Policies for combatting tuberculosis did not have the same temporality in Western Europe as they did in Turkey, where the implementation of large-scale public measures against this “social disease” coincided with the appearance of antibiotics. Sanitary policies posed a challenge to the Turkish state. The young Republic, which was founded in 1923, co-constructed tuberculosis control policies with local Tuberculosis leagues and international organizations. This co-construction was facilitated by the fact that many doctors were both members of Tuberculosis leagues and close to the state apparatus. This proximity, in addition to the implementation of policies to control tuberculosis, resisted changes in government and regime.
The early years of the Republic: A growing concern faced with a lack of resources
While the dying Ottoman Empire, eager to modernize, was concerned about public health—tuberculosis in particular—no large-scale policy was implemented. The Ottoman Tuberculosis League, which was founded in 1918, ceased its activities in 1920 during the occupation of Istanbul. The sanitary issue reemerged with force after the war years, which sorely tested the population. As the new Kemalist authorities sought to build a strong nation, birth rate and child health became key issues. The Ministry of Health was created in 1920, a few years before the proclamation of the Republic. Public authorities estimated the number of persons with tuberculosis at one million, and the importance of the fight against this disease was emphasized in speeches, especially the one Mustafa Kemal gave before the Grand National Assembly on March 1, 1923. However, while state organizations were created for diseases that the government considered as especially threatening to the population, such as malaria and syphilis, this was not the case for tuberculosis. Despite the 1930 public hygiene law, which stated that public health in general—and the prevention of contagious diseases such as tuberculosis in particular—were the remit of the state, the young Turkish Republic devoted a small budget to health, and an even smaller one to tuberculosis. The problem was chiefly tackled by the Republic’s first Tuberculosis leagues, which were created in the 1920s in Izmir (1923), Balıkesir (1923), and Istanbul (1927) by doctors close to the Kemalist authorities. Led by associations rather than the state, the efforts to combat tuberculosis remained occasional, and focused especially on sanitary education, despite the founding of the first tuberculosis dispensaries and sanatoriums (Heybeliada in 1924, Erenköy in 1932).
The 1940s and 1950s: public policies, but not always state policies
The postwar context and the beginning of the Cold War were favorable to the establishment of larger scale tuberculosis control policies. A non-belligerent country before February 1945, Turkey was nevertheless hit hard by the war, and the country was one of the first beneficiaries of the Marshall Plan along with Greece. Poverty and the spread of diseases made the “population issue” even more central for governments, at a time when mortality from tuberculosis was estimated to be 262 per 100,000. This period is considered by medical historiography in Turkey as the pivotal moment in state control over the fight against tuberculosis, notably with the establishment of commissions that met regularly, beginning in 1949, to guide policy. However, at a time when barely 5% of the state budget was devoted to health, and when the management of hospitals was still largely local, the state mainly exerted control by delegating public services. Tuberculosis leagues, which multiplied and federated into a national association in 1948, were attributed public service missions for vaccination and the administration of urban dispensaries, along with the Red Crescent. Beginning in 1948, leagues were largely financed by the state through an income tax on leisure venues at the municipal level. One of their primary activities was propaganda, which presented tuberculosis as a “social disease,” and mainly emphasized the citizens’ responsibility to protect themselves, in keeping with a hygienist and patriotic perspective. The leagues also increased the number of dispensaries—in 1951 they managed 33 of them, as opposed to 11 for the Ministry of Health and Social Assistance—and trained visiting nurses. Moreover, the WHO, which was created in 1948, made Turkey one of the leading countries in the anti-tuberculosis fight. In 1950 the WHO founded an anti-tuberculosis center in Istanbul, which was managed in cooperation with the state and the Istanbul Tuberculosis league. From 1948, detection and BCG vaccination campaigns were first led on a small scale in Istanbul, in schools, within the army, and in factories. They gradually extended to the entire country, in cooperation with the WHO and UNICEF: over 20 million tests and 7 million vaccines were administered during the first campaign between 1953 and 1959. With the introduction of the first antibiotics, the status of tuberculosis changed to that of a curable disease. While preventive actions remained important, the curative aspect became essential in hospitals and dispensaries.
A disease controlled but not eradicated
Both preventive and curative activities continued to develop from the 1960s onward, but were increasingly taken over by the state. A Tuberculosis Control Directorate was officially created in 1963 within the Ministry of Health and Public Assistance to manage most anti-tuberculosis activities. This occurred in the context of “health socialization” plans, which sought to develop a nationwide access to health. In 1971, 162 of the 206 anti-tuberculosis dispensaries belonged to the ministry. Cooperation with Tuberculosis leagues nevertheless continued, especially to target the countryside and informal urban residential neighborhoods (gecekondu), via the creation of pilot zones. The mid-1970s marked the disappearance of tuberculosis as a central issue in Turkey, as the end of the primary anti-tuberculosis propaganda journal Yaşamak Yolu in 1975 clearly reflects. The number of tuberculosis hospital beds decreased, while outpatient treatments developed. In 1983, the Tuberculosis Control Directorate became a simple department within the Ministry of Health, and its share of the budget shrank gradually. While mortality plummeted (from 55 per 100,000 in 1960, to 8.8 in 1980 and 3.2 in 1990, according to the Ministry of Health’s figures), the disease was not entirely eradicated, especially as antibiotic resistance progressed. The late twentieth century, with HIV/Aids and the WHO’s declaration of tuberculosis as a “global emergency” in 1993, marked an important reconfiguration of the issue both globally and in Turkey, where the WHO’s DOTS strategy (Directly Observed Treatment, Short-Course) was implemented in the beginning of the twenty-first century.