A leading expert in health care in Germany and Turkey, Ramazan Salman is changing society's approach towards immigration and the integration of immigrants. By creatively involving the German public, he creates encounters that cause people to overcome deeply rooted prejudice.
The New Idea
Ramazan chose health as a focal point for immigrant integration because it is central to the process of immigration, a precondition for its success. He has built a system in Germany using successful immigrants as bridges between the German health system and immigrant communities. These networks thrive on open dialogue and help immigrants to overcome isolation, depression, cultural barriers and mistrust. More importantly, he assists them in understanding their rights in the German health system. Key to Ramazan’s vehicle to pursue his vision of integration is an "ethnomedical center," which he founded in Hanover in 1990 while studying sociology and medicine. At the core of this center is a system of nationwide networks called MiMi (migrants for migrants) that are led by successful immigrants who have mastered living in Germany and, in turn, reach out to assist other immigrants. This model encourages dialogue around health, immigrant rights, access to institutions and the appropriate wording to initiate talks about health and other integration issues—as they may be sensitive and personal conversations.These networks also provide training by immigrants to teach and enable German medical personnel to adequately attend their immigrant clientele. To avoid a parallel migrant-only health care service, Ramazan connects Germans with immigrants to provide equal access to excellent health care.
Nearly 15 percent of the German population, or approximately 12 million people, are immigrants or the children of parents who immigrated to Germany. According to Ramazan's research—corroborated by scientific studies inspired by his work—there is a direct correlation between how well-integrated immigrants are in their communities and how healthy they are. Since integration remains a serious problem across Germany, the health condition of immigrants is on average worse than that of the average citizen. Immigrants suffer from higher emotional stress (due to a separation from the country or origin and family members, and learning to adapt to new surroundings) and many times live in unhealthy conditions. Many come from cultures with less advanced medical infrastructure and do not know how to access German medical services. While the average life expectancy of a male German blue-collar worker is above 70, it is 61 for a Turkish immigrant living in Germany. More than 30 percent of young German women seek regular breast cancer screenings, but only 2 percent of immigrant women do. HIV and Aids among immigrants is significantly higher than in the German population, as is the rate of child mortality.In addition, proper diagnosis and treatment is complicated by the fact that an expression of health varies from culture to culture. For instance, when a patient says he is possessed by a spirit, a German doctor may assume he is schizophrenic, but in the patient's cultural context, he is conveying that he has a headache.Immigrants are often perceived as less educated than Germans, with the feeling that immigrants come to Germany to use the welfare system. The perception of migrants as "working class" is partly due to the first historical pattern of migration after WWII, when the German government made an effort to attract unskilled labor from Turkey and other countries to help counterbalance the shortage of male workers.
Ramazan anchors immigrant networks in the German institutional health care landscape. When setting up new mentor-driven migrant health information networks in a city or a state, Ramazan looks for two well-connected immigrant-led civil society organizations. With their help, he builds health care information networks by training successful immigrants to become lay medical experts or "health mediators" who then reach out to their communities. He also works with communal health care institutions as well as the municipality or state government. Ramazan has developed a special curriculum to train those fitting the criteria to become lay medical experts or health mediators. The training program also draws on doctors and experts from respective cities or states to teach extra courses. The mediators spread their knowledge by running a series of evening or weekend events and seminars in their community center, mosque, or school for their fellow migrants and by building up local networks and discussion rounds. The mayor or perhaps minister, the leader of the health care administration unit, and the citizen organizations sign a contract with the ethnomedical center to establish quality standards and goals, and define the strategy for labor sharing. The project is collaborative—German doctors and nurses assist in training the immigrant mediators, while the immigrants teach the Germans about the cultural issues surrounding health and illness as well as culturally common health issues. Then Ramazan stages several public events and celebrations where German officials, the mayor, and the health care representatives present the work their immigrant mediators and networks have done—reporting on the success of the project (monitored and statistically and qualitatively evaluated), which attracts quality press coverage. The press then spreads positive news about immigration to the wider public, the mayor is immensely proud of successfully fostering immigration, and the immigrants can showcase their strengths.Ramazan's model is functioning in each of Germany's 24 biggest cities and in several states. He has instructed over 1,000 mediators from 50 different nations—almost 80 percent of them being women—and has directly reached around 60,000 migrants from 70 nationalities. He also teaches several courses a year, each reaching out to 60 attendees. There are now 15 different modules, and topics range from information and discussion on HIV and Aids, child health care, birth control and pregnancy, vaccination, substance abuse, nutrition, first aid, and sports to depression and mental health. All mediators are linked in a nationwide network to ensure exchange of learning and best practices. The costs for a city network are very low, amounting to 30,000 EUR per year for materials and health mediators for each course. Ramazan has succeeded in getting local governments and Germany’s second largest state health insurance company to share the costs. The MiMi networks work as follows: The immigrant civil society organizations that co-sign the contract tap into their network and look for potential mediators. The requirements are that they must (a) be fluent in at least two languages, one of them being German, (b) have a high social index (which Ramazan developed to signify a good education, good reputation, successful integration career), (c) be open to and not prejudiced against any other nationality or ethnicity and, (d) want to be socially engaged and be willing to dedicate significant time to the initiative. Some of the mediators work entirely in their spare time, others are housewives and mothers, others work in the social sector, and some are waiting for official permission to begin their profession in Germany (e.g., lawyers or teachers). Ramazan has started to apply the MiMi system beyond health care to education and schooling and financial services and is working on spreading his model internationally. Participants also organize self-help groups and informal discussion rounds designed to break through taboos. For example, Ramazan was the first to successfully run HIV and Aids prevention seminars in mosques, including instruction on how to use condoms. The key strategy in his model is asking the right, culturally sensitive questions—questions that people can relate to. Furthermore, he founded a translation service for health and social matters that includes a methodology called "intercultural translations." These translators help contextualize conversations so they are culturally sensitive and avoid misunderstandings (like mistaking a headache for schizophrenia). Through this “translation service,” Ramazan has published brochures and health care information material in 15 languages. As the mediators feed their experience back to him and fill in evaluation forms, these brochures are always being amended. Together they decide what topics to include and what issues to raise.
Ramazan was born in Turkey and went with his parents to Hanover, Germany, at the age of six. His father was a bus driver, and since they lived in an apartment owned by the bus drivers’ union in a middle class neighborhood, Ramazan grew up in rather established surroundings. He had many middle class German friends and was the first immigrant child to attend the local Hanover high school. He loved school and started several sports and round table projects. He noticed that his high school resided in an area where many migrants lived, but there were only four foreigners at school. He was aware that the perception of migrants was sometimes peculiar and formed by negative stereotypes. Someone like himself, fluent in German and going to university, was quickly labeled as “not really that foreign” or “not a real migrant.” At university, he worked pro bono with immigrant children with adjustment problems, and was shocked to learn how often they were misdiagnosed by German doctors and psychologists due to mis-communication or prejudice. When he realized that the levels of loneliness and illness were also unusually high among elder migrants, he set up the “institute for transcultural care,” an independent organization with a staff of 21 that offers care and legal advice (especially on guardianship). He is currently working with a financial think tank and a foundation on setting up a “wealth (in)formation service” for migrants since many of them distrust the official banking sector and literally smuggle their money back home in plastic bags or store it under their mattress—always losing money through inflation. Ramazan also founded an international association for intercultural mental health, has authored many books on intercultural medicine and health care, and has spoken at dozens of international conferences in Germany. He is a leading figure on health care in Turkey and Germany and has played a pioneering role in the HIV and Aids discussion in Turkey.