Navigating Bureaucratic Hurdles: Tuberculosis and Healthcare Access in Republican Istanbul

By Zehra Betül Atasoy

Tuberculosis (TB), often referred to as consumption or phthisis, was one of the most dreaded diseases of the 19th and 20th centuries on a global scale. From the 1930s to the 1960s, the period on which this piece focuses, tuberculosis claimed a significant number of lives each year in Turkey.[1] The absence of a structured and centralized TB treatment and prevention system[2] left countless individuals grappling with the disease alone. However, one of the reasons for the lack of access to treatment was the cumbersome bureaucratic processes, exacerbating social class disparities.

Various laws and regulations during that era ensured individuals’ access to essential health services on paper.[3] For those facing financial hardship, the Republican state offered free services. Physicians of the time applauded these advancements.[4] However, the efficiency of this system remains a question. Turhan Selçuk’s cartoon (Figure 1) is an excellent illustration of bureaucratic red tape, as authorities’ efforts to combat paperwork often resulted in more paperwork. The cartoon injects humor, depicting the officers’ surprised expressions as they add new papers to the ever-growing pile. It also emphasizes how bureaucracy could spiral into complex procedures, negatively impacting citizens’ daily lives.

The bureaucratic red tape was particularly evident in healthcare, and social class was crucial in determining access to quality medical care. Affluent individuals could afford private clinic visits, while those with lower incomes faced long waits at hospitals, dispensaries, and sanatoriums, often lacking sufficient beds. Although the state could not increase the number of healthcare facilities due to financial constraints, it provided provisions for low-income TB patients, like coal and medical supplies. However, accessing these provisions also posed challenges.

Figure 1: “- What’s all this?
– Documents on the fight against bureaucracy!” (Yeni İstanbul, 2 October 1950)

This piece examines the emotional terrain of systemic failures and the impact of poverty on access to TB treatment, which is often overlooked in government documentation. It aims to humanize the healthcare problems caused by bureaucratic obstacles, such as prolonged waiting times and worsening patient conditions during interactions between government agencies and healthcare facilities. Furthermore, it delves into the economic burden tuberculosis imposes on affected individuals.

While official records tend to adopt a detached tone, failing to capture the human experience, literature, and news accounts offer a vivid portrayal of individuals grappling with illness amidst bureaucratic hurdles. For example, a case from the Presidential State Archives highlights the bureaucratic language prevalent in official documents. In 1953, Erol Özgürat, a financially struggling student suffering from tuberculosis, penned a letter to the Prime Ministry, seeking free treatment at the Validebağ Preventorium. His plea was denied after several correspondences over three months among government ministries.[5] The outcome of Erol’s predicament and eventual fate remain obscured by the bureaucratic tone of the documents.

The works of authors such as Aziz Nesin, Rıfat Ilgaz, Suat Derviş, and Orhan Kemal serve as primary sources, offering firsthand observations and insights into the emotional and physical toll of navigating healthcare bureaucracy. From the 1930s to the end of the 1950s, these texts provide a nuanced understanding of the challenges faced by individuals traversing bureaucratic mazes while battling illness and financial constraints. Consequently, the piece seeks to humanize individuals affected by tuberculosis, adding depth to the narrative beyond dry state-led accounts. It partially reveals the expected yet often hidden challenges on paper when individuals engage with bureaucratic processes.

Endless Waits at the Tuberculosis Dispensary: “Patients were waiting on the floor, on desks, standing.”

Although health institutions were tasked with monitoring suspected cases and TB-related fatalities on paper, this responsibility was not effectively realized in practice.[6] These institutions struggled to meet the needs of many citizens due to inadequate funding and understaffing, resulting in perpetual lines at dispensaries, which were populated by impoverished individuals who lacked the means to seek treatment at private clinics. Dr. Bedi Şehsüvaroğlu’s visit to the Sultanahmet Dispansery in 1948 exposes the endless waits in challenging conditions:

Young mothers tenderly looking at their babies in their laps, sallow girls, and clean-shaven workers wait in groups. There is no empty seat, even on the park benches (…). Despite the cold, there are so few people with coats or overcoats… That is why the circle around the stove is getting wider and wider.[7]

In 1957, in his short story Gaçıncı Gılinik (Which Clinic), Aziz Nesin vividly portrayed a scene where the narrator observes the bustling activity outside a hospital. The narrator is there for a sick acquaintance and describes the constant movement of people dressed in white. The medical orderlies (hademe) stand out among them, resembling doctors more than the actual physicians, as they strive to embody the quintessential physician’s appearance:

Those who wanted to look more like a doctor in white clothes were the orderlies. There were doctors with uncombed hair and even a little beard. But there were no orderlies like that. The doctors walked as they walked everywhere, with their arms and legs in a relaxed manner, whereas the orderlies strutted like field marshals on inspection. The doctors laughed, and the orderlies pouted.[8]

Nesin satirically critiques the power dynamics within these institutions, where medical orderlies, often more concerned with appearing authoritative than providing care, exacerbated the struggles of vulnerable patients. Indeed, when the narrator inquires about their acquaintance’s well-being, the orderly disregards the question. Similarly, when one of the patients waiting in line for examination collapses in agony, the same orderly mercilessly “runs his foot over the man.”[9] This portrayal of tuberculosis dispensaries and hospitals reveals systemic flaws and human suffering. Patients endured physical discomfort and psychological strain in the lines, underscoring the lack of equitable healthcare access (Figure 2).

Figure 2: The 1988 photograph shows patients and their families waiting outside the X-ray room, with perhaps an orderly in a white coat on the right. Despite being taken later, it highlights long waiting times in healthcare facilities. The attached article discusses doctors’ concerns about X-ray lines and patients’ discomfort in stuffy waiting areas, leading to minimal diagnostic interactions and potential misdiagnosis. (Ahmet Tan, “Günlerin Köpüğü: Verem, sana ne verem,” Cumhuriyet, 12 February 1988.)

Continuous Cycle of Petitioning and (Not)Obtaining Medical Reports

‘I am sick… you are to admit me…’

‘I have no recollection. Well, why don’t you submit a request (istida)…’

I didn’t bother to hear the remainder. Nothing irks me more than this ‘request.’ If something is not supposed to be concluded, just file a request (…).[10]

As the excerpt above indicates, obtaining treatment entailed a lengthy petitioning procedure. One vivid portrayal of this bureaucratic maze is seen in Rıfat Ilgaz’s novel Pijamalılar (In Pijamas), in which he satirizes hospitals, sanatoriums, and their associated bureaucratic red tape during the 1950s.[11] The novel criticizes institutions that fail to function effectively with nuanced dialogues. In Ilgaz’s narrative, there is no central protagonist; instead, the lives of various individuals are observed. It could be argued that the illness assumes the role of the main character. Tuberculosis, a shared affliction among the characters, becomes a tragicomic barrier seemingly insurmountable for impoverished individuals. The narrative provides a means to grapple with the patients’ hardships and accentuates the pervasive anxiety caused by the bureaucratic horrors.

Pijamalılar unfolds with the protagonist, a journalist, undergoing a medical examination that reveals tuberculosis. His journey begins with a glimmer of hope when his boss assures him of assistance from the Deputy Mayor of Istanbul. However, this hope quickly dissipates as the bureaucratic machinery grinds into action. Despite having a pressing medical condition, the narrator finds himself embroiled in paperwork, a frustrating delay in pursuing healthcare.

Navigating the bureaucratic hurdles, the narrator’s trust in approvals gradually fades: “I no longer believe in what is written, drawn, or signed.”[12] His fluency in the state’s language offers little relief from the physical and emotional toll of endless office visits and waits. After persistence, he is approved for hospitalization, only to face further delays due to his non-Istanbul birth registration, resulting in a months-long waitlist. The protagonist’s worsening health and mounting frustration highlight the system’s inadequacies, reflecting the struggles of many caught in bureaucracy.

What fate awaited patients without connections? An illustration of this is the case of Haydar Sönmezocak, a character in the novel Pijamalılar, who experiences setbacks when bureaucratic hurdles impede his access to coal assistance from the state, leading to a relapse in his condition. In the 1940s and 1950s, obtaining coal was a long process involving lengthy bureaucratic procedures. It took months to procure coal from the Coal Distribution Office (Kömür Tevzi Bürosu).[13] While prioritizing coal for low-income individuals[14] could be seen as aiding the tuberculosis struggle, accessing it posed a challenge, especially for those needing to prove their illness since obtaining coal was already difficult for healthy individuals.

Haydar Sönmezocak finds hope in a newspaper offering coal to TB patients but faces bureaucratic red tape. Despite having eighteen medical reports, he is redirected between offices, facing endless paperwork and delays. At the Üsküdar District Governor’s Office, he is sent to the Municipality and then to the Coal Distribution Office, where he learns he needs a new report from Numune Hospital. After a week of exhaustion and another round of paperwork, he finally gets approval, but the process continues to drain his time and energy. Clinic visits add to his ordeal, with long waits and repeated tasks. Given all the struggles, it is no surprise that Sönmezocak’s tuberculosis relapses.

Sönmezocak’s journey is a poignant reminder of the human toll of bureaucratic inefficiency and the desperate lengths individuals like him must go through to access basic necessities in the face of illness. The selection of the character’s name also strengthens Ilgaz’s satirical narrative. Sönmezocak, whose name translates to “Everlasting Hearth,” struggles to navigate the bureaucratic system and fails to obtain coal subsidies for the upcoming winter, ultimately extinguishing his hearth.

Testimonies of “a terrible disaster engulfing poor neighborhoods”

In 1936, Suat Derviş penned a series on the pages of Cumhuriyet, examining the disease through interviews in Istanbul. She sought out individuals unable to find hospital beds or gain admission to sanatoriums, leaving them without proper treatment. By presenting personal stories and testimonies, Derviş humanizes the healthcare crisis, shifting the focus from statistics to the lived experiences of individuals affected by tuberculosis and the healthcare system’s shortcomings. This approach evokes empathy and understanding for those grappling with these challenges.

For Derviş, the inability to access adequate care due to financial constraints aggravates patients’ health outcomes and perpetuates the cycle of illness and poverty. To illustrate, Hamdiye, whose many family members lost their lives due to TB, falls ill herself. The doctor she consults advises her to eat well and rest, but as a widow with a child, she expresses her financial helplessness by asking, “Where am I going to get food?”[15] Similarly, Yusuf faces a dire situation after losing his wife to tuberculosis, which he also contracted before her death. Unable to work due to his illness, he fears for his children’s health (Figure 3).[16]

Figure 3: Hamdiye (on the left) and Yusuf and his children (on the right). Suat Derviş not only conveys the hardships faced by the impoverished but also enriches the narrative by giving a tangible presence to their names.

It is evident in Derviş’s narrative that despite securing initial treatment and hospital beds, many encountered barriers, such as limited access to long-term nutritious diets and rest, crucial for combating TB. Moreover, bureaucratic hurdles and Istanbul’s status as a healthcare hub exacerbated these challenges, leading to prolonged wait times. Even those who embarked on the bureaucratic process optimistically often found themselves defeated.[17]

While Ilgaz and Nesin use satire to portray challenges within the healthcare bureaucracy, Derviş provides her readers with a view of real events and people. Although Ilgaz occasionally brings smiles to readers’ faces, Derviş’s narrative relies on journalistic reporting. It reveals the gravity of the situation as the interview series sheds light on the desperation of impoverished individuals afflicted by the disease. In her final article of the series, Derviş concludes that despite having gathered enough material to continue for months, she chooses to end it, unwilling to further distress her readers in the face of such tragedy. She suggests that increasing the number of healthcare facilities is not the solution to these systemic problems. Instead, by emphasizing the economic aspect of accessing treatment, Derviş proposes that professional groups unite and confront this disaster as a community, thereby removing the state authority from the picture.[18]

Finally, in Orhan Kemal’s story Streptomycin,[19] a young man faces difficulty obtaining his medication from the Association for the Struggle against Tuberculosis (Veremle Savaş Derneği) despite having a prescription. The official informs him that the weekly supply is depleted. His mother confronts the Association and secures the medicine, but instead of giving it to her son, she sells it at a discounted rate near the dispensary. Then, “with nimble steps, flying as light as a feather,” she swiftly purchases a fatty cutlet from the butcher.[20] Kemal’s narrative suggests that the profound impact of poverty and systemic healthcare issues lead to desperate actions and moral dilemmas.

The examination of tuberculosis and healthcare access in Republican Istanbul reveals bureaucratic barriers, systemic shortcomings, and human struggles. Inefficiencies within the bureaucracy often hindered individuals from obtaining proper treatment, exposing social inequalities and worsening the health of already sick individuals. The works examined offer insights into the emotional and physical toll of navigating the healthcare system, humanizing the healthcare crisis of Istanbul’s Republican era surrounding TB.

The analyzed works present a multitude of narratives. Nesin uses satire to address the distorted power dynamics faced by patients waiting in line at dispensaries. Similarly, Ilgaz employs satire to expose the severe inefficiencies and frustrations of the healthcare bureaucracy, highlighting extensive delays and systemic obstacles, thereby providing a more comprehensive understanding of these issues. Meanwhile, the narratives of Derviş and Kemal reveal the economic dimensions of the catastrophe and the resulting moral corruption, portraying the disease as an unavoidable horrifying scenario.

Understanding the sentiments of those without financial means who rely on state healthcare facilities, waiting in queues, and navigating bureaucratic hurdles for treatment is challenging. However, it is easy to envision the troubles of thousands seeking medical care for TB, a disease without a definitive cure for a significant period. The dramatic and sometimes satirical portrayal of these prolonged waits in hospitals without adequate equipment and beds and clinics with limited resources and facing struggles within this bureaucratic maze suggests their common occurrence in everyday life.


Footnotes

[1] Precise statistics from the early Republican period are scarce due to incomplete records. In the 1920s, Turkey saw an estimated 37,000 annual TB deaths (“Verem: Senede 37,000 kişi ölüyor,” Cumhuriyet, 16 February 1930). By the late 1940s, the Ministry of Health reported 40,000 annual TB deaths and 200,000 to 250,000 patients nationwide. This persisted into the 1950s, with 40,000 annual deaths, a number that increased post-war. “Röportajımız: Haydarpaşa Verem Paviyonu,” Yaşamak Yolu 147 (December 1948): 7-8; “Tıb: Hastaneler,” Akis 8:223 (16 August 1958): 24.

[2] The fight against tuberculosis began in the late Ottoman period. However, TB lacked a comprehensive response by the new Republic. Before the government took control after WWII, voluntary organizations were crucial in combating TB by opening dispensaries and raising health awareness. Ceren Gülser İlikan Rasimoğlu, “’Verem İyi Olur Bir Hastalıktır’: Cumhuriyetin İlk Yıllarında Verem Mücadelesi ve Siyaset,” in Bitmeyen Hikaye: Küresel Salgın Çağında Tarihe Yeniden Bakmak (Salgın Hastalıklar ve Kamu Sağlığı Pratikleri), ed. İsmail Yaşayanlar (Istanbul: Tarih Vakfı Yurt Yayınları, 2022): 327-330.

[3] Examples include the 1930 Public Health Law (Umumi Hıfzısıhha Kanunu) and the 1949 Law on the Struggle on Tuberculosis (Verem Savaşı Hakkında Kanun). For an overview of healthcare regulations and spaces, see Mahmut Tokaç and Sabahattin Aydın, “Health Services in Istanbul During the Republican Period,” in From Antiquity to the 21st Century: History of Istanbul, retrieved from: https://istanbultarihi.ist/478-health-services-in-istanbul-during-the-republican-period

[4] “Cümhuriyetin Onuncu Senesi,” İstanbul Seririyatı 15:11 (1933): 207, 210, 211.

[5] BCA 30-1-0-0 / 90-563-11 “Tophane Erkek Sanat Enstitüsü öğrencisi Erol Özgürat’ın Valdebağ Sanatoryumu’nda ücretsiz tedavi edilemeyeceği,” 28 March 1953.

[6] Umumi Hıfzısıhha Kanunu, Resmi Gazete, Articles 113, 114, 115 and 116, 6 May 1930.  

[7] Dr. Bedi Şehsüvaroğlu, “Sultanahmeddeki Verem Dispanserinde bir gün,” Cumhuriyet, 6 January 1948. Dr. Bedi N. Şehsuvaroğlu (1914-1977) served as a faculty member in the Department of the History of Medicine and Deontology at Istanbul University Faculty of Medicine between 1950 and 1977. Renowned for his extensive contributions, he authored articles encompassing the fields of medical history, medical ethics, dentistry, and pharmacology.

[8] Aziz Nesin, “Gaçıncı Gılinik,” in Kazan Töreni (Istanbul: Tekin Yayınevi, 1967): 38.

[9] Ibid, 38-39.

[10] Rıfat Ilgaz, Pijamalılar (Istanbul: Çınar Yayınları, 2016): 8.

[11] The novel reflects Ilgaz’s own experiences as the author battled with TB for many years. He was hospitalized in Istanbul’s Yakacık and Heybeliada sanatoriums.

[12] Ilgaz, Pijamalılar, 14.

[13] Rüknettin Öztamur, “Serbest fikirler: Kömür dağıtma işi,” Cumhuriyet, 10 October 1942. Halık Dilinden Dilekler, Şikayetler ve Fikirler: Halkın kömür dağıtma işinden şikayetleri devam ediyor, Cumhuriyet, 21 October 1945. “Bir kömür için nelere katlanıyoruz?,” Cumhuriyet, 5 January 1955.

[14] “Fukaraya 30 bin kilo kömür dağıtılacak,” Cumhuriyet, 3 January 1946. “Fıkaraya kömür tevzii,” Cumhuriyet, 8 January 1946. “Fakir halka kömür tevzii,” Cumhuriyet, 22 December 1953.

[15] Suad Derviş, “Acı Bir Anket: Veremlilerle Konuştum,” Cumhuriyet, 20 January 1936.

[16] Suad Derviş, “Acı Bir Anket: ‘Karım veremden öldü, ben de veremim!’,” Cumhuriyet, 21 January 1936.

[17] Suad Derviş, “Acı Bir Anket: Hazineler yiyen bir illete karşı 90 kuruşluk kazanç!,” Cumhuriyet, 22 January 1936. Suad Derviş, “Acı Bir Anket: Parasız ve kimsesiz bir ananın feryadı,” Cumhuriyet, 01 February 1936.

[18] Suad Derviş, “Acı Bir Anketin Hulâsası: Veremle mücadele için hastane kâfi değildir,” Cumhuriyet, 03 February 1936.

[19] Streptomycin, an antibiotic medication, is utilized in the treatment of tuberculosis.

[20] Orhan Kemal, “Streptomycine,” Sarhoşlar (Istanbul: Everest Yayınları, 2009), 10-14. The book was first published in 1951. Additionally, Orhan Kemal worked as officer at Adana Society for the Struggle against Tuberculosis in 1945, his short story can be considered inspired by real-life events.


About the Author

Zehra Betül Atasoy holds a Ph.D. in the Urban Environment-History specialization in a dual degree program at the New Jersey Institute of Technology and Rutgers University. Her recent research concentrates on the spatialization of preventive practices, the visibility of infectious diseases in public spaces, and the lived experience of health in the urban environment. She works as lecturer at Kadir Has University-Faculty of Art and Design.


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Citation: Zehra Betül Atasoy, Navigating Bureaucratic Hurdles: Tuberculosis and Healthcare Access in Republican Istanbul, in: TRAFO – Blog for Transregional Research, 18.06.2024, https://doi.org/10.58079/11ufm


OpenEdition schlägt Ihnen vor, diesen Beitrag wie folgt zu zitieren:
Forum Transregionale Studien (18. Juni 2024). Navigating Bureaucratic Hurdles: Tuberculosis and Healthcare Access in Republican Istanbul. TRAFO – Blog for Transregional Research. Abgerufen am 20. Juli 2024 von https://doi.org/10.58079/11ufm


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