Managing Uncertain Times in Turkey: Refugee Healthcare Research during a Global Pandemic

When I entered graduate school in September 2016, Turkey was mired in a series of successive crises. I had spent the first half of the year living in Istanbul, writing about the country's reception of Syrian refugees as a journalist and researcher. During that stretch, a series of suicide bombings and, in my last week in the country, an attempted coup, were formative for the way I made sense of future fieldwork in Turkey. I surmised that it would be wrought with unpredictability. My research interest in Syrian refugees’ access to Turkey's state services was itself marked by uncertainty. This uncertainty was tied to the nature of Syrians’ explicitly temporary legal status within Turkey and the broader domestic and geopolitical context that shaped the contours of Turkey's refugee policy. Given these layers of unpredictability both endogenous and exogenous to my research interest, I planned to design my research with uncertainty as an analytical focus.

Regulation of 2014, which grants status holders access to state services, including healthcare and education.Yet, in other ways, the temporariness of their status looms as an unstable anchor in a turbulent social landscape.Migration scholarship has conceptualized how temporary statuses produce an experience of suspension between inclusion and exclusion, or "liminal legality," for status holders.1 Turkey's "ambiguous architecture of precarity" for Syrians, as Ilhan, Baban, and Rygiel call it, has facilitated Syrians' partial incorporation into Turkish society while at the same time allowing politicians to plausibly brandish the threat of mass deportation back to Syria.2Within this policy context, my research examines how Syrians access healthcare services.I pay particular attention to the remarkably persistent terrain of informal Syrian refugee-run healthcare clinics that emerged to serve the refugee population.
I knew when I began my graduate research that I would have to account for domestic volatility, first and foremost, as a central empirical reality for my interlocutors.My first foray into the field was in 2017, when I began to get a lay of the land as to how Syrian refugees navigated formal and informal healthcare providers.By 2018, noticeable shifts were already occurring in the field: Syrian-run refugee health clinics once accepted by state officials as important institutions in refugee healthcare were being threatened with closure, creating collective unease among clinic managers and doctors.By 2019, many had closed or been shuttered, as antirefugee sentiment coincided with increasingly punitive enforcement in the lead-up to Istanbul's municipal election.
I designed my dissertation project to incorporate data I had previously collected during master's research and predissertation field visits, as well as whatever I would be able to collect in the long shadow of COVID-19.The longitudinal design would account for numerous political changes: shifts in refugee policy, elections, and organizational changes in refugee service provision.The project would ask: How does a temporary protection policy affect healthcare provision and access for refugees over time?Given that temporary status policy was dependent on shifting geopolitical calculations and domestic political whims, and that volatility was a feature of politics in Turkey, my research would focus on the effects of these uncertainties on refugee healthcare.

Medium: Negotiating Trust
Like most qualitative researchers, I was accustomed to adapting my fieldwork strategies with successive visits to the field in the years before the pandemic hit.These adaptations were primarily geared toward maintaining interlocutors' trust while expanding the types of data I could collect in an increasingly restrictive political environment.When I first began my research, one of my preferred methods for meeting Syrians in healthcare settings was to go çat kapı, or straight to a refugee-run clinic and knock on the door.There, I would introduce myself in person at the front desk and ask to speak with available managers about my project.Given that I did my research with informal healthcare providers, phone calls were less reliable than in-person visits.Yet by 2018, I had already shifted to primarily maintaining contact with clinic administrators with whom I had made prior contact.Local officials had started increasing their enforcement visits to threaten clinic closure, and I had no interest in adding to existing stresses as an unknown visitor to unsuspecting clinics.
In late 2018, the province of Istanbul stopped registering Syrian refugees for temporary protection, except under special circumstances. 3The governor of Istanbul then issued a memorandum in 2019 demanding that individuals living in Istanbul but registered in different provinces return to their provinces of registration. 4According to the governor's office, over half of the 500,000 registered Syrians in Istanbul at the time were registered in different provinces, which made them liable to deportation to their provinces of registration after 31 October 2019.During 2019 there was surging alarm among Syrian refugees, exacerbated by the lead-up to a contentious municipal election in Istanbul in which Syrians became a convenient scapegoat for political resentments.During my fall visit to Istanbul that year, I decided to focus my fieldwork on international and Turkish NGOs assisting refugees.I followed developments in the Syrian-run organizations primarily on social media and through informal updates from contacts, opting to scale back interviews during that precarious period.
When the pandemic hit following this period of heightened antirefugee sentiment, I had to negotiate shifting dynamics without the benefit of the in-person interaction in NGO and clinic settings I had planned to help build trust.I was able to travel to Turkey in October 2020 but remained firmly planted in my sublet as I tried to reenter the field digitally.I ended up adapting distinct recruitment strategies and interview mediums based on the types of precarity my interlocutors experienced.For interviews with Syrian refugees about healthcare access, the main axis of precarity was potential legal status irregularity.For interviews with Syrian refugee doctors about their work caring for refugees, the more salient source of instability was their employment status.
For the former group, I relied on network ties I had established in previous field visits and snowball sampling.Network-based recruitment included friends of friends, neighborhood shopkeepers who had relationships with their regular customers, Syrians attending Turkish courses together, and neighborly ties in heavily Syrian neighborhoods.I hoped to speak with Syrians with a range of legal status registrations and surmised that only trustbased snowballing would lead to interviews with individuals with an irregular status.I conducted interviews over Zoom, Whatsapp video, or Whatsapp voice, depending on the interlocutor's preference.This medium led to surprising geographic reach, with respondents ranging from Beylikduzu in the outskirts of the European side of Istanbul to Sultanbeyli in the periurban regions of the Asian side.
My strategy for recruiting Syrian doctors was more targeted.In contrast to snowball sampling within a dense population, snowballing among Syrian doctors would often hit dead ends.Although this was in part due to the relative lack of density of Syrian doctors, it became clear that it also was because some doctors did not necessarily want their colleagues to know they were doing interviews about their informal work.Although individual doctors may decide they are comfortable speaking with a researcher, they may not want to be seen as inviting a stranger into a precarious world.Instead, I had surprising success securing interviews with doctors whom I "cold Whatsapp messaged."Doctors' phone numbers were, for a long time, available publicly on Syrian health clinics' Facebook pages, which I had made sure to log.Many doctors were willing to speak to me after we exchanged information about the study and pleasantries.In numerous cases, the virtual medium worked to an unexpected advantage-anonymity of place for doctors.In some cases, we did our interviews via phone call, with no video, and I told doctors that they should not feel pressured to share with me the names or locations of the clinics in which they worked.Doctors often opened up about both the nature of the informal work they carried out day to day in Turkey as well as the grueling work they conducted in opposition territory field hospitals during the war within Syria.Perhaps counterintuitively, the lack of direct visual contact and locational information coincided with some of the most revelatory interviews that I have conducted throughout years of fieldwork.
COVID-19 forced researchers not only to consider how to transition to virtual research, but also how virtual mediums might differ in their effectiveness for building trust among distinct groups of potential interviewees.In my case, differences were borne out of the vagaries of particular domestic policies in Turkey that shaped migrants' experiences, rather than the pandemic itself.My assessment was that, in the midst of increasingly draconian legal status enforcement, snowballing from trusted sources and video chatting would be optimal for reaching precarious populations.However, for doctors, I found that in some cases the opposite was true.For some, their informal work was easier to talk about if they were atomized, and even visually or geographically anonymous.These research adaptations, in some ways, went against my assumed legal status-based vulnerabilities.Whereas Syrians with a variety of legal status configurations were open to video chats when reached through friends, Syrian doctors, many of whom were now either Turkish citizens or en route to citizenship, were more cautious precisely because they did not want to compromise their standing in Turkish society.

Sequence: Navigating Institutions
Related to research decisions about medium came research decisions about sequence.That is, what can a researcher do during times of physical dislocation from the field, and what aspects of research must wait until-and indeed, if-research can resume in person at a later date?These questions were not just a matter of COVID-19 delaying field site access.Rather, considerations of research sequence loomed largest for me in contexts in which I had to interface with institutions-both as brick-and-mortar spaces to navigate during a pandemic and as centers of state power or, in contrast, potential threats to state power.Given that COVID-19 altered institutional operations in distinct ways, I too adapted my strategies to approaching, leveraging, and stalling institutional interactions.
When I first arrived in the field, I had an institutional affiliation with the Boğaziçi University Social Policy Forum.Within a few months, the rector of Boğaziçi University had been replaced by a government appointee, and the university became a site of resistance to government overreach into educational institutions.At this juncture, an affiliation that I had imagined might facilitate access to government institutions and personnel became a possible liability.I had already been unsure whether the Ministry of Health would grant me any research access to government-run migrant health centers (MHCs) during a pandemic, but had planned to submit an application.The Boğaziçi events changed my calculus.I saved any interviews with Ministry of Health employees for later in my research, when my institutional affiliation would shift to Koç University, a private university with a less politically and symbolically charged relationship with the ruling party.
After my new affiliation began, I started the process of applying to the Ministry of Health for permissions to interview Syrian doctors working in MHCs.I had to consider multiple forms of research uncertainty.First, when would the Ministry of Health resume accepting research proposals for in-person research in government-run health clinics?Second, even if it were accepting projects for in-person research, would the bureaucrats consider accepting a US-based researcher's project?And how might a local university affiliation help or hurt this application?I submitted a Turkey-based IRB approval and research proposal to the Istanbul Provincial Health Directorate in the latter half of my research period, specifically for permission to conduct research with government employees in government MHCs.I eventually received a rejection phone call.The reason given by the official was that, in the aftermath of COVID-19, only a very small number of studies run by Turkish universities were being granted permissions to conduct in-person research.She suggested instead that I conduct my interviews with Syrian doctors employed in the private sector, of which, she assured me, there were many.
It is possible, perhaps even likely, that I would have been dealt a rejection in nonpandemic times as well.As Seda Saluk's contribution to this roundtable discusses, it is becoming increasingly common for Turkey's provincial health directorates to reject research projects by ethnographers if there is any conceivable political valence to the project. 5I was, in contrast, able to eventually visit private, informal, and semiformal clinics in which Syrian doctors worked (a research activity I had already done extensively before the Ministry of Health official suggested I might pursue that path).After vaccinations and the gradual reintroduction of everyday rhythms and activities, I started interviewing doctors in person again, often at the clinics where they worked.This gave me a hint of an ethnographic component that the pandemic had stripped from my dissertation project at its outset.I had visited some of these clinics in previous years.This allowed me to see how clinics over time had changed their design, their technology, their signage, and their services.
In the wake of COVID-19, managing the sequence of my encounters with different institutions-universities as well as government offices-did not ultimately serve my specific interest of getting permission to do research within migrant health centers.The research process itself, however, mirrored some of the phenomena I was researching.The difficulties of navigating the research permission processes of a state institution led me to focus more centrally on the realm of private and informal healthcare providers.The shift mirrored how many of the Syrians I interviewed attempted to use government health centers, became frustrated, and then turned to private or informal providers for their care.This trend was exacerbated during COVID-19.When government clinics limited their operations, some refugee patients turned instead to private clinics.This observation indicated to me how uncertainties in research access reflect features of the field more broadly.When government institutions are difficult to penetrate, whether for public health reasons or political reasons, private and informal institutions become increasingly embedded in the social fabric.

Content: Conceptualizing Key Junctures
Despite my efforts to build uncertainty into my project as an analytical focus, the impact of a pandemic on an already politically unstable context made conceptualizing key turning points in refugee healthcare more complicated.Suddenly, the key junctures in healthcare provision and access I had intended to focus on-the advent of European Union-funded MHCs and the increased policing of both refugee-run clinics and individuals' legal registrations-appeared to pale in comparison to a global health crisis.Health clinics were shuttered, except for emergencies, and neither the doctors nor patients with whom I had planned to conduct interviews were entering healthcare facilities.It seemed that COVID-19 would be an overriding key juncture in healthcare provision and access for refugees.
Yet when I finally began my virtual interviews in late 2020, it became clear as my interlocutors discussed navigating healthcare institutions that the pandemic did not loom particularly large.COVID-19 was far more salient in other ways, chiefly with regard to maintaining gainful employment and steady household income.Although healthcare access was certainly a challenge during this period, there did not seem to be concerns among the Syrian population that differed markedly from the Turkish population, or from other immigrants and refugees living in Turkey more broadly. 6As researcher I had overprojected disruption onto my interlocutors, given my own experience of research disruption.
The evolution of the pandemic's severity, and the gradual rollout of the vaccines, also affected the content of my interviews.The single most discussed healthcare topic in the 5 See also anthropologists Nilay Hatice Erten and Marcia Inhorn's work recounting the increasingly difficult terrain of obtaining ethnographic research permissions in healthcare settings in Middle Eastern countries; Nilay Hatice Erten and Marcia C. Inhorn, "Medical Anthropology in an Era of Authoritarianism," American Anthropologist 122, no. 2 (2020): 381-93.
6 COVID-19 was a hugely destabilizing socioeconomic force for refugees in Turkey, causing difficulties with access to basic needs such as food and masks, as well as crowded and poorly ventilated living conditions, making refugees particularly vulnerable.But counter to prepandemic times, unregistered refugees were legally allowed to seek COVID-19 care without threat of deportation, as a public health measure.
International Journal of Middle East Studies world was, for months, vaccination.As a result, our conversations would often dwell on whether, when, and why Syrians would either take or avoid the vaccine.Although in the end these discussions were a small facet of the fieldwork, they felt omnipresent and central to my work for months, altering the cadence of interviews over time.This is not to say that the pandemic did not affect my interlocutors-it did, with implications for my research.For example, COVID-19 affected Syrian doctors' work trajectories.During the pandemic, private clinics opened more swiftly for regular business, sometimes quietly to avoid sanction.Doctors resumed their informal work to replenish income lost during the mass pandemic lockdowns.Patients who would typically go to free state healthcare providers opted for fee-for-service care because it was the only available option for nonemergency services.Additionally, many of the doctors who had been on the path to gaining their equivalencies hit a wall in the process, as medical programs were closed and rotations halted during the pandemic.In these contexts, doctors continued to work informally in private clinics for longer than they had anticipated.
Ultimately, the pandemic uncertainty was a misleading critical juncture in the conceptualization of shocks to healthcare access for refugees.The pandemic did affect trends I was examining in my project, although primarily as an accelerator of existing trends-exposing durable through lines in refugee healthcare rather than disrupting them.As Erol Köymen argues in this roundtable, disruption can be diagnostic of order.The disruption to the healthcare system exposed the enduring order of private and informal forms of organization among Syrian doctors.

Conclusion
For ethnographic research, COVID-19 was a far-reaching disruption.Yet in a research project already attempting to tease out how temporal and policy uncertainty shaped healthcare, the coronavirus pandemic was both disruption and data.The methodological adjustments I had to make in the face of COVID-19's exogenous shock-adjustments to research medium, activity sequence, and empirical focus-were inflected by the layers of uncertainty that were already features of Turkey's political and social landscape.My virtual recruitment and interview mediums diverged between refugees who might have legal status irregularities and those who worked in legally ambiguous contexts, revealing intersecting but distinct axes of uncertainty among Syrian refugees.I approached my research tasks in an intentional sequence not only to wait out pandemic restrictions, but also to navigate capricious relationships between universities, state ministries, and myself, a Turkish-American researcher based in the United States.Finally, the COVID-19 disruption changed what types of data I collected.Rather than highlighting disruption, interviews revealed social and organizational continuities accelerated by COVID-19's unexpected shock.All of these adjustments mirrored a central theme of my research: that in the face of onerous institutional encounters, informal, trust-based networks provide essential services to individuals whose lives are marked by uncertainty.