By Prof. Dr. A. Gurhan Fisek
There is an important risk occurring owing to treating patients one by one; and this is just like overlooking the forest while looking at trees. Patients and their relatives tries to draw your notice to their individual spheres; make you share their sufferings and find individual solutions to their own problems. They are in the right from their own point of view; yet, this situation should not cause us to overlook the social dimension of the problems.
Only a healthy person establishes healthy relations. Patients and their relatives only concentrate on the their own “saddening” sicknesses. For example, a patient neither has an energy to put an effort for “the program on activating the provision of health services in the long run”, nor has an energy to wait. Only the healthy ones can be engaged in these issues. On that ground, an increase in the number of “healthy” individuals, who are to ponder over health issues and to participate in the planning + activity process, would affect the success of these endeavours.
Contemporary Health Approach
Does ill health concern individuals only?
Or this question may be asked in another way: Is an individual held accountable for ill health by his/her self only?
The World Health Organisation replies to this question by defining the term health: “Health comes to mean a physical, psychological and social well-being”. This definition has been appropriated by the Law No. 224 on the Socialisation of Health, which maintains “health for all” approach.
In this case, physical and psychological well-being have a social dimension as well. In other words, the precondition for physical and psychological well-being is that its social frame has constructive aspects as well.
In fact, “contemporary medicine” approach, which gives its name to the health approach of the 20th century, proposes that individuals should be taken into consideration together with their environments; and reckons that health is not only the concern of patients, but also of everyone whether healthy or not. Put it differently, it appropriates an universal (holistic – integral) approach for the problem to be considered: “It considers preventive, therapeutic and rehabilitative health services as a whole”.
Prof. Dr. H. Nusret Fisek, who was among the founders of the community medicine approach in Turkey, defines health as the mosaic of policies, and calls people’s attention to its multi-disciplinary character and to the importance of team work. Starting from the point that you treat community medicine approach with great respect, you start to incline towards healthy people, try to get their support, and prevent disease and accidents before their occurrence. This causes health to be socialised more; that is to say, causes it to be integrated with society and acquire a social character.
Is preventing diseases an objective to be accomplished by individuals or their families individually? For some minimum scales, the answer is “yes” (like keeping the front of one’s home clean). However, how could other health facilities be achieved individually, which vary from cleansing of the water running down through our facets, to the decontamination of the bakeries that we buy our daily bread, and to the purgation of the brook flowing nearby our homes from sewerage or chemical wastes?
Individuals have many duties for their environments to be made healthy, nonetheless as an individual within a social organisation or as a part of a common struggle. For this reason, preventive health services should not and can not be abstracted from the social activity element.
Likewise, another characteristic of the 20th century in this regard should be emphasised. “Human rights” left its mark on the previous century. “Health rights” and the “right for a healthy living” are the cornerstones of all human rights documents. This means individuals have expectations from society regarding their health; this means the troubles of people are not usually of their own making; and this means “it takes more than one person” as the proverb says.
The basic difference between the contemporary health approach and the traditional one is that the latter is put into use after a disease occurs and it is just like the indemnificatory social security approach of Bismarck (after the car is capsized, there appear many people showing you how to get to a place). Let’s demonstrate these differences through a table:
TABLE-1
Differences between Contemporary and Traditional Health Approaches
|
Subjects |
Community Medicine Approach |
Traditional Approach |
|
Person served |
Serving people when they are both healthy and unhealthy |
Serving people when they are unhealthy |
|
Scope of the services |
Protection, therapeutics and rehabilitation |
Therapeutics and rehabilitation |
|
Evaluation of the person served |
An individual is the integral part of his/her physical, biological and social environment. S/he can not be abstracted from that environment. |
An individual is just a person coming to a hospital or for a medical examination. S/he is a patient who wants his/her disease to be treated. |
|
Causes of diseases |
Biological and social causes |
Biological causes only |
|
Diagnosing and therapeutic services |
If necessary, diagnosing and therapeutic services for commonly occurred and fatal diseases are performed by specially trained and non-physician health personnel. |
Diagnosing and therapeutic services are performed by physicians only. |
|
Providing the service |
Providing the health services for all |
Providing the health services for the ones applying to hospitals and surgeries only |
|
Prevention from diseases |
Having a priority |
Applied in special conditions and limited in scope |
|
Priorities regarding resource allocation |
Limited resources are allocated primarily for the prevention of individuals from commonly occurred, fatal and disabling diseases, and for the treatment of diseases. |
For the treatment of diseases whose diagnosis and treatment are problematic, it is aimed to educate high-qualified specialists and to provide the highest-standard technology |
|
Social concept and planning |
Observing health related events continuously and objectively, improving the services around a plan that is part of the socio-economic development of the country and that is based on these observations |
Not available |
|
Organisation |
A service provided by a team nation-wide, which is complemented and supported by the teams formed by small scale occupational groups |
It may be the service of one physician only. The conception of “team” does not go beyond the walls of hospitals. |
Question 1: By evaluating this table, could you please tell which approach has a dominant influence over the provision of health services in Turkey?
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Contemporary medicine approach
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Traditional medicine approach
It was in the 19th century that the medicine approach was turned towards patients only, and that it appropriated the “star player” (super physicians) approach. Because, it was during that time when the micro-organisms were not known yet, and when the concept of “preventability of diseases” did not took root among people yet. However, scientific and technological developments in the 20th century proved that not only of the contagious diseases, but also the causes of various diseases could be brought to light and they could all be prevented. Also, the 21st century, as we approximate, will be a setting for the effectiveness and success of preventive medicine studies especially through the progress in genetic studies.
Esteeming Human Beings
In my opinion, this question may be answered through the model shown below: human-esteem compound indicator…
“In Turkey, human beings are not esteemed at all”. When we scrutinise this complain that we here most of the times, this would lead us to reach many different angles to be considered. For this reason, it is better to approach this situation in this way: “How can we understand that a person is esteemed?” “What indicates that a person is esteemed?” “What are the indicators of human-esteem?”
The time when this concept is discussed most is when individuals are confronted with the deformities within the society, and when these deformities destroy the order they have established so far. For example, it may be, after a traffic accident, both due to the way the accident occurs or due to the way the health-rescue activities are initiated. Otherwise stated, in the event individuals die or be injured for nothing, it is recalled that the lives of human beings are not esteemed enough. Yet, the same “moment”s may be when social security is already put into use or when it is to sustain its attention for a long time.
Apart from the momentary evaluation of life-esteem and its personification, it should be evaluated in a systematic way. For this particular reason, life of humans should be questioned and the elements that individuals feel its necessity most should be determined. Food, drinking, accommodation, health and etc. are the sine qua non necessities of human beings, and they should be met urgently. The following step, on the other hand, is making these necessities assured.
By taking these two steps of basic necessities into consideration, this is what we propose as the “life-esteem compound indicator”:
TABLE-2
Human-Esteem Compound Indicator 
On the ground of this hexagonal representation, there lies democracy. Because, it is supposed that other six sub-indicators would develop more in parallel to the democratic developments. Therefore, the basic indispensable element of this proposal is democracy, and other indispensable ones are the six sub-indicators. All the sub-indicators are related with each other one way or another, and nourish each other.
These sub-indicators, which increase the esteem given to the lives of human beings, do, at the same time, represent the fundamental human rights. For this particular reason, we should pay attention to the fact that there is a bridge between esteeming human life and human rights.
Society must guarantee the attainments of individuals, but meet the fundamental necessities of humans at first. It is only upon such a ground that individuals may develop themselves and be useful for the society. Beyond any doubt, one of the duties of society; and a significant reason behind this necessity are the indispensability of giving this assurance for “everyone”, not for only “one person”. Because, it is both impossible to give assurance for only one individual, and also nonsense from the standpoint of society.
This model is open to the formation of new hexagons to be annexed to the development of rights. The starting point of this development is one of the corners, that is the right of insisting on one’s rights and of organisation.
Question 2: By evaluating this table, could you tell to what extent lives of humans are esteemed in Turkey?
-
Very much
-
Seldom
As it is clear, it is impossible to consider health as an independent element from all other elements, and to find solutions for health problems with one-dimensional policies. It is for this reason health policies are regarded as the mosaic of policies. In other words, social medicine policies should be reckoned as an indivisible element of social policies.
Social Medicine Policies
Health, whether an individual is part of a community or lives alone in nature together with other creatures, is such a crucial matter that should not be relinquished to individuals only. It concerns other living beings in a community a lot. When it is approach in regard to rights and duties, it also forms a social intervention sphere.
While society acknowledges people to be the right and expect from them to perform their obligations, it does all it can for their contributions to be realised in a convenient environment. This convenience covers health, reconciliation, democracy, and etc.
The struggle that an individual can not undertake by his/her own should be transformed into a “group-based solutions” in which s/he also take place. The enterprise for a group-based solution should be considered not only in terms of people’s from different occupations embarking on a job enthusiastically with a team spirit, but also in terms of synchronisation and co-ordination of different activity fields.
There are many windows thrown up towards the social dimension of health affairs. We compare these windows with the lanes in a running track. The studies made in each and every lane serve for the single objective: Health for all.
I would like to explain this approach by giving examples for some of these lanes:
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Demographic studies;
-
The studies of local governments;
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Manpower policies;
-
Policies on risk groups;
-
Urbanisation and becoming urbanised;
-
Unhealthy enterprises and their works on environment;
-
Ethic and the studies on human rights;
-
Sharing science and technology;
-
Medicine policies;
-
Crises and disaster management;
-
Social development;
-
Health economy and financing.
Each lane serves for the “health for all” ideal on the one hand; on the other hand, represents a service that the society necessitates. For instance, concerning social development, the clean water facilities whose lack is felt deeply at the local scale may serve for health-related objectives, but also for the objectives such as the formation of employment opportunities, gaining income, and etc.
Question 3: By evaluating this list, could we talk about that health policies in Turkey are carried out through “team works”, inter-institutional collaborations and as being the mosaic of policies?
-
Yes.
-
No.
Another example is that there is not any possibility of limiting the “share of science and technology” with the health issues only. However, it is fairly important to share current health-related information and innovations with society and to present new diagnosing means to the use of everyone.
The Correlation between Health and Social Security
Nine of the social security risks have been appropriated universally. When they are examined one by one, it is noticed that they are mostly related with “being deprived of health”: Diseases, occupational health and diseases, disability, death, old age, maternity, and etc… For all of them to be reached to a healthy conclusion, to be prevented or delayed, the efforts may be in line with the requirements of medical sciences.
All these efforts, beside the humanistic factor they undertake, bring many contributions for the system by reducing the social security expenditures. The utilisation of related units for educational and service concerns more results in such a conclusion that reduces the burden loaded over the system.
When we analyse these risks with which society faces, we note that the prevention programs on these risks are taken into consideration under various subject or project headings in social life. For example, the programs carried out for rendering the “occupational disease and accidents insurance” unnecessary are known as “worker’s health-occupational safety” or “occupational health and safety”. The efforts on protecting the society from contagious and various other general diseases and on family planning studies -community health studies in short, are all influential on health insurance and maternity insurance. The risks faced under the scope of disability insurance are kept under control both through the studies mentioned above, and through the programs like prevention of traffic accidents, home accidents, and etc.
In this case, health should be regarded as a remarkable element within the social security system. The reverse is also true. Because, the existence of a social security system would lead the health researches and services to be provided with a high-quality, and would improve the “well-being indicators” of society.
Question 4: Considering the frame presented above, could we talk about that the social security system of Turkey foresees the risks beforehand, take necessary precautions accordingly, and hence works through the “social protection” approach while rendering compensations unnecessary?
-
Yes.
-
No.
“Risk Groups” Approach
It is fairly important that the society should classify the individuals in regard to the risks they face with and should decide on some priorities. In addition to the risks enumerated above, it is possible to mention various other risk groups both from the labour and living circle.
One of these risk groups, which should be touched upon with great care, is composed of the disadvantageous groups within the society:
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Children (child workers, street children, child soldiers, and etc.);
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Women (Young girl workers, non-working girls but not attending schools, girls lacking in vocational training, women exposed to violence, women employed in domestic works, and etc.)
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Old people (the ones requiring a special health care, the ones living at the poverty limit, the ones not able to meet their basic necessities by themselves, and etc.)
-
Disabled people (the ones not having learned a profession, unemployed, the ones not able to meet their basic necessities by themselves, and etc.)
-
Migrants (problems like working, accommodation, illegal employment, protection of rights, and etc.)
-
Chronic patients (alcoholics, the ones requiring a regular health examination, and etc.)
The approaches regarding risk groups are not only related with these particular risk groups only, but also with the rest of the society. For instance, child labour reality does not only cause them to lose their childhood, jeopardise their health, and make their educational level to remain weak. But also, it appears as the mortgage put over the future of a society. Because, tomorrow’s adults, who have a low educational level and who are trained to produce with poor technological opportunities, are the indication of the fact that the future of the society is to be composed of small workshops appropriating this poor technology as well. Young labour elements, which utilise from the social funds both in the primary schools and in apprenticeship education centres, are fairly stranger to team works, organisation and the necessities of the information society; and they have a strong yen to set up their own business.
Just like the society heading towards the treatment of unpreventable diseases with determination despite all its efforts regarding preventive medicine, the child labour problem should be considered through “short-term objectives” until all the economic, social and cultural determinants of this problem are eliminated.
Question 5: Could it be talked of that children, as a risk group that should be protected with great care, are directed to such an educational system that is far from working life, equipped with the guarantee of finding a job and whose objectives have been determined clearly?
-
Yes.
-
No.
Social Reconciliation
“What is the first requirement of an individual, a new-born baby, who has an intercourse for the first time with the world?” This question has only one answer: breathing. This is acceptable for the moment a baby is born; yet, true for throughout the life.
Breathing of a person, his/her heart’s palpitating, and putting an end to his/her pains do have a priority always. A person, accordingly, never forgets the aids made in that direction. For this reason, s/he is full of the feeling of aiding for the ones that aid his/her self (A helpful person is helped when s/he needs it). Here, the foundation of social reconciliation is laid through people’s helping each other for the most difficult times.
Why don’t we use this strong glue ensuring social peace as a conscious policy?
It is fairly meaningful, in that sense, that the “right for living” comes first among all the rights mentioned in the human rights documents. If a person has problems with breathing, if s/he is not able to use his/her five senses unrestrictedly, and if s/he suffers physically, the person’s attention is drawn his/her own self. Then, the importance of the rest (others) becomes gradually diminished, so does his/her social participation. For this reason, it is hard to talk with a sick person about the social solutions, hence hard to prepare long-term programs with them. Because, such a person experiences problems with his/her own bodily structure before all else. His/her inner peace is harmed and s/he endeavours to restore this accordingly.
The precondition of social reconciliation, on the other hand, lies in the efforts to understand the “other” and to put oneself in another’s shoes.
Beside all these, conscious policies would hold back the impairment of health (diseases, accidents), and increase social productivity, sharing and compassion. The worry of being deprived of the share that one gets of the beauties of the world by loosing his/her health would bring forth supporting the preventive services consciously. Preventive health services are such works that cannot be undertaken by one individual only, but by groups. Therefore, this development would allow the members of a society to come close to each other, to be involved in collaborative works, and hence allow the social reconciliation to be strengthened.
Question 6: Are these frequently encountered in Turkey: patients form long queues at the hospitals in order to be treated first; get in these queues even at midnight in order to be treated before all the others; and hence sometimes, they dispute with each other for this particular reason?
-
Yes.
-
No.
The Importance of Volunteer Organisations Regarding Health Issues
The shortcut way of utilisation from extra-institutional human resources and of the transferability of accumulation and experiences is the utilisation from volunteer labour elements. Yet, what makes volunteer labour elements functional is the volunteer organisations.
It is fairly important to be a volunteer, especially in regard to the health affairs. Working just for the sake of “working”, and making this just in order to earn money hinder the expected results on health issues to be taken. Because, the work done is a work that should be done willingly and sincerely.
This is the most important precondition for volunteer organisations to develop a successful piece of work for health affairs. Health workers should also consider this service as part of this volunteerism, and the society should act with the same enthusiasm and compassion as the volunteer organisations do. It is just related with being close to each other, and taking over the flag from the other in the case this other gets weak.
There are many functions that health-related volunteer organisations should undertake. Among these, we may say that making the awareness on “health and the protection of health” widespread comes first. With respect to this, it is aimed to increase the supports given to related institutions and increase the society’s active participation in these decision making processes. This is a provision for multiple management and for putting the ideals of community medicine approach into practice.
Among the activities that the volunteer organisations are involved, the activities carried out in the society have a foremost importance. The activities carried out at homes and districts, building bridges between social development and health issues, and exalting “collective labour” and individuals’ integration with social life are the social gains that these volunteer organisations would bring forth.
Additionally, patients and disabled persons may be helped for their going to the hospitals and assisted at their homes in order to support their participation in social life. These efforts would appear to be an elixir of life for the ones living in the exhaustion limit.
Taking place in all these processes, volunteer organisation should be conceived as the integral part of social policies, and hence should be heeded accordingly. They should be supported through various mechanisms, and should be included in the decision making processes. For all the issues varying from the presentation of the system’s philosophy to all the others, volunteer organisations are needed due to their critical approaches towards the problems.
Volunteer labour may contribute to the activities which require the formation of a multi-disciplinarian team and qualified manpower. Participated not only by the relatives of the patients, but also by the members of society overall, these organisations endeavour to solve problems before they occur, if not, as soon as they occur.
Becoming widespread of volunteer activities throughout the society and the close collaboration between volunteer organisations and health workers, then, would become fairly influential for the improvement of both health affairs and of social reconciliation.
Question 7: Concerning a matter like health which requires magnanimity and an endless tolerance, could we talk about that volunteer organisations play an active role for the provision of health services?
-
Yes.
-
No.
Evaluation
Here, it is the time to evaluate the answers given to 7 questions asked at the end of each section. Please note that each (a) is 1 point, while each (b) is 0; then, count the total score:
If the total score is 0 point, your evaluation regarding the health services in Turkey is VERY NEGATIVE.
If the total score is between 1-3 points, your evaluation regarding the health services in Turkey is NEGATIVE.
If the total score is 6, your evaluation regarding the health services in Turkey is POSITIVE.
If the total score is 7, your evaluation regarding the health services in Turkey is VERY POSITIVE.
My evaluation, unfortunately, is VERY NEGATIVE.
Conclusion
Here, we are face to face with a conclusion that never befits the Ministry of Health which was established by the young TGNA (Turkish Grand National Assembly) in 1920 by the Law No. 3; the law on the “Protection of General Health” (Law No. 1593) passed by the parliament in 1930; and the law on the “Socialisation of Health Services” (Law No. 224) passed in 1961.
However, there are still some points with which we may be consoled. The last two laws, that appeared as the monuments of the community medicine approach, are still in force. Yet, they are looking for social pressure groups that would protect and develop themselves. The importance of the community medicine policies has been discussed more and more; and also, the post-graduate program of the Ankara University-Faculty of Political Sciences includes such a course under the same title.
Nevertheless, there are also many points that we should regret. Signed in 1924, the first child rights declaration, Geneva Declaration of the Rights of the Child states that: “The child must be brought up in the consciousness that its talents must be devoted to the service of its fellow men”. Regrettably, our people do not show this tolerance and magnanimity towards each other.
We cannot reconcile people with themselves and with “others”, if these people’s or their relatives’ diseases are not shown any interest, and if they lost their lives and intimates in disasters for nothing. It is such a regret that the manpower of this country, which is to carry this country towards future and towards the information society, is distrustful towards each other and far from solidarity.
We may note that the Ministry of Health, starting from the 1920’s, reached out to help the people in Asia Minor, which had been neglected until that time, by struggling with the most commonly observed diseases (tuberculosis, malaria, trachoma, and contagious diseases). Also, it should be remembered that the Law No. 224, in 1924, was initiated at the rural and east/south-east regions of Turkey, where social exclusion was experienced most; and it should not be forgotten that this was a conscious administrative choice. All these prove that discovering the correlation between health and social reconciliation” is not something new.
Social reconciliation should be aimed by everyone varying from single individuals to social organisations, from single implementers to decision makers; and community medicine policies should be given weight accordingly. This is the precondition for an individual to reconcile not only with another person, but also with his/her very self.