COVID-19 Outbreak and Turkey

Dear Editor,

According to the World Health Organization’s report dated April 24, 2020, Turkey is in 6th place in the European region in terms of COVID-19 disease, after Spain, Italy, Germany, the United Kingdom, and France. Data indicate that there were 101.790 confirmed cases in Turkey as of April 24, 2020, and that 2.491 people lost their lives because of COVID-19 [1]. The fact that there are fewer deaths than in other nations is gratifying for all of us. In my opinion, the basis of this success lies in the fact that the population of Turkey is young compared with that of continental Europe as well as the selfless efforts of the health workers.

However, in the research conducted by the professional and scientific association of Turkey’s thoracic diseases specialists, the Turkish Thoracic Society, deaths in Istanbul and Trabzon have been shown to increase significantly in 2020 [2]. The research uses publicly available death data. According to the said research, when the deaths between 2016 and 2020 are analyzed, a 10% weekly increase in the number of deaths in Istanbul was observed, especially since the 10th week of 2020, and the total number of weekly burials reached to 2.222 between April 6 and 12, 2020. This number is 1.425 for 2019, 1.460 for 2018, 1.464 for 2017, and 1.389 for 2016. However, the Ministry of Health of the Republic of Turkey reported the number of deaths due to COVID-19 as 624 in all of Turkey for the same week, whereas there were approximately 800 deaths in Istanbul alone in the same week. A similar situation has also been observed in Trabzon since the end of February.

This research of the Turkish Thoracic Society is based on general death data available to the public. Apart from a limited explanation, the data on COVID-19 are entirely within the jurisdiction of the Ministry of Health, and the data in question were not shared with the relevant medical associations and the Turkish Medical Association, which is the professional organization of physicians. For this reason, it is not possible to make an accurate analysis about COVID-19-related deaths in this “twilight” environment. Nevertheless, it is still possible to make some predictions:

1. The deaths due to COVID-19 include only PCR positive cases in many countries as well as in Turkey. Hence, the number of tests performed and the sensitivity of the tests directly determine the diagnosis and mortality rate related to the disease. However, despite public demand, the Ministry of Health of the Republic of Turkey does not explain the repeated test rates and the sensitivity of the tests used for the same patient. Therefore, the number of different people that are tested on a daily basis and the percentage of positive cases detected per test are not known. However, in daily practice, the rate of detection of positivity in tests varies between 30% and 50%. If this sensitivity rate is taken into account, 50% of the patients diagnosed and treated with COVID-19 at best are not included in the official statistics. This difference is the most important reason for the mismatch between the real level of mortality rates and the official figures.

2. In addition, there is another cause for this problem specific to Turkey: the shortage of tests. Turkey made little, if any, number of tests especially in the first phase of the pandemic. For example, the total number of tests conducted in Turkey was 940 on March 10, 2020, when the first case of COVID-19 in Turkey was announced [3]. Similarly, the number of tests conducted was 4.002 on March 17, 2020, when the first death from COVID-19 was announced [3]. These numbers are extremely low, considering Turkey’s 80 million population. Unfortunately, Turkey exceeded 30.000 tests per day only on April 10, 2020 [3]. When we consider the number of daily tests conducted in Germany whose population is similar to Turkey, we can better understand how lesser testing is done. Undoubtedly, lesser testing means underdiagnosing COVID-19 patients, which also means fewer number of COVID-19 deaths.

On the contrary, the government of the Republic of Turkey created the Scientific Committee for the COVID-19 outbreak much earlier than many other countries’ governments. Similarly, they brought their citizens living in China back to Turkey and quarantined them when the outbreak was only confined to there. Again, with a very appropriate application, they made various transportation restrictions, especially in flights.

However, the government’s strategy was poor on three issues. The first and the most important issue is the Turkish government’s inability to work with non-governmental civil organizations because of its inadequate democratic culture. We feel that the government has prioritized political success instead of preventing the epidemic and protecting public health. For this reason, specialist medical associations couldn’t coordinate adequately even with the Turkish Medical Association and Turkish Pharmacists Association during the pandemic. The government did not reveal the data of COVID-19 disease to the public and the related medical-scientific units. They did not allow for a healthy analysis of the data other than their own and to shape recommendations according to these analyses. In fact, in Istanbul, the city where the pandemic was the most intense, they banned some applications of the metropolitan municipality, which could have reduced the effects of the pandemic. Even in practices such as curfew, they did not carry out joint activities with the municipalities [4]. Undoubtedly, this authoritarian style exhibited led to the fact that some measures were late and some were never taken, as well as the people’s unawareness about the real extent of the pandemic. It reduced the competence of the measures taken.

The second mistake of the government is considering the outbreak as a “curable” disease. Because of this perspective, they chose almost all members of the science committee from infection and thoracic diseases specialists. Only recently, public health experts, who know how to suppress and control outbreaks, have been brought into the scientific committee. In the first 30 days of the pandemic, contact tracing was almost never implemented, and this deficiency led to the rapid spread of the disease, especially in the busy and bustling city of Istanbul.

The third mistake of the government is that they chose to calm the outbreak down rather than suppress it, because of the economic effects. For that reason, they allowed shopping centers to remain open for a long time, while restricting many other areas across the country. In addition, although it does not have a life-threatening risk of the disease, they prohibited people under the age of 20 from going out on the streets, whereas they did not put any restrictions for the age group of 20–60 years. In other words, “herd immunity” was applied to people of the working age, between 20 and 60 years old. In addition, because of the government’s conservative nature, restrictions on Friday prayers were imposed very late. For the same reason, Turkish citizens who returned from Saudi Arabia from religious worship were not quarantined, which led to both people getting sick and transferring the disease to the community.

However, although they were not successful in controlling the spread of the pandemic and contact tracing (especially in İstanbul), they followed a successful policy on the treatment of patients. They enabled the use of drugs in the early period. They prevented problems related to the access of the medicine. Similarly, with proper implementation, public and private hospitals have become a part of the fight against the COVID-19 outbreak. Again, they developed a correct attitude and took the treatment of the disease under public guarantee.

Finally, the government does not relay any information to the public and/or to the professional organizations of health professionals about the illness of the healthcare professionals and the fate of their illnesses. For this reason, it is not known how many of the healthcare professionals are sick and how many have died. However, according to the data gathered by the professional organization of physicians, the Turkish Medical Association, at least 1.307 of them being physicians, a total of 2.167 health professionals are suffering from COVID-19 in Turkey as of April 22, 2020. Istanbul takes the first place in the illness of healthcare workers as well as of the general public. A total of 2.005 healthcare professionals, including 960 physicians, have been infected with COVID-19. In Turkey, at least 14 of the 24 health workers, including doctors, lost their lives. According to the research conducted in the provinces where healthcare professionals get sick the most, 1 in 3 healthcare workers has a problem accessing medical surgical masks and 1 in 2 healthcare professionals has a problem accessing N95 masks [5].