Conquered by Dirt and Disease
Turkey's Appeal to American Sanitary and Medical Aid

By Alden R. Hoover, M. D.
(Medical Missionary of the American Board of Foreign Missions)

[The Survey, September 1917]

The following, article contains the substance of a report made by the author in July to the Rockefeller Foundation, which is making a careful study of conditions respecting medical work in Turkey. Dr. Hoover has for some twelve years been engaged in hospital and surgical work for the American Board of Foreign Missions, mostly in central Turkey. For seven months, in 1915, he was director of Red Cross work in Constantinople and had charge of the French hospital (40 beds), the British hospital (120 beds) and a hospital at the military barracks (556 beds). Here he had under his care thousands of wounded soldiers, most of them Ottoman Turks, and was thrown into close relation to Turkish officials, physicians and military men. The following pages contain the fullest and most authentic statement of sanitary and health conditions in Turkey which has come to this country since the outbreak of the war.

Turkey is one of the richest regions in the temperate zone. Valuable mines of silver, copper and coal are untouched. The land after all these centuries yields a fair crop of wheat and barley with cultivation that scarcely more than scratches the ground. Fruits and nuts are of the finest. The apples of Amassia, the filberts of the Black Sea region, the tobacco of the northern region of Asia Minor, the figs of Smyrna, the cotton of the Adana region, the raw silk of Broussa are but a few samples of what might be accomplished throughout the whole country with modern agricultural methods.

As it is, the government has imposed heavy taxation, has encouraged rather than discountenanced the hatred among races. Suspicion takes the place of confidence. Towns and cities are high-walled; there is no such thing as the isolated farmhouse. Every man living for himself has taken from the country what could be gotten without thought of giving a return. The forests have been taken for fuel, even to digging up the roots. The farmer plants and reaps in a small way, may even pull up the stalks of grain by hand in order to save the straw for fodder, and seems content if in this way he ekes out an existence. It is a contentment of ignorance and' resignation, for where the example of better living has been shown them Turks are eager to learn.

Flies, filth and vermin characterize the interior of Turkey. The roadside inns are notorious in this respect. Foreigners find it necessary to provide traveling beds in order to keep away from the vermin. It is common to see the village traveler sitting by the roadside picking the lice from his underclothing. Fleas are taken for granted as a necessary evil, and they are everywhere in evidence. It makes the examination of patients in the out-patient clinic rooms a matter of great discomfort to the foreign physician. Bedbugs infest practically every home in the interior, and in such numbers as to make calling in the homes most disagreeable. A swat-the-fly campaign would be taken as a joke. Filth of all kinds is dumped in the streets, cattle slaughtered, and the blood allowed to drain away in the street. Flies in swarms cover the meats and other foods exposed for sale. A weak attempt has been made in certain cities to enforce an ordinance compelling the screening of food.

As in other countries where the science of medicine is not yet highly developed, the acute infectious diseases claim first place to attention on account of their universal prevalence, their unchecked ravages, and their preventability.

Typhus fever in 1915 caused the death of some 200,000 to 300,000 people in Turkey. The government, instead of cooperating with foreign medical missions as the Serbian government did in a similar emergency, sent their own physicians to cope with the disease, and of these several hundred took the disease and died. In the Erzerum region where, on a conservative estimate, between 60,000 and 160,000 died, soap, water and fuel were almost impossible to obtain during the epidemic. Three of our American board physicians in Asia Minor gave their lives a prey to this disease in trying to fight it single-handed.

Typhoid fever is prevalent throughout the entire country and assumes epidemic proportions, in the summer and fall months. In the Caesarea region in the central part of Asia Minor, many thousands of cattle are slaughtered for making a sort of dried beef. This is done in the late summer. There are no abattoirs, the cattle are in countless instances butchered in the streets of the city. There is no system of drainage except the open sewer. I have seen a patient dying of typhoid fever in a room directly overlooking a courtyard where tons of this dried beef were being prepared and shipped to Constantinople.

The better class escape the disease by living the entire summer in the vineyards outside the cities.

Asiatic cholera runs its terrible course in any given region and then seems to leave that region for several years. It is perhaps as much dreaded as any disease in Turkey; the people look at it in a sort of hopeless terror In the epidemic of 1910, the governor of the province could be interested only after the epidemic had gained headway in all quarters. He then gave strict orders as to quarantine of infected houses. This quarantine consisted in painting a streak of yellow paint on the door-posts of such houses. These signs, however, were absolutely disregarded by the kindly-disposed neighbors of the sick. Orders to eat only cooked fruits and vegetables were disobeyed, for, as they expressed it, "Is the fruit this year any different from the fruit last year?" The city physicians in some instances were afraid to insist on the observance of this rule because of fear some, personal injury to themselves might result.

Smallpox is especially prevalent in the village communities. More than half of the population of such places show the pock marks. The disease does not seem to have a very high mortality in Turkey, but it is the cause of innumerable cases of blindness among children and, in this respect, second only to gonorrheal infection. Vaccination is practiced in larger towns, cities and in the army. Only in the last instance is it systematically carried out.

Malaria, in all the low lands of the country, is the cause indirectly of thousands of deaths annually. The people become infected, take a few doses of quinine, partially control the disease in this way for years, all the time however, physically unfit and an easy prey to other diseases. The disease is so prevalent that quinine sulphate is a household remedy known to every one by the name of "sulphate" and more used than any other drug in the country. The native physicians give the remedy by mouth or intermuscularly, but the result is rarely if ever controlled by microscopic examination of the blood. I have as yet seen no effort to destroy the mosquito larvae, or to screen houses, although some in order to obtain sleep use netting over the bed.

Tuberculosis is ever-present. It is found in every city, town and village of the country. The houses themselves are contaminated, so that family after family occupying them becomes infected. With all their natural dread of the disease, the people take almost no precaution against its spread. The tubercular patient is found in the same room with other members of the family, and his bed upon the floor will be shared with others in the family. He will perhaps take the precaution to keep beside the bed an open tin cup into which he expectorates. Even in well-advanced cases he will be found eating with the family from the common dish.

If the physician pronounces the disease tuberculosis, the word sounds the death sentence for the patient in the minds of the family. They will ask what can be done to prevent others from taking the disease, but with their limited knowledge of germ infection the advice of the physician is of no practical avail, and they are apt to miss the most important point. I have many times had a glass of water brought to me for inspection, with the remark, "You can see, Doctor, there are no germs in this water." Forms of tuberculosis which are not so common in our country are exceedingly common in Turkey; for example, tuberculosis of the bones and joints, tuberculosis of the spine, tubercular glands, tubercular peritonitis, tuberculosis of the kidneys, bladder, etc. I know of no sanatoria for tuberculosis in all the interior of the country. There are ideal locations for the establishment of sanatoria in the mountain regions of the interior, with an elevation of 4,000 to 8,000 feet and with a climate quite as favorable as that of our Colorado.

Syphilis ravages some of the villages to the extent of 80 to 90 per cent of the population. This is accounted for by the manner of living of the village people, who live huddled together and use common eating and drinking utensils.

The disease in such instances is the so-called "innocent" syphilis, carried from one to another in the same manner as any infectious disease. In such districts the disease is not associated in the minds of the people with immorality. A form commonly seen is a syphilitic ulceration of the skin, the so-called chronic syphilide. In the large cities, and especially in the coast cities, the social evil is flagrant. Proper treatment is costly, and in consequence the disease is allowed to run its course. A form of native treatment much used consists of mercury fumigations. This treatment so often results in mercurial poisoning that it is not at all rare to see cases of extensive necrosis of the jaw bone as a sequel. The hospitals of the interior are not equipped, as a rule, to do the Wasserman test, and no scientific study of the situation in regard to this disease is being made.

Gonorrhea is found more in the large centers than in the interior. It is probably the cause of more unhappy homes than any other disease. Pelvic infections in the female are the cause in most instances of the childless home; and in Turkey to have no-child is not only the greatest of misfortunes but held to be a legitimate ground for divorce. As the cause of blindness in infants this disease holds first place. It is the most pitiable as the blindness is so easily and surely prevented by very simple means but the midwives of the country are almost without exception ignorant and uncleanly women.

The infant mortality is hard to estimate, but is probably over rather than under 50 per cent. Very little preparation is made in the ordinary home for the new-born child. It is too often regarded as so much additional burden. The mother is attended by the midwife in the great majority of cases; the people as a rule do not consent to take confinement cases to the hospitals. The American hospitals, however, have been successful in increasing this class of patrons. The practice of the native midwives is absolutely brutal and oftentimes criminal. I have seen a case of contracted pelvis where the bones of the pelvis were broken and pulled wide apart by the combined strength of several midwives, the result being fatal to both mother and child. The induction of criminal abortion is common and results in untold misery from the consequent infection.

The care of the child is simply a matter of doing the same as the forefathers did. The new-born child is wrapped in swaddling clothes, with a sort of finely pulverized earth in place of the napkin. It is nursed whenever it cries and given a "comforter" made of a piece of Turkish sweet wrapped in a rag. At one year of age the child, although it may also nurse until it is two years or older, is given bread and a little of almost anything to eat. It is not unusual to see him toddling about with a half-eaten cucumber in his hand. Instruction in the care of the child has been taken up in some of our American board hospitals, and the eagerness shown on the part of the mothers is evidence of their desire to learn. The example of the care of the child in the American home has been a revelation to many who have had the opportunity to come in touch with American residents. The life of the woman of Turkey is circumscribed by her home, and her children. Perhaps no other line of work among them would be more welcomed than instruction in the care of children.

The infectious diseases of childhood, such as measles, scarlet fever, etc., cause the death of hundreds of the children of each city they visit. These diseases are of practically the same severity as they are in this country, but as soon as the rash is faded the child is allowed to go out and play in the streets, with the result that he dies from complications, pneumonia, nephritis, etc.

Conditions demanding surgical relief are the same as in our own country, except in different proportion as to relative frequency, and the stage of the disease when first seen by the surgeon. Cases are seen in their most aggravated form. The confidence in American surgery is seen in the work of the American hospitals in Asia Minor. The patients often come from distances of five days' journey in a country where travel is difficult. The limited capacity and more limited staff of these hospitals has resulted in the work being pretty largely surgical in nature. To give a few examples:









From the number of out-patients in comparison to the number of in-patients, it is clear that by far the greater number not seen in the hospitals, and of those admitted to the hospitals almost all are surgical cases. The people of the country appreciate western surgery. All classes and all races, Mohammedan and Christian, rich as well as poor, come to the American hospitals. American surgery has proven a most effective means of breaking down prejudice against foreigners.

Turkey offers an unsurpassed field for research in such problems as the surgical forms of tuberculosis, gastro-intestinal diseases, vesical and renal calculus, trachoma, etc. It is a field which is practically open to American surgery. The way has been paved by the medical missionaries of the American board, who have won the confidence of all classes in a remarkable manner. The standard of ethics among the native practitioners is low, and as to proficiency in surgical diagnosis and operative technique, they are not able to take their place as modern surgeons. There are few indeed who would be able to meet the requirements of the American College of Surgeons.

In eye, ear, nose and throat work Turkey's need is pitiful. Trachoma is so prevalent that there should be a clinic for treating trachoma in every city of the country. The disease is a distinct menace to our own country as well as to Turkey, and in spite of strict immigration laws, many cases find entrance into America each year. The amount of defective vision and consequent inefficiency is incalculable. Operations for entropion and trichiasis, and effects of trachoma, are among the most frequent operations we are called upon to perform.

The prevention of blindness by the control of trachoma, gonorrheal ophthalmia and smallpox would be one of the greatest blessings America could give to Turkey. The blind in Turkey are objects of pity, as they are apt to be turned out as unproductive members of society, in a land where the people consider themselves poor enough without taking care of the blind; the deaf, the crippled, the aged and the insane. Cataract is common, perhaps not so prevalent as in India; the native eye surgeons still practice dislocation of the lens with needles, resulting in ultimate loss of the eye. The field for the eye specialist is unlimited.

Deafness and mutism, the result of neglected ear diseases, are frequent. One small school connected with the girls' school under the American board at Marsovan is the only school for this purpose in all Asia Minor. Mastoid disease, and diseases of the antrum, the accessory sinuses, are common and demand the service of the specialist. The American surgeons, although there are no eye, ear, nose and throat specialists among them, have been compelled to enter this field of surgery and have done much for these sufferers.

The researches of men like Rosenow on focal infections, pyorrhea, etc., make one long to enter the unexplored field in Turkey in this line of research. It is the rarest exception to find a well-kept mouth among the middle class in Turkey. Pyorrhea is the rule. The native dentists are very mediocre, while the village people simply allow their teeth to rot uncared for unless because of pain they have them pulled. Outside of the largest coast cities, there are no American dentists in Asia Minor. The Syrian Protestant College at Beyrout has recently established a department of dentistry.

Sanitation and preventive medicine in Turkey are still in their primitive stages. The reason for this backward condition is not in the inherent inferiority of the races which are found there, but rather in the system of government. The centralization of political power in the hands of a few unprincipled men in the capital city, and the ruling of the masses by a system which deliberately aims to keep them ignorant and submissive, results in a condition which brands their country as among the least progressive on earth.

The value of preventive inoculations for such diseases as Asiatic cholera, bacillary dysentery, typhoid fever and smallpox has never been better demonstrated than in the present war. My own prediction that epidemic disease would defeat the Turkish troops at the Dardanelles was not fulfilled, because preventive measures were taken and systematically carried out. As a result no epidemic of these diseases occurred, while typhus fever, against which they have no preventive vaccine or serum, caused the death of over 200,000 people.

I went through the Bacteriological Institute in Stamboul with the Turkish physician in charge and was impressed by the evident adaptability of the Turkish doctors to the situation. With very meager equipment, using, for instance, common flat bottles for culture flasks, storing the prepared sera in old beer bottles, they were getting the desired results. Preventive measures were compulsory for the soldiers, but the general civilian population was unprovided for.

The whole problem of preventive medicine in Turkey is practically untouched. It involves the changing of a whole country from a backward, unprogressive one, where filth and disease make it a real menace to the world, into a clean, livable country, one which might become progressively a real resource to the world's civilization.

The needs of the public health in Turkey may now briefly be summarized as follows:

The control of epidemic diseases;
  Campaign against tuberculosis, syphilis, gonorrhea;
  Child-welfare study, prevention of excessive infant mortality;
  Control of malaria, trachoma, hookworm, anthrax, intestinal and
    parasitic diseases;
  Study of insect-borne diseases;
  War against universally present vermin, lice, fleas, bedbugs;
  Care of insane, blind, deaf, lepers, crippled;
  Education of men and women in modern- medicine and surgery;
    of mothers, nurses, midwives;
    in private and domestic hygiene and sanitation;
    in village and city sanitation;
    in care of water-ways, disposal of sewage, soil pollution, etc.;
    in disinfection, fumigation, quarantine.

Considered geographically, two centers naturally suggest themselves for intensive sanitary and medical aid on these lines:

1. Constantinople for the region north of the Taurus mountains, including northern and central Asia Minor, the Balkan peninsula, southern Russia;

2. Beyrout for the region south of the Taurus mountains, including southern Asia Minor, Syria and Palestine, Mesopotamia and Arabia.

As to language, the northern region is Turkish speaking, and the southern region Arabic speaking.

Constantinople would seem to be pre-eminently favored as a location for a strong medical center. Its geographical location gives easy access to the whole Near East, both southern Europe and western Asia. Its political importance as a great capital city gives prestige to its students. Its polyglot population makes possible the easy handling of students of many nationalities and the provision of an extremely varied clinical material in medical and surgical work. Being in touch with both Occident and Orient makes more natural the introduction of modern methods in medicine and surgery. The prestige of existing American educational institutions of high grade, such as Robert College for men, and Constantinople College for women, paves the way for the introduction of a strong medical school. These things, taken in connection with the great outstanding need, would seem to mark Constantinople as one of the great strategic centers of the world for the development of a medical center for women and for men, which would be a tremendous factor in the emancipation and regeneration of the Near East.

The framework for such plan is laid in the network of American colleges and hospitals already established. In Asia Minor the hospitals of the American Board of Commissioners for Foreign Missions number nine. The strengthening of these "one-man" hospitals would allow a better grade of medical and surgical work to be done and would assure more intelligent cooperation in carrying out preventive and sanitary measures, and in effective research work. The Balkan peninsula and southern Russia have been sending students in large numbers to the colleges in Constantinople and would contribute large numbers to a medical department if such were established. The opportunity seems to me unsurpassed for developing in Constantinople one of the greatest medical colleges for women in the world.

Here, then, we have an opportunity for American helpfulness to a disease-ridden people on an unsurpassed scale and with an unsurpassed prospect of success. A general scheme, such as has been working itself out in my mind during the past ten years, would make use of all the existing facilities and, with them, would create a medical plant of the first order. The location of its units would be influenced by that of the institutions named and by the natural geographical divisions of the city, perhaps as follows:

1. A medical college in proximity to Constantinople College and Robert College, in the region along the Bosphorus a few miles above the city proper, the most beautiful as well as the most healthful location.

2. An American hospital in the same region as the medical college.

3. A polyclinic building, located near the heart of the city in the European section (Galata, Pera, Taxim, Shishli).

4. Branch dispensaries and clinic rooms located in the geographical sections of the city, as at Stamboul, Galata, Pera, Scutari, Kadi-Keuy, and perhaps others.

The whole plant should be, it seems to me, of the same grade as similar institutions in the' United States, such as are classified as "A plus" by the American Medical Association. Teaching would be in the English language without change in the curriculum of existing colleges. The training school for nurses in connection with the hospital should be made especially strong to supply the need for trained nurses throughout the whole country. A department of midwifery would combat the malpractice and criminal work of the ignorant, untrained midwives now working in the country. A department of dentistry would find a field of work, unlimited and untouched as far as concerns research work along the lines of work recently developed in this country, as in pyorrhea alveolaris, focal infections and modern oral surgery. A school of pharmacy is needed to develop pharmacists who will hold to a high standard of ethics in their profession.

The polyclinic plan seems to fit the situation in Constantinople. It would be a modification of the Mayo clinic idea, so successful in this country. The polyclinic would be the "center" of American clinical medicine in the Near East. In the polyclinic building would be associated under one management a staff of specialists, not in jealous individual competition, but in aggressive cooperation for the advancement of American medicine in the Near East. The staff members would be selected with the view to implanting the high standards of American medicine, surgery, preventive medicine, modern medical research, and the high principles of Christian life and service.

The staff of such a polyclinic might include specialists in internal medicine; surgery; eye, ear, nose and throat; gynecology and obstetrics; pediatrics and orthopedics; genito-urinary and skin; nervous system; x-ray and photography; bacteriology, serology and pathology; epidemiology, sanitary engineering and preventive medicine; printing and library work.

The department of epidemiology should train men capable of investigating outbreaks of epidemic disease in any part of the country and of cooperating with the nearest American hospital, and with government officials, for the control and eradication of the disease.

The polyclinic would be the clearing-house for all cases of a serious nature. The patients coming to the polyclinic would be referred to such specialists as were necessary for a thorough diagnosis of the case. The patient would feel that he is here receiving the best the medical profession affords, without the confusion resulting from consulting various doctors in general practice, to be told (as is quite the rule in Turkey) that the opinion of the doctor previously consulted is entirely incorrect. The polyclinic would help in raising the general standard of ethics in the profession. Cases sent to the polyclinic from the branch clinics or coming direct would be sifted out, surgical and serious medical cases being sent to the hospital.

The branch clinics and dispensaries would be the feeders for the polyclinic and the hospital. The staff would consist of one physician, one nurse, one pharmacist and perhaps one relief worker. The work of these clinics would be much like that done in the out-patient departments of our American hospitals. A great deal of trachoma and other eye diseases make necessary clinics for the daily or tri-weekly treatment of such cases. All cases of a minor nature would be treated from these branch clinics.

Turkey in her present condition of filth and disease is a menace to civilization. American prestige in education and medicine has firm hold on the people throughout the country. America seems fitted as no other nation to cope with this urgent need. Medical and surgical work has proven one of the most effective means of winning the confidence of the Moslem people. America has the opportunity in the Near East of making one of the most vivid, practical demonstrations of modern sanitation and preventive medicine the world has ever seen. As a means of bringing Christian culture to the Near East, the medical seems the most effective. If for no other reason than to safeguard the health of other nations from this breeding place and disseminator of disease, America may well afford to embrace the opportunity which is opening before her in this region.

© J. Fred MacDonald, 2013

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