DISCLAIMER: I do not intend for these blogs to be seen as giving clinical advice nor as judging public health policy but rather to recount the lived experiences of family medicine physicians from across the world. I recommend you still follow your local guidance but this goes without saying.
Date of interview: 30th April 2020
Number of confirmed cases at time of interview: 117589
Number of deaths at time of interview: 3081
Population: 82 million
This week I am interviewing my dear friend Dr Ilyas Erken. If you’ve ever been at a Vasco da Gama Movement (VdGM) event, you will know who he is and love him! I have a lot of time for my Turkish friends because they are so friendly, so funny and always the light and life of a party and it is this sociableness which turns out to be a huge consideration in the COVID response for the Turkish family doctors. He lives in ESKİŞEHİR which is half way between Ankara and Istanbul and Ilyas’ home town. Doctors in Turkey are accustomed to working long hours in some pretty tough conditions pre-COVID and Ilyas describes the mood as being pretty chilled at the moment. The reduction in patients and emergencies has been some light relief (even though Ilyas is still working seven days a week currently) but he is fully aware that they need to be prepared because they could be called up at any moment. I was drawn to organising an interview with Ilyas because I had heard about their weekend lockdowns which is an unusual set-up compared to other countries in Europe. I wasn’t sure how they had escaped the mainstream criticism that Sweden has exposed itself to for following an alternative methodology. How could this lockdown with such complex rules be enforced and what was the reasoning behind it?
Ilyas tells me that around 70% of COVID-19 cases are actually in Istanbul, probably related to the fact that it is a tourist hot spot with many travelers from both Italy and China. I was interested to hear that there is an economic link between Istanbul and Milan which means lots of traveling between the two cities for work relations and there are a lots of ex-pats in both cities, which might go some way to explain the migration of the virus. It is thought that Patient 0 was probably a pharmacist who was in contact with tourists from China and they made the link when the doctor that one particular tourist also saw also fell ill.
So what restrictions have been put in place? The Turkish lockdown does seem a bit complex. From Monday to Friday, 20-65 year olds can be out and about within reason but everyone stays at home on the weekends. Those over 65 and those under 20 are on strict quarantine all seven days of the week. Ilyas explains to me that this is because of economic reasons as the government is being realistic about keeping the fragile economy going. Covering people’s salaries as they stay at home is just not an option. He tells me that the government was quick to act, announcing the quarantine for over 65 year olds from going out on the same day that the first case was announced on the 10th March. He tells me that the quarantine has been devastating for many Turkish people who are, as a nation, very sociable and meeting friends in the park or in the shops is a part of every day life. It has been a real effort to remind people to stay at home and I’m really intrigued to hear that part of Ilyas’ job as a family doctor is to call his patients over 65 to remind them of the lockdown rules on a regular basis. We laugh about how we both have encountered cognitive dissonance in our patients who have varying ideas of what self-isolation is and what counts as essential travel. Laugh or cry?
But why the under 20’s? Ilyas agrees that closing the schools has been hard on parents and keeping the children at home has been a challenge. I really feel for the parents across the world who are trying to work from home whilst home-schooling their children. It’s hardly surprising that there is increasing evidence to suggest that, in this environment, women’s work productivity worldwide has been suffering and the gender gap is accentuated because the majority of childcare historically falls on women. Here is a link to a UK article showing that research submitted by men is increasing as those submitted by women are decreasing. Anyway, I am digressing. In Turkey, having this rule where under 20 year olds remain at home means that children and parents are not tempted to let the children and adolescents socialise. Reducing the risk of becoming vectors of disease is especially important given that, like many countries, grandparents look after the grandchildren. Like the UK, he says that the people in their 20s are the hardest to convince to follow social distancing rules or to wear masks. Perhaps it’s because they know they’re less affected; maybe they are more reckless. As imagined, in order to implement a graded system, policemen wander the streets to enforce these rules with a 400 euro fine if found breaking the rules. Ilyas says that he gets stopped around eight times on the way to work to ask why he was out on the weekend. He also points out that the bigger cities are probably more strict at enforcing these rules.
I ask him if this is a popular policy in Turkey. He tells me that he knows that a semi-lockdown is not the best way to slow the disease but a complete ban is just not possible economically. They saw what was happening in Italy and were quick to call the closure of bars, schools and public places. He says that it is still a well-planned measured response by a well-respected scientific committee and that the Minister of Health is a well-trusted individual as he is seen as wise but with humility. As mentioned before in my posts, trust in the government or at least the scientific committee that is leading us is crucial to keep us propelling forward in this pandemic – something that is showing cracks in the UK at the moment as we come out of lockdown. He feels that they are managing ok for now and this is certainly reflected in the numbers. They were all indeed quick to act since family physicians were educating patients before they reported their first case by putting posters up in the waiting rooms and placing hand sanitisers in the waiting rooms. Clinics were buying Personal Protection Equipment (PPE) for themselves before the first case was reported and then as soon as it was, the government started providing. We, in the UK, have just received a huge shipment of PPE (one of eight countries) from Turkey so I wonder if they have a surplus. None of Ilyas’ friends are lacking at the moment but he also says that this is a global problem and we need to help each other on a global scale. This is so indicative of the hospitality in Turkey where you are welcomed into the home like you’re part of the family, get fed until you can’t move and laugh until your jaws ache. They will look after all your needs, even the ones you didn’t know existed. This cultural norm to make sure that everyone is ok clearly translates on a global scale. I really hope that this international collaboration is shared by other countries because, in this global pandemic, none of us are ok unless we are all ok.
And what is life like as a family physician in ESKİŞEHİR at the moment? Ilyas tells me that the health system in Turkey, like the UK, is acting like COVID-19 is the only disease in the world. He has his worries about the aftermath when we have to pick up the pieces for our patients with chronic disease or mental health issues. In Turkey, it’s a government mandate for family physicians to call patients who are over 65 or with chronic diseases proactively every ten days or so just to see if they are ok. In the UK, those who are deemed high risk will get a letter from the government to tell them they need to be ‘shielding’ (i.e. not leaving their house) and then their family doctor will call them to check in on them once during lockdown. I personally find these phone calls a little uncomfortable as we’re supposed to ask them about end-of-life care as well which can feel a little disconnected on the phone and when you haven’t met them before. However, my patients have generally been pretty understanding.
I am really impressed with how the Turkish family physicians have stepped up in the COVID pandemic. Being quite a new specialty, you would expect them to have a limited role in the response. However, this really hasn’t been true. If any of Ilyas’ patients test positive, he takes the list of people that the patient has seen in the past week and calls everyone on that list every day for 14 days to ask them about symptoms but to also remind them about self-isolating. At the moment, he has 54 people that his team calls daily just to remind them. He says that it’s very hard to tell a Turkish person not to go out and socialise and he feels like he’s killing them to tell them to stay at home which is why this message needs to reiterated over and over again. Due to the strong family networks in Turkey, everyone is pitching in to remind others to not go outside and running errands for each other which really helps. He knows that, as a Turkish community, they will have to endure this heartache but he really believes that the most important thing right now is to protect the older people because of their deep-seated place in society.
We talk about Ramadan as well. In Turkey, Ramadan is equally a cultural event not just a religious one. A bit like giving up something for Lent in the UK which is vestige of Christianity, people will follow Ramadan even if not particularly religious. I’m no expert on Islam but I used to work in an area with a large Bengali population so I’ve had to learn about the cultural context of Ramadan and what we need to look out for when patients are fasting. At the moment, I really feel for my Muslim friends and patients because the days are long in the UK and not being able to eat between sunrise and sundown feels like torture to my unfasted body. Not just that but there is a real sociable aspect to breaking the fast and it must be difficult to physically distance at this time. However, Ilyas tells me that the longer days of fasting is seen as being more spiritual and tells me to think about it almost like extra prayer points! Interestingly, he does say that he has noticed that some of his patients have opted not to fast this year because of COVID-19 although we are not sure of the exact reasons why. With religious meetings banned, there must be a real toll on spirituality at the moment, especially when this is a time when people’s faiths are being tested. Being asked to choose between your physical health and your spiritual health must be difficult and I really feel that, as family doctors, we need to allow a conversation for both.
I’d like to finish on something that Ilyas mentioned that has stayed with me since; there is a medical component to COVID-19 but there is also a social, political and economic part. We are all trying to survive and protect ourselves from the disease but we have to see beyond the cytokine storms and the respiratory failures. I’ve been thinking about this because I don’t think life is going to go back to the way it was before any time soon. Finding this new normal for others, including our patients, may be really challenging in terms of finding an identity, finding economic security whilst navigating political changes brought on by this virus. I don’t see this pandemic as a great leveler but I see it is as unmasking divisions – divisions in wealth, divisions in race, divisions in gender. It was spread by the more affluent on their international business trips and ski trips but the more deprived and the more marginalised are suffering the most worldwide as a result of the virus and from the restrictions of lockdown. As we head out of lockdown in the UK and we look for this new normal, I hope this has given us all a moment to reflect on the social determinants of health and how we are not all born equal.
Thank you Ilyas for your time and your humour and your positivity. It also makes me think that despite all the silliness and fun that we all share as part of the VdGM network, I am now getting an insight into all your working lives and the professionalism and the hard work that goes into it. I can’t wait to see you all on the dance floor again.