Covid-19 and healthcare infrastructure in Turkey

By Ebru Kayaalp and Ibrahim Burhan Isik

As Covid-19 swept across the world in the early months of 2020, most countries adopted a similar approach to combatting the virus: encouraging social distancing and other protective measures at first, then imposing lockdowns and other more stringent measures as the virus spread. Despite these measures, many countries were still left with a death rate in the double digits: 11% in Spain, 14.4% in Italy, 17.3% in France, and 15.4% in the UK. By all accounts, Turkey—a country whose healthcare system is regarded as far from the best in Europe—should have had it much worse. But instead it seems to have fared much better, reporting a death rate from the virus of only 2.5%.[1]

What explains this strikingly low number?[2] Turkey’s government was quick to credit the low death rate to its own policies. Others speculated that it might come down to some virus-resistant quality of Turkish genes or to the virus-combatting power of the country’s traditional tripe soup. Still others suggested that the numbers had been doctored—that the virus was running rampant while the truth was hidden from the public. This essay instead adopts an infrastructural approach to the problem and offers a speculative effort to think about new ways of explaining the low numbers of death in Turkey.

Covid-19 has posed unique challenges to existing healthcare infrastructure. Its relatively low fatality rate (compared with, for example, Ebola, MERS, and SARS), high transmissibility, and long incubation period have allowed the virus to spread widely, leaving hospital wards swamped and without sufficient equipment and protective gear to care for patients effectively and safely. In a sense, the virus laid bare what some have called ‘our pre-existing health care crisis’ (Adams 2020). As Caduff suggests, ‘for decades governments have underfunded, understaffed and privatized healthcare systems across the world and these trends have exacerbated the impact of the pandemic’ (2020, 11).

Turkey’s health system is in many ways emblematic of these broader trends. Even before the pandemic hit, it was already apparent that there were huge holes in the country’s existing health infrastructure. We suggest, however, that it was precisely these ‘holes’ that account for Turkey’s success in combatting Covid-19—that the infrastructural deficiencies, lack of regulation, and socially, politically, and ethically fraught nature of Turkey’s healthcare system may help explain the country’s relatively low death rate. We argue that the system’s openness to manipulation and exploitation made it more flexible, lending it a degree of versatility and malleability that proved conducive for responding to Covid-19. The reasons behind Turkey’s seeming success story are thus counterintuitive: overworked healthcare professionals operating in challenging conditions; a privatized medical system that exploits patients; the gratuitous overuse of imaging technologies; the experimental use of drugs based upon no evidence-based science; and the government’s opaque use of PCR tests and Covid-19 codes.

The first two section of the essay argue that infrastructural problems in healthcare have actually given Turkey an advantage and reduced Covid-19 mortality rates, while the last section on medical tests and codes, which we also consider as parts of healthcare infrastructure, discuss that the Turkish government’s obscure reporting and counting of cases also partially account for the low mortality rates. Thus, two different seemingly contradictory processes are taking place at the same time:  while Turkey’s several infrastructural deficits were perhaps advantageous for coping with the Covid-19 pandemic, some others, such as tests and codes are being manipulated by the government, and the numbers collected officially do not represent the real situation. By using both ways, Turkey appears as a success story in its war against Covid-19. Though Turkey’s case is in some respects unique, an analysis of its response shines a light on the complex dynamics at play in healthcare in modern societies.

Based on interviews with healthcare professionals and patients in Turkey[3], this article discusses Turkey’s Covid-19 response under the headings of three different fields in Turkey’s health infrastructure: medical capacity, medical equipment and drugs, and medical tests and codes. Following Simone (2004), Anand (2011), and Harvey and Knox (2015), we do not consider infrastructure merely in physical terms—as limited to highways, pipes, cables, and wires—but rather as an assemblage of people, things, and practices that are constantly in formation across space and time. Infrastructure is always in motion, depending on myriad relations between humans and non-humans, and always open to modification and maneuvering.

In Turkey, the pre-Covid-19 healthcare system—with its ethical loopholes, medical ambiguities, bureaucratic opacities, structural insufficiencies, and market-oriented strategies—has been rearticulated and transformed in line with the emerging requirements of the pandemic; and it is this new infrastructure to which Turkey owes its ‘success’ in combatting the virus. Even though the government’s opaque coding and reporting system helped give the impression of low mortality rates, without the healthcare interventions that were offered (or were not), the Covid-19 mortality numbers would likely have been much higher.

By unpacking the involvement of a variety of actors and their interaction with one another, this article seeks to demonstrate how infrastructure policies regarding Covid-19 involve complex and multidimensional processes that cannot be comprehended within the framework of healthcare infrastructure as a fixed and predetermined entity.

Medical Capacity

From the beginning of the pandemic, the Turkish government touted the number of hospital beds and Intensive Care Units (ICUs) in the country. In terms of hospital beds per person, the Organization for Economic Co-operation and Development (OECD) ranks Turkey only 30th out of the 42 countries for which it provides data; but Turkey does have a high number of ICUs, 29.4 per 100,000 people (not counting children’s ICUs), a higher number than many other countries, such as Italy, which has only around 12.4.[4] The number of ICUs is perhaps the more important figure, as the healthcare professionals we interviewed reiterated several times that Turkey’s high number of ICUs has been instrumental in its Covid-19 response. But why does Turkey have such a large proportion of ICUs in the first place, especially given its relatively low bed capacity?

This discrepancy largely comes down to the fact that private hospitals in Turkey account for a disproportionate number of the country’s ICUs (42%), while having only 23% of the normal bed capacity.[5] The reason why the number of ICUs in private hospitals is so high relates to the privatized nature of Turkey’s medical system.[6] The government pays hospitals more for patients receiving care in ICUs, and private hospitals tend to keep them in these units for relatively longer, often on medically dubious grounds. On 20 March, Turkey’s Ministry of Health declared all private hospitals with at least two doctors specializing in infectious diseases, pulmonology, or internal diseases ‘pandemic hospitals’. The ICUs at these hospitals were also used in Turkey’s Covid-19 response. As one doctor explained to us, ‘Turkey is incredibly unplanned in the health sector. When I was working in a small city with a population of 300,000, there were five private hospitals and [only] one public hospital. And the private hospital where I was working had a [huge] ICU with a 115-person capacity. The private hospitals were making a lot of money from ICU patients.’ In this case, a pre-Covid-19 condition, the privatized healthcare system, turned into an advantage in handling the pandemic. 

ICUs require special staff, especially experienced nurses, to provide effective care. However, the OECD ranks Turkey as the second-worst country in terms of the number of nurses assigned to ICUs.[7] To make up for this, during the pandemic, staff who were not officially qualified were transferred to ICUs from other departments[8] or hospitals. One nurse told us that her ICU’s capacity was raised from 30 to 50 nurses through transfers from different departments within the hospital. Hospitals also took measures to increase their number of doctors. As one doctor in residency explained, ‘rather than having 10 night shifts, I was on duty 14 times [per month]. Also, the hospital created a personnel pool of interns to be transferred from other departments, such as neurosurgery, general surgery, dermatology, pediatrics, and even psychiatry, to the ICU.’ All the doctors we interviewed agreed that it was the heroic efforts of the healthcare personnel that allowed Turkey’s hospitals to handle the influx of Covid-19 patients. As one doctor bluntly put it,

we definitely fall short in numbers. But we, the doctors, are masochists. A doctor barely sees 10 to 15 patients [a day] in Europe. Here, we see hundreds of patients and can continuously work for 36 hours. After being exposed to these conditions for years, we have sort of developed a talent for working in crazy conditions. 

A doctor in residency puts forth a similar argument: ‘Our regular routine is already dense. The conditions of being a resident are incompatible with human rights. But we never say a word. We take it as a normal part of the training. Sleepless nights, the missing equipment … these are normal to us.’

As another doctor explained, these harsh working conditions left Turkey’s medical professionals well placed when faced with a crisis: ‘Doctors in Europe working under “normal” conditions can become paralyzed when confronted with exceptional times, while our healthcare staff—who are [already] overworked in “normal” times—are always well prepared. Because for a doctor in Turkey, normal is the exception.’ Thus, the overworking of medical professionals and the poor working conditions that have become a norm in the Turkish healthcare system proved to be a boon when dealing with the pandemic, allowing doctors and nurses to transition seamlessly from their already hectic routines to the new crisis of the pandemic.[9]

Medical Equipment and Drugs

In its fight against Covid-19, Turkey has benefitted from the relative lack of regulation governing the use of medical equipment and drugs in the country’s hospitals. This has given doctors in Turkey a freer hand, relative to their counterparts in Europe and the United States, to experiment with techniques and treatments which may prove effective against the virus but whose long-term consequences are poorly understood.

In terms of techniques, one distinctive feature of Turkey’s response to the virus is how quick the country was to embrace the use of imaging technologies for diagnostic purposes. Though Turkey lags behind other OECD countries in its number of MRI and CT units, it has always put them to greater use. According to a 2017 OECD report, Turkey has the highest per capita rate in the use of MRIs in the OECD; the report added that ‘MRI exams are being systematically prescribed for patients with various health problems, resulting in overuse of these tests’.[10] Where a normal MRI exam often takes 20 minutes or more, meaning that a single machine working around the clock will produce less than 80 images in a 24-hour period, MRI machines in Turkey routinely produce over 150 images a day, meaning that Turkey’s doctors, for better or worse, have become used to processing scans much more quickly than normal.[11]

The overuse of imaging technologies in Turkish hospitals is, like the country’s high number of ICUs and low number of hospital beds, a result of the economic dynamics of the healthcare system. The companies that sell these high-priced machines are in fierce competition, with each striving to outbid its competitors in offering low-cost scanning to hospitals[12], which then makes the mass use of imaging tests possible. Additionally, radiologists are compensated for each imaging test they prescribe, which creates an incentive for them to prescribe more tests.[13] Yet, as one doctor candidly told us, ‘Did this system help us in handling Covid-19? Yes, it did, especially at the beginning of the pandemic when the PCR tests were scarce…. We took advantage of this system. We did a lot of CT scans. We didn’t care much about PCR. This is how we had early diagnoses…. This practice decreased the mortality rates. But so many patients were needlessly exposed to the radiation.’ Thus, the scans made it possible to quickly detect lung lesions at an early stage, especially in cases where PCR tests were absent. There are several scientific studies (Cinkooglu et.al, 2020; Ye et.al, 2020) which also argue that COVID-19 pneumonia has a specific infiltration pattern in lung areas, and thus CT findings can guide doctors in the diagnosis of the disease.

Another point where Turkey differs from other countries is its unrestricted and unregulated use of untested medicines in Covid-19 treatment. According to a manual published by the Ministry of Health, doctors are free to begin prescribing medicine for Covid-19 treatment after they have made their clinical diagnosis, even without waiting for the results of the PCR test. In the first stage of the treatment, the medicine Hydroxychloroquineis used. If no progress is seen, then patients are given antiviral medicine Favipiravir, which is used for the treatment of influenza in Japan.[14]

Turkey’s minister of health underlines that this standard treatment approach is unique to Turkey: ‘No other country used the drug Hydroxychloroquine in the initial treatment of all suspected and positive cases [of Covid-19]. We stocked one million boxes of the drug before we even had our first case. Also, no other country uses the drug Favipiravir, which is imported from China, in the way we use it’.[15]

All the healthcare professionals we interviewed told us that they used these drugs without hesitation: ‘Our success was related to the early use of Hydroxychloroquine and Favipiravir. I always started with Hydroxychloroquine, followed by Favipiravir. And sometimes I offered the Favipiravir without waiting for a decrease in the patient’s oxygen level. Honestly, the Ministry [of Health] didn’t hold us to account for administering these drugs.’ But one doctor also mentioned that the effectiveness of these drugs was anecdotal at best: ‘Turkey is the country which uses Hydroxychloroquinethe most. But we have no real evidence-based science [to support] why we use this drug…. Favipiravir is the same. It was experimental too. The Ministry of Health has facilitated this process. I have never seen any medicine as easily accessible as these drugs.’ Where these drugs are strictly regulated outside of Turkey, and especially in Europe[16], because of their serious side effects and unproven results, doctors in Turkey were less bound by treatment and ethics regulations, which gave them the freedom to liberally administer them for the treatment of Covid-19.[17] 

To here, we have argued that undaunted efforts of healthcare professionals, market-oriented Turkish medical system, the overuse of imaging technologies and experimental use of drugs are the reasons that might explain the low mortality from Covid-19 in Turkey. In other words, the infrastructural problems in healthcare actually have given Turkey an advantage and reduced death rates. However, we think that there are also other factors that might explain the low mortality rates in Turkey; i.e., the government’s misleading official statistics, its shoddy ways of counting and registering of Covid-19 cases. The next section questions the validity of such low official Covid-19 statistics. To be sure, this argument casts some doubt on the explanations offered above for low rates of COVID-19, but our point is that even with misreporting and misleading statistics, these other conditions still likely played a role in reducing COVID-19 rates.

Medical Tests and Codes

According to Turkey’s Ministry of Health, four million tests had been carried out in Turkey by mid-July, with 216,000 cases of Covid-19 confirmed[18] For every million people, 48 thousand people were administered a PCR test, which is a relatively low figure when compared with a country like Germany, which has a similar population but administered 76 thousand PCR tests per million people.[19] Critics of Turkey’s government claim that officials have been manipulating the Covid-19 statistics by running a low number of tests and adding repeated tests to the total test ratio.[20] A new regulation issued on 19 June restricted PCR tests only to people with obvious Covid-19 symptoms, meaning that asymptomatic patients and people in contact with confirmed Covid-19 patients cannot receive tests. 

In our interviews, we spoke with people who had been diagnosed with Covid-19 but whose coworkers and families had been unable to get tested. A recovered Covid-19 patient told us that his wife never received a test even though they visited doctors several times. According to one nurse, ‘The government’s approach is that if there is no symptom, there is no need for tests. This is a problem. If someone is sick, all the people around that person must be tested. But this approach is not embraced in Turkey’. As Emrah Altındiş, a biologist, explains, ‘Even when a person is close to someone who has [been diagnosed with] the virus, if they don’t show any symptoms, they cannot get a test. The formula is simple: the fewer tests, the fewer [Covid-19] cases. This might be a political victory for the governing party. Yet, for society, fewer tests means a bigger risk’.[21]

Another point of controversy is the lack of transparency in testing figures, specifically the unknown number of repeated tests. A Turkish MP suggested in a statement before parliament that half of the tests in the official statistics might be repeats, if not more: ‘After the treatment of a sick person begins, a doctor can only declare the patient recovered after two [consecutive] negative tests’.[22] A nurse we interviewed echoed this sentiment:

The government says it has run 3.5 million tests so far. I am fairly certain that about one million of these tests were for healthcare personnel. As a nurse, I alone have had 15 tests. And my husband, who is a prison guard, has had lots of tests too. That adds up to 25 tests altogether for both of us. I don’t believe that tests have reached the general public. 

Yet another area in which a lack of official transparency has led to controversy is how sick people are registered in the health system, a process which is both opaque and inconsistent.[23] The World Health Organization offers two different codes for Covid-19 cases: U07.1, the code for patients with a positive PCR test; and U07.2, the code for patients diagnosed with the virus without a test. In Turkey, however, a different coding process, one based on the Australian Coding Standards, was introduced on 9 April: While Covid-19 patients with a positive PCR test are registered as U07.3, those without one are coded under U06.0. According to Turkey’s Ministry of Health, hospitals do not have to report cases under the latter code,[24] meaning that they are likely absent from the official figures. A doctor we interviewed explained that they need to show a positive PCR result to register a Covid-19 patient; without one, the system will not allow them to record the patient as a Covid-19 case even though he is clinically and epidemiologically diagnosed. Thus, when patients die before receiving a PCR test, or if their test results come back negative, their deaths are classified not as Covid-19 fatalities, but instead as cases of viral pneumonia or simply ‘contagious disease (natural death)’.

A recent correspondence (Bayram et. al. 2020) published in Lancet also supports this claim that the official numbers announced by the Turkish government conceals the actual rates of Covid-19 infection and mortality.[25] From March 11 to July 5, the average number of deaths occurred in Istanbul for the last 3 years were 23 232, while this number for 2020 is 27 955.  While the officially reported COVID-19 mortality in the same period was 2771, there were at least 1952 unexplained deaths in Istanbul for this period. The writers, who are all members of the Turkish Thoracic Society explain this discrepancy by non-compliance with WHO codes and Turkey’s reporting of only PCR positive cases.

Conclusion

During our fieldwork, we frequently witnessed that healthcare professionals attribute agency to the virus. In the words of one doctor, ‘Humanity and the virus are getting to know each other. We want to know about it. And the virus wants to know about us’. Emphasizing the importance of co-existence, healthcare professionals point out that the virus is an actor, just as people are: ‘The virus cannot live alone by itself in nature. To survive, it needs a host; and if it kills the host, then it simply cannot exist. So the virus will transform itself until coexistence, living with human beings, becomes possible’. In the case of the current Covid-19 crisis, what we are witnessing is thus a pandemic that involves not only a morphing virus but also a flexible infrastructural network dynamically interacting with that virus, often as much through chance and force of circumstance as through deliberate human action. This human-non-human infrastructure or “assemblage” can help us account not only for the virus’ presence but also the way its presence was rendered visible to various publics.

As we have tried to demonstrate in this essay, the healthcare infrastructure in Turkey has been transformed to meet the requirements of the pandemic. However, it seems that the ethical loopholes, medical ambiguities, bureaucratic opacities, structural insufficiencies, and market-oriented strategies within the existing healthcare system could only work well for a while.

After Turkey lifted COVID-19 measures in June and started the ‘normalization process’, the numbers of patients have undergone rapid increase and the ICU vacancy is in decline.[26] The rapid spread of Covid-19 might easily come to a point that can result a breakdown in the entire health infrastructure despite the various efforts that allegedly worked to quell and effectively stem the epidemic to date. The manipulation of PCR tests and Covid-19 codes in the healthcare infrastructure has been creating an opaque system which curtails any proper attempt of preparedness. Thus, the versatility and malleability of the system that may have proved conducive for responding to Covid-19 for the time being according to a wide swath of clinical professionals, may be undermined as the numbers of patients increase and the rhetoric of low levels of infection are no longer manageable.

Ebru Kayaalp, PhD, is an associate professor at Ankara Bilim University. Her main area of specialization is cultural anthropology and science and technology studies with a focus on disasters, experts and scientific knowledge.

İbrahim Burhan Isik is a doctoral student in the Department of Anthropology at the University of Arizona. His research is focusing on the influences of non-humans in resistance processes.


Notes:

[1] Figures from https://ourworldindata.org/coronavirus, as of 21 July 2020.

[2] For a similar discussion of low mortality rates in Turkey, see Balta and Ozel https://www.institutmontaigne.org/en/blog/battle-over-numbers-turkeys-low-case-fatality-rate

[3] For this article, we interviewed nine informants (five doctors, two nurses, and two Covid-19 patients), attended three webinars organized by doctors, and conducted media research. 

[4] https://dosyasb.saglik.gov.tr/Eklenti/36134,siy2018trpdf.pdf?0 ; https://www.advisory.com/research/global-forum-for-health-care-innovators/the-forum/2020/03/italian-hospitals

[5] https://dosyasb.saglik.gov.tr/Eklenti/36134,siy2018trpdf.pdf?0 

[6] https://sol.org.tr/haber/yogun-bakim-yatagi-sayisinin-arkasindaki-gercek-piyasa-istedi-sgk-destekledi-2520 

[7] https://www.birgun.net/haber/yogun-bakim-hemsiresi-sayisinda-sondan-ikinciyiz-hemsireler-tukenmek-uzere-295144 

[8] https://tybhd.org.tr/duyurular/guncel-durum-raporu-3/

[9] This argument does not mean that doctors in the emergency and urgent care clinics of the largest public urban hospitals in several countries are not overworked. What we want to highlight here is that the overworking conditions in the Turkish public hospitals were repeatedly described as a norm, rather than an exception by our informants.

[10] https://www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-2017_health_glance-2017-en 

[11] https://www.dw.com/tr/haz%C4%B1rolan-%C3%A7ekilen-150-mr-veya-tomografiden-120si-gereksiz/a-51009098

[12] As one of the doctors explained to us, the use of MRI and CT scans in Turkey is very cheap: ‘If it costs 120 USD in another country, it costs 3 USD here.’

[13] https://www.dw.com/tr/hazırolan-çekilen-150-mr-veya-tomografiden-120si-gereksiz/a-51009098 

[14] https://covid19bilgi.saglik.gov.tr/depo/tedavi/ilac/FAVIPIRAVIR_200_MG_TABLET.pdf 

[15] https://twitter.com/drfahrettinkoca/status/1250318172957208576

[16] https://www.ema.europa.eu/en/news/covid-19-chloroquine-hydroxychloroquine-only-be-used-clinical-trials-emergency-use-programmes As one doctor explained to us, the German government was reluctant to lift travel restrictions to Turkey because of Turkey’s use of Hydroxychloroquine. The drug is not in used Germany because the effects of the treatment and the risks associated with it are unclear.

[17] Even though the use of Hydroxychloroquine and Favipiravir were not scientifically proven as beneficial for COVID-19, doctors prescribe them with for Covid-19 patients in Turkey. When we asked the reason why the clinical discourse in Turkey assumed these drugs would be helpful, one of doctors told us that the evidence is totally based upon anecdotal success and the Turkish Ministry of Health depending on these stories started experimental treatments.

[18] https://covid19.saglik.gov.tr 

[19]https://www.worldometers.info/coronavirus/?utm_campaign=homeAdUOA?Si%23countries

[20] https://www.birartibir.org/siyaset/785-daha-yolun-basi-ve-turkiye-nin-kredisi-tukeniyor 

[21] https://www.birgun.net/haber/az-test-az-vaka-demek-iktidar-basari-pesinde-305628 

[22] https://www.birgun.net/haber/aile-calisma-ve-sosyal-isler-komisyonu-koronavirus-icin-toplanmiyor-299696 

[23] https://www.dw.com/tr/dünyada-covid-19-türkiyede-kuş-gribi/a-53127514 

[24] https://tig.saglik.gov.tr/TR,64880/covid–19-klinik-kodlama-kurali-hakinda-duyuru.html 

[25] Also for a similar argument see Elbek (2020). 

[26] https://t24.com.tr/haber/capa-tip-fakultesi-dekani-ndan-koronavirus-uyarisi-onceki-doneme-gore-gelen-hasta-sayisinin-neredeyse-iki-kati-kadar-basvuru-var-dikkat-edilmezse-sayi-yukselir,893200; https://www.birgun.net/haber/ankara-alarm-veriyor-iddiasi-kamu-hastanelerinde-bos-yatak-kalmadi-310038

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Adams, V 2020 Disasters and capitalism … and COVID-19, viewed 30 July 2020, <http://somatosphere.net/2020/disaster-capitalism-covid19.html/>

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Bayram, H., Kokturk, N., Elbek, O., Kılınç, O., Sayıner, A., and Dağlı, E 2020. Interference in scientific research on COVID-19 in Turkey. The Lancet, 396(10249), 463-464.

Caduff C 2020 What Went Wrong: Corona and the World after the Full Stop, Medical Anthropology Quarterly, doi: 10.1111/maq.12599.

Cinkooglu A, Hepdurgun C, Bayraktaroglu, Ceylan N, Savas R 2020 CT imaging features of COVID-19 pneumonia: initial experience from Turkey. Diagn Interv Radiol 26:308–314.

Elbek, O 2020 ‘COVID-19 Outbreak and Turkey’, Turk Thorac J, vol. 21, no. 3, pp. 215-216.

Harvey, P & Knox, H 2015 Roads. An Anthropology of Infrastructure and Expertise, Cornell University Press, Ithaca.

Simone, A 2004 ‘People as Infrastructure: Intersecting Fragments in Johannesburg’. Public Culture, vol. 16, no. 3, pp. 407-429.

Ye, Z, Zhang, Y, Wang, Y. et al. 2020 Chest CT manifestations of new coronavirus disease 2019 (COVID-19): a pictorial review Eur Radiol 30,4381–4389.

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