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Turkey's Struggle with Covid-19: A Cross-border View

Türkiye’nin Covid-19 ile Mücadelesi: Sınır Ötesi Bir Bakış

Radost Asenova, Mehmet Ungan

Euras J Fam Med 2020;9(2):61-9.


Review / Derleme


SARS-COv-2 or a common COVID-19 infection caught all countries off guard. In just a few days, the lives of individuals and the functioning of all societies, starting at the smallest, have changed drastically, their health and lives have been seriously threatened. Many eyes have turned to family doctors who are at the forefront of the fight against the virus. In recent weeks, family doctors have made the highest sacrifice in their lives in the fight. In this extraordinary situation, WONCA Europe made many calls to managers and World Health Organization offices, including our country, wishing that the family doctors in Europe and their academic institutions representing them should not be kept at the lowest possible level. All our knowledge comes from the observations of the doctors, the Ministry of Health and the Media. Talking about Turkey would not be right for us nor for the foreign media because the credibility of the review without seeing and examining all the data will be a question mark. To support the management of pandemic, we need transparent and improved data collection and data delivery in all countries.

Keywords: Coronavirus, Turkey, WONCA Europe, Family Practice


SARS-COv-2 veya yaygın bir COVID-19 enfeksiyonu tüm ülkeleri hazırlıksız yakaladı. Sadece birkaç gün içinde, bireylerin yaşamları ve en küçükten başlayarak tüm toplumların işleyişi büyük ölçüde değişti, sağlıkları ve yaşamları ciddi şekilde tehdit edildi. Birçok göz, virüse karşı mücadelede ön planda olan aile hekimlerine döndü. Son haftalarda, aile hekimleri bu kavgada belki de hayatlarının en büyük fedakarlığını yaptılar. Bu olağanüstü durumda, WONCA Avrupa ülkemiz de dahil olmak üzere, yöneticilere ve DSÖ ofislerine, Avrupa'daki aile hekimlerine ve onları temsil eden akademik kurumlarına mümkün olan en düşük seviyede tutulmamaları konusunda birçok çağrıda bulunmuştur. Tüm bilgimiz doktorların söylemleri, medyanın ve Sağlık Bakanlığının gözlemlerinden alınmıştır. Türkiye hakkında konuşmak, ne bizim için ne de yabancı basın açısından doğru olmaz çünkü, tüm verileri görmeden, incelemeden beyan edilen fikirlerin güvenilirliği soru işaretidir. Pandemi yönetimini desteklemek için, tüm ülkelerde şeffaf ve geliştirilmiş veri toplama ve veri dağıtımına ihtiyacımız vardır.

Anahtar kelimeler: Koronavirüs, Türkiye, WONCA Avrupa, Aile Hekimliği

WONCA Europe is an officially registered European institution in the Netherlands with a secretariat in Slovenia, a member of 47 countries representing the European Region of the Academies and Institutions of the European Family Doctors/General Practitioners (FDs/GPs) and over 120 thousand FDs (1). Therefore, it has a structure in which the observations and researches are transmitted within the application in the European region. There are six sub-institutions under Wonca Europe called Networks (NWs). These NWs are about FD/GP research, education, quality, rural, prevention and young family doctors. In addition, there are 6 groups making kind of institutions representing FDs/GPs in special clinical interest groups (SIGs). These SIGs are on infection, gastrointestinal, cardiology, respiratory, allergy and diabetes. Each of the NWs and SIGs holds its own meetings at least once but generally twice a year, and also organizes important scientific events by attending the European Congresses organized annually by WONCA Europe.

WONCA signed a memorandum of understanding and cooperation agreement with the World Health Organization (WHO) and stepped into a cooperation in the field of primary health care to improve public health. As a serious non-state actor for the past two years, WONCA Europe has been attending WHO meetings and presented a paper or idea. 

As WONCA Europe, our most important calls to the managers of member countries are that it will be very difficult to limit the pandemic without regular continuous and sufficient supply of high quality personal protective materials (PPE) and family doctors with the necessity of family doctors to be included in the the pandemic board of directors, and providing them with enough tests to cover the whole society. It is also possible to conduct violence in Family Health Centers (ASMs), with continuous training on the new information about the risk management and triage of ASM employees, tele-health or digital examination, the urgent implementation, development of all pandemic measures and the assessment of all health problems in accordance with the labor law. We reminded to take legal measures against violence and occupational hazards. Some countries have already implemented them. Unfortunately, our members from countries such as Italy reported that if PPE is not available in the country, our suggestion of not working without PPE was not realistic. They could not find PPE but had to continue their work, and there were many doctors who were sick and lost their lives, and Italian FD colleagues warned us to tighten the measures for our country.

The initial situation can be summarized for all countries but for Family Doctors as follows: "limited information", "uncertainty" and like in every individual "fear". We were trained in accordance with core competencies in uncertainty, and we knew that our profession required the skills to cope with uncertainty (2). As time goes on, the knowledge would increase, so we had to gain time. Fear; could only move away with science due by building a trust. We chose to remove our members from fear with an “absolute science” with a good knowledge, with complex ethical decision-making efforts, and to establish new partnerships to reach sunlight at the end of this dark tunnel.

WONCA appreciates and is concerned with the social dimension of diseases and health diplomacy. WONCA Europe supports its Member Organizations to take part in the country pandemic committees by many messages. Research in Primary Health Care (PHCS) is needed more than ever. Recognition of the political, socio-economic, historical, cultural and health infrastructure contents of interventions in a different world requires only the dissemination of “good information” through WONCA Europe.

Patients with preexisting mental illness are at risk, but family doctors who protect people’s health must be psychologically supported, especially considering Post Traumatic Stress Disorder (PTSD). Webinars, trainings, one-to-one online sessions are held and planned. Health literacy is inevitable and WONCA Europe works in the WHO European expert group. Considering different cultures and populations, WONCA's HAPPY-G Project offers a multilingual health awareness video series about SARS-COV-2. Finally, personal and professional rights in the pandemic and anti-violence measures in primary health care practices can still be supported by WONCA either by direct letter or by regional WHO Offices for our member countries.

There are several rumors about new, effective treatments that suppress SARS-COV-2 infection in the public domain. Some of them were probably the work of fraudsters or crookers, but we preferred to look at what a family doctor could trust. However, no treatment is currently allowed by the European Agency for Medicines (EMA), the Europian Union (EU) official agency, or by the U.S. Food and Drug Administration (FDA) or Centers for Disease Control and Prevention (CDC). There are drugs approved for clinical “trials” only, including both western and traditional medicines. WHO currently does not recommend self-medication, including antibiotics, antivirals, as a prevention or treatment. Online pharmacies registered in EU countries against non-legal internet sellers are available on the EMA website. EMA, together with the pharmaceutical industry and EU Member States, has launched the advanced rapid tracking system to help prevent and reduce supply problems with important drugs used to treat COVID-19 patients (3). All available treatment recommendations are based on evidence at the level of expertise, and information is reviewed and updated as the information develops during the outbreak.

WHO launched an experimental study called "Solidarity" to test four available malaria treatments; remdesivir (EBOLA), ritonavir and lopinavir (HIV); latter HIV drugs plus anti-inflammatory small protein interferon beta. The FDA has approved the use of remdesivir iv for the treatment of patients under a protocol that provides access to experimental medicine for patients with life-threatening diseases. The study would be completed soon, but according to a Chinese study result on the WHO website, mortality with placebo was 13%, while it was reported as 14% in this drug group, and the authors stopped the study (4). The FDA has granted an emergency use permit for chloroquine and hydroxychloroquine, which allows for otherwise unapproved drugs or their use in emergencies. Favilav coronavirus is the first approved medicine in China and has been used in Turkey widely but in the earlier phases of the disease. Turkey is about to publish its own treatment protocol and the success rate seems to be high. Those are in experimental and clinical studies in progress in China-Shenzhen. It is stated that “plasma” containing antibodies is a hundred years old method and is currently in clinical research level for this virus induced disease, although it is currently in use, it is not suitable for family medicine, for it can only be used in hospitals. The drug Ivermectin which is used on refugees by the International Organization of Migration (IOM) institution for parasitic diseases such as Scabies and Strongy parasites in some countries prior to their flight to U.S. is now being used in this pandemic. In addition, some medicines that are said to stop the virus in Turkey, all are mentioned in social, visual and written media. For now, “none of these treatments have been proven” and are not used in family medicine. Vaccines are also underway. Unlike other vaccines specifically targeting COVID-19, BCG is thought to improve the immune system's ability to fight infections and prevent any infection by about 30 percent. It is being tested in a clinical trial against COVID-19 in 4,000 health care workers in the Netherlands and in 1000 Australia. It is hoped that COVID-19 can provide a general protection, not specific. It must be taken into account that we still have at least one more year, which is quite a long time for the end of Oxford and Imperial College vaccination studies in UK.

The outbreak surprised everyone. Even WHO seems to have adapted relatively slow. Family doctors were not ready for this either. WONCA Europe planned to take some practical steps to support them in getting rid of this difficult period. We were unprepared even for PPE. Family physicians play a very important role in Europe and in our country. In fact, even if they are not given enough roles with the desire to work heroically and they are afraid that they may be claimed otherwise after the epidemic has passed, they could collect test samples as family physicians and provide more support if they are provided regularly with PPE, vehicle, personnel, material and if they are in direct contact with and included in the science-pandemic board they could be more helpful.

Hospital intensive care units (ICU) capacities may not be sufficient without the unadequate testing by family physicians and without their contribution to early diagnosis and filiation-case detection studies. WONCA Europe informed governments about the importance of providing adequate PPE for primary health care services (PHCS). We provided the SARS-COV-2 online information they intended to use for their FDs. We provided information to the members to give priority to national guidelines from local and national health authorities. Information from counterfeit drugs from EMA, ECDC guidelines on social removal and testing, difficulties for general practitioners; we have given a webinar on family physicians' perspectives, technical guides, resources for vulnerabilities and “managing stress and anxiety through the crisis”. The WHO training course on this disease has been linked through the WONCA Europe website and has been announced. WONCA Europe now has its own web technology that enables virtual conferences. A monthly newsletter has recently begun. "Health Literacy", "Digital Health", "Quality and Safety" are important issues. WONCA Europe is preparing a Q&A type webinar on the experiences of European countries, including family physicians who have recently recovered from the disease. In addition, a web conference will be made public on the website soon, addressing the academic organizations of WHO World Country Preparations Director and the current European Emergency Health and Communicable Diseases Director.

WONCA Europe tried to raise awareness of the individualized National Pandemic Prep Plans based on country-specific regulatory, financial and management systems. Currently, in the previous influenza epidemic, European Countries, which are pandemic preparation plans made by the WHO recommendation in 2009, have to review with family physicians the extent to which of these plans are applicable. WONCA Europe provided information to countries about pandemic terminology such as surveillance, case detection, fillation, quarantine, isolation, which we think is applied well but should only be used in original scientific meanings. In Family Medicine practices of Turkey it has constantly been emphasized the importance of occupational safety measures, preparation of good and fast communication, vaccination services, and the protection of drug inventory and PPEs. Although it is known that the way of transmission is mainly through the respiratory system, the virus can be obtained from fecal and body fluids, but it would not cause infection, we have suggested to the local governments to examine at least wastewater in terms of monitoring. The Netherlands and some countries monitored airport and city wastes and turned to virus-intensive areas (5).

In Turkey, all of the information is at the level of the Ministry of Health (MoH) website, the statements of the Minister and the press, as well as the opinions of physicians and other specialists, whom one may see in TV programs. It involuntarily restricts us to read this table more accurately and support. Without getting detailed statistics it is not possible to comment on whether Turkey is usually in a good fight with the virus. It would not be easy to make a comment on what could be improved. This applies not only to Turkish colleagues, but also to foreign press and organizations, and creates question marks in terms of the accuracy of the comments made. Unfortunately, the news of the foreign press is open source for the public and the local press. Normal sources are almost those MoH and WHO pages, which can be accessed in terms of Turkey, where there is no scientific publication yet, and the comments that try to be more readable and interesting provide the opportunity to believe and reach the information shaped by the press from abroad. Quality data services and dissemination of the reliable information is also the right way to overcome fear. If there are mistakes, this is normal for the newly recognized COVID-19, it may be corrected in a timely manner and damage can be prevented. Transparent, reliable, and well-collected data is needed in all countries for an improvement in the pandemic challenge.

The most important aspect of Turkey when viewed from the outside is the tight and early measures taken, generous assistance to other countries, the successful struggle of the state, and unfortunately, the number of cases that were increasing rapidly. The daily measures and by those who strictly adhere to the prohibitions and rules, could normalize individuals’s lives, including the Balkans, which were particularly influenced by the eastern bloc, to the precautions and prohibitions taken, without leaving the streets, with their seasonal or social structures in their geographical location and the culture of community life. Working with the economy and to able to reduce slowly the number of state cases they continue to exist. But the Southern European countries, Spain, Italy, partly in France, before as was in Greece, now in Turkey, with an asynchronous timing the pandemic was frightening. Warm social structures, family ties, social ties, such as helpfulness have always been advantageous features of Meditterenean countries have become disadvantages in southern Europe. We were talking in WONCA Europe that the first impression measures were good, but it can be a problem to fulfill the measures taken in daily life with the southern country specific warm and intertwined social structure and that might affect the success negatively.

Turkey’s help in fighting the pandemic to the world has proven it to be a key supporter (6). The lack of protective medical equipment in many countries shows how countries are simply unprepared for a major outbreak and how stock materials are not enough to meet the needs of even medical workers and the population itself. Turkey behaved fast and efficient with the government's other measures as well as just a day after the first death closed the borders and started to work on identification of the first cases in the country to prevent the spread of the virus to whole of Turkey, the schools were closed etc. and this response was talked about a lot in the written press that measures were much faster than European countries. Turkey, has increased the production line medical protective clothing, PPE for its citizens and to prevent the further spread. Masks were distributed for free and it was heard. Tracing back from the devastating earthquake in the country, and dealing with millions of refugees and displaced, the large-scale disasters were routine in Turkey unlike Europe. So when you think that Turkey was ready to be more prepared dealing with such outbreaks and it was not surprising for the rest of the world. In early April, with a call by NATO Euro-Atlantic Disaster Response Coordination Center, Turkey answered the requests for assistance made by the Balkan countries, Italy and Spain, and has supplied test kits to USA and masks to all others. It was noteworthy that the world famous 13th century poet Celaleddin Rumi had a famous saying, "There is a lot of sun after hope and darkness after despair" on medical cases (6). Now we know up to 88 countries by the decision requested medical supplies from Turkey. According to the Ministry of Health, aid has been sent to over 30 countries so far. One of the earliest help from Turkey was to Bulgaria, Iraq and Israel as medical supplies. Turkey has also sent 500,000 US coronavirus test to USA. Health Minister Dr. Koca said that 40,000 to 50,000 daily tests were aimed to screen people in Turkey and it happened. Now the test numbers are declining as the top numbers were already seen according to the MoH. Turkey also provides much-needed medical assistance to Libya. Turkish Armed Forces delivered PPE by aircraft to Great Britain and this is confirmed by the European WONCA Europe members also. England eventually having packages contain PPEs to increase the protection of paramedics in hospitals at COVID-19 fighting front. This definitely brought the necessary relief for panicked medics in England after the COVID-19 death of counseling urologist Abdul Mabud Chowdhury, 53, in a London hospital. The two European countries most affected will receive medical assistance from Turkey are Italy and Spain. To manage the complexities of meeting local demands and helping other countries, the Turkish government has imposed export restrictions, so companies are now receiving state approval before exporting medical protective equipment, the world's most valuable commodity product, control is required for success and is strictly enforced as it seems. Turkey is hosting about 4 million refugees from Syria. Already and 365 thousand are waiting to enter also. In early March, the US United Nations Ambassador Kelly Knight Craft, US Ambassador to Turkey David Satterfield and US-Syrian Special Envoy James Jeffrey, praised by visiting a refugee camp at the border crossing Turkey. Turkey's Syrian refugees in the country have free health access for everyone, even with access to all health facilities for free during the epidemic for all drugs and seamless coordination of cross-border humanitarian aid is admirable. In addition, with a large family medicine force, that has not been effectively commissioned, attracts attention besides with its ICU beds (only thirty percent were full in the top of the curve) and hospitals.

The effectiveness of the measures for pandemic cannot be evaluated clearly yet. However, it is certain that these measures will bear a heavy economic cost. Turkey, a weakened currency of the economy, a high budget deficit, declining central bank reserves, keeping in mind that they are exposed to the coronavirus pandemic in an era where a major portion of the revenues from the tourism sector in 2019 is dissapearing may have an economic cirsis. Turkey was one of the 6 most visited countries in the world. Precautions should also be taken to face the economic crisis caused by the pandemic in the near future. Indeed, increasing economic costs compel balanced smart decisions for Turkey. Therefore, the state also faces a tough fight to save both lives and the economy. At this stage, this may seem like “mission impossible”, but it may be that the public abides by the precautions taken for the corona, not leaving the science, normalization of the health army and keeping the health and morale higher sooner, and the wheels of economy begin to turn faster. The public plays a big role in success as Turkish government seems to be doing its best. However, countries around the world and communities, defeat the coronavirus, economies take hold, to allow people to stay at home and implement social distance they join in radical measures, currently Turkey's unconditional humanitarian aid in hard times of the developed countries is a real support. The news stated Turkey to be worth giving credit to if necessary in second half year. Turkey deserves according to some foreign media (6).

World Meter ( reports more than 200 thousand deaths in the world, healing more than 1 million (7). Dr. Hans Kluge, General Director of WHO European Region on his report on 23rd April declaired that, among 50% of cases in the world, more than 50% of deaths are from Europe, 30% of deaths occured in the last 7 days, new cases increased 25%, they received positive data from Germany, Spain, Italy and Switzerland, England, Turkey, Belarus, Ukraine and in Russia acceleration of the outbreak (8). Then death records from the New York Times in Istanbul, Turkey are struggling to find official figures from the corona virus and expression of a larger disaster emphasizing investigative news (9). The city had recorded approximately 2,100 more deaths than expected between March 9 and April 12, according to the weekly averages of the past two years, according to the newspaper. Although all these deaths were not necessarily attributable directly to the coronavirus, the numbers showed a striking leap in deaths that coincided with the onset of the epidemic, a preliminary indication used by researchers to slow down the pandemic. Officially, 100 thousand cases have been confirmed through Turkey passing China and taking place on the world's most affected countries as 7th. The rising number was thought to be due to the increasing tests. It was also pointed out that the infection rate decreased and daily new cases are much less than those daily recovered cases. 

Nevertheless, unlike other cities, the five-week period between March 9 and April 12 stressed that deaths in Istanbul alone were 30 percent higher than historical average according to some experts and NY Times (10). When I look at the Istanbul Metropolitan Municipality (IBB) death information inquiry page online today, for example, on April 20, 2019, around 190 / day, on April 20, 2020, around 290 / day (about fifty percent more) (9). In parallel, in the first two weeks of April, the most recent figures also showed that deaths in Istanbul were 50 percent higher than the average, according to the NY Times. Stephane Helleringer, a demographer at Johns Hopkins University, said that increases in this size are alarming and may be clearly associated with the outbreak. However, according to our review, there are similar increases in mortality rates in other countries. Pooled mortality estimates from the EuroMOMO network continue to show a marked increase in excess all-cause mortality overall for the participating European countries, coinciding with the current COVID-19 pandemic. That was estimated the excess mortality for each country by comparing the number of people who died from all causes this year with the historical average during the same period. In many European countries, recent data show 20 to 30 percent more people have been dying than normal. That translates to tens of thousands of more deaths in Europe (11). Also in the news it is stated that in the nursing homes in France, over 500 elderly people died in a single day, but these are not included in the corona statistics, according to the press. Therefore, the methods are different in the countries and it is essential that this is in a standard way. Many European countries are currently trying to develop death statistics, which they consider to be lacking or unreliable. Istanbul totals may include both direct deaths related to coronavirus, and deaths from other causes, such as cancer or heart disease, as hospitals avoid taking non-covid patients and as patients avoid seeking medical attention due to fear of infection even though our bed occupancy rates are advantageously at thirty percent. Meanwhile, the daily number of recovered people is now almost same with the daily new case number. It is considered as a positive finding. And the mortality rate is around 30 per 1 million, with official figures.

Nowadays, pandemic precautions are starting to be loosened in Europe. COVID-19 Pandemics affected the world adversely not only in the field of health but also in the economic field. Governments, on the one hand, take measures to protect the health of their citizens, while trying to find solutions to the economic problem that these measures affect the negative. Germany, one of the countries that are actively carrying out the pandemic process, announced that it would make flexibility to its limitations under the measures in early May, and other stores, except for small shops, restaurants and schools, would start working. It is not clear for us why they do that when the numbers again started to rise. Likewise, Britain predicts that although they were late to join the measures in the pandemic process, it can make flexibility in limitations with software applications that will follow COVID-19 patients. Iran has announced that it has removed the measures of angling under the disease. Denmark, Norway, Czechia, Austria and Italy are among the countries that will relax the restrictions. All of them open their kindergartens to the society where the working community depends on being at a place where they can get safe care for your child at that age. On the other hand, the idea that social, herd immunity is ensured and patient care units can cope with new cases that will emerge is an important factor in removing restrictions in Europe. Despite the warnings by the CDC director general that it was likely to have the second wave in the disease, the common point of all these decisions is to create a balance by maintaining both public health and economic health until the most effective drug or vaccine against the disease. It is the opinion of experts who know the effects of past pandemics that things may develop to the direction of triggering another wave. The Washington Post said that the corona epidemic will accelerate and hurt even with the onset of the epidemic with the new influenza season, and said they are expecting a second wave (12). This statement is same with the one from Imperial College in England. It coincides with the estimates of Salman Rawaf and his team. The expert group, which was established for the integration of WHO European Primary Care and Public Health, including me, was invited to a meeting and task about the measures to be taken.

May be not only family doctors but all.population shall be remembering to live with uncertainity. Our parents grandparents were living with that until very recently where techno dependant fast living style replaced the classical one with a totally wrong understanding that with new technology all are predictable and under the controle of human including the nature. Some even started to give up immunization against diseases with the belief that we have taken control of many natural powers, and people thought they have not had any infectious diseases except seasonal flu and colds. How a big mistake. On the one hand, recent coronavirus related studies conducted with a limited number of patients, whose quality is controversial, and even in a refereed journal, is more confusing: we have been hypothesized about coronavirus aggressive behaviour, damages and etc. and we believe in fear. We rely on the release of vaccine and preventive therapies, which must take at least one and a half years to test that they are safe and effective, since they will be applied to millions of healthy people. We try to plan our lives according to the speculative calendars published on the course of the outbreak that no sane person can date due to the large number of factors and the unpredictability of some of them. It was even reflected in the media, where even those who bet on the course of the pandemic and the number of deaths to take place.

Since the first recognition of the factor, by looking at the richness of the information gathered despite the crisis conditions and the countries that are most affected by the pandemic of the whole world, especially the research infrastructure, information that will enable us to give much more clear answers to most of these questions in weeks or maybe a couple of months, we believe. Until then, there is no other way than to go grouping and systematize our limited observations as much as possible and correct the applications for them.

Despite all the progress, unfortunately, we do not have anything clear yet to address this epidemic. This coronavirus pandemic teaches us an important lesson that we are not as capable of as we thought, to accept uncertainty as a natural part of life, and to give up planning as we want the future. We have to live in uncertainty and to confront the troubles that arise with trust until science brings the best to us. We only hope that this time the hard lessons learned from fighting COVID-19 will help us stop a second wave or stop the next outbreak before it becomes a pandemic. 

We are Family Physicians who want to do our best in order to slow down the pandemic spreading rate and straighten the curve responsible for the health of registered individuals with whom we approach our lists with a biopsychosocial look in our countries, and the fact is FDs taking part in pandemic brain teams will strengthen the struggle with pandemic as it may also be in our country. 

If not now, when?.



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How to cite / Atıf için: Asenova R, Ungan M. Turkey's struggle with Covid-19: a cross-border view. Euras J Fam Med 2020;9(2):61-9. doi:10.33880/ejfm.2020090201

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