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The Battle Over the Numbers: Turkey’s Low Case Fatality Rate

BLOG - 4 May 2020

Turkey ranks seventh worldwide in the number of confirmed coronavirus cases reaching almost 120 000 by the last day of April. The country has also been frequently cited for having the fastest rising infection rates in the world, partly due to the increased capacity for testing. In fact, Turkey has become one of the world’s top 10 countries in the number of COVID-19 tests carried out. Turkish Medical Association argues that the infection rates are even higher because the country lists only those who test positive for COVID-19 and opts not to include people who receive COVID-19 treatments based on the clinical symptoms in the overall official figures. The Association also argues that there is incongruity between the number of cases and number of deaths and suggests that the number of fatalities due to COVID-19 are under registered. Indeed, Ekrem İmamoğlu, the mayor of Istanbul - the epicenter of the pandemic in Turkey - informed the public that the number of deaths in the city for this year was 30-35% higher than the same period last year.

Despite the prevalence of the virus among the population and rapidly increasing infection rates, what is striking is Turkey’s lower death rate. Turkey’s death rate per 1 million population is 37, making it even more successful than most comparable European countries for COVID-19. On the basis of official figures, Turkey ranked better than Germany, which has received a great deal of attention and admiration for its low fatality rates.

COVID-19 Rates (as of 30 April 2020)

     Country Total cases Total Deaths Deaths/1 M population Tests/1 Million population
  USA 1,064,572 61,669 186 18,549

Spain

236,899 24,275 519 30,253
Italy 203,591 27,682 458 31,603
France 166,420 24,087 369 7,103
Germany 161,539 6,467 77 30,400
UK 165,221 26,097 384 12,058
Turkey 117,589 3,081 37 11,157

Source: Worldometer
 

Unlike Germany, however, Turkey’s low death rate did not receive much appreciative feedback. On the contrary, it was attacked in news reports and commentaries because of the alleged inaccuracy of its official figures. The low case fatality rate was a source of controversy domestically as well even before the international media focused on the story. The highly polarized climate of the country created two camps around the official figures. The pro-government camp suggested that Turkey is doing great in its crisis management by citing the increased capacity for testing and low fatality rates, choosing to completely ignore the rapidly rising infection rates. On the other hand, the opposition focused on the infection rates and the probable inaccuracy of the numbers on all categories. But even on that score, newly available data (as of April 30) show that the numbers of patients admitted to ICUs, and those on respiratory support systems, are declining.

Indeed, the controversy was not unexpected. As Senem Aydin Düzgit and Fuat Keyman argued in a recent piece, transparency and trust alongside capacity, effective leadership, and efficiency lie at the core of success in fighting the pandemic. In a significant way, Turkey began its struggle against the pandemic in the context of extreme levels of political and societal polarization. Indeed, much of the existing research on Turkey highlights the currently polarized state of Turkish society and a growing ideological and policy-based distance between supporters of political parties. Trust levels in the government also varied significantly as a consequence of this deep cleavage caused by polarization. For close to a decade now the country has also undergone a process of deinstitutionalization which has significantly eroded state capacity. Under these circumstances, the crisis provided the ideal context for the government to show its commitment to deliver and for the opposition to make its case for the government’s incapacity to deliver. As such, the statistical figures ended up as the (almost only) reliable references to objectively measure success or failure. Thus, they turned into the symbolic arena where the political battle takes place in the context of the country’s extensively polarized politics. 

Internationals Pitch in 

Most recently, the NY Times joined this intense domestic political battle with a headline that directly suggested Turkey was hiding a wider coronavirus calamity. According to the NYT, the exact figures could be estimated by comparing this year’s weekly averages of the death toll with the weekly averages from the last two years. NYT echoing the mayor’s subsequent statement reported that Istanbul has registered about 2,100 more deaths this year than the last two years for the same period. Thus, the NYT reasoned, while this striking jump in death rates may not necessarily be directly attributable to the coronavirus, it created a fog over the official COVID-19 related numbers and suggested that a majority of virus-related deaths were not being recorded. 

The day after, however, NYT published another piece, indicating that the problem does not just concern Turkey. It estimated excess mortality rates for 11 countries by comparing the number of people who died from all causes this year with the historical average during the same period. The review of mortality data showed that in these countries 20 to 30% more people have been dying than normal, similar to what the NYT found for Turkey. In fact according to the Financial Times the real figures in the UK are more than double the official rates. Furthermore, even when we assume that the deaths in Istanbul were about 30 percent higher than the official records, and all the other countries were reporting accurate data, Turkey’s fatality rate still remained among the lowest compared to similar European countries and the US. 

The emphasis on the inaccuracy of figures is a function of the implicit bias of analysts who solely regard effective governance as key determinants of success in the handling of the coronavirus crisis.

That debate is likely to continue for some time and we will only have an accurate picture about the numbers once the first wave is over, as is the case elsewhere in the world. Our goal here is not to hit that hornet’s nest but to underline the fact that there are factors other than transparency and assumed incompetency in the Global South that carry a lot of weight in determining outcomes. The emphasis on the inaccuracy of figures and the resulting doubts about the exact rate of mortality caused by COVID-19 is a function of the implicit bias of analysts who solely regard the role of the legitimate political system, strong state capacity and effective governance as the key determinants of relative success in the handling of the coronavirus crisis.

Indeed, these are the key variables in handling the crisis, in flattening the curve for the spread of the disease, in managing both the pandemic and the economy in a relatively balanced way, and in protecting the vulnerable populations from adverse economic effects of the corona crisis. However, death rates may not be necessarily related only to these variables in every domestic context. We believe the demographics of the country and the structure (not the strength) of the health industry are two key variables that help explain the lower than expected death rates, specifically for Turkey. Moreover the norms for the care of the elderly may account at least partially for the difference in the number of deaths for the elderly between Turkey and Western European countries. It is also worth noting that Central and Eastern European countries that have weathered at least the first wave of the pandemic rather successfully did not get the attention they deserved for the way they handled the crisis either. 

Caring for the Elderly

The timing of the preventive measures is crucial in the crisis response. Although Turkey was relatively slow in stopping flights from Iran, (the second epicenter of the pandemic) it was among the first European countries to stop flights to and from China on February 3. Turkey also introduced social distancing measures around mid-March, right after the first confirmed case of Coronavirus, and earlier than many Western countries. Large events and gatherings were suspended; schools were closed nationwide; nonessential shops, venues and public services halted their activities. Borders were closed except for returning residents and citizens. Eventually, travel to and from the country’s 31 big cities was also banned. Production was never halted. And the lockdown targeted only certain age groups.

The most careless decision on the part of the government concerned the policies about the umra. The Directorate of Religious Affairs inexplicably did not cancel umra travel and allowed 21000 citizens to travel to Mecca. After the nature of the pandemic was widely known it took no serious measures to quarantine the returning pilgrims and only after a public outcry did it make an effort to implement a quarantine to the last group of some 5000 pilgrims. If infected, these people were likely to have contaminated many in their surroundings since custom dictates that they receive visitors, well-wishers and others at home to accept congratulations for having done the pilgrimage.

On lockdown, the government initially banned all forms of non-essential movement of people over 65 and people with comorbidities. Later, this specific ban was extended to include people under 20, unless they were employed. These measures did not succeed in containing the spread of the virus and generated an intense debate around the priorities of the Turkish government. In the middle of an ever-deepening economic crisis, the AKP government unsurprisingly opted to protect the economy and kept the workforce mostly at work. In fact, the strategy of Turkey was labeled "class-immunity" in mocking reference to the concept of UK’s "herd-immunity". This strategy, however, created a rapidly increasing infection rate as in elsewhere. 

However, what is unique in Turkey was that this rapid spread of the infection did not overburden the healthcare system and cause its collapse as happened in many other countries. Taking the risk groups and elderly out of public life completely might have been one of the reasons for this difference. For over a month now, Turkey’s elderly population and all people with comorbidities could not step out of their tiny city apartments even for a short walk.

What is unique in Turkey was that this rapid spread of the infection did not overburden the healthcare system.

This policy would have been totally impossible in a different social setting where the family networks around the elderly population are not as dense as they are in Turkey.  As Mine Eder rightly points out, with very limited welfare state provisions, domestic care for children and the elderly in Turkey has, from the very start, always been sourced through either extended family networks or the informal labor market. 

Indeed, taking care of the elderly in Turkey is mostly a family matter and unequally shared by the women of the family: the daughter or the daughter-in-law is responsible for taking care of the parents. When the family is wealthy enough and young women of the family are working, the immigrant woman labor steps in. Many of the middle-class families in Istanbul hire immigrant women mostly from the post-Soviet countries as stay-home caregivers for their parents. This type of labor is cheap and convenient given that they do stay in the same house where they work, transforming the caregiving into a 24-hour job under conditions resembling slave-labor for some and without much intervention coming from the state to regulate working conditions either. 

Most importantly, sending one’s parent to a nursing home is culturally taboo in Turkey and only under extreme circumstances should families send their parents to nursing homes. Conversely, it is the most common form of caregiving in Europe and the US. Therefore, data from varying official sources indicate that in Italy, Spain, France and Belgium between 42% and 57% of the COVID-19 deaths took place in nursing homes. Nursing homes are places where physical distancing is almost impossible among a susceptible population. Moreover, the staff live outside, and are not well-trained enough to handle emergencies. Transferring the care of the elderly to a collective like nursing homes is under normal circumstances a sign of a well-functioning welfare state. It enforces and supports women’s participation in the market by reducing their caregiving responsibilities. However, under conditions of a rapidly spreading virus that victimizes the elderly disproportionately, this form of collective care seems to be one of the major factors in hampering the capacity of some Western European states in limiting fatality numbers and reducing the pressures over health services.

More broadly, demographics matters. For aging populations collective caregiving becomes the only viable option. Turkey has a median age of just over 30, younger than anywhere else in Europe. In Europe, consistently low birth rates and higher life expectancy have transformed the shape of the EU’s age pyramid; marking a transition towards a much older population structure, a development which is already apparent in Italy and France. The median age of the EU-28’s population is rising and was 43.1 in 2018. With an ageing population, neither herd immunity nor class immunity are viable strategies. And as the virus reached the vulnerable populations, it claimed proportionately more lives. 

What About the Health System?

Another factor that might be related to the low fatality rates is the strength of the health industry and the resources and capacity available to it. Many analysts identified the AKP government reform of Turkey’s health care system, one that also presented new ways for the inclusion of the marginalized segments of the population, as a major cause of its initial political success. Indeed, according to World Bank data, between 2002 and 2008, there was a significant increase in health expenditures. However, this trend was reversed and health expenditures began to decline sharply starting in 2009, in the wake of the "great recession". It reached the point whereby among OECD countries, Turkey ranked at the very bottom in terms of total expenditures on health per capita. The number of hospital beds per 100,000 people is also another important indicator of the health care system of a country. Turkey currently has 2.81 beds for 1 000 people ranking far behind Germany (8) or France (5,98).

Why would a country with a relatively young population have this many intensive care beds? The answer lies in the privatization of the health sector.

However, in a sudden crisis like this pandemic, it wasn’t the regular hospital beds that mattered but the number of intensive care unit (ICU) beds. Turkey, interestingly, ranked as one of the top countries in Europe in the number of ICU beds per capita. Why would a country with a relatively young population have this many intensive care beds? The answer lies in the privatization of the health sector. Almost 60 percent of the intensive care beds are in private hospitals.

Intensive care services are the most expensive medical service, the costs of which services are covered by the state insurance system if the patient cannot afford their treatment. Previously, there were a multitude of reports on how private hospitals were abusing the system by unnecessarily and extensively putting the patients in ICUs and charging the public for that. But what could be seen as an investment strategy feeding corruption ironically helped Turkey in delivering effective care to COVID-19 patients. 

One should also look at city-level inequalities in the healthcare system. The national figures may be misleading since the pandemic does not affect the country evenly and metropolitan cities are its epicenters. In the case of Turkey, both the health services and health expenditures are concentrated in Istanbul. This is a feature of the Turkish healthcare system that was sharply criticized for being a symbol of unequal access to health care. This fact, and again unintentionally, became one of the strengths of Turkey’s response to the pandemic. Just like NYC, Istanbul has a disproportionate share of the infections since it is Turkey’s most important international hub. Indeed, as compared to other Western countries, Turkey has fewer globally connected cities. 

Finally, physicians who were used to routinely working under stress for long hours, did not seem to have been overwhelmed by the new wave of patients sent their way by the epidemic. There were many who were infected and a number of well-respected doctors lost their lives. Yet a good, devoted and highly educated medical workforce, slowly increasing in numbers, worked in favor of Turkey and positively affected fatality rates. Finally, as a member of Turkey’s Scientific Council, Dr. Alpay Azad recently said in an interview that medical practitioners in Turkey started using aggressive treatments and medication much earlier than their Western counterparts, suggesting the flexibility of treatment protocols in Turkey as compared to the Western countries. This also raised criticism towards the government for suppressing certain side effects of specific medicines. 

Multiple Factors, Multiple Paths 

The immediate questions about the pandemic in Turkey were well taken: how could a country that was identified as an example of declining state capacity, deinstitutionalization, and low levels of trust, have lower fatality rates than the "exemplary" countries? How could a country in which the central government keeps fighting with the local municipalities in order to hamper their capacity to deliver services to their vulnerable populations (so as not to let them get political credit) be successful in limiting the number of fatalities?

The figures are indeed counterintuitive. Yet the criticisms over Turkey’s fatality rates reflected an implicit bias. The immediate answer was found in the lack of transparency and analysts rushed to argue that the figures could not be true because they were counterintuitive. The numbers were accused of being incorrectly reported. As such, these figures have become a new battle ground. Under these circumstances, reporters and analysts failed to look into the factors that may have explained the discrepancies in numbers. This could have allowed them to give a different perspective on the comparative results between Turkey and Western European countries.

We argued that what was seen as a simple problem of transparency, may hide a more complex explanation. The crisis management system of Turkey benefited a lot from many of the negative externalities that would be seen as a disadvantage in normal circumstances. The Turkish case shows us that success in each separate case is related to multiple factors that interact with the unique social features of a given country. Demographics interacted with politics. Social structures affected the outcome in uncertain ways. Timing, population density all mattered tremendously. 

The most important lesson we should draw from this crisis, however, is that in such emergencies, we need governments and elites that we should be able to trust. We need inclusive and broad health care not just to deal with this crisis but under normal circumstances as well. We need to take care of our vulnerable populations better so that they will be better equipped to survive in times of crisis. We need dense global cooperation to prevent the rapid spread of diseases. We need early detection and monitoring systems. Physicians should report new types of viruses not to their governments, but to the international bodies without fear of prosecution. 

We cannot know how and which groups the next pandemic will hit. We cannot predict what the next crisis will be. A crisis should not be our guide to the future. Improving the inclusiveness of our societies in normal times should.

 

Copyright : Yasin AKGUL / AFP

 

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