Turkey

TURKEY. Area-762,736 sq. km. Population. According to the census of October 28, 1927-13,649,945 people, of which 6,584,404 men and 7,065,541 women. According to the Ministry of Health itself, these data are incomplete. At the end of 1933, the population was 16,200,000 according to various sources. Registration of births and deaths, mandatory by law of August 14, 1913, is carried out very incompletely and its reorganization is planned. The Ministry of Health conducted questionnaires on birth and mortality rates in some districts of Turkey in 1926/27. They covered 1,309 villages with a population of 487,146 people. According to these data: infant mortality (per 1,000)-156, general mortality (per 1,000)-19, birth rate (per 1,000)-39. A repeated survey for 1929-1930 showed respectively: 141.7, 17.9 and 39. - Turkey is a country with a high birth rate and average mortality. Registration of causes of death is poorly established, and the proportion of deaths from unknown causes reaches 40%, but in recent years, thanks to improved sanitary conditions, it has decreased somewhat. Sanitary administration. Under the Ottoman regime, healthcare in Turkey was completely neglected. The government not only did not allocate any significant funds from the state budget for healthcare, but also showed no interest in combating the appalling unsanitary conditions prevailing in the country. European imperialism used this as a pretext to keep Turkey under international sanitary control (the "International Sanitary-Quarantine Council", abolished after the Treaty of Lausanne) and to establish its own medical institutions in the country. The darkness and backwardness in which the Sultan's government had kept the people for centuries contributed to the fact that the population itself distrusted scientific medicine. Not only the village, but also most urban residents turned exclusively to folk healers, monks and elders, who treated with prayers, incantations, "breathing" (blowing into the mouth of the patient), talismans and even walking on the bodies of patients. Women especially avoided seeking medical help. Before the revolution, there were no women doctors; there were almost no midwives either. Dirty, ignorant midwives (ebekadyn) maimed parturient women and infants without punishment, often with fatal outcomes. These phenomena have not yet been eradicated in many areas of Turkey, especially in remote corners. Since coming to power, the Kemalist government has waged a persistent struggle to create a modern healthcare organization and for sanitary education of the population. However, while having to rebuild the entire country and having a small budget, the government can allocate only insignificant funds to healthcare. From the old regime, it inherited a country where epidemics constantly raged, where a number of diseases were in an endemic state, and where the population was deprived of any medical assistance. This is why Turkey still lags behind many European countries in terms of the network of medical institutions, medical-sanitary personnel, and the amount of medical care provided to the population. And yet, it must be said that in ten years of the republic's existence, Turkish healthcare has achieved significant results. Structure of healthcare bodies. The first step of the Kemalist government in healthcare was the creation in 1920 of a special commissariat (ministry) of hygiene and social assistance. Among its departments, we note: 1) the supreme health council (a consultative body); 2) department of medical chambers; 3) administration of border sanitary protection; 4) department of social assistance, including school health services; 5) main sanitary administration with sub-departments: a) sanitary construction, b) social hospitals, c) infectious disease hospitals, d) malaria and others; 6) department of statistics and sanitary publications; 7) pharmaceutical administration; 8) sanitary inspection. (Since 1925, Turkey has been divided into 10 sanitary-inspection districts.) In 1933, 33 doctors worked in the central apparatus of the ministry. For the last 9 years, the ministry was headed by Dr. Refik-Saidam, deputy of Istanbul. The peripheral healthcare network consists of: 1) sanitary administrations of vilayets (57 in number - one in each vilayet), 2) government doctors, distributed among the main cities of vilayets and kazas (districts) (394 in total throughout the periphery), 3) model hospitals, 4) children's hospitals, 5) maternity shelters, 6) medical-consultation homes for infants, 7) nurseries, 8) children's centers, 9) hospitals for the mentally ill, 10) tuberculosis sanatoriums and dispensaries, 11) outpatient clinics, 12) dormitories for medical students and a midwifery school, 13) institutions for the deaf-mute and blind, 14) municipal hospitals, 15) municipal doctors (227 throughout the country), 16) municipal midwives, 17) commissions to combat malaria, syphilis, trachoma and infectious diseases, 18) staff of lower sanitary servants, some of whom are grouped into mobile teams. In addition, private hospitals, private doctors and pharmacies in various populated places are also under the supervision and control of the ministry and its local bodies. Scientific institutions. Among the major scientific institutions, it is necessary to note the Central Institute of Hygiene in Ankara, a model institution built just a few years ago and consisting of: 1) a hygiene school (for internships of doctors), 2) a biological department, 3) a bacteriological analysis department, 4) a chemical analysis department, 5) a department for the production of serums and vaccines (diphtheria, smallpox, anti-rabies, etc.). In addition to this institute, the country has a bacteriological laboratory (city and port) in Smyrna and a port bacteriological laboratory in Istanbul. Medical institutions from 1923 to 1932 (hospitals and dispensaries) grew sharply: in 1923 there were 78 medical institutions (hospitals, dispensaries), in 1932-339; the total number of beds was respectively 4,595 and 9,187. Table 1 shows the distribution of hospitals, dispensaries and the number of beds in them (1929). Through departmental consultations in 1932, 330,010 people passed, in departmental and municipal hospitals Table 1. Who owns Hospitals Dispensers Number of beds in them Religious organizations 72 17 1,371 State institutions 15 3 5,572 5,900 143 1,450 Private institutions 8 900 55 617 patients were hospitalized in 1929 and 68,208 in 1932. In state hospitals in 1924, 5,668 patients passed through consultations and 9,169 were hospitalized. In 1932, the corresponding figures were already 460,450 people and 88,465. Among the hospitals built recently, it is necessary to note the excellent first-class "Model Ankara Hospital" equipped with the latest technology; 3 other model hospitals were created in Sivas, Erzurum and Diyarbekir (all four on the state budget). Treatment in state, vilayet and municipal hospitals, dispensaries and outpatient clinics for the poor is free. In addition to medical institutions belonging to official institutions, there are also several hospitals belonging to foreign colonies (for example the "English hospital" in Istanbul), religious organizations, national minorities, industrial and commercial enterprises, and finally simply private clinics. In 1924, to bring medical care closer to the population, so-called consultation and treatment houses with 5 beds each were opened in 150 kazas (districts), which are a kind of dispensaries. In 9 years of their existence, 11,671 inpatients and 1,865,793 outpatients were treated in these houses. Hospitals are located almost exclusively in the main cities of vilayets. Psychiatric care. In old times, Turkey had only one psychiatric hospital in the suburb of Istanbul-Scutari, the regime of which resembled a prison and where patients did not receive treatment. The republican government, at great expense, carried out a radical reorganization of this hospital and moved it in 1927 to another place (Bakirkoy-in the vicinity of Istanbul). From 650 beds, it was increased to 1,500 in 1933. A few years ago, 2 more hospitals for mental patients were founded: in Manisa and El-Aziz. In 1925, 1,646 inpatients and 898 outpatients were treated in psychiatric hospitals; in 1932-2,939 inpatients and 1,904 outpatients.-A shelter for the deaf-mute, blind and defective children has been created so far only in Smyrna, where in 1932 52 deaf-mute, 12 blind and 4 defective children were taught.-A shelter for decrepit old people and incurable patients exists only in Istanbul, where it is maintained at the expense of the municipality. Medical care for workers exists only in individual large industrial enterprises.-Pharmaceutical affairs. By law of January 24, 1927, the number of pharmacies is limited to one per 10,000 inhabitants. In connection with this, the number of pharmacies fell from 718 in 1927 to 450 in 1929. Almost all Turkish pharmacies, except those attached to state medical institutions, are private enterprises. Fight against infectious and contagious diseases.

An important role in reducing the importation of infectious diseases into Turkey from abroad was played by the Main Directorate of Border Sanitary Protection, created by the republican government after the Treaty of Lausanne, which replaced the International Sanitary-Quarantine Council—a capitulatory institution that had only been concerned with preventing the penetration of epidemics from the Ottoman Empire into Europe. The new administration began to practice strict sanitary processing of arriving passengers by sea. Such processing points were established in a number of ports, including Tuzla, Kavaklar, and Urla. In Istanbul, hospitals with 100 beds were created for sick or suspicious sea passengers, and in Smyrna, hospitals with 50 beds. Bacteriological laboratories for research and analysis were also established in these ports. In 1924, 303 passengers were under treatment and examination in the Istanbul port hospital (Haydarpaşa), and in the Smyrna hospital, 489; in 1932, in the Istanbul hospital, 446, and in the Smyrna hospital, 857 passengers. In the fight against infectious diseases within the country, the republican government also had to start everything anew, as the old regime had not conducted any systematic fight against these diseases. The Ministry of Health began to strictly enforce the law on the mandatory declaration of infectious diseases, on the isolation of patients, and on disinfection (of course, all this was only possible in major centers). In 1930, mobile units for the fight against infectious diseases were created. A new law on improving water supply, where material resources allowed its implementation, also contributed to the reduction of epidemics. In 1925, a disinfection point was completed in Afyonkarahisar; then a disinfection station was built at the dispensary in Etimesgut (a model village near Ankara) and a number of other points. In 1925, there were 54 stationary and 102 mobile disinfection chambers (including formalin apparatuses) in Turkey, and in 1933, 57 stationary and 194 mobile. Plague. After the world war, plague was from time to time introduced into Istanbul from the Mediterranean basin. Through energetic measures taken from 1929, this importation was completely stopped. For the period 1924-29, 40 cases of plague were recorded in Turkey, of which 9 were fatal. Cholera. The Directorate took energetic measures against the importation of cholera into Turkey, which appeared in neighboring Iraq in 1927 and 1931. In 1931, in the eastern vilayets bordering Iraq, 26,306 primary and 15,760 booster cholera vaccinations were administered. Smallpox. A great danger in terms of importation into Turkey was represented by the epidemic of smallpox that developed in Syria in 1929-1931. During these two years, mass smallpox vaccination was carried out in the eastern vilayets of Turkey bordering or close to Syria, covering a total of 1,214,839 people. The remoteness of many areas, the lack of sufficient personnel, and the illiteracy of the population did not allow for universal smallpox vaccination, but still, for the period 1925-32, i.e., over 8 years, 10,781,584 vaccinations were administered (approximately 1.2-1.4 million vaccinations per year). Scarlet fever. From 1925 to 1933, 118,883 Dick reactions were performed, of which 81,329 were positive, and about 90,000 scarlet fever vaccinations were administered, half of which were repeated up to 4 times (mainly in schools). Diphtheria. Anti-diphtheria vaccinations for 1930, 1931, and 1932 totaled 16,681 primary, 13,846 secondary, and 12,076 tertiary. Rabies. Anti-rabies institutes are now present in 5 cities of Turkey (Istanbul, Sivas, Diyarbakır, Konya, and Smyrna). If one considers the vast distances of Anatolia, the difficulty and slowness of communication with individual localities, it becomes clear that this number is far from sufficient and that a significant percentage of those bitten die without receiving medical help. From 1925 to 1932 inclusive, 13,653 bitten persons were vaccinated in these 5 points (11,491 people in one Istanbul institute), of whom 60 died. Malaria. One of the most important fronts of Turkish public health is the fight against malaria, as this disease has been a real scourge for the country since ancient times. A serious fight against malaria was begun in 1925. The first "Malaria Commissions" were created in the Ankara, Aydın, and İzmir zones, where this disease was particularly prevalent. At present, this organization covers malarial areas of 24 vilayets, divided into 11 zones. Each zone has laboratories, malaria dispensaries with 5-10 beds, quinine distribution points, personnel for disinfecting standing water reservoirs. In Adana, there is a malaria hospital with 20 beds. In total, 90 doctors and 313 lower-ranking sanitary personnel work in the malaria commissions. The population of malarial zones is examined twice a year; patients undergo systematic treatment; quinine and eikunin are distributed free of charge to the population; in severe cases, treatment with salvarsan is applied. In addition, with funds from vilayet administrations and from the budgets of the Ministries of Health and Public Works, swamps are drained, stagnant water is drained, etc. From 1925 to 1932 inclusive, 143,855,278 m³ of swamps were drained and 378.1 km of canals were dug. During the same period, quinine was distributed: free of charge—10,747 kg; at a low price, through the Agricultural Bank—10,895 kg. Malaria is particularly prevalent in Turkey in the following vilayets: Ankara, Eskişehir, Çankırı, Kırşehir, Yozgat, Konya, Afyonkarahisar, Bilecik, Seyhan, İçel, Gaziantep, Antalya, Denizli, Aydın, Muğla, Smyrna, Manisa, Balıkesir, Bursa, Kocaeli, Istanbul, Samsun, Amasya. In all malarial zones, the following number of patients were treated over 8 years: 1925—25,418 people; 1926—488,679; 1927—704,615; 1928—769,970; 1929—1,100,719; 1930—1,438,044; 1931—1,660,915; 1932—1,677,908. These figures show that more than half of the residents of malarial zones suffer from this disease. To train qualified personnel for the fight against malaria, a special internship for young doctors has been opened at the Adana malaria hospital. Trachoma. Turkish public health has to wage a serious fight against trachoma, which is imported into Turkey from Arabia and Egypt and is therefore most widespread in the eastern vilayets: Urfa, Malatya, Gaziantep, Maraş, as well as in Adana. Since 1926, trachoma commissions have been created in these vilayets. In 1932, a dispensary with 15 beds was created in Urfa, and in Maraş and Siverek, dispensaries with 10 beds each. In a number of other localities, mobile units for the fight against trachoma have been created. In 1925, 12,588 trachoma patients sought treatment; in 1930, 81,497; in 1931—134,100; and in 1932—56,331. In 1925, the total number of beds for trachoma patients was 40, and from 1930—80. At the Adana hospital, lectures on trachoma are given for sanitary officials. Syphilis. Special commissions have also been created to fight syphilis. In a number of localities in Turkey, syphilis represents a serious scourge. Recently, the number of syphilitics registered by government doctors alone in the country has reached 118,527 people (63,109 women and 55,418 men). The actual number of patients throughout the country significantly exceeds these figures. Syphilis is most widespread in the following vilayets: Sivas, Balıkesir, Bursa, Bolu, Zonguldak, Kastamonu, Ordu, Samsun, Kayseri, Adana, as well as in large cities such as Istanbul and Smyrna. In 1921, the government issued a law on the examination of marriage applicants and the prohibition of marriage for syphilitics; subsequently, this prohibition was extended to other venereal diseases. In 1927, special dermatovenereal dispensaries were opened in Ankara and Smyrna, which gave positive results. In addition, two dispensaries were opened in Istanbul and 1 in Çaycuma (near Zonguldak). Syphilis commissions work in Sivas, Ordu-Fatsa, Çorşamba, Düzce, Orhaneli, and Balıkesir. The government is fighting prostitution by limiting the number of and increasing supervision over brothels, pursuing street prostitution, and medical examination of female personnel in bars and other establishments. Tuberculosis. Tuberculosis is a great scourge for Turkey. The fight against it began only under the new regime and very little has been done so far. In 1924, the first tuberculosis sanatorium with 50 beds was opened on Heybeliada Island (Princes' Islands—near Istanbul). In the infectious disease hospitals of Smyrna and Istanbul (in Haydarpaşa), 25 tuberculosis beds were opened each. By 1932, the number of beds in Heybeliada had increased to 130, and in Haydarpaşa—to 75. In addition, a number of tuberculosis dispensaries were opened. The first of these—in Istanbul in 1933; two others—in Ankara and Bursa—in 1930. In these dispensaries, special food is provided to poor patients; pneumothorax, X-ray examination, analyses, etc., are also performed. The number of patients visiting the dispensaries was: Table 2. Cities First-time visitors Repeat visitors 1931 1932 1931 1932 1284 3015 3004 3046 1422 591 2450 Total 4299 6050 2013 3318 In the sanatorium on Heybeliada from 1927 to 1932 inclusive, 1,110 in-bed patients completed treatment. During the same period, 3,648 people were treated in the tuberculosis department in Haydarpaşa, and in the Smyrna hospital—4,462 people.

In 1926, the first Anti-Tuberculosis League was founded in Smyrna, and in 1928 - in Istanbul. Great attention is paid to the fight against tbc by the 1930 Health Law, but due to lack of funds, most of its provisions have not been implemented. Protection of motherhood and childhood. The first steps have been taken only in regard to medical assistance to parturient women and pregnant women. Medical assistance for them is free, but not everywhere implemented. According to the law of 1/IV 1926, each municipality is obliged to have an orphanage and a 'Drop of Milk' for infants. In Istanbul, Smyrna and Konya there are day nurseries and a children's hospital. An Association for the Protection of Childhood has arisen, which in 1917 had 318 branches in the provinces, and in 1929 already 479. The growth in the number of mothers in maternity shelters and children in day nurseries is quite rapid, as shown by the following figures: table 3; Years Number of parturient women in maternity shelters Number of children in day nurseries and in consultations Number of parturient women who came for advice in day nurseries Number of children brought for consultation 1926 1027 1928 1929 1930 1931 1932 2 370 1930 2 957 2 864 4 707 7 671 9 53S 11816 Б1 68 Б9 86 88 290 292 6 397 8 345 6 471 8 124 14 363 22 177 22 168 Thus, parallel to the emancipation of Turkish women, their utilization of medical institutions is rapidly growing. In some cities there are school doctors and inspectors, in Istanbul in 1927 a preventorium for primary school pupils was founded. To combat child mortality, the ministry has established a number of maternity shelters with children's polyclinics. The work of these shelters is expressed in the following figures: hospitalized in 1926 161 women and 51 children; received outpatient treatment 1 930 women and 6 397 children; in 1932 hospitalized 2 370 women and 292 children; received outpatient treatment 11 816 women and 22 168 children. The first of these shelters were opened in 1925 in Ankara and Konya; in 1929 similar shelters were opened in Malatya, Karahisar, Erzurum, Adana and Corum, and in 1931 - in Balikesir and Van. The Health Law (1930) provides for a number of measures to combat child mortality, in particular the opening by municipalities in cities with a population of over 20,000 people of 'Houses of treatment and consultations for infants'. However, due to the severe economic crisis of recent years, municipalities, with the exception of Istanbul, have not yet opened these dispensaries. In Istanbul they were opened in 3 districts (Scutari, Besiktas, Edirnekapu). - Sanitary education. The ministry has published in recent years a number of brochures. In 10 years, 311,350 copies of various titles have been published. 60 different samples of posters have been published, but with a limited circulation due to lack of funds. 14 titles of scientific books on medicine and hygiene have been published. In addition, the ministry publishes a monthly journal on health 'Sahhie Medjmuasy'. - Medical education and personnel. There is a medical faculty in Istanbul, at which there is a dental school, a school of pharmacy and a school for midwives. The course at the medical faculty is 5-year - after a preliminary course at the natural sciences faculty according to the model of French universities. In the dental and pharmaceutical schools the course is 3-year, in the midwifery school - 2-year and free. According to the law 8/II 1923, every doctor upon receiving a diploma must serve 2 years in government service, and according to the 1926 law, in addition, complete a 3-month internship at the Malarial Institute. In Istanbul and Sivas there are schools for sanitary agents with a 2-year course. In Istanbul since 1925, the Red Crescent has established a school for nurses, the course is paid for by the Red Crescent, but upon completion of it, nurses are obliged to work for 5 years in the hospital they specify. By the law of 14/IV 1928, a corporate organization of doctors was created in the Medical Chambers, into which all doctors must enter. The Chambers manage all professional issues, but by no means are trade unions. In 1926, there were 589 doctors serving in the Turkish Ministry of Health, in addition 184 in departments and 286 in municipal service, for a total of 1,059 government doctors, 347 midwives (of which 327 in municipal service and 20 in departments) and 1,036 sanitary agents. In 1929, there were 2,644 male doctors and 12 women, 664 dentists, 1,311 government pharmacists, 801 midwives and 916 sanitary agents. Of the total number of doctors in government service in 1928, 1,310 were serving, in 1932 - 1,188, as well as 116 pharmacists, 1,246 male and female sanitary workers, 421 midwives, 216 nurses. - The health budget has been continuously growing in recent years, although it is still extremely insufficient given the country's enormous need for medical assistance. The health budget in T. grew according to central state appropriations from 147,476 Turkish lira in 1920 to 4,196,884 lira in 1933. In addition, the Border Sanitary Protection Directorate has its own budget. The budget of departments and municipalities for health is also growing. The municipal budget for health, about which little information is available, amounted to 1,532,231 lira in 1926 and 2,256,016 in 1928.