Key messages

  • Properly managing a pandemic is not only good politics but also good ethics.

  • Populist nationalist attacks on health and human rights have been increasing throughout the COVID-19 pandemic.

  • The Turkish government’s strategy for handling the pandemic has been to withhold information and put the blame on everyone else.

Introduction

The crisis caused by COVID-19 has affected countries across the world, including high-income countries in Europe and North America. Emergency lockdowns have led to a global economic crisis that has especially impacted disadvantaged groups [1, 2]. The pandemic has taught governments the value of real-time information and the cost of ignoring catastrophes. Despite all our efforts, the only thing we can be certain about is that the long-term consequences of the pandemic remain unclear.

While it is common for a crisis to bring people and institutions together, today we see little coordinated action among the various countries. For example, the governments in Sweden, the United Kingdom (UK), the United States (US), Brazil, Turkey, and India tried to combat COVID-19 by taking a laissez-faire approach, with minimal public health interventions and a desire to keep the economy going [3,4,5]. To prevent any social unrest caused by the pandemic, governments of countries with weak economies such as Turkey resorted to the rhetoric of nationalism, created contrived enemies, blamed the West (meaning the European Union (EU), the UK, and the US) [6] by stating that they are jealous of Turkey’s success, gave more authority to security forces, and banned public demonstrations [1, 7, 8].

For authoritarian-minded leaders, the COVID-19 crisis is offering a convenient pretext to silence critics and consolidate power. Populist and autocratic leaders have used the crisis as an excuse to do things it had long planned to do, but had not been able to [9, 10]. Tactics used by such leaders include: imprisoning human rights defenders, journalists, lawyers, political activists, and medical professionals; rejection of public health science and human rights laws; blaming other countries for causing the pandemic; underreporting of COVID-19 cases; condemning the World Health Organization (WHO) for failing to obtain the information that the world needed; forced deportation of immigrants; and withdrawing from international agreements [1, 8,9,10,11,12,13].

The Turkish political system

Turkey’s political system is defined as a presidential system based on autocracy [14]. The country switched to its current system by virtually shutting down parliament in 2018. Many powers of the parliament were restricted, and the powers of the president were increased. The president began to govern the country as head of the executive branch. Another feature of the Turkish system is that the president is also the party leader. In this situation, cabinet ministers are appointed from outside of the parliament and decrees issued by the president govern the country; thus, the president uses the authority of the parliament to legitimize his decrees [14, 15].

Because the president is no longer just a politician, but the embodiment of the nation, any person who complains about the president’s actions is legally punished for criticizing the nation. Among his other powers, Turkey’s president can directly dismiss any public official, confiscate the property of any businessman without a court order, curtail freedoms for any reason, open forest lands for housing, fill positions with unqualified persons, spend public funds without being accountable, abrogate international agreements without asking the parliament, establish and close universities, appoint and dismiss rectors, prohibit those dismissed from public office from seeking their rights in courts, and combine or split up ministries [14, 15]. The president carries out all these acts by decree. Although the opposition has criticized these powers, insisting they are the responsibility of parliament, the power and influence of these opposition parties are almost negligible. There are 600 members who are elected for a five-year term from the 81 administrative provinces of Turkey. The leading party (the Justice and Development Party) has 289 members and the supporting party (the Nationalist Movement Party) has 48 [14]. Together, these two parties have a majority (56.17%) in parliament. Clearly, the ability of the opposition parties to resist the majority is very limited [15]. Consider the example of one leading opposition party, the Peoples’ Democratic Party (PDP) which won 11.7% of the national vote in the 2018 general election. The leader of the PDP, Selahattin Demirtas, has been in prison for four years. Another example is Ömer Faruk Gergerlioğlu, member of parliament from the PDP, who was arrested and sentenced to three years for his social media postings [16].

The Turkish health system

The Ministry of Health (MOH) provides primary, secondary, and tertiary care through its facilities. The universities are also major providers of tertiary care in addition to the private sector. Health services in Turkey are financed through the General Health Insurance Scheme, which covers most of the population [17]. The Social Security Institution, financed through payments by employers and employees and government contributions in case of a shortfall, has a single-buyer power in purchasing health care services. People under 18 years of age are entitled to free health services under the General Health Insurance Scheme, regardless of whether they are formally covered in their own right or as dependents [17].

The Social Security Institution and General Health Insurance Scheme Law was adopted in 2008 to provide the Turkish population with access to a wide range of health services and ensure unity, equity, and efficiency in the delivery of these services. The family medicine system has been implemented throughout the country since 2011. Each person has the right to choose their preferred general practitioner. The country’s mortality vs. morbidity indicators and health inputs (nurses per 1000 population, physicians per 1000 population, hospital beds per 1000 population, etc.) are below the averages of many EU countries [2, 17].

The Ministry of Health and municipalities are mainly responsible for public health. Although the Ministry deals with health promotion and prevention activities, environmental health and food hygiene are under the responsibility of other ministries and municipalities. The Civil Registration System under the Ministry of Internal Affairs is responsible for the administration of death records in Turkey. The municipalities are responsible for providing a burial place and keeping records of the burials [17].

Turkish-Western relations

Since 2015, Turkey’s relationship with its Western allies has created headlines that Turkey is moving away from the West and that it might soon be “lost” to its rivals, especially Russia [6]. Increasing anti-Western rhetoric by the Turkish authorities, continuing human rights violations in the country, the arrest of many academics and journalists, the purchase of a Russian air defense system, ongoing discussions about exiting NATO, openly supporting the Muslim Brotherhood, increasing support for radical religious groups, ruling the country by emergency decrees, publicly contemplating joining the Shanghai Pact, appointing trustees to municipalities belonging to opposition parties, have all led to increasingly difficult relations between Turkey and the West [6, 8, 10, 15, 18, 19]. Reports in the Western press often portray President Erdoğan as a power-hungry autocrat who has abandoned Turkey’s long-standing pro-Western stance in favor of neo-Ottoman and Islamist ideals and stronger ties with Russia [6]. Turkish officials state that their allies have constantly victimized Turkey, that they do not listen to the country’s concerns, that our Western allies do not regard the country as an equal, and that Turkey’s interests are ignored by the US, NATO, and the EU. Thus, Turkey is cooling its relations with many Western institutions and states [18].

Turkey’s response to the pandemic

Since the beginning of the COVID-19 outbreak, the Turkish government has argued that, compared to other countries, the country’s health system has sufficient personnel, medicines and supplies, and intensive care beds [20]. The government has repeatedly told the public that almost every need, from masks to diagnostic kits and medications, has been easily met by the system. In fact, since the first day of the outbreak, Turkey has provided medical supplies and financial assistance to more than 152 countries, among them the US, the UK, Italy, China, and Serbia. Many professional organizations, particularly the Turkish Medical Association (TMA), have criticized the government for sending protective equipment abroad, reminding authorities that there are still those who cannot obtain masks and other simple materials in Turkey [2]. Some countries have returned the materials sent, stating that they do not meet international standards. For example, the UK returned 400,000 protective aprons purchased from Turkey in April 2020 because they did not meet the country’s safety standards and therefore could not be used.

As part of the fight against COVID-19, the Turkish authorities launched a charity campaign called “We are enough for ourselves Turkey” but confiscated donations collected by opposition municipalities that had launched a similar campaign. Journalists criticized those responsible for collecting the aid because they had provided bank account numbers to Turkey’s citizens. The journalists were subsequently arrested and jailed on charges of “insulting” the government and “inciting or humiliating the people to hatred and hostility” [20,21,22].

There have been calls to investigate how the authorities displayed poor pandemic management from the start of the outbreak and withheld COVID-19 cases. Professional organizations have pointed out that there is no recognized institution to report how many people have been infected by COVID-19. They have called on the minister of health to resign so as not to damage the dignity of medicine [2, 8].

Very few public authorities have admitted that the COVID-19 numbers do not reflect the facts. The MOH started giving out the number of cemetery burials, but these cases were for Istanbul alone, which has a population of about 16 million. Given that Turkey has over 82 million people, plus another 6 million migrants, the number of actual deaths from COVID-19, as well as those infected with the virus, suggest the country is in the midst of a major disaster.

After the mayor of Istanbul began announcing the number of people buried in municipal cemeteries, it was revealed that the number of “daily positive patients” shared by the MOH did not cover all positive test results, only the number of people with clinical symptoms. It was noted that those who tested positive were called “cases,” and only those who had symptoms were identified as “patients.” While the reason the MOH hid these cases was being debated, the actual numbers for COVID-19 deaths, which included data from cemeteries in opposition territories, were released [23]. When this new data became available on November 25, 2020, Turkey suddenly had the world’s fourth highest COVID-19 mortality rate, and was first in the number of new cases in Europe [24]. The TMA asserts that the number of reported patients and cases and the number of deaths still do not reflect the truth, and even now, actual positive cases are more than five times the number reported in many instances [2].

“The West is jealous of us”

President Erdoğan and his supporters claim that Western leaders fear a strong and stable Turkey and are jealous of the country [25, 26]. In addition, they insist that foreign powers have been attempting to destroy the country by using their traitor puppets in Turkey, such as the TMA, opposition parties, leftist organizations, and the Kurds. At the heart of this propaganda is the claim that the Ottoman Empire will be reborn under the leadership of President Erdoğan, and foreign powers are said to have put up many obstacles to prevent this from happening [6, 15]. The Turkish authorities have stoked such fears by using textbooks and the media to portray free thinkers, foreigners, and minorities as treacherous. As the saying goes, “The Turk has no friend but the Turk.”

Throughout the pandemic, the Turkish authorities have spared no effort to silence any criticism of their management of the crisis, often stating that Turkey is one of the great success stories in controlling the disease [20]. The Turkish government has claimed that the number of people killed by COVID-19 was similar to that of Germany. It constantly emphasizes that the improvements in the health system over the past 15 years surpass that of Western countries and that this has created significant opportunities in the fight against COVID-19. The authorities frequently assert that Turkey’s success against the plague has been ignored by the West. The authorities often proclaim that “the West is jealous of Turkey” and that Turkey, which is standing on its own two feet, has shown its power to the world at a time when global organizations are losing their meaning [6]. The country’s rulers have repeatedly emphasized that the West is not only jealous of Turkey because of its success in managing the pandemic, but also that the West is disturbed by its economic development and its strategic location [18]. The government has even used a few Turks in other countries in slick campaigns that show it extending a helping hand to Turks everywhere, not just in Turkey. Some of these expatriate Turks have asked the Turkish government for help via social media, stating that the governments of their resident countries have abondened them. The Turkish government has sent ambulance planes to these European countries and brought these citizens back home. Such public relations stunts are organized by a special team to strengthen the rhetoric that “The West is jealous of us” [21].

The Turkish government’s alleged enemies

Even today, it is still not known how many people have died from COVID-19 in Turkey or even how many people have been infected with the virus. Instead of giving honest answers, the authorities have doubled down on the narrative that the country has beaten the pandemic and that five groups of enemies are working in cahoots with the West to undermine Turkey’s triumph. These so-called enemies are the Turkish Medical Association [22, 27], the mayors of cities run by the main opposition parties [25, 28], a limited number of academics who defy the party line and express their views on the pandemic [26], citizens who share their views and experiences on social media or criticize the government [29], and the Science Board [30, 31].

The Turkish medical association

The TMA is a public institution protected by constitutional guarantee. Eighty-eight percent of Turkey’s physicians belong to the TMA. Since the beginning of the pandemic, the TMA has been going public with its concerns that the daily data provided by the authorities is neither accurate nor transparent. When the Turkish government did not share any information about the situation in the provinces in March when it “officially” announced the outbreak, the TMA was the first institution to publish this information, based on data provided by the provincial offices.

The TMA was first officially targeted by the authorities in March 2020. The presidents of the Van and Mardin Medical Chambers were called to their local police departments where their statements were taken, and their cases were subsequently referred to court [2]. The TMA determined that the MOH was not using the international codes recommended by WHO for reporting COVID-19 deaths and made this public in April [1, 2]. The TMA stressed that there were about 10 times as many active patients in society as those diagnosed with polymerase chain reaction (PCR) tests, and concluded that the government’s pandemic strategy was a failure. The TMA warned that the intensive care units at hospitals were full and further noted that, in many provinces, doctors had to decide who to admit to intensive care [2]. The TMA declared that, “you cannot manage this, and we are burnt out.” The authorities responded by demanding that the organization be closed immediately, saying that the TMA was as dangerous as COVID-19 and a threat to the country. The Turkish government claimed that the TMA’s statement was a treacherous act against the government [27]. The TMA insisted it was merely trying to handle the pressure being placed on it, and that it needed to take heed of the warnings and recommendations of the scientific community because they applied universally. It further indicated that it had a legal and ethical responsibility to share this information with the public as the public had the right to health and life [2]. In addition, the TMA confirmed that it would continue to fulfill its responsibilities to protect the health of the public, just as it had always done.

The TMA has continually asked why there is a difference between the COVID-19 numbers presented by the governors and the MOH. The TMA states that if the officials do not provide a clear picture of the situation, the health professionals cannot identify proper ways to combat the pandemic. More than 150 physicians have already lost their lives from COVID, and the TMA fears that this heroism will be wasted.

Mayors of cities governed by opposition parties

Mayors belonging to the main opposition parties, which govern the cities in which 49% of Turkey’s population lives, started sharing information about the number of deaths caused by infectious diseases in their cities in October 2020. These mayors indicated that the actual daily COVID deaths in their regions were as much as five times higher than the numbers published by the MOH [25, 28].

Democratically elected mayors of pro-minority political parties in provinces with Turkish citizens of Kurdish origin, such as Diyarbakir, Mardin, Siirt and Muş, had been removed from their seats due to the government’s agenda against the Kurds. Now the Turkish government manages these municipalities with its own appointees [32]. One of the consequences of this action is that the actual number of COVID-19 deaths in these municipalities are not reported. Secret video footage has been shared on social media of some of these municipalities preparing cemeteries for thousands of people [25, 28]. These provinces, which are economically undeveloped and have high levels of poverty, have stated that there are more deaths and infections than the MOH has reported to the medical chambers. From time to time, some medical chamber managers have been arrested for reporting the actual COVID-19 cases and the effects of the outbreak from the field [2].

Academics giving their views on the pandemic

Although article 27 of the Constitution of Turkey states that “everyone has the right to freely learn and teach science and art, to explain, to share and to conduct research in all kinds of fields,” many academics have suffered administrative and criminal sanctions. After giving an interview that was published on an internet news site about the COVID-19 pandemic, Prof. Dr. Kayıhan Pala was said to have “misinformed the public, leading to panic.” Both the Bursa Public Prosecutor’s office and the rectorate of Uludag University have opened investigations into this matter [2, 26].

Citizens who share their experiences and opinions on social media

The Turkish authorities have reported that, since March 11, more than 1,500 people have been detained and more than 70 arrests made on suspicion of making baseless and provocative COVID-19 claims on social media [32]. In addition, many journalists have been detained by security forces and taken to court as part of the investigations launched following the sharing of information about the COVID-19 outbreak on news channels and social media. Turkey, which has more detained journalists than any other nation, ranks 154th among 180 countries in the World Press Freedom Index [1]. By conducting mass detentions from the very first days of the pandemic, the government has sent a strong message that no one is allowed to question the state’s ability to combat the pandemic.

The Science Board

In November 2020, Turkish officials began blaming the government’s own Science Board, which has no authority and acts only as an advisory body, for covering up its failure to combat the pandemic. The Turkish authorities have tried to publicly humiliate the Science Board by claiming it was shirking its (nonexistent) responsibilities to fight the pandemic [2, 30]. After these statements, some members of the Science Board wanted to resign, but the Turkish government ended its action out of concern that it could face sanctions. Some Science Board members stated that they had no authority to fight against COVID-19 but that they had instead made repeated recommendations regarding the pandemic [31]. Some Science Board members showed courage, stating that the number of cases described was not shared with them and that they were trying to understand the current situation based on the models they had developed.

Conclusion

Properly managing a pandemic is not only good politics but also good ethics. And today, Turkey has a serious problem with ethics. It is seen when people violate quarantine, when celebrities regard themselves as entitled, and when groups oppose doctors who urge the wearing of masks. It is seen when there is stigmatization and attacks on health professionals, increased domestic violence, disobeying social distance rules, and when people endanger themselves and others. The Turkish Medical Association and the Ministry of Health have stated that overcoming COVID/-19 is only possible if every individual shows responsibility towards others. Unfortunately, this message has not been embraced by the Turkish people. And who can blame them, when the government itself has been such a poor role model?

The government’s strategy for handling the pandemic has been to withhold information and blame everyone else. But a pandemic cannot be fought by hiding the numbers, changing terms, spying on social media users, jailing journalists, muzzling doctors, and using the law to frighten dissidents. Experience has shown that COVID-19 can only be conquered by having all institutions, health workers, scientists, and the public fighting together. And since any effective disease strategy will require international cooperation, Turkey should stop saying “the West is jealous of Turkey” and change its discourse to “the world is in solidarity with Turkey in the fight against COVID-19.”