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When the Poor Need Health Care:Ethnography of State and Citizenship inTurkeyÇağri YoltarPublished online: 10 Sep 2009.

To cite this article: Çağri Yoltar (2009) When the Poor Need Health Care: Ethnography of State andCitizenship in Turkey, Middle Eastern Studies, 45:5, 769-782, DOI: 10.1080/00263200903135562

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When the Poor Need Health Care:Ethnography of State and Citizenship inTurkey

CA �GRI YOLTAR

For many in Turkey access to health care is an overwhelming challenge. Problems thatpatients of insufficientmeans encounter in the health care systemhave become a subjectof heated public debate over the last decade. In the news media stories abounded ofpeople who were denied treatment or ‘‘held captive’’ by hospitals, because they did nothave any public health care coverage and were unable to pay the hospital bills. Publicoutrage at these stories and a perception that the health care system is in crisis have ledto a prolonged policy debate on the issue and given rise to various reform proposals. InTurkey access to health care is predominantly enabled by means of a public healthinsurance system. For the vast majority of Turkish citizens state hospitals and publichealth centres are the principal source of health care services; private doctors andhospitals are hardly affordable. As such, a crisis of health care is also a crisis of the statein Turkey. By the same token, individuals’ experiences with the health care system forma critical game field for the making and unravelling of state and citizenship. As citizensin pursuit of health care encounter and interact with the health care bureaucracy, theabstraction that is ‘the state’ gains a concrete shape and form.1

This article is about the everyday construction of state and citizenship in Turkey.Drawing on ethnographic observations from the provincial city of Adıyaman insouth-eastern Turkey, I will explore the ways in which categories of state andcitizenship are substantiated at the local level over the mundane workings of aspecific social assistance mechanism, the Green Card Scheme which was designed toprovide free health care services to poor citizens.

The public health insurance system in Turkey has a quite complicated structure.Until recently, the organizing logic of the system was the employment status of thebeneficiaries. There were separate public funds administered for private sectoremployees, for the self-employed, and for retired government employees and theirdependants.2 In other words the system was in essence exclusively catering for thepopulation employed in the formal job market. This meant that a significant portionof the population, who were either unemployed or involved in the country’ssubstantial informal economy, were left to their own private means to pay for healthcare services.3 Among this group, those who did not have sufficient financial meanswere at risk of being entirely excluded from the health care system. Against thisbackdrop the Green Card Scheme was introduced in 1992 to cover low-income

Middle Eastern Studies,Vol. 45, No. 5, 769–782, September 2009

ISSN 0026-3206 Print/1743-7881 Online/09/050769-14 ª 2009 Taylor & Francis

DOI: 10.1080/00263200903135562

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citizens falling outside the health care coverage provided under the employment-based public health insurance.4 Conceived as a populist social policy instrumentduring the run-up to the 1991 elections, it was meant to be a social assistancemechanism for ‘citizens with insufficient financial means’.5 Today around 9 millionpeople in Turkey get access to health care services under the Green Card Scheme;6

this amounts to as much as 12 per cent of Turkey’s population.By definition the purpose of the Green Card Scheme is to provide free health care

services to those who are considered below the poverty level. In order to obtain aGreen Card, potential beneficiaries are required to prove their need, that is, theirstate of poverty as defined by the laws and the local governing practices of the GreenCard bureaucracy. They are required to interact with the state, make demands, andhave their poverty certified according to a bureaucratic procedure. Located at theintersection of health care and social assistance policies, the Green Card Schemeappears as an important site where low-income citizens come into contact with ‘theTurkish state’ – as manifested by local state officials, bureaucracy, and politicians,and enacted in the form of discourses and practices. As such, the Green Card Schemeprovides a key terrain for the construction of state and citizenship, as well as theeveryday workings of state power and its multiple effects in Turkey.

The theoretical inspiration for this study is the state ethnography literature,7

which approaches the state not as a ‘distinct, fixed and unitary entity’8 consisting of aset of rationalities and institutions, but rather as a ‘phenomenological reality [which]is produced through discourses and practices of power, produced in local encountersat the everyday level’9 and recognizable through its multiple effects.10 Thisconception of the political invites a reconsideration of the workings of state powerthrough seemingly mundane practices such as collection of taxes, distribution ofsocial assistance or provision of health care. It also enables us ‘to examine thedispersed institutional and social networks through which rule is coordinated andconsolidated, and the roles that non-state institutions, communities and individualsplay in mundane processes of governance’.11 In other words, these everydaypractices, encounters and struggles at local level go a long way in determining whatthe state means to its people, how it is substantiated in their daily lives, where itsboundaries are drawn, and how the state shapes individuals as citizens and subjectsthrough informing their everyday experience.12

In their influential volume, Veena Das and Deborah Poole underline theimportance of studying the state at its margins in order to ‘distance ourselves fromthe entrenched image of ‘‘the state’’ as a rationalized administrative form of politicalorganization’,13 and to analyze the dispersed regulatory and disciplinary forms,which constitute what we call ‘the state’. Margins of the state are conceptualized assites ‘where nature can be imagined as wild and uncontrolled’,14 and where ‘state lawand order continually have to be re-established’.15 Das and Poole accordingly arguethat one way to understand the margins of the state is to analyze the specifictechnologies of power that states deploy in order to manage or regulate the‘marginal’ populations or individuals, who are marked as improper or suspect.

The target group of the Green Card Scheme are those who are left at the marginsof Turkey’s public health coverage mechanism, individuals with no place in theformal job market and no money to pay for doctors and medication. In this sense,the Green Card Scheme provides a terrain of interactions ‘at the margins of the

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state’, in other words a site on which the marginalized come into contact with thestate. I am interested to explore through an ethnographic examination of thisinteraction the complex and discordant power processes over which the state and itsattendant inequalities are produced.

Adıyaman is a small province in south-eastern Turkey. My first visit to the city wasin December 2004, for a project on the transformation of the health care system inTurkey. It was during this first visit that Adıyaman made its very peculiarimpression, an overwhelming sense of marginality communicated to me by thingsaround me and by people I have met. This impression became crucial in my choice ofAdıyaman as my field of research. What I saw in Adıyaman in my first encounterwas a city ‘dense with the state’. Indeed what I came to see over my later visits andexperiences with the city and its residents only served to qualify and consolidate thisfirst impression. Adıyaman is a city constituted as a margin where the centre point ofreference is unmistakably ‘the state’.

I have been to Adıyaman several times over the course of my research. In myinterviews with residents of the town, I posed them questions about the Green CardScheme, the health care system, its problems and people’s expectations from it.However I found that in Adıyaman conversations often had a way of boiling downto a discussion of the ‘failures’ of Adıyaman as a ‘provincial, deprived andunderdeveloped city’.

In these conversations, ‘Adıyaman is a blind spot (kor nokta)’ people told me.‘You don’t pass through Adıyaman’, they said, ‘unless you have a reason to be here.’Many people pointed out to me how none of the main regional intercity roads passthrough the city. People in Adıyaman talk a lot about this perception of having been‘cut off’ from the rest of the country. For them this isolation is symbolic. It is asymptom of a larger ill that defines the city’s existence, a feeling of being abandonedby ‘the state’. This feeling of abandonment is always coupled with an almost nihilistsense of hopelessness.

I have been told many stories, each of which was meant to communicate the samefeeling. People told me the story of Adıyaman’s betrayal by the Turkish state’sambitious South-eastern Anatolia Development Project, well known nationally bythe Turkish abbreviation ‘GAP’. GAP was launched in the 1980s as a hugeconstruction scheme to build a series of very large dams and irrigation undergroundto boost agriculture and contribute to the development of the region. I was told thatwhen the Ataturk dam was built – which is to date Turkey’s largest dam and knownas the pearl of GAP, the richest and best yielding agricultural lands of Adıyamanwere flooded. An entire country and 85 villages were left under the water. Asubstantial rural population lost their homes and were forced to settle in slums at theoutskirts of the city. The dam also swallowed the once important intercity road thatlinked Adıyaman to Diyarbakır. For all these sacrifices Adıyaman’s residents wereasked to make, I was told, GAP has not offered anything to the city in return: noirrigation channels, no industrial investments, no development.

Tobacco is the subject of another story of Adıyaman’s ‘disownment by the state’,as several of my informants called it. For decades tobacco production had been themain economic activity in the province. Starting in the 1990s successive governments

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have begun to introduce strict quotas and impose restrictions on the production andtrade of tobacco and dramatically reduce public subsidies to tobacco farmers. As aresult Adıyaman’s tobacco economy was gradually thrown into crisis mode.Landowners, agricultural workers and small enterprises engaged with tobaccoproduction have experienced a huge income loss. When tobacco-producinglandowners shifted to wheat and other crops that were not as lucrative as tobacco,small enterprises in the city faced an economic stagnation due to the loss of incomein the agricultural sector. Landless agricultural workers who used to work in tobaccoproduction have increasingly started to go to other cities for seasonal (mostlyagricultural) work, or if they were lucky they took up undocumented jobs with thecity’s modest textiles industry or low-end service jobs with excessive working hours,poor salaries and no social security whatsoever. In other words, the demise of thetobacco industry had a devastating impact on the city’s economy and dramaticallyincreased poverty. ‘Tobacco was the one thing we had’, one informant said, ‘but thestate took it away.’ ‘I tell you, if it wasn’t for this tobacco law, we’d be in riches farbeyond Antep, Malatya, Mersin, all those wealthy cities people talk about.’

In order to fully appreciate Adıyaman residents’ preoccupation with the state andits unfulfilled promises, one should also understand that Adıyaman is a Kurdish city,which has conspicuously ‘stayed away’ from any significant associations andinvolvement with the Kurdish political movement in Turkey and is generallyconsidered as a ‘docile’ Kurdish province, presented as a community committed tothe Turkish national project. In fact this self-association is part of the frustrationwith the state that I came to hear in my conversations with Adıyaman locals: ‘Wecommit to this state 100 per cent, why does the state fail to own us?’

These accounts and stories of marginality and peripherality constitute certainimaginaries of the Turkish state on the part of Adıyaman locals. As I will try toshow, the everyday interactions and discourses organized around the Green CardScheme in turn produce another set of imaginaries on state and citizenship inTurkey. An interesting question in this connection is to what extent the Green Cardaddresses the frustration Adıyaman locals express over what they perceive as thecity’s neglect and ‘disownment’ by the state, to what extent the Green Card caters toAdıyaman’s ‘desires for the state’, a desire that was both implicit and explicit in themany conversations I had with Adıyaman locals. At the heart of this sense of ‘beingabandoned’ expressed by so many of my informants was a desire for the state tomake a presence in Adıyaman, desire for a state that will own the city (again).

The complaints about Adıyaman’s miseries voiced to me by the city’s residents: fromthe decline of tobacco production to the virtual absence of any investment ininfrastructure and industry reflect of important economic changes which affectedlivelihood and employment opportunities in the province. Widespread unemploy-ment and poverty has an impact on Adıyaman residents’ access to social security andhealth care. As of 2004, around 63 per cent of the city’s population was not coveredby any of the employment-based social security scheme.16 For many of these peopleit is simply not possible to pay their health care expenses out of their own pockets.Thus for these people the Green Card appears to be the only available mechanismfor accessing health care services. Statistics confirm the significance of the Green

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Card Scheme for Adıyaman residents. As of November 2007, 36 per cent of the city’spopulation (600,000) were Green Card beneficiaries.17

Although the Green Card appears to be the only channel of access to health careservices for a considerable portion of Adıyaman’s population, it comes withobstacles and limitations that make it exceedingly difficult for deprived citizens toaccess the promised health care services.

Benefits from the Green Card come within a terrain full of uncertainties, whichhave to do with complications involved in the process of verification of poverty,obtainment of the Green Card and conditionality of its usage. Although there is abroad legislative framework for the Scheme set out by the relevant law and decrees,the eligibility and usage criteria foreseen by this general framework leave ampleroom to the discretion of local authorities. A further element of uncertainty has to dowith the very ambiguities and illegibility of the criteria and rules set out by thelegislative framework. The criteria and procedures described in the law do not lendthemselves to straightforward application; instead, they often require extensiveinterpretation, which inevitably broadens the room for local discretion. As aconsequence of this inherent ambiguity at the heart of the Scheme, local officials tryto come up with various strategies to make these rules legible to themselves. Theuncertainties brought about by the illegibility of the rules on the one hand shapepeople’s encounters with, and hence experiences regarding ‘the state’. But at thesame time these same ambiguities also enable them to interfere with the usualworkings of ‘the state’ by means of various tactics.

On the surface the procedure to be observed for a person to obtain a Green Card isvery clear and seemingly straightforward: if for a household the monthly income perhousehold member is lower than one-third of the net minimum wage, and theapplicant is not covered by the public social security system, he has the right toobtain a Green Card. The problem is that the process of verifying a person’s incomeis a difficult task complicated by uncertainties. The Green Card law and relateddecrees specify the sources of income that are to be taken into consideration whencalculating the monthly income of a household, such as payments for services or rentfrom estates or interests.18 In practice, however, the verification of a givenhousehold’s revenues from all these different sources may easily turn out to be amission impossible for the bureaucrats in charge. It is hardly feasible, for instance, toverify the payment a person receives for the services he provides, unless he isemployed in the formal job market. But of course if he were employed in the formaljob market, he would have been automatically covered by the public healthinsurance system, and would not have needed a Green Card.

In order to identify a person’s level of poverty, the first thing the Green Card officewill do is to ask the Green Card applicant to document all relevant incomeinformation that is already in the records of various state institutions and thereforeallows for official verification.19 But the Green Card bureaucrats in Adıyamancomplain that they can never be sure how much they can trust the information theyreceive from the applicants. Partially, they distrust the very information documentedby other state offices; and partially they worry about things not covered by theserecords, for example an undocumented property or informal sector salary.

Moreover, local officials often face direct or indirect pressure to delimit the numberof Green Card beneficiaries in their province. The officials in Adıyaman’s Directorate

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of Health-Care mentioned to me that sometimes the upper level bureaucrats (such asthe governor of the province, or Ministry of Health officials) simply decide that thepercentage of Green Card holders in the city’s population is too high, and theydemand the termination of a certain number of Green Cards. This pressure fromabove puts the bureaucrats at the Green Card Office in a predicament. There are ofcourse no formal criteria at hand for such an arbitrary termination of a definitenumber of Green Cards in circulation. In such situations, officials choose to apply their‘own’ criteria as to who is a ‘fine’ and ‘deserving’ citizen worthy of a Green Card.

During my first visit to Adıyaman in 2004, a co-administrator from theDirectorate of Health-Care shared with us a very peculiar story as to why theydecided to (arbitrarily) terminate the Green Cards issued for citizens of Aleviteconviction. He told us that at first Alevites were being granted Green Cards; but then‘they started to convert to Christianity’. Apparently when the upper levelbureaucracy demanded a reduction in the number of Green Cards in circulation,local Green Card officials chose to terminate the Green Cards of certain Aleviteindividuals belonging to communities in several villages that were subject to theserumours of conversion. Of course, according to the Green Card legislation, allcitizens – regardless of religious belief or ethnicity – who fit the Scheme’s povertycriteria would be eligible for a Green Card. However, in the absence of legibleguiding criteria, local officials are free to take advantage of their abundantdiscretionary powers to make termination decisions based on their own under-standings of who is a ‘fine’ citizen deserving of the state’s compassion. The same co-administrator further shared with us that ‘we give these people Green Cards. Butthen when they go and convert to Christianity, it is us who get into trouble. They askus: why did you give Green Cards to these people?’ This is an example of how thestate delineates through local practices the category of citizen and its margins.

At other times, the arbitrary delimitation of Green Cards is actualized in moredirect and palpable ways. During my last visit to Adıyaman in April 2007, theadministrator of the Green Card Office complained to me that they demanded fromthe Ministry 100,000 Green Card documents in accordance with their determinationson the number of renewals and new issuance. The Ministry however sent them only20,000 Green Card documents and thereby made it physically impossible for moreGreen Cards to be issued. Faced with this top-down imposition, the local GreenCard Office had no choice but to re-examine applicants and beneficiaries to identify‘those who really need the Green Card urgently’.

One consequence of these constraints is that the local Green Card bureaucrats arepermanently concerned about whether the people who receive the Green Card arethe ones who actually ‘deserve’ it. In my conversations with the bureaucrats, timeand again I have sensed this suspicion in relation to applicants. The bureaucratsseemed sincerely worried that the ‘undeserving’, ‘people who are not really poor’,might somehow trick their way into obtaining a Green Card. In order to preventwhat they perceive as such ‘fraud’ and ‘injustice’, they take the income investigationprocess very seriously. They conduct very detailed investigations not only aboutpeople who apply for a Green Card for the first time, but also about the existingGreen Card holders who have to approach them each year for a renewal.

Over the course of these detailed investigations the police and gendarmerie play acrucial role. The decree regulating the Green Card scheme provides that whenever

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the local Green Card Office considers it necessary, the police or the gendarmerie canbe asked to investigate the living conditions of the applicant. Although the decreerequires this on-site investigation in cases of necessity, my observation was that forthe Green Card bureaucrats in Adıyaman each application necessitates a police orgendarmerie investigation, because they operate from the assumption that eachapplicant is potentially a fraud. I asked the administrator of the local Green CardOffice about the nature of these police/gendarmerie investigations. He told me thathe did not know how the police conduct these investigations, but that the mainconsideration there is whether the applicant has any unregistered income.

I have spoken to some Green Card holders who had been subject to thisinvestigation. They told me that in most cases the police officers just ask around theneighbours and the mukhtar of the neighbourhood about the conditions of thehousehold, whether the family owns a vehicle or an extra property, which membersof the household are employed. But in some cases police officers can choose toactually go inside the house and have a look at the physical conditions, the furnitureand electronic devices, etc. In other words, the methods the police or gendarmerieuse to obtain informal income information can be quite invasive. The more seriousproblem, however, was that no one in Adıyaman was able to explain clearly to methe criteria and the rules under which the police or the Green Card committeeevaluates the reliability of the information obtained from these informal sources andarrive at their ‘verification of poverty’ conclusions.

I encountered, during my interviews, such cases where the applicant does not ownany property according to official records, but the police reports that a neighbour orthe mukhtar of the neighbourhood claims that the person receives a considerableamount of revenue from land registered under his father’s name, or that a familymember has a high-paid job.

Question: I was told that it is because of these police visits that it takes a longtime for the investigation to be completed. So the police officers come,investigate your houses and finances.Respondent1 (R1): Police come, they just observe from the outside.Q: So they do not speak with you at all?R1: They speak behind your back.Respondent 2 (R2): They ask questions of neighbours. If a neighbour tells themthat you own a property or something, then you can forget about the GreenCard, you’ve lost your chance.Q: Neighbours do that sort of thing to each other?R2: It is mundane jealousy.Respondent 3 (R3): My son used to work at that gas station, remember? Heused to wash cars. He was paid peanuts for this job. When police officers cameand asked about him, neighbours told them ‘his son works at Turk Petrol’, thebig oil company! [Laughing]. That is the story of how his Green Card wascancelled. He had been waiting for 12 months. Then people say ‘his son worksat Turk Petrol’, and that was the end of it.[. . .]Q: I hear that once your Green Card is cancelled, you cannot apply again for 12months.

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R1: No you can’t. If my son was really working at Turk Petrol, if he was beingpaid a salary from there, there’d be a record of this, this is a big company.Q: They did not investigate any of that?R1: No, they got this bogus information from the neighbours, and that wasthat.R3: I swear they just came here, spoke with one neighbour, next thing we knowhis Green Card was cancelled.

Which information should the Green Card bureaucrats take into account? Is it theofficial records indicating that the applicant has no registered income; the declarationof the applicant stating that he earns little enough to fall within the Green Cardcriteria; or the statement by some neighbours that the applicant is a high-salariedemployee? The truth is that nobody can tell in advance how the decision will bemade; it is not predictable. The rules are flexible. It is possible for this applicant to beentitled to a Green Card, and it is equally possible that he will be denied a GreenCard. The Green Card process and the rules around it seem to be ‘illegible’ both tothe bureaucrats administering the system and the Green Card applicants/holders.

To the extent that it is hardly possible to access all information about a person’sincome through official records, citizens are not ‘legible’ enough for statefunctionaries as far as their income levels are concerned. This is the major sourceof ambiguity in the Green Card system. The state seems to have adopted a two-tieredstrategy to deal with this problem. On the one hand, in order to make citizens more‘legible’, they invest in solutions such as computerized databases that will supposedlyallow every bit of income information to be accessible to all relevant stateinstitutions. On the other hand, the very ‘illegibility of the rules’ also functions as astrategy for the state to handle the ‘illegibility’ of the citizens.

For instance, as I have pointed out before, the uncertainties in the legislativeframework and the complexities of the application and evaluation process createsignificant room for discretion and interpretation for local Green Card bureaucrats.They are in a relatively flexible position to introduce new criteria or to change theworkings of the procedure at local level. The depth, duration and the agents of theinvestigations pursued with applicants may differ from one district to another andfrom one applicant to another depending on the perceived ‘suspiciousness’ of theapplicant. This very ‘illegibility of the rules’, this very blurry line between the legaland illegal, enables state agents to obtain through non-official channels incomeinformation about applicants beyond what is available in the state registers and toprocess this information under more or less flexible rules.

What legitimizes this ‘flexible’ practice, what makes it defendable, even acceptableand necessary, is of course the organized suspicion against the Green Cardapplicants/holders: Are they ‘poor citizens’ indeed? Or are they frauds who want toget something they do not deserve? For the Green Card bureaucrats in Adıyaman, itis a matter of duty to administer the state’s limited resources in a just way. When putin these terms, ‘illegible rules’ become a necessity for dealing with ‘illegible citizens’.

The illegibility of the Green Card rules and the resulting uncertainties in the GreenCard verification procedure affect not only the state–citizen dealings around theGreen Card Scheme itself, but extend beyond that, to serve to enhance statesovereignty over all aspects of life in Adıyaman. In one of my interviews I was told

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this story about an old man who depends on the Green Card benefits for his healthcare treatments. This man is an acquaintance of one of my informants in Adıyaman.While my informant chats with this man from his village, he learns that the old mandonated the skin of the lamb he sacrificed to the gendarmerie, who came down to thevillage to collect the skins during the Qurban bayram. My informant asks the oldman why he did not donate the skin to the village mosque – which is the usual thingto do – instead of the gendarmerie. The old man says:

I could not afford to donate the skin to the mosque. If I gave the skin to themosque, the gendarmerie would not let me keep my Green Card when the timeof renewal comes, and they would tell me to go ask for free healthcare from themosque where I gave the skin.

It does not matter whether the gendarmerie would indeed interfere with the GreenCard verification process in such a way if the old man gave the skin to the mosque.What matters is that this perceived threat is indeed a possibility. Through thispossibility ‘the state’ acquires a ‘magical presence’;20 it achieves ‘an uncannypresence in the life of the community’, and reinforces its sovereignty. Given theillegibility and unpredictability of the Green Card Scheme, the safe thing for GreenCard beneficiaries to do is to assume that the state is always there and adaptaccordingly. Sovereignty as a potentiality is sufficient for the state to be present.

It should however be noted that there is always room for other potentialities that canbe pursued by citizens, potentialities other than those offered by the official workingsof the Green Card Scheme. Involving numerous uncertainties, the Green Cardprocess can be regarded as a terrain of subjunctivity – that is, a terrain full of doubt,potentiality, hope and will,21 where it is possible for people to act or talk in waysdifferent from those offered by the discursive domain mobilized by the Scheme. Iobserved that people find ways to counter the power and discretion of the GreenCard bureaucracy by employing various tactics informed by their family oracquaintance networks. These tactics are used to find shortcuts inside the GreenCard bureaucracy or to obtain treatment from public health care centres.

Whenever the chance offerings of the moment are with them, applicants can beincredibly creative to find shortcuts within the workings of the Green Card Schemeto achieve their aims. As Das and Poole argue, ‘the state is both experienced andundone through the illegibility of its own practices, documents and words’,22 andfalsification of documents is regarded as one of such practices. During my interviewsin Adıyaman, both local bureaucrats and Green Card applicants/beneficiaries toldme stories of how the Green Card applicants manage to make their incompatibleincome records kept by various state offices ‘look compatible’ with a little help fromacquaintances who work in these offices. I was told that even computer-basedrecording systems could not stop people from obtaining fake records.

The way the computer-based systems of the land office, tax office, or variouspublic health insurance offices work, the officer enters a name into the system, andthe computer displays records such as taxed revenue or insurance status. However,if this officer in question happens to be an acquaintance of a Green Card applicant

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and is motivated to provide a ‘clean and proper’ record for the applicant, all heneeds to do is to type the name with a slightly different spelling. Since no suchname will be listed in the records, it will seem as if there exists no recorded taxedrevenue, land record or public health insurance record for this person. In this way,a slight change will make a person appear eligible in line with the Green Card‘poverty criteria’.

Another common tactic I have heard about in Adıyaman is the use of somebodyelse’s Green Card or other public health insurance documents in order to obtain freehealth care services from public providers. Until a 2005 amendment in the GreenCard law the Scheme did not cover out-patient medication costs for beneficiaries. Inone of my interviews held in 2004 in the period before the amendment, a nurseworking at one of the neighbourhood public health centres in the city openlyadmitted to me that they provided anyone who enters the facility with free healthcare services regardless of social security status. She told me that they sometimeseven allowed people to use their (health care personnel) own documents.

Such tactics in the form of small ‘frauds’ require the complicity of the health carepersonnel at public health care institutions or the functionaries of the Green CardOffice. The tactical question of who will be complicit in the fraud depends on thechance offerings of the moment and the reach of individuals’ personal family oracquaintance networks into the levers of local bureaucracy. Having a relative orknowing someone who works in a medical facility or in a state institution is a greatasset for people who apply for a Green Card or who need to access health careservices by using their Green Cards. In this connection, kinship ties are of criticalimportance in Adıyaman. An applicant may have a relative working in a stateinstitution. This relative in turn will be involved in a network of his own within thecommunity of state servants. I have observed that these linkages are very strong inAdıyaman; and they are organized around a strong feeling of mutual responsibilityand a sense of obligation to meet (within the limits of ‘reasonableness’) the demandsof their relatives, colleagues and acquaintances.

In other words, local state officials operate from a sense of responsibility not onlytowards ‘the state’, but also towards their affiliates from a wider social network.When a relative, a colleague or an acquaintance asks for a ‘favour’ – this usuallymeans a request to interrupt or violate any number of procedural requirementsbrought about by ‘the law of the state’ – they try to meet this demand for the sake ofmutual responsibility that these relationships entail. During my visits to the GreenCard office in Adıyaman, I observed how applicants or beneficiaries who havepersonal relations with officials could confidently pass behind the bench, whereofficials sit, ask for ‘favours’, chat and have tea with officials, while other applicantsor beneficiaries were made to wait on the other side of the bench. It seemed that these‘privileged’ Green Card applicants/holders had access to a mode of interacting withstate officials very different from the logic of poverty and compassion that usuallyinforms the Green Card experience.

Tactics open up alternative potentialities in local constructions of state andcitizenship in Adıyaman. However, one should be aware of the limitations of thesetactics and of the possibilities these relationships enable. De Certeau’s spatialunderstanding of power relations and his conceptions of ‘tactic’ and ‘strategy’ areinstructive in this respect.23 According to de Certeau, a tactic is ‘a calculus which

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cannot count on a ‘‘proper’’ (a spatial or institutional localization) . . ., [it is] amanoeuvre within enemy territory’. As it does not have a place of its own, it cannotaccumulate what it wins: a tactic ‘must constantly manipulate events in order to turnthem into ‘‘opportunities’’’.24 The informal manoeuvring through the Green Cardprocedures enabled by kinship ties in Adıyaman should be interpreted in these terms.The instances I described above are tactics, ‘clever tricks’ employed by Green Cardapplicants/beneficiaries to be able to find their way about within the system.Although these manoeuvres can be understood as ‘traverses’ heterogeneous to thesystem they infiltrate, they remain within the boundaries of the places created by theGreen Card scheme. In contrast to tactics, strategies have their own places, and theyare able to produce, tabulate and impose these spaces. I would argue that if theGreen Card applicants/beneficiaries operate in the realm of tactics, the Green Cardbureaucracy they deal with creates its power effects in the realm of strategies. Thepower to determine the Scheme’s terms of application rests with the localbureaucracies. They are in a relatively flexible position to employ their strategies –and thereby create places of their own – by changing Green Card eligibility criteria asthey see fit.

The space of the Green Card system provides a limited opportunity to the GreenCard applicants/beneficiaries to influence the mechanism to their favour byemploying various tactics over their everyday interactions with local stateinstitutions. It is certainly true that some Green Card applicants and beneficiarieswould be empowered in the process.

However the same ambiguities and uncertainties in the system which make thesetactical manoeuvres possible, may be disempowering for others. As Chatterjeereminds us, ‘governmental activity takes place within the stratified social structuresof class, status and privilege. Benefits that are meant to be available in general, arecornered by those who have greater knowledge of and influence over the system’.25

In other words, the ‘other potentialities’ opened up by the tactical moment areavailable only for those who are culturally equipped in terms of the knowledge,skills, social networks required. For those ‘suspicious’ subjects/citizens who are notas well equipped to find their way about the Scheme, the Green Card remains anexclusionary mechanism.

Adıyaman is a city marked with a strong sense of marginality expressed in the formof ‘disownment’ by the state. It appears that this sense of ‘disownment’ gives rise tocalls for the state to establish a presence in Adıyaman, a presence that will enable itto address the city’s economic miseries and put it on a path to ‘develop’ and‘modernize’. This is not to say that ‘the state’, which features so prominently in theperceptions of the city’s residents, does not already have a presence in Adıyaman. Onthe contrary, I argue that through the complex, illegible and uncertain procedures ofgovernmental technologies like the Green Card, the state appears as a vertical, all-encompassing entity, having a ‘magical presence’ in the everyday life of Adıyaman.

However, this is not the state Adıyaman locals desire. What they desire is the kindof state which would buy their tobacco on subsidies and engage in expensive, large-scale infrastructural investments, and create job opportunities in state-ownedfactories. They desire the developmentalist state which Turkey once was, prior to the

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far-reaching liberalization and privatization drive the country engaged in from 1980sonward. In contrast, the state Adıyaman locals experience in their everydayencounters with the Green Card Scheme is one that promises little and delivers invery uncertain and unpredictable ways.

Although a substantial number of citizens who were once totally excluded fromany public health care coverage are now being ‘re-owned by the state’ – if you will,provided with certain health-care benefits under the Green Card scheme – they arefaced with a plethora of complications and uncertainties in their struggle to accessthe Green Card benefits. Green Card beneficiaries become citizens in the way theyare ‘selected’ as poor, worthy of the state’s compassion. This process of recognitionis engulfed in circumstances of perpetual suspicion. For many of them this process ofselective inclusion/recognition continues to be experienced as exclusion. In a localitylike Adıyaman where people complain about their ‘disownment by the state’, thisexperience of endless uncertainties and ambiguities prevents them from feeling re-owned.

The uncertainties inherent in the workings of the Scheme enable some of therecipients to partially undo these exclusionary effects of the state by means of tacticalinterventions such as the falsification of documents. However, all these tacticalmanoeuvres remain within the spatial field created by the Green Card. Under suchconditions, a mode of existence in Adıyaman outside the realm of the state,independent from it and with no reference to it, becomes unimaginable. The‘magical’ omnipresence of the state remains intact. Adıyaman appears as a city densewith state, a kind of state that is ever present yet forever missed.

Notes

I am grateful to Nazan Ustunda�g and Oktay Durukan for their valuable comments and feedback on an

earlier draft of this article. I also wish to thank Bo�gazici University Social Policy Forum for providing me

financial support throughout my research.

1. A. Gupta, ‘Blurred Boundaries: The Discourse of Corruption, the Culture of Politics, and the

Imagined State’, American Ethnologist, Vol.22, No.2 (1995), p.378.

2. 2008 saw a comprehensive overhaul of the public insurance system. In recent years the current AKP

(Adalet ve Kalkinma Partisi – Justice and Development Party) introduced a comprehensive proposal

that aims to reform the health care system in Turkey. Preparations under this reform agenda are

already at work. For detailed analyses on the recent health care reform attempts in Turkey see T.

A�gartan, ‘Turkish Health System in Transition: Historical Background and Reform Experience’ (PhD

thesis, Binghamton University, 2008); C. Keyder, N. Ustunda�g, T. A�gartan and C. Yoltar (eds.),

Avrupa’da ve Turkiye’de Sa�glık Politikaları [Health Care Policies in Europe and Turkey] (_Istanbul:_Iletisim, 2007). One of the main pillars of the proposed reform is the establishment of a premium-

based General Health Insurance (GHI) scheme, to replace the fragmentary structure of separate public

insurance schemes. The Law regulating this new GHI Scheme was passed by the parliament in 2006,

and after some modifications it was put into practice by 1 Oct. 2008. According to the GHI law, three

separate public health insurance schemes are unified under one GHI Scheme; all citizens in Turkey will

be covered under GHI regardless of their employment status, and they are required to contribute to

the GHI Scheme with respect to their financial capacities. Sosyal Sigortalar ve Genel Sa�glık Sigortası

Kanunu [The Law on Social Security and General Health Insurance Scheme], Resmi Gazete [Official

Gazette], No.5510 (31 May 2006).

3. As of 2004, 52% of the workforce in Turkey was not covered by any of the public insurance scheme.

Calısma ve Sosyal Guvenlik Bakanlı�gı [Ministry of Labour and Social Security], Proposal for Reform

in the Social Security System (Ankara: Calısma ve Sosyal Guvenlik Bakanlı�gı, 2004).

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4. As such the Green Card Scheme came as a novelty. Its organizing logic is not employment status of

the beneficiaries, but their relative poverty, defined in terms of certain criteria. At the time of its

establishment, the Green Card Scheme was considered as a provisional arrangement on the way to a

more general and universal health insurance system. For a detailed historical analysis of

transformations in the health care system in Turkey see A. Gunal, ‘Health and Citizenship in

Republican Turkey: An Analysis of the Socialization of Health Care Services in Republican Historical

Context’ (PhD thesis, Bo�gazici University, 2007). Although the GHI system was established with the

law published in 1 Oct. 2008, those citizens who would be ‘unable to contribute’ – because of their lack

of means – will continue to be covered by the Green Card Scheme until it is replaced with new

legislation, Primsiz Odemeler Yasası [The Law on Without Premium Payments], by the end of 2010.

For the time being, only a draft version of this legislation is available. I will not get into details

regarding this new legislation to replace the Green Card Scheme, but it is important to note that the

envisioned workings of the GHI Scheme reveals a continuity in the way the Turkish state deals with

the provision of health care services to its ‘poor citizens’ under the Green Card Scheme.

5. Odeme Gucu Olmayan Vatandasların Tedavi Giderlerinin Yesil Kart Verilerek Devlet Tarafından

Karsılanması Hakkında Kanun [The Law on the Covering of the Treatment Expenses of the Citizens

with Insufficient Financial Means by the State through Green Card], Resmi Gazete [Official Gazette],

No.3816 (18 June 1992).

6. As of 15 Nov. 2007, the exact number of Green Card holders in Turkey was 8,837,506. See Yesil Kart

Bilgi Sistemi [Green Card Information System], http://sbu.saglik.gov.tr/yesil/ (accessed 15 Nov. 2007).

7. For detailed studies on ethnography of the state, see for example B. Aretxaga, ‘Maddening States’,

Annual Review of Anthropology, Vol.32 (2003); V. Das and D. Poole (eds.), Anthropology in the

Margins of the State (Santa Fe, NM: School of American Research, 2004); A. Gupta and J. Ferguson,

‘Spatializing States: Towards An Ethnography of Neoliberal Governmentality’, American Ethnologist,

Vol.29, No.4 (2002); T.B. Hansen and F. Stepputat (eds.), States of Imagination: Ethnographic

Explorations of the Postcolonial State (Durham, NC and London: Duke University Press, 2001); C.

Krohn-Hansen and K.G. Nustad, State Formation: Anthropological Perspectives (London: Pluto

Press, 2005); M. Nuijten, Power, Community and the State: The Political Anthropology of Organisation

in Mexico (London: Pluto Press, 2003); A. Sharma and A. Gupta (eds.), The Anthropology of the

State: A Reader (Oxford: Blackwell Publishing, 2006); M. Trouillot, ‘The Anthropology of the State in

the Age of Globalization’, Current Anthropology, Vol.42, No.1 (2001), pp.125–37.

8. A. Sharma and A. Gupta, ‘Introduction: Rethinking Theories of the State in an Age of Globalization’,

in Sharma and Gupta (eds.), The Anthropology of the State, p.8.

9. Aretxaga, ‘Maddening States’, p.398.

10. Trouillot, ‘The Anthropology of the State’.

11. Sharma and Gupta, ‘Introduction’, p.9.

12. Ibid.; C. Shore and S. Wright, ‘Policy: A New Field of Anthropology’, in C. Shore and S. Wright

(eds.), Anthropology of Policy: Critical Perspectives on Governance and Power (New York: Blackwell

Publishing, 1997).

13. V. Das and D. Poole, ‘State and Its Margins: Comparative Ethnographies’, in Das and Poole (eds.),

Anthropology in the Margins of the State, p.3.

14. Ibid., p.8.

15. T. Asad, ‘Where Are the Margins of the State?’, in Das and Poole (eds), Anthropology in the Margins

of the State, p.279.

16. Statistics are gathered from local social security institutions in Adıyaman.

17. Yesil Kart Bilgi Sistemi [Green Card Information System], http://sbu.saglik.gov.tr/yesil/ (accessed 15

Nov. 2007).

18. According to the legislation, the sources of income to be considered in calculating the monthly income

of household are as follows: cash payments for services; cash agricultural revenues; rent from estates

or interests; cash transfers or grants from public, private institutions or other people; and in-kind

income in any form above. Regarding the income sources mentioned above, the total monthly income

of the household – including spouses, children, parents, as well as relatives up to third lineage living in

the same household – is calculated and divided into the number of people in the household, and if the

monthly income per household member is lower than one-third of the net minimum wage, he has right

upon a Green Card. Odeme Gucu Olmayan Vatandasların Tedavi Giderlerinin Yesil Kart Verilerek

Devlet Tarafından Karsılanması Hakkında Yonetmelik [The Decree on the Covering of the Treatment

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Expenses of the Citizens with Insufficient Financial Means by the State through Green Card], Resmi

Gazete [Official Gazette], No.21314 (13 Aug. 1992).

19. During the application process, in Adıyaman the applicants are expected to declare the following

information required by the forms: personal information of the applicant; personal information of the

applicant’s dependants and the other persons in the household (even in the case that they do not apply

for the Green Card); social security status of each person in the household; and income of each person

in the household. The forms should be authorized by muhktars of the district (to confirm the residence

address and the household information); the population bureau (to confirm the household

information); the tax office (to check information related to taxation, hence income); the land office

(to check information related to estate ownership); and the district municipality (to check income

information). In addition, the social security statuses of household members are verified through

information from social security institutions. In the decree regulating the Green Card scheme, it is also

mentioned that in cases of necessity the police or the gendarmerie can investigate the living conditions

of the applicants, and if they find out any unregistered information pertaining to the economic or

financial conditions of the applicant, they are to declare it on the form.

20. V. Das, ‘The Signature of the State: The Paradox of Illegibility’, in Das and Poole (eds.), Anthropology

in the Margins of the State, p.230.

21. For further discussion on subjunctivity see S. Reynolds-Whyte, ‘Subjectivity and Subjunctivity:

Hoping for Health in Eastern Uganda’, in R. Werbner (ed.), Postcolonial Subjectivities in Africa (New

York: Palgrave, 2002), pp.171–90; B. Good, Medicine, Rationality, and Experience: An Anthro-

pological Perspective (Cambridge and New York: Cambridge University Press, 1994).

22. Das and Poole, ‘State and Its Margins: Comparative Ethnographies’, p.10.

23. M. De Certeau, The Practice of Everyday Life (Berkeley: University of California Press, 1984).

24. Ibid., p.xix.

25. P. Chatterjee, The Politics of the Governed: Reflections on Popular Politics in Most of the World (New

York: Columbia University Press, 2004), p.66.

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