HEALTH AND SANITATION

Statistics concerning births, deaths and the incidence of disease available in 1968 were incomplete and consisted of estimates based on partial reporting covering the country's provincial capitals and district centers. For 1968 the crude birth rate was given provisionally by the United Nations as 43 per 1,000 of the officially estimated population. There was no comparable estimate of the death rate but on the basis of some 107,000 deaths listed by the World Health Organization as reported to provincial and district centers in 1966, the crude death rate for the entire country was probably on the order of 10 to 12 per 1,000 population. Based on the Turkish Demographic Survey, the United Nations estimated life expectancy at birth in 1960 to be 52.7 years. Infant mortality for the period 1960-64 was estimated as 165 per 1,000 live births. Inadequate public sanitation and a harsh winter climate in the interior of the country are the principal environmental factors affecting the level of health. The water supply is often unsafe for consumption because of pollution by human wastes or unsanitary methods of storage and distribution. Only a few of the larger cities have chlorinated and filtered water supply and sewage disposal systems built to modern standards. There is considerable urban crowding and sanitation services are hard pressed to meet the needs of the city dwellers. These conditions favor insects and other vectors of disease.

Many of the people, particularly the rural dwellers, do not relate causative factors to the spread of disease. There is also a conflict between traditional religious beliefs and modern scientific concepts. The ancient Islamic values of many of the people involve a fatalistic acceptance of disease and physical distress as expressions of the divine ordering of nature, not to be challenged by mere humans. Through educational programs and religious reforms, and above all through the demonstration effect, there is growing acceptance of modern medicine, particularly in its curative aspects. Even the more remote villagers in the late 1960's were receptive to mass immunization or village sanitation programs and sought modern medical aid, if available, in the event of sickness.

During the 1960's according to the World Health Organization, the most prevalent communicable diseases reported at registration centers in the provincial and district capitals were trachoma and tuberculosis (see table 7). Trachoma, a blinding eye infection and very contagious, is widespread throughout the Middle East. In Turkey its incidence is greatest in southern Anatolia and in the southeast. During the 1960's with the aid of modern drugs, the government's Directorate of Health was conducting a campaign

Source: Adapted from World Health Organization. Second Report on the World Health Situation, 1957-60, 1963; and ibid., Third Report on the World Health Situation, 1961–64, 1967.

against trachoma. In 1967 there were five special eye clinics with facilities for several hundred bed patients, and over 50 control dispensaries in areas where the disease was most prevalent. Because of increased diagnostic effort, the number of cases reported increased considerably during the early years of the campaign. Inadequate housing, crowding and poor diet combine to make tuberculosis one of the principal disease problems, particularly in urban areas, despite an intensive campaign to control it. Pulmonary tuberculosis accounted for about 5 percent of all reported deaths in 1964, but the government estimated that over 50,000 new cases would appear each year and that there were over half a million cases of active tuberculosis in the country (see table 8). Other respiratory diseases occurring in the country include influenza, pneumonia, whooping cough (among children), and diphtheria. Inoculation has helped to reduce the incidence of whooping cough and diphtheria among children but does not reach all of the rural people.

Malaria has long been endemic to the country, and in 1925 when control measures were begun, about half the population was thought to be suffering from the disease. Since then control programs have progressively reduced the incidence rate. The "Exceptional Malaria Law," enacted in 1942, introduced antimalaria measures in areas with over 7 million inhabitants, and by 1950 insecticides were being used on a wide scale and modern medication was being made available to patients. In 1964 only

Table 8. Most Important Causes of Deaths Reported in Turkey's Registration Districts

Source: Adapted from World Health Organization, Second Report on the World Health Situation, 1957-60, 1963; and ibid., Third Report on the World Health Situation, 1961–64, 1967.

about 5,000 new cases of malaria were reported. Most occurred in the southeast coastal region.

Syphilis and gonorrhea are found, particularly in the cities, towns, and villages of central and western Turkey. First efforts to control venereal diseases were made in 1926 and since then the numbers of venereal disease control dispensaries and mobile control units have progressively increased. Typhoid and paratyphoid fever, small pox, tetanus and typhus are being controlled, if not entirely eliminated by vaccinations, including those administered on a mass basis by mobile immunization teams. Measles is an important disease of childhood and remains endemic throughout the country. Occasionally it occurs in epidemic form among village children.

Health Services and Facilities

The government is constitutionally responsible for improving health in the country and since World War II there have been many advances in health facilities, largely through the efforts of the government. The Ministry of Health and Social Welfare is the government's main agency for carrying out public health programs. A General Directorate of Health is the Ministry's planning and operating agency. The Directorate has a Director of Health Services in each province with regional responsibilities, but many of the Directorate's functions are highly centralized. It plans preventive programs such as mass immunization drives, supervises government hospitals and dispensaries, sets standards and fees for the medical profession, inspects factories for compliance with health and safety regulations, conducts research and special training courses, and oversees the work of the public

health officers in the provinces. In addition it has under its supervision the School of Hygiene, where health officers and physicians take special training, and the Refik Saydam Institute of Hygiene, a laboratory that does work in research, diagnosis, and manufacture of vaccines and serums.

In early 1967 the country had a total of 688 hospitals and other health facilities, exclusive of those pertaining to the Armed Forces, with an overall rated capacity of 75,016 beds (see table 9). The ratio of hospital beds to population was 2.3 per 1,000. Over half of the bed capacity (41,979) was provided by 511 state-maintained institutions. In addition to installations operated by the General Directorate of Health, there is a network of facilities operated by the Workers Insurance Institution, under the Ministry of Labor. Care at state-owned medical installations is free for all citizens who lack the means of paying. Eligibility for such care is determined by local representatives of the Ministry of Health and Social Welfare. In fiscal year 1966 total government expenditure on health services as reported by the World Health Organization amounted to LT976 million (LT9.00 equals US$1.00-see Glossary). This represented nearly 9 percent of all current expenditure and was equivalent to about LT31 per capita.

Among the country's private medical facilities are the infirmaries and hospitals maintained by the larger private business enterprises in compliance with the Labor Code (see ch. 21, Labor Relations and Organization). In 1965 there were 54 private hospitals and clinics in the larger cities, established as profit-making institutions. They had a rated capacity of some 1,500 beds. Philanthropic organizations supported over 100 nonprofit health installations in 1965 mainly in the cities. These facilities had a rated capacity of over 5,500 beds.

At the beginning of 1967 there were 11,335 doctors licensed to practice medicine in the country. About 70 percent or 8,005 were

Source: Adapted from World Health Organization, Supplement to Third Report on the World Health Situation, 1965-1966 (PHA/68.1), 1968.

in full-time government service. Others had part-time government contracts, and only about 10 percent were in wholly private practice. The overall doctor to population ratio was 1 to 3,200 but the services of the doctors were not evenly distributed. About twothirds were practicing in Istanbul, Ankara, and Izmir, where only about 5 percent of the total population lived. The rural villages with two-thirds of the population were served by about 15 percent of the doctors.

In the late 1960's there was a great shortage of trained nurses; traditionally nursing has been considered an employment for women of low status. In 1966 the country had about 3,000 fully trained registered nurses-less than one-third the number of doctors in practice. There were nearly 2,000 nurses aides that were trained as assistants. As with the doctors, the nurses were concentrated in the urban areas. In addition to nurses there were about 5,000 professional midwives with medical training who mainly served the rural areas.

About 2,000 dentists were licensed to practice in the country. Well over half of this number worked in the Ankara, Istanbul, and Izmir provinces. Although there is no formally recognized training program for dental technicians, there are individuals in both rural areas and cities who provide some dental services, mostly learned from working in dentist's offices. There were 1,933 pharmacists reported by the World Health Organization in 1966, of whom some 80 percent were employed by private firms in Istanbul, Ankara, and Izmir.

The government health services employ sanitarians (saglik memurus) to accomplish many public health tasks. Trained in public hygiene, first aid, and other elementary medical techniques, their usual duties include regular monthly visits to villages to improve sanitary conditions, medical examinations in villages, and immunizations against diseases. There were about 6,000 sanitarians in government service in 1966.

Since 1936 various forms of social insurance have been introduced. Most of the coverage is provided by the government's Worker's Insurance Institution and the Pension Fund of the Republic of Turkey. Participation is compulsory for workers in establishments employing 10 or more persons and the program includes industrial accident, disease, old age, sickness and maternity insurance. There are also a number of quasi-governmental or private mutual benefit funds, some of which are aided by contributions from employers (see ch. 21, Labor Relations and Organization).

There are many private and international groups active in pro