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Trends in mortality in Turkey, 1960--1995

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Trends in mortality in Turkey, 1960--1995

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Content INFORMATION TO USERS This manuscript has been reproduced from the microfilm master. U M I films the text directly from the original or copy submitted. Thus, some thesis and dissertation copies are in typewriter face, while others may be from any type of computer printer. The quality of this reproduction is dependent upon the quality of the copy submitted. Broken or indistinct print, colored or poor quality illustrations and photographs, print bleedthrough, substandard margins, and improper alignment can adversely affect reproduction. In the unlikely event that the author did not send U M I a complete manuscript and there are missing pages, these w ill be noted. Also, if unauthorized copyright material had to be removed, a note w ill indicate the deletion. Oversize materials (e.g., maps, drawings, charts) are reproduced by sectioning the original, beginning at the upper left-hand comer and continuing from left to right in equal sections with small overlaps. Photographs included in the original manuscript have been reproduced xerographically in this copy. Higher quality 6" x 9” black and white photographic prints are available for any photographs or illustrations appearing in this copy for an additional charge. Contact U M I directly to order. ProQuest Information and Learning 300 North Zeeb Road, Ann Arbor, M l 48106-1346 USA 800-521-0600 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. TRENDS IN MORTALITY IN TURKEY, 1960-1995 by Ne§e Kanoglu A Dissertation Presented to the FACULTY OF THE GRADUATE SCHOOL UNIVERSITY OF SOUTHERN CALIFORNIA In Partial Fulfillment of the Requirements for the Degree DOCTOR OF PHILOSOPHY (Political Economy and Public Policy) December 2000 Copyright 2000 Ne§e Kanoglu Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. UMI Number: 3041478 Copyright 2000 by Kanoglu, Nese All rights reserved. U M I* UMI Microform 3041478 Copyright 2002 by ProQuest Information and Learning Company. All rights reserved. This microform edition is protected against unauthorized copying under Title 17, United States Code. ProQuest Information and Learning Company 300 North Zeeb Road P.O. Box 1346 Ann Arbor, Ml 48106-1346 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. UNIVERSITY OF SOUTHERN CALIFORNIA 1HIORAOUATI SC H O O L UMVOUITY P A R K LO S ANOHJB. CALIFORNIA 900f? 77ns dissertation, written by ............................... under the direction of Dissertation C o mmittee, and approved by sU its mem bers* has been presented to and accepted by The Graduate School, in partial fulfillment of re quirements for the degree of DOCTOR OF PHILOSOPHY Dun of C ndm tt Studies Date.... DISSERTATION COMMITTEE Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. This thesis is dedicated to the best parents one could ever have: my wonderful mother, Giilender §eref, and my great father, Adil §eref. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ACKNOWLEDGEMENTS I want to thank the chair of my thesis committee: Richard A. Easterlin, Univer sity Professor. Words are not enough to describe his guidance, constant support, encouragement, and understanding. A special thanks must go to my thesis committee member Laurie A. Brand, Professor of International Relations, not only for being a great professor, but for being a great person as well. I have never forgotten the period when I was expecting my first child, taking classes, and also working as a research assistant for Professor Brand. Unlike many other professors, instead of immediately telling me what my taks were, she would begin by asking me how my family and I were doing. Many many thanks Professor Brand for everything you have done for me. I am particularly indebted to David M. Heer and Maurice Van Arsdol, Pro fessors of Sociology, for supporting me throughout my Ph.D. study. I learned the foundations of population research from Professor Heer and Professor Maurice Van Arsdol through attending their classes and seminars. They also encouraged me to apply for the Population Reference Bureau fellowship and the Fred H. Bixby m Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Foundation fellowship. Through these fellowships, I was able to decrease my non- research work load, and have more time for my research and with my family. My special thanks must go to these two great organizations for supporting me during the most difficult period of my career. An additional note of thanks also must go to Professor John E. Elliott, the chair of Political Economy and Public Policy Program, for his contributions to my academic life. He widened my horizon through his great lectures, and made me decide to enroll in the PEPP Ph.D. program. Dr. Farideh Motamedi deserves special thanks for being there for me during my life at USC. She understood the problems of international students, and helped each one of them in adjusting to the new and different life at University of Southern California (USC). Dr. Motamedi, you will always have special place in my heart. There are many other people at USC who contributed to my happiness, but it is not possible to mention each one of them. Among them Amentha Dymally, Sandra Dymally, and Sandra Morales deserves special recognition. They made my life easier and happier. I also want to thank to the State Planning Organization of Turkey for their support in pursuing my educational goals. The staff of the State Planning Or ganization, the Ministry of Health, especially §ahinde Yalginkaya, State Institute of Statistics, and UNICEF of Turkey deserves sincere appreciation due to their support during the data collection phase of the thesis. iv Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Finally, none of this would have been possible without my friends and family. A special thanks must go to my dearest friends: Serpin Demirciler, Dge Ozersen, Birsen Ulupmar, Deborah Senior, and Samira Salem, for always being there for me. You will always be in my heart. I am very greatful to my parents, who always supported me in whatever I have done. I am also indebted to my aunts, Nadiye Baydar, Emine Kavaklioglu, and Fatma Murat for their support in every step of my life. Sincere thanks also go to my uncles Mustafa Murat, Mehmet Murat, and Omer Murat for always being there for me. Many thanks also must go to my grandfathers, Haci Omer Murat, and Ali Osman §eref, my grandmothers, Ummiihan Murat and Hanife §eref, my sister Sibel Kancaoglu, and my brother Osman §eref, and each other member of my extended family who were always there when I needed. I also want to thank to my daughter, Dilge Giildehen Kanoglu, for making me the happiest person in the whole entire world through her love and her beautiful smile, and to my son Doruhan Kanoglu for his kisses, hugs, and great sense of humor. You two mean more than anything to me. Above all, I owe everything to my husband, Utku Kanoglu, who even in the hardest times, never stopped believing in me. Utku, you are my love and my best friend. Thank you for being who you are. v Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. CONTENTS ACKNOWLEDGEMENTS iii LIST OF TABLES ix LIST OF FIGURES xiii ABBREVIATIONS xv ABSTRACT xviii 1 INTRODUCTION 1 2 LITERATURE REVIEW 7 3 OVERVIEW OF DEMOGRAPHIC AND SOCIO-ECONOMIC CHANGES IN TURKEY SINCE 1923 19 3.1 Overview of Demographic Changes in Turkey Since 1923 .............. 20 3.2 Overview of Economic Changes in Turkey Since 1923 .................... 32 3.3 Overview of Other Socio-economic Changes in Turkey Since 1923 38 4 METHODOLOGY AND DATA 48 4.1 D a ta ............................................................................................. 48 4.2 Methodology ........................................................................................ 53 5 TRENDS IN MORTALITY IN TURKEY, 1960-1995 59 5.1 Trends in Overall Mortality in Turkey During the 1960-1995 Period 60 5.2 Trends in Cause-specific Mortality in Turkey During the 1960-1995 P e rio d ......................................................................................... 65 5.2.1 Cause of Death Patterns in 1960 ........................................... 65 5.2.2 Cause of Death Patterns in 1995 ........................................... 66 5.2.3 Changes in Mortality Patterns During the 1960-1995 Period 67 vi Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 6 PNEUMONIA 73 6.1 Trends in Pneumonia in T urkey......................................................... 74 6.2 Factors Affecting Mortality From Pneumonia.................................... 79 6.2.1 Pneumonia and Public Policy In itiativ es............................... 87 6.2.2 Pneumonia and Economic Factors........................................... 94 7 ENTERITIS AND OTHER DIARRHOEAL DISEASES 107 7.1 Trends in Enteritis and Other Diarrhoeal Diseases in T u rk e y .................................................................................. 108 7.2 Factors Affecting Mortality from Enteritis and Other Diarrhoeal Dis eases .......................................................................................................... 113 7.2.1 Enteritis and Other Diarrhoeal Diseases and Public Policy Initiatives..................................................................................... 119 7.2.2 Enteritis and Other Diarrhoeal Diseases and Economic Factors 128 8 PREGNANCY, CHILDBIRTH, INFECTIONS OF NEWBORN, AND OTHER DISEASES PECULIAR TO EARLY INFANCY 139 8.1 Trends in Pregnancy, Childbirth, Infections of Newborn, and Other Diseases Peculiar to Early Infancy in T urkey........................................ 140 8.2 Factors Affecting Mortality from Pregnancy, Childbirth, Infections of Newborn, and Other Diseases Peculiar to Early In fa n c y ................145 8.2.1 Pregnancy, Childbirth, Infections of Newborn, and Other Diseases Peculiar to Early Infancy and Public Policy Initiatives 148 8.2.2 Pregnancy, Childbirth, Infections of Newborn, and Other Diseases Peculiar to Early Infancy and Economic Factors......................................................................... 167 9 TUBERCULOSIS 177 9.1 Trends in Tuberculosis in T u rk e y ..........................................................178 9.2 Factors Affecting Mortality from Tuberculosis.............................................................................................. 183 9.2.1 Tuberculosis and Public Policy Initiatives ...............................193 9.2.2 Tuberculosis and Economic F acto rs...........................................199 10 OVERVIEW OF CAUSES OF MORTALITY DECLINE IN TURKEY, 1960-1995 204 10.1 Importance of Public Policy Initiatives in the Mortality Decline . . 204 10.1.1 The One-party Period: 1923-1950 .......................................... 206 10.1.1.1 Health Policies During the One-party Period . . . . 207 10.1.1.2 Education Policies During the One-party Period . . 209 10.1.1.3 Other Policies Affecting Health During the One- party Period ................................................................ 213 vii Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 10.1.2 The Menderes Period: 1950-1960 ........................................... 214 10.1.2.1 Health Policies During the Menderes Period . . . . 215 10.1.2.2 Education Policies During the Menderes Period . . 217 10.1.2.3 Other Policies Affecting Health During the Menderes P eriod............................................................................ 218 10.1.3 The Post-1960 Military Coup Period: 1960-1980 .................. 219 10.1.3.1 Health Policies During the Post-1960 Military Coup P eriod............................................................................220 10.1.3.2 Education Policies During the Post-1960 Military Coup Period ................................................................224 10.1.3.3 Other Policies Affecting Health During the Post- 1960 Military Coup Period...........................................228 10.1.4 The Open-market Economy Period: 1980-Today..................... 231 10.1.4.1 Health Policies During the Open-market Economy P eriod............................................................................233 10.1.4.2 Education Policies During the Open-market Economy P e rio d ..........................................................234 10.1.4.3 Other Policies Affecting Health During the Open-market Economy Period.....................................237 10.2 Importance of Economic Factors in the Mortality D ecline..................................................................................... 243 11 CONCLUSION 247 REFERENCE LIST 255 viii Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. LIST OF TABLES 3.1 Population trends in Turkey................................................................... 22 3.2 Number of persons per square kilometer.............................................. 25 3.3 Percent distribution of population by place of residence.................... 26 3.4 Internal migration................................................................................... 27 3.5 Crude birth rate (CBR), crude death rate (CDR), infant mortality rate (IMR), and total fertility rate (TFR)........................................... 29 3.6 Life expectancy...................................................................................... 30 3.7 Per capita gross domestic product (GDP) in 1990 Geary-Khamis Dollars...................................................................................................... 33 3.8 Percentage distribution of labor force, by sectors................................ 36 3.9 Proportions of GDP by sector of origin................................................ 37 3.10 School enrollment, by school levels........................................................ 39 3.11 Literacy rate for population age six and over, by sex.......................... 40 3.12 Number of health personnel, 1923-1995................................................ 43 3.13 Students in and graduates from facilities of medicine......................... 44 3.14 Institutions providing curative services................................................. 45 3.15 Budget of the Ministry of Health and Social Assistance..................... 46 3.16 Municipalities with more than 3,000 population that have scientifi cally appropriate water establishments................................................. 47 ix Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 4.1 Mid-year city population by level of development................................ 50 4.2 Distribution of mid-year city population, by age groups.................... 52 4.3 Distribution of mid-year city population, by sex................................. 53 4.4 Distribution of provinces, by level of economic development.............. 56 5.1 Crude death rate (per 1,000 population) for all causes, by level of development............................................................................................. 62 5.2 Age-specific death rate (per 1,000 population) for all causes.............. 63 5.3 Crude death rate (per 1,000 population) for all causes, by sex. . . . 64 5.4 Percentage distribution of deaths by leading causes in 1960............... 65 5.5 Percentage distribution of deaths by leading causes in 1995............... 67 5.6 Contribution of selected causes of death in mortality decline in Turkey during 1960-1995 period......................................................................... 70 5.7 Percentage distribution of province population in 1990, by level of development and by age......................................................................... 71 6.1 Crude death rate (per 100,000 population) for pneumonia, by level of development......................................................................................... 76 6.2 Age-specific death rate (per 100,000 population) for pneumonia. . . 77 6.3 Crude death rate (per 100,000 population) for pneumonia, by sex. . 78 6.4 Percentage of children with ARIs symptoms, by mother’s education. 88 6.5 Percentage of children with ARIs symptoms taken to a health facil ity, by mother’s education...................................................................... 88 6.6 Percentage of children with ARIs symptoms that are not given any treatment, by mother’s education.......................................................... 89 6.7 Vaccination in 1993, by mother’ s education.......................................... 91 6.8 Nutritional status of children in Ahath/Antalya, by age and by sex. 95 x Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 6.9 Nutritional status, by mother’ s education............................................. 98 7.1 Crude death rate (per 100,000 population) for enteritis and other diarrhoeal diseases, by level of development............................................ 110 7.2 Age-specific death rate (per 100,000 population) for enteritis and other diarrhoeal diseases............................................................................I ll 7.3 Crude death rate (per 100,000 population) for enteritis and other diarrhoeal diseases, by sex......................................................................... 112 7.4 Prevalence of diarrhoea in 1993, by mother’s education......................... 121 7.5 Treatment of diarrhoea in 1993, by mother’s education......................... 121 8.1 Crude death rate (per 100,000 population) for pregnancy, childbirth, infections of newborn, and other diseases peculiar to early infancy, by level of development..............................................................................142 8.2 Age-specific death rate (per 100,000 population) for pregnancy, child birth, infections of newborn, and other diseases peculiar to early infancy. .....................................................................................................143 8.3 Crude death rate (per 100,000 population) for pregnancy, childbirth, infections of newborn, and other diseases peculiar to early infancy, by sex...........................................................................................................144 8.4 Infant mortality in 1983 (in 1,000), by parents’ education..................... 148 8.5 Infant mortality in 1983 (in 1,000), by parents’ literacy....................... 149 8.6 Infant mortality in 1983 (in 1,000), by mothers’ age at giving birth. 150 8.7 Infant mortality in 1983 (in 1,000), by birth interval.............................. 151 8.8 Prenatal care (PNC) in 1993, by mother’s education............................. 151 8.9 Infant mortality in 1983 (in 1,000), by number of children....................153 8.10 Percentage of surviving children in 1989, by mother’ s education. . . 154 8.11 Median duration of breastfeeding in 1993, by region.............................. 156 8.12 Initial breastfeeding in 1993, by mother’ s education...............................158 xi Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 8.13 Maternal mortality, by age group..............................................................165 8.14 Nutritional status in 1993, by some demographic characteristics. . . 169 8.15 Frequency of breastfeeding in 1993, by mother’s education................... 172 9.1 Crude death rate (per 100,000 population) for tuberculosis, by level of development............................................................................................ 180 9.2 Age-specific death rate (per 100,000 population) for tuberculosis.. . 181 9.3 Crude death rate (per 100,000 population) for tuberculosis, by sex. 182 9.4 The general rate of infection for tuberculosis in 1953, by age groups. 195 9.5 Percentage of children 12-23 months who had received BCG vacci nation in 1993, by mother’ s education......................................................196 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. LIST OF FIGURES 3.1 Percent distribution of population by place of residence.................... 26 3.2 Life expectancy at birth........................................................................ 31 3.3 Literacy rate for population age six and over, by sex......................... 40 5.1 Crude death rate (per 1,000 population) for all causes, by level of development............................................................................................. 62 5.2 Age-specific death rate (per 1,000 population) for all causes............. 63 5.3 Crude death rate (per 1,000 population) for all causes, by sex. . . . 64 6.1 Crude death rate (per 100,000 population) for pneumonia, by level of development........................................................................................ 76 6.2 Age-specific death rate (per 100,000 population) for pneumonia. . . 77 6.3 Crude death rate (per 100,000 population) for pneumonia, by sex. . 78 7.1 Crude death rate (per 100,000 population) for enteritis and other diarrhoeal diseases, by level of development............................................ 110 7.2 Age-specific death rate (per 100,000 population) for enteritis and other diarrhoeal diseases............................................................................I ll 7.3 Crude death rate (per 100,000 population) for enteritis and other diarrhoeal diseases, by sex.........................................................................112 8.1 Crude death rate (per 100,000 population) for pregnancy, childbirth, infections of newborn, and other diseases peculiar to early infancy, by level of development............................................................................. 142 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 8.2 Age-specific death rate (per 100,000 population) for pregnancy, child birth, infections of newborn, and other diseases peculiar to early infancy. .................................................................................................... 143 8.3 Crude death rate (per 100,000 population) for pregnancy, childbirth, infections of newborn, and other diseases peculiar to early infancy, by sex...........................................................................................................144 9.1 Crude death rate (per 100,000 population) for tuberculosis, by level of development............................................................................................180 9.2 Age-specific death rate (per 100,000 population) for tuberculosis. . 181 9.3 Crude death rate (per 100,000 population) for tuberculosis, by sex. 182 xiv Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ABBREVIATIONS ANAP Anavatan Partisi AP Adalet Partisi ARIs Acute respiratory infections BCG Calmette vaccine BMI Body mass index CARI Control of acute respiratory infections CBR Crude birth rate CDC The U.S. Centers for Disease Control CDR Crude death rate CHP Cumhuriyet Halk Partisi DP Demokrat Parti DPT Diphtheria, pertussis, and tetanus vaccination DYP Dogru Yol Partisi EODD Enteritis and other diarrhoeal diseases FAO Food and Agriculture Organization of the United Nations FPAT Family Planning Association of Turkey Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. GDP Gross domestic product GNP Gross national product HU Hacettepe University Institute of Population Studies IMR Infant mortality rate INH Izoniazid iu Istanbul University JICA Japanese International Cooperation Association KiTs Kamu Dctisadi Te§ebbiisleri KOYl Kalkinmada Birinci Derecede Oncelikli Yoreler KOY2 Kalkmmada Ikinci Derecede Oncelikli Yoreler LDCs Less developed countries MEG Modern economic growth MOH Ministry of Health and Social Assistance MR Mortality revolution NCHS The U.S. National Center for Health Statistics ORS Oral rehydration salts ORT Oral rehydration theraphy PAS Para-amino-salicylic acid PCIODI Diseases related to pregnancy, childbirth, infections of newborn, and other diseases peculiar to eaxly infancy PNC Prenatal care Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. SD Standard deviation SIS State Institute of Statistics SPO State Planning Organization TAQSAV Turkish maternal-child health and family planning foundation TFR Total fertility rate TL Turkish lira TR Republic of Turkey TRT Turkish Radio and Television Establishment TT Tetanus toxoid vaccination TUBITAK Turkish Scientific and Technical Research Council UN United Nations UNESCO United Nations Educational, Scientific and Cultural Organization UNICEF United Nations Children’s Fund UNPFA United Nations Population Fund USC University of Southern California WHO World Health Organization W W I First World War W W II Second World War xvii Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ABSTRACT The purpose of this study is, first, to analyze the trends in mortality in Turkey during the 1960-1995 period, and, then, to determine whether economic develop ment or public policy based on improvements in medical/technological knowledge was primarily responsible for the mortality decline. Data for this study are mainly taken from Death Statistics, published by the State Institute of Statistics, and Health Statistics, published by the Ministry of Health and Social Assistance. In this study, the causes of death approach is used. The causes of death that dominated mortality trends during the period were: pneumonia, enteritis and other diarrhoeal diseases, pregnancy, childbirth, infections of newborn and other diseases peculiar to early infancy, and tuberculosis. Study results showed that both modern economic growth and mortality revolu tion in Turkey occurred around 1950. However, this result does not mean that the mortality decline in Turkey was a simple by-product of modem economic growth. Instead, public policy initiatives based on better knowledge were the driving source of mortality decline in Turkey. In particular, the Adnan Menderes governments xviii Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. were very effective in putting health-related policies into practice by prioritizing infrastructure, health and education in public investments, and encouraging pri vate sector in other investments. Moreover, their policies favoring less developed regions contributed positively to the mortality decline in these areas. As a result, less developed regions not only have lower mortality compared to more developed regions, but also experienced a greater rate of decline in mortality. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. CHAPTER 1 INTRODUCTION This study has two main purposes: First, to analyze the trend in mortality in Turkey during the 1960-1995 period, and second, to identify the factors responsible for the trend, i.e. to analyze whether the economic development or public policy initiatives based on medical/technological improvements were the main factors re sponsible for the mortality decline in Turkey during the 1960-1995 period. There is much more agreement on the fact of mortality decline in less devel oped countries (LDCs) such as Turkey than on its causes (Easterlin 1996, ch. 1 and 6). Considerable disagreement remains about whether the decline in mortality has been primarily a by-product of social and economic development as reflected in private levels of nutrition, clothing, housing, transportation, medical care, and water supply, or whether it was primarily produced by public policy initiatives with an unprecedented scope or efficacy. A third possible explanation is that med ical/technological improvements reduced the relative costs of good health. Gen erally, the third possibility is included within the public policy position because 1 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. it is clear to most observers that the major medical/technological changes that have occurred, such as immunization against a host of infectious diseases, vector eradication, and chemotherapy, had to be embodied in social programs in order to affect the mortality of the masses in LDCs. Demographers have almost unan imously favored the public policy-technological change explanation of mortality decline (Preston 1980, pp. 289-291). Since the mid-eighteenth century, the defining feature of human history has been the phenomenon of modern economic growth (MEG). In the areas where it started, MEG has raised the material living level, measured in per capita Gross Domestic Product (GDP), of the average person more than ten times. During the same period, world population increased at an unprecedented rate. The moving force behind this very high population growth was remarkable reduction in human mortality. As a result, average life expectancy at birth doubled, from around 35 to 70 years. However, the huge decline in mortality, i.e. the mortality revolution (MR), is not a simple by-product of MEG. Instead, both MEG and MR stem from the advancement in science and technology during the last three centuries (Easterlin 1995, ch. 1, p. 1). MEG started in Great Britain around 1750. On the other hand, not until the latter part of the nineteenth century, does substantial and sustained reduction in mortality begin. The MR initially started in northwestern Europe. In spite of its late start, the MR spread throughout the world more rapidly than MEG. Today, in many less developed areas of the world, life expectancy at birth is close to 70 years, 2 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. which is not very different from the developed areas’ average of 74 years (Easterlin 1995, ch. 1, p. 11). Even in the least developed regions, life expectancy is very close to other regions despite significant economic differences. For example, in Sub- Saharan Africa, life expectancy at birth is around 64 years (Easterlin 1995, ch. 6, p. 4). Timing and spread of the MR differ significantly from those of MEG. The more rapid spread of the MR compared to MEG reflects the fact that the institutional, educational, or capital requirements of disease control are considerably less than those for the modern technology of economic production. The cause of death approach is used to analyze the trend in mortality in Turkey and to identify the factors responsible for the trend. First, the deaths are classified according to causes of death and the trends in mortality from different causes of death are analyzed. Then, the causes of death which dominated mortality trends during the 1960-1995 period are chosen and analyzed in more detail to investigate the causes behind the mortality decline. Factors that can affect mortality trends are grouped together as economic factors, e.g. nutrition and housing, and public policy initiatives, e.g. education, medical/technological developments, and other public health policies, including but not limited to governments’ health regulations and health related campaigns. Education is included in public policy initiatives because, in Turkey, education is primarily free public education and the government plays an important role in both general and health education through its policies and campaigns. Then, cities in Turkey are grouped according to their economic well-being, and they are compared with each other to analyze whether there is 3 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. significant difference in mortality levels and mortality trends among cities with different level of economic development. Data for this study are mainly taken from Health Statistics (related years), published by the Ministry of Health and Social Assistance (MOH), and Death Statistics (related years), published by the State Institute of Statistics (SIS). Even though some statistics regarding deaths are available for the pre-1960 period, in this study, only 1960-1995 death statistics are used. This is mainly because it was not possible to calculate comparable and reliable death rates for the pre-1960 period. The results of this study showed that, pneumonia, enteritis and other diarrhoeal diseases (EODD), diseases related to pregnancy, childbirth, infections of newborn, and other diseases peculiar to early infancy (PCIODI), and tuberculosis dominated the mortality trends in Turkey during the 1960-1995 period, and they accounted for 72 percent of the decline in mortality during this period. This study also showed that, in Turkey, both MEG and MR occurs around 1950, i.e. during the Adnan Menderes government. The Menderes governments (1950-1960) concentrated on health, education, and infrastructure investments, and encouraged private sector on other investments. Moreover, by prioritizing less de veloped regions in public investments through different policies, the Menderes gov ernments managed to increase the level of development in these regions. Menderes' policies required more financial resources. But, the Menderes governments priori tized health, education, and infrastructure investments not only through increasing 4 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. the budgets for these sectors, but also prioritizing these sectors through increasing the share of their budget in total budget. More financial resources may be needed for better health, but governments’ policies cannot be assumed to be favorable to health. The Menderes governments’ policies not only affected the mortality during the 1950-1960 period, but also afterwards since the positive effects of better education and better infrastructure on mortality contributed not only to the health of that generation, but also to the future generations. For example, during the 1950-1960 period, school enrollment rates increased significantly, which in turn contributed to the health of the future generations since better educated parents can better take care of their children through better income and better treatment. The investments in cleaner water establishments during the 1950s and most of the 1960s, contributed to the decline in mortality, especially to the decline in mortality from EODD, in cities not only during the 1950-1960 period, but also during the following years. Availability of cleaner water may be considered as an economic factor. However, the governments’ role was important since they were the ones prioritizing infrastructure issues in their government programs and increasing the financial resources available for these purposes. The government policies were based on better medical/technological knowledge. However, the governments were the primary agents putting the new knowledge into practice through their wide-ranged policies. In conclusion, public policy initiatives based on better medical/technological 5 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. knowledge were driving source of mortality decline in Turkey during the 1960- 1995 period. Economic development may be important for the least developed regions of the world. However, in the case of Turkey, there is no evidence showing that during the period studied, i.e. 1960-1995, economic factors such as better nutrition and better housing were the driving source of mortality decline. Effects of better infrastructure, e.g better transportation, better sewerage, and availability of cleaner water, were important especially in 1950s and 1960s, but even in this case, the governments’ role through prioritizing these sectors shows the importance of public policy in achieving better health. 6 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. CHAPTER 2 LITERATURE REVIEW The causes of secular mortality decline are a source of ongoing controversy among demographers, historians of medicine, economic historians, and others who try to understand the dynamics involved. There is much more agreement on the fact of mortality decline than on its causes. Considerable disagreement remains about whether the decline in mortality has been primarily a by-product of eco nomic development as reflected in private standards of nutrition, clothing, hous ing, transportation, medical supply, or whether it was primarily produced by public policy measures with an unprecedented scope or efficacy. A third possible explana tion is that medical/technological improvements reduced the relative costs of good health. Generally, the third possibility is included within the public policy position because it is clear to most observers that the major medical/technological changes that have occurred, such as immunization against a host of infectious diseases, vector eradication, chemotherapy, had to be embodied in social programs in order 7 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. to affect the mortality of the masses in less developed countries (LDCs). In this chapter, the different arguments in the mortality literature will be discussed. Some researchers, such as Thomas McKeown, claimed that the MR is simply a by-product of the MEG (McKeown 1976). Supporters of this view argue that the improvement in living standards, and particularly nutrition brought by economic growth, led inevitably to improved health and lower mortality. Thomas McKeown’ s argumentation, as expressed in The Modem Rise of Population (McKeown 1976), is based on the unique data of the returns of deaths classified by age and certified cause of death available for the entire population of Britain during 1837-1971. He observed that the cause of death which contributed most to the mortality decline dining this period had been that of air-borne micro-organisms, especially tubercu losis. Deaths from water-borne and food-borne micro-organisms followed those of air-borne micro-organisms (McKeown 1976, ch. 3). Making use of these results, McKeown proceeded to minimize the contribution of different factors to this trend by means of reductive logic. He argued that medical advances could not be credited for the decline in mortality because, with a few exceptions, the death rate for most of the diseases was declining long before effective chemotherapy or other scientific techniques had become available. He ruled out sanitary and public health measures since they were effective after the second half of the nineteenth century, and mortality had been declining long before. According to McKeown, the decline in the death rate from tuberculosis had accounted for the majority of the decline of mortality dining the nineteenth and twentieth centuries, 8 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. and these were largely unaffected by advances in public health. By this reductive logic, reasoning by exclusion, McKeown concluded that nutrition was the only important factor in explaining the mortality decline. McKeown has been criticized by many researchers on different grounds. First of all, his study was based on the supposition that nutrition and living standards were improving during the 1700-1850 period. However, during the nineteenth cen tury an increasing percentage of the population was living in the urban centers of Great Britain. The poor conditions of city life, new types of jobs in industry, and massive use of child labor were detrimental to the general health of the population. The poor living conditions of the urban centers were certainly apparent to writers such as Charles Dickens and Emile Zola. As a result of the negative effects of urbanization, mortality ceased to decline during most of the central decades of the century (Chadwick 1965). McKeown did not have any evidence that nutritional levels were increasing during this period. Massimo Livi Bacci has argued that living standards were in fact worsening during the eighteenth century, and there is very little evidence to assume an improvement in levels of nutrition during the eighteenth century (Bacci 1991). Bacci argues that the mortality decline probably took place in the absence of improvement in the nutritional levels. In addition, McKeown’ s theory of the importance of nutrition can only be proved inferentially. Finding more convincing proof became a major task for many researchers. One way of doing it was to gather information on real incomes and 9 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. living standards. This is an imperfect measure since it is based on the assump tion that the increases in incomes are immediately and uniformly used to improve nutritional levels of the population. Robert Fogel suggested that looking at long term evolution of heights can be a better way to understand mortality decline, and he argued that the differences between British and French mortality levels toward the later part of the eighteenth century could be predicted from height differentials (Fogel 1986 and 1989). Roderic C. Floud was careful to distinguish between nutrition (food intake) and nutritional status. Nutritional status also includes the disease environment and thus is partially the consequence of public health (Floud 1989 and 1991). In other words, nutritional status is affected not only by nutritional intake, but also the disease environment. The reduction or elimination of disease can improve nu tritional status. As a result, stature can increase without any change in nutritional intake. Therefore, trends in stature cannot be taken as a proxy for trends in per capita income. Fogel was folly aware of this problem (Fogel 1986, pp. 446-447, Fogel 1991, p. 40 and Fogel 1994, pp. 371, 375). The nutrition and the disease environment is also taken into account by some other researchers such as Peter Lunn. Lunn accepts that low body-weight increases a child’ s susceptibility to some diseases such as diarrhoea. Progressive and long- lasting diarrhoea tend to stunt growth and decrease resistance of the body to infections. In this situation, nutrition is both cause and result of a generalized disease environment, and thus it is difficult to separate nutritional factors from 10 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. public-health factors, especially during the first years of life. Moreover, the severity and the duration of malnutrition are important in understanding the effects of malnutrition on mortality levels. Malnutrition may affect the body resistance, but the severity of malnutrition is important in determining the lethality of the disease (Limn 1991). Moreover, McKeown’ s results and his insistence on nutrition as the only im portant factor in mortality decline before the second part of nineteenth century is based on non-existent data on the cause of death during the earlier period and ignores the important medically induced decline of smallpox during the early part of the century (Schofield and Reher 1991). McKeown insisted on the importance of nutrition in his early writings. However, he also recognized importance of a multi-casual approach to mortality decline in his later writings (McKeown 1983). Pritchett and Summers also argued like McKeown that economic development was the most important cause of mortality decline (Pritchett and Summers 1996). On the other hand, they acknowledged in several parts of their paper Wealthier is Healthier that other factors such as investments in specific child health improve ments can also be important in explaining mortality decline (Pritchett and Sum mers 1996, pp. 846, 852, 864). They even stated in their paper that '‘investments in specific child health improvements are expected to be more ‘cost effective' in producing health gains than economic growth.” (Pritchett and Summers 1996, p. 11 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 865) However, even though they acknowledged importance of other factors, they concentrated on identifying the casual effects of income in their paper. McKeown’ s insistence on the unchallenged importance of nutrition in mortal ity decline runs against a long-standing tradition of demographers, economic and medical historians, as well as the views of most contemporaries, who believed that improvements in public health and sanitation had been the main source of mor tality decline. Samuel Preston’s research for the 1930-1960 period showed that economic growth played a very small role in the mortality decline and, as a result, in the improvement of life expectancy (Preston 1975). In the study of MEG, Solow’ s partitioning growth in output per man-hour due to movements along a production function as inputs per man-hour increased, i.e. input growth, and shifts in the production function due to technical change, is widely recognized as a classic (Easterlin 1995, ch. 6, pp. 7-8). Preston’ s division of the advance in life expectancy into that due to improvements in health technology, including public health as well as medicine, and due to MEG, as measured by real national income per capita is similar to Solow’ s partitioning of the sources of economic growth into technical change and input growth. Preston claimed that the efficiency of public health-technology, i.e. scientific and technological advances and public health initiatives, was the prime mover and the most important factor in explaining declining mortality (Preston 1975). Preston estimated that, income, nutrition and other indicators of the standard of living had been responsible for 10- 25 percent of the rise in life expectancy at birth during the 1930-1960 period for the 12 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. countries he analyzed (Preston 1975, p. 237). Preston’ s study showed that it was not the movement along the health production function, but upward shift of the function via technological improvement was the factor that accounted for most of the improvement in life expectancy. In other words, Preston believed that economic development/nutrition was not the prime mover behind improved life expectancy. In his later study, Preston revised his earlier study, which covered a larger number of countries than the earlier study, and concluded that the contribution of the shift factor was around 50 percent (Preston 1980). This change in results was largely due to his inclusion of literacy along with income as an independent variable (Preston 1980). Like Preston, Joel Mokyr, a prominent economic historian, has clearly separated himself from the idea that economic development/nutrition was the prime mover behind improved life expectancy (Mokyr 1993 and 1996). According to Mokyr, technology is the prime mover behind improved life expectancy. According to Preston and others who believe that public health and technology was the prime mover in the increase in life expectancy, the State fulfilled a key role in effectively organizing public defense against diseases, providing basic health facilities and public education in accord with scientific advances in health care. Medical advances such as Jenner’ s smallpox vaccine, discoveries of Pasteur, the establishment of tuberculosis sanatoriums to isolate patients, the use of diphtheria antitoxin, are all important in mortality decline. Scientists and doctors were also important since they were behind the most public health related policies. They 13 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. were the leaders of many public health reforms. Public health measures were often opposed by local business interests who felt that these reforms would hinder economic growth. In the case of the cholera epidemic in Hamburg in 1892, the public authorities under the pressure from local economic interests, neglected to establish a system of filtered water for the city, and when the cholera epidemic appeared, they waited as long as possible before declaring state of epidemic. As a result, 1.4 percent of the population died from cholera in 1892. However, in the nearby Port of Bremen, only six persons died because many precautionary measures had been taken on time (Schofield and Reher 1991, p. 15). Therefore, one can say that medical advances are not enough to prevent death. They need to be put into practice. Public authorities are important in preparing public policies and programs based on new medical knowledge to fight against diseases. European governments played an important role in regulating public health programs. The efforts of the governments ranged from quarantine, vaccination, the installation of sanitation and sewerage system to education of mothers on issues such as breastfeeding, household sanitation, and food purity. According to Marie- France Morel, the implementation of ideas and practices based on medical research at the household level was a very important factor in the decline of many diseases, especially infancy and early childhood diseases (Morel 1991, pp. 199-200). Medical research was behind of these policies, but on its own, medical progress was not sufficient. Changes in attitudes and behavior were also needed. The implementation of new ideas took a considerable amount of time and effort by 14 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. governments. The process of health education, especially education of mothers, faced different challenges in different regions due to the differences in cultural and educational backgrounds. Kuznets, Coale and Hoover have argued that the distinction between economic development and public health interventions creates a false dichotomy (Kuznets 1975, Coale and Hoover 1958). According to these authors, development itself strengthens the nation-state, improves communication among nations and therefore facilitates the transfer of medical technology and scientific improvement. But, this presupposes the existence of modern medical technology. Like real per capita income, there has been a sharp increase in the rate of improvement in life expectancy since the late nineteenth century. There was not an abrupt break with the past, but there was a shift from a lower to higher rate of change in life expectancy. Easterlin calls this a “take-off.” (Easterlin 1997, p. 10) The dating of this “take-off” varies from one country to another. In England, the rate of improvement in life expectancy rises dramatically, starting about 1871. In Sweden, the rate of improvement in life expectancy rises dramatically after 1875. The take-off in fife expectancy occurs around 1893 in Prance, 1923 in Japan, 1940 in Brazil, and 1945 in India. Taking all six of these countries together, the rate of improvement in life expectancy after take-off was three to six times greater than the improvement in life expectancy before the take-off (Easterlin 1997, pp. 10-11). Among these six countries, in England, France and Japan, MEG was underway some time before life expectancy take-off. In Sweden and Brazil, MEG and take-off 15 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. in life expectancy occurred about at the same time. However, in India, the take-off in life expectancy precedes MEG. Even though in England and in Sweden, the take-offs in life expectancy happened almost at the same time, in early 1870s, the dates for their MEG differ by about 70 years (Easterlin 1997, pp. 11-12). In other words, in some countries, take-off in life expectancy happens before, at the same time, or after the MEG. However, as it happened in England and Sweden, even when the life expectancy take-off followed MEG with a lag, the duration of the lag differed significantly from one to another. Between England and Sweden, the duration of the lag differs by three-fourths of a century (Easterlin 1997. p. 12). When these six countries are taken as a whole, it can be seen that the im provement in life expectancy started later than MEG. Rapid improvement in life expectancy started after the 1870s. However, MEG was underway in two or three countries by the 1870s. In other words, the take-off in MEG happened before the take-off in life expectancy, but improvement in life expectancy spread more rapidly compared to MEG. The time span of the take-off dates for life expectancy was much shorter than the time span of the take-off dates for MEG, about seventy years compared to one hundred and seventy years. Moreover, despite the economic stagnation of the 1920s and the 1930s, the improvement in life expectancy pro ceeded steadily during the interwar period, in France, Brazil, India and Japan. In England and Sweden, there were some downward trends in life expectancy during the early and mid 1900s. In other words, in four out of six countries, the improve 16 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ment in life expectancy continued even in the case of the retardation in economic growth during the Interwar period (Easterlin 1997, pp. 12, 95-97). It is tempting to attribute the improvements in life expectancy to MEG, but it is not supported by the data. There was little or no increase in per capita income during the period of mild improvement in life expectancy in India in the first half of the twentieth century, and this was also the case for Sweden prior to 1850 (Easterlin 1997, p. 13). Moreover, in England, the early improvements in life expectancy were associated with a significant decline in mortality from smallpox, a disease that is largely unaffected by nutritional status (Easterlin 1997, p. 13). Decline in mortality from smallpox was achieved by smallpox vaccination. Smallpox vaccination not only lowered the mortality from smallpox, but also from other diseases by reducing the proportion in the population of people vulnerable to other diseases because of damaged immune systems due to smallpox. Therefore, one needs to be careful when suggesting that improvement in life expectancy is partly or wholly the result of MEG (Easterlin 1997, pp. 13-14). One can expect a positive effect of income on life expectancy because an in crease in per capita income is expected to increase the quantity and quality of food consumption, and to improve the quality of housing, shelter. However, one needs to step back, and examine consequences of MEG, such as urbanization, emergence of low-life-expectancy squatter housing areas, and their effects on life expectancy. Moreover, one also needs to analyze other factors involved in the process of lower 17 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. mortality, such as medical/technological improvements, and public health pro grams. Some researchers, such as Patrick Galloway, have pointed to the importance of climate in determining the changes in mortality. According to Galloway, warmer summers or colder winters have been linked to higher-than-average mortality, es pecially among the infants and young children (Galloway 1985 and 1986). Alfred Perrenoud also believed that ecological and biological factors were the main factors responsible for the changes in mortality. After studying the changes in age patterns of mortality, he argued that despite the differences in the level of development, differences in political organizations, social and cultural charac teristics, the countries showed similarities on mortality patterns. He suggested that to understand these similarities, one needs to look at ecological and biological explanations (Perrenoud 1991). On the other hand, Helleiner argued that epidemics followed a law of their own (Helleiner 1965). Chambers, like Helleiner, also believed that epidemics followed a law of their own independent of human intervention (Chambers 1972). The discussion of the causes of mortality decline is continuing. The purpose of this study is not to solve this dilemma, but to explore these issues by analyzing Turkey’ s experience of mortality decline during the 1960-1995 period. 18 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. CHAPTER 3 OVERVIEW OF DEMOGRAPHIC AND SOCIO-ECONOMIC CHANGES IN TURKEY SINCE 1923 Since the founding of the Republic of Turkey in 1923, there have been substan tial changes in its demographic and economic structure. These changes are among the largest and most significant events of modern times for Turkey. The changes in the Turkish demographic and economic structure affected the health of people in Turkey. There are also other socio-economic, such as educational and institutional, changes that contributed to the health of the people. In this chapter of the study, demographic, economic, and other socio-economic changes that may have affect on the health of the people in Turkey will be analyzed. 19 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 3.1 Overview of Demographic Changes in Turkey Since 1923 In Turkey, during these past more than 70 years, the population has been al most completely replaced. This population renewal process was not one of simple reproduction with no changes in characteristics. The spatial distribution of popula tion, the density of habitation and population size all changed fundamentally. The pre-Republican population structure and characteristics no longer exist. Turkey is now a much more urbanized country, families no longer have as many children as in the past, though individual variation exists as before. The types of population changes so far experienced by Turkey, and expected to occur in the near future, are given the label of “demographic transition” in the demographic and historical literature. Almost every country has experienced some kind of demographic transition, where there is a decline from high death and birth rates to low ones. The sequence of changes is not the same everywhere in the world history. A great deal of scholarship has been devoted to the search for generic or universal explanations of how transitions occur, when they start, and how long they take. However, there are many differences in timing and detail country by country. It seems that in each country, and even in subcultures of countries, there are unique conditions and complex historical as well as contemporary reasons for the way in which the demographic results occur over time (For more information about the fertility transition, see especially McNicoll 1994, Greenhalgh 1988 and 20 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1994, Bulatao and Lee 1983, Hodgson 1983, Easterlin et al. 1980. Concerning mortality transition, see Kunitz 1990 and 1991, Cleland and Van Ginneken 1988, Caldwell 1986, Preston 1976 and 1980). In Turkey, the first stage of transition can be dated from 1923 to 1950. Though complete statistics on death rates do not exist for the entire period, there was a steady decline of death rates during this period, except for a brief reversal during the Second World War (WW II). However, fertility, instead of following and bal ancing the decline of mortality, increased significantly from 5.5 children in 1923 to 6.85 children in 1950. It fluctuated between 5.5 and 7.1 until the permanent decline of fertility began during the 1950s (SIS 1995, p. 4, 9, 12). Turkey thus exhibits the typical demographic transition in that mortality decline precedes fertility decline. Turkey’ s particular demographic and socioeconomic history prior to and during this first period was responsible for the increase in fertility. During the early years of the Republic of Turkey (TR), there were serious shortages of adults, especially males, in the working ages. This situation was a legacy of the Ottoman period and the struggle for independence when many adults were lost as military casualties or due to disorganized and poor health conditions. Due to many human losses during the First World War (WW I) and “Kurtulu§ Sava§i,” the Turkish War of Independence, and also due to high levels of infant mortality during the 1930-1960 period, the Turkish government perceived that an increase in population growth was needed. Moreover, for Turkey’ s defense needs and the shortage of manpower for development, the Turkish authorities decided to encourage higher levels of fertility. 21 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The “Law of Public Hygiene” was passed in 1930. This law was the most explicit law regarding the pronatalist attitudes of the Turkish government. By this law, the import and sale of contraceptives was prohibited, and also, in order to encourage births, monetary awards were given to women who had six or more children. There were a number of other laws which attempted to prevent abortions. With falling death rates and rising birth rates, as can be seen in Table 3.1, the population of Turkey increased rapidly during the 1923-1950 period from 13.6 to 21 million. Table 3.1 Population trends in Turkey. Census Total population (000) Growth rate (%) Urban population (000) Growth rate (%) Rural population (000) Growth rate (%) 1927 13,648 - 2,236 - 11,412 - 1935 16,158 2.1 2,735 2.5 13,423 2.0 1940 17,821 2.0 3,203 3.2 14,618 1.7 1945 18,790 1.1 3,442 1.4 15,348 1.0 1950 20,947 2.2 3,782 1.9 17,165 2.2 1955 24,065 2.8 5,425 7.2 18,640 1.6 1960 27,755 2.9 7,308 6.0 20,447 1.9 1965 31,391 2.5 9,383 5.0 22,008 1.5 1970 35,605 2.5 12,754 6.1 22,851 0.8 1975 40,348 2.5 16,707 5.4 23,641 0.7 1980 44,737 2.1 20,330 3.9 24,407 0.6 1985 50,664 2.5 25,890 4.8 24,774 0.3 1990 56,473 2.2 31,805 4.1 24,668 -0.1 Source: SIS 1995, pp. 44-47. Before 1923, i.e. during the pre-Republican period, information related to pop ulation was limited and not very reliable, especially due to frequent changes in area and population, resulting from wars during the Ottoman Empire period. However, 22 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Maddison states that, during the 1900-1927 period, the population growth rate was low, around 0.8 percent, and there was a “take off” in population growth around 1927-1935 (Maddison 1995, pp. 108-109). The “take off” in population growth around 1927-1935 may be an indicator showing that changes in population policies contributed to population growth since the “Law of Public Hygiene” which was passed in 1930 was encouraging population growth. Moreover, change in sex ratio may also have contributed to population growth, but there is no information about the sex ratios during the Ottoman period and early Republican period. During 1927-1935, as can be seen in Table 3.1, the population growth rate was 2.1 percent, and during the 1935-1940 period, it was 2.0 percent (SIS 1995, pp. 44-47). During the First World War (WW I), i.e. during the 1914-1918 period, the population growth rate was very low, around 0.7 percent, mainly due to war casualties and economic difficulties (Maddison 1995, pp. 108-109). During the Second World War (WW II), population growth was very low, around 1.1 percent, even though Turkey did not participate in the war (SIS 1995, pp. 44-47). Until 1960, the population growth rate increased continuously, except the WW II period, and in the 1955-1960 period, the population growth rate was 2.9 percent (SIS 1995, pp. 44-47). The second stage of Turkey’ s demographic transition is dated from about 1955 to 1985. During the 1950s, fertility began to decline and it did not reverse after wards. However, the rate of decline was not fast enough to catch up immediately with the previous decline in death rates, so the population continued to grow. From 23 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1955 to 1985, the population more than doubled, from 24 to 51 million (SIS 1995, p. 5). High population growth that continued during the second stage of the transition was due not only to pronatalist policies, but also to a decrease in mortality resulting from successful campaigns to eradicate some contagious diseases (SPO 1993, p. 15). By 1960, a change of opinion regarding population policy began to take place, which was partly due to medical problems, especially high maternal mortality resulting from illegal abortions, and slower per capita gross national product (GNP) growth resulting from high population growth. In the First Five- Year Development Plan (1963-1967) (SPO 1964), the repealing of anti-contraceptive laws, the creation of a family planning program, training of health personnel about these issues, and educating public on family planning issues was advocated (SPO 1993, p. 15). Preparations for new “Population Planning Law” began in 1962 and it was en acted in 1965. According to the new law, preventive measures to avoid pregnancy would be allowed. However, there were still strict conditions regarding to abortion or sterilization. Later on, the law was revised and became more liberal by differ ent revisions. The Turkish government revised the “Population Planning Act” in 1983. According to the new law, abortion became legal under the supervision of government. According to the 1983 revision, termination of unwanted pregnancies during the first ten weeks on demand was legalized. As a result of legal abortion, illegal abortions and maternal mortality resulting from illegal abortions decreased significantly (TR-UNICEF 1996, p. 121). 24 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. During the second stage of Turkey’s demographic transition, population density increased significantly. As can be seen in Table 3.2, population density more than doubled, from 31 to 65 during the 1955-1985 period (SIS 1995, p. 44). Table 3.2 Number of persons per square kilometer. Year Density 1927 17 1935 21 1940 23 1945 24 1950 27 1955 31 1960 36 1965 40 1970 46 1975 52 1980 57 1985 65 1990 72 Source: SIS 1995, p. 44. Another important development of the second stage was rapid urbanization. The proportion of urban population, which measures the degree of urbanization, rose very little before 1950. The growing momentum of economic change, with job growth increasing faster in urban than rural locations, brought large changes after 1950. As can be seen in Table 3.3 and Figure 3.1, the urban proportion rose from 22.5 percent to 51.1 percent during 1955-1985 period (SIS 1995, p. 44). Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 3.3 Percent distribution of population by place of residence. Census Urban population (%) Rural population (%) 1927 16.4 83.6 1935 16.9 83.1 1940 18.0 82.0 1945 18.3 81.7 1950 18.1 81.9 1955 22.5 77.5 1960 26.3 73.7 1965 29.9 70.1 1970 35.8 64.2 1975 41.4 58.6 1980 45.4 54.6 1985 51.1 48.9 1990 56.3 43.7 Source: SIS 1995, pp. 44. 100 —— U rban R ural ae u c < u u < u c u 1940 1960 1970 1990 1920 1930 1950 1980 Y ear Figure 3.1 Percent distribution of population by place of residence. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. When the population of Turkey went through an intensive process of urbaniza tion, especially from the 1950s onwards, problems were inevitably caused by the provision of urban services and emergence of large areas of squatter housing in un planned cities. As can be seen in Table 3.4, the migration rate was higher during the 1955-1975 period compared to later years. Table 3.4 Internal migration. Period Ratio of male migrants to female migrants Migration rate Rural Urban 1955-1960 1.18 -11.3 34.7 1960-1965 1.18 -11.2 28.4 1965-1970 1.26 -17.3 35.1 1970-1975 0.89 -17.8 28.2 1975-1980 1.04 -14.1 18.3 1980-1985 1.06 -21.0 22.3 1985-1990 0.95 -21.5 18.4 Note: Migration rate is the net migrants per year per 1,000 population. Source: SIS 1995, p. 47. Information concerning international migration is limited, because there is no existing system for collecting statistics on this subject. In general, a few statements can be made. A net international outflow of population was typical of the 1960s and during most of the 1970s. It was related mainly to Turks working in Europe and to family re-unification with workers. There were also short periods of immigration from Bulgaria as well as other neighboring countries. 27 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The second stage of Turkey’ s demographic transition does not end with any specific event. The downward trends of mortality and fertility continued during the third stage of demographic transition. However, the marker that shows that Turkey entered a third phase was a definite decline in the rate of population growth. This happened during the 1980s. The population growth rate decreased to 2.2 percent during the five-year period, 1985-1990, in spite of additions due to immigration. By 1990, the rate of natural increase was 1.8 percent per year. By 1994, it was 1.6 percent (SIS 1995, pp. 5). This third stage of demographic transition is considered to be complete after two things happened. First, fertility should fall to a level where births approximately replace the parent generation, but no more than that. Second, population growth should stop. These two conditions do not happen at the same time. For a long time after the fertility reaches the replacement level, the population continues to grow. Young adults of the present generation are much more numerous than the survivors of the previous generation due to past history of fertility. They will add to the population of older ages as they live out their lives. According to the projections in one study, the demographic transition in Turkey is expected to be complete by the mid-21st century (SIS 1995, p. 6). During these three stages of demographic transition, especially after the WW II, there were significant improvements in many health related indicators, such as infant mortality rate, and crude death rate, in Turkey. The values for crude birth rate, crude death rate, infant mortality rate and total fertility rate for 1935-1985 28 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. are given in Table 3.5. As can be seen in Table 3.5, during 1935-1985, there was a 34 percent decrease in the crude birth rate. During the same period, there was a 74 percent decrease in the crude death rate. The information about infant mortality is not available for the pre-1950 period. However, there was a 65 percent decrease in the infant mortality rate during the 1950-1985 period. During the 1935-1985 period, there was a 43 percent decline in the total fertility rate. Table 3.5 Crude birth rate (CBR), crude death rate (CDR), infant mortality rate (IMR), and total fertility rate (TFR). Period CBR per 1,000 population CDR per 1,000 population IMR per 1,000 births TFR per woman 1935-1940 45.6 31.4 Not available 6.66 1940-1945 43.1 33.9 Not available 6.55 1945-1950 45.9 27.0 Not available 6.85 1950-1955 48.2 23.5 233 6.85 1955-1960 46.8 19.8 203 6.54 1960-1965 42.0 16.4 176 6.11 1965-1970 39.0 13.5 153 5.62 1970-1975 34.5 11.6 138 5.04 1975-1980 32.0 10.2 120 4.51 1980-1985 31.2 9.4 102 4.10 1985-1990 30.0 8.4 81 3.77 1990-1995 27.3 7.4 65 3.35 Source: Shorter and Macura 1982, pp. 28-64 (for 1935-1950 period), UN 1995, p. 848 (for 1950-1990 period), and TR-UNICEF 1991, p. 43 (for CDR for 1935-1950 period). During these three stages of demographic transition, the life expectancy in Turkey increased considerably, except for a decrease during the 1940-45 period. There is no information available regarding life expectancy for the period before 29 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1935. However, as can be seen in Table 3.6, life expectancy at birth almost doubled from 1935-1940 period to 1985-1990 period. Life expectancy at birth for females increased from 36 to 67 from the 1935-1940 period to the 1985-1990 period. The change for males was from 35 to 63 during the same period. The detailed infor mation about life expectancy at birth (e(0)) and life expectancy at age five (e(5)) are given in Table 3.6. In Figure 3.2, the increase in life expectancy at birth from 1935-1940 to 1985-1990 period is shown graphically. In Table 3.6, life expectancy at birth value for both sexes in the 1955-1960 period, seems low. It is expected to be around 46.5. However, this is the value given in the source, i.e. SIS 1995, without any explanation. Table 3.6 Life expectancy. Period e(0) e(5) Both sexes Males Females Males Females 1935-1940 35.43 34.68 36.23 51.4 50.2 1940-1945 31.34 30.10 32.65 47.6 47.9 1945-1950 38.10 36.68 39.59 53.1 54.0 1950-1955 43.52 41.96 45.16 57.8 59.1 1955-1960 44.61 44.68 48.63 57.9 60.4 1960-1965 49.93 47.93 52.02 58.9 61.7 1965-1970 53.12 51.07 55.27 59.9 62.9 1970-1975 55.09 52.99 57.30 60.1 63.1 1975-1980 57.01 54.78 59.37 60.4 63.5 1980-1985 59.04 56.88 61.32 61.0 64.2 1985-1990 64.91 62.67 67.26 63.7 67.6 Source: SIS 1995, pp. 40-41. 30 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 70 Total - • * Male — A " Female O 0 ) 1935 1940 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 Period Figure 3.2 Life expectancy at birth. As was previously mentioned, there was a decline in life expectancy in Turkey during the Second World War (WW II) period. The life expectancy at birth de creased 11.5 percent from 1935-1940 to 1940-1945 period. As can be seen in Table 3.6, there was a big increase, 21.6 percent, in life expectancy from 1940-1945 to 1945-50 period. This may look like a take-off date for life expectancy. However, the increase in life expectancy during this period is partly based on the decline in life expectancy dining the WW II period. The comparable mortality data is not available for the pre-1960 period. Therefore, the exact take-off date for life expectancy cannot be determined. However, starting with the 1945-1950 period, there is continuous increase in life expectancy in Turkey. Moreover, there was sig nificant increases in some other health indicators after 1950. During the Prime 31 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Minister Adnan Menderes governments, 1950-1960, number of hospitals in Turkey almost doubled, and number of in-patient beds more than doubled (SPO 1997, p. 155). The increase in the numbers of hospitals and beds during this period were significantly higher than those of earlier periods. Therefore, 1950 can be consid ered as a take-off date for life expectancy in Turkey. In other words, in Turkey, the take-off in life expectancy happens around the same time of that of MEG. This will be explained in detail in next section of this chapter. There is another take off in life expectancy in Turkey after the 1980-1985 period. The second take-off in life expectancy mainly based on health-related campaigns and improvement in literacy level through the “Reading-Writing Campaign.” These campaigns will be explained in detail in chapters 6 and 7. 3.2 Overview of Economic Changes in Turkey Since 1923 There was also significant changes in Turkish economy since 1923, especially after 1950. An exact take-off date for life expectancy in Turkey could not be given. However, a confident take-off date for MEG can be given for Turkey. In Turkey, the onset of MEG occurs around 1950. In his analysis of the modernization of Turkey, Reynolds states that 1950 designates the beginning of MEG in Turkey (Reynolds 1985, pp. 328-335). According to Reynolds, per capita income is the deciding factor in determining the take-off date for MEG (Reynolds 1985, pp. 328-335). 32 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Per capita income in Turkey increased significantly after 1950. GDP per capita for the 1913-1994 period are given in Table 3.7. Table 3.7 Per capita gross domestic product (GDP) in 1990 Geary-Khamis Dol lars. Year GDP Annual growth rate (%) 1913 979 Not available 1923 561 -0.5 1925 738 14.7 1930 985 5.9 1935 1,070 1.7 1940 1,321 4.3 1945 893 -7.5 1950 1,299 7.8 1955 1,655 5.0 1960 1,801 1.7 1965 2,009 2.2 1970 2,437 3.9 1975 3,084 4.8 1980 3,192 0.7 1985 3,559 2.2 1990 4,263 3.7 1994 4,226 -0.2 Source: Maddison 1995, pp. 184-185. According to Maddison, GDP per capita continuously increased after 1950 (Maddison 1995). However, many Turkish government sources state that there was a decrease in per capita GDP after the military coup of September 12, 1980. During the 1980-1985 period, GDP per capita decreased 13.7 percent, from $1,538 to $1,327 (SIS 1998, pp. 694-695), and GNP per capita decreased 13.6 percent, from $1,570 to $1,356 (SPO 1996, p. 6), but the death rate continued to decrease Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. from 6.68 to 6.20 per thousand during the same period. These sources are very con vincing because after the military coup, due to uncertainty, the Turkish economy slowed down. Reynolds was right in his timing of the beginning of MEG in Turkey, i,e. eco nomic take-off, but the basis for his conclusion as resting primarily on per capita income growth is misleading. Income is not the only factor that affects MEG. One needs to take into account other prerequisites of MEG such as urbanization, change in composition of GDP, i.e. less-agrarian, education, mortality and other health indicators, productivity, transportation. In Turkey, permanent structural change starts around 1950. First of all, the distribution of labor force by sector changed significantly after 1950. As can be seen in Table 3.8, the proportion of the male labor force employed in agriculture, forestry, and fishing decreases from 76 percent to 54 percent during the 1950-1970 period (Mitchell 1995, p. 100). The proportion of the male labor force employed in manufacturing industry, mining, and construction increases from 12 percent to 17 percent during the 1950-1970 period. The proportion of the male labor force employed commerce and finance rose slightly from 3 to 8 percent during the same period (Mitchell 1995, p. 100). The female labor force was mainly agrarian before 1960. However, after 1960, due to urbanization and better education of women, women started to be employed in other sectors, such as manufacturing and service sectors. The proportion of the total labor force employed in agriculture decreased 34 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. from 85 to 68 percent during the 1950-1970 period, and it continued to decrease afterwards (Mitchell 1995, p. 100). The composition of GDP changed considerably after 1950. As can be seen in Table 3.9, in the 1950-1955 period, agricultural production accounted for 47 percent of GDP, but by 1970, it decreased to 26 percent. During the 1950-1970 period, the share of manufacturing, mining and construction in GDP increased from 17 to 28 percent (Mitchell 1995, p. 1030). MEG requires certain social and political conditions. If the workers do not have the capacity to do the job, the adoption of new mode of production cannot be achieved. Therefore, education is a necessary prerequisite to equip a population with the ability to learn. Factors such as education and institutions also contribute to both life expectancy and MEG. The health of a population also affects its ability to learn and also its productivity. In the following section, some other socio economic changes since 1923 that can affect the health of the people in Turkey will be analyzed. 35 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Reproduced w ith permission o f th e copyright owner. Further reproduction prohibited without permission. Table 3.8 Percentage distribution of labor force, by sectors. Year Agriculture, Manufacturing industry, Commerce, TVansport and Services and forestry and fishing mining and construction finance, etc. communication others Males 1935 73 12 5 2 8 1945 70 11 5 2 12 1950 76 12 3 2 7 1960 61 15 5 3 16 1970 54 17 8 4 17 1980 44 22 11 4 19 Females 1935 94 4 Negligible Negligible 2 1945 91 4 Negligible Negligible 2 1950 96 2 Negligible Negligible 2 1960 95 3 Negligible Negligible 2 1970 90 5 1 Negligible 4 1980 87 5 2 Negligible 6 Total 1927 82 6 5 Negligible 8 1935 82 9 3 2 5 1945 75 9 4 2 10 1950 85 7 2 1 5 1960 75 10 3 2 10 1970 68 12 5 2 13 1980 60 16 7 3 14 o? Source: Mitchell 1995, p. 100. Reproduced w ith permission o f th e copyright owner. Further reproduction prohibited without permission. Table 3.9 Proportions of GDP by sector of origin. Period Agriculture, forestry and fishing Manufacturing, mining and construction Transportation and communication Trade Other 1950-1955 47 17 7 11 18 1955-1960 43 20 8 9 19 1960-1965 36 23 7 10 20 1965-1970 30 28 8 11 20 1970-1975 26 28 8 13 23 1975-1980 25 27 8 13 23 1980-1985 20 33 10 16 21 1985-1990 17 37 10 17 18 Source: Mitchell 1995, p. 1030. os - » l 3.3 Overview of Other Socio-economic Changes in Turkey Since 1923 One of the most striking achievements since the founding of the Turkish Re public has been the increase in both school enrollment and literacy. Educational attainment increased dramatically since 1923. A five-year primary school educa tion is compulsory in Turkey; but there is a high dropout rate after primary school. There was improvement in first primary school enrollments, and then, especially after 1950s, in secondary and higher school level enrollments. As can be seen in Table 3.10, during the 1950-1995 period, secondary, high school and college enroll ment rates continuously increased. There was very little improvement in college enrollment rates during the 1970-1980 period, because many families did not want to send their children to universities due to fear of terrorism at the universities. The September 12, 1980 military coup positively affected college and higher school enrollment rates, because after the military coup, soldiers started to control the terrorism at universities, and this security feeling contributed positively to the school enrollments. During the 1950-1960 period, there was approximately a 22 percent increase in primary school enrollment rates, secondary school enrollment rates more them tripled, emd high school enrollment rates almost doubled dining the same period (SPO 1996, p. 139). The values for school enrollment rates that are given by Mitchell emd those are given by Turkish government significantly differ from each other (Mitchell 1995 38 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. and SPO 1996). In this study, the government sources have been used, because they are more accurate. Mitchell’ s values are extremely low, especially when one compares them with census literacy rates. The age grouping for Table 3.10 is assumed to be 6-10 for primary school, 11-13 for secondary school, 14-16 for high school, and 17-21 for college. The age groups are not given in the source, but it still gives an idea of the improvement in school enrollment rates in Turkey after the 1950s. Table 3.10 School enrollment, by school levels. School level (%) 1950 1960 1970 1980 1990 1995 Primary school 55.0 67.0 102.0i 99.6 102.1 104.4 Secondary school 6.0 19.0 31.7 42.2 58.8 65.6 High school 4.6 9.0 17.7 28.9 35.9 53.0 College + 1.5 3.4 6.8 7.4 14.5 26.7 Source: SPO 1996, p. 139. As can be seen in Table 3.11 and in Figure 3.3, in 1935, only 10 percent of females and 29 percent of males were literate in Turkey. According to the 1990 census figures, these values were 72 and 89 percent respectively, for the population age 6 and over. However, considerable regional and urban-rural differences in liter acy and educational attainment exist in Turkey, in addition to differences between males and females. 39 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 3.11 Literacy rate for population age six and over, by sex. Year Total Male Female (%) (%) (%) 1935 19.25 29.35 9.81 1940 24.55 36.20 12.92 1945 30.22 43.67 16.84 1950 32.37 45.34 19.35 1955 40.87 55.79 25.52 1960 39.49 53.59 24.83 1965 48.72 64.04 32.83 1970 56.21 70.31 41.80 1975 63.62 76.02 50.47 1980 67.45 79.94 54.65 1985 77.29 86.35 68.02 1990 80.46 88.78 71.95 Note: 1945 and 1950 values are calculated according to population 7 years of age and over and 5 years of age and over, respectively. Source: SIS 1993, p. 13. 100 Total Male —— Female - u c 41 U 4J CL. 1990 1930 1950 1960 1970 1980 1940 Y ear Figure 3.3 Literacy rate for population age six and over, by sex. 40 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. There is no known study showing the differences between male and female school enrollment rates for the study period. However, there is information about the male and female literacy levels. Literacy levels, especially female literacy, improved significantly after 1960. As can be seen in Table 3.11, during the pre- 1960 period, there was some improvement in both male and female literacy, but the continuous improvement in literacy levels started after 1960. Moreover, the gap between male and female literacy levels diminished during 1960-1995. In other words, the rate of increase in female literacy was higher than that of males during the study period. For example, during 1960-1990 period, the female literacy level almost tripled, but there was only around 65 percent improvement in the male literacy level. There were also significant changes in health-related indicators after the es tablishment of the Turkish Republic in 1923. Information about the number of health personnel is given in Table 3.12, and information about the students in and graduates from faculties of medicine is given in Table 3.13. Information about distribution of institutions providing curative services and some other health related indicators are given in Table 3.14. As can be seen in Table 3.14, the annual growth rate in number of in-patients beds is the highest for 1950-1960 period. Moreover, number of institutions providing curative services almost doubled during the same period. As can be seen in Table 3.15, the ratio of the budget of Ministry of Health (MOH) to the budget of the State increased from 2.21 percent to 4.12 percent 41 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. during the 1923-1990 period. However, the trend is irregular. There was a contin uous increase in the ratio during the 1950-60 period. The Menderes governments prioritized investments in infrastructure, health, and education sectors in their gov ernment programs. After 1960, the ratio of the budget of MOH to the budget of the State decreased. On the other hand, the budget of the MOH, in 1950 prices, was continuously increasing during the 1950-1980 period. The Menderes governments prioritized infrastructural investments in addition to health and education related investments. As can be seen in Table 3.16, in 1945, only 8.4 percent of the municipalities with more than 3,000 population had scientifically appropriate water establishments. However, this percentage increased to 73.6 in 1962. In other words, there was a significant increase in the availability of clean water during the 1945-1962 period, and Menderes was the Prime Minister of Turkey during most of that period (1950-1960). In addition, there were other socio-economic changes in Turkey after 1950, such as better transportation through roads instead of railroads and better electrifica tion. In other words, 1950 can be specified as not only a take-off date for MEG, but also as the take-off date for MR in Turkey since all the previously mentioned changes contributed to the health of the people, especially after 1950. After overviewing the demographic and socio-economic changes in Turkey since 1923, the method emd data that were used in this study to analyze the trends in diseases in Turkey will be explained in the following chapter. 42 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Reproduced w ith permission o f th e copyright owner. Further reproduction prohibited without permission. Table 3.12 Number of health personnel, 1923-1995. Years Physician Dentist Pharmacist Nurse Midwife Health technician 1923 554 0 69 140 Not available 560 1953 6,881 957 1,026 1,496 1,946 3,474 1955 7,077 958 1,256 3,526 Not available 3,927 1960 8,214 1,367 1,406 2,420 3,126 3,550 1965 10,895 1,932 1,771 2,969 4,336 4,676 1970 13,843 3,245 3,011 8,796 11,321 9,954 1975 21,714 5,046 7,002 27,781 Not available 10,961 1980 27,241 7,077 12,039 26,880 15,872 11,664 1985 36,427 8,305 12,202 30,854 17,987 10,525 1990 50,639 11,100 15,792 44,984 30,415 21,547 1995 67,160 13,630 17,912 67,490 43,000 42,900 Note: Number of nurse and midwives are not separately available for 1923, 1955 and 1975. For these years, number of midwives is included in the number of nurses. Source: HU 1993, p. 26 and SPO 1997, p. 156. Reproduced with permission o f th e copyright owner. Further reproduction prohibited without permission. Table 3.13 Students in and graduates from faculties of medicine. School year Number of faculties of medicine Number of students Number of graduates Male Female Total Male Female Total 1963-64 4 4,126 1,063 5,189 329 97 426 1968-69 8 6,013 1,379 7,392 747 165 912 1973-74 15 7,549 1,601 9,180 865 165 1,030 1978-79 18 10,737 3,321 14,058 1,282 277 1,559 Source: MOH Health Statistics related years. £ Reproduced w ith permission o f th e copyright owner. Further reproduction prohibited without permission. Table 3.14 Institutions providing curative services. Year Number of institutions Number of in-patients beds Population per bed Population per physician Number of health centers Number of health stations 1923 86 6,347 1,920 19,856 Not available Not available 1930 167 9,561 1,360 Not available Not available Not available 1940 198 14,383 1,240 Not available Not available Not available 1950 301 18,837 1,110 3,038 Not available Not available 1960 566 45,807 600 2,825 Not available Not available 1970 746 87,134 409 2,572 851 2,231 1980 827 114,217 394 1,652 1,827 6,594 1985 Not available 119,018 428 1,398 2,887 8,811 1990 899 137,662 412 1,121 3,454 11,075 1995 Not available 151,972 409 925 4,927 11,888 Source: HU 1993, p. 24 and SPO 1997, p. 155. Cn Reproduced with permission o f th e copyright owner. Further reproduction prohibited without permission. Table 3.15 Budget of the Ministry of Health and Social Assistance. Years In current prices (Thousand TL) Ankara cost of living index In 1950 prices (Thousand TL) Ratio of the MOH budget to the national budget (%) 1923 3,038 Not available Not available 2.21 1925 4,860 Not available Not available 2.64 1930 4,502 Not available Not available 2.02 1935 4,820 Not available Not available 2.54 1940 8,185 Not available Not available 3.05 1945 18,809 Not available Not available 3.12 1950 60,615 35 60,615 4.08 1955 152,463 45 118,582 5.18 1960 382,762 89 150,524 8.97 1965 590,950 108 191,512 4.10 1970 888,080 148 210,019 3.08 1975 3,815,161 331 403,416 3.54 1980 31,822,605 2,365 470,948 4.21 1985 137,462,333 11,353 423,781 2.54 1990 2,633,217,000 Not available Not available 4.12 Source; HU 1993, p. 40 and SPO 1997, p. 109. Reproduced w ith permission o f th e copyright owner. Further reproduction prohibited without permission. Table 3.16 Municipalities with more than 3,000 population that have scientifically appropriate water establishments. Year Number of municipalities with > 3,000 population Municipalities with scientifically appropriate water establishments Number % 1933 501 29 5.8 1945 583 49 8.4 1962 554 404 73.6 1968 688 640 92.8 1972 869 813 92.8 1977 1,022 957 93.4 1980 1,028 964 93.8 1982 990 936 94.5 Source: SPO 1983, p. 397. 4 * . -v | CHAPTER 4 METHODOLOGY AND DATA This chapter of the study attempts to explain the characteristics and the source of data and the methodology used to determine the driving force behind the mor tality decline in Turkey during the 1960-1995 period. 4.1 Data Data for this study are taken from Death Statistics (related years), published by the State Institute of Statistics (SIS), and Health Statistics (related years), published by the Ministry of Health and Social Assistance (MOH). Details concerning deaths in Turkey are compiled by the SIS. These death statistics are classified in compliance with international standards and in accor dance with the “International Statistical Classification of Diseases, Injuries, and Causes of Death” categories containing 50 and 150 diseases as required by the World Health Organization (WHO). From 1931 to 1949, these statistics were col- 48 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. lected from all provincial centers and published for the 25 provincial centers that were most populous. Beginning in 1950, these data have been collected and pub lished for all provincial centers. Since March 1, 1957, statistical data concerning mortality have been collected from all provincial and district centers. Even though some statistics regarding deaths are available for pre-1960 period, in this study, only 1960-1995 death statistics will be used. This is mainly because it is not possible to calculate comparable and reliable death rates for the pre-1960 period. During 1949- 1951, the death figures are available only for some provincial centers, and during the 1952-1959 period, the data are available for all provincial centers, but not for district centers. However, for the period 1952-1959, provincial center population figures are not available; population figures are available for only provincial and district centers together. Death statistics and population data for the provincial and districts centers are available after 1960. Therefore, this study will be based on comparable data during the 1960-1995 period. Gathering statistical data on deaths at the sub-district and village level was begun in 1982, but the results cannot be published because they are still incomplete. Mid-year city population for the 1960-1995 period is taken from SIS Death Statistics (SIS Death Statistics related years). The city is defined as the area within municipal boundaries of provincial and district centers. The mid-year city population values used in this study, shown in Table 4.1, are taken from SIS Death Statistics, and are very similar to those given in censuses, except for 1985. For 1985, census city population is about 4 million higher than that of SIS Death Statistics. 49 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. In this study, both death statistics and population are taken from the same source. If census city population for 1985 had been used, the death rates for 1985 would have been lower than those calculated here. Table 4.1 Mid-year city population by level of development. Year Very developed Developed Less developed Least developed Turkey 1960 4,766,678 1,748,641 1,275,144 1,035,045 8,825,508 1965 5,855,206 2,120,819 1,549,619 1,280,173 10,805,817 1970 6,710,526 2,669,193 1,996,310 1,707,359 13,083,388 1975 9,126,797 3.225,323 2,419,322 2,097,626 16,869,068 1980 10,439,600 3,755,900 2,875,300 2,408,700 19,479,500 1985 11,967,649 4,465,035 3,508,129 2,846,930 22,787.743 1990 18,840,600 5,744,900 4,466,200 3,915,800 32,967,500 1995 22,108,000 6,481,000 5,286,000 4,530,000 38,405,000 Source: SIS Death Statistics related years. Percentage distribution of mid-year city population by age is assumed to be the same as that of urban population. There are small differences between urban and mid-year city population. In this study, mid-year city population is used to calculate death rates because death statistics were also collected on a city basis. In SIS Death Statistics, the mid-year city population was not available for dif ferent age groups. The city population for different age groups was calculated by using the age distribution of urban population for 1966 and 1990 (UN 1977, pp. 220-221 and UN 1992, pp. 244-245). For 1990, the age distribution of population is not given separately for (0-1), (1-4), and (5-14) age groups. Therefore, distribution of population for (0-14) age group by (0-1), (1-4), and (5-14) age groups, is assumed 50 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. to be the same of that of 1966. The same kind of adjustment has been made for (65+) age group. For 1990, the age distribution of the population is not given separately for (65-74) and (75+) age groups. Therefore, distribution of population for (65+) age group by (65-74) and (75+) age groups is assumed to be the same of that of 1966. Finally, the distribution of population for (0-1), (1-4), (5-14), (10-14), (15-24), (25-44), (45-64), (65-74), and (75+) age groups is projected for 1960-1995 period. In this projection, linear change is assumed. The distribution of mid-year city population by age is given in Table 4.2. Distribution of mid-year city population by sex was available only for 1965 and 1975 (SIS Death Statistics related years). The distributions of mid-year city population by sex for other years are projected by assuming Unear change during the 1960-1995 period. The distribution of mid-year city population by sex is given in Table 4.3. In Turkey, it is required by law to obtain a “Permission Form for Burial” for a dead person. However, the reported rate of death is lower than the real rate of death calculated by researchers due to some underreporting. There is no known study showing that underreporting in some regions is higher than others or that the rate of underreporting changed during the study period. Therefore, in this study, no adjustment has been made for underreporting. 51 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Reproduced w ith permission o f th e copyright owner. Further reproduction prohibited without permission. Table 4.2 Distribution of mid-year city population, by age groups. Year 0-1 1-4 5-14 15-24 25-44 45-64 65-74 75+ Total 1960 264,765 1,014,933 2,391,713 1,341,477 2,329,934 1,138,491 291,242 97,081 8,825,508 (3.0) (11.5) (27.1) (15.2) (26.4) (12.9) (3.3) (1.1) (100,0) 1965 302,563 1,177,834 2,841,930 1,728,931 2,906,765 1,393,950 334,980 118,864 10,805,817 (2.8) (10.9) (26.3) (16.0) (26.9) (12.9) (3.1) (1.1) (100.0) 1970 353,251 1,347,589 3,336,264 2,211,093 3,584,848 1,687,757 392,502 143,917 13,083,28 (2.7) (10.3) (25.5) (16.9) (27.4) (12.9) (3.0) (1.1) (100.0) 1975 421,727 1,653,169 4,166,660 3,019,563 4,706,470 2,176,110 506,072 168,691 16,869,068 (2.5) (9.8) (24.7) (17.9) (27.9) (12.9) (3.0) (1.0) ( 100.0) 1980 467,508 1,811,594 4,675,080 3,662,146 5,532,178 2,493,376 545,426 194,795 19,479,500 (2.4) (9.3) (24.0) (18.8) (28.4) (12.8) (2.8) (1.0) (100.0) 1985 524,118 2,005,321 5.309,544 4,534,761 6,585,658 2,916,831 615,269 227,877 22,787,743 (2.3) (8.8) (23.3) (19.9) (28.9) (12.8) (2.7) (1.0) (100.0) 1990 725,285 2,736,303 7,483,623 6,923,175 9,692,445 4,219,840 890,123 296,708 32,967,500 (2.2) (8.3) (22.7) (21.0) (29.4) (12.8) (2.7) (0.9) (100.0) 1995 806,505 3,033,995 8,487,505 8,525,910 11,483,095 4,915,840 998,530 345,645 38,405,00 (2.1) (7.9) (22.1) (22.2) (29.9) (12.8) (2.6) (0.9) (100.0) Note: The values in parenthesis show the share of each age group in total city population. Source: UN 1977 and 1992. Table 4.3 Distribution of mid-year city population, by sex. Year Male Female Total 1960 4,721,647 4,103,861 8,825,508 (53.5%) (46.5%) (100.0%) 1965 5,783,813 5,022,004 10,805,817 (53.5%) (46.5%) (100.0%) 1970 6,986,529 6,096,859 13,083,28 (53.4%) (46.6%) (100.0%) 1975 9,004,842 7,864,226 16,869,068 (53.4%) (46.6%) (100.0%) 1980 10,382,573 9,096,927 19,479,500 (53.3%) (46.7%) (100.0%) 1985 12,145,868 10,641,875 22,787,743 (53.3%) (46.7%) (100.0%) 1990 17,538,710 15,428,790 32,967,500 (53.2%) (46.8%) (100.0%) 1995 20,431,460 17,973, 540 38,405,00 (53.2%) (46.8%) (100.0%) Note: The values in parenthesis show the share of male or female population in total. Source: SIS Death Statistics related years. 4.2 Methodology The purpose of this study is to analyze the trends in mortality, and then to try to identify whether the economic development or public policy initiatives based on medical/technological improvements, including but not limited to education and public health campaigns, were the main factors responsible for the mortality decline in Turkey during the 1960-1995 period. 53 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. To evaluate these alternative hypotheses, the cause of death approach is used. In the first stage of the study, the deaths are classified according to causes of death and the trends in mortality from different causes of death are analyzed. In the second stage of the study, the causes of death which are principally responsible for the overall decline in mortality, i.e. the causes of death that dom inated mortality trends, during the 1960-1995 period axe chosen and analyzed in more detail to investigate the causes behind the mortality decline. Factors that can affect mortality trends are grouped together as economic factors such as nutrition and housing, and public policy initiatives such as education, medical/technological development, and public health policies. Education is included in public policy initiatives because, in Turkey, education is primarily free public education, and the government plays an important role in both general and health education through its policies such as campaigns, sectoral priorities in their government programs, and cooperation with non-governmental organizations. In the third stage, cities in Turkey are grouped according to their economic well-being, and then they are compared with each other to analyze whether there is significant difference in mortality levels and mortality trends among cities with different levels of economic development. As can be seen from Table 4.4, cities in Turkey are grouped in four different categories according to their level of economic development: very developed, de veloped, less developed, and the least developed. The indicator for this grouping was GDP per capita, i.e. economic well-being. GDP per capita is not available 54 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. by city population only, but it is available by province population, i.e. includ ing sub-district and village population. However, the death rates are available at provincial and district centers level, not in sub-district and village level. GDP per capita that is available for population including sub-districts and villages is used as an indicator for GDP per capita for city population, i.e provincial and district centers population. Then cities are ranked in descending order by their GDP per capita (in U.S. dollars) for 1987, 1988, 1989, and 1990. The rankings for these years are very similar. However, 1989 is chosen as a base year for ranking these cities because 1989 was the last year Turkey had 67 provinces. Beginning in 1990, some districts became provinces. In other words, administrative divisions changed after 1990. Changes in administrative division were taken into consideration throughout the study. Until 1990, there were 67 provinces in Turkey. By 1995, there were 76 provinces. During the 1990-1995 period, 9 districts became new provinces. The groupings are made according to 67 provinces, and the new provinces are included in their old provinces for the period after 1990. If the new provinces, or old districts, consisted of more than one province, then some adjustment has been made. For example, Aksaray was previously a district in Nigde. After 1990, Aksaray became a province, and included some of the population from Ankara province. However, since it mostly consisted of Nigde province, after 1990, it was treated as a part of Nigde province. 55 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Reproduced with permission o f th e copyright owner. Further reproduction prohibited without permission. Table 4.4 Distribution of provinces, by level of economic development. Very developed Developed Less developed Least developed Kocaeli Aydm U§ak Giresun Istanbul Bolu Ainasya Qankiri Kirklareli Nev§ehir Kayseri Adiyaman Izmir Denizli Trabzon Sivas Bursa Kiitahya Diyarbakir Yozgat Mugla Zonguldak (Bartin) Malatya Ordu Tekirdag Hatay Isparta Erzurum Bilecik Sakarya Kastamonu §anhurfa Qanakkale Burdur Tokat Tunceli Ankara (Kinkkale) Artvin Kahramanmara§ Mardin kel Konya (Karaman) I<ir§ehir Van Antalya Samsun Nigde (Aksaray) Giiinii§hane (Bayburt) Manisa Gaziantep Sinop Bitlis Eski§ehir Elazig Erzincan Bingol Edirne Rize Afyon Kars (Ardahan, Igdir) Bahkesir Qorum Siirt (Batman, §irnak) Hakkari Adana Mu§ Agri Note: Provinces in parenthesis were district of provinces next to them and they became provinces themselves after 1990. Source: SIS 1997a, pp. 704-707. In the very developed region group, there are 17 provinces, and each province in this group has more than $2,000 per capita GDP, and an overall average of $2,811. The developed region consists of 16 provinces, and each province in this group has $1,400-2,000 per capita GDP, and an overall average of $1,607. The less developed region consists of 16 provinces, and each province in this group has $1000-1400 per capita GDP, and an overall average of $1,232. The least developed region consists of 18 provinces, and each province in this group has less than $1,000 per capita GDP, and an overall average of $717 (SIS 1997a, pp. 704-707). Death rates for different causes, by level of development, by sex, by age groups are calculated. For example, the death rate from any cause of death by age groups is calculated by (deaths in age group/population in age group) per 100,000. After calculating death rates for each of the causes of death, the causes of death that dominated the mortality trends during the 1960-1995 period are analyzed in more detail. In other words, causes of death which were not only prevalent, i.e. important, but also for which the crude death rates decreased significantly during the study period are analyzed in more detail. The causes of deaths that dominated mortality trends during the 1960-1995 period were pneumonia, enteritis and other diarrhoeal diseases (EODD), diseases related to pregnancy, childbirth, infections of newborn, and other diseases peculiar to early infancy (PCIODI), and tuberculosis. During the 1960-1995 period, the crude death rate for all causes declined from 10.92 per thousand to 4.42 per thousand. The four groups of causes of death that 57 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. dominated mortality trends also accounted for 72 percent of the total decrease in crude death rate. There were some changes in classification of diseases in Turkey during the study period. In Turkey, classification of diseases is based on “International Statistical Classification of Diseases, Injuries, and Causes of Death.” In Turkey, the classifi cation of diseases changed in 1975. Prom these changes, the causes of deaths which dominated the trends in mortality during the 1960-1995 period were not signifi cantly affected, except the diseases related to PCIODI. In other words, there were no important shifts in mortality trends in pneumonia, EODD, and tuberculosis due to classification changes. However, there were significant changes in classification of diseases related to PCIODI (SIS Death Statistics related years). Therefore, diseases related to PCIODI are grouped together to minimize the effects of classification changes on mortality trends. Causes of death 40 through 44 in the old and new classification, by 50 selected causes, axe grouped as PCIODI. Pneumonia was cause of death 31 in the old classification and 32 in the new. EODD was cause of death 36 in the old classification and 4 in the new. Tuberculosis was cause of death 1 and 2 in the old classification and 5 and 6 in the new. In following chapter, first the overall situation of mortality in Turkey diming the 1960-1995 period will be analyzed. Then, mortality patterns for 1960 and 1995 will be compared to determine the causes of death that dominated mortality trends during the 1960-1995 period. 58 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. CHAPTER 5 TRENDS IN MORTALITY IN TURKEY, 1960-1995 The goal of this chapter is to analyze the part played by changes in causes of death during the mortality transition. By looking at cause-specific mortality and its changes in Turkey, one can reach a better understanding of the process of mortality change and can show how the transition resulted in a change from a situation in which infectious diseases, especially diseases related to infancy, predominated the mortality in Turkey to a situation in which heart diseases and malignant neoplasms, especially middle age and elderly diseases, are the most important causes of death. To achieve this goal, first, the overall situation of mortality in Turkey, such as crude death rate by level of development, by age, and by sex, during the 1960-1995 period, will be analyzed. Second, the principal causes of death during the beginning of the study period will be analyzed. Third, the principal causes of death dining the end of the study period will be analyzed. Then, these two periods will be 59 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. compared to determine which causes of death were principally responsible for the decline in mortality during the 1960-1995 period. 5.1 Trends in Overall Mortality in Turkey During the 1960-1995 Period In Turkey, as can be seen in Table 5.1 and Figure 5.1, the crude death rate from all diseases decreased significantly, from 10.92 to 4.42 per thousand population during the 1960-1995 period. Throughout the study period, the total death rate was the highest for the very developed region, and the lowest for the least developed region. In 1995, the very developed region had more than twice as high a death rate as that of the least developed region, i.e. 5.14 and 2.38 per thousand respectively (SIS Death Statistics related years). In other words, total death rates significantly differ in different regions by different levels of economic development. As can be seen in Table 5.2 and Figure 5.2, the age-specific death rate for all causes was also different for different age groups, and it was the highest for the 0-1 age group in 1960. However, after 1965, the death rate for the 75+ age group became the highest due to significant improvements in infant mortality. As can be seen in Table 5.3 and Figure 5.3, the crude death rate for all causes differed by sex. In 1960, males were in a slightly better position compared to females, i.e. 10.85 and 11.02 crude death rate per thousand, respectively. After 1965, females have lower death rate than males. In 1995, the crude death rates for 60 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. males and females are 4.76 and 4.04 per thousand, respectively. In other words, women had a greater improvement in mortality compared to men during the 1960- 1995 period. After explaining the overall trends in mortality, the next section will analyze the changes in cause-specific mortality in Turkey during the 1960-1995 period. 61 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 5.1 Crude death rate (per 1,000 population) for all causes, by level of development. Year Very developed Developed Less developed Least developed Turkey 1960 11.70 11.08 9.90 8.32 10.92 1965 9.61 8.55 8.12 6.61 8.83 1970 9.28 7.55 6.58 5.29 7.99 1975 8.57 6.44 5.13 4.22 7.13 1980 7.99 6.22 4.59 4.21 6.68 1985 7.52 5.56 4.37 3.92 6.20 1990 5.35 4.23 3.56 2.38 4.56 1995 5.14 4.31 3.30 2.38 4.42 Source: SIS Death Statistics related years. C o 3 a o a u 4) a < a u a 4) 'O 4) T3 3 W 4 o 12 N . 10 8 6 — Very developed - - Developed —— Less developed Least developed — Turkey 4 2 0 — 1960 1965 1970 1995 1975 1980 1985 1990 Y ear Figure 5.1 Crude death rate (per 1,000 population) for all causes, by level of development. 62 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Age-specific death rate (per 1,000 population) T a b le 5.2 Age-specific death rate (per 1,000 population) for all causes. Year 0-1 1-4 5-14 15-24 25-44 45-64 65-74 75+ Total 1960 124.71 10.95 1.23 2.21 3.22 14.64 36.52 110.97 10.92 1965 94.88 6.10 0.97 1.66 2.87 12.88 39.53 110.66 8.83 1970 82.52 4.62 0.82 1.44 2.39 11.41 44.45 111.73 7.99 1975 82.74 4.56 0.87 1.21 1.84 9.56 38.04 121.10 7.13 1980 67.48 3.52 0.64 1.05 1.68 9.37 42.69 139.44 6.68 1985 49.70 2.65 0.59 0.76 1.58 11.12 41.10 152.99 6.20 1990 30.16 1.27 0.36 0.50 1.18 9.11 29.33 142.70 4.56 1995 24.90 1.02 0.32 0.54 1.19 9.03 37.42 126.68 4.42 Source: SIS Death Statistics related years. 1000 5-14, 1 5 -2 4 ,------ 25-44 Total 65-74, 100 1960 1965 1970 1975 1980 1990 1985 1995 Y ear Figure 5.2 Age-specific death rate (per 1,000 population) for all causes. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Crude death rate (per 1,000 population) T ab le 5 .3 Crude death rate (per 1,000 population) for all causes, by sex. Year Male Female Total 1960 10.85 11.01 10.92 1965 8.93 8.72 8.83 1970 8.31 7.63 7.99 1975 7.42 6.81 7.13 1980 7.06 6.24 6.68 1985 6.60 5.75 6.20 1990 4.86 4.21 4.56 1995 4.76 4.04 4.42 Source: SIS Death Statistics related years. 12 Male — * - Fem ale Total 9 6 3 0 — 1960 1990 1995 1965 1970 1975 1980 1985 Y ear Figure 5.3 Crude death rate (per 1,000 population) for all causes, by sex. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 5 .4 Percentage distribution of deaths by leading causes in 1960. Cause % Pneumonia 17.96 Heart diseases 17.50 PCIODI 12.51 EODD 11.76 Malignant neoplasms 5.28 Tuberculosis 5.04 Other diseases 29.95 Source: SIS 1962. 5.2 Trends in Cause-specific Mortality in Turkey During the 1960-1995 Period 5.2.1 Cause of Death Patterns in 1960 At the beginning of the study period, i.e. in 1960, mortality in Turkey mainly resulted from infectious diseases (SIS 1962). As can be seen in Table 5.4, in 1960, the most important cause of death was pneumonia. About 18 percent of all deaths were due to pneumonia. As can be seen in Table 5.4, all top-five leading causes of deaths, i.e. pneumonia, heart diseases, PCIODI, EODD, and malignant neoplasms, collectively accounted for two thirds of all deaths, and all other diseases account for the remaining one third of deaths in 1960 (SIS 1962). Tuberculosis is included in Table 5.4 even though it was not one of the top five causes of death, because tuberculosis was still one of the most important causes of death in 1960, and it 65 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. was one of the diseases that dominated the trend in mortality in Turkey during the 1960-1995 period. This situation will be explained in more detail later in this chapter. 5.2.2 Cause of Death Patterns in 1995 The composition of deaths changed considerably during the study period. By 1995, pneumonia was no longer a leading cause of death, and only 1.66 percent of all deaths were due to pneumonia in 1995, compared to 17.96 percent in 1960 (SIS 1997b). EODD were no longer a leading cause of death. In 1995, heart dis eases were still an important cause of death in Turkey and accounted for 41.32 percent of total deaths (SIS 1997b). Malignant neoplasms followed heart diseases and accounted for 10.82 percent of total deaths. Deaths from PCIODI were still important and accounted for 7.65 per cent of the deaths in 1995 (SIS 1997b). In 1995, cerebrovascular disease and accidents became the next two leading causes of deaths, and they accounted for 6.49 and 3.58 percent of the total deaths, respec tively (SIS 1997b). As Table 5.5 shows, all five of these leading causes of death, i.e. heart diseases, malignant neoplasms, PCIODI, cerebrovascular disease, and accidents, together accounted for almost 70 percent of total deaths, and all other diseases accounted for the remaining 30 percent of deaths in 1995 (SIS 1997b). 66 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 5.5 Percentage distribution of deaths by leading causes in 1995. Cause % Heart diseases 41.32 Malignant neoplasms 10.82 PCIODI 7.65 Cerebrovascular disease 6.49 Accidents 3.58 Other diseases 30.14 Source: SIS 1997b. 5.2.3 Changes in Mortality Patterns During the 1960-1995 Period As the previous discussion has shown, the composition of death in Turkey changed considerably during the 1960-1995 period. Pneumonia and EODD are no longer leading causes of death. In 1960, deaths from accidents, including motor vehicle accidents, accounted for 3.07 percent of total death and it was not one of top five leading causes of death (SIS 1962). By 1995, deaths from accidents ac counted for 3.58 percent of total deaths and now it is one of top five causes of death (SIS 1997b). The death rate from accidents decreased during the 1960-1995 pe riod. However, after the campaigns to fight against EODD and pneumonia, death rates from pneumonia and EODD decreased in importance and the death rate from accidents became one of the top five causes of deaths by 1995 (SIS 1997b). The death rate from heart diseases decreased from 191 to 183 per 100,000 during the 1960-1995 period. Heart diseases are now the leading cause of death in Turkey 67 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. and accounted for 41.3 percent of all deaths in 1995. The death rate from malignant neoplasms decreased from 58 to 48 per 100,000 during the 1960-1995 period, and in 1995, malignant neoplasms was the second most important cause of death (SIS 1962 and 1997b). Heart diseases and malignant neoplasms are still among the most important causes of death, even in the most developed countries of the world. They are also the two leading causes of death in Turkey today. For example, in 1995, they accounted for more than half of the all deaths, i.e. 52.14 percent, in Turkey. When the death rate from heart diseases is analyzed by level of development, it can be seen that the death rate from heart diseases is the highest in the very developed region, and it is the lowest in the least developed region. This was the case throughout the 1960-1995 period (SIS Death Statistics related years). For example, in 1960, the death rate from heart diseases was 216 per 100,000 for the very developed region in Turkey whereas it was 139 per 100,000 for the least developed region. In 1995, the death rate from heart diseases was 210 per 100,000 for the very developed region in Turkey whereas it was 107 per 100,000 for the least developed region (SIS 1997b). As can be seen from these results, the death rate from heart diseases for the very developed region was almost two times higher than that of the least developed region. When the death rate from malignant neoplasms is analyzed by the level of development, it can be seen that the death rate from malignant neoplasms is the highest in the very developed region, and it is the lowest in the least developed 68 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. region. This was the case throughout the 1960-1995 period (SIS Death Statistics related years). For example, in 1960, the death rate from malignant neoplasms was 76 per 100,000 for the very developed region, whereas it was 27 per 100,000 for the least developed region. In 1995, the death rate from malignant neoplasms was 59 per 100,000 for the very developed region, whereas it was 23 per 100,000 for the least developed region (SIS 1997b). As these results show, the death rate from malignant neoplasms for the very developed region was almost three times higher than that of the least developed region. As can be seen from previous discussion, the least developed region has lower mortality in almost all diseases compared to the very developed region. After explaining the changes in mortality patterns in Turkey during the 1960- 1995 period, now the causes of death that were principally responsible for the decline in mortality during the 1960-1995 period can be determined. To determine these causes of death, one needs to look for not only the causes of death that were important in Turkey, but also for which the crude death rate decreased significantly during the study period. Heart diseases and malignant neoplasms were important causes of death through out the study period, but crude death rate for these diseases did not decrease sig nificantly during the 1960-1995 period. In other words, they were not the diseases that dominated mortality trends in Turkey. On the other hand, as can be seen in Table 5.6, crude death rates for pneumonia, EODD, PCIODI, and tuberculosis decreased significantly during the study period, and they were important causes of 69 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. death. In other words, they were the causes of death that dominated the trends in mortality in Turkey during the 1960-1995 period. Table 5.6 Contribution of selected causes of death in mortality decline in Turkey during 1960-1995 period. Causes-of-death Crude death rate per 100,000 1960 1995 Change Pneumonia 196 7 189 EODD 128 3 125 PCIODI 137 34 103 Tuberculosis 55 2 53 All causes 1092 442 650 Source: SIS 1962 and 1997b. As can be seen in Table 5.1. during the 1960-1995 period, there was a 56 and a 61 percent decline in crude death rates for all causes for very developed and developed regions, respectively. These values for less and the least developed regions were 67 and 71 percent, respectively (SIS 1962 and 1997b). These results show that the less developed regions are not only in a better situation compared to the more developed regions in mortality, but also they had higher rate of decline in mortality during the study period, despite their economic disadvantages. One may argue that age-standardized death rates need to be used instead of the crude death rates. However, death statistics are available at city level, but age distributions of city populations are not available. Age distributions of province populations were available for 1990, but not for the entire study period (SIS 1993, pp. 74-77). Age distributions of city populations differ from that of province 70 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 5.7 Percentage distribution of province population in 1990, by level of development and by age. Year Very developed Developed Less developed Least developed Turkey 0-4 8.9 10.4 11.8 13.9 10.5 5-14 21.3 25.0 27.0 29.6 24.4 15-24 20.5 19.5 19.8 19.7 20.0 25-44 30.3 26.2 23.7 21.4 26.9 45-64 14.5 14.2 13.3 11.8 13.8 65-74 2.8 2.8 2.7 2.3 2.7 75+ 1.6 1.8 1.6 1.2 1.6 Unknown 0.1 0.1 0.1 0.1 0.1 Turkey 100.0 100.0 100.0 100.0 100.0 Source: SIS 1993, pp. 74-77. population since province populations include sub-district and village population, in addition to city population. Moreover, the share of the 0-1 age-group was not given in the 1990 age distribution of province populations. But, the biggest decline in mortality during the study period was in the 0-1 age group. As a result, age- standardized death rates for different cities for the 1960-1995 period could not be calculated, and therefore, the crude death rates for city population were used in this study. Based on the 1990 age distributions of provinces. Table 5.7 is prepared to show how the age distribution differs by level of development. As Table 5.7 shows, the less developed regions have higher percentage of the 0-4 age group, and lower percentage of the 65+ age group population compared to more developed regions. Among the diseases that dominated the mortality trend in Turkey during the 1960-1995 period only tuberculosis was important for the infants, the working 71 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. age population and the elders. Other diseases that dominated the mortality trend, i.e. pneumonia, EODD, PCIODI, were mainly infant diseases. Therefore, even after age standardization, the result that less and the least developed regions had greater rate of decline in mortality, i.e. better improvement in life expectancy, during the study period will not change. To sum up, in Turkey, during study period, there was a change from a situation in which infectious diseases dominated mortality to a situation in which heart dis eases and malignant neoplasms were the most important causes of death. During this period, four groups of diseases, i.e. pneumonia, EODD, PCIODI, and tuber culosis dominated the mortality trends and they accounted for 72 percent of the decline in mortality. All other diseases accounted for only 28 percent of the decline in mortality during the 1960-1995 period. In the next four chapters, these diseases that dominated mortality trends in Turkey during the 1960-1995 period, and the factors that may have effect on these trends will be analyzed in detail to determine either public policy initiatives or economic factors were mainly responsible for the decline in mortality in Turkey during the study period. 72 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. CHAPTER 6 PNEUMONIA Pneumonia, which is an infection or inflammation that affects the bronchial tubes and lungs, is usually caused by bacteria. However, viruses and other or ganisms can cause pneumonia as well. It may also develop as a complication of another viral illness, such as measles or chickenpox. It sometimes follows a viral upper respiratory infection, such as a cold or bronchitis (IU 1998, pp. 331-345, especially pp. 331-332). Symptoms of pneumonia may include productive cough with yellow, green, rust-colored or bloody sputum, which is a mucus coughed up from the lungs. Some other symptoms are fever and shaking chills, rapid and shallow breathing, rapid heartbeat, chest-wall pain that is often made worse by coughing or taking a deep breath, and fatigue which is worse than one would expect from a cold (IU 1998, p. 337). In this chapter of the study, first, the trends in mortality from pneumonia in Turkey will be analyzed. Second, factors that may affect mortality from pneumonia 73 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. will be discussed. Last, the question of whether public policy initiatives, based on advancement of medical/technological knowledge, or economic factors, such as income, nutrition and housing, were mainly responsible for the decline in mortality from pneumonia will be analyzed. 6.1 Trends in Pneumonia in Turkey Pneumonia was the most important cause of death in Turkey during the 1960s. In 1960, about 18 percent of deaths were due to pneumonia (SIS 1962). There was a significant change in death from pneumonia during the 1960-1995 period. In 1995, only 1.7 percent of all deaths were due to pneumonia (SIS 1997b). One can easily say that pneumonia is no longer a leading cause of death in Turkey. When regional differences in mortality from pneumonia are analyzed, one can see that there is no significant differences among regions with different level of economic development. As can be seen in Table 6.1 and Figure 6.1, at the beginning of the 1960s, the crude death rate from pneumonia was the lowest for the very developed region, and the highest for the developed region, i.e. 178 and 230 per 100,000 population respectively. The least developed region had a lower death rate from pneumonia compared to the developed region throughout the study period. By 1970, all regions had similar death rates from pneumonia, and in some years the least developed region was in a better position than the very developed region regarding deaths from pneumonia (SIS Death Statistics related years). 74 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Even though the death rate from pneumonia does not significantly differ by level of economic development, it differs significantly by age. As shown in Table 6.2, and Figure 6.2, the age-specific death rate for pneumonia was the highest for the 0-1 age group. In other words, pneumonia affected mainly the infants. The share of infant deaths was more than half of the all deaths from pneumonia throughout the study period. It was 63 percent in 1960, and it decreased to 56 percent in 1995 (SIS Death Statistics related years). As can be seen in Table 6.3 and Figure 6.3, crude death rates from pneumonia did not differ by sex, except for 1960 and 1975. Overall, one can see that there is no significant differences between males and females regarding deaths from pneumonia (SIS Death Statistics related years). 75 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 6.1 Crude death rate (per 100,000 population) for pneumonia, by level of development. Year Very developed Developed Less developed Least developed Turkey 1960 178 230 209 207 196 1965 117 144 137 124 126 1970 101 109 99 92 101 1975 76 69 53 59 69 1980 55 69 48 65 58 1985 26 29 26 34 28 1990 11 14 15 15 12 1995 7 8 9 8 7 Source: SIS Death Statistics related years. O 250 Very developed Developed Less developed Lease developed Turkey ^ 4 3 § • a 200 ^ \ \ \ \ o o o o o 150 u 0 ) a 100 a > 4 - > <0 u (Q 0 ) T3 a > T J 3 u O 1960 1965 1975 1980 1985 1995 1970 1990 Y ear Figure 6.1 Crude death rate (per 100,000 population) for pneumonia, by level of development. 76 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Age-specific death rate (per 100,000 population) Table 6.2 Age-specific death rate (per 100,000 population) for pneumonia. Year 0-1 1-4 5-14 15-24 25-44 45-64 65-74 75+ Total 1960 4090 455 22 7 9 34 96 295 196 1965 3049 259 14 4 4 15 61 177 126 1970 2586 200 12 4 3 14 66 149 101 1975 1961 148 8 3 2 5 22 116 69 1980 1654 136 8 2 2 5 22 74 58 1985 815 64 4 1 1 4 17 58 28 1990 398 26 2 1 1 2 8 33 12 1995 197 18 2 1 1 3 13 47 7 Source: SIS Death Statistics related years. 4 10 15-24, 5-14, 25-44 45-64, 65-74, Total 3 10 2 10 1 10 o 10 1960 1965 1970 1975 1980 1985 1990 1995 Y ear Figure 6.2 Age-specific death rate (per 100,000 population) for pneumonia. 77 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 6 .3 Crude death rate (per 100,000 population) for pneumonia, by sex. Year Male Female Total 1960 188 206 196 1965 123 129 126 1970 100 103 101 1975 55 86 69 1980 57 59 58 1985 28 28 28 1990 12 13 12 1995 7 7 7 Source: SIS Death Statistics related years. 250 Male Fem ale Total a o a. 200 150 a 100 ■ a 3 u CJ 1960 1965 1970 1975 1980 1985 1990 1995 Y ear Figure 6.3 Crude death rate (per 100,000 population) for pneumonia, by sex. 78 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 6.2 Factors Affecting Mortality From Pneumonia In the health and mortality literature, different factors such as medical/techno logical improvements, education, public policy initiatives, income, nutrition, hous ing, and climate are mentioned as important in affecting the mortality from pneu monia (See especially, Gordon et al. 1964, Preston and Nelson 1974, McKeown 1976 and 1983, Caselli 1991). In this section, first these factors and their effect on mortality from pneumonia in general, and then, the situation in Turkey in partic ular will be discussed. Medical/technological improvements, such as measles and whooping cough vac cinations, use of antibiotics and other medications such as penicillin flacons, cot- rimoxazole tablets, and acetaminophen or aspirin to reduce fever are mentioned as important in explaining reductions in mortality from pneumonia (TR-UNICEF 1991, pp. 180-181). The proper use of prescribed medications is also mentioned as important in treating pneumonia (TR-UNICEF 1991, pp. 180-181). For example, for the use of antibiotics, it is very important to take the entire course that is prescribed or recommended by the doctor. Less educated mothers generally buy the medicine according to pharmacists’ recommendation without consulting the doctor, and they discontinue the use of antibiotics when the symptoms started to disappear due to the high cost of antibiotics and inadequate knowledge about how long it needs to be used (TR-UNICEF 1991, p. 181). Therefore, improvement in people’s knowledge, 79 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. through both general education and health education may be another important factor affecting mortality from pneumonia. For example, Turkish Demographic and Health Survey: 1993 (MOH et al. 1994) showed that better educated mothers are more likely to take their children to hospital for treatment for acute respiratory infections (ARIs) (MOH et al. 1994, p. 102). ARIs consist of mainly pneumonia, but also include bronchitis and influenza, and ARIs are one of the most important causes of infant mortality. According to Cleland and Van Ginneken, mother’ s education level was an important factor affecting infant mortality. Even after controlling for economic characteristics result ing from better education, the effects of education on the infant mortality remain statistically significant. Cleland and Van Ginneken stated in their study that, even after adjustment for economic factors, 1-3 years of schooling is associated with a fall of 20 percent in childhood risks of death, and this strong relationship between mother’ s education and child survivorship is found in almost all major regions of developing world (Cleland and Van Ginneken 1988, p. 1365). A study done in Nigeria showed that the mother’ s education was a more deci sive determinant of child survivorship than many economic family characteristics such as husband’ s occupation. There are many reasons for the positive relation ship between education of mothers and the child survival rate. For example, better education of mothers means economic advantage. According to Cleland and Van Ginneken, economic advantages resulting from better education of mothers account 80 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. for about 50 percent of the overall education-mortality relationship. Another ex planation is better educated mothers are able to make better use of existing health services. This relationship was very different in different countries because there were some countries whose primary health services were so weak that they had no effect on the health of mothers and children. On the other hand, there were countries whose health services tend to accentuate educational disparities because of differential access (Cleland and Van Ginneken 1988, p. 1357). Cochrane and his colleagues’ research covering 33 countries and the United Nations’ research covering 15 countries showed similar results in explaining the relationship between maternal education and childhood mortality (See Cleland and Van Ginneken 1988, p. 1358). Both studies found a linear relationship between maternal education and childhood mortality, with an average 7-9 percent decline in mortality ratios with each one-year increment in mother’s education, and there was a stronger association in childhood than in infancy (Cited in Cleland and Van Ginneken 1988, p. 1358). This result may be due to protection against diseases during the infancy through breastfeeding since clinical studies that showed the superiority of breastmilk over other types of nourishment and they found that breastmilk, especially colostrum, protected the newborn baby against diseases. Therefore, breastfeeding is also mentioned as an important factor affecting infant mortality. However, the level of breastfeeding can be affected by different factors such as medical knowledge, mother’ s educational level, women’ s participation into 81 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. labor force, and public health initiatives. The effects of breastfeeding on infant mortality in Turkey will be analyzed in more detail in chapter 8. Better educated mothers may be more effective compared to less educated moth ers at translating financial resources and facilities into better health and survivor ship for their children (Cleland and Van Ginneken 1988, pp. 1359-1360). Better educated mothers have better knowledge of health requirements and they are bet ter aware of causes of diseases compared to uneducated mothers. Mothers with no schooling attribute most of the cause of diseases to supernatural causes, whereas educated mothers attribute mostly to natural causes. Better educated mothers have a greater sense of personal responsibility for, and control over the welfare of children because uneducated mothers have a more resigned and fatalistic outlook (Cleland and Van Ginneken 1988, p. 1364). Another study showed a small effect of maternal education on quantity of food intake or nature of diet for Bangladesh (Cleland and Van Ginneken 1988, pp. 1363-1364). In Turkey, there is no known study showing that education of mothers is related to quantity of food intake. There is information about the nutritional status and education of mothers, especially in the Turkish Demographic and Health Survey: 1993 (MOH et al. 1994). However, nutritional status is not only affected by income, but also by disease environment and quality of food. For example, better educated mothers may have better knowledge of nutritional needs, or, as was previously discussed, better educated mothers have better knowledge of when to introduce solid foods to infants. Less educated mothers are more likely to introduce 82 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. solid foods into infants’ diets either too early or too late; both have negative effects on infants’ health. Not only mother’s education, but also father’s education level mentioned as an important factor affecting infant mortality in many studies (See especially, Baya 1998 and Majumder et al. 1997). Banza Baya analyzed the impact of father’ s edu cation on child survival in Burkina Faso. According to Baya, the effect of mother’ s education on child survival between 1 and 23 months becomes non-significant when one controls for certain exogenous variables, in particular father’s education. On the other hand, according to Baya’ s study results, there is a significant, independent positive impact of father’ s education on child survival (Baya 1998). A study on mortality in Bangladesh also showed the importance of father’s education on infant and child mortality. Study results showed that the preceding birth interval length, followed by the survival status of the immediately preceding child, are the most important factors associated with infant and child mortality. It is also stated in the study that sex of the index child, and both mother’ s and father’ s education were also significant (Majumder et al. 1997). Studies like Baya’ s and Majumder’ s showed that not only mother’ s, but also father’s education level were important factors affecting infant and child mortality. Therefore, it is important to point out the necessity to take into account father’ s characteristics as well when studying mortality. However, in Turkey, there is lim ited information about the effect of fathers’ education on mortality. Most of the studies are concentrated on mothers’ education since mothers are considered as the 83 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. parent responsible from taking care of their children, and fathers are considered as the parent responsible from earning income for living, i.e. the “bread winner.” Therefore, even though this study results may concentrate on the importance of mothers’ education, the importance of fathers’ education in child survival should not be forgotten. As can be seen from the previous discussions, both better medical/technological knowledge, and parents’ education levels were mentioned as important factors af fecting not only infant mortality in general, but also mortality from pneumonia, in particular. However, public policy initiatives are needed in many cases to make the new knowledge available to the public, and to improve the education levels of parents. In other words, the effects of medical/technological improvements, ad vancement of knowledge, education, and public policy initiatives are all connected to each other. Therefore, the effects of medical/technological improvements, ad vancement of knowledge, education, and public policy initiatives will be analyzed as a group, in the “Pneumonia and Public Policy Initiatives” section of this chapter. On the other hand, the economic factors, reflected in income, nutrition, hous ing, are mentioned as important factors affecting mortality from pneumonia (See especially, Gordon et al. 1964, Preston and Nelson 1974, Caselli 1991, Lunn 1991). Gordon reported a higher incidence of respiratory infections in poorly nourished areas of the developing world (Gordon et al. 1964). Peter Lunn also argues that there is a definite influence of nutrition on respiratory infections (Lunn 1991, p. 137). On the other hand, studies carried out in Bangladesh, Costa Rica, Indonesia, 84 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. and Gambia showed that respiratory infections could not be related to nutritional status (See especially James 1972, Sommer and Tarwotjo 1984). Moreover, there is a discussion about whether the illness is caused by deterioration of nutritional status, or the deterioration of nutritional status caused by illness through loss of appetite and lower absorption of nutrients (Lunn 1991, p. 135). In other words, the influence of nutrition on pneumonia is not very clear. The argument behind higher income leading to lower mortality from pneumonia is based on the assumption that when income increases, the nutritional status of people improves. However, as will be explained later in this chapter, this is not always the case. It is true that well-nourished individuals are substantially more resistant to diseases than those suffering from malnutrition (Puranen 1991, p. 98). However, increased income does not necessarily mean better nutrition. Higher income does not necessarily mean better housing either. When the industrialized cities become overcrowded, the demand for housing increases. Burnett argues that improved housing in industrialized cities could even result in an increase in mortality when higher rents meant there was less to spent on food (Burnett 1991, p. 176). Industrialization also means air pollution and crowded cities. Caselli argues that, in 1951, industrial smoke and air pollution together with unfavorable climate conditions was probably sufficient to explain high mortality from ARIs in England (Caselli 1991, p. 88). Puranen argues that, overcrowding, low housing standards are also important factors in transmission of the pneumonia and other infectious diseases (Puranen 1991, p. 98). As a result of rapid industrialization, 85 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. low quality squatter housing areas that are overcrowded and lacking clean water and ventilation, became an important part of many industrialized cities. The effects of economic factors, such as income, nutrition, and housing, on mor tality from pneumonia in Turkey will be analyzed as a group, in the “Pneumonia and Economic Factors” section of this chapter. Climate is also mentioned as an important factor affecting mortality from pneu monia and other ARIs (See especially Caselli 1991, p. 72; Vallin 1991, p. 44; Pre ston and Nelson 1974). Preston and Nelson argue that harsher climate conditions in England and Wales, compared to Italy, may be the explanation for higher mortality from ARIs in the former (Preston and Nelson 1974). However, this hypothesis is contradicted by the very low mortality rates from these diseases in Norway (Caselli 1991, p. 88). On the other hand, Vallin argued that, climatic factors may have favored England, compared to France, during mid-18th century, since temperate, cool countries are less exposed than those with a warmer climate to the spread of some infectious diseases (Vallin 1991, p. 44). One can see that, in Turkey, the incidence of and mortality from ARIs increases during winter times (MOH et al. 1994, p. 100). However, climate is not the factor affecting the long-term trends in mortality from pneumonia. Instead, it can partly explain regional differences in mortality from pneumonia. Therefore, it will not be analyzed in detail. After having reviewed this information about the factors that can effect mortal ity from pneumonia in general, effects of these factors on mortality from pneumonia 86 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. in Turkey can be analyzed. In the next section of the study, first the effects of pub lic health initiatives, and then, the effects of economic factors on mortality from pneumonia in Turkey will be discussed. 6.2.1 Pneumonia and Public Policy Initiatives In Turkey, almost 80 percent of deaths from ARIs are from pneumonia (SIS Death Statistics related years). During the 1960s and 1970s, pneumonia was one of the most important causes of death in Turkey. However, by 1985, pneumonia was no longer a leading cause of death in Turkey. During the 1960-1985 period, in Turkey, the death rate from pneumonia decreased from 196 to 28 per 100,000. By 1995, the death rate from pneumonia was 7 per 100,000 (SIS 1997b). Among the factors that mentioned before, education was the most important factor that affected the decline in death rate from pneumonia in Turkey. According to Turkish Demographic and Health Survey: 1993 (MOH et al. 1994), improvement in general education level, especially education of mothers, affects the incidence of pneumonia (MOH et al. 1994, pp. 102-103). As can be seen in Table 6.4, percentage of children under five years with ARIs symptoms, rapid breathing and coughing, two weeks prior to the survey differed significantly by mother’s level of education. Children of better educated mothers are less likely to have ARIs symptoms. According to Turkish Demographic and Health Survey: 1993 (MOH et al. 1994), as Table 6.5 shows, the percentage of children with ARIs symptoms taken to a 87 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 6 .4 Percentage of children w ith ARIs symptoms, by m other’s education. Mother’s education (%) No education/Primary incomplete 15.3 Primary complete/Secondary incomplete 11.2 Secondary complete/Higher education 9.5 Source: MOH et al. 1994, p. 102. Table 6.5 Percentage of children with ARIs symptoms taken to a health facility, by mother’s education. Mother’s education (%) No education/Primary incomplete 32.8 Primary complete/Secondary incomplete 37.3 Secondary complete/Higher education 55.8 Source: MOH et al. 1994, p. 102. health facility such as health house, health center, hospital or private doctor, dif fered significantly by mother’s level of education (MOH et al. 1994, pp. 102). As in the case of many other illnesses, better educated mothers, are more likely to take their children to a health facility for treatment of ARIs. The Turkish Demographic and Health Survey: 1993 (MOH et al. 1994) also shows that, the likelihood of a child not to be given any kind of treatment decreases with the mother’s level of education (MOH et al. 1994, pp. 102). As can be seen from Table 6.6, less educated mothers are more likely to do nothing to treat ARIs. These results show that mothers’ level of education does matter in incidence of pneumonia in Turkey: children of better educated mothers are less likely to have 88 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 6.6 Percentage of children w ith ARIs symptoms that are not given any treatm ent, by mother’s education. Mother’ s education (%) No education/Primary incomplete 34.6 Primary complete/Secondary incomplete 23.3 Secondary complete/Higher education 6.4 Source: MOH et al. 1994, p. 102. ARIs symptoms. Moreover, it also shows that better educated mothers are more likely to seek treatment for their children. The Turkish government played an important role in improving the general education level in Turkey. First of all, according to “National Education Funda mental Law,” which was launched in 1973, primary education is compulsory and free in public schools for every child that is 6 years old (TR-UNICEF 1991, pp. 231-234). Compulsory primary education was a legal requirement even during the Ottoman Empire period. The law, “Regulations for General Education,” passed in 1869, made many provisions, including compulsory primary education (Kazamias 1966, p. 63). However, school enrollments were very low before 1950. According to Easterlin, primary school enrollment rates in Turkey were very low until the 1940. During the 1920s, there was little schooling. By 1940, there was some schooling, and after 1950 there was high level of schooling (Easterlin 1995, ch. 5, p. 16). Another source also supported the idea of significant, improvement in schooling after 1950 (SPO 1996, p. 139). As was previously discussed in chapter 3, there was significant improvement in school enrollments during the 1950-1960 period. 89 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. During the 1950-1960 period, secondary school enrollment rates more than tripled, and high school enrollment rates almost doubled. Dining the 1960-1970 period, there was still significant improvement in school enrollment rates. After 1970, im provement in school enrollment rates continued, but the rate of increase was not as fast as those in the 1950s and 1960s. Moreover, in order to improve the general literacy level, especially for people who are not at school age and illiterate or the elders who knew only the old al phabet, the Turkish government started the “Reading-Writing Campaign” in 1981. The rate of increase in the literacy rate was significantly higher after 1981 compared to earlier periods. This campaign contributed positively to both male and female literacy, but especially female literacy such that during the 1980-1985 period, the percent of female population aged six and over and literate increased from 54.65 to 68.02 whereas the increase for males was from 79.94 to 86.35 (SIS 1993, p. 13). During the pre-campaign period, 1975-1980, the death rate from pneumonia decreased from 69 to 58 per 100,000 population. However, following Reading- Writing Campaign, during the 1980-1985 period, the death rate from pneumonia decreased faster, compared to the earlier period, from 58 to 28 per 100,000 (SIS Death Statistics related years). The high improvement in literacy levels during the 1980-1985 period resulted not only from prior increase in school enrollment but also from the Reading-Writing Campaign. Another factor that affected mortality from pneumonia in Turkey was vacci nation. The ARIs-related deaths decreased as a result of increasing immunization 90 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. rates for measles and whooping cough, along with improvements in the health infrastructure (SPO 1993, p. 25 and HU 1993, p. 201). Education played an im portant role in vaccination. As can be seen in Table 6.7, the percent of children 12-23 months who are fully vaccinated, and the percent of who received measles vaccination differed significantly by mother’ s level of education. Table 6.7 Vaccination in 1993, by mother’ s education. Mother’s education Percentage of children who received Full Measles vaccination vaccination No education/Primary incomplete 48.0 64.5 Primary complete/Secondary incomplete 70.9 83.8 Secondary complete/Higher education 83.6 89.3 All children 64.7 77.9 Source: MOH et al. 1994, p. 98. With the goal of achieving universal child immunization by 1990, Turkish gov ernment launched a national immunization campaign in 1985. The intensive na tionwide immunization campaigns for diphtheria, pertussis, and tetanus (DPT), polio and measles started in 1985. People were vaccinated against these diseases before 1985, but the coverage rates were low (HU 1993, p. 196). In Turkey, there is no reliable information about the vaccination, i.e. when it started and the cov erage rate for the pre-campaign period. However, according to Population Issues in Turkey (HU 1993), the coverage rates for each vaccine previously mentioned more than doubled as a result of the 1985 campaign (HU 1993). For example, the 91 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. percentage coverage of all cMdren less than five years old for 3 doses of DPT and polio vaccination rose from 37 before to 76 after the campaign. The same ratio for measles vaccination rose from 37 to 83. Moreover, the percentage of vaccination for measles in infants less than one year old was 12 percent before the vaccination campaign, and increased to 72 percent after the campaign (HU 1993, p. 197). In addition to the improvement in education and vaccination levels, the Turk ish government played an important role in fighting against pneumonia through “Control of Acute Respiratory Infections (CARI)” campaign. Until 1986, there was no active nation-wide campaign to fight against pneumonia, except the vac cination programs and health education programs on television and radio. Even though mortality from pneumonia was low by 1986, Turkish authorities wanted to eliminate pneumonia deaths completely. Therefore, in 1986, the Turkish govern ment together with UNICEF put the CARI campaign into practice. The CARI campaign started in Qankiri, one of the least developed provinces, and later in 17 other least developed provinces. By 1995, the campaign was being carried out in 63 provinces covering 72 percent of population (MOH et al. 1994, p. 100). The Turkish government also actively involved in these campaign activities, in coopera tion with the World Health Organization (WHO) and UNICEF. During the CARI campaign, different medications were used to treat patients. Penicillin flacons and cotrimoxazole tablets were sent to health centers and Mother and Child Health and Family Planning Centers by the government. These medications are distributed to 92 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. patients free of charge by authorities (TR-UNICEF 1991, p. 180). The use of dif ferent medications such as penicillin flacons, cotrimoxazole tablets, and antibiotics may have affected the mortality from pneumonia in Turkey (MOH et al. 1994, p. 102). However, there is no known study showing when they began to be used and how widespread their use was. Both the vaccination and the CARI campaign policies are based on advancements in medical knowledge, and public authorities played an important role in putting the new knowledge into practice. After the introduction of the CARI campaign, more patients started to get infor mation about how to use the antibiotics directly from doctors, and the antibiotics provided to patients were free of charge, which made them more likely to continue the use of antibiotics for the time doctor suggested. Education about ARIs and how to use antibiotics given to patients not only through the CARI campaign, but also through mass media, especially television spots (TR-UNICEF 1991, pp. 180-181). The Turkish government required certain programming on each television channel to educate people about different health issues. These programs were important in improving people’ s knowledge of health issues. This also contributed positively to the appropriate use of antibiotics. Television spots such as "Dikkat.” meaning be careful, “1 Dakika,” meaning one minute, “Her Qocuk Bir Can,” meaning each child one life, were shown many times during the day generally for 1-3 minutes to educate the public on different issues. Almost 45 percent of these spots were about hygiene, health and the importance of the environment (TR-UNICEF 1991, pp. 274-276). Therefore, one can say that improvement in knowledge through health 93 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. education, was another factor affecting both the incidence and the mortality from pneumonia in Turkey. As a result, one can say that public policy initiatives, including but not limited to education, vaccination, and CARI campaigns, played important role in fighting against pneumonia in Turkey during the 1960-1995 period. Public policy initiatives were mainly based on improvement in medical/technological knowledge, such as availability of vaccinations and different medications. 6.2.2 Pneumonia and Economic Factors Economic factors, reflected in income, nutrition, and housing are mentioned as important factors affecting mortality from pneumonia (See especially, Gordon et al. 1964, Preston and Nelson 1974, Caselli 1991, Lunn 1991). However, these factors did not contribute significantly to the decline of mortality from pneumonia in Turkey during the 1960-1995 period. One of the most important economic factors that may affect mortality from pneumonia is nutrition. However, economic growth does not necessarily mean better nutrition. For example, in squatter housing areas of Turkey, where more than 25 percent of urban population of big cities were living, in addition to low quality of housing, the malnutrition problem was more apparent compared to both other urban and rural areas of Turkey (TR-UNICEF 1991, pp. 368-370). As can be seen in Table 6.8, Yildinm and Lohfeld found that, in 1990, among 1,620 children in Antalya’ s Ahath squatter housing areas, 39.4 percent of the girls 94 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. less than one year old had some level of malnutrition problem, low, medium, or serious, where as this ratio was 21.7 percent for boys of the same age (Cited in TR-UNICEF 1991, p. 370). These significant differences between the nutrition level of boys and girls may be an indicator of mothers’ giving priority to their sons in case of food inadequacy. The malnutrition problem in this area increases by age due to the lower rate of breastfeeding. Among the children, all ages together, a serious malnutrition problem was found for 5.3 percent of the girls and 4 percent of the boys in the Ahath squatter housing area (TR-UNICEF 1991, p. 370). Table 6.8 Nutritional status of children in Ahath/Antalya, by age and by sex. Age Girl Boy Well-nourished Malnourished Well-nourished Malnourished (%) (%) (%) (%) 0-1 60.6 39.4 78.3 21.7 1 52.6 47.4 57.6 42.4 2 45.6 54.4 53.2 46.8 3 38.9 61.1 58.3 41.7 Total 49.2 51.8 58.3 41.7 Source: TR-UNICEF 1991, p. 371. Children under five years-of-age are classified as undernourished according to three anthropometric indices of nutritional status, i.e. height-for-age, weight-for- height, and weight-for-age. As recommended by the World Health Organization (WHO), the nutritional status of children is compared with an international refer ence population defined by the U.S. National Center for Health Statistics (NCHS), and accepted by the U.S. Centers for Disease Control (CDC). Each anthropometric 95 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. index is expressed in terms of the number of standard deviation (SD) units from the median of the NCHS/CDC/WHO international reference population. Use of the international reference population is based on the finding that well-nourished young children of all population groups for which data exist follow very similar growth patterns. In any large population, there is variation in height and weight, and this variation approximates a normal distribution. The international refer ence population serves as a point of comparison in examining the differences in the anthropometric status of subgroups in a population and also the changes in the nutritional status over time. Children are classified as undernourished if their z-scores are below minus two or minus three standard deviations (-2SD or -3SD) from the median of the reference population (MOH et al. 1994, p. 112). The height-for-age index is an indicator of linear growth retardation. Children whose height-for-age is below minus three standard deviations (-3SD) from the me dian of the reference population are considered “severely stunted,” very short for their age. Children whose height-for-age is below minus two standard deviations (-2SD) from the median of the reference population are considered “stunted,” short for their age, and are chronically undernourished. Height-for-age represents a mea sure of the long-term effects of undernutrition in a society, and is also affected by recurrent and chronic illness (MOH et al. 1994, p. 112). The weight-for-height index measures body mass in relation to body length and a representative of current nutritional status. Children whose weight-for-height is below minus three standard deviations (-3SD) from the median of the reference 96 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. population are considered “severely wasted,” very thin for their height. Children whose weight-for-height is below minus two standard deviations (-2SD) from the median of the reference population are considered “wasted,” thin for their height, and are acutely undernourished. Wasting represents a failure to receive adequate nutrition in the period immediately preceding the survey. It may also reflect acute food shortage. The Turkish Demographic and Health Survey: 1993 (MOH et al. 1994) showed that 2.9 percent of children under five years are wasted, and 0.4 per cent of them are severely wasted. Overall, wasting is not a problem in Turkey (MOH et al. 1994, p. 112). The weight-for-age index is a composite index of height-for-age index and weight- for-height index, and it takes into account both acute and chronic undernutrition. Children whose weight-for-age is below minus three standard deviations (-3SD) from the median of the reference population are considered “severely underweight.” Children whose weight-for-age is below minus two standard deviations (-2SD) from the median of the reference population are considered “underweight.” (MOH et al. 1994, p. 112) As can be seen from Table 6.9, in Turkey, education of mothers is an important factor affecting nutritional status, i.e. better educated mothers are more likely to have better nourished children. In Turkey, undernutrition is not a problem among children of mothers with secondary education or higher; the percentage of children who are below the (-2SD) cut-off point is close to that seen for the reference population, 4.3 per cent for Turkey and 2.3 per cent for the reference population. 97 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Reproduced with permission o f th e copyright owner. Further reproduction prohibited without permission. Table 6.9 Nutritional status, by mother’s education. Mother’ s education Height-for-age Weight-for-height Weight-for-age % below -3SD % below -2SD % below -3SD % below -2SD % below -3SD % below -2SD No education/Primary incomplete 12.9 33.6 0.7 4.4 4.3 17.9 Primary complete/Secondary incomplete 3.3 15.7 0.3 2.3 0.8 7.2 Secondary complete/Higher education 0.8 4.3 0.3 1.5 0.0 2.5 Total 6.3 20.5 0.4 2.9 1.9 10.4 Source: MOH et al. 1994, p. 115, and errata sheet. On the other hand, almost one third of the children whose mother lack formal education, i.e. no education or primary incomplete, are classified as stunted (MOH et al. 1994, p. 115, and errata sheet). In other words, education of mothers is also very important factor affecting nutritional status of children in Turkey. In Turkey, even when the quantity of nu tritional intake is not changed, the quality of nutrition may be changed due to better education of mothers. Educated mothers can better understand the importance of balanced diet, breastfeeding, and give better nutrition to their children. According to the Turkish Demographic and Health Survey: 1993 (MOH et al. 1994), better educated mothers have better nourished children (MOH et al. 1994, p. 115). The food industry plays an important role in Turkey’ s production and exports. Around 20 percent of all manufacturing industry exports come from the food indus try. Therefore, overall, undernourishment is not an important problem in Turkey. It may be a problem in some regions, especially in the eastern region, more than others, but there is no known study showing that the level of the problem changed for better nutrition during the 1960-1995 period. The comparable information about food intake is available, not for the 1960-1995 period, but for the 1960-1980 period. During the 1960-1980 period, crude death rates from pneumonia decreased con siderably, from 196 to 58 per 100,000 population. However, according to the Food and Agriculture Organization of the United Nations (FAO) reports, during the 99 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. same period food supply did not change much such that calories per capita de creased 3110 to 3002 from 1960 to 1980 (FAO 1965, pp. 252-253 for 1960 and FAO 1985, pp. 268-270 for the 1965-1980 period). Moreover, total protein supply per capita decreased from 97.5 to 82.9 grams per day. The composition of protein sup ply, vegetable versus animal protein, changed such that people started to consume more animal protein compared to earlier years (FAO 1965, pp. 252-253 for 1960 and FAO 1985, pp. 268-270 for the 1965-1980 period). In other words, during the 1960-1980 period, the decline in mortality from pneumonia was achieved without any improvement in nutritional intake. As was previously mentioned, In Turkey, industrialization did not have an im portant affect in nutritional intake. It is true that, when economic well-being of people increases, people are more likely to have financial resources to spend for better nutrition, better housing, or better treatment. However, it is not always the case. Moreover, industrialization has negative effect on health through air pollution. For example, low air quality in urban areas, as a result of industrialization, con tributed negatively to ARIs in Turkey (TR-UNICEF 1991, p. 180). During the beginning of the 1980s, the air pollution was an important problem only for Ankara, the capital, but as a result of urbanization, by the end of the 1980s, air pollution had become a problem in almost all developed cities of Turkey. For example, in winter of 1989-90, the number of days that sulfurdioxide level above limits were very high for some very developed cities, was 135 for Ankara, 74 for Manisa, and 100 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 60 for Istanbul. On the other hand, for most of the least developed cities, the number of days that sulfurdioxide levels were above limits was 0 or very few (See TR-UNICEF 1991, pp. 96-97 for detail). The information about air quality is available only for some years, and there is no information about air pollution by level of development throughout the study period. Turkish authorities tried to decrease the negative effects of urbanization through their policies such as their regulations on air pollution. By the mid-1980s, government required each building have some air filters on its chimneys to filter the smoke coming from them for better air quality in big cities such as Istanbul and Ankara. Moreover, there were some fines for the residents of buildings when the check on their chimneys by authorities showed high sulfurdioxide levels. As a result of these fines and regulations, in many buildings, including government offices, in addition to use of air filters on chimneys, the limited use of central heating systems only during the evening and morning time became a common procedure. As a result, the number of days that sulfurdioxide level exceeded limits became very low in winter 1993-94 compared to winter 1989-90: no day for Ankara, 21 for Istanbul. However, the level was still high for industrialized cities in which air pollution regulations were not applied: 51 for Eski§ehir, and 53 for Kiitahya (See TR-UNICEF 1996, pp. 64-66 for detail). These results show that government regulations were effective in improving air quality in industrialized cities where the regulations were properly applied. Air pollution reaching high levels in cities, and indoor pollution due to heating and smoking, and motorized vehicles contributed to 101 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. increasing numbers of ARIs in Turkey (HU 1993, p. 20). The air quality regulations were effective after the mid-1980s, and by that time deaths from pneumonia were already at low levels. Therefore, air quality regulations were not very important in explaining the decline in mortality from pneumonia during the study period. As for housing, even though MEG can improve it, it does not necessarily do so. As a result of rapid industrialization, squatter housing became an important problem for the big cities of Turkey. For example, in 1990, in Gaziantep 40 per cent of urban population was living in squatter housing. This ratio was 36 percent for Izmir, 34 percent for Diyarbakir, 26 percent for Adana, and 25 percent for Istanbul, and 21 percent for Antalya (TR-UNICEF 1991, p. 357). Information about the past and future of squatter housing areas is limited to only a few cities that were mentioned here. It is not possible to provide reliable information about the percentage of the population living in squatter housing areas of Turkey as a whole or for every city, but it is clear that squatter housing is an important prob lem. The Turkish government tried to solve squatter housing problems through prohibiting their construction, not providing water, road and transportation ser vices, not licensing them after their construction, and even demolishing some of the houses after they were built. However, the government could not completely solve this problem due to rapid urbanization and high demand for houses, and af ter the 1950s, many “gecekondu”s, meaning low quality illegal squatter houses that were built overnight, were built in big cities. Moreover, after 1980, new houses, called “apartkondu," meaning legal, multi-floor apartment but low quality like the 102 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. “gecekondu”s were built (TR-UNICEF 1991, pp. 355-357). Especially in Istanbul, 10-15 floor low quality “apartkondu”s were built after 1980. Even though the gov ernment gave permission for a few floors, the builders managed to secure permission for 10-15 floors by bribing government officials. “Apartkondu”s may look like big apartments, but most of these houses were built with very low quality materials and did not meet the government standards on sewerage, water, and construc tion issues. Hence, most of these “apartkondu”s collapsed during the August 1999 earthquake. This shows that squatter housing is still an important problem in Turkey. The low quality of housing affected death from pneumonia in Turkey. As was the case in squatter housing areas of Antalya, people living in low quality housing are more likely to have pneumonia compared to not only non-squatter housing parts of urban areas, but also compared to rural areas. According to the research done by Tezcan et al. in 1989, during the winter, the children in squatter housing areas are more likely to have symptoms such as coughing, runny nose and high fever indicating some type of respiratory infections (Tezcan et al. 1989). Children living in squatter housing parts of urban areas are more likely to have acute respiratory infections such as bronchitis and pneumonia compared to children living in rural areas (TR-UNICEF 1991, pp. 370-371). To sum up, the decrease in mortality from pneumonia mainly resulted from improvement in the general education level, and public policy initiatives played an important role in education. Education’ s effect on mortality from pneumonia was 103 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. important throughout the study period, but especially during the 1960s and 1980s. Improvement in general education affected mortality from pneumonia through im proving mothers’ awareness and their ability to deal with health-related issues. In addition to general education, other public policy initiatives such as vaccination campaigns, the CARI campaign, health education programs, and use of antibi otics and other drugs played an important role in decline of the mortality from pneumonia. Vaccination campaigns’ contribution to the decline in mortality from pneumonia was important especially after 1985, and the use of medications’ contri bution to the decline in mortality from pneumonia was important especially after 1986. Health education was also important throughout the study period, but espe cially after the 1980s through the use of television for education purposes. Public policy initiatives are based on advancement of medical/technological knowledge, but government authorities played an important role in making the new knowledge known to the public. On the other hand, economic factors were not important in explaining the mortality decline from pneumonia. The evidence on this was very convincing. If the decline in the death rate from pneumonia had been simply a by-product of MEG, the death rate from pneumonia would have been lowest for the very developed region, which has 4 times higher per capita GDP compared to the least developed region in 1989, and highest for the least developed region. However, this was not the case for Turkey. Even though the most developed region had a lower death rate from pneumonia compared to the least developed region in 1960, 104 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. the least developed region caught up with the most developed region by 1970, and even had lower death rate for pneumonia in 1970 and 1975. This was the case without any economic catch up. Moreover, the least developed region had lower death rate from pneumonia compared to developed region throughout the study period. By 1970, all regions had similar death rates from pneumonia (SIS Death Statistics related years). The similar death rates observed even though there were still great differences between the economic levels of the very developed region and the least developed region. This indicates that there were other factors, such as education, exposure to disease, vaccination and use of different medications, that contributed to the mortality from pneumonia. Other evidence that shows that economic development was not the main reason behind the decrease in the death rate from pneumonia is the decline in the mortal ity from pneumonia during the economic decline period of 1980-1985. In Turkey, during the 1980-1985 period, the economic well-being of people decreased. Follow ing the military coup of September 12, 1980, the economic future of the country was uncertain and GDP per capita decreased 13.7 percent from $1,538 to $1,327 (SIS 1998, pp. 694-695), and GNP per capita decreased 13.6 percent, from $1,570 to $1,356 (SPO 1996, p. 6) during the 1980-1985 period. However, the death rate from pneumonia decreased from 58 per 100,000 to 28 per 100,000 during the same period. The rate of decrease in the death rate from pneumonia during the 1980- 1985 period was higher than the one in earlier period, namely 1975-1980. In other 105 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. words, the death rate from pneumonia continued to decrease during the 1980-1985 period even in the presence of economic decline. If the decline in mortality from pneumonia were only a by-product of MEG, one would have expected an increase in the death rate during economic decline. This was not the case in Turkey. Moreover, even though MEG has positive effects on the death rate from pneumonia, its negative effects on pneumonia through higher exposure to disease, air pollution and low quality squatter housing are undeni able. The Turkish government had to intervene to decrease the negative effects of industrialization on pneumonia through mandatory air quality and housing re quirements. There is no evidence showing that the pre-1980 decline in mortality from pneumonia is based on economic factors. On the contrary, there is evidence that, during the 1960-1980 period, nutritional intake decreased quantitatively, but mortality from pneumonia also decreased significantly. Quality of nutritional sta tus may have improved during the same period, not due to better income, but due to better education of mothers. The improvement in the literacy levels and the positive relationship between education and better treatment of pneumonia showed that the mortality decline from pneumonia is based mainly on better edu cation. Advancement in medical and technological knowledge was also important in explaining mortality decline in pneumonia. The Turkish government played very important role in not only improving education, but also putting the new knowledge into practice. 106 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. CHAPTER 7 ENTERITIS AND OTHER DIARRHOEAL DISEASES Diarrhoea is an intestinal disorder characterized by abnormal frequency and fluidity of fecal evacuations. Diarrhoea occurs when the intestines push stools through before the water in the stools can be reabsorbed by the body. As a result, the stools become watery and loose and bowel movements occur more frequently. Symptoms of diarrhoea may also include fever, abdominal cramps and nausea in addition to loose and frequent bowel movement (IU 1998, pp. 369-372). Diarrhoea can cause the body to lose large amounts of water and essential minerals called electrolytes. Since infants have lower body resistance, diarrhoea can easily result in dehydration and death. Therefore, when infants have diarrhoea, parents need to give special attention. In this chapter, first the trends in mortality from enteritis and other diarrhoeal diseases (EODD) in Turkey will be analyzed. Secondly, factors that may affect 107 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. mortality from EODD will be discussed. Last, the question of whether public policy initiatives, based on advancement of medical/technological knowledge, or economic factors, such as income, nutrition and housing were mainly responsible for the decline in mortality from EODD in Turkey will be analyzed. 7.1 Trends in Enteritis and Other Diarrhoeal Diseases in Turkey Enteritis and other diarrhoeal diseases was the fourth leading cause of death in Turkey and accounted for 11.8 percent of the deaths in 1960. This ratio decreased to 0.7 percent by 1995. EODD is no longer a leading cause of death in Turkey (SIS Death Statistics related years). When regional differences in mortality from EODD are analyzed, as can be seen in Table 7.1 and Figure 7.1, there axe no significant differences in mortality from EODD among regions with different levels of economic development today. However, during the 1960-1980 period, developed and very developed regions had higher death rates from EODD compared to less and least developed regions. At the beginning of the 1960s, the death rate from EODD was the lowest for the least developed region, and the highest for the developed region: 97 and 167 per 100,000, respectively. However, by 1980, all regions had similar death rates from EODD, and in some years, the very developed region was in a little better position than the other regions regarding death from EODD (SIS Death Statistics related years). 108 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Even though the death rate from EODD does not differ significantly by level of economic development now, the age-specific death rate for EODD was and still is different for different age groups. As shown in Table 7.2 and Figure 7.2, the death rate from EODD is the highest for the 0-1 age group throughout the study period. In other words, EODD affect mainly infants. Almost two thirds of all deaths from EODD throughout the study period were infant deaths. The share of infant deaths in deaths from EODD was 65 percent in 1960, and it decreased to 63 percent in 1995 (SIS Death Statistics related years). As can be seen in Table 7.3 and Figure 7.3, the crude death rate from EODD did not differ by sex, except for the years 1960 and 1965. During this period, females had a little higher mortality rate compared to males. However, overall, there are no significant differences between males and females regarding death from EODD (SIS Death Statistics related years). 109 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 7.1 Crude death rate (per 100,000 population) for enteritis and other diarrhoeal diseases, by level of development. Year Very developed Developed Less developed Least developed Turkey 1960 124 167 116 97 128 1965 67 88 59 54 69 1970 55 59 42 43 52 1975 41 36 22 33 36 1980 25 30 17 27 25 1985 15 18 18 21 17 1990 5 7 8 7 6 1995 2 4 5 6 3 Source: SIS Death Statistics related years. 175 — Very developed — - Developed Less developed — Least developed Turkey 3 a o a o o o 150 125 O o H 100 u a > a. <u T 3 n u CJ 1960 1995 1965 1970 1975 1980 1985 1990 Y ear Figure 7.1 Crude death rate (per 100,000 population) for enteritis and other diarrhoeal diseases, by level of development. 110 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 7.2 Age-specific death rate (per 100,000 population) for enteritis and other diarrhoeal diseases. Year 0-1 1-4 5-14 15-24 25-44 45-64 65-74 75+ Total 1960 2785 313 7 4 6 17 33 82 128 1965 1811 119 4 2 2 11 24 58 69 1970 1496 81 3 2 2 6 19 41 52 1975 1118 60 3 1 1 3 11 39 36 1980 779 48 2 0 1 3 11 29 25 1985 522 31 2 0 1 4 11 28 17 1990 155 17 1 0 0 2 5 25 6 1995 97 7 1 0 0 1 3 14 3 Source: SIS Death Statistics related years. c o 3 Q * O a u 0 ) a a > < T 3 T3 0 a i a c n 1 a ) o i < 4 10 0- 1 , - 45-64 5-14 25-44 1-4, 15-24 65-74 75+ Total 3 10 2 10 1 10 o 10 1960 1965 1970 1975 1980 Y ear 1985 1990 1995 Figure 7.2 Age-specific death rate (per 100,000 population) for enteritis and other diarrhoeal diseases. I l l Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 7 .3 Crude death rate (per 100,000 population) for enteritis and other diarrhoeal diseases, by sex. Year Male Female Total 1960 124 133 128 1965 66 72 69 1970 53 52 52 1975 35 38 36 1980 24 26 25 1985 16 17 17 1990 6 6 6 1995 3 3 3 Source: SIS Death Statistics related years. o 150 Male * - Fem ale — Total 3 Q * O a 125 o o 100 o o < 0 T3 a u O 1960 1965 1980 1970 1975 1985 1990 1995 Y ear Figure 7.3 Crude death rate (per 100,000 population) for enteritis and other diarrhoeal diseases, by sex. 112 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 7.2 Factors Affecting Mortality from Enteritis and Other Diarrhoeal Diseases In the health and mortality literature, different factors such as medical/techno- logical improvements, breastfeeding, education, public policy initiatives, income, nutrition, housing, and climate are mentioned to be important in affecting mortality from EODD (See especially, Scrimshaw et al. 1968, Scrimshaw 1981, Gershwin et al. 1985, Caselli 1991, Lunn 1991, Morel 1991, Vallin 1991). In this section, first these factors and their effect on mortality from EODD in general, and then, the situation in Turkey in particular will be discussed. Medical/technological improvements are mentioned as important factors affect ing mortality from diarrhoea (See especially, Caselli 1991, Morel 1991). Availabil ity of better water and sewerage systems (Caselli 1991, p. 78), pasteurization and sterilization of milk (Morel 1991, p. 212), and use of antidiarrhoeal medications such as oral rehydration salts (ORS) (TR-UNICEF 1998, p. 10), are based on medical/technological improvements, and may affect mortality from diarrhoea. Another factor that may affect mortality from EODD is breastfeeding. Morel argues that, breastfed babies are not only likely to have lower mortality in general, but also lower mortality from diarrhoea in particular (Morel 1991, pp. 200-202). For example, in Germany, in the villages of Gabelsbach/Bavaria, where artificial feeding was widespread, the infant mortality was very high. On the other hand, in Hesel/Hanover, in which almost all children were breastfed, the infant mortality 113 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. was very low, almost one third of that of Gabelsbach’s. Morel argues that this is mainly due to the differences in the method of infant feeding practices, i.e artificial feeding versus breastfeeding (Morel 1991, p. 202). Morel also states that pleas to mothers to breastfeed their children formed part of the moral code from ancient times, and it was based purely on moral arguments and beliefs. After physicians acquired knowledge about the chemical composition of breastmilk, level of breastfeeding increased (Morel 1991, p. 200). Therefore, advancement in knowledge may be another factor that affects the trends in mortality from EODD. Based on new knowledge, mothers started to give more importance to breast feeding. However, the level of breastfeeding is not the same in everywhere. This is mainly because even when new knowledge is available, it is not always the case that people use it the same way. Customs, beliefs, and education level can all affect the use of new knowledge. Moreover, public policy initiatives are needed in many cases to make this new knowledge known to the public. Therefore, in many countries, governments started to put some policy initiatives into practice, such as for poor families paying wet-nurses’ fees for a year, paying allowances to natural mothers for breastfeeding, offering paid vacation time for breastfeeding mothers, and giving nursing time permission to working mothers to encourage mothers to breastfeed (Morel 1991). Moreover, governments initiated programs to improve people’ s knowledge through general education and health education, which also may affect the mortality from EODD (TR-UNICEF 1998). 114 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The effects of medical/technological improvements, advancement of knowledge, education and public policy initiatives are all connected to each other. Therefore, their effect on mortality from EODD in Turkey will be analyzed as a group, in the “Enteritis and Other Diarrhoeal Diseases and Public Policy Initiatives” section of this chapter. On the other hand, economic factors, reflected in income, nutrition, housing, are mentioned to be important factors affecting mortality from enteritis and other diarrhoeal diseases (See especially, Caselli 1991, Chandra 1983, Gordon et al. 1964, Gershwin et al. 1985, Lunn 1991, Scrimshaw et al. 1968, and Scrimshaw 1981). Chandra argues that EODD is definitely influenced by nutritional status (Chan dra 1983). Peter Lunn also stated that there was definite influence of nutrition on diarrhoea (Lunn 1991, p. 137). Gordon et al. reported an increased incidence of diarrhoeal diseases in poorly nourished areas of developing world (Gordon et al. 1964). Moreover, Tomkins reported that, in Nigeria, there was more than twice the incidence of diarrhoeal diseases in wasted children with an expected weight-for- height below 80 percent compared to children with normal weight (Tomkins 1981, p. 131). On the other hand, many studies carried out in Bangladesh, Guatemala, Costa Rica, and Indonesia showed that the relationship between measurement of weight deficit and the incidence of diarrhoea was minimal or absent (See especially Black et al. 1984, Chen et al. 1980, James 1972, Delgado et al. 1983, Sommer and Tarwotjo 1984). 115 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. One explanation for these different results is that the severity and the duration of malnutrition may be important. Diarrhoea may last longer in severely mal nourished areas. The term malnutrition has been used loosely in this discussion, meaning food inadequacy in general. However, it is well known that specific vi tamins and minerals as well as macronutrients are essential for a normal immune system. Therefore, even in the case of adequate nutrition, inadequacy of some vitamins and minerals can lower immuno-competence in individuals, i.e. greater susceptibility to infectious diseases. Moreover, the incidence of disease is different than its severity, i.e. whether it is life-threatening or not. Therefore, malnutrition may be important for the incidence of EODD, but severe malnutrition or malnutri tion that lasts long-term may be important for explaining mortality from EODD. For example, Lunn states that a wasted child is at a greater risk compared to a stunted child (Lunn 1991, p. 140). Martorell and Ho also argue that stunting seems to be less important in this respect. For a stunted child, there is slower growth following each infection (Martorell and Ho 1984). It is true that, in the presence of malnutrition, illness is likely to be more severe and long-lasting. However, not all illnesses are affected the same way, some re spond far more than others. Almost all infections are associated with some degree of anorexia. Episodes of pain, fever, vomiting and abdominal distention undoubt edly decrease the appetite. In addition to the decrease in appetite, in the case of diarrhoea, there is also decrease in the absorption of the three major nutrients, i.e. carbohydrate, fat, and protein, and a number of trace elements and vitamins 116 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. (Lunn 1991, p. 135). Lunn argues that the reasons for the decreased absorption include a reduced intestinal transit time, allowing less time for absorption, and pathogen-induced damage to the structure and function of the intestinal mucosa. A study done in Guatemala indicated loss of a 500-600 kcal/day in a young child (Rosenberg and Scrimshaw 1972). This is almost half of the young child’s daily consumption. Powander also calculated an average loss of protein for most ill nesses. Powander found an average loss of protein was 0.6 kg/day during most illnesses, but it rises to 0.9 kg/day for diarrhoea (Powander 1977). Scrimshaw also argued that other nutrients, especially vitamins, were also lost from the body in the presence of diarrhoea (Scrimshaw 1981). When diarrhoea occurs chronically over several weeks, the children become wasted. Even if it is the case that diarrhoea is affected by nutritional status, there is still the discussion about the cause, i.e. whether the deterioration of nutritional status caused or worsened the illness, or the illness, through malabsorption of nutrients, loss of appetite, lower absorption of nutrients, etc. caused the deterioration in nutritional status (Lunn 1991, p. 135 and iU 1998, p. 369). Therefore, one can say that, the way that nutritional status affects mortality from diarrhoea is not very clear. It is true that better nutrition, based on MEG, means higher body resistance. When the economic well-being of people increases, people are more likely to have financial resources to spend for better nutrition, better housing with appropriate sewerage system and clean water. As a result, they are expected to have a lower 117 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. death rate from EODD. On the other hand, MEG has also negative effects on health through industrialization and urbanization. Industrialization also means air pollution and overcrowding cities. As a result of rapid urbanization, in many industrialized cities, availability of clean water became problem. In other words, industrialization does not necessarily mean cleaner water and better housing. Es pecially, in squatter housing areas of industrialized cities, the clean water becomes difficult to obtain. Caselli argues that contaminated water that contains parasites, viruses, or bacteria is another factor that may cause diarrhoea (Caselli 1991, p. 78). The effects of economic factors, such as income, nutrition and housing, on mortality from diarrhoea in Turkey will be analyzed as a group, in the “Enteritis and Other Diarrhoeal Diseases and Economic Factors” section of this chapter. Climate is also mentioned as an important factor affecting mortality from diar rhoea (See especially Caselli 1991, p. 72 and Vallin 1991, p. 44). Caselli mentioned the importance of climate on mortality from EODD (Caselli 1991, p. 72). Caselli stated that EODD accounted for 10 percent of all Italian deaths, but only 6 percent of the those of England and Wales’. He attributes this situation not only to the infrastructure of public health, but also climate conditions. Caselli argues that, in Italy, climate conditions were favorable to the development of diarrhoea. As a result of hot weather, both the infant deaths and the deaths from diarrhoea were at a maximum during the summer months (Caselli 1991, p. 72). Vallin also men- 118 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. tioned the effect of climate on mortality, particularly mortality from the diseases of the digestive system (Vallin 1991, p. 44). Climate can partly explain regional or individual differences in mortality from EODD, but it cannot be the explanation for the long-term trends in mortality in Turkey. Therefore, it will not be analyzed in detail. Having given the general information about the factors that can effect mortality from EODD in general, the effects of these factors on mortality from EODD in Turkey will be analyzed in the next section of the study. First the effects of public policy initiatives, and then, the effects of economic factors on mortality from EODD in Turkey will be discussed. 7.2.1 Enteritis and Other Diarrhoeal Diseases and Public Policy Initiatives Dehydration brought on by severe diarrhoea is an important cause of mortality among children in Turkey. During the 1960-1995 period, the death rate from EODD in Turkey decreased mainly due to better education. According to Turkish Demographic and Health Survey: 1993 (MOH et al. 1994), there is big a difference in the prevalence of diarrhoea by mother’s level of education (MOH et al. 1994, p. 103). In this survey, the percentage of children under five years and who had diarrhoea in the two weeks preceding the survey, and children who had diarrhoea in the preceding 24 hours are <tnalyzed by different background 119 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. characteristics. As can be seen in Table 7.4, result of the study showed that children of better educated mothers are less likely to have diarrhoea. As can be seen from Table 7.5, children of better educated mothers are more likely to receive treatment for diarrhoea. The percentage of children who do not receive any treatment differs significantly by mother’ s level of education. The type of treatment also differs by the mother’ s education level. Since diarrhoea causes the body to loose large amounts of water and essential minerals called electrolytes, more fluid needs to be given to people with diarrhoea. The percentage of children with diarrhoea receiving increased fluids increases by mother’ s level of education. Both Turkish Demographic and Health Survey: 1988 (HU 1989) and Turkish De mographic and Health Survey: 1993 (MOH et al. 1994) showed that mothers with higher education treated their diarrhoetic children better (MOH et al. 1994, p. 105). As was explained in chapter 6, Turkish government played an important role in improving general education level. Improvement in the education level contributed to the mortality decline in EODD. In addition to increase in general education level, government provided health education to public, and used mass media for this purpose. People were educated about the ways to prevent diarrhoea through television spots and some other educational programs on television. Television spots were found to be less effective than educational programs since they were very short, and therefore, they were not very effective to change the behavior of the audience. 120 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Reproduced with permission o f th e copyright owner. Further reproduction prohibited without permission. Table 7.4 Prevalence of diarrhoea in 1993, by mother’ s education. Mother's education Diarrhoea in the preceding 2 weeks (%) Diarrhoea in the past 24 hours (%) No education/Primary incomplete 28.2 13.8 Primary complete/Secondary incomplete 24.3 10.7 Secondary complete/Higher education 17.7 6.5 All children 24.8 11.2 Source: MOH et al. 1994, p. 103. Table 7.5 Treatment of diarrhoea in 1993, by mother’ s education. Oral rehydration therapy Mother’s education Percentage taken to a health facility ORS packets (ORT) Recommended home solutions Percentage receiving increased fluids No treatment No education/Primary incomplete 23.9 8.0 2.9 48.9 30.0 Primary complete/Secondary incomplete 24.6 13.7 7.1 61.4 22.1 Secondary complete/Higher education 29.7 13.8 2.3 71.9 11.0 All children 24.8 11.4 4.9 57.0 24.2 £ 2 Source: MOH et al. 1994, p. 105. However, television programs such as “Can Suyu,” meaning water for life, were found to be very effective in educating public on health issues (§ahin and Diizen 1995). “Can Suyu” was a public education program prepared as a thirteen-series- soap opera. This program was prepared by Turkish Radio Television Establishment (TRT) and UNICEF in 1994. It is true that “Can Suyu” started in 1994, but the death rate from diarrhoea decreased long before. But, there were other health education programs before, and “Can Suyu” is only an example of many health education programs prepared by Turkish government. “Can Suyu” is given as an example because the effects of this program on behavioral change is analyzed in a study by §ahin and Diizen in 1995, and therefore, it can be an indicator of the effects of other health-related programming, since there is no known study that shows the effects of the other educational programs. The purpose of “Can Suyu” was to send UNICEF’s messages about health, education and social life to the public in order to educate the public to raise children who are healthier and better educated, and also to develop long-lasting behavioral change for better social life for all. §ahin and Diizen found that this program had an important effect on the behavior of women, while entertaining them. According to their study, 14 percent of the sample said that they learned what to do in case of diarrhoea from this program, and all of them said that they changed their wrong behavior after watching the program (§ahin and Diizen 1995, p. 21). In addition to what to do in case of diarrhoea, 14 percent of the sample said that they learned about the importance of hygiene from this program and they all said that they changed 122 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. their behavior afterwards. This change can also affect the incidence of diarrhoea (§ahin and Diizen 1995, p. 21). In short, §ahin and Diizen found that “Can Suyu” changed the behavior of the audience when they needed to deal with diarrhoea. Education of the public, especially mothers through the mass media, affected their behavior, and as a result it affected death from diarrhoea. The Turkish Demographic and Health Survey: 1993 (MOH et al. 1994), states that mothers were educated about diarrhoea treatment by health personnel during their weaning instruction. According to the survey, the use of ORS packets was the highest in children aged 6-23 months, and the higher use of ORS packets among the mothers of children less than two years old supports the statement of mothers are receiving training in diarrhoea treatment during weaning instruction (MOH et al. 1994, p. 104). In educating mothers, especially in health education, advancement of knowledge played an important role. For example, physicians acquired knowledge about the chemical composition of breastmilk, which later affected the level of breastfeeding (Morel 1991, p. 200). Morel argues that breastfed babies are less likely to have diarrhoea compared to bottlefed babies (Morel 1991, pp. 200-202). In Turkey, breastfeeding is almost universal, around 95 percent, and rural areas have higher percentage and longer time of breastfeeding but also higher level of incidence of di arrhoea compared to urban areas (MOH et al. 1994, pp. 103, 108-110). Therefore, one may think that breastfeeding did not have an important effect on mortality from diarrhoea. However, there are other factors, such as mother’ s education level 123 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. and availability of clean water, that differ significantly between urban and rural areas. Therefore, the higher level of incidence of diarrhoea in rural areas compared to urban areas is a reasonable result. Breastfeeding had a positive effect on mortality from diarrhoea in Turkey. Even though the level of breastfeeding is almost universal in Turkey now, this was not the case during the 1960s and 1970s. During the 1960s and 1970s, bottle feeding, i.e. the use of formulas, was very popular among families with middle and high levels of income. There is no known study showing these levels, but it can be easily said that, especially German-based formulas are brought in Turkey and sold to urban families during these years. Therefore, the level of breastfeeding in urban areas was lower than that of the rural areas. However, after 1980, based on advance ment of knowledge, mothers in urban areas were educated about the importance of breastfeeding. As a result, the level of breastfeeding in urban areas increased. The level and duration of breastfeeding in less developed areas are longer than that of developed areas. The eastern region, in particular, mainly consisting of less and least developed provinces, has a period of breastfeeding that is almost twice as long as than that in the western region, which mainly consists of developed and very developed provinces. (MOH et al. 1994, pp. 111). The level of breastfeeding by different background characteristics, and the effects of breastfeeding on infant mor tality will be analyzed in the next chapter in detail. Here, the improvement on the level of breastfeeding in Turkey, and its effect on diarrhoea need to be mentioned, since there is close relationship between breastfeeding and diarrhoea. 124 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Not only the level, but also the way or quality of breastfeeding is important. In spite of universal breastfeeding, there are problems related to early introduction of supplementary foods and late initiation of breastfeeding in Turkey. On the other hand, almost half of the breastfed children do not receive solid foods until one year of age (MOH et al. 1994, pp. 109-110). The Turkish government educated mothers not only about the importance, but also the proper way of breastfeeding through the international “Baby Friendly Hospitals Initiative,” which was launched in 1990 (TR-UNICEF 1998, p. 11). These policies were effective mainly after 1990. Therefore, they are not very important for the mortality decline during the 1960-1995 period. But, similar policies were applied in hospitals before the “Baby Friendly Hospitals Initiative,” during the 1980s, to educate mothers about the importance of breastfeeding and proper way of introducing solid foods to infants. In addition to education about the importance of breastfeeding, the Turkish authorities put some policy initiatives into practice in order to improve the level of breastfeeding in urban areas. For example, the free distribution baby formulas to hospitals by formula producing firms was prohibited and contracts are signed by the firms and given to the authorities to prevent free distribution of formula in early 1980s (TR-UNICEF 1996, p. 164). Breastfeeding mothers who are in the workforce were also given some free time by the government to breastfeed their children. Moreover, in formula advertisements, the governments required formula- producing companies to mention the “breastmilk is the best for infant feeding"” slogan during the early 1980s. These policy initiatives are only a few examples of 125 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. governments’ role in improving the level of breastfeeding in Turkey, especially in urban areas where bottle feeding was more common. In other words, government authorities played an important role in improving the level of breastfeeding and educating mothers regarding the proper way of breastfeeding, which in turn may affected mortality from diarrhoea. However, there is no known study showing how the improvement in proper breastfeeding affected mortality from diarrhoea in Turkey. Educated mothers were more receptive to the proper way of breastfeeding, and the importance of breastfeeding. However, the median duration of breastfeeding for better educated mothers was still lower than that of less educated mothers (MOH et al. 1994. p. 111). This was mainly because working mothers had less time for breastfeeding, and it was still the case even after government policies to improve the level of breastfeeding were put into practice. Therefore, the positive effects of education and public policy initiatives on the level of breastfeeding, and on the level of mortality from diarrhoea, decreased as a result of the negative effects of industrialization and higher working force participation of women. In addition to their role in education and breastfeeding, governments also played an important role in putting other medical/technological advancements into prac tice, which also affected the death rate from diarrhoea. For example, as a result of medical progression, some medications, such as ORS and antibiotics, are found and used in fighting against diarrhoea. In Turkey, ORS packets and antibiotics have been widely used in fighting against diarrhoea, especially after 1980 (MOH 126 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. et al. 1994, p. 105). There is no information about the use of medications to fight against diarrhoea for the pre-1980 period. The effects of ORS packets on diarrhoea related deaths are important after 1980. It is true that most of the de cline in diarrhoea related deaths happened in the pre-1980 period. But, even after 1980, during the 1980-1995 period, there was still important decline in diarrhoea- related deaths. For example, during the 1960-1980 period, the crude death rate from EODD per 100,000 population decreased from 128 to 25. During the 1980- 1995 period, the crude death rate from EODD per 100,000 population decreased from 25 to 3 (SIS Death Statistics related years). Public authorities implemented campaigns to promote the use of ORS and other medications. In other words, governments played an important role in putting medical advancements into prac tice through campaigns. For this purpose, “The National Control of Diarrhoeal Diseases Program” was implemented in 1986 (MOH et al. 1994, p. 103), and the Turkish government cooperated with UNICEF in implementation of the policies of “The National Control of Diarrhoeal Diseases Program” to fight against diarrhoea. The main objective of “The National Control of Diarrhoeal Diseases Program” was prevention of deaths by prevention of dehydration. For this purpose, oral rehydration therapy (ORT) has been used. Activities such as educating mothers on prevention of dehydration and use of ORT, and strengthening communication activities resulted in the reduction of dehydration and diarrhoea-related deaths (TR-UNICEF 1996, p. 160). During this program ORS packets are procured by Ministry of Health and distributed free of charge from health units. ORT 127 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. usage increased from 44 percent in 1988 to 57 percent in 1993, and death rate from diarrhoea decreased considerably during this period. Unfortunately, the same success has not been achieved in the prevention of diarrhoea cases per se (TR- UNICEF 1998, p. 10). One can see that, even though the incidence of diarrhoea did not change dining the 1988-1993 period, the death rate from diarrhoea continued to decrease mainly because increased use of ORS packets (TR-UNICEF 1996, p. 160). If the decrease in death rate from diarrhoea were a by-product of MEG, one also would have expected to find a decrease in the incidence of diarrhoea. However, this was not the case in Turkey during the 1988-1993 period (MOH et al. 1994, p. 103). The reason behind the lower death rate from diarrhoea was the better treatment of diarrhoea, and the main reason behind better treatment was better education of mothers. As a result, one can say that education and public policy initiatives, including but not limited to initiatives promoting breastfeeding and use of ORS packets, played an important role in the decline in mortality from EODD in Turkey. 7.2.2 Enteritis and Other Diarrhoeal Diseases and Economic Factors In Turkey, improvement in nutritional status was not the main factor responsible for a decline in mortality from EODD. The effect of industrialization on nutrition 128 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. is expected to be positive, but it was not the case in Turkey. Overall, inadequacy of food is not an important problem in Turkey. If there is any nutritional problem, it is not a problem of inadequate food, but a problem of unbalanced nutrition. Especially for mothers, obesity is an important problem. According to the results of Body Mass Index (BMI) calculations, 19 percent of the mothers are obese. Additionally, 32 percent of mothers are overweight (MOH et al. 1994, pp. 112- 116). Wasting is also not a problem in Turkey. Only 2.9 percent of children are wasted, thin for their height, and 9.5 percent of children under five years old are underweight for their age (MOH et al. 1994, p. 115). By age five around 20 percent of children are stunted, short for their age, compared to international reference population. Stunting is more prevalent in rural areas, in the eastern region of Turkey, and among children of mothers with no education. Turkish Demographic and Health Survey: 1993 (MOH et al. 1994) states that stunting occurs more frequently among children who are of higher birth order, and among those born after an interval of less than 24 months (MOH et al. 1994, p. 115). These factors are also affected by mother’ s level of education. Less educated mothers are more likely to have more children and a shorter birth interval (MOH et al. 1994, p. 115). In this study, the very small percentage of people who were wasted is not ignored, but there is no known study arguing that this value was higher in the 1960s. Moreover, there is evidence showing that the main nutritional problem is not inadequacy of food, but bad nutritional habits based on customs and poor medical knowledge. For example, for infants, introduction of solids too early or too late 129 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. is a problem. Especially, in nutrition of infants, customs play an important role. Mothers get information from the elders or from other mothers about when to introduce solids. Sometimes breastfeeding mothers do not introduce solids until the child is one year old, or they introduce the solid foods as early as two months old. Early introduction of solids is one of the factors that increases the risk for diarrhoea (TR-UNICEF 1996, p. 162). If nutrition affects mortality from EODD, it is not because of increases in nu tritional intake, based on better income, but because of changes in behaviors of mothers about nutrition, especially nutrition of infants, and through effects of bet ter education, e.g. lower birth orders, and longer birth intervals. In Turkey, the quantity of nutritional intake may not be changed, but the quality of nutrition may be changed due to better education of mothers. Educated mothers can bet ter understand the importance of balanced diet and breastfeeding, and give better nutrition to their children. As was previously mentioned, the Turkish government played an important role in improving education levels. Moreover, food intake did not change much during the 1960-1995 period. Even if food inadequacy is a problem for the very poor, there is no reliable information about the change in food intake for the better during the 1960-1995 period. How ever, the information for the 1960-1980 is available. During the 1960-1980 period, deaths from EODD decreased considerably, from 128 to 25 per 100,000 population. However, during the same period food supply did not change much: calories per capita decreased 3110 to 3002 from 1960 to 1980, and total protein supply per 130 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. capita decreased from 97.5 to 82.9 grams per day. The composition of protein sup ply, vegetable versus animal protein, changed such that people started to consume more animal protein compared to earlier years (FAO 1965, pp. 252-253 for 1960 and FAO 1985, pp. 268-270 for the 1965-1980 period). In other words, there is no reliable information showing that nutritional intake in Turkey changed for the better during the study period. Therefore, one can say that nutritional improvement, based on higher income, is not the factor responsible for the decrease in death rate from EODD in Turkey. If the decline in mortality from EODD were only a by-product of higher income, one would also have expected a decrease in the incidence EODD. But, this was not always the case in Turkey. For example, during the 1988-1993 period, the mortality from EODD decreased, but incidence of EODD stayed same, around 24 percent (MOH et al. 1994, p. 103). In Turkish Demographic and Health Survey: 1988 (HU 1989), the prevalence of diarrhoea during the last two weeks before the survey, for the same period (August-September) was 24 percent (Cited in MOH et al. 1994, p. 103). The measures designated to prevent diarrhoea, which were introduced following the 1988 survey, did not result in any change in diarrhoea prevalence during the 1988-1993 period (MOH et al. 1994, p. 103). However, the death rate from EODD continued to decrease during the same period. This is an indicator that better treatment, not prevention due to better income, was responsible for the decline in mortality from EODD during the 1988-1993 period. 131 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Moreover, the decrease in death rate from diarrhoea during the 1960-1995 pe riod did not result from the availability or convenience of cleaner water. The municipalities that have more than 3,000 population were examined, and in 1933, only 5.8 percent of the municipalities had scientifically appropriate drinking water establishments. This value increased to 8.4, 73.6, and 92.8 percent for the years 1945, 1962, and 1968, respectively. However, after 1968, there is no continuous increase in this value, but there is still a continuous decrease in death rate from EODD. During the 1968-1980 period, the percentage of municipalities that had sci entifically appropriate drinking water establishments increased from 92.8 percent to 93.8 percent, with small ups and downs. However, the death rate from EODD decreased from 52 to 25 per 100,000 population during the 1970-1980 period. In other words, after 1968, there was no significant improvement in availability of sci entifically appropriate drinking water establishments, but there was still significant decline in death rate from EODD (SPO 1983, p. 397). There was improvement in availability of scientifically appropriate drinking water during the pre-1968 pe riod, but the decrease in death rate from EODD continued after 1968, even though there was almost no improvement in the availability of scientifically appropriate drinking water in cities. Therefore, availability of cleaner water can not be the explanation for the decrease in death rate from EODD after 1968. It may be an important factor in explaining the decrease in the death rate from EODD during the earlier periods since there was significant improvement, but after 1968, one 132 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. needs to look at different factors affecting the mortality from EODD for explana tion. Moreover, Turkish governments played an important role in the availability of clean water through their policies such as prioritizing infrastructure investments, especially during the 1950s. On the other hand, MEG had negative effects on availability of cleaner water. Even though more than 90 percent of urban areas have scientifically appropriate drinking water establishments, the percentage of population who had access to safe water was decreasing because of rapid industrialization, unplanned and rapid urbanization, and the establishment of squatter housing around the cities. As a result of industrialization, the quality of housing did not improve all around the cities. Instead, the squatter houses, with important water and sewerage problems, were built. According to a report prepared by UNICEF, during the 1990-1996 period, in Turkey, only 63 percent of the urban population had access to safe water (UNICEF 1998, p. 105). In other words, availability of scientifically appropriate drinking water establishments does not always mean availability of safe water, especially when there are illegally made houses. This is the case for big cities, especially for Istanbul and Ankara, in Turkey. In the squatter housing areas, EODD was a very big problem, especially in hot climate cities such as Adana, §anliurfa, and Gaziantep. The residents of squatter housing areas are more likely to have EODD compared to other areas of the city (TR-UNICEF 1991, p. 370). To solve the problem of EODD in squatter hous ing areas, people living in these areas were educated about both prevention and 133 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. treatment of diarrhoea, and ORS packets were distributed free of charge by public authorities for better treatment. Moreover, in many industrialized cities, even in non-squatter housing areas, there was not enough water for every day, and therefore, residents of these cities were able to use tub water a few days of the week. This was especially the case after 1990. Therefore, in Turkey, industrialization brought many problems, such as inadequate or dirty water associated with some bacterial problems, while improving the economic well-being of people. For example, in Istanbul, it is still recommended not to drink the tub water in the apartments because of the problems in sewerage and water systems. In this study, “drinking water” term is used exchangeably with “tub water,” meaning the tub water available in houses for daily use. As a result, in some big cities and touristic areas, bottled spring water is also used especially after water pollution problems and for better taste. The negative effects of industrialization on water and sewerage systems men tioned consistently in annual programs. In the Annual Program: 1977 (SPO 1977), it was stated that, as a result of rapid industrialization, and rapid and unplanned urbanization, the existing drinking water and sewerage establishment became inad equate. This situation increased the negative effects of industrialization on public health (SPO 1977, p. 311). In many Annual Programs, it was stated that, as a re sult of rapid industrialization, water resources such as lakes and rivers had become very dirty, and this situation was affecting public health negatively, especially in industrial cities, because population became really dense in some industrial cities, 134 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. and the cost of cleaning water resources had become very expensive. As a result, the Turkish government decided that a “Sector Main Plan” had to be prepared for drinking water-sewerage sector to solve the problems related to this issue (SPO 1977, p. 311). In addition to water and air pollution, many companies did not do the necessary cleaning of their industrial waste because of the high cost. As a result, environ mental problems increased in industrialized cities. For example, Halig problem, meaning pollution of “the Golden Horn,” in Istanbul, and Izmit Bay pollution problem reached such high levels that the government started a study to deal with the problems of industrial areas. As a result, some of the establishments, especially leather factories, have been moved to other areas. Limitations were also placed on the establishment of new firms, e.g. on meat and meat products factories. More over, the authorities initiated new requirements for cleaning up the industrial waste. Turkish government also prepared the “Environment Law” in 1983 (SPO 1984a, p. 342). Another evidence that shows that MEG was not the main reason behind the decrease in the death rate from EODD is that the decrease in death rate from EODD, even in the face of economic decline during the 1980-1985 period. During the 1980-1985 period, the death rate from EODD decreased from 25 to 17 per 100,000 (SIS Death Statistics related years). In other words, industrialization negatively affected public health in Turkey. Water pollution was especially important for EODD. To solve any problem related 135 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. to industrial waste and pollution, Turkish government actively involved and pre pared laws and put them into practice. In other words, Turkish government had to involve to improve public health by decreasing negative effects of industrializa tion through making some laws, helping firms to prepare plans for industrial waste cleaning systems, prohibiting establishment of new companies on specific industri ally dense areas, moving some companies, e.g. leather companies, to other areas, and also giving them some financial support to solve the problems related to rapid and unplanned industrialization. To sinn up, in Turkey, the decline in mortality from EODD was mainly based on better education. Education was important in the mortality decline throughout the study period, but especially during the 1960s and 1980s. The quality of breast feeding was also important in the mortality decline, especially after 1985. The use of medications, based on advancement in medical/technological knowledge, such as ORS packets and antibiotics were important, especially after 1980. However, public policy initiatives are needed to improve the level of education and quality of breastfeeding, and also to put new knowledge into practice. Economic factors were not the main reason behind the mortality decline from EODD. Even though MEG may have positive effects on the death rate from EODD through higher income, its negative effects on EODD through water pollution and low quality squatter housing are undeniable. During the 1950s and 1960s, new scientifically appropriate water establishments were built. Cleaner water also may have contributed to the mortality decline during the 1960s, but not afterwards. 136 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. It is true that industrialization improved the economic well-being of people and governments, and as a result, they had more financial resources to spend for im provements in the availability of clean water and better the sewerage systems. In Turkey, people and government authorities worked together to improve the avail ability of drinking water and sewerage systems. In other words, there was financial participation from people through municipalities for the improvement of availability of clean water and better sewerage especially after 1980. On the other hand, industrialization was the main reason behind the sewerage and water problems: Through industrialization and rapid urbanization, the sew erage systems in cities became inadequate and availability of clean water became more problematic. Due to rapid and unbalanced industrialization, the water and sewerage systems became inadequate, especially in big cities, which affected health negatively. Therefore, the Turkish government stated that a plan, called “Sector Main Plan,” would be prepared by the authorities to improve the availability of clean water and sewerage and to solve the related problems (SPO 1977, p. 311). In other words, the Turkish government had to intervene to decrease the negative effects of industrialization through many public policy initiatives. One can still argue that, during the 1960-1980 period, the mortality from EODD was higher for the developed and very developed region compared to less and least developed regions, but by 1980, they caught up with less developed regions be cause of better financial condition. However, one needs to ask why developed and 137 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. very developed regions had higher mortality from EODD in the first place, de spite the big income advantages. One answer may be that, at the beginning of the study period, the negative effects of industrialization were so high, resulting in higher mortality from EODD for developed and very developed regions, but later on, the governments reduced these negative effects through many public policies. Another answer may also be that mothers in developed regions have higher edu cation compared to less developed regions. Therefore, they learned how to treat EODD better and the mortality gap between different regions decreased. The an swers may vary. However, based on previous discussion, it is clear that the decline in mortality from EODD was not due to better income, based on MEG. Instead, it resulted from better education, better breastfeeding, and advancement in med ical/technological knowledge. The Turkish government was the primary agent in improving the level of education and quality of breastfeeding, and also putting new knowledge into practice. 138 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. CHAPTER 8 PREGNANCY, CHILDBIRTH, INFECTIONS OF NEWBORN, AND OTHER DISEASES PECULIAR TO EARLY INFANCY The diseases related to pregnancy, childbirth, infections of newborn, and other diseases peculiar to early infancy (PCIODI) includes abortion, other complications of pregnancy, childbirth and puerperium, delivery without mention of complica tion, congenital anomalies, birth injury, difficult labor, other anoxic and hypoxic conditions, and other causes of perinatal mortality, i.e. causes of death 40 through 44 among fifty causes of deaths (SIS Death Statistics related years). ‘ ‘ Interna tional Statistical Classification of Diseases, Injuries, and Causes of Death” had a new revision, 9th revision, in 1976. Prom 1960-1975, 8th revision, and afterwards, 9th revision was effective. PCIODI were affected considerably from these changes (SIS Death Statistics related years). Therefore, PCIODI analyzed as a group to minimize the effects of the classification changes on these diseases. 139 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. In this chapter, first the trends in mortality from PCIODI in Turkey will be analyzed. Second, factors that may affect mortality from PCIODI will be discussed. Last the question of whether public policy initiatives, based on advancement of medical/technological knowledge, or economic factors, such as income, nutrition and housing, were mainly responsible for the decline in mortality from PCIODI will be analyzed. 8.1 Trends in Pregnancy, Childbirth, Infections of Newborn, and Other Diseases Peculiar to Early Infancy in Turkey During the 1960-1995 period, mortality from PCIODI decreased considerably, from 137 to 34 per 100,000. Mortality in this group was the third leading cause of death in Turkey in 1960 and accounted for 12.5 percent of deaths. In 1995, it accounted for 7.65 percent of total deaths in Turkey. In other words, in spite of the decline in the death rate, the mortality from PCIODI is still significant (SIS Death Statistics related years). When regional differences in mortality from PCIODI are analyzed, one can see that there are significant differences among regions with different level of economic development. As can be seen in Table 8.1 and Figure 8.1, at the beginning of the 1960s, the death rate from PCIODI was the lowest for the least developed region, 140 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. and the highest for the very developed region, i.e. 63 and 162 per 100,000, respec tively. During the 1960-1995 period, the least developed region was continuously in a better position than the most developed region regarding death from PCIODI. In other words, death rate from PCIODI differs significantly by level of economic development. The very developed region has a death rate from PCIODI at least two times higher than the least developed region throughout the 1960-1995 period. As can be seen in Table 8.2 and Figure 8.2, the age-specific death rate for PCIODI was different for different age groups, and it was the highest for the 0-1 age group. Maternal mortality was very small part of this group of deaths. Table 8.3 and Figure 8.3 show that the age-specific death rate from PCIODI did not significantly differ by sex. 141 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. T a b le 8 .1 Crude death rate (per 100,000 population) for pregnancy, childbirth, infections of newborn, and other diseases peculiar to early infancy, by level of development. Year Very developed Developed Less developed Least developed Turkey 1960 162 140 99 63 137 1965 132 117 91 56 114 1970 116 89 55 41 91 1975 123 91 43 53 97 1980 96 64 46 58 78 1985 74 47 36 36 58 1990 49 34 30 24 41 1995 38 35 29 20 34 Source: SIS Death Statistics related years. o 175 — Very developed — - Developed — Less developed '*** L east developed — Turkey H 3 a o a 150 o o o 125 o o H 100 u < u a . c 1960 1970 1980 1985 1965 1975 1990 1995 Y ear Figure 8.1 Crude death rate (per 100,000 population) for pregnancy, childbirth, infections of newborn, and other diseases peculiar to early infancy, by level of development. 142 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 8 .2 Age-specific death rate (per 100,000 population) for pregnancy, child birth, infections of newborn, and other diseases peculiar to early infancy. Year 0-1 1-4 5-14 15-24 25-44 45-64 65-74 75+ Total 1960 4331 10 0 10 14 1 0 0 137 1965 3884 5 0 7 13 1 0 0 114 1970 3236 7 0 3 6 0 0 0 91 1975 3757 17 0 2 2 0 0 0 97 1980 3224 0 0 1 0 0 0 0 78 1985 2513 0 0 1 1 0 0 0 58 1990 1849 0 0 0 1 0 0 0 41 1995 1606 0 0 0 0 0 0 0 34 Source: SIS Death Statistics related years. o * a k . t o a to u to at -o c j < u Q . t n i < u O l < 4 10 3 10 0-1. 25- 44, ■ 1-4 , .......... 1 5 -2 4 — 45- 64, Total 2 10 i 10 v. 0 10 1980 1960 1965 1970 1975 1985 1990 1995 Y ear Figure 8.2 Age-specific death rate (per 100,000 population) for pregnancy, child birth, infections of newborn, and other diseases peculiar to early infancy. 143 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 8 .3 Crude death rate (per 100,000 population) for pregnancy, childbirth, infections of newborn, and other diseases peculiar to early infancy, by sex. Year Made Female Total 1960 135 139 137 1965 114 116 114 1970 93 90 91 1975 100 93 97 1980 82 72 78 1985 62 54 58 1990 43 38 41 1995 36 32 34 Source: SIS Death Statistics related years. o • H 150 Male Fem ale Total H = 3 § • a 125 o o o o o H 100 k . a > a. 1960 1965 1970 1980 1985 1990 1975 1995 Y ear Figure 8.3 Crude death rate (per 100,000 population) for pregnancy, childbirth, infections of newborn, and other diseases peculiar to early infancy, by sex. 144 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 8.2 Factors Affecting Mortality from Pregnancy, Childbirth, Infections of Newborn, and Other Diseases Peculiar to Early Infancy Improvement in medical/technological knowledge played an important role in decline of deaths from PCIODI. For example, the use of ultrasonography to check on a baby’ s development helped in discovering many problems with the baby be fore she was bom. As a result, doctors can see many problems in advance, and they may be ready to deal with these problems. Some other medical/technological improvements, e.g. pasteurization and sterilization of milk, and the use of differ ent vaccines, especially tetanus toxoid vaccine, were important in explaining the decline in mortality from PCIODI. Another improvement in medical/technological knowledge that helped the decline in infant mortality was the new knowledge about breastmilk. Scientists discovered that breastmilk is sterile and contains all the nu trients needed by children in the first few months of life, and it provides some immunity to disease through the mother’ s antibodies and helps in reducing the prevalence of diarrhoea and nutritional deficiencies (Schofield and Reher 1991, p. 20; Morel 1991, pp. 200-202). Governments played an important role in educating public on importance of breastfeeding through many programs. Not only education about the importance of breastfeeding and other health issues, but also the improvement in general edu- 145 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. cation played an important role in decline in both infant and maternal mortality. As can be seen from the discussions in chapter 6, better educated parents, espe cially better educated mothers are more likely to take their children to hospital for treatment. It is also reported that better educated mothers are more likely to have regular check-ups during the pregnancy. As a result, children of better educated mothers, and mothers themselves have lower risk of mortality (TR-UNICEF 1991. p. 181). Therefore, advancement of knowledge, both medical/technological knowledge, and improvement in people’ s knowledge through general education and health ed ucation, is expected to play an important role in explaining the trends in mortality from PCIODI. However, public policy initiatives are needed in many cases to make this new knowledge known by public. Therefore, the effects of advancement of knowledge and public policy initiatives will be analyzed as a group, in “Pregnancy, Childbirth, Infections of Newborn, and Other Diseases Peculiar to Early Infancy and Public Policy Initiatives” section of this chapter. On the other hand, the economic factors, reflected in income, nutrition, and housing, are mentioned as important factors affecting mortality from PCIODI (See especially, TR-UNICEF 1998, pp. 140-145; and MOH et al. 1994, pp. 87-118). As previously discussed, better income is expected to bring better nutrition and better health care. The argument is that when you have more money, you can afford better nutrition and better health care. In short, the supporters of this view argue that better income means better living standards, and it means better 146 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. health (MOH et al. 1994, pp. 87-118). However, other factors such as education also affect the nutritional status and use of health care. Therefore, it is not an easy task to separate how much of the effect is due to better education and how much of it is due to higher income. The effects of economic factors, such as income, nutrition, housing, on mortality from PCIODI will be analyzed as a group, in “Pregnancy, Childbirth, Infections of Newborn, and Other Diseases Peculiar to Early Infancy and Economic Factors” section of this chapter. Moreover, genetic factors are also mentioned in different studies as important factors affecting maternal and infant mortality (See especially, Perrenoud 1991, Puranen 1991, Comstock 1978). Genetic factors are not the factors affecting the long-term trends in mortality. Instead, they can partly explain individual differ ences in mortality from PCIODI. Therefore, genetic factors will not be analyzed in detail. Having given the general information about the factors that can effect mortal ity from PCIODI in general, we can now analyze the effects of these factors on mortality from PCIODI in Turkey. In next section of the study, first the effects of public health initiatives, and then, the effects of economic factors on mortality from PCIODI in Turkey will be discussed. 147 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 8.2.1 Pregnancy, Childbirth, Infections of Newborn, and Other Diseases Peculiar to Early Infancy and Public Policy Initiatives In Turkey, this group of deaths mainly consist of infections of newborn, birth injuries, and other diseases peculiar to early infancy. In other words, maternal mortality and genetic anomalies account for a very small amount, around 5 percent, of deaths in this group. Table 8.4 Infant mortality in 1983 (in 1,000), by parents’ education. Parents’ education Mother Father Primary incomplete 111.10 147.60 Primary complete/Higher education 96.80 92.00 Relative risk 1.15 1.60 Source: TR-UNICEF 1991, p. 120. Many factors have affected mortality from PCIODI in Turkey during the 1960- 1995 period. According to Hacettepe University Institute of Population Studies’ 1983 Turkish Population and Health Survey (HU 1987), the age of the mother, the birth interval, the number of children, the use of health services during pregnancy, and the parents’ education level were the main factors affecting infant mortality in Turkey (Cited in TR-UNICEF 1991, pp. 119-123). In 1983 Turkish Population and Health Survey (HU 1987), both mother’ s and father’ s education levels are found to be important factors affecting infant mortality. As shown in Table 8.4, higher 148 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. education of parents means lower infant mortality (Cited in TR-UNICEF 1991, p. 119). In both 1988 Turkish Population and Health Survey (HU 1989) and Turkish Demographic and Health Survey: 1993 (MOH et al. 1994), mothers’ education was considered and found as important. However, in 1983 Turkish Population and Health Survey (HU 1987), both fathers’ and mothers’ education were found as important factors affecting the infant mortality (Cited in TR-UNICEF 1991, p. 120). Moreover, as can be seen in Table 8.5, when both of the parents are literate, the infant mortality rate is considerably lower compared to other cases. These results show that the education level of parents matters in infant mortality (Cited in TR-UNICEF 1991, p. 120). Table 8.5 Infant mortality in 1983 (in 1,000), by parents’ literacy. Parents’ literacy Infant mortality Both of them illiterate 131.0 Only one of them literate 121.0 Both of them literate 87.9 Source: TR-UNICEF 1991, p. 120. In Turkey, mother’ s age is also an important factor affecting infant mortality. As can be seen in Table 8.6, 1983 Turkish Population and Health Survey (HU 1987) showed that, having a baby at very young ages or over age 35 increases the risk for baby (Cited in TR-UNICEF 1991, p. 120). The educational level of the mother is also an important factor affecting the age at marriage and at giving birth. 149 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. T a b le 8 .6 Infant m ortality in 1983 (in 1,000), by mothers’ age at giving birth. Mothers’ age Infant mortality <18 146.6 19-34 98.5 > 35_________ 119.9 Source: TR-UNICEF 1991, p. 120. Another factor that may affect infant mortality is the birth interval. As can be seen in Table 8.7, 1983 Turkish Population and Health Survey (HU 1987) showed that, the relative infant mortality risk is 1.55 times higher for infants with less than a two year birth interval compared to infants a birth interval of two years or more. The educational level of the mother is also an important factor affecting the birth interval (Cited in TR-UNICEF 1991, p. 121). Using health services during the pregnancy is another factor affecting the infant mortality rate. According to 1983 Turkish Population and Health Survey (HU 1987), for mothers who used health services during the last pregnancy, the infant mortality for 1,000 is 57.8, whereas for who did not use any health services the infant mortality for 1,000 is 79.0 (Cited in TR-UNICEF 1991, p. 123). Prenatal care differed considerably by mother’ s education level. As seen in Table 8.8, better educated mothers are more likely to choose a doctor as a prenatal care (PNC) provider. Less educated mothers either do not have any prenatal care or go to traditional caregivers such as nurses and midwives (MOH et al. 1994, p. 88). 150 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Reproduced with permission o f th e copyright owner. Further reproduction prohibited without permission. Table 8.7 Infant mortality in 1983 (in 1,000), by birth interval. Birth interval Urban Rural Total < 24 months 85.0 146.5 125.2 > 24 months 64.8 94.6 80.9 Relative risk 1.31 1.55 1.55 Source: TR-UNICEF 1991, p. 121. Table 8.8 Prenatal care (PNC) in 1993, by mother’ s education. Mother’ s education PNC provider (%) Doctor Trained nurse or midwife Other No PNC No education/Primary incomplete 23.9 13.0 1.0 62.1 Primary complete/Secondary incomplete 53.4 19.4 0.5 26.7 Secondary complete/Higher education 84.6 7.8 0.2 7.4 All births 46.8 15.5 0.7 37.0 Source: MOH et al. 1994, p. 88. Other studies have shown that, better educated mothers are more likely to better take care of themselves during pregnancy and their children afterwards. For example, according to The Situation of Children and Women in Turkey: An Executive Summary (TR-UNICEF 1998), education is a very important factor in accessing prenatal care. The frequency of requesting PNC increased sharply among women with more education. Women who had completed secondary school or who had higher education requested more than double the amount of PNC than women who had less than a primary school education or no education at all (TR- UNICEF 1998, p. 13). In Turkey, almost one-third of the total deliveries took place at home without any assistance from trained health personnel. In the eastern region, where educational level is lower, almost two-thirds of women deliver at home without any assistance from trained health personnel. Some cultural constraints such as fear, shame, and timidy inhibit access to available health services, as well as transportation problems, especially in the mountainous eastern region, and poor quality care at first level health units. Financial constraints are not the main reason behind low PNC levels because this care is provided free of charge for poor people in health units. However, it still is a contributing factor to maternal mortality since less educated mothers generally have a low economic and social status, and transportation cost is considered in decision making for PNC especially for poor mothers living in the mountainous eastern region (TR-UNICEF 1998, p. 13). The Turkish government provided free prenatal care for poor people, and as result, women had better access to health care. 152 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Another factor found to be important in infant mortality is the number of children. As can be seen in Table 8.9, according to 1983 Turkish Population and Health Survey (HU 1987), especially at old ages, e.g. after 30 years of age, having more than 4 children increases the infant mortality risk considerably. In Turkey, for mothers 30 years old or older, the relative infant mortality risk is 2.1 times higher for mothers of 4 children or more compared to that of mothers of less than 4 children. The educational level of mother is also an important factor affecting number of children. (Cited in TR-UNICEF 1991, p. 122). Table 8.9 Infant mortality in 1983 (in 1,000), by number of children. Number of children Infant mortality Mother’s age > 25 i Mother’ s age > 30 < 4 69 58.1 > 4 111.3 123.4 Relative risk 1.6 2.1 Source: TR-UNICEF 1991, p. 122. As can be seen in Table 8.10, the 1989 Turkish Demographic Survey (SIS 1991) showed that the percentage of surviving children differed considerably among moth ers with different levels of education (Cited in SIS 1998, p. 111). Better educated mothers’ children have higher survival rates compared to those of less educated mothers. 153 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 8.10 Percentage of surviving children in 1989, by mother’s education. Mother’ s education % Illiterate 77.7 Literate without any diploma 82.1 Primary complete 87.4 Secondary complete 94.3 High school and equivalent complete 95.7 Higher education and university complete 96.9 Total 81.7 Source: SIS 1998, p. 111. These results show that education of mothers does affect survival of children in Turkey. The improvement in general education level and education campaigns con tributed to the decline in mortality from PCIODI in Turkey. Moreover, people were educated through mass media about the pregnancy and infant mortality-related is sues, such as the importance of the age at pregnancy, the importance of at least two-year interval between children, the importance of having fewer children, the importance of doctor control during the pregnancy. In other words, improvement in both general education and health education contributed to the decline in mortality from PCIODI in Turkey during the 1960-1995 period. Another important factor that affected mortality from PCIODI in Turkey was breastfeeding. Breastfeeding especially affected the mortality from infections of newborn and other diseases peculiar to early infancy. Breastfeeding is almost uni versal in Turkey. Around 95 percent of all children are breastfed for some period of time, and differentials in the proportion of children breastfed are quite small, 154 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. i.e. no subgroup has less than 94 percent of children as having ever been breastfed (MOH et al. 1994, pp. 108-110). Improvements in medical knowledge showed that early initiation and intensity of breastfeeding, and the age at which the child receives supplemental foods are important for the health of infants (See especially Morel 1991). Breastfeeding had positive effects on mortality from PCIODI. Even though the level of breastfeeding is almost universal in Turkey today, it was not the case dur ing the 1960s and 1970s. After 1980, based on advancement of knowledge, mothers in urban areas were also educated about the importance of breastfeeding. As a result, the level of breastfeeding in urban areas increased. The improvement in the level of breastfeeding in urban areas contributed to the mortality decline. As was stated before, the mortality from PCIODI in very developed region was con siderably higher than that of least developed region throughout the study period. This was mainly due to higher level and longer duration of breastfeeding. As a result of improvement in the level of breastfeeding in urban areas, the mortality gap between very developed and least developed regions decreased. However, the very developed region has still a death rate from PCIODI two times higher than the least developed region (SIS Death Statistics related years). This is mainly due to longer duration of breastfeeding, which protects the newborn from infections. The duration of breastfeeding in less developed areas is still longer than that of developed areas. The eastern region, mainly consisting of less and least developed provinces, has a duration of breastfeeding almost twice as long as the western 155 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. region, which, mainly consists of developed and very developed provinces. As can be seen in Table 8.11, the median duration of any breastfeeding was 8.7 months for the western region whereas it was 17.3 months for the eastern region (MOH et al. 1994, pp. 111). According to Turkish Demographic and Health Survey: 1993 (MOH et al. 1994), all regions had a similar level of exclusive breastfeeding, but the southern region has higher level of full breastfeeding due mainly to a warmer climate. Full breastfeeding means either children who are exclusively breastfed or receive plain water only in addition to breastfeeding (MOH et al. 1994, pp. 111). In the southern region, mothers give water to their babies in addition to the breastmilk thinking that babies need not only breastmilk, but also water because of the hot weather. Table 8.11 Median duration of breastfeeding in 1993, by region. Region Median duration in months Any breastfeeding Exclusive breastfeeding Full breastfeeding West 8.7 0.4 0.6 South 13.1 0.5 1.4 Central 10.8 0.5 0.7 North 7.5 0.5 0.6 East 17.3 0.5 0.6 Source: MOH et al. 1994, p. 111. Not only the level, but also the quality of breastfeeding is important. In spite of the almost universal breastfeeding, there are problems related to late initiation of breastfeeding in Turkey. According to the Turkish Demographic and Health Survey: 156 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1993 (MOH et al. 1994), only one-fifth of last-bom were started breastfeeding as early as within one hour of birth (MOH et al. 1994, pp. 107-108). Around one-fourth of the last-born children were not put to the breast during the first day. This delayed exposure to breast is mainly influenced by cultural norms and religious beliefs. There is a religious practice that calls for breastfeeding to start after three calls to prayer (ezan) following to child’ s birth. This practice means that there is almost a 15-hour delay in the initiation of breastfeeding (MOH et al. 1994, p. 108). The early initiation of breastfeeding is beneficial to both mother and the child. On the one hand, suckling stimulates production of oxytocin, a hormone that causes the mother’ s uterus to contract. On the other hand, the first breastmilk, i.e. colostrum, protects the newborn from infections because of its high concentration of antibodies (MOH et al. 1994, p. 107). Since early initiation of breastfeeding protects the newborn from infections, it can be an important factor affecting the decline in mortality from PCIODI in Turkey. As Table 8.12 shows, better educated mothers are more likely to initiate breastfeeding earlier compared to less educated mothers. Therefore, one can say that, even though breastfeeding is almost universal in Turkey, improvement in the quality of breastfeeding was affected by the improvement in the mother’s level of education during the 1960-1995 period. Breastfeeding mothers need to know when and how to introduce supplementary foods. In Turkey, early introduction of supplementary foods is a problem. For example, introduction of cow’s milk and other kinds of liquids instead of infant formula or in addition to breastmilk at as early as one month is a common problem. 157 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 8.12 In itia l breastfeeding in 1993, by mother’s education. Mother’s education Among last-born children percentage who started breastfeeding Within one hour Within one day of birth of birth No education/Primary incomplete 19.0 70.3 Primary complete/Secondary incomplete 20.1 78.1 Secondary complete/Higher education 21.2 79.8 All children 19.9 75.9 Source: MOH et al. 1994, p. 108. Solid foods are introduced into the diet as early as 2-3 months of age. According to a research done in 1974, 43 percent of infants three months of age or younger were introduced to some kind of supplementary food such as infant formula, cow milk, and other liquids (TR-UNICEF 1991, p. 181). Early introduction of supplementary foods to infants increases the risk of gastrointestinal infections, which is one of the most important causes of infant mortality in Turkey (MOH et al. 1994, pp. 109- 110). In 1993. early introduction of supplementary foods was still a problem. For example, the proportion of children receiving solid or mushy foods was 29 percent by age 4-5 months (MOH et al. 1994, p. 110). On the other hand, almost half of the breastfed children do not receive solid foods until one year of age. The late introduction of solid foods may be considered one of the underlying causes of undernutrition among Turkish children (MOH et al. 1994, p. 110). 158 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The Turkish government educated mothers not only about the importance, but also the proper way of breastfeeding through the “International Baby Friendly Hospitals Initiative.” (TR-UNICEF 1998, p. 11) The “Baby Friendly Hospitals Initiative” was launched in 1990 by Turkish government and the World Health Or ganization (WHO) to encourage the early initiation of breastfeeding, to decrease the infant mortality resulting from wrong feeding practices, and other important issues related to child nourishment (MOH et al. 1994, pp. 107-112). In these hospitals, mothers are educated about the importance of early initiation of breast feeding, duration of breastfeeding, and timing of introduction of supplementary foods, which had a positive impact on the health of children. This program aimed at teaching successful breastfeeding procedures to mothers under the guidance of WHO-UNICEF’s “Ten Steps in Successful Breastfeeding” strategies. Moreover, the Turkish government formed the “National Baby Friendly Hospi tals Evaluation Team” and the “Breastmilk High Committee.” The members of these organizations educated health personnel on breastfeeding issues, and evalu ated hospitals according to their success or failure on these issues. As a result of their evaluations, the successful hospitals are given the award of “Baby Friendly Hospitals.” In 1994, 45.4 percent of the all births took place in “Baby Friendly Hospitals.” (TR-UNICEF 1996, p. 164) The Turkish government aimed at, bring ing all maternity hospitals up to the level of “Baby Friendly Hospitals” by the year 2000. To attain this goal, the Turkish authorities declared the first week of 159 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. August as “Breastfeeding Week,” and they educated the public on the importance of breastmilk and related issues throughout the week via the mass media. The staff of 56 “Baby Friendly Hospitals” around the country have been con tinuously trained to emphasi2e the importance of proper breastfeeding practices under the “International Baby Friendly Hospitals Initiative.” (TR-UNICEF 1998, p. 11) However, these policies were effective mainly after 1990. Therefore, they are not very important in explaining the mortality decline during the 1960-1995 period. But, similar policies were applied in hospitals before the “Baby Friendly Hospitals Initiative,” during the 1980s, to educate mothers about the importance of breastfeeding and the proper way of introducing solid foods to infants through other policies and projects such as the “Safe Motherhood Project.” These poli cies helped mothers to understand the importance of breastfeeding in infant’ s life. However, there is no known study showing how important was the improvement in proper breastfeeding in affecting the mortality from infections of newborn, and other diseases peculiar to early infancy in Turkey. To educate mothers about infant and maternal health, the “Safe Motherhood Project” was introduced in the early 1980s. This project contributed to the decline in maternal and infant mortality. It covered health personnel, governmental and non-governmental organizations, voluntary organizations, married women in the 15-49 age group and their husbands, couples planning to get married, pregnant women, and mothers who have recently given birth. By this project, government 160 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. authorities cooperated with national organizations such as the Directorate of Reli gious Affairs, General Directorate of Turkish Radio and Television Establishment (TRT), General Directorate of Social Insurance and related departments of univer sities, and international organizations such as UNICEF, WHO, the United Nations Population Fund (UNPFA), UNESCO, Japanese International Cooperation Asso ciation (JICA), USAID, John Hopkins University, German and Italian Technical Cooperation, and voluntary organizations such as the Family Planning Association of Turkey (FPAT), the Turkish Family Health and Planning Foundation, the Turk ish Maternal-Child Health and Family Planning Foundation (TAQSAV), in order to raise the level of maternal-child health and to extend the scope of the family planning services (SPO 1993, p. 27). Through the “Safe Motherhood Project,” woman to woman education and con traceptive delivery project for squatter housing areas was started in 1985. This project was such a success that it became an FPAT policy. Moreover, the Family Counseling Bureau was founded in 1984 and still continues its work with great suc cess (SPO 1993, p. 28). Some other programs done through the “Safe Motherhood Project” are: “Youth to Youth Family Health Training,” which was initiated in 1990 to cover young people in particular, informative programmes on AIDS and other sexually transmitted diseases, a “Telephone Counseling Services” initiated in 1992 to answer health related questions. Moreover, vocational courses are given to women and young girls in the squatter housing areas of big cities. In these courses, 161 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. family planning, nutrition, and other health related issues were covered (SPO 1993, p. 35). In short, the government authorities played an important role in improving the level of breastfeeding and educating mothers on the proper way of breastfeed ing, which in turn affected infant mortality, especially mortality from infections of newborn and other diseases peculiar to early infancy. In addition to education about the importance of breastfeeding, the Turkish authorities put some policy initiatives into practice in order to improve the level of breastfeeding. For example, the free distribution baby formula to hospitals by formula-producing firms is prohibited and contracts are signed by the firms and given to the authorities to prevent free distribution of formulas during 1980s (TR-UNICEF 1996, p. 164). In order to discourage the import of formula, the import tax on formulas, except the ones that are needed for specific cases such as formulas used for children with allergy to milk products, almost tripled after 1986. In addition, in order to encourage breastfeeding, breastfeeding mothers who are in the workforce were also given some free time during the working hours, called "slit izni,” by the government to breastfeed their children. Moreover, in formula advertisements, governments required formula producing companies to mention that “breastmilk is the best for infant feeding” slogan in 1980s. These policy initiatives are only a few examples of government’ s role in improving the level of breastfeeding in Turkey, especially in urban areas in where bottle feeding was more common. 162 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Moreover, vaccinations, especially tetanus toxoid vaccination (TT), was an im portant factor that affected both maternal and infant mortality in Turkey. TT is one of the most important preventive measures for neonatal tetanus. According to the Turkish vaccination schedule, two doses of TT are necessary for full immuniza tion of an unvaccinated pregnant woman. But, if a woman has been vaccinated during a previous pregnancy, she might only require one dose of the TT (MOH et al. 1994, pp. 90-91). The Turkish Demographic and Health Survey: 1993 (MOH et al. 1994) also showed that education had an important effect on TT vaccina tion. Mothers with secondary or higher education have almost twice as much TT vaccination coverage as mothers with no education or primary incomplete (MOH et al. 1994, pp. 90-91). As was explained in previous chapters, during the study period, especially during the 1960s and 1980s, mothers’ educational level increased significantly, and this had a positive impact on vaccination coverage in Turkey. Education played an important role not only in TT vaccination, but also in other vaccinations. As was mentioned in chapter 6, the percentage of children who were fully vaccinated differed significantly by mother’ s level of education. In 1993, only 48 percent of children of a mother with no education or primary incomplete were fully vaccinated. On the other hand, this ratio was 70.9 for children of a mother with primary complete or secondary incomplete, and 83.6 for children of a mother with secondary complete or higher education (MOH et al. 1994, pp. 98-99). A child’s birth order was also found to be important in vaccination. In 1993, 55 percent of children with birth order 4 or higher were fully vaccinated. On the other 163 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. hand, two-thirds of children with lower birth orders were fully vaccinated (MOH et al. 1994, pp. 98-99). Other medical/technological improvements also affected the mortality from PCIODI in Turkey. For example, the use of ultrasonography and other devices helped to discover the problems related to maternity in advance. However, the in formation about when ultrasonography and other devices were available in Turkey and to what degree they affected the mortality from PCIODI is not available. Another problem affecting infant mortality in Turkey was the practice of swad dling babies. This practice delayed infant’s proper growth, and it was also held responsible for rickets and other deformations (Morel 1991, p. 200). In 1988, infant mortality for swaddled babies was 123 in 1,000. On the other hand, the number for non-swaddled babies was 67 in 1,000 (TR-UNICEF 1991, p. 123). In Turkey, mothers were educated on the negative effects of swaddling and this education also based on better medical knowledge. The education of mothers about swaddling may also have contributed to the decline in infant mortality. However, there is no known study showing the changes over time in the practice of swaddling babies in Turkey. As can be seen from the previous discussion, public initiatives were very impor tant in explaining the decline in infant mortality in Turkey during the 1960-1995 period. They were also important in explaining maternal mortality. In Turkey, half of all maternal deaths occur during the childbirth, one-fourth during the preg nancy, and the rest after birth, during the childbed period, i.e. forty-day period 164 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. following childbirth. During childbirth, the main reasons for death of mothers are bleeding and infections (TR-UNICEF 1996, p. 120). Before 1980, both infant mortality and maternal mortality were significant. However, since 1980, maternal mortality has not been important cause of death in Turkey. As can be seen in Table 8.13, maternal mortality decreased signifi cantly during the 1960-1980 period (SIS Death Statistics related years). As pre viously mentioned in chapter 3, public policy initiatives and the improvement in the mother’s level of education played an important role in the decline in maternal mortality. Table 8.13 Maternal mortality, by age group. Year Age groups 15-24 25-44 45-64 1960 0.10 0.14 0.01 1965 0.07 0.13 0.01 1970 0.03 0.06 0.00 1975 0.02 0.02 0.00 1980 0.01 0.00 0.00 1985 0.01 0.01 0.00 1990 0.00 0.00 0.00 1995 0.00 0.00 0.00 Source: SIS Death Statistics related years. As a result of the changes in population policy, illegal abortions and maternal mortality decreased considerably. In 1960, 4 percent of the deaths from PCIODI was due to maternal mortality, but in 1995, only 0.3 percent of the deaths from PCIODI were due to maternal mortality (SIS Death Statistics related years). After 165 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 1980, the deaths in this group were mainly infant deaths, i.e. more than 95 per cent, especially birth injury, infections of newborns, and other causes of perinatal mortality. Before 1980, for this group of deaths, not only infant mortality, but also child and maternal mortality were important (SIS Death Statistics related years). Previous examples show that the Turkish authorities played an important role in improving maternal and child health in Turkey. Government programs based on the improvements in medical/technological knowledge such as importance of breastmilk, importance of having less children and importance of longer birth in terval. Education of the public on other health issues was also based on better knowledge. For example, the importance of a daily bath, clean hands, and steril ization of baby bottles are all based on advancement of knowledge. In addition to their role in general and health education, and breastfeeding, governments also played an important role in putting other medical/technological advancements, e.g. pasteurization and sterilization of milk, and use of ultrasonog raphy, into practice. These medical/technological advancements were also based on improvements in knowledge, and affected the death rate from PCIODI. However, there is no known study showing the timing and development of the use of these new technologies, and the level of their effect on the death rate from PCIODI in Turkey. In conclusion, it can be said that public health initiatives based on better knowl edge were important in explaining the decrease in mortality from PCIODI in Turkey during the 1960-1995 period. 166 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 8.2.2 Pregnancy, Childbirth, Infections of Newborn, and Other Diseases Peculiar to Early Infancy and Economic Factors Among the economic factors, nutrition is the most important factor that af fected mortality from PCIODI in Turkey. Adequate and balanced nutrition is very important for the health of both expecting mothers and infants. During the 1960- 1995 period, there were no important changes in the production or supply of foods. However, there were some changes in diet due mainly to public initiatives and better education of mothers. Even though it seems that there are no important nutritional problems in Turkey, some families are overconsuming and have to deal with an “overweight problem,” whereas some others are experience a “hidden hunger” problem. This is mainly because of mothers having not enough information regarding the nutri tional values of different foods. In order to educate people more on nutrition issues, Turkish authorities started a project called “Halkm Beslenmede Bilinglendirilmesi.” meaning educating people on nutrition, in 1988 (SPO 1988, p. 310, and SPO 1989a, p. 334). It is true that this program started almost at the end of this study pe riod, but there were other public initiatives that affected the nutritional status of children in Turkey during the earlier periods of this study. One of them was the improvement in mother’ s general education level. The overall improvement in mother’ s education level helped in fighting nutritional prob- 167 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. lems. As was explained in chapter 6, Turkish Demographic and Health Survey: 1993 (MOH et al. 1994) showed close relationship between some nutritional indi cators and mother’ s education level. In other words, in Turkey, better educated mothers are more likely to have better nourished children and undernutrition is not a problem among children of mothers with secondary or higher education (MOH et al. 1994, p. 115). Therefore, income is not the only factor affecting nutritional status of children. Income is important for the nutritional status of children and mothers. However, nutritional status is affected by different factors. As can be seen in Table 8.14, in addition to education, birth order, birth interval, age and sex of the child are also important factors affecting nutritional status of children (MOH et al. 1994, pp. 113-116, and errata sheet). However, there is no known study showing the effects of these factors on mother’ s nutritional status. Birth interval is found to be one of the most important variables affecting the height-for-age index, i.e. children who are bom with an interval less than two years are much more prone to be stunted. There is striking differences in the percentage of children classified as stunted according to mother’ s level of education. Children of mothers with no education or primary incomplete have more than two times higher percentage of being stunted compared to children of mothers with primary complete and secondary incomplete, and seven times higher percentage of being stunted compared to children of mothers with secondary complete or higher education (MOH et al. 1994, pp. 113-115). 168 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Reproduced with permission o f th e copyright owner. Further reproduction prohibited without permission. Table 8.14 Nutritional status in 1993, by some demographic characteristics. Demographic Height-for-age Weight-for-height Weight-for-age characteristic % % % % % % below below below below below below -3SD -2SD -3SD -2SD -3SD -2SD Age < 6 months 0.5 3.7 0.0 2.1 0.0 1.0 6-11 months 0.9 9.2 0.6 2.9 2.8 10.3 12-23 months 3.0 19.4 0.1 5.0 1.4 11.6 23-35 months 8.6 22.3 0.4 2.8 3.6 12.7 36-47 months 9.6 26.0 0.7 2.0 1.2 10.5 48-59 months 10.5 29.3 0.6 2.4 2.0 12.0 Sex Male 5.9 21.1 0.4 3.3 1.7 10.3 Female 6.7 19.8 0.4 2.5 2.0 10.5 Birth order 1 3.9 14.0 0.2 2.1 1.0 7.9 2-3 4.9 19.6 0.2 2.2 1.1 8.7 4-5 10.3 27.0 1.3 4.6 3.6 13.7 6 + 13.3 33.2 0.5 5.9 5.0 18.9 Birth interval First birth 3.9 14.1 0.2 2.1 1.0 7.8 < 2 years 11.9 30.9 0.3 3.1 2.9 17.0 2-3 years 8.8 28.3 0.7 4.0 3.1 12.4 4 or more years 1.9 10.4 0.4 2.7 0.7 5.8 All children 6.3 20.5 0.4 2.9 1.9 10.4 Note: -2SD values include children who are below -3SD. Source: MOH et al. 1994, p. 113, and errata sheet. As was discussed in chapter 6, undernutrition is not a problem for children of mothers with secondary complete or higher education. Overall, only 1.9 percent of the children under five are found to be “severely underweight.” The percentage of children whose weight-for-age index is minus three standard deviations (-3SD) from the median of the reference population is 4.3 for children of mothers who have no education or primary incomplete. However, this value is zero percent for children of mothers with secondary complete or higher education. In the Turkish Demographic and Health Survey: 1993 (MOH et al. 1994), birth interval and birth order were found the two most important factors affecting weight-for-age index. Birth interval and birth order are also closely related to the mother’ s education level (MOH et al. 1994, pp. 112-115, and errata sheet). As can be seen from the previous discussion, in Turkey, nutritional status is affected significantly by the mother’s education level. Income also affects the nu tritional status of people, especially of very poor. However, there is no known study showing that the nutritional status of very poor changed for better during the 1960-1995 period. On the other hand, as was discussed in chapter 6, there were significant changes in mother’s education level during the study period, which contributed to nutritional status and to the decline in mortality from PCIODI. It is true that education affects income. However, improvement in mother’ s educa tion level also affects number of births, birth interval, age at marriage, and as was discussed before, these factors were found to be very important in maternal and infant mortality. Therefore, in Turkey, the decline in mortality and improvement in 170 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. nutritional status mainly resulted from improvement in mother’s education level, not from better income. Industrialization may have a positive effect on nutritional status of mother and child through higher income. However, industrialization may have negative effects on nutritional status of infant because industrialization may negatively affect breastfeeding because working mothers can not breastfeed their children as long as non-working mothers. As a result of industrialization, more women join the labor force. When women start to spend most of the time with some kind of outside the home economic activity, the task of breastfeeding tends to be irregular (TR-UNICEF 1998, p. 11). This irregularity negatively affects the production of breastmilk. That is why level of breastfeeding in less developed regions, such as the eastern region of Turkey, is higher and lasts longer. In Turkey, there was improvement in breastfeeding during the study period due to better education of mothers about the importance of breastfeeding. However, even though Turkish government tried to decrease the negative effects of industrialization through some policies, e.g. six-week paid maternity leave, two-hour a day paid nursing time allowance for breastfeeding mothers and an additional one-year unpaid maternity leave, it did not solve the problems of working mothers’ about breastfeeding. This is mainly because for economic reasons, mothers started to work after the six-week paid maternity leave (TR-UNICEF 1998, p. 11). It is true that better educated mothers better learned about the proper way of breastfeeding, and importance of breastfeeding compared to less educated mothers. 171 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 8.15 Frequency of breastfeeding in 1993, by mother’s education. Mother’ s education Percentage of babies less than 6 months old that were breastfed 6 or more times in last 24 hours No education/Primary incomplete 85.2 Primary complete/Secondary incomplete 80.9 Secondary complete/Higher education 73.8 All children 81.2 Source: MOH et al. 1994, p. 111. However, as can be seen in Table 8.15, the median duration of breastfeeding for better educated mothers was still lower than that of less educated mothers (MOH et al. 1994, p. 111). Higher work force participation of educated women compared to less educated women made breastfeeding more difficult for the former, i.e. better educated mothers had less time for breastfeeding. It was still the case even after government policies to improve the level of breastfeeding were put into practice. Therefore, the positive effects of education and public policy initiatives on the level of breastfeeding, and on the level of mortality from PCIODI, were decreased through the negative effects of industrialization. Ozbay found an important decrease in women’s participation in the labor force during the 1955-1985 period (Ozbay 1989). Ozbay argues that the percentage of economically active female population was 72.1 in 1955, but it decreased to 32.7 in 1985. She argues that, this situation is mainly the result of rapid urbanization (TR-UNICEF 1991, p. 262). Ozbay states that, when there is rapid urbanization, 172 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. economically active women in rural areas become housewives in urban areas. The women who were working in agriculture in rural areas cannot find job in urban areas mainly due to lower education level and limited job opportunities. As a re sult of urbanization, female participation in the labor force may be lower compared to earlier years. This may indicate higher levels of breastfeeding in urban areas. However, mothers working in agriculture can bring their children with them to the field or take time off for breastfeeding. On the other hand, mothers working in non-agricultural areas do not have the same kind of opportunities. Even after gov ernment regulations such as maternity leave and paid two-hour a day breastfeeding time, in Turkey, breastfeeding in urban areas was still lower and lasted shorter time compared to rural areas. This is another negative effect of industrialization on in fant nutrition and health. Moreover, females in urban areas, especially the ones living in squatter areas, did other work such as cleaning, taking care of someone else’s children, and these women were not registered as “in the work force” to avoid insurance and social security costs. Therefore, women’s participation in the work force is higher than that was recorded in Ozbay’ s study, and Ozbay recognizes this situation in her study (TR-UNICEF 1991, p. 262). In addition, there was an increase in women’ s non-agricultural labor force participation, during the late 1980s, due to the improvement in the female education level. However, the data on the level of this improvement is not reliable for the reasons mentioned above, i.e. avoiding from insurance and social security costs and helping family business (TR- UNICEF 1991, p. 262). As a result, in Turkey, industrialization had a negative 173 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. effect on breastfeeding and on infant nutrition during the study period. However, education of mothers and other public initiatives helped to decrease the negative effects of industrialization on breastfeeding. With industrialization, it is expected that income increases. As a result of higher income, it is expected that, people have more income to spend on health issues, and that is why many researchers argue that better income means lower mor tality. However, in Turkey, during the 1970-1975 period, death rate from PCIODI increased from 91 to 97 per 100,000 even though there was improvement in the economic well-being of people (SIS Death Statistics related years). Therefore, im provement in economic well-being does not necessarily mean lower mortality. In Turkey, due to rapid urbanization, there was high demand for houses in the city, and the cost of housing increased. Therefore, people constructed their own houses, called “gecekondu,” meaning made overnight, which were of very low quality. Squatter housing became an important problem in big cities, especially in Istanbul and Ankara. This situation, negatively affected the people living in these houses. There is no known study showing whether and how the low quality of housing in squatter housing areas affected the mortality from PCIODI. Since the squatter housing areas generally do not have clean water and ventilation, it is expected that this situation increased the mortality from infections of newborn and other diseases related to early infancy. Through housing reforms, the government tried to improve the quality of hous ing by legislating some requirements about the quality of the housing, e.g. sewerage 174 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. requirements and air filter requirements for better air quality. In other words, the Turkish government had to intervene to offset the negative effects of industrializa tion on quality of housing. To sum up, in Turkey, the decline in mortality from PCIODI mainly resulted from public policy initiatives. Education’s effect on mortality from PCIODI was important throughout the study period, but especially during the 1960s and 1980s, and public policy initiatives played an important role in education. In addition to general education, public initiatives promoting breastfeeding and vaccination, medical/technological improvements, and health education programs, played an important role in the decline in mortality from PCIODI. The effect of breastfeed ing on mortality from PCIODI was important throughout the study period, but especially after 1980. Vaccination was important throughout the study period, but more important for the decline in mortality from PCIODI after 1985. Public pol icy initiatives were based on advancement of medical/technological knowledge, but government authorities played an important role in making new knowledge known to public. Improvement in general education affected mortality through improving mothers’ awareness and their ability to deal with health-related issues. On the other hand, economic factors were not important in explaining the mor tality decline from PCIODI. The evidence on this was very convincing. First of all, the very developed region has an average GDP per capita almost four times higher than the least developed region, but the very developed region had death rates from PCIODI twice as high as the least developed region throughout the study period. 175 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. This situation was mainly the result of higher levels and longer duration of breast feeding in least developed regions compared to very developed region. Moreover, the crude death rate from PCIODI continued to decrease during the economic de cline period of 1980-1985. If the decline were only a by-product of MEG, one would have expected an increase in death rate during economic decline. This was not the case in Turkey. Moreover, even though MEG has positive effects on the death rate from PCIODI, its negative effects through lower and shorter levels of breastfeeding, higher exposure to disease, air pollution and low quality squatter housing are un deniable. The Turkish government had to intervene to decrease the negative effects of industrialization on breastfeeding through many programs that were discussed above. There is no evidence showing that improvement in nutritional status in Turkey was based on economic factors. On the contrary, there is evidence that, nutritional status may be improved, not due to better income, but due to better education of mothers. The previous discussions showed that, in Turkey, the decline of mortality from PCIODI was based mainly on improvement in education, breast feeding, and advancement of medical/technological knowledge. However, public policy initiatives were needed to put the new knowledge into practice. 176 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. CHAPTER 9 TUBERCULOSIS Tuberculosis has been known for a long time and it is called different names. Tuberculosis is first mentioned in old Indian religious books (1500 B.C.) and is called “the king of illnesses” (rogaraj) and “the illness of kings” (rajayakshma) (Kocaba§ 1991, p. 3). During the eighteenth century, since the mortality rate from this disease was very high, the English priest John Bunyon called tuberculosis “the captain of all these men of death.” The Greeks first called it “phtisis,” and then later they called it “consumption.” Whatever it is called, it was and it still is an important cause of death around the world (Kocaba§ 1991, p. 3). There axe different types of tuberculosis. For example, tuberculosis of the res piratory system, tuberculosis of meninges and the central nervous system, tuber culosis of the intestines, peritoneum, and mesenteric glands, tuberculosis of the bones and joints. Tuberculosis primarily attacks the lungs, but it still can develop all parts of the human body. Generally, 80 to 90 percent of the cases are pul monary tuberculosis, i.e. tuberculosis of respiratory system. This disease spreads 177 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. mainly by infection from one person to another, by droplet infection, or indirectly through dust or bacteria in milk (Kocaba§ 1991, p. 3). In Turkey, 85-90 percent of deaths from tuberculosis are from tuberculosis of the respiratory system (SIS Death Statistics related years). In this chapter of the study, first the trends in mortality from tuberculosis in Turkey will be analyzed. Second, factors that may affect mortality from tuberculo sis will be discussed. Last, the question of whether pubUc health initiatives, based on advancement of medical/technological knowledge, or economic factors, such as income, nutrition and housing, were mainly responsible for the decline in mortality from tuberculosis will be analyzed. 9.1 Trends in Tuberculosis in Turkey During the 1960s, tuberculosis was an important cause of death. About 5 percent of deaths were due to tuberculosis. The composition of deaths in Turkey changed considerably during the 1960-1995 period. Tuberculosis is no longer an important cause of death in Turkey. Only 0.5 percent of all deaths were due to tuberculosis in 1995 (SIS Death Statistics related years). When regional differences in mortality from tuberculosis are analyzed, as can be seen in Table 9.1 and Figure 9.1, there are no significant differences among regions with different level of economic development today. However, during the 1960-1980 period, the death rate from tuberculosis for the very developed region 178 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. was higher than that of the other regions. For example, in 1960, the death rate from tuberculosis was the lowest for the developed region, and the highest for the very developed region, i.e. 46 and 60 per 100,000 respectively. However, by 1990, all regions had similar, low death rates from tuberculosis, and overall the least developed region is in a better position than the very developed region regarding deaths from tuberculosis (SIS Death Statistics related years). The death rate from tuberculosis differs significantly by age. As can be seen in Table 9.2 and Figures 9.2, the age-specific death rate for tuberculosis is the highest for the elderly, i.e. 65+ age groups. Then comes the working age group, 25-64 age group, and infants, 0-1 age group. In other words, the age-specific death rate for tuberculosis was different for different age groups, and it was the lowest for the 5-14 age group. Until the 1990s, tuberculosis in working ages, was higher than that of other ages, except the elderly, i.e. 65+ age groups. However, by 1990, the death rate from tuberculosis had reached very low levels. As a result, now. there are no significant differences in mortality from tuberculosis by age, except among the elderly. High mortality for the elderly is reasonable because of deteriorating immune systems (SIS Death Statistics related years). As can be seen in Table 9.3 and Figure 9.3, age-specific death rates from tuber culosis did differ by sex. The death rate for males is about two times higher than that of females (SIS Death Statistics related years). 179 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 9.1 Crude death rate (per 100,000 population) for tuberculosis, by level of development. Year Very developed Developed Less developed Least developed Turkey 1960 60 46 53 52 55 1965 39 29 38 33 36 1970 25 16 21 15 21 1975 14 9 7 6 11 1980 11 7 5 5 9 1985 8 5 4 3 6 1990 4 3 3 2 3 1995 3 2 1 1 2 Source: SIS Death Statistics related years. c o 3 a o a o o o u a ) a < a u I T 3 a > a ) 3 U a 60 “* * Very developed * - Developed ■ — Less developed — L east developed — Turkey 50 40 30 20 10 0"— 1960 1965 1970 1995 1975 1980 1985 1990 Y e a r Figure 9.1 Crude death rate (per 100,000 population) for tuberculosis, by level of development. 180 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Table 9 .2 Age-specific death rate (per 100,000 population) for tuberculosis. Year 0-1 1-4 5-14 15-24 25-44 45-64 65-74 75+ Total 1960 71 41 10 41 68 122 100 122 55 1965 29 19 6 18 47 87 104 93 36 1970 17 9 3 10 25 51 88 68 21 1975 11 5 1 5 10 31 54 59 11 1980 20 7 1 3 7 21 49 50 9 1985 14 5 1 2 5 15 31 43 6 1990 4 1 0 1 3 9 15 36 3 1995 3 1 0 0 2 7 16 20 2 Source: SIS Death Statistics related years. < Q 125 Q. S . 0- 1, * ■ 45- 64, 5- 14, 15- 24, ------- 2 5 -4 4 Total •>, 65- 74, 100 O o H u & 0 ) •U <0 0 > 'O O •H > 4-1 0 & t n 1 < u O l 1960 1965 1970 1975 1985 1995 1980 1990 Y ear Figure 9.2 Age-specific death rate (per 100,000 population) for tuberculosis. 181 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. C rude death rate (per 100,000 population) T a b le 9 .3 Crude death rate (per 100,000 population) for tuberculosis, by sex. Year Male Female Total 1960 64 45 55 1965 44 26 36 1970 28 14 21 1975 15 7 11 1980 15 5 9 1985 8 4 6 1990 5 2 3 1995 0.03 0.01 0.02 Source: SIS Death Statistics related years. 75 Hale Female Total 60 45 30 15 0 — 1960 1995 1980 1985 1990 1965 1970 1975 Y e a r Figure 9.3 Crude death rate (per 100,000 population) for tuberculosis, by sex. 182 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 9.2 Factors Affecting Mortality from Tuberculosis There were many medical/technological improvements, such as sanatoriums, application of surgical and preventive measures, and chemotherapy, that were used to fight against tuberculosis. For example, in 1887, the first tuberculosis sanatorium was established by Robert Phillips in the city of Edinburg (Oger 1991, p. 35). With the beginning of the twentieth century, the numbers of sanatoriums expanded rapidly. The treatment in sanatoriums was based on fresh air, rest, and also good nutrition. Treatment by pneumothorax also became widely used. This treatment involved collapsing part or the whole part of the diseased lung with the aid of nitrogen gas to allow the lung to rest. This is done to facilitate the healing process. This treatment was introduced by Italian Carlo Forlanini (Oger 1991, p. 35). Later on, this method was refined and combined with other surgical measures such as thoraco-plastic surgery. This method involved the removal of some ribs and also collapsing the diseased lung to allow it to rest. After 1950, through certain surgical methods, the parts of the lung affected by tuberculosis were removed. Most of the earlier surgeries often resulted in the disablement of the patients (Puranen 1991, p. 115). During the 1940s, important changes occurred in the treatment of tuberculo sis. Two important drugs were discovered. The discovery of para-amino-salicylic 183 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. acid (PAS) by Swedish Jergen Lehmann and the discovery of streptomycin by the American Selman Waksman in 1944 have historical importance. Moreover, in 1952, a third drug izoniazid (INH) was discovered and other advances followed these dis coveries. Puranen argues that, the discovery of rifampicin, which not only limits the growth of the bacillus, but also kills it, was an important discovery. As a result of the combined effects of different drugs that attack the disease in different ways, the emergence of bacterial resistance can be avoided (Puranen 1991, p. 116). Another important effect of medical/technological intervention is early detec tion through X-rays. In addition to the treatment in sanatoriums, surgery, and chemotherapy, a wide range of preventive measures such as early detection by use of X-rays were applied. X-rays were developed by Rontgen in 1895 (Oger 1991. p. 35). Puranen argues that the massive use of X-rays enabled large numbers of people to be screened. As a result, it led to the more rapid detection of tuberculosis (Puranen 1991, p. 115). The use of the Calmette vaccine, usually known as BCG, was another impor tant step for preventing tuberculosis. This vaccine was invented by Calmette and Guerin, and it was introduced into Sweeden in the 1920s. However, use of the BCG vaccine did not become widespread until the 1950s (Puranen 1991, p. 115). It is not clear how strong acquired immunity by BCG vaccination is. Immunity need not necessarily have been acquired through vaccination. If there is a widespread bovine tuberculosis problem, the milk would also contain the tu bercle bacilli. Puranen argues that differences between age-specific mortality rates 184 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. from tuberculosis in parishes in which cattle were infected with the tubercle bacilli and those in which they were not infected with the tubercle bacilli, may have been due to bovine immunization. Puranen stated that in parishes in which bovine tuberculosis was widespread, infant mortality from this disease was higher, even though the overall death rate from tuberculosis was lower than in others. According to Puranen, bovine tuberculosis caused higher infant mortality from tuberculosis, but in the meantime, it also provided some degree of protection against tubercu losis in later life for those who survived the previous infection (Puranen 1991, p. 109). Public authorities also played an important role putting medical discoveries into practice to fight against tuberculosis. Moreover, they played an important role in mortality decline from tuberculosis by educating the public on health is sues. Puranen argues that, the education of public about hygiene is very important in explaining the decrease in death rate from tuberculosis (Puranen 1991, p. 113). The general education is also very important. For example, Puranen argues that in some coastal villages of Sweden, tuberculosis was found in almost half the farms. To understand the difference between coastal villages and farms, their living con ditions and their general standard of health were investigated, and all the known means to fight tuberculosis were then applied. The change in the quality of housing and public education were found to be important affecting the mortality from tu berculosis (Puranen 1991, p.115). During this improvement period, through public education, the old habit of nailing up windows during the winter was abandoned. 185 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Moreover, attempts were made to prevent people from spitting on the floor and to educate them in matters of hygiene. As a result, a considerable drop in the mor tality from tuberculosis in the experimental area, compared with similar nearby villages, was found (Puranen 1991, p. 113). Legislation making notification and treatment of the disease mandatory may also have played an important part in the decrease of mortality from tuberculosis. Puranen argues that public authorities played an important part in the decline of mortality from tuberculosis through the application of medical inventions and also by making the notification and the treatment of the disease compulsory (Puranen 1991, p. 115). Advancement of medical/technological knowledge, and improvement in peo ple’s knowledge through general education and health education are expected to play an important role in explaining the trends in mortality from tuberculosis in Turkey. However, public policy initiatives are needed in many cases to make this new knowledge known by public. Therefore, the effects of advancement of knowl edge and public policy initiatives will be analyzed as a group, in the “Tuberculosis and Public Policy Initiatives” section of this chapter. On the other hand, the economic factors, reflected in income, nutrition, and housing, are also mentioned as important factors affecting mortality from tubercu losis (See especially, Puranen 1984 and 1991, McKeown 1976, Caselli 1991, Marche and Grunelle 1950, and Leitch 1945). 186 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Industrialization had some negative effects on human health through urbaniza tion. Urbanization increased the risk of exposure, and as a result, it may have increased the death rate from tuberculosis. Graziella Caselli argues that high mor tality from tuberculosis at working ages shows the negative effects of industrial ization on health (Caselli 1991, p. 77). However, this effect differed from town to town due to the differences in the level and speed of industrialization, population density, and the presence of certain kind of industries (Puranen 1991, p. 112). If the industrialization is rapid, then overcrowding becomes a big problem in the towns. Moreover, the quality of housing declines, especially when there is no government intervention. For example, squatter housing becomes a general problem in towns. These houses are built in a very short period of time and generally have poor hygiene conditions. It is known that the tubercle bacillus can survive in dirt and dust for a very long time, so that overcrowding and poor hygiene are fatal factors in tuberculosis. As a result of rapid industrialization, towns become open to this disease. Mortality from tuberculosis was higher in a small town situated in an area in which tuberculosis was more frequent, than in a large town with a lower level of incidence of the disease. However, when the size of the town reaches a certain level, size alone becomes the dominant factor (Puranen 1991, p. 112). Puranen argues that in Sweden, until the mid-1930s, death rates from tuberculosis were higher in towns than in rural areas, but after 1936 the situation was reversed, and within 187 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ten years, the death rate from tuberculosis in towns became lower than those in rural areas (Puranen 1991, p. 112). Puranen also argues that there is an important connection between mortality from tuberculosis and the type of industries. He states that during the last decades of the nineteenth century, the highest number of deaths from tuberculosis occurred in the iron and steel town of Eskilstuna, Sweden (Puranen 1991, p. 112). The neighboring areas were also dominated by the same type of iron and steel indus tries, but the death rates from tuberculosis were significantly lower than those of Eskilstuna. Puranen states that, in Eskilstuna, morbidity from tuberculosis among grinders was five times as high as in other groups, and the members of some occu pations, such as metalworkers, tailors, and smiths were at higher risk than others (Puranen 1991, p. 112). Puranen argues that the combined effect of degree of industrialization and certain kinds of industrial employment make the situation worse (Puranen 1991, p. 112). Chadwick also noted that the overcrowding in tailors’ workshops was associated with higher incidence of tuberculosis during the nineteenth century in England (Chadwick 1965). However, occupation is related to education, income is related to occupation, and income may affect nutrition and housing. Therefore, it is not easy to differentiate how much of the effect is resulting from occupation, and how much of it coming from other factors related to occupation. 188 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. As Puranen stated, the quality of housing may be another important factor affecting mortality from tuberculosis (Puranen 1991, p. 115). As a result of indus trialization, the towns became overcrowded, and squatter houses with poor hygiene were built all around them in a very short time and had no ventilation. As a result, housing conditions were at their worst in the early industrial towns, so also were the mortality rates. When the conditions were improved during the later nine teenth century by housing reforms, towns had better housing facilities than rural areas, and mortality from communicable diseases decreased considerably in urban areas of England. However, the death rates were still consistently higher in urban areas (Burnett 1991, p. 176). As a result, Burnett states that bad housing could clearly facilitate the transfer of communicable diseases, but it is unwise to give a quantifiable “weight” to the effect of housing in the mortality decline since it is not possible to isolate the house as a physical structure from associated amenities such as water supplies and sewerage, from its external environment, and also from social and economic environment of its inhabitants. He argues that poor housing almost always went with overcrowding, poor sanitation and poor nutrition. How ever, improved housing may also mean higher rents, and as a result of higher rents, it may mean less money to spend for nutrition. This happened during the industri alization, and many workers in towns lived in low quality houses such as squatter houses since good quality housing became very difficult to afford in towns (Burnett 1991, p. 176). 189 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Another important economic factor that may affect mortality from tuberculosis is nutrition. This view is supported in many studies. For example, Marche and Grunelle argued that people who enjoy a good diet have a higher resistance to tuberculosis than those who suffer from malnutrition (Marche and Grunelle 1950). Leitch also supported their view, arguing that protein deficiency is particularly dangerous, especially deficiency of animal proteins (Leitch 1945). Mortality from tuberculosis increases during times of famine and scarcity. If the standard of living worsens in an area in which tuberculosis is endemic, then the death rate from the disease in the affected generation will be high (Puranen 1991, p. 108). Peter Lunn also argued that tuberculosis is a disease that is sensitive to nutritional status (Lunn 1991, p. 137). In short, many researchers have accepted that reduction of nutritional intake is expected to lead to an increased incidence of tuberculosis, especially in societies in which the disease is endemic. Modern studies have also shown that there is a clear relationship between the level of alcohol consumption and the incidence of tuberculosis, especially when there is decline in general health caused by poorer nutrition (Hangren and Ohnell 1969, p. 225). Thomas McKeown argued that the decline of tuberculosis played an important role in the overall decline of mortality in the later part of the nineteenth century. McKeown stated that improved nutrition must have been chiefly responsible for the decline of mortality (McKeown 1976 and 1983). However, even for England, it is not clear that the overall mortality decline can be attributed to improved nu trition. According to Philip Curtin, diet changed very little during the mid-19th 190 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. century among British troops stationed in the United Kingdom, but the death rate from tuberculosis decreased by 75 percent during the same period (Curtin 1989, pp. 41-42). Curtin suggests that improved ventilation in barracks and public health education may have helped reduce the transmission of tuberculosis during the late 19th century. Moreover, eradication of smallpox may have reduced mor tality from tuberculosis and other diseases by improving the general level of the immune system. Even though poor nutrition makes people less resistant to tuberculosis, nutri tion alone cannot provide protection against tuberculosis. In a research, differences in the death rates from pulmonary tuberculosis in Stockholm, in groups with ex tremely good and extremely poor living condition, were studied (Puranen 1991. p. 111). In this research, three groups were studied for the 1749-1860 period: members of the royal court, poor women inmates at Sabbatsberg Poorhouse, and prisoners at Norrmalms Women Prison. Members of the royal court were divided into six categories to be able to distinguish royal family from others such as royal guards and royal servants. According to the result of the study, consumption was a common cause of death in all three categories, including the members of the royal family even though they enjoyed a nutritionally good diet (Puranen 1991, p. 111). When there is a high general risk of exposure to tuberculosis, members of the court were not able to resist the attacks of the tubercle bacillus. Therefore, Puranen argued that the part played by nutrition in relation to tuberculosis should not be exaggerated, especially in the presence of high general risk of exposure to 191 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. the disease. During the period studied (1749-1860), there was a substantial im provement in nutrition, but all the other factors remained unchanged. However, there was not an important change in the death rate from tuberculosis even after the changes in nutrition occurred. In other words, even though the groups studied were extremes, one can say that the exposure to disease, rather than nutritional status was the key factor in determining the mortality rate from tuberculosis. The effects of economic factors, such as income, nutrition and housing, on mor tality from tuberculosis in Turkey will be analyzed as a group, in the “Tuberculosis and Economic Factors” section of this chapter. There are other factors such as climate and genetic factors that can affect the death rate from tuberculosis. Caselli states that there was a big difference in mortality from tuberculosis between England and Wales and Italy at the end of the nineteenth century. He argues that mortality from tuberculosis was much higher in England and Wales, and this difference was not due solely to differences in medical practice or diagnostic conventions (Caselli 1991, p. 72). Caselli says it is true that adequate means of diagnosing tuberculosis were still lacking in a number of Italian regions, but more favorable climatic conditions in addition to a later start and slower pace of urbanization acted as a check on tuberculosis. He also adds that this disease was more prevalent in northern and central European countries, where the climatic conditions were less favorable. The difference in climate can partly explain regional differences, but cannot explain the trends, since there were no significant, climate changes during the last few decades. 192 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Genetic factors can also affect the death rate from tuberculosis. Children of tubercular parents are not born with this disease. However, it is possible that they may have inherited lower resistance to this disease. Puranen argues that hereditary elements in occurrance of this disease cannot be ignored (Puranen 1991, p. 108). Comstock also argues in favor of hereditary factors, saying that twin studies have shown that monozygotic twins suffered from a higher incidence of tuberculosis even when they had been reared apart (Comstock 1978). Climate and genetic factors will not be analyzed in detail since they can partly explain regional and individual differences, not long-term trends in mortality from tuberculosis. Having given the general information about the factors that can effect mortality from tuberculosis in general, the effects of these factors on mortality from tuber culosis in Turkey can be analyzed. In next section, first the effects of public policy initiatives, and then, the effects of economic factors on mortality from tuberculosis in Turkey will be discussed. 9.2.1 Tuberculosis and Public Policy Initiatives Tuberculosis control activities in Turkey began in 1918 by a non-goveramental organization (NGO). Governmental participation began in 1949 by the promulga tion of “Tuberculosis Law.” The fight against tuberculosis continued actively since thereafter. Anti-tuberculosis activities are carried out by the General Directorate for Fighting Tuberculosis attached to the Ministry of Health. The objectives of 193 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. the fight against tuberculosis are to get the disease under control through pre ventive and therapeutic measures and finally eradicate it. In Turkey, there are five basic principles in fighting against tuberculosis: training or education, preven tive measures or avoidance, early diagnosis, early treatment, and social assistance (MOH 1973, pp. 111-128). These principles have been adapted to accomplish the eradication of tuberculosis. As was the case for many other countries, in Turkey, public authorities played an important role in the decline of the mortality rate from tuberculosis. However, pubUc health initiatives to fight against tuberculosis were mostly based on medi cal/technological improvements. In other words, the intervention done by public authorities in accordance with the progress in medical/technological knowledge. One of the basic interventions was preservation of the health of non-infected peo ple through vaccination. Preservation of health and protection against tuberculosis through BCG vaccines has found a wide field of application in Turkey. For this purpose, a BCG Campaign Department was established as a part of Ministry of Health in 1953. The BCG campaign was also started in 1953. During the first fifteen years of the campaign, traveling vaccination groups went more than three times through the provinces, districts, sub-districts and villages (MOH 1971, p. 53). Other than traveling inoculation groups of the BCG campaign, tuberculin tests and BCG vac cines were also applied by stationary centers that were a part of the campaign, 194 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. traveling X-ray tuberculosis control teams, tuberculin and BCG teams and tuber culosis dispenseries. There is no reliable information on the state of the infectious prevalence before 1953. The infectious prevalence of tuberculosis was first estab lished during the first cycle of the BCG campaign activities. As can be seen in Table 9.4, during the first cycle of BCG campaign, in 1953, the general rate of infection was 56 percent (MOH 1971, p. 53). Table 9.4 The general rate of infection for tuberculosis in 1953, by age groups. Age group (%) 0-6 years old 13 7-14 years old 35 15-19 years old 57 20 years and older 86 Total 56 Source: MOH 1971, p. 53. From the investigations made in 1965 on 10,000 children in the 0-6 age group in 60 villages of 5 provinces, it was found that the infection rate from tuberculosis, which was 10.4 percent for these villages and provinces before the vaccination period, i.e. before 1953, had dropped to 3.8 percent in 1965 (MOH 1971, p. 53). In other words, the BCG vaccination significantly affected the infection rate from tuberculosis in Turkey. Improvement in the general level of education also played an important role in the decrease in mortality from tuberculosis because better educated mothers are more likely to have their children vaccinated against different diseases. For 195 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. example, as can be seen in Table 9.5, the level of BCG vaccination increases with mother’ s level of education (MOH et al. 1994, p. 98). Table 9.5 Percentage of children 12-23 months who had received BCG vaccination in 1993, by mother’ s education. Mother’ s education % No education/Primary incomplete 74.6 Primary complete/Secondary incomplete 96.2 Secondary complete/Higher education 99.0 Source: MOH et al. 1994, p. 98. Moreover, based on the improvement in medical knowledge, authorities started to give more attention to early diagnosis and early treatment. This was also very important in fighting against tuberculosis. Activities for early diagnosis and treat ment started in 1960 with the set of traveling X-ray tuberculosis teams. In addition to test and vaccine applications in the provinces, districts and villages, the traveling X-ray teams also made tuberculosis controls by taking microfilms. Any suspicious cases noticed were sent to tuberculosis dispenseries or chest disease hospitals for further examination, and if necessary, treatment was given to the patients (MOH 1973, pp. 121-129). The massive use of X-rays enabled large numbers of people to be screened, and therefore, tuberculosis cases were detected faster. The Turkish government played an important role in finding possible tubercu losis cases by screening people before going into military service or before starting a job. Having an X-ray and providing a tuberculosis-free report became a re quirement before starting a new job. This requirement continued until the 1990s. 196 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Because by 1990, the mortality rates from tuberculosis were low, around 3 per 100,000, and the government stopped mandatory screening for job purposes. How ever, general health screening before starting military service and other military- related places, e.g. military schools and military jobs, continued because of the close contact with others in these places. This may be true for other jobs, but in military jobs, especially in military schools and military service, people have closer contact with each other since they are together not only during the day time, but also during the night time sharing Uving quarters with many other people. Gov ernment policies such as tuberculosis screening before starting to work or entering military service helped in fighting against tuberculosis in Turkey. Moreover, in tuberculosis dispensaries, BCG vaccines and other preventive mea sures applied where necessary and those diagnosed as infected are taken under control for treatment. Moreover, in these dispensaries, the public is systematically educated on tuberculosis. After the first month of the treatment, the symptoms such as coughing and sweating, generally disappear, but the treatment has to be continued at least 6-9 months. To encourage continuing treatment, educational materials such as books, pamphlets, posters, slides, and films, were provided to pa tients as a part of health education (MOH 1973, pp. 123-129, 223-224). Moreover, the treatment is given free of charge. Training or education was also one of the most important parts of the public health policies. Training has been accepted as a basic principle and given priority in fighting against tuberculosis. Training activities are carried out in two ways. First, 197 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. the health personnel was trained about tuberculosis. Second, health education is given to the public and the patients. Health training activities are carried out all through the year with the aid of all kinds of educational facilities and equipment. These activities are especially intensified during the first week of January every year. The first week of January is called as “ verem sava§ haftasi,” meaning training and propaganda week for the fight against tuberculosis. Patient education is carried out at every stage of the service and the patient, his family and the social circle is warned against tuberculosis. Training of the health personnel is done at the training centers (MOH 1971, pp. 52-53). In conducting health education activities, the Directorate General of Health Education and Medical Statistics and other organs of the Ministry of Health, have cooperated with other concerned ministries, such as the Ministry of Education, and also the National Organization for Fighting Tuberculosis, the Turkish Radio- Television Establishment (TRT), the press, public cultural centers, and other sim ilar organizations (MOH 1971, p. 30). In addition to the education of public about tuberculosis, hygiene education of students at school was an important part of the fight against tuberculosis. Weekly check-ups for cleanness, such as control of nails, handkerchief and hair as an indi cator of general hygiene, became a part of the weekly routine at schools, especially in elementary schools. Health education in Turkey was limited until 1963. Starting in 1963, however, the health education units were established in some cities. By 1969, each city in Turkey had “health education unit.” (MOH 1971, pp. 52-53) 198 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. In Turkey, the effect of pasteurization and sterilization of milk on mortality decline from tuberculosis is very limited. This is because, except for a few very developed cities, it is the raw milk, not pasteurized milk, that is generally bought from farmers who sell their milk door to door, and then this milk is boiled before consumption. In other words, pasteurization cannot be the factor explaining the decline in mortality from tuberculosis in Turkey. As can be seen from the previous discussion, in the fight against tuberculosis, public health policies went hand in hand with medical/technological improvements, and they both played an important role in the decline in mortality from tubercu losis. The Turkish government played an important role by implementing public policies based on the improvements in medical/technological knowledge. Espe cially, vaccination and X-rays were important medical/technological advancement used by public authorities to fight against tuberculosis. 9.2.2 Tuberculosis and Economic Factors As was previously discussed, many studies have argued that a reduction in nu tritional intake is expected to lead an increased incidence of tuberculosis, especially in societies in which the disease is endemic (See especially McKeown 1976, Marche and Grunelle 1950, Leitch 1945, Lunn 1991). Thomas McKeown argued that improved nutrition must have been chiefly re sponsible for the decline in mortality from tuberculosis (McKeown 1976 and 1983). Marche and Grunelle argued that people who enjoy a good diet have a higher 199 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. resistance to tuberculosis than those who suffer from malnutrition (Marche and Grunelle 1950). Leitch also argued that protein deficiency, especially deficiency of animal proteins, is dangerous (Leitch 1945). Peter Lunn argued that, tuberculosis is a disease that is sensitive to nutritional status (Lunn 1991, p. 137). Even though poor nutrition make people less resistant to tuberculosis, good nutrition alone cannot provide protection against tuberculosis. When there is a high general risk of exposure to tuberculosis, people who had access to good diet were not able to resist the attacks of tubercle bacillus (Puranen 1991, p. 111). Puranen argued that, the exposure to disease, rather than nutritional status was the key factor in determining the mortality rate from tuberculosis, and therefore, the part played by nutrition in relation to tuberculosis should not be exaggerated. It is true that tuberculosis is affected by nutritional status. However, in Turkey, the decline in mortality from tuberculosis did not result from better nutrition. Dur ing the study period there is no known study showing any significant improvement in nutritional intake in Turkey. However, there axe some studies showing a decline in nutritional intake during the 1960-1980 period, in which most of the decline in mortality from tuberculosis was achieved. For example, during 1960-1980 period calorie supply per capita decreased from 3110 to 3002, and total protein supply per day decreased from 97.5 gram to 82.9 gram (FAO 1965, pp. 252-253 for 1960; FAO 1985, pp. 268-270 for the 1965-1980 period). However, the death rate from tu berculosis decreased from 55 per 100,000 to 9 per 100,000 during the same period (SIS Death Statistics related years). In other words, there was no improvement 200 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. in nutritional intake, but there was a significant decrease in the death rate from tuberculosis in Turkey during the 1960-1980 period. Another piece of evidence which shows that economic development was not the main reason behind the decrease in the death rate from tuberculosis is the decline in the mortality from tuberculosis during economic decline period of 1980-1985. In Turkey, during 1980-1985 period, the economic well-being of people decreased. However, the death rate from tuberculosis decreased from 9 to 6 per 100,000 during the same period. The rate of decrease in death rate from tuberculosis during the 1980-1985 period was higher than the one during the earlier period, namely 1975- 1980. In other words, the death rate from tuberculosis continued to decrease dining the 1980-1985 period even in the presence of economic decline. If the decline in mortality from tuberculosis were simply a by-product of MEG, then one would have expected lower mortality for higher income areas. This was not the case for Turkey. The very developed region has an average GDP per capita almost four times higher than that of the least developed region, but the least developed region has lower mortality from tuberculosis than the very developed region throughout the study period. It is true that to increase the funds available to fight against tuberculosis, Turkish government mandated in 1948 that 10 percent of the municipality tax taken from the entertainment places would be given to an organization, "Verem Sava§ Demegi,” meaning national organization to fight tuberculosis, in that area. One may argue that this fund may have contributed to the the decline in mortality 201 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. from tuberculosis. However, although this fund was available 12 years before the study period began, the main decline in mortality from tuberculosis happened after 1959, i.e. during the 1960-75 period. During 1950s, there were some ups and downs, and there was very little decline in the death rate from tuberculosis (SIS Death Statistics related years). To siim up, in Turkey, public authorities played an important role in the decline in mortality from tuberculosis. However, public policy initiatives to fight against tuberculosis were mostly based on medical/technological improvements. In other words, the intervention was done by public authorities in accordance with the progress in medical/technological knowledge. Preservation of the health of non infected people through BCG vaccination and health education, early detection of tuberculosis through X-rays, treatment of patients in tuberculosis dispenseries or chest disease hospitals and sanatoriums by the help of new drugs, application of surgical and preventive measures, and chemotherapy, were all based on medi cal/technological improvements. The role of medical and technological improve ment was especially important during the 1960s and 1970s. Improvement in the general level of education also played an important role, especially during the 1960s, in decline in mortality from tuberculosis because better educated mothers are more likely to know about the importance of hygiene and vaccination in fighting against tuberculosis. On the other hand, economic factors were not very important in explaining the mortality decline from tuberculosis. The evidence on this was very convincing. 202 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. First of all, the very developed region has an average GDP per capita almost four times higher than the least developed region, but the least developed region has lower mortality from tuberculosis than the very developed region throughout the study period. In addition, the crude death rate from tuberculosis continued to de crease during the economic decline period of 1980-1985. If the decline were only a by-product of MEG, one would have expected an increase in the death rate during economic decline. This was not the case in Turkey. Moreover, even though MEG has positive effects on the death rate from tuberculosis, its negative effects on tu berculosis through overcrowding and low quality squatter housing, are undeniable. The Turkish government had to intervene to decrease the negative effects of indus trialization on tuberculosis through mandatory housing requirements. Moreover, there is evidence that nutritional intake decreased in quantity during the 1960-1980 period. The quality of nutritional status may be improved during the same period not due to better income, but due to better education of mothers. In short, the public policy initiatives based on advancement in medical/technological knowledge were mainly responsible for the decline in mortality from tuberculosis in Turkey during the 1960-1995 period. 203 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. CHAPTER 10 OVERVIEW OF CAUSES OF MORTALITY DECLINE IN TURKEY, 1960-1995 In this chapter of the study, the health-related policies of the Turkish govern ments during the 1960-1995 period will be analyzed first. Then, the effects of economic factors on the decline in mortality during the study period will be sum marized to determine whether the public policy initiatives or the MEG were the driving source of mortality decline in Turkey. 10.1 Importance of Public Policy Initiatives in the Mortality Decline All the discussion in this section is based on the Government Programs: 1923- 1995. There are other more detailed health related policies in State Planning 204 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Organization (SPO) Annual Programs and Five-year Development Plans (SPO re- leated years), Ministry of Health’s programs, and Ministry of National Education’ s programs. However, these programs are based on the government programs. The purpose of this study is not to analyze all the health related policies of Turkey, but to shed a light on the effects of the government’ s policies on the health of the people in Turkey during the study period. Therefore, the public policies analyzed here will be limited to the government programs. Government Programs: 1923-1995 (TR 1923-1995) are obtained through inter net from “http://www.tbmm.gov.tr/ambar/HP#.htm,” where # shows the order of the government program, i.e. # changes from 1 to 57 program meaning 1st through 57th government. During the study period, 24th through 52nd govern ments of Turkey were in power. However, as will be explained below, the effects of the policies of the prior governments were also important in explaining the mortal ity decline in Turkey during the study period. Therefore, they will also be taken into consideration in analyzing the effects of government programs on the health of people in Turkey. Health related policies in the Turkish government’ s programs include policies regarding health, education, housing, environment, and infrastructure, such as wa ter, sewerage and roads. These policies will be analyzed in four different time periods. The first period (1923-1950) was called the “one-party period,” covers the policies from the establishment of the Turkish Republic to 1950. Even though the multi-party system in Turkey was started in 1946, one party, Cumhuriyet Halk 205 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Partisi (CHP), a left-wing party, was in power until 1950. Therefore, the 1923-1950 period analyzed separately. The second period, the “Menderes period,” was named after Adnan Menderes who was the Prime Minister of Turkey during the 1950-1960 period. The “Menderes period” covers the policies of the Demokrat Parti (DP), a right-wing party. This period is analyzed separately because there were significant changes in the government’ s policies during Demokrat Parti administration, and 1950 was also the start of the MEG in Turkey. The second period ended with the May 27, 1960 Military Coup. After the 1960 Military Coup, three ministers, including the Prime Minister Adnan Menderes, were executed. The third period (1960-1980) was named as the “Post-1960 Military Coup Period,” and lasts until the Military Coup of September 12, 1980. In addition to political changes after September 12, 1980, there were also economic changes such that 1980 is the start ing point of open-market economy in Turkey. The fourth period (1980-Today) was called as the “Open-economy period.” Turkey still has open-market economy, but this study will be covering until 1995. 10.1.1 The One-party Period: 1923-1950 During 1923-1945, there was a one-party, Cumhuriyet Halk Partisi (CHP), in Turkey. The left-wing and right-wing ideas were included in CHP’ s programs even though CHP is considered as a left-wing party. For example, Celal Bayar who was the Prime Minister during the 1937-1939 period, was also the President of the Demokrat Parti (DP), and also the President of Turkey during the 1950-1960 206 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. period. During the 1923-1950 period the priorities of government were to solve problems related to defense, foreign affairs, and economic problems. 10.1.1.1 Health Policies During the One-party Period After the establishment of the Turkish Republic in 1923, Turkish governments prepared some policies to deal with health problems. However, until 1937, the governments’ priorities were foreign affairs and defense, since Turkey participated the First World War (WW I) and the problems related to the war had not been completely resolved. Therefore, there was no detailed health policy in the pre- 1937 government’s programs. Health policies in the pre-1937 Turkish government programs covered issues related to malaria, syphilis, and tuberculosis. Celal Bayar was the first Turkish Prime Minister who emphasized health issues, and explained his health related policies in detail in his 1937 government program. Some of these policies were related to general health issues such as policies to improve quality and number of hospitals and beds, and to increase the number of doctors and midwives. There were also specific programs aimed at reducing the deaths from specific diseases, especially diseases related to mother and child health, e.g. improving number of maternity hospitals and childcare facilities, and increasing the number of infant observation houses, for better mother and child health. Celal Bayar was also the first Turkish Prime Minister who stated the importance of sports for good health in his government program. In his 1937 government 207 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. program, Celal Bayar stated that all citizens would have the opportunity to do sports and also enjoy weekends and holidays in order to achieve higher productivity and better health in the country. The 1938 government program was a continuation of the 1937 government program. In addition to the new policies on health issues, Celal Bayar governments continued to work on other health issues such as those related to malaria, syphilis, and tuberculosis, as before. After the 1938 Celal Bayar government, in 1939, Dr. Refik Saydam became the Prime Minister. In Saydam’ s government programs, there were no important new policies or policy changes related to health even though Refik Saydam was the Minister of Health before and one of the most prominent Ministers of Health in Turkey’ s history. This was mainly because of the WW II. In spite of the fact that Turkey did not participate the WW II, the effects of the war were felt deeply in the country. Therefore, during the Refik Saydam governments, the priority of the government was to preserve the peace and solve economic problems resulting from the war. After Dr. Refik Saydam, §iikru Saragoglu became the new Prime Minister of Turkey in 1942. In Saraxjoglu’ s government programs, there was no new policy related to health. The 1942-1946 period was ‘ ‘ years of scarcity” resulting from WW II. As a result, the government controlled the distribution of food and other necessities such as oil and clothing. Recep Peker, the Turkish Prime Minister during the 1946-1947 period, men tioned new policies in his 1946 government program to increase the number of 208 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. health technicians in villages, to encourage doctors to go to villages and small towns, to increase the number of health personnel in general. In Peker’s 1946 government program, there were also some new policies to increase the number of students in medical schools. Even though Recep Peker had detailed health policies, he was the Prime Minister of Turkey for only fourteen months, and therefore, it was not possible to determine how successful was Peker in putting his policies into practice. Hasan Saka governments followed the Peker government. There was no new policy regarding health in either 1947 or 1948 Hasan Saka government programs. However, Hasan Saka mentioned in his programs that he supported the importance of health and education, and he would continue to work on these issues by staying faithful to earlier party programs. He also emphasized the benefit of foreign experts to improve scientific and technological knowledge in the country. §emsettin Gunaltay was the Prime Minister of Turkey during the 1949-1950 pe riod. There was no detailed health policy in 1949 Gunaltay’ s government program. The main issue during the 1949-1950 period was fraud in the elections. 10.1.1.2 Education Policies During the One-party Period Until 1928, i.e. during Inonii governments and Okyar government, there was no detailed education policy. However, Ismet Inonii stated the importance of liter acy in his 1927 government program, and mentioned the establishment of “Millet Mektepleri,” i.e. nation schools, to teach the Latin alphabet to anyone in Turkey. 209 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. inonii also mentioned that there will be some 2-4 months courses for working peo ple to make them become literate and learn basic things needed in life. Timing for these courses were scheduled according to the free time of its participants. Even though Ismet Inonii did not mention his education policies in detail in his government programs, the education was given priority in addition to defense and foreign affairs. In particular, the President of the time, Atatiirk, and his leadership in educational reforms need to be mentioned; he was called the “chief instructor” of the “School of the Nation.” Atatiirk’ s role was not creating an acceptance of the value of education, because it was already there. His role was in the expansion of education to the masses to decrease the sharp divisions between rulers, i.e. elites, and the ruled, i.e. illiterate masses (Kazamias 1966, p. 265). Moreover, under the Atatiirk’s leadership, in 1928, Turkey’ s first Constitution’ s related article which made Islam the state religion was amended, and in 1937, the principle of secularism was incorporated into the Constitution (Kazamias 1966, p. 185). Secularism does not mean the disestablishment of religion. It indicates change in general value-system of the society, changes in the patterns of authority, and a more rational or scientific approach to life (Kazamias 1966, pp. 265-66). Therefore, through many reforms, education became available not only to the elites but also to the masses. Language reform in particular was very important. By this reform, use of Arabic script was prohibited by the government in 1929. All history books were rewritten in Latin script. In 1923, the Ministry of Education took over the administration and control of all religious schools and their funds (Kazamias 1966, 210 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. p. 185). Moreover, the government took other steps such as the use of a replica of the Swiss code, starting in 1930, and the abolishment of the famous fez in 1925, to undermine the influence of religion in society (Kazamias 1966, pp. 185-86). One may think that Atatiirk’s reforms were implemented during the 1920s and 1930s, and therefore, were not important for this study. However, the effect of these reforms on society was very deep and important. Through these reforms, the influence of religion on education diminished. As a result, the authority of religious leaders or elders diminished, and the prestige of careers in the military and in religion decreased. Instead of religious or military positions, people started to prefer self-employment, technical or professional jobs. Moreover, people became more independent in their decision-making due to less influence from their elders, and they started to go to other towns or cities to continue their education. In other words, these reforms had a positive effect on the education of the masses in Turkey. Celal Bayar became the Prime Minister of Turkey in 1937. Bayar not only explained his education policies in detail, but also he was the first Turkish Prime Minister who mentioned the importance of the different educational needs of the country in his 1937 government program. He emphasized the importance of primary education. He also suggested the establishment of Ankara University in his 1937 government program. In his 1937 government program, Bayar stated that he did not want to see an army of tired and angry people with diplomas. By this, he did not mean that he would discourage university education. What he meant was that a country needs all kind of professions, i.e. craftsmen as well as engineers. 211 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Therefore, he suggested establishment of technical schools as well as high schools and universities. Moreover, in his program, Celal Bayar stated that his government will continue to send students to Europe’ s best science and arts centers, and bring experts from abroad to increase the expertise of Turkish people in their professions. As was explained before Dr. Refik Saydam and §iikru Saragoglu governments were in power during the WW II period. Therefore, their emphasis was on defense and solving economic problems related to the war. However, both of them accepted the importance of education in their government programs. Saragoglu, in his 1943 government program, mentioned that, in his government budget, the biggest in crease was given to education sector. He also mentioned that school attendance increased considerably during last ten years such that people attending primary schools increased from 525,000 to 970,000, people attending secondary schools in creased from 3,500 to 100,000, people attending high schools increased from 6,800 to 30,000, and people attending universities increased from 7,000 to 16,600. These numbers show that the improvement in school attendance, especially for secondary and high school, was very high in Turkey during this period. Recep Peker, who followed Saraqoglu as the Prime Minister, included detailed education policy in his 1946 government program. He was the first Prime Minister who mentioned the construction of Milli Kiitiiphane, meaning national library, in Ankara. In his government program, he also mentioned policies to increase the number of student dormitories, and to improve the number of teachers, and to 212 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. fasten the construction of schools in the villages by getting help from the villagers living there. During Hasan Saka governments and §emsettin Giinaltay government pro grams, there was no emphasis on education. These governments stated that they will follow previous party policies regarding these issues. 10.1.1.3 Other Policies Affecting Health During the One-party Period Until Celal Bayar, the policies on other health related issues, such as clean water, sewerage, transportation, and housing, were not discussed in government programs. Celal Bayar proposed policies to increase the number of clean water establishments and to improve hygienic situations of the meat processing estab lishments in his 1937 government program. The Prime Minister Recep Peker prioritized transportation issues in addition to defense and foreign affairs in his 1946 government program. Better transportation facilitated access to hospitals, and contributed indirectly to better health. Peker also stated in his government program that his government would cooperate with tiler Bankasi, a bank working together with the government and municipalities on especially infrastructure issues, to improve the availability of clean water establish ments and sewerage systems. 213 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 10.1.2 The Menderes Period: 1950-1960 After 1945, there was a multi-party system, and the largest two parties were CHP and DP. During the late-1940s, there was a big discussion about fraud in the elections. It was suggested by many people who supported DP that CHP used its long-lasting ruling party position to affect and even change the results of the elections. Celal Bayar, who was the Prime Minister of Turkey during the 1937-1938 period, became the President and Adnan Menderes became the Prime Minister of Turkey as a result of 1950 elections. Demokrat Parti was the ruling party, Celal Bayar was the President, and Adnan Menderes was the Prime Minister of Turkey for ten years, i.e. until the May 27, 1960 Military Coup. The Adnan Menderes governments made significant changes in public pol icy. During the CHP period, the governments followed statist policies, and were involved in almost all parts of the economy such as production, and banking. Menderes was the first Turkish Prime Minister who mentioned the importance of private sector, in addition to the public sector in his government programs. In his 1950 government program, Adnan Menderes stated that public manufacturing, public transportation, and public banking, had become a big burden for govern ment budget. Therefore, he suggested that the public sector needs to be limited to necessary subjects such as health, education, and infrastructure. 214 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Statist policy was an important part of CHP’s party program. However, Adnan Menderes stated in his 1950 government program that his government will do what governments need to do, i.e. work on infrastructure, health, and education issues, and will encourage the private sector on other issues. Menderes also mentioned that Kamu Iktisadi Te§ebbiisleri (KITs), meaning public economic enterprises, had become very costly, and therefore, needed to be privatized. His policy was de velopment with the private sector, ensuring that governments provide necessary infrastructure that is needed for development. Adnan Menderes stated in his 1954 government program that education, health, agriculture, and public works invest ments would be given their deserved priority during his governments. 10.1.2.1 Health Policies During the Menderes Period Adnan Menderes’ policies contributed significantly to the health of people in Turkey. He was the first Turkish Prime Minister who mentioned the importance of the establishment of portable hospitals and health centers in his government program in order to provide better access to health services, especially in the least developed regions and in rural areas. In addition, Menderes was the first Turk ish Prime Minister to prioritize preventive health services before curative health services. Menderes prioritized the least developed and rural areas in his health policies through the establishment of portable hospitals and health centers. In his 1951 government program, Menderes suggested that each person needed to have health insurance. He was the first Prime Minister in Turkey’s history to 215 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. set this goal in his government program. This is one of the goals that Turkish governments are still trying to achieve. In his 1954 government program, Adnan Menderes provides information about the health sector budgets, investments and its results. During the 1950-54 period, the Ministry of Health budget, in current prices, increased from 60 million Turkish Lira (TL) to 128 million TL. This was an almost 75 percent increase in the Ministry of Health budget in real prices (SPO 1997, p. 109). During the Menderes period, there was also significant improvement in the ratio of the Ministry of Health budget to the national budget. During the pre-1950 period, this ratio was 2-3 percent, but this ratio was 4.08, 5.18, and 8.97 percent for 1950, 1955 and 1960, respectively (SPO 1997, p. 109). After the May 27, 1960 Military Coup, this value was de creased again staying in between 4.21 and 2.54 percent with some ups and downs during the 1965-1990 period (SPO 1997, p. 109). In his 1951 government program, Adnan Menderes mentioned the importance of improving the number of beds in hospitals. As a result of the increase in the health budget, the number of beds in hospitals increased significantly. Menderes states in his 1954 government program that during the 1950-1954 period, the number of health centers in Turkey increased from 16 to 242, and the number of beds increased from 7,759 to 15,871. These values differ somewhat from those of HU (1993) and SPO (1997). According to Hacettepe University Institute of Population Studies (HU) and State Planning Organization (SPO), during the 1950-1960 period that Menderes was the Prime Minister of Turkey, the number of institutions providing 216 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. curative services almost doubled, from 301 to 566, and during the same period, the number of in-patient beds more than doubled, from 18,837 to 45,807 (HU 1993, p. 24 and SPO 1997, p. 155). Even though these values are different from each other, they can give an idea about how big the improvement in health services during the the Menderes period was. According to Menderes’ 1954 government program, during the 1950-1954 period, the number of tuberculosis hospitals and dispenseries increased from 7 to 84. The increase in the number of tuberculosis hospitals and dispenseries contributed to the decline in mortality from tuberculosis which was one of the diseases that dominated the trends in mortality during the 1960-1995 period. Based on these values, one can easily conclude that the Menderes governments prioritized the health sector. This situation should not be taken for granted since even though all Turkish governments accepted the importance of health sector, their priorities were very different as can be seen from their government programs and the amount and the share of the Ministry of Health budgets in total budget. 10.1.2.2 Education Policies During the Menderes Period In the education sector, Adnan. Menderes’ policies were as important as those in the health sector. In his 1950 government program, Menderes stated that new detailed education policy based on the latest scientific knowledge would be prepared and education would be a part of everyone’ s life in Turkey. 217 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Adnan Menderes continued to make new policies in education and health during his 1951 government program. He prioritized the least developed regions and the east region in educational reforms, and stated that the first university would be constructed in the eastern region. Moreover, he emphasized the importance of teacher quality in education in his 1951 government program. Adnan Menderes gave priority not only to the health sector, but also to the education sector in his governments’ budgets. During the 1950-54 period, the Ministry of Education budget, in current prices, increased from 197 million TL to 313 million TL, around 30 percent increase in real prices. Menderes concluded his 1954 government program by stating that, dining the next four years, in Turkey, there would be no village without drinking water, no subdistrict without electricity or scientifically appropriate water establishment, no provincial district without secondary school and health center or hospital, and no province without high school. This statement shows that his priorities as a government were better infrastructure, better education, and better health. 10.1.2.3 Other Policies Affecting Health During the Menderes Period Menderes concentrated on dealing with fundamental issues, such as health, education and infrastructure, instead of producing the things that the private sector could easily produce. In his 1950 program, Menderes prioritized infrastructure investments such as cheaper transportation options, i.e. roads instead of railroads, 218 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. which contributed to the mortality decline by facilitating access to hospitals and health centers. Menderes prioritized the construction of clean water establishments not only for urban areas, but also for villages. During the 1933-1945 period, the percentage of municipalities with scientifically clean water establishments increased from 5.8 to 8.4 (SPO 1983, p. 397). On the other hand, during the 1945-1962 period, in which Menderes was the Prime Minister of Turkey for ten years, the same value increased from 8.4 to 73.6 (SPO 1983, p. 397). Availability of cleaner water contributed positively to the mortality decline in Turkey during the study period, especially by affecting mortality from EODD. In his 1950 program, Menderes prioritized issues such as mechanization in agri culture to increase productivity. In addition, Menderes governments encouraged the amelioration of husbandry. Both mechanization and amelioration studies in agriculture not only contributed positively to the achievement of higher agricultural products, but also affected the health of people in Turkey through the improvement in the availability of food and clothing. 10.1.3 The Post-1960 M ilitary Coup Period: 1960-1980 After the May 27, 1960 Military Coup, full general Cemal Giirsel was the Pres ident and the Prime Minister of Turkey until November 20, 1961. His government is called Milli Birlik Hukumeti, meaning national unity government. On November 219 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 20, 1961, Ismet Inonii became the Prime Minister of Turkey, and Cemal Giirsel continued to be the President. 10.1.3.1 Health Policies During the Post-1960 Military Coup Period In 1960 Cemal Giirsel government program, there was no significant change in health polices. The 1961 Cemal Giirsel government did not prepare a program. Cemal Giirsel stated in his 1960 government program that he would continue to prioritize the less developed areas in health sector investments. He also proposed the establishment of Yiiksek ihtisas Hastahaneleri, meaning hospitals that have specialties in specific areas, for better treatment of different diseases. ismet Inonii followed Cemal Giirsel as the Prime Minister of Turkey. In his 1961 government program, inonii stated that his government would continue to encourage the establishment of the drugs industry and construction of hospitals as before. During the 1962 inonii government, the State Planning Organization (SPO) was established, and annual programs and five-year development plans for health and other sectors were prepared by the SPO officials and they were used in government policies. Inonii’ s policies for health sector in his government programs look like a continuation of those of Adnan Menderes’. Inonii, like Menderes, continued to prioritize the less and least developed regions in his health sector policies. 220 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Suad Hayri Urgiiplii became the Prime Minister of Turkey in 1965. There was not any significant change in health sector policies in Urgtiplii’s government program compared to earlier programs. Suleyman Demirel became the Prime Minister of Turkey on December 27,1965, and he was the Prime Minister until March 12,1970. Demirel’ s party, Adalet Partisi (AP), was a right-wing party. AP was established after the abolishment of DP by the 1960 Military Coup, and it was seen by many people as a continuation of Demokrat Parti (DP). Therefore, AP’s policies were very similar to those of DP’s. Like Adnan Menderes, Demirel governments also prioritized the least developed and rural areas, especially the eastern region and villages. Five-year development plans were prepared by the State Planning Organization (SPO) since 1963, to improve the level of development in Turkey. However, the least developed areas, especially the eastern region, was given higher priority after Demirel (See especially Demirel’s 1969 government program). Suleyman Demirel proposed policies to improve the health related issues in the eastern region, such as giving priority for hospital construction to provinces with fewer hospitals and in-patient beds, and monetary incentives for health personnel to encourage them to work in the eastern region. Demirel’ s health policies which were mentioned in his government programs included the following: health insurance, improvement in the level and quality of health personnel, better distribution of health personnel, better access of women to health services, and specific policies 221 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. aimed at better mother and child health in order to decrease infant and child deaths, such as developing mother-child health program. During the Prime Ministers Nihat Erim, Ferit Melen, Naim Talu, Biilent Ece- vit, and Prof. Dr. Sadi Irmak governments, all together that lasted around four years, there were no important policy change in health sector. They continued to work on previous health issues such as general health insurance, better distribution of health personnel nationwide, favoring the less developed regions to decrease re gional differences in development, and improvement in the level of health personnel. Demirel followed Biilent Ecevit as the Prime Minister. Demirel’s 1975 government was a coalition government, and there were no significant changes in health policy during this period, i.e. 1975-1977. 1977 Biilent Ecevit government continued to follow previous health policies. But, in his new government program, Ecevit started to give more emphasis on achieving a higher number of health personnel in Turkey. To achieve this goal, he suggested improving the education facilities of the faculties of medicine that were established in the eastern and southeastern regions of Turkey. However, the 1977 Ecevit government was in power only for a month. Therefore, there were no significant changes in health-related issues during this period. On July 21, 1977, Demirel became the Prime Minister of Turkey for the fifth time. He continued to follow the previous health policies, concentrating more on increasing the number of hospitals, and encouraging health personnel to work in 222 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. less developed regions. He also encouraged the drug industry to work on producing drug raw materials. In 1978, Ecevit became the Prime Minister of Turkey. The 1978 Ecevit govern ment concentrated on motherhood issues in addition to previous health policies. In his 1978 government program, Ecevit stated that his government will make new legal arrangements to support working mothers by acknowledging their mother hood responsibilities and increasing their rights as a mother through policies such as giving vacation time before and after the baby’s birth. In December 1979, Demirel became the 43rd Prime Minister of Turkey. Demirel was the Prime Minister of Turkey until the September 12, 1980 Military Coup. In his 1979 government program, Suleyman Demirel stated that the biggest problems of Turkey were high inflation rates, around 100 percent, and anarchy. Therefore, health and education policies were not given priority in the 1979 Demirel govern ment program. On the other hand, Demirel mentioned the negative effects of “Tam Giin Qali§ma Yasasi,” full-time working requirement for health personnel, by stat ing that, as a result of this requirement, the hospitals which did not have enough drugs before had also become the ones that also did not have enough doctors. This law required doctors to work full-time in hospitals, i.e. doctors were not able to work part-time in hospitals and work in their private offices afterwards. As a re sult of this law, many qualified doctors abandoned their jobs at hospitals, especially professors at university hospitals, and this situation resulted in the inadequacy of health personnel in many hospitals. 223 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 10.1.3.2 Education Policies During the Post-1960 Military Coup Period During Cemal Giirsel governments, there was no significant change in education policies. His education policies were the continuation of previous policies, and there were no specifics in his government program about his education policies. Inonii, in his 1961 government program, stated that the establishment of the Turkish Scientific and Technical Research Council (TUBiTAK) would be accel erated, and high level scientists and researchers would be trained according to a plan. In his 1962 government program, Inonii stated that the educational system of Turkey would be analyzed in detail and future education policies would be pre pared according to a plan prepared by the SPO. Establishment of the SPO is an important change in policy making, because through annual programs and five- year development plans, the future needs, educational or other, of the country can be analyzed, and policies can be prepared accordingly. Inonii continued to follow previous education policies that aimed at decreasing regional differences. Suad Hayri Urgiiplii became the Prime Minister of Turkey after inonii. Urgiiplii did not bring important new policy for education sector. In his 1965 government program, Urgiiplii stated that he supported the idea of equal opportunity for each citizen in pursuing their educational goals. After Urgiiplii, Siileyman Demirel became the Prime Minister of Turkey in 1965. Demirel’s first government lasted for more than four years. In his 1965 government program, Demirel proposed many policies to improve the level of education in the 224 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. eastern region, such as increasing the number of schools, including two universi ties, boarding schools, and specific schools for agriculture, husbandry and forestry. DemireFs education policies to improve the literacy level aimed at not only the eastern region, but also Turkey as a whole; they included education of adults, night-time education at some universities in addition to day-time education, im proving the number and quality of schools and teachers, and the use of mass media, especially radio and television for educational purposes. Demirel continued to im prove his education policies during his 1969 and 1970 governments that lasted until 1971. As in his 1965 government program, Demirel continued to prioritize the east ern region in his education policies in order to decrease the differences in the level of development among regions. Nihat Erim, who followed Demirel as the Prime Minister of Turkey, had im portant policies regarding to education. In his 1971 government program, Nihat Erim stated that his government would start “tek kitap duzeni,” meaning the same book system, for each primary and secondary school in order to achieve harmony in the quality of education. He also stated that some measures would be taken in order to provide inexpensive books for college and university students. In addi tion, there were many other policies including: the augmentation of the required basic education from 5 to 8 years in some areas as an experiment, use of television for educational purposes all around Turkey, including villages, encouragement of teaching as a profession, and incitement of scientific and technological research. The Erim governments lasted about 14 months. Many policies in Erim’ s programs, 225 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. such as increasing the required basic education from 5 to 8 years, could not have been put into practice during the time he was the Prime Minister. During the terms of Prime Ministers Ferit Melen and Naim Talu, there was not any new policy change in education sector. In his 1972 government program, Ferit Melen supported the importance of the use of mass media for educational purposes, and improvement in the number of teachers at each level of education. Naim Talu government’ s education policies were a continuation of the previous policies. On the other hand, the next Prime Minister Biilent Ecevit brought some im portant new policies regarding education. In his 1974 government program, Ecevit stated that his government would promote the education system based on inter national research, technological improvements, and observation, rather than mem orizing whatever the books or teachers say. Moreover, he stated in his 1974 gov ernment program that his government would increase the educational credits and scholarships for low-income families. Senior full professor Sadi Irmak became the Prime Minister of Turkey on Decem ber 17, 1974. He was the Prime Minister who stated the importance of “Mektupla Ogretim” in his 1974 government program, meaning university education through the television and the mail, to decrease the negative effects of teacher inadequacy. But, there is still the discussion about the quality of this kind of education. Irmak also mentioned in his program that the construction of new universities needed to be based on a plan. In addition, Sadi Irmak stated in his 1974 government program 226 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. that there would be university preparation courses in less developed regions to pre pare students for university entrance exams. This policy aimed at improving the chances of students in less developed areas for earning higher scores in university entrance exams. However, Sadi Irmak was the Prime Minister of Turkey for less than five months. Therefore, his education policies did not have significant effects on Turkish education system. Demirel became the Prime Minister of Turkey again in 1975. The 1975 Demirel government continued to follow previous policies regarding education. However, in his 1975 government program, Demirel proposed the use of the mass media, especially radio and television, for health education purposes. In his 1977 government program, Ecevit proposed a campaign, called “Okuma- Yazma Seferberligi,” meaning Reading-Writing Campaign, to improve the literacy level all around Turkey. This campaign started in 1981. Ecevit mentioned other policies in his government program to increase the student capacity at universities, and to encourage students to become research-oriented. Beginning from the 1977 Ecevit government through 1979 Demirel government (1977-1980), the anarchy that started around 1974 became a bigger problem in Turkey. The most significant obstacle related to education was personal safety and security in schools, especially in high schools and universities. There were extreme leftist, nationalist, and religious groups fighting with each other on and off campus every day. Therefore, many families did not want to send their children to school to keep them away from this anarchy. Even though both Ecevit and Demirel 227 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. prioritized education in their programs, their primary concern during the late 1970s was assuring security in the country in addition to solving economic problems. 10.1.3.3 Other Policies Affecting Health During the Post-1960 Military Coup Period After the 1960 Military Coup until 1961 Inonii government, there were not any important policy changes in other health related issues. Inonii was the first Prime Minister who mentioned the negative effects of industrialization, such as squatter housing. In his 1961 government program, Inonii mentioned that squatter housing had become an important problem in big cities as a result of industrialization and internal migration. Therefore, he stated that his government would work on problems of rapid urbanization, especially the problems of squatter housing areas. In his 1962 government program, Inonii emphasized the importance of urban planning, and he proposed low interest rate-housing credits for low income families to solve the squatter housing problem. During the 1963 inonii government (1963- 1965), the squatter housing problem in big cities escalated to higher levels, and therefore, the government gave monetary assistance to those who constructed their own houses in cities and villages. Moreover, the government controlled the increase in rents. These policies negatively affected the quality of the structures because many houses were built by owners themselves, who did not have expertise in the field of construction. 228 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Suad Hayri Urgiiplii, the next Prime Minister of Turkey, continued to work on other health-related issues. One effort was the establishment of Koy I§leri Bakanligi, the Ministry of Village Affairs. This ministry tried to achieve better coordination in issues related to villages, including water, electricity, and education, to increase their standard of living. The activities of this ministry contributed to the well-being of people living in rural areas. Demirel followed Urgiiplii as the next Prime Minister of Turkey. Demirel’s policies were not limited to health and education. He included many policies in his programs for the eastern region and other less developed areas such as roads for better transportation, water, sewerage and electricity for both health and de velopment, and encouragement of tourism for economic development. In order to encourage investments in the less and the least developed regions, special privi leged credits were given to investments in these areas. Especially in his 1969 and 1970 government programs, Suleyman Demirel stated what his government would be doing to improve the eastern region’s level of development step by step. Demirel’ s policies were not limited to the eastern region. His policies addressing better health for all Turkish people attempted to improve the road, water and sewerage problems of squatter housing areas and prevent the construction of new squatter houses through low interest-rate housing credits for the poor; he also proposed cheap land for houses, ready-to-use projects for better quality houses, policies for cleaner environment. Especially in his 1975,1977, and 1979 government programs, Demirel proposed many policies to address the air pollution and housing 229 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. problems resulting from rapid urbanization. He also mentioned the importance of urban planning in his 1979 government program. Demirel’s policies were not all new. Most of these policies were mentioned in Menderes’ government programs, and some other Prime Ministers’ programs. As explained before, privileges were given to the least developed areas during the ear lier governments, especially during the Adnan Menderes governments, to support their development. However, what was new with Demirel was that the policies for the eastern region’ s development were based on long-term development plans, and these policies were explained in detail in his government programs. Moreover, dur ing Demirel governments, the scope of the support widened through other policies such as privileged credits and special plans for the eastern region’s development. During the Nihat Erim governments, there were some new policies regarding the environment. First of all, resulting from rapid industrialization, there were some important air and water pollution problems in big cities. Nihat Erim was the first Prime Minister who mentioned air and water pollution problems in his government programs and stated that his government would work on these issues seriously. Ecevit brought some important policies regarding the environment and squatter housing areas. Ecevit also mentioned in his 1974 government program that his government would try to solve squatter housing problems of big cities either through nationalization of these houses or providing other houses for the residents of these squatter houses. Ecevit also brought up the policy of low interest rate credits and 230 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. “toplu konut,” a kind of multi-floor housing, credits for the low and middle income families. Other Prime Ministers such as Naim Talu, Ferit Melen, and Sadi Irmak did not have important other health-related policies during the Post-1960 Military Coup period. Their primary concern was not on the issues such as environment, housing, infrastructure. However, as was previously mentioned, they brought some other policies regarding to health and education. 10.1.4 The Open-market Economy Period: 1980-Today This period starts with the Military Coup of September 12,1980. In addition to political changes that happened after September 12,1980, there were also economic changes such that January 24, 1980 is the starting point of open-market economy in Turkey. The fourth period continues until today. After the 1980 Military Coup, the primary purpose of the government was to establish peace and security, and to prevent anarchy in Turkey. Full general Kenan Evren became the President of Turkey, and he entrusted Biilend Ulusu as the Prime Minister. In the meantime, previous political parties were abolished, and some of their leaders’ active participation in political life was not permitted. Ulusu was the Prime Minister of Turkey for more than three years until the 1983 elections. As a result of the 1983 election, the president of the Anavatan Partisi (ANAP), meaning motherland party, Turgut Ozal, became the Prime Minister of Turkey. Anavatan Partisi, which was also a right-wing party, supported many policies that 231 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Menderes and Demirel governments had supported before him, such as the im portance of the private sector in the economy, and the limitation of government investments to infrastructure and public work areas. However, what differentiated Ozal from other right-wing parties was his open-market policies. Before 1980, there was substantial limitation on imports. Through the January 24, 1980 regulations, called “24 Ocak Kararlari,” the Turkish economy was opened to foreigners. Ozal not only decreased the restrictions on imports, but also gave many incentives to in crease exports and foreign investments. His open-market policy is still followed by other governments of Turkey regardless of whether they are left-wing or right-wing governments. Turgut Ozal was the Prime Minister of Turkey until November 9, 1989. On November 9, 1989, Ozal was elected as the President of Turkey. Anavatan Par tisi was the ruling party until November 20, 1991. During the 1989-1991 period, Yildirim Akbulut (November 9, 1989-June 23, 1991), and Mesut Yilmaz (June 23, 1991-November 20, 1991) were the Prime Ministers of Turkey. On November 20, 1991, Suleyman Demirel became the new Prime Minister of Turkey. Demirel was no longer deprived of politics, and he was the leader of Dogru Yol Partisi (DYP), meaning the right way party. Demirel was the Prime Minister of Turkey until June 23, 1993, the day that he became the President of Turkey. Demirel was the President of Turkey until May 2000, and during Demirel’ s presidency, almost all of the governments were coalition governments consisting of left and right-wing parties. 232 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. 10.1.4.1 Health Policies During the Open-market Economy Period In his 1980 government program, Ulusu stated that he would continue to sup port “Tam Gun Qah§ma Yasasi,” i.e. the law requiring full-time status for health personnel. Ulusu also mentioned other policies to provide better health services to less developed regions. In addition, there were other policies prepared to achieve better family planning. Ozal had significant contribution to Turkey’ s health sector. In his 1983 govern ment program, Ozal emphasized the importance of check-ups for expecting moth ers. He also prioritized the importance of better distribution of health personnel around Turkey. Ozal, instead of specifying service requirements for health person nel in less developed regions, gave special incentives such as higher salary and free housing to health personnel to encourage them to go to the less developed areas. Moreover, in his 1983 government program, Ozal proposed other policies such as tax exemption for health insurance premiums, and policies to increase the number of health centers and establishment of private hospitals. In addition, during the Ozal’s term, there was better cooperation with international organizations, espe cially with UNICEF, to decrease mortality from specific diseases such as diarrhoea and pneumonia. Control of Acute Respiratory Infections (CAR!) campaign and the National Control of Diarrhoeal Diseases Program, were implemented in 1986 during the 1983 Ozal government. 233 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Yildirun Akbulut and Mesut Yilmaz followed Ozal’ s health policies. In addi tion to the previous policies, Akbulut encouraged the practice of having a family physician to have better prevention from diseases, and to avoid waiting in hospi tals. Yilmaz also followed previous health policies. His priorities were education and environment issues, which also contributed to the health of people. Demirel, the next Prime Minister of Turkey, stated in his 1991 government pro gram that his government would emphasize the development of preventive health services instead of curative ones. His government concentrated on issues such as health education and encouragement of having a family physician to prevent the patient lines in hospitals that give curative services. When Demirel became the President of Turkey in 1993, Tansu Qiller became the Prime Minister of Turkey. She continued to support policies for better health through continuing “green card” program for the poor, i.e. free health services to the people who have “green card.” Qiller continued to support previous health policies, such as the emphasis on health insurance, and the establishment of regional hospitals to prevent patient lines in the big city hospitals. 10.1.4.2 Education Policies During the Open-market Economy Period During 1980 Ulusu government, the main education policy was reassuring peace and security at schools for better education and attendance. In order to achieve this goal, a security checkpoint screened students for weapons before entering into 234 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. schools. Moreover, Ulusu government tried to prevent teachers from becoming propagandist for any political group. In addition, in schools, Ataturk’ s principles were emphasized to prevent students from becoming a part of extreme leftist or rightist groups. Moreover, in order to improve the general literacy level, especially for the people who are not at school age and illiterate or the elders who knew only the old alpha bet, the Turkish government started the “Okuma-Yazma Seferberligi,” meaning the Reading-Writing Campaign, in 1981. In this campaign, many adults volun teered, and the television was used to support this campaign in addition to night reading-writing classes. This campaign gave illiterate people the chance to learn how to read and write free of charge from teachers, volunteers, and the mass media, especially television. This campaign had a significant effect on the improvement in the literacy rate (TR-UNICEF 1991, p. 201). As can be seen in Table 3.11, during the 1975-80 period, the percent of the population aged six and over and literate increased from 63.62 to 67.45. However, during the 1980-85 period, percent of pop ulation aged six and over and literate increased from 67.45 to 77.29. The rate of increase in the literacy rate was significantly higher after 1981 compared to earlier periods. This campaign contributed positively to both male and female literacy, but especially female literacy such that during the 1980-85 period, the percent of the female population aged six and over and literate increased from 54.65 to 68.02 whereas the increase for males was from 79.94 to 86.35 (SIS 1993, p. 13). 235 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Ozal continued to follow previous education policies. However, he gave more emphasis on foreign languages. He stated in his 1983 government program that each student attending secondary or higher education must learn at least one foreign language. This policy is in accord with his idea of opening up the Turkish economy. Ozal was aware of the need for learning foreign languages, especially English, in order to be a part of not only the European Union but also developed world. In his 1987 government program, Ozal stated that during his 1983 government term, the bed capacity in student dormitories had been doubled, giving better college or university education opportunity for people coming from less developed regions. Yildirim Akbulut and Mesut Yilmaz followed Ozal’ s education policies. In ad dition to previous policies, Akbulut suggested, in his 1989 government program, the encouragement of the pleasure and habit of reading and improvement of the library facilities all around Turkey. Mesut Yilmaz stated in his 1991 government program that his government would start the necessary preparations to make ed ucation, health, and housing expenses exempt from taxation. Yilmaz also put higher schooling goals for each level of education, including preschool, in his 1991 government program. He also stated that primary education would be increased to 8 years by 2000. Yilmaz proposed the use of one of the television channels only for educational purposes, and better use of technological improvements, such as the computer, video and the television, for educational purposes. In addition, Yilmaz stated in his program that the new “Education Master Plan” would be prepared, 236 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. and there would be a campaign for university and higher education. Yilmaz’ s poli cies to encourage private companies to become involved in establishing universities is also another important step in Turkey’s education since many people and com panies benefited from these incentives and they were capable of establishing good quality private universities. Demirel, the next Prime Minister, supported the education system through con tinuing free education and encouraging the research-oriented education. However, there were no significant changes in education policies during the 1991 Demirel government program. Tansu (filler was the next Prime Minister of Turkey. She emphasized the need for better education of women in her program. She mentioned the importance of labor force participation for women, especially in non-agricultural sectors. She also encouraged private sector investments in education sector through lower taxation rates, and low interest rate credits. 10.1.4.3 Other Policies Affecting Health During the Open-market Economy Period Biilend Ulusu continued to support other health related policies such as the improvement of squatter housing areas, and “toplu konut,” a kind of multi-floor housing, in order to achieve better housing facilities for the low and middle income families, and other policies to solve environmental problems. 237 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Turgut Ozal’s policies related to decreasing the level of development differences among regions were very important. Less developed and least developed regions were grouped as “Kalkmmada Birinci Derecede Oncelikli Yoreler (KOY1)” and “Kalkinmada Ikinci Derecede Oncelikli Yoreler (KOY2),” meaning first and sec ond degree prioritized areas for development, respectively. Ozal prioritized less developed regions through many policies such as long term and low interest rate credits and lower tax rates for the investments in these areas, free housing, called lojman, for the people working in these areas, and giving a part of the investment costs as a donation by government. Turgut Ozal was not the first Prime Minister who proposed policies to support the less developed regions. As was previously discussed, before Ozal, starting with Menderes, many Prime Ministers supported less developed regions, especially the eastern and the southeastern regions, through many policies. What is new with Ozal was the increase in the incentives given by the government to improve the level of development in these areas. Moreover, pre vious government incentives were mainly limited to the eastern and southeastern regions of Turkey, but Ozal’ s KOY1 and KOY2 provinces covered not only the east ern and the southeastern provinces, but also other less developed provinces around Turkey. Moreover, Ozal’s cooperation with international organizations, such as the WHO and UNICEF, were also very important in dealing with health related issues. In addition to Ozal’s policies to improve the level of development in less devel oped regions, he also stated new policies in his 1983 government program to solve the problems related to rapid urbanization. Ozal wanted to improve the living 238 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. standards in middle-size cities to prevent problems of big cities become impossible to deal with. He also suggested improving free housing facilities for government officials. Ozal also stated in his 1983 government program that his government would work on drinking water and sewerage problems of big cities. Moreover, he brought up minimum quality requirements for coal and fuel oil, and proposed tran sitioning to central heating system and heating with natural gas to prevent air pollution in big cities. In addition, Ozal’s governments brought up new require ments for industrial firms for industrial waste purification. His policies to clean up densely polluted areas such as Halig, izmit and Izmir bays, and Marmara Sea, are all evidence of Ozal’s sensitivity to the environment. Yildinm Akbulut and Mesut Yilmaz followed Ozal in other health related issues. In addition to previous policies, Yilmaz suggested in his 1991 government program that low interest rate credits will be given to firms to establish their purification facilities, and his government would cooperate with international organizations to solve environmental problems. He also stated in his program that the establishment of children environment clubs would help to solve future environment problems by explaining the importance of environmental protection to future generations. Siileyman Demirel became the Prime Minister of Turkey, and proposed new policies in his 1991 government program to decrease the level of development gap between regions. These policies include, but are not limited to, regional develop ment plans for eastern and southeastern regions. 239 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. The next Prime Minister of Turkey, Tansu (filler mentioned the preparation of “Aksiyon Plam,” meaning action plan, in her 1993 government program for the improvement of the level of development in the eastern and southeastern regions, (filler also suggested other incentives to encourage investment in these areas. Both Demirel and Qiller supported the development of less developed areas by favoring these areas in their government programs. Most likely, (filler’s the best contribution to health related policies is her envi ronment related policies. Qiller brought new tax requirements to solve the garbage problems of the big cities. Mesut Yilmaz became the Prime Minister of Turkey again in March 1996. Yilmaz, and other Prime Ministers after him, Necmettin Erbakan and Biilent Ece vit, continued to support the health sector through their similar policies. However, since their policies were effective after the study period, i.e. 1960-1995, they will not be analyzed in detail. In conclusion, public policy initiatives based on the improvement in medi cal/technological knowledge were very important for the decline in mortality during the study period. For the diseases that dominated the mortality trend during the 1960-1995 period, i.e. pneumonia, EODD, PCIODI, and tuberculosis, the effect of medical/technological improvements were very important. For example, the med ical/technological improvements were important for the decrease in pneumonia- related deaths. During the CARI campaign, penicillin flacons and cotrimoxazole tablets are sent to health centers and Mother and Child Health and Family Planning 240 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Centers by government. The use of antibiotics was an important factor affecting the trends in mortality from pneumonia. Another medical improvement that af fected mortality from pneumonia was the use of vaccines for measles and whooping cough. As mentioned in chapter 6, ARIs decreased as a result of increasing immu nization rates for measles and whooping cough, along with improvements in the health infrastructure. In fighting against EODD, medical/technological improvements were also found to be important. For example, the new knowledge about the importance of breast feeding, antidiarrhoeal medicines, pasteurization and sterilization of milk, all helped the fight against EODD. However, public policy initiatives such as “National Con trol of Diarrhoeal Diseases” campaign, prohibition of free-distribution of formula, and regulations to solve water pollution problems, were needed to put the better medical/technological knowledge into practice. Regarding mortality from PCIODI, medical/technological improvements were also found to be important. Pregnant women were observed by health personnel during pregnancy by the help of equipment such as ultrasonography, which in turn helps to discover some possible risks in advance. Medical improvements also showed the importance of having fewer children, having longer birth intervals, and the importance of having children at ages not too young or too old. Among the four diseases that dominated mortality trends in Turkey during the study period, improvements in medical/technological knowledge contributed the most to the decline in mortality from tuberculosis. Use of X-rays for early detection, 241 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. use of BCG vacination for prevention, sanatoriums, surgery, chemotherapy, and new drugs for treatment are some examples of medical/technological advancement that affected deaths from tuberculosis. In the treatment of tuberculosis, some new drugs played an important role. The discovery of PAS (para-amino-salicylic acid) by the Sweden Jergen Lehmann and the discovery of streptomycin by the American Selman Waksman in 1944 were of historical importance. Moreover, in 1952, a third drug INH (izoniazid) was discovered. The discovery of rifampicin, which not only limits the growth of the bacillus, but also kills it, was quite important discovery. As a result of the combined effects of different drugs that attack the disease in different ways, the emergence of bacterial resistance could be avoided. In addition to the treatment in sanatoriums, surgery, and chemotherapy, a wide range of preventive measures such as vaccination, and early detection by use of X-rays were applied. The use of BCG vaccine was an important step in fighting against tuberculosis in Turkey. Medical/technological improvements were important for public policies. The information about the timing of the use of the new knowledge previously mentioned is limited. From personal interviews conducted with doctors and pharmacists, it can be said that the t iming of the use of new knowledge differed. In Turkey, there is no official handbook for use in fighting against different diseases. During 1960s, there was very few, one or two, microbiology books that were written in Turkish. Therefore, most of the information given to medical students by their instructors. The quality of the information was dependent on the professors’ knowledge of 242 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. foreign language. During the 1950s and 1960s, the main foreign language thought in schools was French. After the 1970s, English became more important. However, the foreign languages that are taught in most of the schools were not enough to follow up foreign scientific literature. Therefore, the professors who were educated abroad or understood foreign literature could better inform their students about scientific developments. In other words, the availability of the new knowledge was not the same in everywhere. Due to the limitations on the data about the development of scientific knowledge in Turkey, it will only be mentioned that the government policies were based on the new knowledge, but it was not uniformly available for the health personnel. In some areas, the government had to intervene through their programs and policies in order to achieve better distribution of the new knowledge. Government policies were needed to put the new medical/technological knowledge into practice. Therefore, it can be said that, public policy initiatives based on advancement of medical/technological knowledge, were essential in the mortality decline in Turkey during the 1960-1995 period. 10.2 Importance of Economic Factors in the Mortality Decline MEG did not bring better housing or better nutrition for everyone in Turkey. As a result of rapid industrialization, squatter housing around big cities became a big 243 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. problem. These houses were built in a very short time and with very low quality materials (TR-UNICEF 1996, p. 281). Moreover, squatter houses are made by people who are not experts on construction. In planned areas of Ankara, 99 percent of the houses have connection to sewerage system, whereas this value was 60 percent for unplanned squatter houses. However, in Ankara, many of planned houses’ wastes or their sewerage connections are still directly connected to open streams. On the other hand, around 40 percent of the squatter houses are using fosseptic pits. Even for squatter houses with sewerage connections, there was another problem due to low quality connections to sewerage system. Most of the pipes that connect squatter houses to sewerage system are laid down by the residents themselves. In other words, the job was not done by the experts on that area. As a result, the pipes are plugged or overflow often, and upkeeping of these connections became almost impossible (TR-UNICEF 1996, p. 281). About 90 percent of the municipalities have scientifically appropriate drink ing water establishments. However, due to rapid urbanization, big cities such as Istanbul, Izmir and Ankara still have important drinking water problem. As a result, some restrictions are put on the use of water in these big cities: for exam ple water is provided to residents of these cities only on specific days of the week. Therefore, people have to stock water in bath tubs or buckets, to use on the days in which water is not provided. In these big cities, low-cost subterranean water re sources are exhausted quickly, and as a result, high-cost water resources are used. In addition, water resources such as rivers and streams are under the threat of 244 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. becoming dirty through house and industrial wastes. Moreover, since the squatter houses around the big cities are constructed close to water basins, the wastes from these houses negatively affect the quality of drinking water (TR-UNICEF 1996, pp. 280-281). As a result of the uncertain quality of water, bottled water distribution (which is very expensive) or distribution through water station (which is less ex pensive than the bottled water) is becoming more prevalent in big, industrialized cities. As previously mentioned, the Turkish government and municipalities had to intervene to solve or decrease the negative effects of industrialization through their policies, such as cleaning industrial and other kinds of waste, and mandating air quality requirements in big cities. Industrialization does not necessarily mean better nutrition. In Turkey, under nourishment is not a significant problem. It is a problem in some regions, especially in eastern region, more than others, but there is no report showing that the level changed for better nutrition during the 1960-1995 period. On the other hand, there is evidence showing that nutritional intake decreased during the 1960-1980 period, in which most of the mortality decline was achieved. To sum up, the decrease in mortality in Turkey was not due to the improve ments in nutrition resulting from better income but due to public policies based on advancement in medical/technological knowledge. Especially Menderes gov ernments were very effective in putting their health-related policies into practice. Here, the contribution of other governments that were previously discussed are not 245 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. ignored. However, Menderes government was the one that was able to put them into practice and start MEG and MR because they were the ones who limited the government’s role in the economy to infrastructure, health and education, and left the other investments to the private sector. Moreover, their policies favoring less developed regions contributed positively to the mortality decline in these areas. As a result, not only are less developed regions in a better position compared to more developed regions regarding mortality, but they also had a greater rate of decline in mortality during the study period. There was another MR after 1980, during the 1980-1985 period mainly due to campaigns to fight against pneumonia and EODD, and policies supporting safe motherhood and breastfeeding. In this period, Ozal governments played an im portant role through their cooperation with international organizations to achieve success in their health related policies. These policies required greater financial resources, but government policies were needed to achieve this kind of nationwide success in mortality decline. In conclu sion, public policies based on better medical/technological knowledge were the driving source of mortality decline in Turkey during the 1960-1995 period. 246 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. CHAPTER 11 CONCLUSION Economic well-being is neither necessary nor sufficient in improving life ex pectancy. There are many cases of improved life expectancy in the absence of marked economic growth. In Costa Rica, despite economic crises and stagnation, life expectancy increased from 35 to 56 years during the 1920-1950 period. This im provement in life expectancy was due to a sizable public health program (Mata and Rosero 1988, pp. 38, 57, 143). In Korea (Kimura 1993), Britsh Guiana (Mandle 1970 and 1973), Sri Lanka (Meegama 1981), Cuba (Diaz-Briquets 1977, 1981 and 1983), and Taiwan (Barclay 1954) life expectancy improved significantly prior to 1940 despite declining living standards. In parts of Sub-Saharan Africa, mortality revolution has been occurring after the Second World War (WW II) despite falling real per capita income (Sen 1994). In Turkey, the decline in mortality was continuous during the study period (1960-1995) in spite of the economic ups and downs. Moreover, for the diseases that dominated mortality trends in Turkey during the 1960-1995 period, i.e. pneumonia, 247 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. enteritis and other diarrhoeal diseases, pregnancy, childbirth, infections of newborn and other diseases peculiar to early infancy, and tuberculosis, the less and least developed regions have similar and sometimes even lower death rates compared to more developed regions. In addition, for all causes, the very developed region has higher death rates than the least developed region throughout the study period, even though the very developed region has significantly higher GDP per capita than the least developed region. Moreover, the rate of mortality decline during the 1960-1995 period was the lowest for the very developed region and the highest for the least developed region, 56 and 71 percent, respectively. This happened without any economic catch-up. In Turkey, the positive effects of economic growth via improved living standards were substantially offset by growing exposure to disease, and the inadequacy of water and sewerage system. Infant mortality rates in rural areas are expected to be higher than those in urban areas and infant mortality rates in developed cities are expected to be lower than those in less developed cities. However, in Turkey, as a result of rapid urbanization, infant mortality in very developed cities such as Istanbul, Ankara, and Izmir, became higher than in many less developed cities such as Isparta and Trabzon (TR-UNICEF 1991, p. 369). Therefore, industrialization can improve economic well-being of people, but it does not necessarily mean lower mortality. These examples suggest that in Turkey, improvement in life expectancy was not largely a function of modem economic growth. 248 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. However, substantial improvement in life expectancy was achieved through pub lic policy initiatives. These initiatives include but are not limited to education, advancement of medical/technological knowledge, and public health programs and regulations. One of the most important factors that affected life expectancy was the improvement in the education level in general. After the Second World War (WW II), education gained priority in government policies because it was a pre-condition for new targets, i.e. rapid industrialization and democratization of political system. As a result, education was given the first priority in government policies. Giving high priority to education was accepted, not only by policymakers but also by the general public. To meet the people’ s aspirations for better education, the governments since 1950 have tried to improve educational system in Turkey (HU 1993, p. 119). In 1935, only 10 percent of females and 29 percent of males were literate in Turkey. According to the 1990 census, these figures were 72 and 89 percent respec tively, for the population age 6 and over. During the 1960-1990 period, the literacy ratio for the male population 6 years old and over increased from 54 to 89 percent. The same ratio for the female population 6 years old and over increased from 25 to 72 percent. Not only did the literacy rates for male and female population increase, but the gap between male and female literacy decreased considerably as well during the same period (SIS 1998, p. 83). In addition to general education policies, the Reading-Writing Campaign which was launched by the Turkish government in 1981 had positive effect on literacy 249 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. level. During the 1975-80 period, the literacy rate increased from 76 to 80 percent and from 50 to 55 percent for males and females, respectively. On the other hand, after the launching of Reading-Writing Campaign in 1981, the rate of increase in literacy rate grew considerably, reaching 86 and 68 by 1985 for males and females, respectively (SIS 1998, p. 83). As can be seen from these results, the Reading- Writing Campaign had an important role, especially in improving female literacy. Higher literacy had a positive effect on life expectancy because in Turkey, a negative correlation has been found between the education level of mothers and the causes of deaths which dominated mortality trends during the 1960-1995 period. The Turkish government cooperated with international organizations, especially the UNICEF and the WHO, in implementing its policies. International organiza tions alone could not have similar success without the sunport and leadership of Turkish government. Due to previous unpleasant experience with foreign countries, when a policy comes through a foreign country or an international organization, the public generally questions the intentions and looks for other motives, such as whether there is a surplus product that foreign countries want to sell to Turkey, or low quality product will come to Turkey through the companies or organizations of foreigners, or whether foreign countries want to impose their values on Turkish society. Therefore, leadership of the government was essential. The argument that the mortality decline in Turkey was based on economic development and better nutrition is not valid because during the 1960-1995 period there are no reliable data showing the improvement in nutritional intake of people 250 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. in Turkey. Moreover, if income were the only explanation, one cannot explain the situation that women experienced a greater improvement in mortality decline relative to men. In 1960, there was only 0.16 difference between men and women crude death rates for all causes, and men were in the better situation. But in 1995, there was a 0.72 difference between men and women crude death rates, and women were in the better situation (SIS Death Statistics related years). Why did women do better compared to men even though men had better access to financial resources? There are other factors involved. For the all causes of death that dominated the mortality trends during 1960-1995, except tuberculosis, women had a higher death rate compared to men in 1960. However, by 1995, women had the same or lower death rate compared to men for all these diseases. In 1960, 46 percent of the deaths involved infant and child mortality. But, in 1995, only 14 percent of the deaths were infant and child mortality-related (SIS Death Statistics related years). If the decrease in the death rate during the 1960- 1995 period was mainly due to better nutrition resulting from better income, then it is difficult to explain why all age groups did not show similar patterns of mortality. For example, during the 1960-1995 period, the death rate for all causes decreased from 10.92 to 4.42 per 1,000 population. There was a decrease in death rates for almost all age groups, except for 65-74 and 75+ age groups. The death rate increased from 36.52 to 37.42, and from 110.97 to 126.68, for 65-74 and 75+ age groups, respectively (SIS Death Statistics related years). 251 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. In addition, the decrease in death rates were very different for different diseases. For example, the decrease in the death rate was 96 percent for pneumonia, and 98 percent for enteritis and other diarrhoeal diseases during the 1960-1995 period, whereas the decrease in the death rate for heart diseases during the same period was only 5 percent (SIS Death Statistics related years). If the improvement in income and better nutrition were the drivers behind the mortality decline, then one cannot explain explained the differences in the rate of mortality decline for dif ferent causes of death. It was because the improvement in medical/technological knowledge for some diseases was not as advanced as it was for others. In addition, public authorities were involved in many programs to fight against pneumonia, en teritis and other diarrhoeal diseases, pregnancy, childbirth, infections of newborn and other diseases peculiar to early infancy, and tuberculosis. Moreover, the im provements in mothers’ education level made it easier to put the new knowledge into practice. For example, better educated mothers are more likely to have fewer children, practice more than a two-year birth interval, possess better knowledge to deal with diseases, and as a result, they axe more likely to have lower mortality. The combination of better medical/technological knowledge, public programs to put new knowledge into practice, and better educated people to understand the importance of the new knowledge made longer life possible in Turkey. It is true that both MEG and MR in Turkey happened at the same time, around 1950, but this situation does not mean that MEG was the driving source of mor tality decline in Turkey. Instead, governments, especially Menderes governments, 252 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. were very effective in putting their health-related policies into practice. Here, the contribution of other governments that was previously discussed are not ignored. The health related policies of Menderes governments were not all new. However, Menderes governments were the ones that were able to put them into practice and start MEG and MR because they were the ones who limited the government’ s role in the economy to infrastructure, health and education, and left the other invest ments to the private sector. Moreover, their policies favoring less developed regions contributed positively to the mortality decline in these areas. As a result of these policies favoring the less developed regions, even though there is significant eco nomic differences between regions, less developed regions are in a better position compared to more developed regions regarding mortality. Moreover, not only are less developed regions in a better position compared to more developed regions, but they also had a greater rate of decline in mortality during the study period. There fore, it can be said that Celal Bayar, the President of Turkey during the Menderes Period (1950-1960), Adnan Menderes, the Prime Minister of Turkey during the 1950-1960 period, and his governments can be viewed as the “architects” of mod ern Turkey. Menderes and two of the ministers in his government, Fatin Rii§tii Zorlu and Hasan Polatkan, were executed after the 1960 Military Coup. Celal Bayar was not executed because of his old age. In conclusion, the results of this study show that the mortality decline in Turkey during the 1960-1995 period was mainly based on education and advancement in medical/technological knowledge, and the Turkish government was the primary 253 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. agent putting the new knowledge into practice through its wide-ranging policies. Economic development may be important for the least developed regions of the world. 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Creator Kanoglu, Nese (author)

Core Title Trends in mortality in Turkey, 1960--1995

Degree Doctor of Philosophy

Degree Program Political Economy and Public Policy

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Economics, General,health sciences, public health,OAI-PMH Harvest,Political Science, public administration,sociology, demography

Language English

Contributor Digitized by ProQuest (provenance)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c16-127455

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Rights Kanoglu, Nese

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