km).” World Bank. <http://data.worldbank.org/indicator/IS.RRS. TOTL.KM>.
Fisher, James. “Deep Water Houston: From Laura to the Deep Water Jubilee.” Houston History Fall 2014: 2–7.
Thompson Design Group. “Master Plan for Buffalo Bayou and Beyond.” August 2002.
Gurdeniz, Cem. Interview. Benjamin Jones. 2 March 2016.
United States Census Bureau. “Four Texas Metro Areas Collectively Add More Than 400,000 People in the Last Year.” 24 March 2016. United States Census Bureau. 16 April 2016 <https://www.census.gov/newsroom/ press-releases/2016/cb16-43.html>.
Gurel, Sami. Interview. Benjamin Jones. 21 March 2016. Houston Pilots. Houston Pilots. 16 April 2016 <www. houston-pilots.com>. Houston Port Authority. “Navigation Safety Guidelines.” Houston Pilots. 16 April 2016 <http://www. houston-pilots.com/documents/pdf/NavigationSafetyGuidelines.pdf#zoom=150>. Howard, Harry N. “The Stairs After the Montreux Convention.” Foreign Affairs 15.1 (1916). Klineberg, Stephen. “Reports and Survey Highlights.” 2009. Kinder Institute for Urban Research. 16 April 2016 <https://kinder.rice.edu/has/reports>. Martin Associates. “The Economic Impact of the Port of Houston.” Pamphlet. 2015. Morris, Holly Beretto and Gregory. “Capitalism and the Common good.” Financial History 111 (Fall 2014): 14–17. Oil Companies International Marine Forum. OCIMF. org. 16 April 2016 <http://ocimf.org/media/8922/turkist%20Straits.pdf>.
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Too Many Emergencies: Comparing Inappropriate Emergency Care Usage in Turkey and the United Kingdom By Alex Alexander Executive Summary
sarily. Healthcare is not an infinite resource, and national healthcare systems, especially systems of government-provided universal coverage such as the British National Health Service, need to find a way to direct healthcare resources to those patients that truly need them. Already, rising healthcare costs are making it increasingly difficult for systems such as the NHS to continue to attempt to provide comprehensive and quality care to everyone regardless of ability to pay, possibly making them choose between compromising either quality or comprehensiveness of care (Weale 410). Although decreasing unnecessary usage will not completely relieve the pressures facing such systems, it will make sure that their resources are being used as efficiently as possible.
One of the largest unnecessary costs in any national health system is the overutilization of emergency care facilities. Many patients that come to emergency departments do not have ailments that require emergency medical attention, if they require treatment at all. This study explores this issue in two national health systems, in the United Kingdom and Turkey, in order to assess the extent of the problem in each country and how effectively each country addresses the issue. Causes that were found for inappropriate emergency department attendances include difficulty in accessing alternative care sources in both nations and a profound difference in Turkey between the type of care provided by primary care providers and the type of care expected by the public. In the United Kingdom, evidence suggests that the nation may have lowered the amount of unnecessary emergency department attendances as much as practically possible. The study follows by making policy recommendations for both countries. For the United Kingdom, further investment in current strategies is recommended, as well as further expansion of the emergency care network. For Turkey, education campaigns and new performance criteria are recommended to realign expectations of medical care. These recommendations should lower the rate of inappropriate emergency department visits in Turkey, bringing its health system closer to that of the United Kingdom.
The UK is not the only nation to introduce a system of universal healthcare coverage, and neither is it the only nation to suffer from the problem of unnecessary usage. In 2003, Turkey began an overhaul of its healthcare system known as the Health Transformation Program (HTP) designed to consolidate the various forms and sources of healthcare coverage into a unified and universal system (Atun). This system, which in some aspects bears similarities to the NHS system, has been effective in increasing the accessibility of healthcare services in Turkey and has helped to improve the general health of the Turkish population (Atun). Despite these improvements, inappropriate use of care burdens the system with inefficiency.
Introduction
Perhaps the most visible victims of overutilization within both healthcare systems are there emergency care facilities. Known as emergency departments or rooms in Turkey and accident and emergency centers in the UK, these facilities are essential parts of healthcare systems, providing immediate care in the case of medical emergencies. To serve their function effectively, they need to be highly visible, accessible, and
One of the most difficult challenges national healthcare systems face is the issue of overutilization of care. Often, the focus is placed on expanding care, increasing accessibility. Making care available to everyone is important, but governments must also tackle the competing problem of inadvertently encouraging those who do not need healthcare to seek it unneces29
provide care rapidly. In part due to these very reasons, patients tend to visit these centers even when they would be better served at primary care facilities or when they do not actually need immediate care at all (Mills).
system was obtained from the Health and Social Care Information Centre, which publishes reports about the activity of the NHS England. These reports and related data are publicly available. Other sources of data include The King’s Fund, a non-profit organization that also publishes reports and articles on the activities of the NHS. Academic articles describing medical care in both nations were reviewed as well. These studies provided background information as well as relevant data.
In any health system there will some level of inappropriate emergency care use. If medical professionals cannot correctly diagnose ailments in every instance, it is inevitable that some patients will present at emergency care centers with cases that do not require emergency medical care. Completely eliminating these visits is not practically possible, and therefore the goal should be to lower the frequency of these visits to the lowest practical level. This lowest practical level is extremely difficult to estimate, as any level will impose wasteful costs. The minimum must be found empirically, by gauging the marginal benefit of additional policies to discourage unnecessary emergency care usage. A diminished marginal benefit, as it appears is the case in the United Kingdom, will indicate that a national health system has approached the lowest practical level of inappropriate emergency care use.
Quantitative data was supplemented with in-person interviews with healthcare professionals in London and Istanbul. A larger share of the data collected regarding Turkey was obtained via interviews. It was often difficult to find quantitative data on the Turkish system as comprehensive as that found on the NHS because reports published by the Turkish Ministry of Health, though helpful, provide more general statistics and the level of access to raw data sets was significantly less than that provided by the UK government. Academic articles regarding the issue of unnecessary emergency department visits are usually published in Turkish language journals, making it difficult to obtain data. As a result, estimates and anecdotal evidence obtained from interviews were used when government-published or academic data were unavailable or not readily accessible. Interviews also provided valuable qualitative data about the causes and consequences of unnecessary emergency department visits.
This report shows that although the United Kingdom still suffers from overcrowding in accident and emergency departments (Omar), it has made significant strides in the past several decades and appears to be approaching the lower limit of inappropriate cases (Mann and Tempest). Overcrowding in British accident and emergency departments may be due to other issues, such as lack of available beds or staffing shortages (“What’s Going on in A&E? The Key Questions Answered”). Turkey, however, suffers from the issue much more egregiously and must take stronger action to relieve the burden these visits place on the healthcare system. By exploring the causes behind inappropriate care and the strategies employed by both nations, I found that not only are Turkish efforts to increase availability of alternative care centers less robust than British efforts, but also that Turkey faces a much deeper challenge in changing the public’s expectations of quality medical care. Turkey must therefore reevaluate its strategies in order to lower the frequency of inappropriate emergency room visits.
Findings Emergency care utilization Emergency care facilities in both countries have relatively effective triage systems to separate patients based on severity and urgency. In Istanbul, minor cases such as upper respiratory infections or twisted ankles are categorized “green,” mid-level cases such as high fevers are categorized “yellow,” and severe cases such as heart attacks or major trauma are categorized as “red” (Mardin). Cases are categorized by a physician upon preliminary examination (Mardin). In England, accident and emergency departments have Minors units for less urgent cases and Majors and Resus units for severe cases (Omar). Because most cases that would qualify as red or would go to the Majors or Resus units arrive via ambulance, the problem of unnecessary emergency department visits is confined to the sections to green
Research Methodology Most of the data regarding the British healthcare 30
Anecdotal estimates also place the amount of inappropriate emergency room attendances at 80-85% (Mardin).
cases Minors units. In terms of total visits, English accident and emergency centers received 19 million visits over the fiscal year 2014-15, with four million visits in London (Accident and Emergency Attendances - England, 2014-15: Provider Level Analysis). Information about the total number of visits to emergency departments in Turkey is more difficult to find, but estimates place the number at about four times as high that in England (Aktas). When viewed per capita, on average an individual in Turkey will visit an emergency room over twice as often per year as an individual in England as seen in Figure 1 (“Turkey”) (Population Estimates Summary for the UK, Mid-2014).
Overutilization of emergency services has both medical and economic consequences Interviews with health professionals provide information about the consequences of such a high proportion of non-urgent cases coming to emergency departments in Turkey. Although wait times in Turkey are not greatly impacted — non-urgent cases usually only wait for 1-2 hours (Aktas) — this comes at the cost of increased medical errors because patients can only see a physician for a short period of time due to constant overcrowding (Mardin). Overutilization is also an issue for ambulance services. This results in ambulance services being rationed and sometimes not being deployed in emergency situations (Mardin). In England, wait times are higher, with over 8% of total patients visiting accident and emergency centers waiting for over four hours (“What’s Going on in A&E? The Key Questions Answered”). English accident and emergency staff also suffer from shorter and delayed breaks, making fatigue an issue in England Figure 1. Annual Per Capita Emergency Visits. Population data for Turkey was obtained as well. from the World Bank and population data for England was obtained from the Office of National Statistics census data. Gross visits data was obtained from the Health and Social Care Information Centre (for England) and from Dr. Can Aktaş (for Turkey).
The governments of these nations heavily fund national healthcare, including emergency care, and therefore inappropriate emergency department visits pose an economic burden as well. One study estimates the total cost of inappropriate accident and emergency department visits in England at approximately £136 million ($197 million) (“Reducing Needless A&E Visits Could save NHS Millions”). NHS trusts must employ additional staff, including doctors, nurses, and healthcare assistants in addition to the costs of unnecessary tests and scans undertaken (Omar). It must be noted, however, that some cost will inevitably incurred because there will always be some non-emergent cases coming to emergency de-
Determining whether emergency department attendances are “appropriate” or “inappropriate” is difficult. The Keogh Urgent and Emergency Care Review found that 40% of visits to accident and emergency departments in England require no treatment at all. An alternative report found that only 15% of English accident and emergency department visits did not require emergency assessment and instead could have been seen by a community general practitioner (Mann and Tempest). Again, official information about “inappropriate” attendance is difficult to find in Turkey, but studies have shown the proportion to range from 22-84% (Eroglu et al. 967) (Öztürk 20). 31
partments. Because the United Kingdom may be approaching this lower limit, this cost may also be near its lower limit.
ber 2014). The majority of general practitioners have waiting lists of over three days (Omar). The UK government has also encouraged general practitioners to remain open seven days a week, but as of this writing only a small proportion of general practitioners have been able to do this, mainly due to deficiencies of staff and resources (Omar). Turkish family medicine physicians are responsible for over twice as many patients on average as seen in Figure 2 (General Directorate of Health Research). Similarly to the UK, the Turkish government has also pushed to extend the hours of these family medicine centers (Mardin).
The UK has a more developed system of urgent care provision Emergency departments are not the only urgent and emergent care providers in the British and Turkish health systems. Both systems employ primary care providers, known as general practitioners in the UK and family or community health centers in Turkey. These are designed as the first point of entry to the respective healthcare systems of the two countries, providing basic medical care and referrals. On average, each general practitioner is responsible for 1,591 patients in England, while in London that average is slightly higher at 1,723 (Patients per GP Septem-
In the UK, the urgent care network comprises other types of facilities in addition to general practitioners and accident and emergency departments. These include walk-in centers, urgent care centers, and minor injuries units (An Alternative Guide to the Urgent and Emergency Care System in England). These provide care for cases not serious or emergent enough to warrant a trip to an accident and emergency department, while still offering care in situations where a general practitioner may not be available or equipped to handle the case. These facilities, however, tend to have long waiting times and patients resort to accident and emergency departments instead, seeking more immediate medical care. The NHS also maintains a non-emergency number (111) that can be called when in need of non-urgent medical advice (Omar). This service has, however, received criticism for not properly recognizing serious cases such as sepsis (Roberts). Turkeyâ&#x20AC;&#x2122;s urgent care network, on the other hand, is significantly less developed. Currently, emergency departments are the only major type of urgent care facility outside of family health centers. There are some plans to introduce minor injuries units similar to those found in the UK, but as of this writing, those facilities have yet to materialize (Mardin). Discussion This study found that Turkey faces a much stiffer challenge from overutilization of emergency care. While the United Kingdomâ&#x20AC;&#x2122;s overutilization is primarily a result of difficulties in accessing alternatives to emergency care and may even be approaching the lowest level practically achievable, Turkey faces two significant under-
Figure 2. Patients per Primary Care Physician. Top) Country statistics Bottom) Major city statistics. Regional averages were obtained from the Health and Social Care Centre (for England) and the General Directorate of Health Research (for Turkey). Averages were calculated by dividing total population by total primary care physicians in the region.
32
Difficulty in accessing primary care increases inappropriate emergency center visits in both the United Kingdom and in Turkey.
lying causes to emergency care overutilization. In addition to lower accessibility of emergency care alternatives than in the United Kingdom, Turkey also faces a difference between the expectations of patients and the actual type of care meant to be provided by family doctors. As a result, even the strategies that Turkey is currently pursuing will not fully address the problem, as they tend to mirror the policies enacted by the United Kingdom.
As discussed earlier, the healthcare systems in both the UK and Turkey are designed so that general practitioners (in the UK) and family medicine physicians (in Turkey) provide the vast majority of primary care. Most of the non-urgent cases that take resources at emergency centers are cases that can be successfully handled by these primary care providers (Aktas) (Omar). So why do so many patients come to emergency centers instead?
Overutilization of healthcare facilities is more pronounced in Turkey As seen in Figure 1, Turkey sees significantly more, even when accounting for differences in population. Turks on average attend an emergency department more than twice as often as the English. Total annual emergency room visits exceed the total population of the country.
In England, some of this tendency to turn to the accident and emergency department first comes from difficulty in obtaining immediate care from general practitioners. When attempting to schedule appointments, 11% of patients were unable to schedule an appointment (GP Patient Survey 2016 8). Of the patients that were able to schedule an appointment, 37.6% were able to schedule an appointment for the same day (GP Patient Survey 2016 9). The patients unable to see a general practitioner the same day, however, still have the option to visit an accident and emergency center, which comes with a guarantee of being seen relatively quickly, waiting hours instead of days.
A greater proportion of Turkish emergency department visits are also deemed unnecessary. Although estimates vary due to the difficulty inherent in categorizing a visit as “unnecessary,” estimates for Turkey are consistently higher than those for England. The lowest estimate found for Turkey, an estimate whose authors concede may be an underestimate, was approximately seven percentage points higher than the lowest estimate in England. The English upper estimate of 40% refers to patients that “are discharged [from an accident and emergency department] requiring no treatment” (Urgent and Emergency Care Review Team). These patients may still have had reasonable cause for concern and been justified in visiting the emergency center, if only for assessment. It is still small compared to the upper estimates for Turkish unnecessary emergency center visits. Estimates in excess of 80% would signal a major problem that must be addressed. Although English accident and emergency departments do receive non-emergent cases, the problem is less severe than in Turkey. The estimate of 15% represents approximately 2.1 million visits (Mann and Tempest). This number may be close to the lowest practical level achievable in the United Kingdom (Mann and Tempest). Turkey faces the problem of non-urgent emergency center visits much more acutely than England does and therefore must do more to address the issue by tackling the reasons people have for choosing to attend an emergency care facility when they do not need to do so.
Even when appointments can be obtained, many general practices are open only during normal business hours. Individuals may often be unable to attend an appointment during those hours, due to their own work obligations. Of people who could not see a general practitioner because the facility was closed, 33% attended an accident and emergency center (GP Patient Survey 2016 15). Although the majority of accident and emergency visits occur during normal working hours, over 35% of attendances to accident and emergency departments still occur outside the hours of 9:00am and 6:00pm as seen in Figure 3 (Accident and Emergency Attendances - England, 2014-15: Provider Level Analysis). Many of these attendances may be patients without access to their general practitioner coming to the emergency center in search of immediate medical attention. Only 56.4% of people know how to contact a general practitioner service out of normal hours (GP Patient Survey 2015 14). This confusion easily leads to patients that desire medical attention resorting to one 33
Figure 3. Accident and Emergency Attendances by Hour, England, Fiscal Year 2014-15. Data obtained from the Health and Social Care Centre.
of the most visible sources of care, the accident and emergency departments.
cine physicians to provide the kind of immediate, results-focused care that they seek. This lack of trust is one of most significant underlying causes found in Turkey. In 2007-08, only 40% of patients were â&#x20AC;&#x153;convinced that the FD [family doctor] was aware of their personal situationâ&#x20AC;? and only 44% were convinced that the family doctor knew their medical history (Kringos et al.). Without basic confidence in their family medicine physician, a patient cannot be expected to view them as a primary source of care, even before accounting for the previously mentioned impediments to accessing that care. Patients will seek out the care that they believe can address their own medical concerns as effectively and as quickly as possible. Clearly, primary care facilities in Turkey are not fulfilling either of these criteria, at least in the eyes of the people they serve.
Turkish patients also face difficulty in obtaining care from family medicine physicians. Although the basic issue is similar, however, the problem is much larger in Turkey. As in the UK, Turkish patients find it difficult to make appointments with their family medicine physicians and they face the same issue of these facilities closing outside of normal working hours (Mardin). However, as seen earlier, there are less than half as many family medicine physicians per patient in Turkey than there are general practitioners per patient in England. As a result, Turkish patients experience a much more acute lack of designated primary care. Turkey additionally faces a disconnect between the services provided by primary care and the publicâ&#x20AC;&#x2122;s expectations of medical care. In Turkey, the issue goes deeper than a simple lack of access to primary care. Even if they could get appointments with family medicine physicians, they may choose not to do so. Many Turkish patients do not place much trust in their primary care providers (Aktas). Family clinics often cannot run tests in house, forcing patients to visit separate testing centers. Turkish patients value immediate results over more nuanced care, so they see family doctors just as sources of prescriptions instead of reliable sources of medical advice (Aktas). They do not trust family medi-
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The tendency of many patients in Turkey to favor immediate results over quality of care helps explain why so many prefer the emergency department to the family medicine center. Although the tendency to choose options that provide care as quickly as possible is by no means unique to Turkey, the fact that so many sacrifice the quality of care they receive by choosing to attend overcrowded emergency rooms in order to avoid spending the time required to visit a family medicine physician provides insight into the attitudes and expectations patients in Turkey have towards medical care. These expectations are even visible in the standards by which the Turkish government measures the progress of
their healthcare programs. Instead of attempting to judge the system based on the quality of care that patients receive, the major concern is whether patients can access care (Mardin). The performance targets system used to determine primary care salaries does not account for such things as family planning or chronic disease management (Öcek et al.), care that cannot be provided on an immediate basis. The system rewards physicians on a “mostly ‘pay for quantity’ approach,” (World Bank 30).
seek immediate assessment and reassurance by attending accident and emergency centers (Omar), their expectation of the quality of care they receive predisposes them to seek the more comprehensive care that can be obtained from general practitioners instead of the faster but less comprehensive care given by an accident and emergency center. British patients do not appear to view the accident and emergency department as an alternative to their general practitioners. People in both the UK and Turkey attend emergency departments unnecessarily for many reasons. However, the difference in the expectations of medical care found between the two countries helps to explain why this issue is so much more pronounced in Turkey. Although costs of care and access to primary care are important factors, they are only supplementary to the more deeply seated attitudes towards medical care patients face. The basic issue of what kind of treatment people expect from their physician must be considered when designing solutions to this problem in either country.
The official goal of providing some kind of medical care without much regard for its quality makes sense when one considers the fact that many Turkish patients seek medical care with the goal of receiving some kind of treatment, even if it may not be the most effective form of treatment, as quickly as possible. Despite the previously mentioned low expectation that family doctors know patient medical and personal history, 95% of patients still report being satisfied by the treatment they received from the family doctor (Kringos et al). Apparently, knowing patient medical and personal history, essential for long-term health management, does not factor much into the patient’s satisfaction with the quality of care. The patient view of “quality of care” depends primarily on the availability and accessibility of care, instead of whether this care is the most effective or efficient care possible. Emergency care centers are designed to see and treat patients quickly, with their ability to run tests and scans in-house. Family medicine clinics do not share that design, and most cannot run tests or scans. When considering the expectations held by the Turkish people for their medical care, it is clear that emergency care centers meet those expectations better than family care clinics. Although in the UK this desire for immediate reassurance is not absent, it is less pronounced than in Turkey. The basic attitude towards primary care is different, with 84.9% of patients stating that they have had a good overall experience with their general practice (GP Patient Survey 2016 13). This greater level of trust in primary care shows a different expectation of primary care. The fact that government-commissioned surveys ask about patient satisfaction with the quality of care received show the emphasis placed not just on access, but on quality as well (GP Patient Survey 2016). Although British patients do often
Both the United Kingdom and Turkey have focused strategies on expanding access to alternative care, even though underlying causes differ. The fact that the kind of care British patients expect aligns more closely with that delivered by a general practitioner than that provided by an accident and emergency department allows the British government to focus on bolstering the accessibility of alternative urgent care and educating patients about its proper use. The Turkish Ministry of Health faces the much more daunting task of changing the public’s underlying expectation about what constitutes quality medical care. This objective cannot be achieved using the same strategies that the UK has employed and will require a different, more fundamental approach. The UK has focused on expanding the accessibility sources of care outside of the accident and emergency department. Strategies include expanding general practice hours and establishing walk-in urgent care centers and a non-emergency medical advice phone line (Omar). The fact that these initiatives have met with limited success is more a result of a lack of resources 35
than a lack of fundamental effectiveness. Not all general practices have been able to expand their hours due to lack of staff and resources (Omar). Walk-in centers experience long wait times, encouraging patients to visit accident and emergency centers instead (Omar). Investing in additional resources for general practices and expanding numbers of walk-in centers would allow these strategies to more effectively offload emergent patients from accident and emergency departments. The criticisms of the NHS 111 phone line also stem from a lack of medically trained professionals available to handle these calls (Roberts). Again, failures in the UK’s strategies to tackle unnecessary emergency department use result from the inability to implement these strategies as completely or as effectively as necessary due to a lack of resources. The limited success faced by British attempts to decrease unnecessary emergency department visits may be because the system is already approaching the lowest level of inappropriate visits practically possible. It is inevitable that some patients will attend accident and emergency departments with conditions that do not warrant such a trip. Even medical professional sometimes make errors about the severity of patients’ conditions, so members of the non-medically trained public understandably will want to err on the side of caution when attempting to judge the severity and urgency of their medical needs. At 15%, “attendances to the A&E are unlikely to diminish,” (Mann and Tempest). A 1983 study of a London accident and emergency department found that 39% of attendances were non-emergencies (Davison, Hildrey, and Floyer 37), and although this study is not representative of the whole country at the time, it does suggest that unnecessary emergency department use has fallen over time in the UK. The continuing sense that emergency departments remain overwhelmed (Omar) may be due to rise in total attendances, which increased by 35% between fiscal years 2003-04 and 2014-15 (“What’s Going on in A&E? The Key Questions Answered”). Emergency centers may be overwhelmed, but they do not appear to be overwhelmed due to inappropriate visits. Turkey’s attempts to address inappropriate emergency visits has been much less vigorous than that seen in the UK. This may stem partly from the fact that Turkey’s universal healthcare system is much newer than the British NHS and that the
Turkish Ministry of Health simply has not had the time to implement strategies to lower unnecessary emergency room visits. Another explanation returns to the differences in expectations of medical care between Turkey and the UK. Turkish assessments of medical quality focus on accessibility of care over effectiveness or efficiency of care, so the motivation for reform within the government is less pronounced in Turkey as in the UK. As a result, strategies have been limited in implementation. Receiving care for non-urgent cases, categorized as green cases, is no longer free, in an attempt to discourage non-urgent cases from visiting emergency centers. This strategy has been largely ineffective in reducing the number of unnecessary visits (Mardin). The difficulties in obtaining care from family doctors appears to outweigh the cost incurred by coming to the emergency center with a minor ailment. Family care centers have been encouraged to open on Saturdays, and some did in fact expand their hours, but this effort has been largely ineffective due to a lack of information about which centers implemented the policy (Mardin). Even when that information is available, patients are reluctant to visit primary care physicians other than their own, relating to the lack of trust they place in primary care providers in general (Mardin). The Ministry of Health also plans to open walk-in care centers throughout the country, one per 100,000 population, that would be open while family care centers are closed (Mardin). For these centers to be effective in reducing the load on emergency centers, they will need to provide the kind of immediate, in-house care that emergency centers provide. However, this strategy, along with the other strategies, do not tackle the underlying cultural issue of what the Turkish public expects medical care to look like. Until quality of care is linked to comprehensiveness, effectiveness, and efficiency over immediacy of results, family medicine centers will continue to be chronically underutilized and emergency medicine centers will continue to be chronically overutilized, resulting in further difficulty in managing conditions that require longitudinal care such as chronic disease. Conclusions and Recommendations Because the underlying causes of inappropriate emergency care use differ between Turkey and the United Kingdom, they must pursue different policy directions in order to address the issue. 36
Turkey must first enact policies to change shift public expectations of medical care. This includes changing performance metrics to focus on quality over quantity of care and education campaigns to promote long-term management and prevention over immediate results. The United Kingdom must further invest in existing emergency care alternatives and, because it may not be possible to further reduce inappropriate accident and emergency visits significantly, the government should invest in expanding the capacity of the accident and emergency network to accommodate increasing usage.
the physicians time to provide better quality care to the patients they see. This will allow patients to obtain primary care outside of the emergency room. The UK is implementing the right kind of reforms, but a lack of resources has limited their effectiveness. The UK faces a different challenge. As discussed earlier, the NHS may not be able to decrease the level of inappropriate accident and emergency attendances by much. The British public already sees quality medical care as synonymous with effective, long-term health management, the kind of care provided by general practitioners. Therefore, most patients do view their general practitioners as the principal source of care and trust them to provide quality care, the care that they expect. The British government does not need to shift the direction or objectives of its strategies in an attempt to drastically reduce non-emergent cases attending accident and emergency departments. Instead, it needs to devote more resources to these strategies. Investing more in providing general practices with the resources they need to extend hours, including promoting the training and recruitment of staff, would allow this reform to be implemented more completely. Similarly, investing more in opening new walk-in urgent care centers and expanding the capacity of already existing centers would decrease wait times at these centers, making them practical alternatives to accident and emergency departments. Training and recruiting more professional medical staff to operate the NHS 111 phone line would make it safer and therefore more trusted and used. These reforms should be assessed for their usefulness once they have been implemented completely, not while limited implementation hampers their effectiveness. This kind of investment may require more funding, which would be the primary political impediment, but without it, these strategies will not be able to effectively address the problem that they are designed to tackle. Once these policies are implemented fully the proportion of inappropriate accident and emergency department visits should be reassessed. If these strategies do not significantly lower that proportion, this would signal that the UK has
Turkey must change the expectations patients have of medical care. What few strategies that the Turkish government has made in attempting to address the problem of unnecessary emergency department visits have often mirrored the policies enacted by the UK. They have been largely ineffective because they have failed to tackle the root cause of these visits. Turkish patients expect immediate, tangible results from medical care, not the long-term care that comes from a family doctor. Strategies to change this expectation should be implemented in order promote visiting family medicine centers instead of emergency departments. The Turkish government must focus on changing the expectations that the public has towards medical care. It must create and implement educational campaigns promoting preventative care and long-term health management over immediate, treatment-focused care. In addition, the government should reform performance target criteria to include quality of care indicators instead of focusing on the quantity of care provided. This will change the kind of healthcare that Turkish patients seek, pushing those that seek primary care towards family medicine doctors instead of towards emergency rooms. Once expectations of care have been shifted, the Turkish government should focus on expanding and improving its primary care network. Promoting the training of more family medicine doctors and opening more family medicine centers will decrease the high patient to primary care provider ratio. This will decrease the load on these physicians, not only making it easier for patients to obtain appointments, but also allowing 37
reached the lowest level of inappropriate accident and emergency department visits that is reasonably possible. At this point, the only way to reduce the load on emergency departments would be to expand the emergency care network, expanding current centers and opening new ones. The UK may have a similar healthcare system to Turkey, as both nations provide universal, government provided healthcare coverage. However, with regard to the issue of inappropriate emergency care usage, the two nations must pursue different strategies due to differences in public attitudes towards what constitutes quality medical care. The Turkish Ministry of Health is pursuing similar strategies to those pursued by the British NHS. The older, more established NHS may be able to serve as a role model to Turkey, but only once the public attitude towards medical care has shifted away from a desire for immediate and tangible results and towards a more longterm view focusing on management through primary care. Until then, Turkey must pursue its own strategies, tailored to its own, unique challenges.
GP Patient Survey - National Summary Report. GP Patient Survey. Ipsos MORI, 7 Jan. 2016. Web. 11 Apr. 2016.
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Accident and Emergency Attendances - England, 2014-15: Provider Level Analysis. N.p.: Health and Social Care Information Centre, 28 Jan. 2016. XLSX.
Turkey. Ministry of Health. General Directorate of Health Research. Health Statistics Yearbook 2014. By Mehmet Rifat Köse, Berrak Bora Başara, Cemil Güler, Gökalp Kadri Yentür, Asiye Aygün, Ayfer Pekeriçli, Birsen Birge Kayiş, İrem Soytutan, Selen Begüm Uzun, and Tuğcan Adem Özdemir. Republic of Turkey, 2015. Web. 11 Apr. 2016.
Aktaş, Can. Personal interview. 3 Mar. 2016. An Alternative Guide to the Urgent and Emergency Care System in England. The King’s Fund. The King’s Fund, 7 Apr. 2014. Web. 11 Apr. 2016. Atun, Rifat. “Transforming Turkey’s Health System — Lessons for Universal Coverage.” New England Journal of Medicine 373 (2015): 1285-289. Web. 11 Apr. 2016.
“Turkey.” The World Bank. The World Bank Group, 2014. Web. 11 Apr. 2016. The United Kingdom. NHS England. Urgent and Emergency Care Review Team. High Quality Care for All, Now and for Future Generations: Transforming Urgent and Emergency Care Services in England - Urgent and Emergency Care Review End of Phase 1 Report. NHS England, 13 Nov. 2013. Web. 11 Apr. 2016.
Öcek, Zeliha, Meltem Çiçeklioğlu, Ummahan Yücel, and Raziye Özdemir. “Family Medicine Model in Turkey: A Qualitative Assessment from the Perspectives of Primary Care Workers.” BMC Family Practice 15.38 (2014): n. pag. BioMed Central. BioMed Central. Web. 11 Apr. 2016. Davison, Anthony G., A. C C Hildrey, and M. A. Floyer. “Use and Misuse of an Accident and Emergency Department in the East End of London.” Journal of the Royal Society of Medicine 76 (1983): 37-40. Sage Journals. Web. 11 Apr. 2016.
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Eroglu, Serkan E., Siddika N. Toprak, Oguz Urgan, Ozge E. Onur, Arzu Denizbasi, Haldun Akoglu, Cigdem Ozpolat, and Ebru Akoglu. “Evaluation of Non-urgent Visits to a Busy Urban Emergency Department.” Saudi Medical Journal 33.9 (2012): 967-72. Web. 11 Apr. 2016.
World Bank. TURKEY Performance-Based Contracting Scheme in Family Medicine – Design and Achievements. The World Bank Group, 15 Feb. 2013. Web. 11 Apr. 2016. Öztürk, Yasemin. “Evaluation of Knowledge and Attitude About Urgency of Patients in Emergency Department.” Tıp Araştırmaları Dergisi 12.1 (214): 20-25. Web. 11 Apr. 2016.
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Comparative Study of Recent Health Policy Changes in Turkey and the United States: Health Transformation Program and The Patient Protection and Affordable Care Act By Hannah Crowe Executive Summary
determine the next steps for health care in Turkey and the United States, and points to the complicated nature of national health care policy reform.
Government mandated health care policy informs decisions that affect the accessibility, affordability, and overall quality of health care within a country. In recent years, the health care systems of both Turkey and the United States have undergone significant changes that have subsequently impacted the aforementioned accessibility, affordability, and quality of health care within these two countries.
Introduction In recent years, national policy makers have instigated substantial changes in health care policy in Turkey and the United States with the intention of improving health care in these two nations. As the largest city in Turkey and the fourth largest city in the United States, Istanbul and Houston are home to 14 million and 4 million people, respectively. The two cities are considered major hubs of health care activity within the two countries. The implementations of the Health Transformation Program in Turkey and The Patient Protection and Affordable Care Act in the United States have significantly altered the health care landscapes of both Istanbul and Houston.
Beginning in 2003, Turkey initiated the Health Transformation Program (HTP). In 2010, President Obama of the United States signed The Patient Protection and Affordable Care Act (Obamacare) into law. Both of these policy initiatives aim to address major health care concerns within Turkey and the United States, including expanding health coverage, lowering costs, and improving quality of care.
In an effort to make health care more affordable, more accessible, and of higher quality, national policy makers within Turkey and the United States initiated widespread health care policy reform. The office of the Turkish Prime Minister at the time, Recep Tayyip ErdoÄ&#x;an, began implementing the Health Transformation Program in 2003. United States President Barack Obama signed The Patient Protection and Affordable Care Act into law in 2010. Perhaps not surprisingly, the Health Transformation Program and The Patient Protection and Affordable Care Act address many of the same issues within Turkey and the United States.
This paper is a comparative study of the impact on the health care systems of Turkey and the United States following the recent adoption of the Health Transformation Program and The Patient Protection and Affordable Care Act. The goal of this study is to examine the success of the two health care systems, using the benchmarks of accessibility, affordability, and quality. This report examines the recent changes in each countryâ&#x20AC;&#x2122;s health care system by reviewing literature published on this topic and by interviewing physicians and health care experts. The findings from this research suggest that both Turkey and the United States have made strides in increasing access to health care through their recent initiatives, but that HTP and Obamacare have been met with mixed results in terms of cost reduction and improving quality of care. This report suggests that future research is needed to
Prior to the implementation of the Health Transformation Program in Turkey, Turkish citizens were overall quite dissatisfied with the health care landscape of the country. Turkey suffered from low financing in the health care sector, 39
insufficient numbers of physicians, nurses, and technicians to meet the demands of a growing Turkish population, and inadequate health care coverage throughout the Turkish population— particularly within rural and lower income groups. According to an article published in The New England Journal of Medicine titled “Transforming Turkey’s Health System – Lessons for Universal Coverage,” the goals of the Health Transformation Program are as follows: “improve public health, provide health insurance for all citizens, expand access to care, and develop a patient-centered system that could address health inequalities and improve outcomes, especially for women and children” (Transforming Turkey’s Health System – Lessons for Universal Coverage, 2015). The management of public hospitals was transferred over to the Turkish Ministry of Health, and the coverage of health insurance has been widened for low-income populations (Health Transformation Program in Turkey and Primary Health Care Services, 2008).
As illustrated by Figure 1, which is provided by the U.S. Department of Health and Human Services, the goals of The Patient Protection and Affordable Care Act focus on expanding access to healthcare while simultaneously improving affordability and quality of health care in the United States. Intended benefits include improving quality of care and lowering health care costs by providing free preventative care, providing health discounts for senior citizens, protecting against health care fraud, and providing small business tax credits for businesses that provide health insurance to employees; enacting consumer benefits by providing coverage for individuals with pre-existing conditions and providing consumer assistance in selecting insurance plans; and expanding access to health care by opening the Health Insurance Marketplace to purchase affordable health insurance plans (U.S. Department of Health and Human Services, 2014). In summary, much like the Turkish Health Transformation Program, The Patient Protection and Affordable Care act seeks to improve the
Figure 3: Intended benefits of The Patient Protection and Affordable Care Act
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tion and Affordable Care Act in Turkey and the United States have generated a large body of literature on the evolution of these two health care systems and the impacts they have had on their respective countries. The World Health Organization has published a series of studies entitled “Health Systems in Transition” to explore various changes in health care policies worldwide. Included in this WHO series is an extremely helpful report on the recent health care changes that have occurred in Turkey with respect to the Health Transformation Program. In November of 2008, the Turkish Minister of Health, Dr. Recep Akdağ, published an extensive report on the progress made in Turkey by the Health Transformation Program following the first five years of its implementation, entitled “Health Transformation Program in Turkey and Primary Health Care Services.” This report contains reliable statistics on various aspects of the health care system in Turkey, such as health care spending and number of annual physician visits, both prior to and following the implementation of the Health Transformation Program.
overall health care landscape of the United States by expanding access to health care, improving affordability, and improving health care quality. Issue Statement Following the implementation of the Health Transformation Program in Turkey and The Patient Protection and Affordable Care Act in the United States, the health care landscapes of these two countries have been greatly altered. The Ministry of Health in Turkey initiated the Health Transformation Program in 2003 with the goal of addressing national health care concerns such as expanding access to health care and improving quality of care. The Obama administration signed The Patient Protection and Affordable Care Act into law in 2010 with the intention of fulfilling similar goals. The purpose of this paper is to compare the health care systems of Turkey and the United States with respect to the relatively recent adoption of the Health Transformation Program and The Patient Protection and Affordable Care, using the benchmarks of accessibility, affordability, and quality to do so. Accessibility, affordability, and quality are the three main components of health care that both the Health Transformation Program and The Patient Protection and Affordable Care Act seek to address within Turkey and the United States. They are also useful benchmarks by which to assess both the effectiveness and the shortcomings of HTP and Obamacare because they speak to the overall success of any given health care system.
Literature and statistics published by the U.S. Department of Health & Human Services, ObamaCare Facts, and healthcare.gov have been instrumental in gaining a comprehensive understanding of the changing landscape of health care in the United States today. The research of Dr. Vivian Ho, the James A. Baker III Institute Chair in Health Economics, director of the Center for Health and Biosciences, a professor in the Department of Economics at Rice University, and a professor in the Department of Medicine at Baylor College of Medicine, has also contributed greatly to my understanding of the progress and current challenges of The Patient Protection and Affordable Care Act. I have worked as an administrative and research intern for Dr. Ho at the Baker Institute for the past two years, and the work I have completed during my time with the Health Policy Forum, as well as my continuing relationship with Dr. Ho and my familiarity with her work, provided me with much direction for this paper.
Methods Over the past decade, the health care systems of both Turkey and the United States have undergone significant changes that have subsequently impacted the accessibility, affordability, and quality of health care within these two countries. This report uses two primary methods in order to explore the recent changes in each country’s health care system: a review of literature published on this topic and several interviews with physicians and health care experts in both Turkey and the United States. The broad and sweeping impacts of the Health Transformation Program and The Patient Protec-
The published literature mentioned above, along with many other articles and studies I have encountered during my research of this fascinating and current topic, has been both informative and helpful in expanding my understanding of the changes in health care in Turkey and the 41
United States following the implementation of recent national health care legislation. But it is necessary to take the exploration of this topic one step further in order to gain a comprehensive understanding of the impact of the Health Transformation Program and The Patient Protection and Affordable Care Act. During my time in Istanbul, I was lucky enough to have the opportunity to interview three extremely knowledgeable individuals—Dr. Deniz Mardin, Yusuf Kurtlu, and T. Cengiz Yilmazyavuz. Prior to traveling to Turkey, I had the opportunity to interview Dr. Aysegul Sahin in Houston, Texas.
published on the Health Transformation Program and The Patient Protection and Affordable Care Act all contributed to my understating of the changing landscape of health care in Turkey and the United States. I will present and discuss the findings of my research in the following sections of my paper. Findings According to a report published by the World Health Organization, the Health Transformation Program in Turkey “aims to improve the governance, efficiency, and quality of the health care sector” throughout the country (World Health Organization – Country Cooperation Strategy at a glance: Turkey, 2013). In order to do so, the Health Transformation Program has reorganized the Ministry of Health in order to enhance its effectiveness in developing and implementing health policy efforts throughout Turkey and has established a Public Health Institution to focus on developing and implementing preventative health care measures. The development of the Family Medicine Program has been an important milestone of HTP. The Family Medicine Program involves assigning each patient to a specific primary care doctor to reduce unnecessary emergency room visits and streamline diagnoses. Furthermore, since the implementation of the Health Transformation Program, investment in the health care system has steadily increased such that the proportion of public health expenditure to GDP increased from 3.8% to 4.4% from 2002 to 2008 (World Health Organization – Country Cooperation Strategy at a glance: Turkey, 2013).
Each of the three interviews I conducted in Istanbul provided me with a different unique and valuable perspective on the changes in health care following the implementation of the Health Transformation Program as they apply to Turkey, and more specifically, to Istanbul. Dr. Deniz Mardin is a Turkish physician and health policy expert at Koc University in Istanbul. She was able to share her experiences prior to and following the Health Transformation Program as both a practicing physician and a health policy researcher. Yusuf Kurtlu is an administrative professional in charge of overseeing data in the management of several public hospitals in Istanbul. Through my conversation with him I was able to glean the perspective of someone working on the administrative side of health care. Finally, I spoke with T. Cengiz Yilmazyavuz, the Chief Financial Officer of the American Hospital, a private hospital in Istanbul. He was quite knowledgeable about the various health care changes following the implementation of HTP.
Beyond reorganizing the health care system to maximize efficiency, implementing the Family Medicine Program, and increasing monetary investment in the health care sector, another main goal of the Health Transformation Program is to expand insurance coverage in Turkey. Since the implementation of a universal health care system in Turkey 1982, all Turkish citizens have had a guaranteed right to health insurance and health care services. But for the most part, universal health care coverage has failed to materialize—particularly for the poor and unemployed. A “Green Card” system initiated in 1992 sought to cover low-income populations, but failed to do so effectively until after the implementation of the Health Transformation Program. Since the implementation of HTP, the number of Green Card recipients in Turkey has increased signifi-
Prior to traveling to Istanbul, I interviewed Dr. Aysegul Sahin in Houston. Dr. Sahin is a pathologist practicing medicine in Houston, Texas at the University of Texas MD Anderson Cancer Center. Though she now lives in America and practices medicine here, she is from Turkey and received her medical degree in Ankara from Ankara University Faculty of Medicine. Furthermore, she travels to Turkey frequently. Interviewing her was particularly valuable because she was able to speak to the successes and shortcomings of the health care systems in both Turkey and the United States, particularly as it pertains to the accessibility of health care. My interview with Dr. Sahin in Houston, as well as my interviews with Dr. Mardin, Yusuf Kurlu, and T. Cengiz Yilmazyavuz in Istanbul, and my study of research and literature 42
to medical physicians following the implementation of HTP. According to a report published by the Turkish Ministry of Health in 2008, the number of patient examinations increased by 125% from 2002 to 2008 (Health Transformation Program in Turkey and Primary Health Care Services, 2008). Furthermore, the average number of annual physician visits per patient increased from 2002 to 2008, from 3 to 6.3 visits (Health Transformation Program in Turkey and Primary Health Care Services, 2008).
cantly, from 2.4 million to 10.2 million (Transforming Turkey’s Health System – Lessons for Universal Coverage, 2015). In the United States, Obama’s Patient Protection and Affordable Care Act seeks to address many of the same issues as the Health Transformation Program. In an important step toward a universal health care system for the United States, Obamacare “requires all Americans to have health insurance,” mandates large employers to provide adequate health insurance for their employees, and expands Medicaid, the social health care program for low-income families (ObamaCare Explained: An Explanation of Obamacare, 2016). Furthermore, The Patient Protection and Affordable Care Act opened the Health Insurance Marketplace in an effort to subsidize and regulate private insurance. Following the implementation of Obamacare, low-income individuals and families who do not qualify for Medicaid, the unemployed and self-employed, and anyone else who does not get health insurance from his or her employer can buy affordable private health insurance through the Marketplace.
In regards to accessibility, Dr. Deniz Mardin emphasizes the importance of the implementation of the Family Medicine Program for expanding health care accessibility to include all Turkish citizens. According to Mardin, matching patients up with a primary care physician has been instrumental in improving both accessibility and overall patient satisfaction throughout Turkey. While the services provided under the new health care system are similar, she says, overall “people are much happier with the new system. For a lot of people, health care is more accessible” following the implementation of the Health Transformation Program. Yusuf Kurtlu echoed many of the same sentiments as Mardin, particularly emphasizing the importance of the implementation of the Turkish home care system and its positive impact on health care accessibility in Turkey. According to Kurtlu, prior to the implementation of HTP, patients, without exception, had to go to a hospital to receive treatment. Following the implementation of HTP, however, under certain circumstances patients are able to receive treatments within the comfort of their own homes.
Much like the Health Transformation Program, The Patient Protection and Affordable Care Act is a “comprehensive health insurance reform” that seeks to improve “access, affordability, and quality in health care for Americans” (U.S. Department of Health & Human Services, 2014). Given the ambitious goals of the Health Transformation Program and The Patient Protection and Affordable Care Act, it is unsurprising that both health care reform efforts have been met with mixed results. This section of my paper explores the information I have gathered from my conversations with Turkish and American physicians and policy experts in Istanbul and in Houston, as well as the information I have derived from my research of published literature and statistics on health policy changes in Turkey and the United States in order to assess the three benchmarks of accessibility, affordability, and quality.
Dr. Aysegul Sahin also commended Turkey’s recent strides in health care accessibility. Despite living and working in Houston, since the implementation of the Health Transformation Program Dr. Sahin reserves her own doctor appointments and checkups for when she returns home to Istanbul. She cites the ease of getting an appointment in Turkey—as compared to the advanced notice required in the United States—as her reason for this. According to Dr. Sahin, while in Houston you might have to schedule a dentist or doctor appointment a month in advance, it is possible to schedule a similar appointment only a day before your intended visit in Turkey. As did the implementation of the Health Transformation Program in Turkey, the implementation
Accessibility The implementation of the Health Transformation Program in Turkey has resulted in a definite improvement in the accessibility of health care in Istanbul and throughout all of Turkey. Perhaps most notably, patients have much easier access 43
of The Patient Protection and Affordable Care Act in the United States has resulted in a definite increase of accessibility of health care in the United States. Most notably, there has been a substantial decrease in the number of uninsured American citizens following the implementation of Obamacare. According to a study published by the National Center for Health Statistics, nearly 16 million fewer people are uninsured in the United States following the implementation of The Patient Protection and Affordable Care Act (Division of Health Interview Statistics, National Center for Health Statistics, 2015). And the impact of Obamacare has an especially important impact on Texans, in particular. According to a study conducted by Dr. Vivian Ho through Rice University’s Baker Institute and The Episcopal Health Foundation, in 2014 alone, 746,000 Texans—225,000 of whom were previously uninsured—purchased health insurance through the Marketplace (Early Effects of the Affordable Care Act on Health Insurance Coverage in Texas for 2014, 2014).
Turkey’s lack of manufacturing capabilities in this field force the country to rely almost entirely on importation when it comes to medical equipment, which naturally has associated costs. Aside from overall health care costs, the second aspect of affordability is the amount of money patients actually play for health services. Unfortunately, there seems to be a lack of consensus on how the implementation of the Health Transformation Program has impacted this dimension of health care. Dr. Mardin conveyed her opinion that Turkish patients are paying more for the same services under the legislation of the Health Transformation Program than they were before, and cites the increased preference for private health care as opposed to public health care as a main contributor. Yilmazyavuz spoke to this as well in his explanation of the changes in the hospital system following the implementation of the Health Transformation Program. Prior to the implementation of HTP, public health insurance would not pay for visits to or stays in private hospitals. Following the implementation of HTP, however, Yilmazyavuz says, “most of the private hospitals sign an agreement with the minister of health” which allows public health insurance to cover costs associated with this hospital. In this way, affordability of health care has increased since the implementation of the Health Transformation Program because Turkish patients are able to use their public, government provided health care to take advantage of the services provided at private hospitals.
Affordability From an affordability standpoint, Turkey has experienced mixed results following the implementation of the Health Transformation Program. According to the information I obtained from many of my interviews in Istanbul, overall patients are paying more for health care services, particularly within the private sector. Published data regarding changes in affordability following the implementation of HTP, however, is rather inconclusive. Of concern is the fact that health care costs nationwide continue to rise as a result of an increased preference by Turkish patients for high tech, expensive, and invasive treatments. According to Dr. Mardin, when it comes to medicine “Turkish people like technology” and prefer invasive tests and treatments to non-invasive tests and treatments even when the latter are available. And with this increased preference for technologically advanced medical procedures comes increased medical costs. T. Cengiz Yilmazyavuz of the American hospital also mentioned this concerning aspect of the Turkish health care landscape. Not only does he recognize the preference of Turkish patients for perhaps unnecessarily advanced medical technologies, Yilmazyavuz also laments the fact that Turkey is “not a manufacturer of the high quality medical equipment” that Turkish patients increasingly demand.
The impact of The Patient Protection and Affordable Care Act on the affordability of health care in the United States is also rather unclear. For a variety of factors, and despite recent efforts, health care costs have continued to rise in the United States over the past several decades. This is largely due to the recent growth in use of prescription drugs and other expensive medical treatments (The Rise in Health Care Spending And What To Do About it, 2005). Furthermore, with a lack of drug price regulation in the United States, prices for many medications are becoming increasingly astronomical. While The Patient Protection and Affordable Care Act has been able to do little to slow these rising costs, health insurance for consumers has become more affordable since the implementation of Obamacare. Under the new legislation, health care in the United States has become more 44
Figure 4: Sharp drop-off in the rate of uninsured in the United States following the implementation of Obamacare and the 1st Open Enrollment of the ACA
the Harvard School of Public Health and the Harvard Kennedy School of Government, since the introduction of the Family Medicine Program in Turkey through HTP, patient satisfaction with primary care services has increased from 69% to 90.7% from 2004 to 2011 (Reflections on Ministerial Leadership: Health Reform in Turkey, 2013). Furthermore, since the implementation of the Health Transformation Program, patient satisfaction with public hospitals has increased from 41% to 76% from 2003 to 2011 (Reflections on Ministerial Leadership: Health Reform in Turkey, 2013).
affordable due to the following: insurance companies are forbidden from discriminating against patients based on age, gender, or any preexisting medical conditions, the Marketplace subsidizes premium and out-of-pocket health care costs, and young adults are permitted to stay on their parents’ health insurance plans until age 26 (ObamaCare Facts: Facts on the Affordable Care Act, 2016). Quality On a positive note, patient satisfaction with health care in Turkey has significantly increased since the implementation of the Health Transformation Program. Yusuf Kurtlu was quick to mention that “satisfaction surveys are conducted all the time” and emphasized the importance of these surveys in accurately assessing the successes and shortcomings of HTP thus far. While my conversations with health care workers in Turkey regarding patient satisfaction were certainly valuable, the data clearly speaks for itself. According to research spearheaded by
But despite the undeniable rise of patient satisfaction, there are concerns that Turkey has actually experienced a decrease in quality of health care following the implementation of the Heath Transformation Program. With a greater emphasis placed on accessibility of health care, physicians are allotted a shorter amount of time to visit each patient. According to Yilmazyavuz, it is the norm for Turkish physicians to be allotted only five minutes with each patient. And despite the fact that the number of physicians in Turkey did not in45
crease from 2002 to 2008, the number of patient examinations increased by 125% (Health Transformation Program in Turkey and Primary Health Care Services, 2008). Dr. Mardin expressed similar concerns, but was quick to mention that despite decreasing quality, patients are overall more satisfied with their health care because “they can get an appointment anytime they want.” According to Dr. Mardin, “quality of health care in Turkey is getting worse,” since the implementation of the Health Transformation Program, but the ease of access following the implementation of HTP greatly outweighs the detriments of lower quality for most Turkish patients.
care, perhaps at the expense of health care quality. Conclusions Turkey The implementation of the Health Transformation Program in Turkey has improved health care accessibility throughout the country, but at a possible cost of affordability and quality of care. Overall, Turkish patients are paying more for health care services under the Health Transformation Program than they were previously. Furthermore, with an increased focus on accessibility, physicians are unable to spend a sufficient amount of time with each patient, resulting in a decline in quality. Of utmost importance is the necessity for a mindset shift within the Turkish population that will direct preferences away from increased technology use in health care, which does not necessarily correlate with increased quality of care or higher rates of positive health outcomes.
There has been a debatable improvement in the quality of health care in the United States following the implementation of The Patient Protection and Affordable Care Act. Most policy experts agree that it is too early to tell how Obamacare impacts quality of health care in the United States. In some ways, The Patient Protection and Affordable Care Act has undeniably improved quality of care by introducing the electronic health record (EHR) system. EHRs store a patient’s medical records electronically, allowing doctors to set up online patient portals to educate their patients and provide status updates. Advanced online systems can even use EHRs to predict when a patient’s health is deteriorating, and further research is in the works to investigate this potential (Five Ways Obamacare Has Improved Your Health Care, 2015).
The United States As is the case with the Health Transformation Program in Turkey, The Patient Protection and Affordable Care Act has been met with mixed success in the United States. Obamacare has certainly succeeded in its goal of improving the accessibility of health care, and this is largely due to the increase in the number of Americans with health insurance as a result of the health care Marketplace. The impact of Obamacare on affordability and quality are somewhat unclear. Heath care costs continue to rise within the United States, and it is necessary to address this trend, particularly given the nation’s aging population. Furthermore, with the increasing rules, regulations, and incentives written into health care legislation, which could negatively impact physician performance, it is necessary to continue monitoring the quality of health care in the United States.
But despite these positive improvements, there are concerns that The Patient Protection and Affordable Care Act is actually driving a wedge between patients and physicians by overly complicating the health care system of the United States. An article published in the Washington Times titled “Obamacare Prevents Quality Care” outlines several concerns of a practicing surgeon, Dr. Constance Uribe. Uribe laments that “the practicing physician is buried in more mandates, more regulations, and more penalties” under the Patient Protection and Affordable Care Act than ever before (Obamacare Prevents Quality Care, 2012). According to Uribe, “the art of medicine is becoming the trade of medicine” under The Patient Protection and Affordable Care Act (Obamacare Prevents Quality Care, 2012). It is of growing concern within the United States—as it is in Turkey—that Americans are overly focused on the accessibility of health
Concluding Thoughts As evidenced by the mixed success of national healthcare reform initiatives like the Health Transformation Program in Turkey and The Patient Protection and Affordable Care Act in the United States, it is very difficult—if not impossible—for a national government to initiate health care reform that successfully addresses all pertinent 46
issues. Given the ambitious goals of the recent health care legislations passed in Turkey and The United States, it is unsurprising that the two have been met with mixed results. Though some aspects of both HTP and Obamacare are successful, future modifications of both systems are needed in order to maximize effectiveness and address the needs of the changing populations of Turkey and the United States. Given the large and rather complicated impact of both the Health Transformation Program and The Patient Protection and Affordable Care Act on the health care landscapes of Turkey and the Untied States, both countries should launch public health campaigns in order to inform the public and maximize the success of these two health care initiatives.
Spending And What To Do About It. Department of Health Policy and Management, Rollins School of Public Health, at Emory University in Atlanta, Georgia, Web. “Understanding the ACA.” Pan Insurance Agency. 26 Jan. 2014. Web. Uribe, Constance. “Obamacare Prevents Quality Care; Government Meddling Driving Doctors from Medicine.” The Washington Times (Washington, DC). 20 July 2012. Web. “WHO Country Cooperation Strategy (CCS) Brief: Turkey.” WHO. Web. Yilmazyavuz, T. Cengiz. “Interview with T. Cengiz Yilmazyavuz.” Personal interview. 3 Mar. 2016.
Works Cited Akdag, Recep. “Turkey Health Transformation Program.” Belge Gaster. Republic of Turkey, Ministry of Health, Nov. 2008. Web. Atun, Rifat. “Transforming Turkey’s Health System — Lessons for Universal Coverage.” New England Journal of Medicine N Engl J Med 373.14 (2015): 1285-289. Web. Ho, Vivian, Elena Marks, and Patricia Gail Bray. “Early Effects of the Affordable Care Act on Health Insurance Coverage in Texas for 2014.” Rice University’s Baker Institute. Rice University’s Baker Institute; The Episcopal Health Foundation. Web. Joachim, Maria, and Michael Sinclair. “Reflections on Ministerial Leadership: Health Reform in Turkey.” President and Fellows of Harvard College, 2013. Web. “Key Features of the Affordable Care Act.” HHS.gov. 07 June 2013. Web. Kurtlu, Yusuf. “Interview with Yusuf Kurtlu.” Personal interview. 3 Mar. 2016. Mardin, Deniz. “Interview with Deniz Mardin.” Personal interview. 2 Mar. 2016. “ObamaCare Explained | An Explanation of ObamaCare.” Obamacare Facts. Web. “ObamaCare Facts: Facts on the Affordable Care Act.” Obamacare Facts. Web. “ObamaCare: Uninsured Rates.” Obamacare Facts. Web. Patel, Kavita, and Domitilla Masi. “Five Ways Obamacare Has Improved Your Health Care.” Newsweek. 23 Mar. 2015. Web. Sahin, Aysegul. “Interview with Aysegul Sahin.” Personal interview. 2 Feb. 2016. Thorpe, Kenneth E. “Health Affairs.” The Rise In Health Care
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Comparative Analysis of Approaches to and Treatments of Schizophrenia: Houston and Istanbul By Rishi Suresh Executive Summary
long-term illnesses that require continual care and monitoring for numerous years. Thus, treatment compliance and physician follow-ups are crucial factors in positive patient outcomes. Schizophrenia is a late-onset neuropsychiatric illness that is especially disabling and affects approximately 1.1% of the adult U.S. population (NIH). Patients often lose touch with reality and present with relatively sudden and significant changes in mood and behavior. Presenting between the ages of 16-30, schizophrenia affects people during a critical period of academic and professional development (NIH). Often, patients will initially present with “negative symptoms,” during what psychiatrists call a prodromal period. These symptoms include reduced emotions, vocal and facial expression, diminished interest in everyday activities, and minimal verbal communication (Taskiran). Patients will then generally develop “positive symptoms” which include hallucinations, delusions, thought and movement disorders. Finally, schizophrenia can create cognitive deficits in executive functioning—involved in decision-making—and working memory.
Neuropsychiatric illnesses have some of the greatest disease burdens of any condition worldwide. They are often chronic illnesses that require long-term medication and compliance with treatment protocols. Schizophrenia—a devastating neuropsychiatric illness—causes patients to experience sharp deviations from reality. The purpose of this project was to analyze and understand the social factors surrounding treatment of schizophrenia between Istanbul and Houston. The study found that both the United States and Turkey struggle to deal with social stigma surrounding psychiatric conditions. Scared of the negative social implications of being labeled as a “psychiatric patient,” people may not come in for a psychiatric consult early in the presentation of a specific condition. Both countries also struggle with patient compliance. Turkey’s community mental health center model might be an effective way to provide the proper resources to maintain compliance and prevent relapse. Introduction Neuropsychiatric illnesses are some of the most devastating conditions in the world today. Though non-communicable, the WHO estimates that mental and neurological conditions contribute to approximately 30.8% of all of the years lived in disability (World Health Organization). Furthermore, in developed nations like the United States, mental disorders are estimated to cost approximately 2.5% of the GNP, an underestimate that does not take into account the opportunity cost of families who have to take care of patients long term (World Health Organization). If left untreated, many neuropsychiatric illnesses make it nearly impossible for patients to become productive members of society; their aberrant behavior is stigmatized and prevents forward professional and personal advancement. Additionally, many neuropsychiatric disorders are
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The causes of schizophrenia are not entirely clear. Schizophrenia definitely has some genetic heritability; however, there are numerous cases where patients present with schizophrenia while having no family history and vice versa (Gejman). Thus, many researchers believe that a variety of non-genetic risk factors also play a role in the incidence of schizophrenia. Environmental risk factors include virus exposure, malnutrition during pregnancy, and repetitive marijuana usage. The scientific community generally believes that a wide variety of genes play a role in determining susceptibility to the disease. Most recently, in January of 2016, a study published by Dr. Aswin Sekar claims to have found a substantial link between schizophrenia and a protein known as C4, which is used in the immune system to mark foreign pathogens for destruction. In fact, he found that schizophrenia patients
present with substantially higher level of C4 in their brain (Sekar, Bialas and de Rivera). Interestingly, he noted that C4 in the brain actually is used to prune synapses or connections between neurons, a process that occurs in normally functioning brains. However, when C4 accumulates, these connections become “over-pruned” and important synapses become degraded. As scientific discoveries like Dr. Sekar’s accumulate, the underlying biochemical mechanisms behind schizophrenia will become easier to understand, leading to the development of more effective prevention options.
before they suddenly start exhibiting cognitive decline and positive symptoms. These symptoms are often just written off as poor adjustment to significant changes in the adolescent’s life, such as moving into a new college environment. Such assumptions can also delay access to treatment. Schizophrenia is generally a treatable illness; thus, analyzing the social barriers to access to treatments is important to understanding patient outcomes. The two cities chosen for this study were Houston, TX, U.S.A. and Istanbul, Turkey. Houston is home to the Texas Medical Center, one of the largest medical centers in the entire world, which has dedicated institutions like the Menninger Clinic and the DePelchin Center that serve psychiatric needs (Texas Medical Center). Istanbul also has top tier medical systems like Koc University Hospital and Acibadem Hospital (Yavuz).
Treating schizophrenia generally requires longterm compliance with antipsychotic drugs like chlorpromazine and cognitive behavioral therapy (Mayo Clinic). However, compliance is sometimes impaired because of uncomfortable side effects including weight gain, muscle spasms, restless movements, or constipation (Konkel). Recently, newer drugs like Abilify have entered the market, and cause fewer side effects than traditional antipsychotics. However, such drugs have not yet been approved in many parts of the world (Taskiran). In exceptionally dangerous situations, schizophrenic patients might be hospitalized for a few weeks in order to make sure they do not harm themselves or others. However, schizophrenia can generally be managed with outpatient treatment consisting of antipsychotics and psychosocial interventions. These interventions range from individual therapy to group/ family therapy and are crucial supplements to overall success of the treatment regimen.
However, both Turkey and the United States have insufficient numbers of psychiatrists. The United States has less than 50,000 psychiatrists, whereas Turkey has only around 250 child/ adolescent psychiatrists (Serious Shortage of Psychiatrists, Taskiran). Thus, accessibility of psychiatric treatment is clearly a large problem in both countries. Furthermore, both countries do seem to differ in their approach to treating patients. While the United States uses a more therapy-heavy, holistic approach to dealing with schizophrenia, Turkish physicians often focus on psychopharmacology. The purpose of this project is to draw comparisons and find differences between the two health systems and create policy recommendations that mitigate barriers to proper treatment.
Issue Statement
Methodology
Though schizophrenic symptoms can often be managed fairly well with proper treatment, there are numerous social factors that could potentially hinder accessibility to proper care. The general public does not understand diseases like schizophrenia well; merely being labeled as having a “psychiatric illness” elicits significant negative reactions. This stigma often causes patients to sometimes wait until the disease has progressed significantly before going to a psychiatrist (Taskiran).
A thorough literature review was done to study schizophrenia and psychiatric illness. Afterwards, formal personal interviews were conducted with various professionals in both Houston and Istanbul. First, an interview with Dr. Deniz Mardin, a professor in the Koc University Public Health Department was conducted to discuss the health care system in Turkey, recent health care reforms, and medical education. Another formal interview was conducted with Dr. Yunus Yavuz, a surgeon at Koc University Hospital discussing the insurance system in Turkey. A formal interview with Dr. Hale Yapici Eser, a psychiatrist at Koc University Hospital was also conducted. Dr. Eser
Furthermore, schizophrenia is especially taxing due to how late it presents in life. In other words, many schizophrenia patients will have lived the vast majority of their lives as normal children 50
actually has studied schizophrenia quite extensively before, so this interview was important in understanding how psychiatrists diagnose schizophrenia in Turkey. Another formal interview conducted in Istanbul was with Dr. Sarper Taskiran, a child and adolescent psychiatrist at Koc University Hospital. Dr. Taskiran did his fellowship training in the United States and so was able to speak to the similarities and differences between the two countries with regards to psychiatry and schizophrenia. Finally, a formal interview was done with Dr. Oner Gurkan Gonen at the Methodist Hospital in Houston. He worked both in Houston and in Istanbul and gave his perspective on the differences between the two systems.
University School of Medicine in St. Louis). However, neurologists make significantly more money, which shows why medical students may opt for neurology over psychiatry (Profiles Physician Database). Furthermore, in both Turkey and the United States, psychiatry is discriminated against by other specialties, making it more unpopular (Gonen). Specifically, many physicians tend to look down on psychiatry’s emphasis on cognitive therapy apart from pure basic science (Gonen). In Dr. Gonen’s experience as a medical student and resident in Istanbul, he felt that faculty never truly tried to push students into psychiatry; rather they were encouraged to enter other residencies.
Findings
Drugs/Treatment Istanbul has a universal healthcare system called the SGK insurance system, which is provided to all citizens. Under SGK, citizens are able to get healthcare at reasonable costs and can even get their drugs for free (Mardin). This directly contrasts with the United States, where medicines are often exceptionally expensive and subject to substantive price hikes (Medscape). Though free medical care exists through the SGK system, Turkish citizens have the ability to purchase private insurance if they choose to do so in order to access higher-end hospital systems like Acibadem (Yavuz). The health care system in Turkey still has some room for improvement, however. Drugs actually take about 5-6 years longer to come to Turkey than the United States. For example, the drug Lurasidone—which is used to treat schizophrenia—is not yet available in Turkey even though it has fewer side effects than conventional medications (Taskiran). Furthermore, some classes of drugs are entirely missing from the Turkish drug market. For example, medications with amphetamines—such as Atavan or Aderol—are not allowed, making treatment of ADHD particularly difficult (Taskiran). Another troubling trend in Turkey is that patients can actually buy drugs for themselves without a prescription. For some psychiatric patients, buying drugs without a prescription may be a way of avoiding the stigma of going to a psychiatrist. However, without the help of a practicing physician, such practices are dangerous and can cause serious damage (Mardin).
Accessibility Both Houston and Istanbul have significant accessibility issues. According to Dr. Taskiran, there are only about 250 child/adolescent psychiatrists in Turkey for a population of about 80 million people. Given that about half of Turkey’s population is under the age of 18, this number is clearly insufficient (Taskiran). Turkey has attempted to rectify this issue by instituting mandatory service requirements following completion of training. Essentially, after finishing their residency, physicians are required to practice in a government-mandated area (Mardin, Eser, Taskiran). This shortage in psychiatrists could be because people are often discouraged from entering psychiatric residencies when they are medical students (Eser, Mardin). Many students who are interested in the brain will opt for studying neurology or neurosurgery instead of psychiatry because of substantial differences in salary (Eser). The United States also struggles with accessibility, though not quite as much as Turkey. From 1995 to 2013, psychiatrists in the United States increased only about 12%, even though the total number physicians increased by 45% during this time period (Serious Shortage of Psychiatrists). Compensation might again be the reason for why few people choose to go into psychiatry in the United States. Psychiatrists receive salaries that are relatively low compared to other specialties; in fact, the mean annual wage for a psychiatrist is 28% lower than that of surgeons (Simon). Furthermore, neurology and psychiatry residencies— both residencies that focus on the brain—are four years long in the United States (Washington
Treatment Times Over the past few years, Turkey has made significant health care reforms in order to boost avail51
ability of physicians (Mardin). Previously, people who wanted to see a physician had to wait in incredibly long lines and were sometimes unable to get proper treatment. To fix this issue, the government set time limits for patient-physician interactions. For psychiatrists, current regulations suggest that the time of consult should not exceed 10 minutes (Taskiran). Especially with follow up patients, Turkish psychiatrists sometimes spend literally two minutes to see a patient (Gonen). In the United States, the amount of time spent with patients is substantially greater, going as high as 45 minutes to an hour for an initial psychiatric consult (Taskiran, Gonen). This amount of time is critical to ensuring proper treatment and care. It allows the physician to collect a much more detailed history, establish a rapport with the patient, talk to family members, and also better explain treatment protocols to patients (Gonen). The mutual trust generated by a well-developed patient-physician relationship is crucial to maintaining compliance. The number of patients psychiatrists are expected to see per day in Turkey is exceptionally high and can hamper quality of care. For example, during mandatory service, Dr. Eser was forced to see around 50 patients per day, while Dr. Taskiran saw around 80 per day. This trend in treatment times speaks to a larger difference between the two countries. In Istanbul, the focus is substantially more on pharmacology and prescriptions rather than therapy and holistic treatment—which take time and are heavily emphasized in the United States (Taskiran).
Family support can mitigate some the harms posed by social stigma associated with psychiatric illnesses. In Turkey, family support is actually quite strong. Families think of it as their obligation to take care of ill family members. According to Dr. Taskiran, some psychiatric patients—especially those afflicted by serious illnesses like schizophrenia—live with their parents well into their thirties and forties. Even if a patient’s immediate family is not present, distant relatives will sometimes at least help pay for the treatment (Taskiran). This contrasts quite significantly with the United States, where this level of support is usually not present in U.S. family structures. Stigma also obscures the publicly available information in Turkey. For example, it is sometimes common for deaths associated with psychiatric illnesses to be coded as something else to preserve the family’s honor (Taskiran). College Students College students are especially affected by psychiatric illnesses like schizophrenia. Schizophrenia’s initial presentation is in late adolescence to early adulthood, which is right around the time when students leave home to go to college. So, during initial presentation, students may lack the support system necessary to combat the psychiatric condition, causing many to drop out of college (Taskiran). At Koc University, a private institution in Istanbul, about 5-20 students each year out of a campus of 5500 require medical leaves of absence for psychiatric reasons (Taskiran). Generally these students are able to come back and finish their degrees in six or seven years; however, at public universities there are many reports of students dropping out and never finishing degrees.
Stigma Stigma is one of the most difficult things for people to overcome in receiving treatment for a psychiatric illness. The label “psychiatric illness” itself carries a negative connotation in both the United States and Istanbul that adversely affects treatment efforts (Taskiran). For example, even going to the pharmacist is a dreaded task for many psychiatric patients; it is fairly common for pharmacists to judge a patient for using something as simple as an antidepressant (Taskiran). Furthermore, discrimination in schools is fairly common. If two children/adolescents get into a conflict, teachers may side with the person without a psychiatric illness. Stigma not only delays the amount of time it takes for a patient to seek psychiatric care, but also affects compliance with treatment regimens.
In the United States, there are better social support systems to help students with psychiatric illness. For example, at Rice University, there are numerous free counseling resources that students can use if they need help. In fact, many universities in the United States have similar counseling centers that can direct students to the proper resources to ensure that they are treated properly. Furthermore, many U.S. institutions have “leave of absence” options, which allow students to take a semester or two off and still finish degrees without having any trouble. Even hospital systems like Methodist have significant social service programs that can set up patients in rehabilita52
treatments, patients will relapse, creating a cycle patients are often stuck in (Taskiran). The Kaiser Family Foundation estimates that there are still about 2.7 million uninsured Americans who have serious mental illnesses, suggesting that the United States has significant work to do in bridging the uninsured gap and ensuring that cost is not a barrier to receiving care (Kaiser Family Foundation).
tion clinics and find other support groups to help them comply with treatment (Gonen). Health Care Systems The Turkish health system is definitely much different from the United States’. In Turkey, essentially everyone has some form of health coverage. Specifically, the SGK system in Turkey ensures that drugs are essentially free and that people can access healthcare at an affordable price. However, this healthcare system does come at a significant cost; by making healthcare accessible to everyone, treatment times have become restricted. This ultimately diminishes the quality of the treatment a physician can provide (Gonen, Eser, Taskiran).
Compliance Most psychiatric disorders—especially schizophrenia—require compliance with long-term drug treatments and therapy. Thus, maximizing compliance with treatment regimens is one of the most important considerations in treatments of psychiatric patients. However, both Turkey and the United States struggle with ensuring that patients are compliant. In Turkey, only about 30% of patients are compliant and many patients often require hospitalization again (Eser). According to the NIH, over one third of U.S. patients are noncompliant with their medications (NIH/NCBI). Compliance is difficult to establish in Turkey for a few reasons. First, the shorter treatment times make it extremely difficult to establish a rapport. If the patient does not trust the physician well, compliance is unlikely (Gonen). Furthermore, compliance could also be impaired because of how medical treatment is viewed in Turkey. Instead of thinking preventatively, people tend to go to doctors only once a problem comes up (Mardin). Thus, Turkish citizens generally would not want to take a long-term medication when the underlying symptoms seem to disappear (Mardin). Furthermore, people do not generally go in for follow-up appointments in Turkey, further exacerbating the issue (Mardin, Eser). Finally, the drugs needed to treat schizophrenia often have uncomfortable side effects; thus, if the symptoms subside, patients might stop taking the medicine. Newer drugs like Lurasidone or Abilify have significantly less side effects such as minimized weight gain and reduced tremors, but are unavailable on the Turkish drug market (Taskiran). Turkey has recently tried to combat the compliance issue by establishing community health organizations that are held responsible for follow up appointments (Eser). The pay of the government physicians at these community health organizations is tied to how well they follow up with their patients (Eser). Physicians are given a form
The United States system is much more complicated and has a variety of different programs including the Affordable Care Act, Medicare, Medicaid, etc. There are still millions of Americans who are uninsured and face prohibitively high costs to receiving treatment (KFF). The Affordable Care Act (ACA) substantially increased coverage for mental health illnesses by mandating that each small employer health insurance plan covers mental health and substance abuse disorders (Mental Health). Furthermore, the ACA takes a step in the right direction by preventing insurance companies from denying coverage for pre-existing psychiatric conditions like schizophrenia (Brink). However, though progress is being made in terms of law, in reality psychiatric patients are finding it extremely difficult to receive coverage. They are often unable to find mental health providers who fit their insurance plans; thus, many find the high cost of treatment prohibitive. Furthermore, though the ACA allows patients to remain on their parents’ insurance until they are 26, they have to become insured on their own afterwards (HealthCare.gov). This policy is problematic for late-onset diseases like schizophrenia; soon after onset, patients would have to figure out how to pay for expensive medications and also figure out how to get the insurance coverage that allows for proper long-term coverage. Furthermore, the Medicare system has flaws as well. Impoverished psychiatric patients are originally able to get drugs while they are destitute under Medicare. However, once they return to normal functioning and get employed, they might pass the Medicare income threshold. If their private health insurance does not cover the cost of their psychiatric 53
called an RS-30 that they must fill out and submit to the government that includes information about compliance with treatment and treatment changes (Eser). Such a system provides a significant incentive for physicians to attempt to follow up with their patients. In the case of a long-term condition like schizophrenia, such follow-ups would be crucial. This system is still in its infancy, but may progress to be an effective means of increasing compliance in the future (Taskiran). The United States has great support systems that also help maintain compliance. For example, systems like Methodist Hospital provide resources and contact information for support groups that are shown to increase treatment compliance and also create a sense of belonging for psychiatric patients (Gonen).
patient outcomes for people dealing with schizophrenia. Turkeyâ&#x20AC;&#x2122;s community health organizations and the social services provided in America are both somewhat effective in increasing compliance but need to be executed better in order to be successful. Recommendations Houston/U.S.: 1. Expanding Coverage for Psychiatric Illnesses: There are numerous individuals with serious psychiatric illnesses who are unable to pay for their own medication due to the complexities surrounding health care laws. Drugs and psychiatric treatments are sometimes not covered by insurance; the high costs of uninsured treatments are often barriers to effective psychiatric treatment. The United States should try to seriously reform the health insurance system with regards to psychiatric care. The points of focus should be on ensuring that the vast majority of health care providers accept a wider range of insurance and enforcing the notion that insurance policies specifically treat mental illnesses the same as illnesses in other parts of the body.
Conclusions Both Turkey and the United States must make improvements in order to boost their treatment of psychiatric illness like schizophrenia. Turkey and the United States both struggle with accessibility to quality psychiatric resources. Turkey has made significant improvements over the past few years in ensuring that appointments are widely available. Now, it must focus on increasing the number of practicing psychiatrists to alleviate the amount of strain currently on the healthcare system. In Turkey, psychiatrists are forced to see too many patients in too short a time period, which can compromise quality.
2. Drug Prices: Drug prices are exceptionally high in the United States and can be a barrier to treatment. Poorer individuals are disproportionately affected by mental disorders; in fact, the WHO estimates that people with low socioeconomic status are eight times as likely to develop schizophrenia as people in a high socioeconomic status (World Health Organization). Thus, it makes sense for the United States to try and at least subsidize the cost of psychiatric medications for people in the lowest income bracket. Otherwise, these individuals might be unable to purchase their medication, forever entrenching them in a cycle of poverty they cannot break out of. By subsidizing low-income psychiatric patients, the United States can boost compliance with treatment while also helping these people break out of psychiatric illness.
The insurance/healthcare system in the United States needs significant improvement. There are numerous gaps where people do not have the necessary coverage. The laws surrounding the Affordable Care Act and other health care systems are exceptionally abstruse and difficult to navigate. Sometimes in the United States, the cost of treatment and drug prices can be significant barriers to treating underlying psychiatric illnesses. Turkey does a great job with providing baseline insurance through the SGK system. Thus, in Turkey price is rarely a true determinant of whether someone is able to undergo psychiatric treatment.
3. Incentive Programs for Medical Students: The United States needs to increase the number of medical students who choose to pursue psychiatry as a viable residency option. Increased advertising during residency and dispelling some of the negative attitudes towards psychiatry can be effective means of incentivizing medical students. Concerns that psychiatry is â&#x20AC;&#x153;ineffectiveâ&#x20AC;?
Stigma greatly affects both Turkey and the United States. In both countries, stigma is a hindrance to proper treatment and long-term compliance. The United States and Turkey need to find ways to deal with this issue to ensure the best 54
support for these movements and involving large public figures would help deal with the crippling stigma that affects psychiatric patients.
and “not real science” need to be addressed early on in medical school before such beliefs become entrenched in a medical student’s mind (Sakarya).
Minimizing stigma would also help solve many of the other issues discussed in this study. First, more patients would voluntarily come to get treatment during the initial stages of their illness. Secondly, more medical students might be incentivized to enroll in psychiatric residencies (Taskiran). Finally, by increasing the number of psychiatrists, the health care system will become less burdened, improving quality of care in both Houston and Istanbul.
Istanbul/Turkey: 1. Increasing interest in psychiatry: Turkey’s main objective at the moment should be increasing the number of medical students choosing to go into psychiatry. Currently the lack of psychiatrists is overwhelming the system and compromising care. As Dr. Mardin pointed out, many medical schools do not stress psychiatry as a prestigious residency to be a part of, thus most students choose other fields of medicine. However, many students are interested in neuroscience and the brain; clearly showing how psychiatry goes beyond merely cognitive therapies and is grounded in “hard science” can also help redirect some of these students into psychiatry (Sakarya). Increasing the number of available physicians will lead to longer patient-physician interaction, improving quality of care.
Works Cited
Brink, Susan. Mental Health Now Covered Under ACA, but Not for Everyone. 29 4 2014. 22 3 2016 <http://www.usnews. com/news/articles/2014/04/29/mental-health-now-covered-under-aca-but-not-for-everyone?page=2>. ‘ Eser, Hale Yapici. Interview. Rishi Suresh. Istanbul, 3 3 2016. Fifer, Sheila, et al. Rising Mental Health Drug Costs: How SHould Managed Care Respond? 2005. 24 3 2016 <http:// www.medscape.com/viewarticle/511163 >.
2. Improve Drug Approval Processes The drugs available in Turkey often lag well behind the United States; sometimes it takes up to 5-6 years after when it is released in the United States for a drug to become accepted for treatment in Turkey. One of the best examples of this is Abilify, which is a schizophrenia treatment that has fewer side effects than traditional ones. However, the drug is currently unavailable in Turkey. Bridging the gap in drug availability would help provide the best treatment for psychiatric patients.
Gejman, PV, AR Sanders and J Duan. “NCBI.” Psychiatric Clinics of North America 33.1 (2010): 35-66. Gonen, Oner Gurkan. Interview. Rishi Suresh. Houston, 1 4 2016. HealthCare.gov. How to get or stay on a parent’s plan. 3 4 2016 <https://www.healthcare.gov/young-adults/children-under-26/>. Hitt, Caitlyn. Kate Middleton Speaks Out Against Mental Illness Stigmas: Shares Parenting Plans for Prince George, Princess Charlotte. 17 2 2016. 16 26 3 <http://www.ibtimes. com/kate-middleton-speaks-out-about-mental-illness-stigmas-shares-parenting-plans-prince-2311227>.
Both Countries: Both Istanbul and Houston would benefit greatly from educational campaigns to dispel the assumption that psychiatric illnesses like schizophrenia categorically make patients dangerous. Organizations like the National Alliance on Mental Health in the United States already are working on trying to create campaigns that fight against the stereotypes associated with mental illnesses. Large public figures such as Leonardo DiCaprio, Carrie Fisher, and David Beckham have detailed their personal experiences with mental illness in an attempt to remove the stigma from these disorders (Winter). In fact, Kate Middleton—the Duchess of Cambridge—even launched a largescale campaign directed at getting kids the necessary help for mental illness (Hitt). Expanding
Kaiser Family Foundation. Key Facts about the Uninsured Population. 5 8 2015. 25 3 2016 <http://kff.org/uninsured/ fact-sheet/key-facts-about-the-uninsured-population/>. Konkel, Lindsey. Schizophrenia Treatment. 25 9 2015. 3 4 2016 <http://www.everydayhealth.com/schizophrenia/ guide/treatment/>. Mardin, Deniz. Interview. Rishi Suresh. Istanbul, 2 3 2016. Mayo Clinic. Schizophrenia. 24 1 2014. 22 3 2016 <http:// www.mayoclinic.org/diseases-conditions/schizophrenia/basics/treatment/con-20021077>. Mental Health. Health Insurance and Mental Health Services. 24 3 2016 <http://www.mentalhealth.gov/get-help/ health-insurance/>. National Institute of Health. Schizophrenia. 2 2016. 20 3 2016 <http://www.nimh.nih.gov/health/topics/schizophrenia/ index.shtml>.
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NIH. National Institute of Mental Health. 20 3 2016 <http:// www.nimh.nih.gov/health/statistics/prevalence/schizophrenia.shtml >. Profiles Physician Database. 2013-2014 Physician Salary Survey. 2015. 15 3 2016 <http://www.profilesdatabase.com/ resources/2013-2014-physician-salary-survey/ >. Ross, Janell. Obamacare mandated better mental health-care coverage. It hasn’t happened. 7 8 2015. 24 3 2016 <https://www.washingtonpost.com/news/the-fix/ wp/2015/10/07/obamacare-mandated-better-mentalhealth-care-coverage-it-hasnt-happened/>. Sakarya, Direnc, Ulas Mehmet Camsari and Bulent Coskun. “Motivations of medical students towards psychiatry: A perspective from Turkey.” International Review of Psychiatry 25.4 (2013): 399-405. Sekar, Aswin, et al. “Schizophrenia risk from complex variation of complement component 4.” Nature 530 (16): 117183. Serious Shortage of Psychiatrists Across Much Of United States. 7 9 2015. 22 3 2016 <http://houston.cbslocal. com/2015/09/07/serious-shortage-of-psychiatrists-acrossmuch-of-united-states/>. Simon, Christophe. US faces severe shortage of psychiatrists as demand grows - report. 9 9 2015. 3 4 2016 <https:// www.rt.com/usa/314777-us-shortage-psychiatrists-demand-grows/>. Taskiran, Sarper. Interview. Rishi Suresh. Istanbul, 3 3 2016. Texas Medical Center. Our Members. 22 3 2016 <http:// www.texasmedicalcenter.org/members/>. Washington University School of Medicine in St. Louis. Length of Residencies. 2 4 2016 <https://residency.wustl.edu/Residencies/Pages/LengthofResidencies.aspx>. Winter, Lisa. A Plus. 28 October 2015. 20 3 2016 <http://aplus. com/a/15-celebrities-standing-up-mental-illness-stigma>. World Health Organization. Chapter 2: Burden of Mental and Behavioural Disorders. 2001. 20 3 2016 <http://www. who.int/whr/2001/chapter2/en/index3.html>. —. “Mental health, poverty and development.” 7 2009. World Health Organization. 24 3 2016 <http://www.who.int/ nmh/publications/discussion_paper_en.pdf>. Yavuz, Yunus. Interview. Rishi Suresh. Istanbul, 2 3 2016.
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Factors Leading to Childhood Dental Decay: A Comparative Analysis of Turkey and the United States By Tim Wang Executive Summary
porosis, and 29% more likely to have diabetes (NADP). Furthermore, research shows that poor oral health often leads to malnutrition stemming from chewing problems (Gil-Montoya). Malnutrition is particularly prevalent in elderly individuals because of the accumulation of oral health problems over time. In addition to its effects on physical health, oral health has far-reaching social and psychological ramifications (US Department of Health and Human Services). Socially, poor oral health can diminish self-confidence, which can in turn induce anxiety or depression. Economically, poor oral health can lower work productivity and lead to debilitating dental treatment costs. As such, oral health deserves to be an area of focus because it has significant influence on the quality of life of all ages and socioeconomic classes. Oral health is especially important during the formative ages of childhood (ages 5-17), because an individualâ&#x20AC;&#x2122;s adult oral health status is built upon the foundational level set during childhood.
Contrary to popular belief, oral health extends far beyond the mouth and has direct impacts on systemic health. As such, oral health is an essential determinant of physical well-being and quality of life. Currently, both Turkey and the United States face significant oral health challenges, namely the high rates of preventable childhood dental caries in the two countries. The state of oral health in children necessitates attention because it directly shapes the dental well-being of the next generation of adults. To understand the causes of the high prevalence of childhood dental caries, a comparative study was conducted in the two countries using qualitative methods. In particular, the providers of dental care, as well as the governmental policies and cultural attitudes toward oral health were examined. The investigation revealed that both countries can attribute their high rates of preventable childhood dental caries to the access to and the utilization of dental care. In turn, this study offers public oral health recommendations aimed to foster mutual improvement in both Turkey and the United States.
Early childhood caries is the most common childhood dental disease. Defined as a chronic infectious disease, dental caries are caused by the proliferation of bacteria on tooth enamel. The responsible bacterium is most often Streptococcus mutans, which feeds off of sugary residues on the tooth. In doing so, bacteria erode the tooth enamel by acidifying the mouth and demineralizing the tooth (Colak). However, childhood caries are largely preventable with proper oral hygiene practices. A widely used tool to measure dental caries is the decay-missing filled teeth index, or DMFT (Broadbent and Thomson). For children, DMFT is often collected at 12 years-old because that is when they finish primary school. Another important quantifying metric is the prevalence of dental caries, which denotes the proportion of individuals with dental caries within a population (Lo).
Introduction Oral health is an essential determinant of physical well-being and quality of life. Contrary to popular belief, oral health extends far beyond the mouth and has direct impacts on systemic health. According to the American Academy of Periodontology, oral health has been shown to be linked to chronic diseases including diabetes, heart disease, respiratory disease, osteoporosis, and certain cancers (American Academy of Periodontology). Poor oral health is a risk factor that greatly increases an individualâ&#x20AC;&#x2122;s likelihood of developing one of the above chronic diseases. In fact, individuals in the United States without dental insurance are 67% more likely to have heart disease, 50% more likely to have osteo-
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Over the past several decades, oral health has
generally improved in most developed countries (Marthaler). In particular, DMFTs for children and adults have generally decreased in the European division within the World Health Organization over the last 30 years (Marthaler, O’Mullane and Vrbic). Despite being in the European division, Turkey has not experienced the same oral health improvements as its peer countries. The DMFT data for Turkey comes from two national surveys – one conducted in 1988 and one in 2004 (Saydam, Oktay and Möller). There have been no additional national surveys conducted. From 1988 to 2004, there was only a slight improvement – from 4.4 to 3.7 – in DMFTs of the 5-6 years age group, while the prevalence of caries only slightly decreased from 84% to 70%. The 12-year-old age group did not fare much better, decreasing from 84% prevalence of caries and 2.7 DMFT in 1988 to 61% and 1.9 in 2004. The treatment index was low, as only 1% of 5-6 year olds had their decayed teeth filled. Even though most dental caries are preventable, the quantification of the high rates of caries in 1988 did not spur significant improvements. As such, the data suggests that the problem of oral health in Turkey has yet to be addressed (Gokalp).
because the oral health status of children directly shape that of the next generation of adults. To understand the causes of the high prevalence of childhood dental caries, a comparative analysis was conducted in the two countries. Specifically, the providers of dental care in both countries, as well as the governmental policies and cultural attitudes toward oral health were examined. In turn, this study offers transferable oral public health recommendations that can foster a mutual improvement of the oral health situations in both Turkey and the United States. Methods To determine the current status of childhood oral health in Turkey and the United States, an exten-
While dental caries in children in the United States were relatively well managed in the 1980s, there has been a reversal in the trend over the last few decades. In fact, caries in the primary teeth of children actually increased between 1988 and 2004, from 24% to 28% (Center for Disease Control and Prevention). The prevalence of dental caries was 23% for children ages 2-5, 56% for children ages 6-8, and 58.2% for children ages 12-19 in 2011 (Dye, Thornton-Evans and Li). While most of these incidents were treated, there was still a significant 15.3% of caries that remained untreated. By 2012, 17.5% of children ages 5-19 had untreated dental caries (Dye, Thornton-Evans and Li). Even though the prevalence of dental caries in the United States is lower than that in Turkey, the existing rate of childhood caries is still a significant issue. The United States should aim to eliminate childhood caries since it is mostly preventable. Issue Statement It is evident that both Turkey and the United States still face significant oral health challenges. In particular, the current high rates of childhood dental caries in both countries demand attention 58
Findings The high rates of childhood dental caries in Turkey and the United States are influenced by three main aspects: providers of care, governmental policy, and cultural attitudes.
sive literature search was conducted. Academic studies from the PubMed database and various oral health journals provided the quantitative basis for this study. Notably, the 1988 national survey of Turkish oral health was obtained directly during the interview of Dr. Gulcin Bermek.
Turkey: Providers of Care Turkish Oral health care is provided by both public and private institutions. The public sphere, which is funded by the government, includes the Ministry of Health, Social Insurance Organization (SGK), Ministry of Defense, and dental universities. The private sphere is primarily comprised of private practices, where the patient pays for treatment. The majority of dental care, according to Dr. Betul Kargul, is centered around public community Oral and Dental Health Centers. From 2002 to 2011, Turkey greatly expanded its public oral health infrastructure. The number of Oral and Dental Health Centers increased from 14 to 117 and the number of dental clinics increased from 1 to 5 over that period (Ministry of Health of Turkey). These improvements boosted treatment volume, as the number of dental fillings completed went from 371,000 to 8,334,000, and the number of fixed prostheses went from 349,000 to 5,576,000 (Ministry of Health of Turkey). Despite this progress, there is still currently an inadequacy of dental infrastructure. Specifically, there is shortage of dental personnel. In 2009, the dentist-population ratio in the two largest cities of Istanbul and Ankara were 1: 1978 and 1: 1438, respectively (Topaloglu-Ak, Eden and Frencken). The ratio decreased in smaller cities, such as 1: 12,980 in Sanliurfa, and became even lower in rural areas. It is evident that there are not enough dentists to cover the oral health care needs of the people, especially in rural areas.
The majority of the original research done in this investigation came from in-person qualitative interviews with medical and oral health experts. These interviews attempted to elicit expert perspectives to explain the data indicating a prevalence of preventable early childhood caries. These interviews provided the basis for the analysis of the factors that lead to early childhood tooth decay in Turkey and the United States. The interviewees’ areas of expertise spanned oral public health, pediatrics, dental academia, and public policy. In-person, recorded interviews were conducted on the following experts: • Gulcin Bermek, Ph.D. – Public oral health professor and dentist at Istanbul University Faculty of Dentistry. Dr. Bermek was a key informant for this project, as she is considered a field leader in Turkish oral public health. Her national survey in 1988 on Turkish oral health statuses is one of the most cited publications in the field. • Deniz Mardin, M.D. – Public health instructor at Koc University School of Medicine • Betul Kargul D.D.S., Ph.D. – Professor, Department of Pediatric Dentistry at Marmara University Dental School • Kadriye Peker D.D.S., Ph.D. – Professor, Department of Dental Public Health at Istanbul university Faculty of Dentistry • Jason Wang D.D.S, Ph.D. – Private Dentist, owner of Carewell Dental Clinic in Plano, Texas • Ming Zeng D.D.S. ¬– Private dentist, owner of dental clinic in Plano, Texas The following experts were interviewed via phone and online-correspondence: • David Capelli, D.M.D., Ph.D., M.P.H. – Director of Department of Comprehensive Dentistry at the University of Texas Helath Science Center at San Antonio • Meric Salbas, D.D.S., M.D. – Public health and restorative Dentist from Ankara University Faculty of Dentistry
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To complicate the issue, dentists are not incentivized to work in public oral health. Dr. Gulcin Bermek indicates that the government is unable to give each child fluoride varnish because of insufficient personnel. She explains that “there are no auxiliary dental personnel in Istanbul; there are more than a million kids and only a small group of nurses [who are not even] specialized to do dental treatment” (Bermek). Instead of entering the public sector, most Turkish dentists enter the private sector. Dr. Betul Kargul indicates that out of the total active dentist population of 22,000 people, 65% work in private practices, 25% in government hospitals, and 9% in University hospitals (Kargul). This is problematic because private clinics are not incentivized to participate in public health efforts. Dr. Meric Salbas states that “there are no specific regulations for private dentists [regarding public oral health] …. It’s left to the parents’ choice of priorities to take the children to dentists for examination” (Salbas). The elimination of private providers from public oral health further reduces the available personnel for public oral health endeavors.
ening the Public Health Capacities and Services (Ministry of Health of Turkey). As such, the document is “in line with national and international health strategies” (Ministry of Health of Turkey). In other words, the Turkish plan incorporates the most up-to-date recommendations and best practices for promoting oral health. For Turkey’s commitment to implement preventative strategies for sustainable promotion of oral health, the European Office of the WHO commended that Turkey has “an exemplary health sector strategic plan for other countries” (Ministry of Health of Turkey). Therefore, the Turkish governmental policies for oral health is in accordance to that of countries with very low rates of childhood dental caries. However, there is a disconnect between policy on the systemic level and actions on the local level, which allows the proliferation of dental decay. Turkey: Cultural Attitudes The most significant cause of the high rates of childhood caries stems from the present cultural attitude towards oral health. Dr. Gulcin Bermek indicates that “the lack of oral health culture… is the factor that leads to all the other issues” (Bermek). In other words, the lack of awareness is a major cause of preventable dental diseases. There was general consensus among all of the Turkish experts – Dr. Kargul, Dr. Peker, Dr. Salbas, and Dr. Mardin - that the lack of an oral health culture was the key root issue that lead to the high rate of childhood caries. Their perspectives highlighted three main consequences of a lack of oral health culture that lead to high rates of childhood caries.
Turkey: Governmental Policy The Turkish government policies toward oral health are well-intentioned and deemed adequate by international standards. In 2008, Turkey implemented a National Health Insurance policy that reduced the cost of health care, which included dental care (Kargul, Provision of Oral Health Care in Turkey). Dr. Gulcin Bermek states that the cost of care is not prohibitive of the utilization of services. She also indicates that dental treatment is free for Turkish children ages 5 to 15 (Bermek). The government identified children in that age group as a priority, so they are entitled to receive free treatment from both public and private institutions for “orthodontic treatment, restoration of teeth and root canal therapy on first and second molars” (Topaloglu-Ak, Eden and Frencken). In addition, government policy offers fluoride varnish treatment to all children (Bermek). Fluoride treatment strengthens the enamel, which protects teeth from cavities. Thus, this policy directly aims reduce childhood caries. Looking into the future, the official Turkish Oral Health Strategic Plan for 2013-2017 envisions a sustainable oral health system based on prevention. The strategic plan was created in collaboration with the World Health Organization and in accordance to the Tallinn Charter, which is also known as the European Action Plan for Strength-
First, a lack of oral health culture creates widespread ignorance about dental caries. Dr. Bermek explains that many adults in Turkey do not even consider dental caries as a real disease, but simply a condition to be treated when it arises. Naturally, parents do not take special precautions to protect their own or their children’s teeth. In fact, many parents have unknowingly impacted the oral health of their children. For instance, many mothers habitually add sugar to milk for their infants or toddlers (Salbas). The sweetened milk causes an acidification of the mouth, which fosters overnight proliferation of bacteria that cause dental caries. To make matters worse, even when childhood dental caries are identified, many parents tend to neglect them. Dr. Betul Kargul explains that many parents 60
sion that they don’t have enough money to go see a dentist.” This contributes to the problem of childhood caries because minor caries are often not treated due to misinformed concerns about cost. Moreover, Dr. Bermek laments that “if only [parents] knew how important oral health was, they would sacrifice a lot of things to take care of it. This attitude is true in all socioeconomic classes.”
think that since “deciduous [baby] teeth are temporary, there is no need to treat them. [Parents] don’t know that the issues can pass [from deciduous] to permanent teeth” (Kargul). Thus, a lack of information regarding the nature of dental caries and how to prevent them lead to a proliferation of a preventable diseases. Second, the lack of oral health culture leads the public to favor treatment over prevention. For many, visits to the dentist are “problem-oriented,” rather part of a routine (Peker). Dr. Betul Kargul states that “the problem with oral health centers also is that they are curative based, not preventative based”. Dr. Peker indicates that while regular dental check-ups are important, “people will not go unless they have some serious problems, like pain”. As such, there is only treatment and no prevention, since the problem has already manifested. This is problematic because most dental caries can be prevented or easily treated early on. Dr. Bermek indicates that “for many youths, the cavities are easily taken care of, if discovered and treated early enough. For some, it’s as easy as brushing and fluoride rinsing for a few days. We have shown this through our case studies in the past.” However, by the time that dental caries cause physical discomfort, it is often too late. The attitude of treatment over prevention permeates from individual families to health care providing institutions. Dr. Deniz Mardin states that “current oral health programs are like patches, where they are trying to block some of the problems, but [they are] not structured systemic changes for oral health” (Mardin). She explains that “preventative efforts take years, and since people don’t see quick results, [policymakers] try to just change [their approach]. They say it’s not working, but in reality you have to wait for it.” Thus, the lack of dental culture influences a favoring of treatment over prevention, which only contains current caries without preventing the manifestation of new ones.
In conclusion, all of the interviewed Turkish experts point to the severe lack of awareness regarding oral health in Turkey. Dr. Bermek emphasizes that “the [dental] system is quite ready to accept patients, and the technology is there. Oral health awareness and education just need be built into this country’s beliefs.” As such, it is evident that the lack of oral health culture is one of the main culprits in high dental caries in children. United States: Providers of Care In the United States, oral health is provided by both private and public actors. By the end of 2014, 205 million Americans, or 64% of the total population, had dental health care. Of this group, 155.3 million people (76%) had private dental plans and 49.6 million had public dental benefits, which included Medicaid, the Federal Children’s Health Insurance Program, and TriCare for military personnel (NADP). However, the lack of dental insurance was a significant barrier preventing the other 100 million Americans from receiving dental care (Childress). The American Dental Association reports that “racial and
Third, the absence of an oral health culture creates under-awareness regarding treatment options for dental caries, which in turn causes an under-utilization of dental services. Dr. Bermek claims that “the [dental services] are there but the people are not using them. For 5 to 15 yearold children, they have free of charge dental health in Turkey. However, no one knows about the fact that they have free dental health. Dental health is covered in national security health policies, but many people have the false impres61
ethnic minorities, people with chronic diseases, the frail and the elderly, and [the] economically disadvantage, bear a disproportionate share of dental disease” (ADA). Even though the United States in 2014 had 141,800 dentists and 174,100 hygienists, there was still a significant gap in dental coverage. Specifically, there were 4230 Dental Health Professional Shortage Areas (HPSAs), which affected 49 million people (HRSA). The current uneven provision of dental care leaves a significant portion of the population with inadequate dental care.
service varies among different socioeconomic classes. He specifies that “large segments of the population (poor adults and elderly) do not have the same access to care as persons with dental insurance.” In particular, Dr. Cappelli specifies that undocumented children have very bleak treatment options for dental care. Researchers at Princeton confirm that “a shortage of dentists who will accept Medicaid patients is one of the most frequently cited reasons for states’ failure to deliver early and periodic screening, diagnostic, and treatment (EPSDT) to poor children” (Lewit and Kerrebrock).
United States: Governmental Policies On the whole, the U.S. government has neglected oral health in recent decades. The underestimation of oral health is reflected through the Affordable Care Act (ACA), which overhauled the American health care system in 2010. The ACA does not mandate dental coverage for adults, which indirectly deems oral health as supplemental instead of integral to physical health (HealthCare.gov). In addition, although the ACA requires insurers to make dental coverage available for children under the age of 18, individuals are not required to actually buy the coverage (HealthCare.gov).
The U.S. government, through its neglect of oral health through legislation, implied that it does not regard oral health as an important aspect of physical well-being. As a result, there exists a lack of access for significant portions of the American populations, which enables the proliferation of preventable oral health diseases in children, especially those of low socioeconomic status. United States: Cultural Attitudes In the United States, there is a dearth of quantitative studies regarding the cultural attitudes toward oral health, especially relating to children. However, the existing studies indicate that attitudes toward dental caries in children are heavily influenced by the lifestyle of the parents. A study by the WHO found that “parental attitudes significantly impact the establishment of habits favorable to oral health” (Adair). In fact, researchers have found that lower caries rate in mothers correlated with better oral hygiene in and more dental treatment for their children. (Sarnat, Kagan and Raviv). The importance of women in influencing the oral health attitudes of children can be attributed, at least in part, to the fact that women are primary caretakers of children in a majority of U.S. families. Dr. Ryan Quock confirms that “primary factor that affects a child’s attitude toward dentistry is his/her parents’ attitude (Quock). Moreover, he remarks that “an anxious mother who had a negative previous experience will transfer that negativity to her child, even without using words.” Because of the impact of parental attitudes toward oral health, the same oral health habits are passed on from one generation to the next generation. This can be particularly dangerous in groups with poor oral health literacy, because the same habits are endlessly perpetuated (Rustvold). As such, low socioeconomic groups can suffer from
For socioeconomically disadvantaged Americans under Medicaid, the coverage for children, while provided free of charge, is not consistent throughout the country. The level of coverage for dental treatment is often diminished in priority and varies greatly by state. In 2011, a majority of states used 2 percent or less of their Medicaid budgets on dental care (Heitz). In fact, many dental offices reportedly refused to treat children on Medicaid because of very low profit margins. Alarmingly, a 2009 Kaiser report showed that 19 million children had no dental insurance at all (Childress). As a result of governmental neglect, access to dental care is a major factor for preventable childhood caries in poor populations. Dr. David Cappelli indicates that “while poor children have access to dental services in Medicaid and CHIP, a large segment of the population still does not have access to adequate dental services” (Cappelli). He hypothesizes that the insufficient service could be due to geography, the unwillingness of local dentists to accept Medicaid, and difficulties in public transportation to dental services. Moreover, Dr. Cappelli confirms that access to dental 62
In the United States, the governmental policy regarding oral health is one of neglect, as reflected through the exclusion of dental care for adults in the Affordable Care Act. In fact, the government does not offer oral health care to most of the general public. Instead, citizens are tasked to acquire dental care through private insurance companies, creating a severe lack of access to oral health care in individuals of lower socioeconomic status. Children in those groups suffer disproportionately from preventable dental caries because they cannot access basic preventative dental care. As such, the lack of access to care in the United States is due to neglectful governmental policy.
the inadvertent generational perpetuation of negative oral health behaviors. On the other hand, Dr. Jason Wang and Dr. Ming Zeng, two private general dentists in an upper middle class suburban neighborhood, agree that families in middle to upper socioeconomic classes tend to have adequate oral health habits (Wang and Ming). The importance on oral health is often spread throughout the family, from the parents to the kids, and also throughout communities from family to family. As such, cultural attitudes toward oral health varies greatly between different socioeconomic groups. Despite the socioeconomic disparities on cultural attitudes, there is an overall yearning for positive oral health. Dr. David Cappelli points out that “people [of lower socioeconomic status] who lack access to care still value the opportunity to receive dental care, but the lack of means to do so.” This shows that regardless of cultural attitudes, the oral health of lower socioeconomic groups is negatively limited by a lack of access to care.
In both countries, there is a lack of access to care, which ultimately lead to a proliferation of preventable childhood dental caries. Utilization of Dental Care The populations’ utilization of existing dental care in Turkey and the United States is most heavily influenced by cultural perception toward oral health.
Analysis An analysis of the three dimensions reported in the findings section reveals that Turkey and the United States have two mutual factors leading to high rates of childhood dental caries. Despite their situational differences, both countries can attribute their high rates of preventable childhood dental caries to 1) the access to dental care and 2) the utilization of dental care.
In Turkey, the lack of an oral health culture contributes to the ineffectiveness of the inadequate oral health infrastructure. The general public do not view oral health as an essential component of health, so they do not seek dental preventative measures. Dr. Gulcin Bermek illustrates that “people easily understand the danger and pressing need to address more visible diseases, such as eye diseases. However, they don’t accept that oral health diseases, such as periodontal diseases, as a form of diseases.” The neglect results in many children not receiving useful dental prevention procedures, such as sealants and fluoride treatments. Moreover, the ignorance of good practices for oral hygiene in adults influences similar behaviors in children. Thus, the Turkish population does not take advantage of the existing oral health resources, which results in high rates of preventable childhood caries. In the United States, although the oral health culture is better than that in Turkey, there is still room for improvement. Like Turkish people, many Americans view oral health as supplemental, rather than essential, to physical health. This stems from an ignorance of the wide ranging effects of oral health on overall well-being. The underestimation of oral health exists in the public and policy makers alike. Ultimately, the cultural
Access to Dental Care Access to care is primarily determined by governmental policies and the state of oral health infrastructure in Turkey and the United States. In Turkey, governmental policy regarding oral health is very positive and adequate to reduce the rates of childhood dental caries. However, the execution of the policy is problematic. Dr. Gulcin Bermek summarizes that “while the government regulations are good… with pens and paper, you cannot create anything.” In other words, the oral health infrastructure in Turkey is unable to carry out the programs outlined by the governmental policy. The resulting lack of access in Turkey reflects that favorable governmental polices toward oral health do not automatically solve the problem of high rates of childhood dental caries. 63
attitudes of policy makers render the attitudes of the public towards utilization of dental care irrelevant. Even if people of low socioeconomic status want to utilize dental care, they cannot because of the lack of access.
regard, awareness campaigns should specifically be targeted toward mothers, since they have a significant influence on the oral health behaviors of their children. To increase the utilization of dental services in both countries, efforts should be made to spread cultural recognition of the importance of oral health. This could take the form of educational awareness campaigns in primary education. For example, kids should be informed about the importance of oral health and good dental hygiene practices at a young age. In addition, educational campaigns will foster the creation of an oral health culture that will shift from treatment-based to prevention-based in the long term.
Thus, the people in both countries could benefit from increased awareness of the importance of oral health to increase the utilization of existing dental services. Conclusions In Turkey and the United States, the access to and utilization of dental care constitute the two major factors leading to a high prevalence of childhood caries. In fact, the high rates of childhood dental caries reflect a larger conclusion about the oral health situation of the general population as a whole. Since many parents value the health of their children as equal, and often greater, than their own, it is logical that the oral health of children often correlates with that of their parents. In turn, if the high rates of preventable caries in children can be reduced, it follows that there will be an improvement of overall population oral health status.
Works Cited
ADA. Action for Dental Health: Access to Care. 2016. 16 April 2016. <http://www.ada.org/en/public-programs/action-for-dental-health/access-to-care>. Adair, P M., et al. “Familial and cultural perceptions and beliefs of oral hygiene.” Community Dental Health (2004): 102-111. American Academy of Periodontology. Periodontal Disease and Systemic Health. 2015. 17 April 2016. <https://www. perio.org/consumer/other-diseases>.
Recommendations The key to address the issues regarding the access to and utilization of dental care lies in the need to “sell the problem” (Bermek). The high rates of childhood dental caries illustrate the need for oral health improvement in the general population of both countries.
Bermek, Gulcin. Factors Leading to Childhood Dental Decay: A Comparative Analysis of Turkey and the United States Tim T Wang. 3 March 2016. Broadbent, J M and W M Thomson. “For debate: problems with the DMF index pertinent to dental caries data analysis.” Community Dent Oral Epidemiol. (2005): 400-409.
In Turkey, there is a need to increase governmental funding to improve oral health infrastructure. In particular, efforts should be made to incentivize young people to become public dentists, perhaps through monetary compensation or social benefits. In addition, current dentists should be incentivized to join public health dentistry. Finally, institutions should be created to train auxiliary dental personnel to bolster public dental health efforts. This will increase the access to care in Turkey.
Cappelli, David. Factors Leading to Childhood Dental Decay: A Comparative Analysis of Turkey and the United States Tim T Wang. 8 April 2016. Center for Disease Control and Prevention. Hygiene-related Diseases: Dental Caries (Tooth Decay). 16 December 2014. 15 April 2016. <http://www.cdc.gov/healthywater/hygiene/ disease/dental_caries.html>. Childress, Sarah. America’s Dental Care Crisis. 19 June 2012. 15 April 2016. <http://www.pbs.org/wgbh/frontline/article/ americas-dental-care-crisis/>. Colak, Hakan., et al. “Early childhood caries update: A review of causes, diagnoses, and treatments.” J Nat Sci Biol Med (2013): 29-38.
In the United States, there is a need for legislation to expand the access to dental care. In particular, the Affordable Care Act should be revised to include mandatory dental services to the entire public, instead of only children. Only with increased access to care will the actual utilization of those services need to be addressed. In this
Dye, B A, et al. “Dental Caries and Sealant Prevalence in Children and Adolescents in the United States, 2011–2012.” 2015. <http://www.cdc.gov/nchs/products/databriefs/ db191.htm>.
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scholar.library.pdx.edu/cgi/viewcontent.cgi?article=1611&context=open_access_etds>.
Gil-Montoya, J A., et al. “Oral health in the elderly patient and its impact on general well-being: a nonsystematic review.” Clin Interv Aging 10 (2015): 461-7.
Salbas, Meric. Factors Leading to Childhood Dental Decay: A Comparative Analysis of Turkey and the United States Tim T Wang. 29 March 2016.
Gokalp, S G., et al. “National survey of oral health status of children and adults in Turkey.” Community Dent Health (2010): 12-17.
Sarnat, Haim, Aviva Kagan and Amiram Raviv. “The relation between mothers’ attitude toward dentistry and the oral status of their children.” Pediatric Dentistry 6.3 (1984): 128131. <http://www.aapd.org/assets/1/25/Sarnat-06-03.pdf>.
HealthCare.gov. Dental Coverage in the Marketplace. 2016. 16 April 2016. <https://www.healthcare.gov/coverage/dental-coverage/>.
Saydam, G, İ Oktay and I Möller. “Türkiyede Ağız Diş Sağlığı Durum Analizi.” Dünya Sağlık Örgütü Avrupa Bölgesi-Sağlık Bakanlığı (1990).
Heitz, David. The Sorry State of Dental Care in the United States. 18 October 2014. 16 April 2016. <http://www.healthline.com/health-news/the-sorry-state-of-dental-care-in-theunited-states-101814>.
Topaloglu-Ak, A, E Eden and J E Frencken. “Managing dental caries in children in Turkey - a discussion paper.” BMC Oral Health (2009): 9-32.
HRSA. Health Professional Shortage Areas Find. 2016. 15 April 2016. <http://datawarehouse.hrsa.gov/tools/analyzers/ hpsafind.aspx>.
US Department of Health and Human Services. “Oral Health in America: A Report of the Surgeon General --Executive Summary.” 2000. National Institute of Dental and Craniofacial Research. National Institute of Health. 15 April 2016.
Kargul, Betul. Factors Leading to Childhood Dental Decay: A Comparative Analysis of Turkey and the United States Tim T Wang. 3 March 2016. —. “Provision of Oral Health Care in Turkey.” n.d. EADPH. 15 April 2016. <http://www.eadph.org/congresses/15th/ProvisionTurkey.pdf>.
Wang, Jason J and Zeng Ming. Factors Leading to Childhood Dental Decay: A Comparative Analysis of Turkey and the United States Tim T Wang. 1 April 2016.
Lewit, E M and N Kerrebrock. “Child Indicators: Dental Health.” The Future of Children (1998): 133-142. <https:// www.princeton.edu/futureofchildren/publications/ docs/08_01_Indicators.pdf>. Lo, Edward. “Caries Process and Prevention Strategies:Epidemiology.” 2014. <http://www.dentalcare.com/media/ en-US/education/ce368/ce368.pdf>. Mardin, Deniz. Factors Leading to Childhood Dental Decay: A Comparative Analysis of Turkey and the United States Tim T Wang. 1 March 2016. Marthaler, T M. “Changes in dental caries 1953-2003.” Caries Res. (2004): 173-81. Marthaler, T M, D M O’Mullane and V Vrbic. “The prevalence of dental caries in Europe 1990-1995. ORCA Saturday afternoon symposium 1995.” Caries Res. (1996): 237-55. Ministry of Health of Turkey. “Strategic Plan 2013-2017.” 2012. <http://sbu.saglik.gov.tr/Ekutuphane/kitaplar/stratejikplaning.pdf>. NADP. Who Has Dental Benefits? 2014. 5 May 2016. <http:// www.nadp.org/Dental_Benefits_Basics/Dental_BB_1.aspx>. Peker, K B. Factors Leading to Childhood Dental Decay: A Comparative Analysis of Turkey and the United States Tim T Wang. 3 March 2016. Quock, Ryan. Factors Leading to Childhood Dental Decay: A Comparative Analysis of Turkey and the United States Tim T Wang. 8 April 2016. Rustvold, Susan R. “Oral Health Knowledge, Attitudes, and Behaviors: Investigation of an Educational Intervention Strategy with At-Risk Females.” PDXScholar (2012). <http://pdx-
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The Typical and the Unconventional: The Influence of Campus Design on Student Behavior By Madeleine Pelzel Executive Summary
dents. The design of the residential living quarters and adjoining open spaces at a university determines whom students see most often, in what type of space they congregate, and where their time is spent. In most cases, the architectural footprint of a campus unfolds over decades of development and new construction. The campus can be thought of as a small scale city, and thus college and university planners share with their colleagues in urban planning many of the same challenges of creating vibrant, diverse, and secure spaces for human living.
This research investigates and compares the effect of architectural design on student social behavior on the campuses of Rice University in Houston, Texas, and Koc University in Istanbul, Turkey. Koc represents the typical pattern of most schools, with dormitory living spaces separated from dining and recreational facilities. By contrast, Rice features a distinctive residential college system in which these spaces are integrated within a single structure. Interviews with administrators and students were conducted at both schools.
Issue Statement
The study finds that campus architecture promotes distinct patterns of student interaction, depending in particular upon the relationship between private and common spaces. The opportunity for spontaneous encounters and new friendships is much higher when students are required to traverse public gathering places en route to and from their rooms. A distributed network of common spaces increases the development of specific group identities, cultures, and traditions as compared with a single central gathering area.
Rice University in Houston, Texas, and Koc University in Istanbul, Turkey represent distinctly different approaches to campus architecture. As Rice has grown through the years, new residential colleges have been constructed according to prevailing architectural trends and designs, leading to a rich diversity of architecture across campus (Rodd). By contrast, the campus of Koc was for the most part built all at one time, with a singular design language and unity of architectural themes throughout the student living and recreational spaces (Karakas).
The study also finds that the campus exists as a city within a city. The characteristics of city planning that produce urban and suburban neighborhoods of more or less diversity, social interaction, healthy lifestyle, and security are also found on the college campus. The presence of multiple public gathering places favors diversity over homogeneity and increases the psychological sense of belonging and interpersonal trust. Introduction
This research investigates the relationship between architectural design and social behavior on these two university campuses, with further reference to similar issues and concerns in the city as a whole. The designs of the respective campuses give rise to dramatic differences in the way that students engage with one another and their surroundings. Just as campus planning creates patterns of interaction at colleges and universities, so urban planning is concerned with the social environment of the entire city.
At universities across the world, students live on campuses and form social communities. When constructing student housing and other common spaces, universities make design decisions that significantly influence the social behavior of stu-
Background: Rice University Initially the colleges at Rice were seen as â&#x20AC;&#x153;East Hall, West Hall, North Hall, and South Hall.â&#x20AC;? It was a very utilitarian system, and the halls were simple dormitory facilities. Only men were al67
lowed to live on campus. Women could attend the university but had to live off campus. In the late 1950â&#x20AC;&#x2122;s, students began to voice a desire for a more community-oriented form of student housing. After a student-initiated proposal to create a residential college system, a distinctive communal identity for each college was established, which continues to this day (Rodd). Rice now has eleven separate residential colleges, each of which has very specific traditions and expectations. The colleges have grown into living units of people that compete as teams, make large decisions, and function cohesively with one another in ways that go far beyond academics and residency.
of oneness and unity. The residential college system only adds to this experience by giving every student a common bond towards his/her college. (McDonald).
Rice is a very contained campus. Its monolithic footprint within Houston lies at the collision of three distinct city grids. Thus, the campus is uniquely positioned to pull together these different strands of the city. Because Rice is a singular campus with no satellites, there is a strong sense
Background: Koc University
At many universities, the student center or union building is the hub of social interaction. At Rice, however, the residential college system has resulted in a diminished role for the student center. David Rodd, the campus architect and Rice alumnus, comments, â&#x20AC;&#x153;I think this is shifting, though. It would be great to give the students a more varied experience, and architecture can go a long way to enhance and enrich student life.â&#x20AC;?
Koc University, founded in 1993, has one main campus and four satellites. The primary campus sits on a sixty-two acre estate that houses sixty buildings, including laboratories, libraries,
Rice University Map
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gest difference between our dorms and yours (Rice) is that yours are independent from each other—they form individual communities. Here [at Koc], the community is formed in the student center. Rather than separating everyone to eat, we bring them all together in one place in the middle of campus.”
dormitories, faculty residences, social venues, a health center, and athletic facilities (Karakas). The West Campus, located three kilometers from the Main Campus, contains only student housing. Shuttles run continually between West and Main. Of Koc’s 6,000 students, only 2,500 are provided housing each year (Karakas), with half living at West and the other half at Main. The other three campuses are Istinya (master/continuing education classes), Beyoglu (research facility near Taksim Square), and Ankara (in the capital city) (Bayirli).
Research: Method In order to investigate and compare how Rice and Koc approach residential architecture and planning, interviews were conducted with administration, staff, faculty, and students at each institution. At Koc, the Facilities Manager and the Facilities Directorate were interviewed. At Rice, the Campus Architect, the Senior Director of Housing and Dining, and Undergraduate Dean, among others, were interviewed. In addition, there was a student forum at Rice, and discussions were held with students at both universities. This data was then synthesized through the lens of an architectural education and personal experience in both environments.
The Main Campus has three types of dorm buildings (Bayirli). There are twelve type A dorms, five type B dorms, and one type C dorm. Each of the dorm buildings is labeled only with a letter of the alphabet. The different types notate whether or not there are communal bathrooms (type B) or bathrooms en suite (type A) or dining options attached (type C) (Bayirli). In no way do students identify with their building or claim it as their “home” with any sense of loyalty. At Koc, the dorm buildings hold no social functions and are set apart from the rest of campus, while the student center is massive and central. As Cenk Bayirli, the facilities manager, stated, “The big-
Koc University Residential Campus Plan
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Comparison: The Residential Area
creating a campus center—a hub where students from both residential areas (Main and West campuses) would come to congregate, eat, study, and socialize (Karakas).
Rice University Each residential college at Rice has a very specific culture. Richard Johnson, Director of Sustainability at Rice, notes, “Each college’s identity is shaped by the architecture.” Sometimes this is shaped by floors, and at other times by larger public spaces in each dorm building. Rice has built four new residential colleges in the past fifteen years (Johnson). Michael Graves, a prominent postmodern architect, designed the additions and renovations on the North side of campus, while Rodolfo Machado, an influential Boston architect, did the new buildings on South campus (Rodd). There was one driving motivation in all new buildings: develop spaces that draw people out of their rooms and into community (Rodd). Students want nice rooms, but the nicer the rooms, the more likely students are to stay in them and avoid common spaces (Hutchinson). Nicer rooms equal worse community.
Comparison: Circulation Rice University Throughout my interviews, one factor was consistently noted as being the primary difference among the colleges: circulation. Although most of the colleges that were built in similar time periods reflect similar circulation styles, two buildings digress from this model: Sid Richardson (Sid) and Lovett. The circulation at Sid, which involves a double elevator core in the middle of the tower, creates a central congregation space on each floor in front of the elevator where everyone waits to go down to the lobby together (Forum). At Lovett, on the contrary, there is no centralized way to exit the building, so it’s easy to leave without encountering others (Forum). A distinct difference in circulation pattern is also apparent between “old” Wiess and “new” Wiess. Dean Hutchinson, the Master at Wiess during the transition, remembers, “It was impossible to get into the old Wiess without going through the commons. The E-shaped building had quads that opened toward the inner loop. Students had to go through the commons and quad to get to their rooms. This meant that there was no way to get to your room without seeing others. The chance of encounters were extremely high, which is a good thing for students.” The new Wiess, and the layout of all of the colleges built after it, makes passing through common space an option rather than a requirement.
Undergraduate Dean of Students John Hutchinson observes, “In some regard, part of our failure is that we have made things a little too nice. It works against the sense of community when people are overly comfortable in their rooms.” David Rodd, Rice’s campus architect, was also involved in the planning of Wiess and Martel and the renovation of Jones and Brown. Rodd states that “The experience of living in the college and what that means goes a long way in shaping the way we were designing. It would be great to give the students a more varied experience, and architecture can go a long way to enhance and enrich student life. This has been a topic of consideration for some time.”
At the student forum, comments from Wiess residents testified to a sharp dichotomy between public and private space in the building. One student stated, “The only truly public space is the commons, where you place yourself in a glass box in which everyone can see everyone else at all times and everything you say is being overheard. So there’s absolutely no floor culture or intermediate public space at Wiess where you would meet random people that you otherwise wouldn’t have. Everything has to be intentional. You either want to be in a place or not. You don’t happen to pass through any certain public space every day.”
Rather than focus on a centralized campus plan, Rice has made eleven different centers. Each of these has its own patterns and eccentricities. Rice has used this opportunity to understand the dynamics of the college system in relationship to the architecture and to experiment with three basic characteristics within the buildings and their surrounding areas: circulation, green space, and scale. Koc University At Koc, the dorm building is solely a place for sleeping. The focus of the campus design was not around the residential buildings, but around 70
not clearly “owned” by either Hanszen or Wiess. Access to it is difficult, and there is no visibility into it until you are clearly in the space (Hutchinson). There’s also no particular programming or activity that takes place there. This is one of the most unused places on campus (Johnson).
A student from Duncan also added, “The lack of any common space within the hallways makes them a barrier to social interaction--everything must be purposeful.” On the contrary, a student from Jones said, “When you get to your floor you have to walk through a lobby with couches and a projector so you always go talk to people unintentionally.” She adds, “When you are placed on a floor freshman year (at Jones) you are assigned your friends. The floor completely gave me my identity at Rice.”
“Regarding Duncan and McMurtry’s quads, had there been more student life on the first level of the colleges, their quads may have been livelier. It (the current setup) creates a barrier between the towers and the outdoors space,” David McDonald speculates. By comparison, Will Rice and Hanszen clearly own their quads, yet they maintain a porous perimeter with easy entrances into residential areas. Dean Hutchinson adds, “The success of a quad relies on four main factors: clear ownership by a college, the appropriate scale, things that draw people there, and multiple access points.”
Koc University The dorm buildings at Koc are all placed in very close proximity to one another, set apart from the academic portion of the Main Campus. Upon entering a dorm, there is no lobby or gathering space, but rather an elevator and two staircases. The hallways are long and narrow and do not open up to any larger, central areas. The circulation in and around each of these buildings is the same: long, double-loaded corridors (Bayirli).
Koc University At Koc, the green space is centralized in the same way as are dining and socializing spaces. None of the residential buildings have adjacent green space. There is one large common lawn with amphitheater-like steps leading down to it that separates the dorm area from the academic area of campus (Bayirli). This large open expanse creates a kind of buffer between the “living” and “work” environments of the main campus, rather than a place where the two can meet (Karakas).
Comparison: Green Space Rice University A college’s “quad,” or surrounding outside space, is a significant element that affects circulation. The alignment between the college’s primary building and its quad(s) plays a decisive part in whether or not the quad is utilized (McDonald). David Rodd remarked, “The layout of the colleges onto their quads is something that we have been thinking more and more about. You’ve got a college creating a quad, and the commons with a visual and physical relationship to the quad. The master’s house is close by but isn’t intruding.” David McDonald, the senior director of Rice Housing and Dining, also commented on the quads: “The relationship of the Will Rice commons to the Lovett quad is fascinating. The Baker layout is spider-like. They don’t have one central quad. I think you can build colleges close together, I just think orientation matters. You can’t put two “front doors” too close together.”
Comparison: Scale of Space Rice University Nearly every one of the interviewees mentioned the size of the public space as a key factor in creating environments in which many different types of people feel as though they belong. Breaking up large public spaces into manageable sizes makes people feel comfortable. Bridget Gorman, Will Rice Master and Sociology professor, discusses the Will Rice commons, “Big cavernous spaces do not create good interactions. I think the most successful commons are the ones with adjoining separate smaller spaces off of the main space. Our (Will Rice) PDR (private dining room) and commons flow together with double doors, parallel to the game room and parlor, which can be closed off or not. [This situation] allows so many different types of stu-
One thing that seems to determine whether or not a quad or large space is successful is the degree to which college residents take ownership of it (Johnson). A negative example of this is the outdoor plaza on top of the South Servery. It was meant to be a shared public space, as it is 71
Synthesis: Effects on Social Culture
dents to occupy the same space while carving out portions for themselves. I call the game room the last bastion of the geeky boy. The freshman use the parlor, which is public but still their own zone.”
Rice University According to David MacDonald, students feel that the best and most fulfilling interactions are unplanned. The desirability of such spontaneous meetings and “sidewalk conversations” was a common thread throughout all of the research. Architecture has the power to make people feel comfortable and to foster the intimate encounters that grow into lasting friendships (Spieler).
When asked about how the scale of space matters, David McDonald brought up the number of students within each college. Duncan and McMurtry have 325 beds, over 50 beds larger than any of the other colleges (McDonald). He speculated that this larger number may negatively impact the culture at these two colleges, but stated that currently there is no way to determine how size influences social interactions. He did mention, however, that if there were to be an additional college built it would likely have a lower number of beds than Duncan or McMurtry.
The visibility in and out of public spaces and quads also affects their use. People feel comfortable entering a space when they can see that other people are there and/or people they know are there (Johnson). The perception of acceptability to be in a space is the key factor-it’s a mass group mentality. The tipping point for trying to nucleate a group is always a critical mass of people--and it doesn’t work without sight (Hutchinson). If someone can’t see that a lot of people are doing something, then they aren’t going to do it (Johnson). A really desirable space does not necessarily make people congregate there (McDonald).
The scale of the college’s quad is also a factor in its use. Wiess’s quad, for example, is commonly thought to be too large. “It feels more like a nice lawn to look out at rather than something to use,” one student said. He continued, “There is an unease of being in the center of the quad. When you’re walking through the quad, you’re performing, in a way. It doesn’t create any sort of relationship to the building. It would be great to have coincidental interactions with people—a pseudo-public space. It can’t be added onto a building that is already designed like this. You need spaces that you are forced to walk through. The architecture is structuring the behavior.”
Bridget Gorman, who has been an Associate at Wiess, RA at Jones, a member of many building committees, and who is currently the Master of Will Rice, adds, “I think that the way we construct space is super important for social interaction. Even in academic buildings, the culture of the faculty is affected by the building. Also, I think the way our (Will Rice’s) space is structured is a huge part of the reason our demand for on-campus housing remains so high.”
Another student from McMurtry commented on the paths and benches that were added to the center of their quad. This simple maneuver activated their quad, making its scale accessible and increasing the culture of the quad. In this instance, the landscape adjusted for the shortcomings of the architecture (Forum).
The traffic flow of students in and around the colleges is something that Dean Hutchinson discussed at length when reflecting on the design of the college system in relationship to the student body: “When you are returning to your college, you should pass through the community on the way to your room. You should see people. You should not be able to bypass the community to get straight to your room. If that’s the case, you lose the opportunity for the random encounter that may result in something fun or productive.” Thus, at Sid, students commonly meet new people on the elevator or in lobby. Duncan, by contrast, doesn’t have this sort of interstitial space.
Koc University At Koc, there is no variability in the scale of the public space, since there is only one such space. The student center does, however, accommodate for gatherings of different sizes through small niches and the arrangement of furniture (Bayirli). This shows the inevitable need for space at multiple scales to foster productive social engagement.
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have cumulatively shaped the experience and cultural ethos of the student community (Rodd). Urban planners can only dream about having a similar level of control over the fabric of an entire city (Spieler). Cities are more complicated primarily because of the involvement of many more stakeholders and decision-makers.
David Rodd adds, “(The) position of the commons in relation to the residency is the most important piece of architectural distinction in the colleges. In some colleges, the communities are stratified by floor culture while others are more commons-centric.” When asked about the number of people per college, Bridget Gorman speculated, “Too many beds makes people feel redundant, like their social role in the college is already filled.”
The history of urban planning is a history rich in thinking about what social structures are created as cities grow. Urban planning is, at its core, about creating social structure. Christof Spieler, a Rice alumnus, faculty member, and practicing urban planner, suggests that both cities and universities are ultimately asking the same question: are you trying to enable or trying to control?
The residential college thus becomes another common denominator for the formation of friendships, along with shared interests, activities, major, class, etc. In these examples, and many others, the social culture of universities has a direct correlation to its architecture, just as the inhabitants of the city react to their built environment (Spieler). There are pros and cons to the different college layouts. A student from Hanszen remarked, “Hanszen, Sid, and Brown have some of the best culture, but worst amenities. We complain a lot about the nicer colleges--but really a standardization of all of these would take away part of the soul of the system.”
Security and lifestyle are some of the primary factors that “The City” aims to control. Historically, one could consider Baron Haussmann’s plan for Paris. In his renovation, the broad avenues would allow the government to easily reclaim the city if the people revolted (Rearick). Social control in this way is at the root of some aspects of city planning.
Koc University Throughout conversations with Koc students, it was apparent that the students’ friends consisted primarily of people who were in similar classes, clubs, or activities as they were. There simply was no other common denominator to “break the ice.” This further enforced the idea of the centralized socialization space. One student commented while in the Student Center at Koc, “I rarely spend time in my room. All of my friends are here, I don’t really hang out with the other people on my floor.” This idea can be seen at Rice in a small way at each of the colleges’ whose culture is more commons-focused. The student went on to discuss how the clubs tend to form social cliques and social stratification.
In the modern day, security is something that cities and corporations promote in part by placing layers of control around their perimeter. Universities have begun to do this as well. The secure perimeter also creates a psychological sense of deterrence. This is especially evident at Rice; while Red lines highlighting Haussmann’s new boulevards (Rearick).
Synthesis: The City The campus and the city share many characteristics. A crucial difference, however, is that colleges and universities have a central, singular planning authority that can actually control what happens on campus. A city, by contrast, may or may not have an effective zoning and planning commission and rules. The decisions made by university planners regarding the architecture and spatial organization of the campus at Rice 73
the border is porous and not literally fenced off, the perception of there being a distinct perimeter deters most potential intruders (Rodd). At Koc, on the other hand, everyone must pass through a singular entrance that is guarded (Karakas).
various green spaces and gathering spaces for students. The residential colleges at Rice (with dormitories that include community gathering and recreation spaces and adjoining green spaces) resemble small towns--as soon as somebody does something, everyone knows (Spieler). Visibility is comforting but also awkward and scary, at times, and can encourage uniformity.
City planners have always had a vested interest in creating pleasant social environments (Spieler). For example, well-designed parks encourage people to engage in healthy physical activities and create beautiful green spaces for social gatherings. Or consider the garden city movement, which Sir Ebenezer Howard began in the UK in the late nineteenth century (Lapping). Howard proposed that a city functions best when communities are surrounded by “greenbelts.” Universities fulfill similar functions with the
In a way, what the college system does on a small scale, the university does on a large scale: it creates a group of people who are inside and a group of people who are outside. In doing so, it implicitly (or sometimes explicitly) sets up this idea of “I am safe around these people because they
Ebenezer Howard’s diagram of the Garden City (Lapping)
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matic diversity in small areas (Spieler, 2016).
are part of this same group that I am a part of,” as Christof Spieler observed. This degree of trust can create wonderful social environments where everyone feels comfortable leaving their doors open, but can give rise to unintended issues on campus as well. These effects vary significantly from one campus to another, primarily in correlation with the size of the student body. The feeling of trust also increases with the exclusivity of admission (Rodd).
The relationship of campus space to urban space can be extended by comparing one of the long halls in a dorm like Baker, Will Rice, or Hanszen, to a successful street that encourages people to stroll up and down and stop in at different establishments. If there was a long stretch of hallway with no rooms that were open or had students, people may stop and not venture down to the other part. Similarly on a street, if there are all kinds of great shops and restaurants, and then suddenly there is a long stretch with no street-front engagement, the streetscape is cut in two. The microcosm of one hallway at Rice can be compared to a city street in this way. The sense of ownership, belonging, and not feeling like an outsider also transfers to the streetscape.
Neither Koc nor Rice have Greek life. At many universities, though, fraternities and sororities represent communities in which people can feel confident that their peers are similar to them, forming “safe” social groups within the large campus of strangers. Fraternities and sororities are usually the most homogenous places on any given campus. This replicates the same dynamic that is typically found in suburbs. Suburbs are a way for people to spend time around people who are like them. Suburban planning is centered on the idea that people who move into a suburb should be similar to the people who currently live there (Spieler).
Richard Johnson reflects further on how these different models of neighborhood interaction are manifested in the different colleges at Rice. “Wiess is the icon of urban sprawl. Each room is plush with amenities and has easy access out of the building through an outward-facing single loaded corridor. You don’t have to pass through the commons to leave, and the quad isn’t a social space. There aren’t the same types of interactions that you would find in a pedestrian-oriented city. The other extreme is the old fashioned city where the street or square is the social space. Jones is more representative of this mentality, where each floor has a central public zone that is directly connected to the main paths of circulation in and out of the rooms.”
In this respect, Rice resembles a type of suburban space. There is a sense that everyone here has been vetted, has made it through the system, and is “acceptable,” so the feeling of trust permeates the entire campus. The more rigorous the selection process, the stronger is the common denominator among students, eliminating the need for race or money to serve as a unifying bond. Campus architecture is implicated in and expresses these sensibilities. Rice was built in the middle of an open prairie (Rodd), in a place that had no history--a blank slate. From its beginning, however, the university had aspirations of being a high powered and lasting institution, a fact reflected in every building or landscaped lawn (Spieler).
There need to be spaces that people can easily see into and wander into, without being invited or having a specific reason to pass through. Such spaces foster social hubs, regardless of where they are located within the colleges. When you aren’t forced to pass through an area or you can’t see into it, there’s a feeling of needing invitation or reason to enter the public zone. Public spaces aren’t as successful when people are able to bypass them easily.
The suburb is one model for how a neighborhood functions. People move, in cars, from one privately controlled area to another as quickly as possible, with little or no social interaction. The only social space is one’s own home or a specifically programmed space. By contrast, in the traditional city, where homes are often small and cramped, the street or square is the primary social space. Suburbs reinforce socioeconomic homogeneity, whereas cities are typically characterized by constant interaction and by dra-
Conclusion Architecture controls so much on the campus that people are completely oblivious to it. It has become the constant, the thing that never changes. It’s inherent to what is happening, how 75
people move through the day. It’s something that is just accepted.
Master – College Masters are tenured professors and their spouses entrusted with being the faculty leaders of any given college. Along with living next to the college with their families in a master’s house (the Will Rice Master’s House is right next to Newer Dorm), college masters help the college to accomplish its shared goals, solve challenges, celebrate its communal achievements, and most of all, be a voice of experience when needed.
At Rice, most of the colleges that were built in the same time period reflect similar architectural trends. In order to be fully engaged in the college system, students need to find a niche within it where they feel a sense of belonging. Multi-function use of space is the key to success. When a large space is partitioned and can be flexible, it simultaneously supports all parts of the community and every type of student. People are attracted to transparency and a sense of belonging. This kind of architecture can draw people together in meaningful and positive ways. “I don’t think we need our residential colleges to turn into suburbia with a bunch of cul-de-sacs.” Richard Johnson goes on, “The architecture shapes our interactions so much that we really don’t even see it or recognize that it’s doing what it is.”
Culture – the way the college typically socializes Quad – Green lawn next to a residential college in which students play and study. Commons – Each colleges’ dining and living. Students also occupy this space to study, play ping pong, etc. PDR – Private Dining Room. A closed off dining room adjacent to every colleges’ commons.
At Koc, the dorm buildings carry no identity or culture. The students form their social circles purely through organizations and common interests. The dorms hold no space for congregation; instead, social interaction is concentrated in one central building.
Works Cited
Bayirli, Cenk Efe. Facilities Manager Madeleine Pelzel. 2 March 2016. Forum, Student. Group of Students Madeleine Pelzel. 28 March 2016.
This study has explored how architecture shapes the experience, behavior, and identity of students on two different kinds of campuses, and further relates the design of campus space to issues of city planning and models of urban and suburban environments. University campuses are complex places in their own right, containing diverse elements that interact among themselves while being situated within the larger entity of the city. Both Rice and Koc are deeply woven into the fabric of their respective cities, Houston and Istanbul. The comparison of the two campus designs has yielded valuable insights into the student experience at each university and the placement of each campus in its host city.
Hutchinson, John. Dean of Undergraduates at Rice University Madeleine Pelzel. 7 April 2016.
Vocabulary Appendix
Rearick, Charles. “Introduction: Paris Revisited.” French Historical Studies (2004): 1-3. Web. 5 April 2016. <http:// eds.a.ebscohost.com.ezproxy.rice.edu/eds/pdfviewer/pdfviewer?sid=38320d64-ae8a-46c8-845d-541dfff5075c%40sessionmgr4005&vid=2&hid=4103>.
Johnson, Richard. Director of Sustainability at Rice University Madeleine Pelzel. 30 March 2016. Karakas, Ilker. Facilities Directorate Madeleine Pelzel. 2 March 2016. Lapping, Evan Richert and Mark. “Ebenezer Howard And The Garden City.” Journal Of The American Planning Association 64.2 (1998): 125. Web. 6 April 2016. <http:// eds.a.ebscohost.com.ezproxy.rice.edu/eds/detail/detail?vid=1&sid=28f056af-5924-4c1b-af56-a6ed8b5cd9ec%40sessionmgr4001&hid=4103&bdata=JnNpdGU9ZWRzLWxpdmUmc2NvcGU9c2l0ZQ%3d%3d#AN=604872&db=bth>. McDonald, David. Senior Director of Housing and Dining at Rice University Madeleine Pelzel. 22 April 2016.
Residential college (college) -- small, permanent, cross-sectional societies of students and faculty within a larger university. Students are assigned one at random when they enter the university.
Rodd, David. Campus Architect Madeleine Pelzel. 24 March 2016.
Servery – the cafeteria associated with a residential college.
Spieler, Christof. Professor in the Practice Madeleine Pelzel. 5 April 2016.
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Comparative Cultural Heritage Policy and Conservation in Istanbul and Houston By Matthew Proffitt Executive Summary
and the Black Sea. Its commercial and historical center lies on the European side and about a third of its population lives on the Asian side (HowToIstanbul.com). The city hosts a population of around 14 million residents, is one of the world’s most populous cities, and ranks as the world’s 7th-largest city proper and the largest European city (http://www.citypopulation.de/Turkey-C20.html). Istanbul, which formerly belonged to the Roman, Byzantine, and Ottoman Empires, is now the Turkish Republic’s most important city from a cultural and economic perspective. Istanbul is the only city in the world standing upon two continents, Asia and Europe, and possesses a blend of culture and heritage from both sides. The influence of the Roman/Byzantine empires was that of a largely Christian culture which was the groundwork and basis for most present European cultures. On the other hand, the culture of the Ottoman empire which ruled over Istanbul next was an Islamic one which carried with it several of traditions and practices that were present in what is today referred to as the Middle East. These two cultures are considerably different from one another and as a result, Istanbul is characterized by heritage sites that are roughly split into two subsets which differ greatly from one another. Beyond the physical artifacts of two immense and disparate empires, Istanbul holds the distinction of being known as the bridge between East and West and the point of exchange between Europe and Asia. This in and of itself has led to Istanbul developing a cultural zone unique in the world.
Houston and Istanbul are very different cities with Istanbul possessing 2,000 more years of history than Houston. Istanbul has seen two very distinct cultures rule over it (the Christian influence of the Byzantine Empire and the Islamic rule of both the Ottomans and modern day Turkish republic) while Houston’s short history has been monopolized by essentially a single culture. Bearing these facts in mind, this paper examines and compares the different policies and approaches to Cultural Heritage policy and conservation in Istanbul and Houston. This paper examines the attitudes and approaches to these policies by both ordinary citizens and the governmental officials involved in making those policies. In addition, the paper also explores governmental policies which not only determine sites of cultural heritage but also those which are responsible for the upkeep and maintenance of these sites. While attitudes toward cultural heritage are remarkably similar in both cities, Istanbul deals mainly with the preservation of physical artifacts whereas Houston works to create cultural heritage through more grassroots movement. When it comes to policies, Istanbul and Houston unsurprisingly follow very different approaches and deal with different problems as a result. Finally, the paper presents distinct solvency recommendations in light of these different problems while simultaneously addressing potential problems such recommendations could face. Introduction Before examining the policies and attitudes of cultural heritage in Istanbul and Houston themselves, it is first necessary to understand the relevant background information of each city’s cultural heritage policy. Istanbul, historically also known as Constantinople and Byzantium, is the most populous city in Turkey and the country’s economic, cultural, and historic center. Istanbul is a transcontinental city in Eurasia, straddling the Bosphorus strait between the Sea of Marmara
Istanbul has four areas which were registered on the UNESCO World Heritage List in 1985 due to their outstanding universal value: Sultanahmet Archaeological Park, Suleymaniye Conservation Area, Zeyrek Conservation Area, City Walls Conservation Area (UNESCO World Heritage Center) but since that inscription, significant threats to these sites have been continually identified. These include, but are not limited to, the continued degradation of architecture within the pro77
tected zones, the quality of repairs and reconstruction of the Roman and Byzantine walls and associated palace structures, lack of coordination between national and municipal authorities and of decision-making bodies for safeguarding World Heritage at the site, and the impacts of new buildings and new development projects on the World Heritage property (UNESCO World Heritage Center).
States Census Bureau). Houston was founded in 1836 and is a global city, with strengths in business, international trade, entertainment, culture, media, fashion, science, sports, technology, education, medicine, and research. The city has a population from various ethnic and religious backgrounds and a large and growing international community. Houston is the most diverse city in Texas and has been described as the most diverse in the United States (Gates). And the history of this land stretches back far before Houston was incorporated in 1836. At one time Houston was a series of coastal plains home to a variety of trees, swamps, and marshland. It was in the midst of this temperate grassland that Native Americans went about the business of life – hunting, fishing, and other activities that were essential to their survival. The first report of Native Americans in Texas was by a group of survivors from Spanish explorer Cabeza de Vaca’s party in 1535. They came upon a group of Native Americans, possibly members of the Karankawas or Akokisas peoples that were common in what is now the Houston area. The Spaniards’ journals give in-depth descriptions of life in the community—creating dugout canoes, fishing, gathering plants for food and medicine, and building different shelters to accommodate the seasons. And although agencies like the Moore Archeological Consulting have uncovered and preserved thousands of artifacts from the Akokisa tribe, the majority of these heritage artifacts have been lost to time and no significant sites remain from this time period (Audet). As a result, the majority of Houston’s cultural heritage comes from that time period after 1836. This is vastly more recent than Istanbul which possesses more than 2,000 years of preserved heritage over Houston and whose cultural landscape is much more varied. From the brief period in which Houston has been preserving cultural heritage, it has been dominated by what is essentially a single culture. For the purposes of this paper the brief
In response to the series of continued complaints received by the Turkish government, the Minister of Culture worked in coordination with law makers to craft and implement the 2011 Istanbul Historic Peninsula Site Management Plan (Istanbul Historic Peninsula Site Management Plan). This plan has remained in place since it was first drafted and put into place. Despite the active efforts by the government to improve the treatment and quality of the cultural heritage sites in Istanbul, they have failed to resolve several exigent problems and even taken several actions that oftentimes puts those sites at risk. Houston on the other hand is the most populous city in Texas and the fourth-most populous city in the United States with a census-estimated 2014 population of 2.239 million people (United
Figure 1 (Studies) A- Sultanahmet Archaeological Park B- Suleymaniye Conservation Area C- Zeyrek Conservation Area D- City Walls Conservation Area
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Issue Statement Cultural heritage is most widely known as the legacy of physical artifacts and intangible attributes of a group or society that are inherited from past generations, maintained in the present and bestowed for the benefit of future generations. It is an essential part of society and each successive generation has to deal with the problems and challenges associated with maintaining and preserving the cultural heritage within their cities. The various policies and programs cities choose to implement in order to deal with cultural heritage often reveals key aspects of a cityâ&#x20AC;&#x2122;s attitude towards cultural heritage. Studying these policies and attitudes in turn allows one to better understand a city itself. This becomes even more important when attempting to understand different cultures (as cultural heritage is, by name, inextricably tied into the cultural milieu of the city or nation in which it is found). To that end, this paper shall examine the cities of Houston and Istanbul through a comparative analysis in order to gain insight into the attitudes and policies toward cultural heritage in each. Each of these cities is a major center of commerce and international attention, and as such, each is worthy of study in and of themselves. By examining them through a comparative lens, this paper will be able to more clearly ascertain the different approaches and attitudes towards cultural heritage as well as draw attention to the similarities they share. In doing so, this paper will be able to generate a greater understanding not only of cultural heritage in each city but of the cities themselves.
period of the Texas Republic possessed no real or unique traits that distinguished it from the larger American culture, especially when one considers that a large majority of the settlers and leaders who held power in the republic maintained a culture almost identical to that of the larger United States and tried for nearly the entirety of its existence to become part of the United States. This is also very different from Istanbul which, as has already been covered, saw two very distinct and disparate cultures rule over it. As a result, it is not unsurprising that UNESCO does not recognize a single site of cultural heritage within Houston (although the missions of San Antonio are listed) (UNESCO World Heritage Center). Still, it is nonetheless home to many cultural institutions and exhibits. These organizations attract more than 7 million visitors a year to the Museum District and the cultural heritage within Houston has increased almost exponentially in the past few decades. As evidenced by the fact that 40% of the regionâ&#x20AC;&#x2122;s cultural organizations did not previously exist before the year 2000. There are currently approximately nine cultural organizations per 100,000 residents in the Houston region and the funding to these organizations has increased in almost direct proportion. From 20002010, expenditures from cultural organizations grew by 65% (approximately $227 million) (Center For Houstonâ&#x20AC;&#x2122;s Future). However, as Houston has increasingly seen its cultural heritage gaining traction and funding, it has had to deal with many corresponding problems as well.
Research In order to most accurately analyze and compare the current policies and attitudes towards cultural heritage in both cities, this paper uses several different avenues of research. The research conducted in Istanbul and Houston is multi-modal and explores two distinct aspects of analysis for both cities. The first of these is the general attitude towards preservation and cultural heritage in both cities and the second is an examination of the cultural heritage policies each city possesses. The research for these sections were gathered through several sources; interviews, a literature review, and I also had the opportunity to observe several of the sites of cultural heritage in both cities personally. The first of these sources is formal interviews with profession-
Figure 2 (Center For Houston's Future)
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als specializing in the field and informal interviews with college educated non-professionals. These interviews have been substantiated and expounded upon by pertinent policies that collaborate the opinions. In the areas where interviews were unable to adequately address, pertinent news stories, policies, and quantitative figures were employed to gain the necessary research. One limitation of this research is that government officials of each city were not able to respond to the views and opinions expressed and therefore could potentially have responses or solutions to the problems posed throughout this paper.
heritage sites. When it comes to the attitude that exists behind such policy it becomes apparent that government often prioritizes other interests over those of the sites. In the opinion of a young, college educated man I spoke with in Istanbul, the government either doesn’t care about preserving cultural heritage or it purposely chooses to prioritize other projects despite knowing that said projects may hurt the sites. And the actions of the government appear to support this claim as several infrastructure projects still exist which are dangerous for the historic areas. The most significant of these projects is the Marmaray Rail Tube Tunnel Station, whose construction and operation has ended up eroding the Theodosian Seawalls. Despite having recently celebrated the 1600th anniversary of the completion of the Theodosian Walls, which were completed in 413, the government has persisted in pursuing a project which is actively harming them. The walls, which are of Roman-Byzantine origin, once protected Constantinople against attacking armies. Along the walls, there is a green corridor of open space – one of the few green spaces in the metropolis of Istanbul – which includes parks and traditional agricultural land. However, the construction and continued operation of the Marmaray station is currently threatening this cultural heritage: the walls are deteriorating and in parts, close to collapse, and due to infrastructural changes and growth, the walls and the accompanying “green” corridor are in danger of losing their identity even more (Aachen university). The danger to the site has been recognized by news outlets both in and out of Turkey and UNESCO’s Reactive Monitoring Mission Report has repeatedly included the project as a significant threat to the site. Projects like this one are far from alone throughout Istanbul. Another project of note is the Gebze-Halkali Surface Metro System which was also included in UNESCO’s Reactive Monitoring Mission Report ( ICOMOS). This project has been developing connections of rail lines, between the European and the Asian continents, in Istanbul through an underwater tunnel under the Bosporus Strait. However, its construction has also taken it through sites of cultural heritage where construction speed and progress was frequently favored over preservation of the sites. These are only two examples but it is already clear that governmental policies frequently put heritage sites in direct danger.
Another potential limitation is due to the fact that Istanbul had far fewer available or useable resources so the majority of work there was drawn from a detailed interview with a leading expert in the field, Dr. Nisa Semiz, as well as from UNESCO reports, and the site management plan released by government itself. Dr. Semiz is an is an expert on cultural heritage in Turkey and a faculty member of the T.C. İstanbul Kültür University (Istanbul Kultur University). UNESCO is the United Nations Educational, Scientific and Cultural Organization and it is tasked with building intercultural understanding through the protection of heritage and support for cultural diversity. UNESCO created the idea of World Heritage to protect sites of outstanding universal value and releases reports detailing the conditions and problems of the sites (UNESCO.org). The research for Houston cultural heritage was drawn from a variety of different sources (thanks in no small part to fact that it was a lot easier to gain access to more varied sources) with the majority of research on policy drawn from the March 24th, 2015 Advisory Committee Meeting Presentation on the City of Houston Arts and Cultural Plan (CITY OF HOUSTON). This was done because the presentation itself drew from a variety of sources and was most comprehensive resource available in terms of explaining Houston cultural heritage policies. Findings General Attitudes towards Preservation and Cultural Heritage The first aspect of the research that needs to be examined is the general attitudes towards preservation and cultural heritage that exist in Istanbul and Houston. As has already been established, Istanbul is a city which has long struggled with protecting and maintaining its cultural 80
that this apparent paradox can be explained by the fact that, in contrast to Istanbul, most of Houston’s cultural heritage is of a more grass roots nature. What this means is that whereas Istanbul has to contend with maintaining massive or ancient physical artifacts, the cultural heritage within Houston more closely aligns with those intangible attributes of a group or society that are inherited from past generations. This is evidenced by the fact that HoustonCulture.org lists, almost exclusively, clubs, associations, and societies on their Houston Cultural and Community Resource Directory (Houston Culture). Despite such a large difference between Istanbul and Houston, the two cities do share one key aspect when it comes to attitudes towards cultural heritage. Namely, that both cities have shown a willingness to prioritize other projects over cultural heritage preservation. In Houston’s case, the majority of funding for cultural heritage comes from private sources with the city itself only providing designing or granting land (another difference in attitude from the government ran approach of Istanbul) (Project For Public Spaces). Houston spends a majority of its resources on increasing its economic connections and urban development just like Istanbul, showing a key similarity between two such important transnational hubs.
When it comes to attitudes towards preservation, there also remains a distinct difference between the treatment of Byzantine and Ottoman heritage sites. Despite possessing just as many if not more sites from the Byzantine period, Istanbul frequently favors preservation policies that help Ottoman sites while simultaneously ignoring or only partially benefiting Byzantine sites. Dr. Semiz approached this difference in attitude and approach by explaining that while there is no legal difference or separate treatment policies for the two cultures’ heritage under the law, in reality, political figures care more about Ottoman heritage because they receive better press and favorability when they create projects benefiting Ottoman sites (something that usually isn’t replicated when projects are declared for Byzantine sites) (Semiz). In light of such analysis, the difference in treatment is easy to understand but there remains the problem that as a result of such a difference, Byzantine sites are more often ignored and fail to receive the attention and care that they require. What is fascinating is the fact that Houston shares many of the same attitudes towards cultural heritage as Istanbul. A fact which is evident by the treatment towards the Nau Center for Texas Heritage. This center was designed to showcase various aspects of Houston history but was never constructed when the organizers were unable to raise the $80 million needed (Schleifer). The Center would have featured homages to the region’s railroads, the Johnson Space Center, the discovery of oil at Spindletop, and more but failed to gain the necessary capital and has seen no serious attempt to revive it since the project stalled out last year (four months after the ground for the site was broken) (Schleifer). Interestingly, the center was unable to meet funding goals despite the fact that contributions to this sector increased by $142 million over the past decade. This is likely because despite such an increase in funds, 88% of that amount went to merely 27 organizations, even though it has already been shown that there are 8.94 cultural organizations per 100,000 residents in the Houston region (Center For Houston’s Future).
Comparative Analysis of Cultural Heritage Policies Istanbul Now that existing attitudes and views toward cultural heritage preservation have been established, it is time to evaluate the substantive policies that each city employs in regards to their cultural heritage. Ever since the adoption of the 2011 Istanbul Historic Peninsula Site Management Plan (Istanbul Historic Peninsula Site Management Plan), Istanbul has received credit for an improvement in treatment and preservation of their heritage sites. And there is no denying that things are better now than they were in the past. More attention has been paid to the care of sites and the government has taken active steps to rectify problems addressed in previous UNESCO reports. To this end, the plan has helped decrease the continued degradation of the vernacular architecture within the protected zones and the quality of repairs to and reconstruction of Roman and Byzantine walls and associated palace structures has greatly improved. The plan resolved the issue of a previously identified ab-
In light of this seeming paradox between Houston’s recent surge in the interest of cultural heritage and the inability to complete a center designed to showcase such heritage, further investigation was needed. This paper contends 81
sence of a World Heritage management plan and has helped increase coordination between national and municipal authorities and of decision-making bodies for safeguarding World Heritage at the site. As a result of such improvements, UNESCO has declared that after changes done by the Plan, a few of the sites are no longer in danger and most of the sites which are still in danger, are not quite in as much danger (UNESCO World Heritage Center). However, despite such publically lauded advances in policy, there remain critical issues that need to be addressed and in several cases, the policies of the new site management plan are actively endangering the sites.
loopholes, “KUDEB has to work harder and harder to keep things intact (Semiz).” UNESCO has repeatedly recommended to the Turkish government that KUDEB should be fully made aware of the government’s actions in regard to the conservation of the built heritage and that certain conservation activities in the hands of the government need to be turned over to KUDEB. One UNESCO mission summed it up perhaps best when they explained that “KUDEB appears too small to be effective in conserving as large a site as the Historic Peninsula (Istanbul Metropolitan Muniplaity).” In an overview of the effects of current policies toward cultural heritage, Dr. Semiz stated that “Istanbul is losing its heritage day by day and that the policies of Government haven’t really changed,” and she concluded that personally, she was not so hopeful about the future (Semiz). Unfortunately, Dr. Semiz is not alone in her assessment. An assessment of the 2011 Istanbul Historic Peninsula Site Management Plan conducted by Daniel David Shoupa and Luca Zana entitled Byzantine Planning: Site Management in Istanbul concluded that there are several severe potential risks of the uncritical application of managerial and urban planning tools when it comes to cultural heritage (Zana). And despite the problems UNESCO has said Istanbul has resolved, they still list ground transport infrastructure, housing, and management activities as factors hurting the heritage sites. In addition, although they recognized that Istanbul has created a World Heritage management plan, they have been critical of the fact that such a plan has not seen the development that they were hoping (UNESCO World Heritage Center). In short, although Istanbul established a World Heritage management plan, they have done almost nothing to update or adapt the plan in the five years since it was released.
Dr. Nisa Semiz outlined one of these new policies explicitly when she discussed how after the new site management plan the Minister of Culture has become responsible for protecting and maintaining zones (to a far greater degree than before) but at the same time, he continually allows the government to access the historical peninsula (Semiz). This access can be seen in the large public projects that were discussed previously and such actions would seem to be in direct conflict with the Minister’s tasks and responsibilities. In addition, Dr. Semiz went on to elaborate how, although several laws exist to protect the sites, they are either not enforced, or are simply unenforceable (Semiz). The most important of these laws, and a law which UNESCO itself has addressed in the aforementioned Reactive Monitoring Mission Report is law 5366 ( ICOMOS). This law is supposed to be the main law which protects the heritage sites in Istanbul, however, according to Dr. Semiz, it “creates a legislative gap which opens a door for government projects (Semiz).” This is collaborated by the UNESCO which described how there is a distinct lack of impact studies before large-scale developments, but such developments are implemented within the framework of Law 5366 regardless ( ICOMOS).
Houston Now that Istanbul’s policies have been fully developed, it is imperative to examine the policies of Houston. This needs to be done in order to outline where the policies have similarities and differences. Houston’s policies towards cultural heritage are determined by five major bodies; the Mayor and leadership team, the City Council, the Offices of Cultural Affairs and Communication and the Planning Department who cover everything from approving and adopting
Unsurprisingly, this makes things difficult for KUDEB, Istanbul’s Conservation Implementation and Control Bureau which was established for the preservation of natural and cultural assets and is tasked with maintenance, repair permissions, regional and building audits, settlement opinions, technical assistance and education, and conservation laboratory services (KUDEB). Dr. Semiz explained how, in light of such legal 82
Aside from institutional criticisms of Houston’s cultural heritage policies, there are also private citizen concerns and criticisms. This is evident by the fact that citizens participating in the community meetings frequently report that they desire greater cultural activities and programs in their neighborhoods. There is a sense that Houston is lacking in terms of available locations and activities for cultural heritage, despite the fact that over the past few decades, Houston has experienced an incredible rise in cultural heritage. Moreover, while citizens express great appreciation for the fact that Houston has major downtown institutions for cultural heritage, they rarely patronize them, citing a range of barriers. This include economic (on the grounds that they are too expensive), transportation (because they are difficult to get to), cultural (because of widespread belief that many of the programs don’t relate to them) and time (because the demands of work and family prevent attendance) (CITY OF HOUSTON). Overall, citizens in Houston not only desire more sites of cultural heritage (something that is not a concern in Istanbul [with perhaps the exception of Kurds seeking greater representation]) but they desire centers of cultural heritage which more closely align with their expectations of such sites or else they feel no need to provide the capital for such projects.
a plan, to leading the plan’s development, and to incorporating such Cultural plans into the General plan (CITY OF HOUSTON). Unlike in Istanbul, where the government manages cultural heritage almost entirely themselves, the work of the Houston cultural heritage organizations would not be possible without the aid of private consulting teams like McNulty Consulting, Black Sheep Agency, and the Cultural Planning Group composed of MJR Partners, Outreach Strategies, and Places Consulting. In addition, whereas the government is responsible (both financially and strategically) for nearly the entirety of cultural heritage programs and policies, Houston only provides 1.75% of design and construction costs for conservation on projects that are above ground (CITY OF HOUSTON). Other than that, Houston’s main strategy for providing support for cultural heritage is through major grant programs done through contracted private agencies. In other words, Houston gives grants to roughly four major agencies; the Houston Arts Alliance, the Miller Theatre Advisory Board, the Museum District Association, and the Theatre District Improvement, Inc. who in turn give out those grants to the organizations operating beneath them (CITY OF HOUSTON). This means that the Houston government has no real control over where these grants go and determination of what organizations need the grants to help with cultural heritage is almost entirely private process. Such a process is about as far from Istanbul’s as feasibly possible. Although Houston never receives attention from international agencies (or even national ones) for its cultural heritage policies, it nonetheless faces several distinct challenges and problems of its own. The first of which is that there is a wide-spread perception among small and midsized organizations that that they are consistently required to go through more legal and bureaucratic processes than major institutions who are given special treatment and different provisions. In addition, such large institutions are often seen as closed organizations, with no opportunity for smaller organizations to “move in to them” for funding participation (CITY OF HOUSTON). Such apparent favoritism of major institutions is unsurprising within the larger context of private organizations which are in charge of the Houston cultural heritage environment because larger institutions have an easier time lobbying and working with the private agencies in charge of grant distribution.
As for the cultural organizations themselves, there is a strong need for affordable performance, exhibition, rehearsal and production space and Houston leadership has admitted that addressing this issue may need to be the subject of a longterm cultural and support facilities development plan. The problem with that is that Houston is almost unique among major cities in its lack of a robust Office or Department of Cultural Affairs. Major functions have been outsourced to the Houston Arts Alliance, or in the case of grants, to other partner organizations (CITY OF HOUSTON). Without a strong cultural affairs agency, the City lacks the ability to work effectively within Houston for policy development, new program initiatives, political clout, etc. This issue is yet another example of a problem which Istanbul does not have and can’t truly relate to as a result. Upon examining the cultural heritage policies and problems that Houston and Istanbul possess, it quickly becomes apparent that the treatment of cultural heritage and the problems from those policies are very different in each city. Much of this can be attributed to the cities themselves: 83
the history and attitudes that each possess are very different. As has already been examined, Istanbul has much more preserved history, actual physical artifacts, and sites of cultural heritage. In contrast to this, most of Houston’s cultural heritage is of a more grass roots nature and aligns more closely with those intangible attributes of a group or society that are inherited from past generations. What this translates into is different policies and problems. In light of such staggering differences, what is surprising is not the fact that there are differences but that there are as many similarities as there are.
Additionally, while Houston’s policies are focused on creating sites for cultural heritage and whose problems revolve around the difficulties in doing so, Istanbul’s policies are mainly focused on preserving (or at least they appear on surface to be). In reality Istanbul policy has been largely responsible for creating many problems that they were designed to prevent. Dr. Semiz summed up this situation best by explaining that “It is not possible to continue in this way…we won’t have any of our history left” while at the same time conceding that “On the same hand, it is not possible to stop those big metropolitan projects (Semiz).”
Conclusions and Implications The research gathered on Istanbul and Houston’s general attitude towards preservation and cultural heritage in both cities and the comparative cultural heritage policies each city possesses presents several interesting conclusions and implications for future work. First and foremost, it is apparent that Istanbul and Houston share several similarities when it comes to general attitudes towards preservation and cultural heritage. Both cities have expressed a clear willingness to favor other programs and projects which increase economic connections and urban development over those involving cultural heritage. As a result, the cities have often hurt their respective fields of cultural heritage. For Istanbul, this is exemplified by the fact that the government often moves ahead with projects that put heritage sites in direct danger while in Houston, this translates to lack of capital or support to create sites of cultural heritage. Moreover, whereas Istanbul addresses cultural heritage from the standpoint of preserving the vast amount they already possess, Houston is in the process of building up sites of cultural heritage and working to increase cultural heritage rather than focus on preserving the little that already exists.
Recommendations While research detailing and outlining the attitudes towards and policies related to cultural heritage is useful for gaining a greater appreciation and understanding for cross-cultural connections, it is imperative that such research also be used to advance the fields it examined. Without doing so, such research amounts to little more than a status report and fails to advance any of the fields that it exams. In pursuit of such goals this paper will also provide brief recommendations for both cities in the hope that they can be used as blueprints for future innovation. When it comes to Istanbul, the main problems of governmental policies damaging sites of cultural heritage should have more confrontation on a grassroots level. An example of such activity can be seen in the Symposium of Land Walls. This is an organization made up of a group of college students who work to preserve the walls and their surroundings and make them part of sustainable urban development. This project is in direct response to the Marmaray Rail Tube Tunnel Station, whose construction and operation has ended up eroding the Theodosian Seawalls (Aachen university). Such a response is wholly appropriate within the context of the Turkish social and political environment. Because the organization is not a direct challenge to the Turkish government policies it does not draw the expected backlash. At the same time however, it is able to both take steps to repair and protect the Theodosian Seawalls while also drawing attention to the fact that the Seawalls are only in danger because of the programs and policies of the government. Despite the benefits that such an organization brings it is also important to recognize that they have, as of yet, failed to truly stop the continued harm to the site or been able to convince the
When it comes to examining the comparative polices that each city has in place for cultural heritage, it is easily apparent that Houston and Istanbul are about are dissimilar to each other as feasibly imaginable. Whereas Istanbul’s policies for cultural heritage are run almost exclusively through the government (which includes the funds necessary for such policies), Houston’s policies are mainly run by private institutions who not only provide the majority of funding by themselves but who also determine where governmental funding goes when there is some. 84
government to stop its project. However, by using the Symposium of Land Walls as a basis, more programs can be implemented or designed to achieve similar results that may be able to, in time, gain the widespread recognition and support to stop similar governmental projects. As far as Houston is concerned, more research and policy suggestions should be encouraged to attempt to address the problems cultural heritage in the city currently faces. This is needed because although Houston can easily identify these problems, no real solutions or answers have been introduced to the public domain at this time. In light of this, support for organizations like The Center for Houston’s Future should be encouraged. The Center is a regional think tank that works to solve the region’s toughest problems through meaningful research, innovative strategies, and engaging diverse leaders. They track and document progress on critical indicators to advance the region’s sustainability in the 21st century. The Center for Houston’s Future brings business and community together (thereby attempting to merge public and private domains) in order to innovate for the future of the Houston region in several distinct areas (Center for Houston’s Future). Their work on cultural heritage is contained in The 2014 Center for Houston’s Future Art & Cultural Heritage Community Indicator Report and it outlines several potential solutions to the problems that Houston is currently facing (Future). The validity of such suggestions has yet to be truly examined and encouraging such organizations only further increases the fact that cultural heritage policy will be largely left in the hands of private organizations but such organizations nonetheless to a better job of bringing the public and private domains together and only by generating a wealth of ideas, can appropriate policies be chosen. Works Cited
April118 2016. http://www.futurehouston.com/cfhf.cfm?m=1 Center For Houston’s Future. Houston Indicators. 2016. 18 April 2016. http://thehoustonindicators.org/arts-culture/ CITY OF HOUSTON. “Advisory Committee Meeting.” Mayor’s Office of Cultural Affairs. Houston: www.houstontx.gov, 2015. PPT. https://www.houstontx.gov/culturalaffairs/artsculturalplan/presentation20150324.pdf Future, Center for Houston’s. Art & Cultural Heritage Community Indicator Report. Think Tank. Houston: Center for Houston’s Future, 2014. PDF. http://www.futurehouston.com/ cmsFiles/Files/2014ArtsCulturalHerIndicReprtFINAL.pdf Gates, Sara. Huffington Post. 5 March 2012. 18 April 2016. http://www.huffingtonpost.com/2012/03/05/houston-most-diverse_n_1321089.html Houston Culture. n.d. 18 April 2016. http://www.houstonculture.org/listings/indexa.html HowToIstanbul.com. Istanbul Guide. n.d. Web Page. 18 April 2016. http://howtoistanbul.com/en/list/istanbul_guide/2continents-1-city http://www.citypopulation.de/Turkey-C20.html. n.d. 18 April 2016. http://www.citypopulation.de/Turkey-C20.html Istanbul Historic Peninsula Site Management Plan. October 2011. PDF. 18 April 2016. http://www.alanbaskanligi.gov.tr/ files/Management_Plan_090312_TUM.pdf Istanbul Kultur University. n.d. 18 April 2016. http://www.iku. edu.tr/ENG/4/1259/faculty-of-art-and-design.html Istanbul Metropolitan Muniplaity. KUDEB. n.d. PDF. 18 April 2016. http://www.ibb.gov.tr/sites/kudeb/Documents/icerik/ KUDEB-ABOUT_US_.pdf KUDEB. n.d. 18 April 2016. http://www.ibb.gov.tr/sites/ kudeb/Documents/index2.htm Project For Public Spaces. n.d. 18 April 2016. http://www. pps.org/reference/artfunding/ Schleifer, Theodore. Houston Chronicle. 15 March 2015. 18 April 2016. http://www.chron.com/news/houston-texas/ houston/article/Plans-for-80-million-cultural-center-in-downtown-6135856.php Semiz, Dr. Nisa. Interview. Matthew Proffitt. 29 February 2016. Http://thehoustonindicators.org/arts-culture/ Studies, European Journal of Turkish. https://ejts.revues. org/5044. n.d. 2 May 2016.
ICOMOS. Report on the joint UNESCO World Heritage Centre. May 2009. PDF. 18 April 2016. file:///C:/Users/Matthew/ Downloads/mis356-apr20091.pdf
UNESCO World Heritage Center. n.d. 18 April 2016. http:// whc.unesco.org/en/list/356
Aachen university. Cultural Heritage and Urban Development in Istanbul. 31 May 2013. 18 April 2016. http://www. rwth-aachen.de/cms/root/Die-RWTH/Aktuell/Pressemitteilungen/Mai/~dvst/Kulturerbe-und-Stadtentwicklung-in-Istan/ lidx/1/
UNESCO.org. n.d. 18 April 2016. http://whc.unesco.org/en/ soc/3298 United States Census Bureau. 2014. 18 April 2016. http:// www.census.gov/quickfacts/table/PST045215/4835000 Zana, Daniel David Shoupa & Luca. “Byzantine Planning: Site Management in Istanbul.” Conservation and Management of Archaeological Sites (2013): 169-194. PDF.
Audet, Marye. Houston Family Magazine. n.d. 18 April 2016. http://www.houstonfamilymagazine.com/2013/10/31/houstons-native-american-heritage-runs-deep/ Center for Houston’s Future. Center for Houston’s Future. n.d.
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A Comparative Analysis of Asylum Policies and Responses to Syrian Refugees in Turkey and United Kingdom By Mishi Jain Executive Summary
risen over the last few years, and as the conflict exacerbates, civilians are fleeing to seek refuge in other countries. Officially being deemed a humanitarian crisis, the Syrian refugee crisis is the largest refugee exodus in history (BBC 2016). Unbelievably high numbers of Syrians are seeking refuge in other states which are finding it difficult to provide the money, shelter, food, and resources necessary. The UN has reported that “about 70% of the population is without access to adequate drinking water,” many more are unable to acquire their basic food needs, most children are out of school, and the majority of Syrians live in poverty (World Vision 2016). The Syrian refugee crisis is dire and has been prolonged. IS has also capitalized on the situation to cultivate a ‘war within a war’ and recruit people to join their terrorist movement to establish a ‘caliphate.’ The death toll in Syria is dramatically increasing, and it is quite palpable that global efforts are needed to even attempt to resolve the situation. Rather than turning a blind eye to the crisis, states ought to sufficiently address and resolve the Syrian refugee crisis.
With the onset of the Syrian refugee crisis in 2011, this conflict has affected countries all over the world with far-reaching consequences. This paper aims to compare the asylum processes and policies of the United Kingdom and Turkey and analyze each country’s individualized response to the Syrian refugee crisis. Through qualitative interviews in Istanbul and London as well as an analysis of quantitative data through the UNHCR and other organizations, I arrived at the conclusion that the United Kingdom and Turkey might benefit from viewing their refugee crises with a broader lens. I see an advantage in the UK learning from Turkish policies and also that Turkey re-evaluates the 1951 geographical restrictions on refugees. Additionally, my research suggests that both UK and Turkey might alleviate some of the stress on their respective systems by changing the types of benefits provided to refugees. Further, this research suggests that refugees from countries besides Syria are underserved. Lastly, I believe that the decision-making with regard to refugee status could be restructured so as to alleviate some obstacles faced by refugees in dire need of assistance.
Chart 1: Distribution of Syrian Asylum Seekers and Refugees; UNHCR, BBC
Introduction With pro-democracy uprisings starting in as early as 2011, the derelict, lengthy war in Syria saw its beginnings. President Assad’s forces open fired on protestors, sparking demands for Assad’s resignation. Eventually, the conflict escalated into a civil war where Assad’s security officers fought the opposition who had gotten ahold of arms to defend themselves (BBC 2016). As if the civil war between the government and opposition was not complex enough, the introduction of the Islamic State (IS) further complicated the war. The United Nations has consistently called for an end to the use of arms and terror, murder, and conflict, however Assad’s government, the opposition, and IS are unable to cooperate effectively. As a result, the death toll in Syria has drastically
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Issue Statement
The Syrian refugee crisis clearly has far-reaching consequences that affect more than simply Syria itself. The UNHCR Syria End of Year Report 2015 conveys the gravity of the crisis, and as the situation further deteriorates, the UNHCR calls on governments across the world to take action by accepting greater numbers of refugees, providing humanitarian aid, or sending monetary funds to countries undertaking high numbers of refugees. The United Kingdom and Turkey, however, engage with the Syrian refugee crisis in radically different ways, and this is not solely the result of policy. Turkey, due to its geographical proximity, cultural similarity, and history of relationship with Syria, has needed to directly address the crisis and completely overhaul its previous asylum policies. In turn, Turkey holds a unique relationship with the Syrian refugees, especially in contrast to refugees from other places. On the other hand, the United Kingdom remains far removed from the crisis, even separated by water from the rest of Europe, which allows it to maintain relative distance from the situation. The British asylum system is quite different from that of Turkey’s, as it is structured, clear, and strict, and the UK has not altered their asylum system in response to the crisis. Turkey’s system is rather convoluted, unstructured, and lacks clear regulations. As such, the geopolitical differences between the UK and Turkey have been significant from the onset, resulting in the drastically different asylum policies, processes, and responses to the crisis.
With the onset of the Syrian refugee crisis, countries across the world have been forced to reconsider their asylum policies and assess how to best manage the massive influx of Syrian asylum seekers. Both London and Istanbul play crucial roles due to their status as successful and entrepreneurial global cities. Istanbul, the city where “East meets West,” plays a key geographic and symbolic role, and the economic success of the city makes it an attractive refuge to many asylum seekers. Similarly, London’s role as a financial center and global city brimming with opportunities is a safe haven for asylum seekers, despite its geographical distance from Syria and other conflict zones. London and Istanbul, as key global cities, provide employment opportunities to refugees and create local networks to assist them. Both provide benefits granted to refugees by the federal government through housing, education, and social services and serve as attractive locations for refugees who wish to integrate into each society. This paper finds two radically different engagements with how the United Kingdom and Turkey address the influx Syrian refugees, and I will document the problems and prospects of each government’s policies. While these differences are based on more than solely policy, as aforementioned, I will aim to compare the asylum pro-
Chart 2: Numbers of Syrians in Need of Assistance; UNHCR Syria End of Year Report 2015
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Definitions: Asylum Seeker vs. Refugee According to the United Nations High Commissioner for Refugees, the agreed upon definition for an asylum seeker is someone who is claiming asylum and has submitted an application, awaiting a decision. A refugee, on the other hand, has had their asylum application accepted and has been granted permission to seek protection in the country the application was submitted in. The key difference is that asylum seekers are awaiting a decision while refugees have been granted asylum.
cesses and policies of the United Kingdom and Turkey, specifically focusing on these countries’ responses to the refugee crisis. First, I will describe the international legal regulations that frame my discussion of refugees and asylum seekers. Then, I will give a brief history of the asylum processes of the United Kingdom and Turkey and proceed to describe their processes in present day. After discussing how the UK and Turkey have responded to the Syrian Refugee Crisis, I recommend that the United Kingdom and Turkey might benefit from viewing the refugee crisis with a broader lens and that Turkey re-evaluate the 1951 geographical restrictions on refugees. Additionally, I recommend both UK and Turkey to consider expanding benefits for refugees to alleviate some stress on their respective systems and devolve some decision-making powers to local government to alleviate some obstacles faced by refugees in dire need of assistance.
International Legal Frameworks There are a set of legal frameworks that structure the way United Kingdom and Turkey engage with asylum seekers and refugees. United Kingdom has chosen to ratify all of the following legal frameworks, while Turkey has chosen to opt out of some. These frameworks set the standards and limitations within which the UK and Turkey operate in regards to asylum seekers and refugees. 1951 Geneva Convention
Research Methodology Istanbul Due to language barriers and time restrictions, my research for Istanbul is primarily conducted through qualitative methods, rather than quantitative. Through a series of interviews with professors and research assistants at universities in Istanbul, I garnered relevant information on the asylum processes and responses to the Syrian refugee crisis. I interviewed Müge Dalkıran, a research assistant at Kültür University, Dr. Ahmet İçduygu, Director of the Migration Research Center at Koç University, and Dr. İlke Yüksel, a researcher at the Migration Research Center at Koç University. Additionally, Turkey’s Law on Foreigners and International Protection dated April 2014 has been used as a source regarding the new temporary protection law for Syrian asylum seekers.
Both Turkey and the United Kingdom have ratified the 1951 Convention Relating to the Status of Refugees, which was held in Geneva. This coherent document is arguably the most important international agreement regarding refugees and attempts to consolidate all previous international agreements. According to Article 1, a refugee is a person who “owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion, is outside the country of his nationality, and is unable to or, owing to such fear, is unwilling to avail himself of the protection of that country” (UNHCR). As per the Convention, Turkey and the UK are required to abide by minimum human rights standards and provide the right to work, access to housing, education, public relief, and freedom of religion and movement for refugees.
Methodology London Due to a wealth of resources available online regarding London’s asylum processes, my research in London is both qualitative and quantitative. I conducted an interview of Ms. Alanna Thomas who is a senior researcher at Migration Watch UK, a London based think tank focused on analyzing migration issues. Additionally, I utilized United Nations High Commissioner for Refugees UK (UNHCR UK) for quantitative data on Syrian refugees in the UK as well as data from the Migration Observatory at Oxford University.
1967 Protocol to the Convention Relating to the Status of Refugees The 1951 Convention expressly limited granting refugee status to people who were fleeing conflict in Europe before January 1, 1951 (UNHCR). The United Kingdom ratified the 1967 Protocol which removed the geographical and time restrictions that the 1951 Convention placed. As a result, the UK can accept refugees regardless of time and their geographical area. Turkey, 89
however, “expressly maintained its declaration of geographical limitation upon acceding to the 1967 Protocol” (UNHCR). Turkey did not ratify the 1967 Protocol so asylum seekers outside of Europe and after January 1, 1951 are ineligible to apply for legal refugee status there.
tion on asylum in 1942 which expressly declared its commitment to national security over human rights (Kirişci 7). Turkey was one of the original drafters of the 1951 Geneva Convention and ratified the Convention on March 30, 1962. They agreed to the international legal framework set up by the Convention to protect people facing severe conflict and human rights violations. However, one key difference between Turkey and the United Kingdom is that Turkey chose to opt out of the 1967 Protocol to the Convention that removed geographical restrictions. Turkey is the only country to sustain the geographical limitation of only accepting refugees that are fleeing conflict in Europe. Refugees attempting to enter Turkey from outside the Europe can only be granted temporary stay (Kirişci 1). Turkey has recently set up the General Directorate of Migration Management (GDMM) which is a recent advancement in Turkey’s asylum law, considering its geographical position. The GDMM oversees immigration law and asylum law. Prior to the establishment of the GDMM, Turkey lacked proper policies and a coherent asylum system.
Dublin III Regulation The Dublin III Regulation is a European Union (EU) law which determines a member state’s responsibility towards asylum seekers. The United Kingdom agreed as per this regulation that they can send asylum seekers back to the initial country in the EU that the asylum seeker first landed in. This ensures that asylum seekers submit applications in the country they first entered. The UK has utilized the Dublin III Regulation to prevent asylum seekers from submitting applications in multiple EU member states and sends them back to where they first arrived. History of United Kingdom’s Asylum Processes The United Kingdom’s position on asylum seekers and asylum law has not changed significantly since the 1951 Geneva Convention for a couple of reasons: 1) the UK has been shielded from crisis because of its geography. It is separated by water from the rest of Europe, so there are significantly fewer applications to the UK than the rest of the EU. 2) The UK has opted out of EU legislation on asylum, such as the temporary protection laws. The UK has to actively opt-in on the policies to be affected by them. For the aforementioned reasons, the government has not felt the need to substantially alter their asylum laws (Thomas). After signing on to the 1951 Geneva Convention on March 11, 1954, they also ratified the 1967 Protocol to the Convention that removed the geographical and time restrictions, so the UK can accept asylum seekers from anywhere at any given time. The Immigration and Asylum Act of 1999 established support for those who are denied refugee status or whose claims for asylum are ongoing. There is legislation currently being proposed in the UK government that seeks to limit the number of times one can receive benefits if they have been denied refugee status (Thomas).
Findings United Kingdom Today The United Kingdom’s asylum processes are structured and straightforward. Once an asylum seeker has stepped foot on UK territory, they are eligible to apply for asylum in the country. Asylum seekers submit their applications to the Home Office, the ministerial department of the United Kingdom (UK) that oversees matters related to immigration, police, security, and more. Asylum seekers can also have their application sent to the UK specifically if they have family members there (Thomas). After submitting an application to the Home Office, asylum seekers await decisions on whether they have been accepted. If accepted, asylum seekers are granted refugee status, as per the Geneva Convention, and given permission to remain in the UK for four years (Thomas). The term “leave to remain” is used in describing this permission. After four years, refugees can apply for permanent status in the UK. Refugees can be granted “indefinite leave to remain,” which allows them to permanently settle in the United Kingdom without a time restriction. On the other hand, refugees can be granted “exceptional leave to remain,” which allows refugees to stay
History of Turkey’s Asylum Processes Turkey is no stranger to mass influxes of refugees and has experienced them for many years now. From the Albanians to the Kurds in 1920s and 1990s respectively, Turkey has had ambivalent responses to refugees. It adopted its first legisla90
necessities such as food, clothing, and toiletries (House of Commons Library). Mothers and young children are given a few extra pounds as well, and mothers can apply for maternity payment. All refugees have access to the free National Health Service (NHS) healthcare with free prescriptions of medicine, dental care, and eye care (House of Commons Library). Finally, children between the ages of 5-17 are required to attend school free of charge. If an asylum seeker is refused refugee status, they are still given ÂŁ35.39 per week for necessities. Asylum seekers whose claims are ongoing are eligible for some financial support under Section 95 of the Immigration and Asylum Act 1999. Although they are excluded from working and NHS in most cases, they have access to some housing and living expenses (ASA Project).
in the UK, however, they are required to return if the situation in their home country improves. Finally, asylum seekers can be refused refugee status in the UK, and if so, they hold the right to appeal the rejection decision within specific time limits. If an asylum seeker appeals their rejection, a judge oversees the case and determines whether to allow the appeal, dismiss the appeal, or remit the appeal, which is requesting the Home Office to reassess their decision (House of Commons Library). Decisions made by the judge on an appeal case are final and cannot be re-appealed. This asylum process affects the UK population in a variety of ways. First, if they are granted refugee status, they add to the legal and permanent resident population. While asylum seekers are awaiting decisions, they add to the temporary resident population. If they are denied refugee status and choose to remain in the UK, they add to the illegal population, as they have not departed the country.
As evident through Chart 3, asylum applications in the UK have fluctuated for quite some time, which can be attributed to the presence or lack thereof largescale conflicts worldwide. While applications increased from 1987 to 2002, UK experienced a decline in 2014 (Migration Observatory). The Migration Observatory at Oxford University states that although in 2014 the UK was the sixth highest recipient of asylum claims in the European Union, they initially refused 59% of asylum applications in 2014. Thus, being granted refugee status in the UK can be particularly difficult, as the system is quite structured and restrictive.
Benefits If an asylum seeker in the United Kingdom has been granted refugee status, they are given benefits that many UK permanent residents also have access to (Thomas). First, they are given cash support of ÂŁ36.95 per person in a household that they can collect from the post office every week. This cash support aims to provide for basic
Chart 3: Numbers of Asylum Applications in the UK; Migration Observatory
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Response to Syrian Refugee Crisis The United Kingdom’s initial response to the Syrian refugee crisis consisted of providing humanitarian aid to the surrounding countries of Syria in order to provide relief to those in conflict zones. As such, the beginning of the crisis saw UK’s response only in regards to monetary aid. However, in early 2014, the UK Government created a ‘Syrian Vulnerable Person Resettlement (VPR) Programme’ to establish routes for Syrian refugees to seek asylum in the UK (House of Commons Library 2016). With the increased severity of the Syrian refugee crisis and the especially high rate of asylum seekers from Syria attempting to escape conflict, the United Kingdom announced plans to expand the Syrian VPR Programme, declaring that they will accept 20,000 Syrian refugees over five years. UK will directly accept these refugees from conflict-zones in Syria but not if they are coming from elsewhere in Europe.
Government’s approach to the Syrian refugee crisis remains one that is primarily focused on providing humanitarian aid rather than physically taking in substantial numbers of refugees. Turkey Today Turkey’s asylum processes are rather convoluted in comparison to the United Kingdom’s. Despite Turkey initially being primarily a site of emigration, it has now become a place where people fleeing persecution seek refuge. First, the geographical limitation from the 1951 Convention remains, so only European asylum seekers can submit applications. That being said, non-European asylum seekers can apply for temporary status, which gives them conditional refugee status, humanitarian residence permits, or temporary protection (Refugee Solidarity Network). Non-European asylum seekers, such as Iraqis, Iranians, Afghans, and Somalians can then temporarily stay in Turkey but must eventually pursue permanent residence elsewhere.
The UK Government also announced that they will work cooperatively with UNHCR to assist unaccompanied children in conflict zones, and official reports state that 5,580 Syrian refugees were granted refugee status from 2012 to 2015. 1,337 Syrian refugees were settled by the end of 2015 directly through the VPR Programme (House of Commons Library). The number of Syrian asylum applicants to the UK has increased from previous years. Applicants from Syria represent 8.4% of the total applicants to the UK (Migration Observatory). The UK has committed £2.3 billion to assist refugees in Syria, “making it the second largest bilateral donor to the Syrian refugee crisis” (House of Commons Library). As evident, the UK
Turkey’s new Directorate General for Migration Management (DGMM) passed the Law on Foreigners and International Protection, which took effect in April 2014. This law completely overturned previous asylum and immigration policies and established new standards. In regards to the general process, asylum seekers must submit an application with law enforcement units in Turkey, and the application gets reported to the governorates who carry out various actions (Law on Foreigners and International Protection 68). After submitting an application, asylum seekers are granted a registration document which
Chart 4: UK Government’s total monetary aid to refugee crisis; UK Government
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Response to Syrian Refugee Crisis Syrians fleeing conflict arrived in Turkey and applied for residence and work permits starting in 2011, however the numbers were not very high then (Yüksel). Syrians cannot apply for asylum in Turkey because of the 1951 Convention’s geographical restrictions, and as such, they are technically not considered “refugees.” As aforementioned, the Directorate General for Migration Management announced a new Foreigners and International Protection Law in 2014 which indicated Turkey’s improved stance on asylum seekers and immigrants (Kirişci 37). This comprehensive document is Turkey’s first domestic law on asylum and is largely a response to the Syrian refugee crisis (Kilberg 2014). Although the law covers a plethora of areas, a major focus of the law is on temporary protection particular to Syrians. The law specifically does not use the word “Syrians,” but in practice, temporary protection has been granted overwhelmingly to Syrian refugees (Yüksel). According to the law, “temporary protection may be provided for foreigners who have been forced to leave their country, cannot return to the country that they have left, and have arrived at or crossed the borders of Turkey in a mass influx situation seeking immediate and temporary protection” (Law on Foreigners and International Protection 93).
details their identity information and indicates their protection. This document allows applicants awaiting decisions to remain in Turkey for the time being. Applicants may be required to stay in specific accommodations as they await decisions. In considering applications, the DGMM conducts interviews of the applicants to offer them an opportunity to discuss their situation. Decisions are made no later than six months after the submission of the application and are individually considered (Law on Foreigners and International Protection 80). If an asylum seeker is denied refugee status, they can appeal their decision within ten days through administrative review or judicial appeal. Benefits Asylum seekers who are granted refugee status can use a variety of services. They have access to primary and secondary education, Social Security, and universal medical insurance if they are not already covered. Applicants and conditional refugees can apply for work permits after six months and have access to the labor market (Law on Foreigners and International Protection 90). If granted work permits, they are allowed to work independently or be employed without prejudice.
Chart 5: Breakdown of Asylum Seekers in Turkey; UNHCR Turkey
Fact and Figures
Initially, Turkey reacted by establishing camps on the border of Turkey and Syria. There are approximately 24 camps that account for only 10% of the Syrians in Turkey with the total number being around 250,000 Syrians in the camps (Yüksel). Syrians are given ₺85, access to schools, and food, and there are approximately 25,000 Syrians in the largest camp currently (Dalkıran). Before the temporary protection law, Syrians migrants in Turkey were not granted access to basic rights such as education, healthcare, and more because they were not legally considered “refugees.” The lack of official legislation at the time resulted in
As the chart above indicates, the asylum applications from non-Europeans in 2015, excluding Syrians, vary quite a bit. However, the acceptance rate for refugees seems to be quite high, pinpointing Turkey’s willingness to grant refugee status. These numbers are representative of refugees fleeing persecution in countries such as Iraq, Iran, Afghanistan, and Somalia, among other countries. The number of individual asylum applications drastically increased starting in 2011 as a direct consequence of the refugee crisis. 93
the entire asylum process being in a status of disarray facing the mass influx of Syrians. There was no institution to determine one’s asylum status before so those who genuinely needed protection were being sent back (Dalkıran). Fortunately, the temporary protection law which took effect in April 2014 grants Syrian migrants access to many basic rights. This legal framework grants Syrians fleeing conflict access to free healthcare services, work permits, and education if they remain in the location they are registered in.
in the world. Despite Turkey’s noteworthy strides towards improving conditions for Syrian refugees through the temporary protection law and the creation of DGMM, Turkey faces a multitude of challenges, of which I cover a few. First, in practice, the temporary protection law is not as successful as it would seem to be on paper. According to Müge Dalkıran, who has physically worked in the camps in addition to conducting academic research on this topic, there is no unanimity in the implementation of the law. Officers across Turkey implementing the new law often do not thoroughly understand the various sections of it due to a lack of information and communication. Even more, the law still considers the Syrian refugees as “temporary,” when the reality is that it is highly unlikely they will return home anytime soon (Kirişci 1). By considering them temporary when they are clearly not, the Turkish government commits an injustice to refugees who genuinely need long term protection and stifles their holistic integration into Turkish society, perpetuating their alienation and segregation. Next, it is important to note that not all Syrians are receiving these benefits, because one must be legally ‘registered’ under the law to have access to the benefits. Many Syrians in Turkey are registered, however, there are Syrians that are being smuggled into Turkey and from there into the EU, and as they are ‘unregistered,’ they do not
Turkey has recently brokered a deal with the European Union to manage the massive influx of Syrian migrants. The EU-Turkey deal requires migrants entering Greece to be sent back to Turkey if they are illegally crossing over without applying for asylum. For every migrant returned back to Turkey, one migrant is resettled in the European Union, capped at 72,000 migrants (BBC 2016). The Turkish government will also be given $3.3 billion in order to help the government manage the migrants coming in. As a bonus for Turkey, their citizens will be granted visa-free travel in the Schengen zone and talks regarding Turkey’s EU membership will be accelerated. Challenges of the Syrian Refugee Crisis Turkey has accepted the highest number of Syrian refugees, more than any other country
Chart 6: Number of Syrian Refugees in Camps from 2011-2014; Brookings Institution
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seem to be holistic enough to truly integrate Syrian migrants into their respective societies. While the United Kingdom has been financially assisting with the refugee crisis, they can advantage by learning from Turkish policies in order to integrate refugees into British culture and society. The current British system does not include a thorough enough integration system which risks the overlooking of refugees and barriers they may face to integration.
receive any benefits (Dalkıran). There is a significant population of Syrian refugees who are not staying in camps and are unregistered; in turn, they remain invisible, rendering the Turkish government incapable of helping them. Policy Recommendations The Syrian Refugee Crisis is growing exponentially by the day, and the current policies of the United Kingdom and Turkey may no longer be adequate. As a result of my research and findings, I propose the following policy recommendations:
First, the UNHCR finds that “family separation, time spent in the asylum procedure and reception, absence of documentation, the transition phase upon recognition, language and health” are integral factors that play a significant role in determining how effectively a refugee integrates into traditional society (UNHCR 2013). While the UK provides benefits to refugees as aforementioned, the transition from being an asylum-seeker to a refugee can be incredibly difficult and is an area for substantial improvement. Delays in documentation and provision of services creates a rough transition for refugees. As such, the United Kingdom can implement policies to ensure that documentation and services are expedited for refugees.
1) Turkey may consider re-evaluating the 1951 Convention geographical restrictions Turkey’s commitment to accepting the high number of refugees they have thus far and more to come is truly commendable. However, I believe some policy changes are necessary for the government to implement if they truly want to ameliorate the current situation. First and foremost, it will be beneficial to Turkey to recognize that the majority of Syrian migrants in Turkey are going to be there for the long haul, as they attempt to integrate into the community (Kirişci 21). Under the current Law on Foreigners and International Protection, non-European asylum seekers, particularly Syrians, can only be considered for “temporary protection,” which inhibits them from the prospects of long-term legal protection and full access to services. The UNHCR Turkey cannot officially register Syrians in Turkey as refugees, since they technically do not possess such status. Such a temporary protection policy is highly detrimental to both the Turks and Syrians, as it inhibits progress, reform, and integration. As such, Turkey should re-evaluate its position and consider ratifying the 1967 Protocol to the 1951 Convention to lift the geographical restriction of only accepting asylum seekers from Europe. Such a policy change would allow Syrian migrants to be granted legal “refugee status” and be given leave to remain to permanently settle in Turkey. Thus, Turkey should re-evaluate the 1951 geographical restrictions and revisit its Law on Foreigners and International Protection to make the necessary policy changes.
Even more, refugees cite employment access as being a major barrier to integration (UNHCR 2013). Although the United Kingdom provides working rights to refugees upon being granted legal status, “loss of identity documentation and qualification certificates, non-acceptance of qualifications or educational attainment, trauma and uncertainty, anxiety over family separation, the long period of inactivity in the asylum system, and limited social networks” all play a role in making access to employment opportunities difficult. Overall, the United Kingdom can cultivate a more thorough integration system that allows and encourages refugees to integrate into British society more than they are now. Through in-depth integration policies that create employment opportunities, offer language and vocational training, and cultivate access to housing, the UK can facilitate the transition from asylum-seeker status to refugee status. A seamless transition allows for refugees to easily integrate into the community and identify with “British” culture. In turn, a more welcoming political environment is cultivated which could poten-
2) UK might benefit from adopting broader integration policies and assimilation system Although it is commendable and necessary that the United Kingdom provides healthcare, education, and working rights, these benefits do not 95
tially allow the UK to accept more refugees in the near future.
Gower, Melanie, Hannah Cromarty, and Ben Politowski. "Syrian Refugees and the UK." Research Briefings - Parliament UK. House of Commons Library, 11 Mar. 2016. Web. 22 Mar. 2016.
3) Turkey may benefit from balancing the needs of both Syrians and Turks As noticeable, Turkey’s response to the Syrian refugee crisis has set a high standard for what a humanitarian response should truly look like. Their actions are highly commendable and have allowed for a plethora of Syrians to seek refuge in their country. However, due to the increased influx of Syrian refugees in need of assistance, many Turkish people need have been increasingly neglected.
Hawkins, Oliver. "Asylum Statistics." Research Briefings - Parliament UK. House of Commons Library, 4 Mar. 2016. Web. 1 Apr. 2016. İçduygu, Ahmet. 2016. “Overview of Turkey’s Asylum Policies.” Formal Oral In-Person Interview. Kilberg, Rebecca. "Turkey's Evolving Migration Identity." Migration Policy Institute, 24 July 2014. Web. 15 Apr. 2016. Kirişci, Kemal. Syrian Refugees and Turkey's Challenges: Going Beyond Hospitality (2014): Brookings Institution. 14 May 2014. Web. 15 Mar. 2016.
Turkey is beginning to feel the strain of assisting the incredibly high number of refugees it has been which is most evident on the poorer Turkish residents. Due to resources being pooled to assist the Syrians, Turkish residents have been receiving fewer services. I recommend that Turkey ensure that they are aptly dividing their budget to ensure that the services that exist for Turkish residents do not get cut. Though this may require other European Union countries to financially assist Turkey to a greater extent, it is incredibly important to budget accordingly and ensure that the existing resident population is not forgotten. Additionally, Turkey should enlist greater help from international organizations to help with Syrian refugees. Through their help Turkey could ensure that services and benefits for poorer Turkish residents are not forsaken in lieu of helping Syrian refugees.
"Migrant Crisis: EU-Turkey Deal Comes into Effect." BBC News. 20 Mar. 2016. 18 Apr. 2016. "Protecting and Supporting the Displaced in Syria." UNHCR Syria: End of the Year Report 2015. United Nations High Commissioner for Refugees, Web. 15 Mar. 2016. "Refugees and Asylum in Turkey." Refugee Solidarity Network. Web. 12 Apr. 2016. Republic of Turkey. Ministry of Interior. Directorate General of Migration Management. Law on Foreigners and International Protection. Republic of Turkey Ministry of Interior, Apr. 2014. Web. 2 Mar. 2016. "Section 95 Support." Family Advocate 18.2, Family Law Clauses: The Custody Case (1995): 18-20. Asylum Support Appeals Project, Sept. 2011. Web. 15 Apr. 2016. "States Parties to the 1951 Convention and Its 1967 Protocol." United Nations High Commissioner for Refugees, Apr. 2015. Web. 8 Apr. 2016. "Syria Refugee Crisis FAQ: How the War Is Affecting Children." World Vision, 11 Apr. 2016. Web. 20 Apr. 2016.
Works Cited
"A New Beginning: Refugee Integration in Europe." UNHCR News. Sept. 2013. Web. 23 July 2016.
"Syria Regional Refugee Response." Data.UNHCR. United Nations High Commissioner for Refugees, Web. 2 Apr. 2016.
Ackerman, Xanthe. "Education for Syrian Refugees in Turkey – Beyond Camps." The Brookings Institution, 17 Jan. 2014. Web. 10 Mar. 2016.
"Syria: The Story of the Conflict." BBC News. BBC, 11 Mar. 2016. Web. 20 Mar. 2016.
"Appeal an Asylum Support Decision." Gov.UK. 13 Mar. 2015. Web. 10 Apr. 2016.
"Temporary Protection Regime." Asylum Information Database. Refugee Rights Turkey, Web. 14 Apr. 2016.
"Asylum Support." GOV.UK. 8 Jan. 2016. Web. 20 Mar. 2016.
"The 1951 Convention Relating to the Status of Refugees and Its 1967 Protocol." United Nations High Commissioner for Refugees, Sept. 2011. Web.
Blinder, Scott. "Migration to the UK: Asylum." Teaching History No. 93.History & ICT (1998): 4-5. Migration Observatory. Oxford University, 8 Aug. 2015. Web. 15 Mar. 2016.
Thomas, Alanna. 2016. “Overview of United Kingdom’s Asylum Policies and Processes.” Formal Oral Interview.
Dalkıran, Müge. “Overview of Syrian Refugees’ Experiences Inside and Outside Camps in Turkey.” Formal Oral In-Person Interview. Garza, Frida. "Germany Is Taking in More Refugees in 2015 than the US Has in the past 10 Years." Quartz. 07 Dec. 2015. Web. 25 Mar. 2016.
Yüksel, İlke. 2016. “Overview of Turkey’s Response to the Syrian Refugee Crisis.” Formal Oral In-Person Interview.
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