In its initial years, the nascent Turkish republic established the Ministry of Health and Social Assistance in order to promote public health. Beyond simply facilitating its modernizing agenda for the emergent nation-state as it sought to define itself against an Ottoman past, this institution was also geared toward remedying a self-defined population crisis by prioritizing and confronting particular diseases and health conditions. One of the maladies of utmost concern was syphilis. Based upon an analysis of official primary sources, this article engages with how the developing republic distinguished and consequently politically constructed—or framed—the syphilis problem from the vantage of its new forward capital, Ankara. Integral to this project of confronting this sexually transmitted [End Page 266] disease, public health officials projected upon both this ailment and their understanding of the suitable means for its treatment their own views of what constituted appropriate sexual practices and relations. In doing so, certain subgroups of the population, especially prostitutes, were particularized as targets for surveillance and policing through regimes of licensing and compulsory medical examinations. Stemming from the state's framing of the disease—and its definition of appropriate sexual practices—this article also examines the subsequent legislative and public health education projects that followed.
Ankara, prostitution, public health, public health education, sexuality, syphilis, venereal disease, Turkey
Years before the October 29, 1923, establishment of the Turkish republic, the Ankara-based nationalist leadership of the emergent nation-state created an institutional infrastructure devoted to public health. Established on May 20, 1920, under the direction of Dr. Adnan (Adıvar) (1882-1955), the husband of nationalist and feminist Halide Edıb (Adıvar) (1884-1964), the Sıhhat ve İçtimai Muavenet Vekaleti (i.e., the Ministry of Health and Social Assistance) followed his initial plan as its officials confronted a number of diseases and conditions that he deemed to pose a particular threat to the populace.1 Among other diseases, syphilis was one of the few that were designated as a priority target for eradication.2 This identification (or framing) of syphilis as a distinct danger to the peoples of Anatolia had profound ramifications that pertained to how the nascent state defined the disease but also to how it regarded, surveilled, and assembled records pertaining to its entire population and to how it particularized certain subgroups (i.e., women, in general, but prostitutes, in particular) for epidemiological policing and medical intervention.
In this article, we engage with the early Turkish republic and its approach to syphilis not merely as a problem of epidemiology but as [End Page 267] an issue of public health (i.e., as a matter of governance). Following the subsequent paragraphs, in which we survey the nature of the primary sources analyzed and the historical geographic and conceptual contexts of our study, we initiate our inquiry by analyzing how syphilis was framed as a problem in modern medicine, in general, and from the vantage of the emerging modernist capital, in particular.3 This question of the framing of the disease as a deliberate act undertaken by the state and its public health officials establishes the basis for our own inquiry into the ways in which the early republic elected to confront it. From this foundation, we describe and analyze how Dr. Muslihiddin Safvet, the provincial director of the Ministry of Health and Social Assistance for Ankara, enacted disease control measures in the capital and its surrounding province and how he envisioned the Ankara example as the ideal model for the wider republic.4 This anticipated model, not unlike programs observable in France and other European countries, established particular provisions for the monitoring and policing of brothels and prostitutes— thus sanctioning prostitution as an acceptable sexual practice, so long as it was mediated by the state and its medical officials. In addition to these gendered and other measures addressed by Dr. Muslihiddin Safvet with regard to syphilis in the early capital—which also renders us a view as to how the nascent state collected and assembled information regarding its populace, we also examine how the Ankara-based state came to engage with the disease through two other mechanisms of governance: legislation and education.5 In [End Page 268] addressing the legislative efforts that ensued in the subsequent years and continued thereafter, the state's expression of authority over the health and wellbeing of its citizens is laid bare, and through our analysis of its initiatives in public health education, we see how the state employed medicalized knowledge and thus engaged directly with its citizenry to shape gendered relations, sexual practices, and associated notions of morality amid its more commonly studied agendas of nation-building, modernization, and secularization.
Our research on the historical geographies of syphilis as viewed, defined, and confronted from the vantage of the emerging republic's forward capital is based upon our collection, transcription and translation, and analysis of official primary documents and our engagement with secondary academic sources pertaining broadly both to comparative histories of syphilis and governance.6 We examine concepts of governmentality, in general, and the governmentalities of public health and medicine, in particular.7 In Turkey's early republican period, the state sought to achieve a comprehensive knowledge of its many provinces but also of its citizenry.8 Reflecting not only [End Page 269] this population-centered mission of the state and its drive to gather information but also its bio-political essence, the republic initiated an ambitious project whereby regional surveys were to be compiled at the provincial scale by those doctors assigned by the Ministry of Health and Social Assistance to function as provincial directors of public health. Assembled province-by-province and published over the course of the early 1920s (with a few reaching publication a bit later), these volumes titled as the Türkiye'nin Sıhhî-i İçtimaî Coğrafyası ("The Medical-Social Geography of Turkey," with subtitles that indicated specific provinces) rendered a fantastic amount of information concerning most parts of the country during these formative years of the nation-state.
As historical primary sources, these socio-medical surveys of the emergent republic's provinces were the result of early questionnaires developed by the ministry and assigned for completion by provincial health directors.9 While these inquiries yielded the anticipated data concerned with demographics, incidence of disease and other health conditions, and the availability (or scarcity) of modern health services, they additionally probed to reveal much more information, as well. Encompassing matters of ethnography and cultural traditions, folklore, language, socioeconomic data, and physical geographies, these sources also divulged a great deal about the perspectives and attitudes of their authors (i.e., the state's provincial directors) concerning the peoples, places, and afflictions observed in Anatolia. In doing so, the surveys are especially telling as to how particular diseases of concern were framed not just biologically but also socio-culturally and politically by the nascent republic's chief medical professionals and policy makers. Despite their rich factual and perceptual contributions to the historical record concerning the peoples, officials, and health concerns of the early republic, they have been largely overlooked by historians, geographers, and other scholars of public medicine, with the exception of a few general [End Page 270] works that simply describe and categorize their contents.10 Or rather, others that detail singular volumes in narrative fashion for individual provinces.11 Their oversight thus far may have resulted from either the more recent development of a broader interest in social histories of health and disease (as contrasted with traditional concerns for historians—such as nationalism, state-building, and religious-secular relations) or the fact that, with only two exceptions wherein they have been transcribed and translated from Ottoman Turkish to modern Turkish.12 Many still remain in their original Ottoman text.13 With the exception of those few that were published at a somewhat later date.14
While these socio-medical geographies are excellent sources for critical (i.e., deconstructive) analysis, they are also particularly revealing of innovative and progressive trends in Turkish medicine. In particular, the physicians and health officials of Anatolia were not only examining the etiologies and epidemiologies of various afflictions with regard to their bio-medical aspects. Rather, they were incorporating considerations of physical geographic, socio-cultural, economic, political, and other geographies—and sometimes even mapping these findings—in ways consistent with how so-called founders of medical geography would function in subsequent decades.15 And in a manner that continues to typify the study of [End Page 271] disease ecologies into the present day.16 Preventative medicine (esp. in the form of prenuptial examinations) was also conveyed as an essential component for the development of a modern system of healthcare. Moreover, most of these appointed physicians were well aware of the constraints imposed upon public health initiatives by both poverty and geography, so many of them emphasized repeatedly the imperatives of both free and accessible treatment (e.g., often recommending traveling doctors and other types of mobile services), preventative services, and associated education.
Although a great many scholarly works have focused previously upon the emergence of Ankara as the new republic's forward capital—and the associated rejection of Istanbul as that of both the Ottoman sultans and the Caliphate,17 far fewer works have focused upon the establishment of particular institutions of governance during this period.18 However, given the profound rural-urban contrasts in 1920s Turkey, the distinctive institutional nature of Ankara in this context of stark (and enduring) center-periphery disparities cannot be overemphasized. In this setting, the ambitious policy initiatives formulated in the capital rarely were realized with immediacy as applied policies in the country's towns and villages.19 As such, our article addresses primarily the political and medical framing (i.e., discourse) of syphilis as it emanated from the capital and, to a limited extent, as it was perceived from and applied there and within [End Page 272] Ankara's wider province rather than how these policies were experienced and realized (or not) throughout all of Anatolia. As we reveal, integral to this framing of syphilis was the combined framing (and hence the frequent endorsement) of prostitution, as conveyed largely from a decidedly proregulationist perspective.20 With this limitation of the scope of our immediate inquiry in mind, it might also be noted that the ambitions (and the promises) of this new Ankara-based republic would be difficult to overstate.
The aspirations of the new state were many and are often summarized according to the six "arrows" of Kemalism.21 These include republicanism, populism, secularism, revolutionism, nationalism, and statism.22 As the new republic's forward capital, Ankara was not only intended to embody materially and symbolically these developmental trajectories; it was also envisioned to become the essence of everything that Istanbul was not under the preceding centuries of Ottoman rule.23 In this context, a good number of both the achievements and the objectives claimed by early republican health officials were declared in ways that juxtaposed them with the perceived neglect, shortcomings, or outright failures of Istanbul and their Ottoman predecessors.24 With respect to particular diseases and to the state of the entire population, in general, such discursive contrasts continued for many years. For instance, conveying the tenor and examples of such proclaimed juxtapositions of imperial failure and republican achievement were many of the works published by the Ministry of Health and Social Assistance both during this period and in the subsequent decades.25 [End Page 273]
This setting characterized by abundant ambition and self-congratulation was also noteworthy, however, for contrasting expressions of particular anxieties. While most vivid among these concerns were the images of losses of territory from World War I, of losses of sovereignty during the subsequent period of the British and French occupation of Istanbul, and of invasion by foreign powers (as associated with the landing of Greek forces and the 1919-23 War of Independence), overall, there were also particular concerns over the health and number of the national populace in terms of nationalistic, geopolitical, and economic. Reflecting the drive for reproducing and controlling the populace, parliamentary and other meetings of state officials26 were replete with a "demographic discourse" that called for urgent measures.27 As a disease that undermined the health and (economic) wellbeing of the population and that contradicted the objectives of associated pronatalist policies, syphilis was a major concern for the medical officials and politicians of the early republic. Defining, legislating, and teaching the public about syphilis were thus projects that were seemingly as essential to the disease's eradication as were actual therapeutic regimes of treatment.
Framing Syphilis in Modern Medicine—and in a Modern capital
Syphilis plagued European societies since as early as the late-fifteenth century.28 However, little had been achieved in its accurate diagnosis and effective treatment until the first decades of the twentieth [End Page 274] century.29 Indeed, as one historian of medicine observed, the disease seemed to thrive amid the advent of the modern age; "one of several diseases caused by members of the Treponema group of spirochetes, a corkscrew-shaped bacterium, . . . syphilis, like typhus, should be regarded as typical of the new plagues of an age of conquest and turbulence, one spread by international warfare, rising population density, changed lifestyles and sexual behavior, the migrations of soldiers and traders, and the ebb and flow of refugees and peasants."30 Post-World War I Anatolia clearly fit within this category of turbulent contexts that were ideal for the disease's increased transmission. By the early 1900s, however, scientists working mostly in Germany identified the disease with respect to its causative bacterium (i.e., Treponema pallidum, though it was labeled initially as Spirochaeta pallida), developed an effective diagnostic test (i.e., the Wassermann test), and devised the first ever effectual treatment for the disease. While the chemotherapeutic approach to syphilis, as based upon the arsenic compound arsphenamine (known more commonly as Salvarsan), was hailed as a wonder drug by most—and as a "magic bullet" by its creator, immunologist Paul Ehrlich (1854-1915), it was modified to be less toxic shortly after its initial development due to a number of fatalities and was distributed thereafter as Neosalvarsan.31
These revolutionary changes in how humanity might confront syphilis were matched by evolving notions of what medicine should entail under the auspices of the modern state. For public health officials of the early twentieth century,
medicine . . . must become a positive and systematic enterprise, undertaking planned surveillance of seemingly healthy and normal people as well as the sick, tracing cohorts from infancy to old age, charting the incidence of inherited, chronic and constitutional conditions, and plotting ill-health against such variables as income, education, class, [End Page 275] diet and housing. Disease thus became conceptualized in the twentieth century as a social no less than biological phenomenon, to be understood statistically, sociologically, psychologically—and politically.32
These developments in treating syphilis enabled public health officials in Europe, the United States, and elsewhere "to take a more aggressive stand in the fight against venereal diseases and to encourage the growth of the public health field."33 However, the matter of how officials were to apply their bio-political mandate was yet to be determined in many different cultural, socioeconomic, and political settings. In these varied contexts, how the disease would be framed by public health officials, politicians, and others determined (1) the entire scope of the syphilis problem itself as understood and acted upon, (2) which segments of a populace would be associated with the disease and its dispersion, and (3) what measures would be deemed appropriate in attempting its resolution.
Accompanying these technological and professional/institutional shifts in medicine, attitudes also changed regarding many diseases. Amid Europe's transitions from the medieval and Renaissance periods to those of the early modern and modern periods, one medical historian observed of syphilis that, "[a]s middle class morality became dominant, the disease began to be considered a social stigma. It went underground, which greatly hindered efforts to control the disease until very recently."34 Additionally, diseases began to be regarded as the consequences not of ill fortune but of individual volition, and this was particularly the case—and might still be viewed to be so—with sexually transmitted diseases.35 Under these developments in the re-framing of diseases—and especially of those transmitted sexually, our scrutiny of who was regarded to have volition is a crucial matter as state health officials prioritized the surveillance and [End Page 276] policing of the assumed choices (i.e., the sexual practices) of some citizens while overlooking entirely the choices of many others.
In the United States and most countries of Western Europe, state and public health officials did not focus on the "soldiers and traders" associated with the geographic spread of syphilis—though the health of military troops was one of the primary causes for governmental concern over sexually transmitted diseases. Rather, in the enforcement of public health, sex workers were targeted as modern states identified commonly the scourge of venereal diseases to be the practice of prostitution—as embodied (symbolically and physically) by the female sex worker (and not by her clients). In this manner, we contend, prostitutes became the common scapegoats for sexually transmitted diseases as states and societies found their targeting to be more socially and politically acceptable than an assignment of even partial responsibility to servicemen, veterans, or other male citizens of the nation.
In countries like France, the state solution thus entailed assertions of governmental control as state officials mediated sexuality; brothels were licensed, and registered prostitutes were compelled to submit to regular medical examinations. By contrast, both in Britain and (especially) in the United States, the nature of governmental control over the long term tended not toward the regulation of sexuality (with some notable exceptions for Britain during the period of Contagious Diseases legislation) but toward its prohibition, with varying outcomes.36 In the case of Turkey, the state and its officials exhibited a posture regarding public health, sexuality, and prostitution that was far more consistent with the mediated French example.37 [End Page 277]
In the socio-medical geography report that he compiled for the Ministry of Health and Social Assistance, the provincial director of health for Ankara, Dr. Muslihiddin Safvet, discussed what he viewed as the scope of the syphilis problem in Turkey:
Syphilis is the greatest misfortune left to our country by World War I. A long time ago, Kastamonu was the province where syphilis was most common; unfortunately, today, this sinister disease is in almost every part of Anatolia, even in its smallest villages. Because of poverty, the numbers of people involved in open and secret prostitution increased, and since they are not subject to any control, syphilis started to invade every part of the country with all its might, entering into [even Turkey's] elite families.38
Identifying both social ills and sexual practices that he felt contributed to a syphilis epidemic (i.e., poverty and prostitution), Dr. Muslihiddin Safvet spoke to the specific circumstances of Ankara and the disease. Although he wrote that the city recently experienced substantial population growth, he observed that any accurate estimate of the rate of this increase would be merely speculative. While a 1925 survey of the city and its surroundings provided figures for that year, ongoing trends (e.g., migrations, population exchanges, and other dynamics) complicated further calculations of rates of growth. For 1925, the provincial population of Ankara was numbered at 312,549 people (165,463 females and 147,086 males) by reports from the city's office of birth registration and from state physicians.39 Commenting on these demographic observations and processes, he wrote:
A major proportion of Ankara's population is Turkish. In the city and its towns there are non-Muslims, especially Greeks, Armenians, and Jews. Since the Greeks were subject to the population exchange following the Lausanne Treaty, if one extracts them from this non-Muslim population, the remaining is a small number of Armenians and Jews. . . . Due to the population exchanges, there are migrants from Salonika and there are also people who were not subject to the population exchanges but arrived from Serbia and Bulgaria and their settlement is not yet complete. Therefore, we are unable to know the real number of [Ankara's] population. In order to [End Page 278] get an accurate number, we must include people who migrated to Ankara after the 1912 Balkan War and the 1914 war [i.e., World War I] as well as those who came following the Lausanne Treaty as part of the population exchanges and those state officials who settled in Ankara after it became the capital.40
Of greater significance than matters of demographic statistics for Dr. Muslihiddin Safvet, however, were factors of socioeconomic stress that derived from the turbulence of World War I, the War of Independence, and the transition from empire to republic. In his view, such tensions contributed sharply to declining standards of morality in Turkish society.41 The diminished observance of morals and decency, he continued, was a direct consequence of scarcities and privations. As he wrote:
Until World War I began, morality was very good in the area. The hardship and poverty caused by the war altered public morality. Prostitution exists more in the villages than in the towns. Those who were involved in secret prostitution in the villages gradually did so openly, and thus, day-by-day, morality began to fall into disarray. As an evil consequence of the war, young women who became sole survivors [of their families] or who were widowed ended up working as maids for people here and there, [but they] later fell into a seductive trap and this led to their loss of chastity. These were the causes of the decline of morality. Sometimes the fiancés of young women were killed at war and nobody showed an interest in them anymore, they began to become spinsters, and they ended up being raped amid promises of marriage and [thus] lost their chastity.42
According to his narrative of these circumstances, once such women lost their youth and their chastity, they sometimes would marry young men as much as fifteen or twenty years their junior, but rarely with promising outcomes. These women, devoid of family support, their honor, or alternative economic opportunities, fell commonly [End Page 279] into prostitution.43 This societal stress, he concluded, thus contributed not only to the moral declines that promoted prostitution, it also led to increased rates of diseases like syphilis.44 It also led to acts of criminality as perpetrated by male youths who sought money for the services of prostitutes.45
Given the prevalence of such factors, the provincial director for Ankara reported the following figures for 1923 occurrences of the disease (Table 1).46 He cautioned, however, that he suspected that the actual number of persons with syphilis in Ankara was, in his estimation, far higher than conveyed by the numbers of reported cases that he was able to verify. In viewing these figures, it is interesting to speculate as to the far higher number of cases reported for November 1923—the month following the October 29, 1923, declaration of the republic (and one presumes—associated festivities).
As Ankara emerged to become, first, the nationalists' center of operations and, second, the republic's new capital, Dr. Muslihiddin Safvet noted that women involved in prostitution in these other sizeable urban centers likely departed for Ankara and then further spread the disease there. Since those sex workers who migrated to the new capital for greater opportunities were not subject to immediate medical examinations, syphilis in Ankara continued to, in his words, "sink its teeth into the youth." In earlier times, he observed, it was sufficient to send the prostitutes taken in by authorities for a medical examination at the city hospital. Lately, he continued, in order to compel them to remain in one location and thus facilitate more effective surveillance and policing, a brothel was established officially near the Kengri Gate—named for the city to which its outgoing [End Page 280] road led (now known as Çankiri).47 Their registration was handled by the police and health officials, they were inspected twice per week, and their total number was between sixty and seventy. He further stated that most of the women at the brothel came from places beyond Ankara and that few were from the city itself or nearby local communities.48
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Reported Cases of Syphilis Patients Treated in Ankara, 1923
Prior to the establishment of the registered and policed brothel at the Kengri (Çankırı) Gate, prostitutes in Ankara were not subject to any serious enforcement of either examinations or treatment. In his view, this absence of public health enforcement—and what he perceived as a prevalent state of local "ignorance and naiveté," contributed to both the emergence of and the increasing rates of [End Page 281] transmission of syphilis in the city. As he concluded, once the disease arrived in this otherwise unmonitored setting, it found a suitable environment in which it could thrive.49
By 1925, Dr. Muslihiddin Safvet claimed that measures taken to combat syphilis thus far in his province had achieved a solid record of success. Based upon his accounts, these measures went beyond simply responding to reported cases. The practices and procedures that he noted, in particular, included the establishment of the aforementioned licensed brothel, the registration of its prostitutes, and the twice-weekly examinations of these licensed sex workers, on the one hand, and the implementation of mandatory prenuptial medical examinations for both men and women, on the other hand. Relying upon his estimation that syphilis was increasingly contained in the Ankara region over the past few years, he indicated that it was time for the rest of the nation to learn from this experience and that similar procedures should be applied throughout Anatolia—especially in those subregions that he viewed as syphilis-ridden.50
For Dr. Muslihiddin Safvet, Ankara served as a good model not only due to his report of its relative successes thus far but also because the city was sizeable and there were a large number of prostitutes in the vicinity of the capital. This presumed number of prostitutes, he speculated, enabled him to suggest both certain dynamics associated with the population, in general, and of prostitutes, in particular. First, due to the city's size, he considered it to have relative standing with other large cities at the time, noting Istanbul, Bursa, and Izmir.51 Second, for him, the city revealed what might be accomplished elsewhere should adequate resources be devoted to the problem. Compared with other cities, Ankara seemed to possess more funds and a greater scale of investment in public health. The hospital that existed before Ankara became the new republic's capital was renamed as Nümune Hospital, and after 1924, it was repaired, renovated, and equipped with a new unit with three rooms devoted to treating venereal diseases. With its modern facilities for bacteriology and a surgery room, it was one of the most modern hospitals in Anatolia and boasted having 150 beds, of which 100 were for the free [End Page 282] treatment of citizens while the remaining fifty were for paying patients. Furthermore, dispensaries were established in neighboring towns and all their expenses were paid by the Ministry of Health and Social Assistance, so that both poor and rich could receive necessary treatment at no cost.52
Based upon his assessment of the disease and its propensity for further transmission in the absence of direct confrontation and state provisions for treatment, Dr. Muslihiddin Safvet was a strong proponent for state-led surveillance and policing of the population at large and for making healthcare accessible. At the most rudimentary level, he sought to increase the scope of existing practices for everyone within the country as associated with their prenuptial examinations. Profoundly critical of merely practicing such examinations of would-be husbands and not their intended brides, he pointed out that a large number of women might suffer from either acquired or inherited forms of syphilis and that their omission in prenuptial examinations would enable the disease to spread further. However, this proposal was not without detractors. At least one deputy of parliament rejected any examination of girls or women prior to marriage—assuming that it would impugn their presumed virginity. Regardless, by 1924, females were included in state requirements for prenuptial examinations. Positive results from the Wasserman test for syphilis would necessitate a regime of treatment prior to being approved for marriage by the state. These measures were deemed essential, given that many who suffered from syphilis were unaware of their status or were otherwise inclined to keep their status a secret.53 He even indicated that subjecting those citizens seeking either public employment or other official work to examinations would also enhance broader, state-led efforts toward both the detection and the treatment of syphilis.54
Consistent with the commentaries and recommendations (esp. regarding the establishment of state-monitored brothels) found in many of the other provincial socio-medical geographies, however, Dr. Muslihiddin Safvet's main focus regarding the disease concerned the state's engagement of a perceived problem with [End Page 283] prostitution.55 Returning to his discussion of successful results reportedly achieved in Ankara, he noted that any origin of venereal diseases (esp., syphilis and gonorrhea) from brothels had been eliminated due to the enforcement of twice-weekly medical examinations of licensed prostitutes. Viewing the Ankara example as a success story in public health, he proposed that the time had arrived to expand the fight against syphilis in the capital to other parts of Anatolia—and with the goal of eventually targeting other similar diseases.56
A fervent sponsor of epidemiological surveillance, Dr. Muslihiddin Safvet advocated a powerful state role that would record and monitor the nation's syphilitics. To this end, he endorsed that all those diagnosed with the disease should be subject to mandatory therapy, though they should have the option of having their own physician administer their treatment. This regime of compulsory treatment would be monitored through the maintenance of a treatment report card with weekly signatures from the treating physician that would be presented regularly to local health officials. In the event of migration, syphilis patients were obliged to inform health officials in the jurisdiction of their new home. In order to achieve adherence—and eradication of the disease, he also advocated enforcing compliance through punishment, when necessary.57
From our review and analysis of the other socio-medical geographies authored by the health directors of Turkey's additional provinces, Dr. Muslihiddin Safvet's advocacy of a greater state role in public health was not unique. His detailed suggestions for the role of the state did, however, distinguish his report from those of his peers, as most of them did not articulate with so great a level of specificity the measures that they also advocated—measures, as presented more thoroughly by Dr. Muslihiddin Safvet, that were codified eventually into public health law, with only a few exceptions. Moreover, the [End Page 284] roles of physicians in the early republic and in its parliament were significant as many of them not only worked as officials who informed governmental policy through their appointments in the Ministry of Health and Social Assistance, but there were a good number of doctors serving as lawmakers in the Turkish parliament, as well.58 Even Turkey's second Minister of Health and Social Assistance, Dr. Refik (Saydam) eventually rose to become the republic's Prime Minister (1939-42).
Confronting Syphilis Through Legislation
In seeking to alleviate the problems of venereal disease, the Ankara-based republic was not the first state to seek a legislative remedy—even in Anatolia.59 Though the state that would later boast of its achievements on behalf of its female citizenry—and not without good cause.60 However, the republic may also be seen to have undermined profoundly the standing of women through its endorsement of prostitution.61 In this section, we address the legislative efforts to control syphilis and other venereal diseases, but we also engage with [End Page 285] the legislative provisions for prostitution, as mediated by the state— and thus endorsed as a measure in the promotion of public health.
Upon the establishment of the Ministry of Health and Social Assistance, one of its first projects entailed the nascent state's campaign against syphilis. Enhancing the ministry's movement to fight against the disease, several legislative steps were taken in the 1920s and 1930s. Although the 1930 Public Health Law (or the Umumî Hıfzısıhha Kanunu) is regarded as the most comprehensive legislative action in the early development of Turkey's public health system, there were several prior measures that were subsequently combined and augmented to become the backbone of this 1930 law. In 1921, the ministry passed the Law for the Prevention and Containment of Syphilis (or the Frenginin Men-i Sirâyet ve İntişarının Tahdidi Kanunu). This law mandated free, state-sponsored treatment for those suffering from syphilis.62 As this law was further expanded to become part of the 1930 Public Health Law, the state further mandated that all state doctors and state health institutions must treat syphilis patients free of charge. Furthermore, it required syphilis patients to obtain treatment and, in case of neglect, allowed health officials to pursue them and to compel their treatment.63
Although the 1921 law stipulated free treatment for syphilis patients, it was soon realized that many doctors utilized quite different treatments, often reflecting their diverse histories of medical training and their varied understandings concerning the properties and appropriate uses of different medications. In order to achieve its intended results, the Ministry of Health and Social Assistance searched for ways to standardize treatment regimes. In 1925, it created a syphilis commission comprising some of the country's most prominent doctors. This commission worked to establish a standard of agreed-upon therapies for syphilis, including methods of treatment, acceptable medications, and appropriate dosages. Based upon the recommendations of this commission, the ministry sponsored the Regulations for the Treatment of Syphilis and distributed these guidelines to the nation's health officials and practitioners. According [End Page 286] to this regulation, the treatment of syphilis in Turkey would be based upon only the latest scientific methods and these approved therapeutic measures would be applied uniformly throughout the country.64
As indicated, the most comprehensive legislative treatment of syphilis (among other afflictions) began in Ankara with the April 24 passage of the 1930 Public Health Law.65 In its entirety, this law had fifteen sections and covered various health-related issues throughout its 309 articles. With particular regard both to syphilis and to sexually transmitted diseases, in general, the law combined several previous laws (which it elaborated upon), introduced distinctly new provisions, and deferred some matters for later clarification and resolution. Overall, it reflected the state's ambitious project to create a centralized system of medicine with both therapeutic and preventative missions that would have the full authority and legitimacy of the state at its foundation.
With regard to its syphilis-related structure, the 1930 Public Health Law had provisions that dealt with (1) treatment, the reporting of information, and patient confidentiality and education (i.e., Articles 103 through 109), (2) preventative measures, patient and population monitoring and examinations, and enforcement (i.e., Articles 110 through 127), and (3) the governance of brothels and prostitutes (i.e., Articles 128 through 134).66 In the initial articles dealing with sexually transmitted diseases, citizens were assigned legal responsibility for undergoing treatment (or for having their children treated) if infected, physicians were made responsible for reporting patient records to the state67 but also for maintaining patient confidentiality, and state institutions were required to render [End Page 287] free treatment.68 Furthermore, individuals suspected of being infected could be compelled to undergo an examination, to be provided either by the state or by a person's own physician, and those proven to be infected would be compelled to undergo a full course of monitored treatment, with provisions for pursuit, isolation, and force, if deemed necessary.69 Also, in line with state goals to better educate citizens about (and encourage conformity with) public health initiatives, the state required all patients (or their legal guardians) to receive state-published informational pamphlets and counseling from their treating physicians.70
Enforcing public health (and applying discipline in order to achieve it), the law also outlined the illegality of knowingly spreading sexually transmitted diseases, with provisions for punishment, so long as infected victims brought forward their complaints within six months of alleged transmission. Parents of children infected with syphilis were also legally prohibited from hiring a wet nurse. Areas with a high incidence of syphilis would warrant the formation of local commissions charged with eradicating the disease and enforcing all necessary state regulations. Infected soldiers would not be discharged until cured and both men and women would be subject to prenuptial examinations.71 Marriages were forbidden for those [End Page 288] infected with sexually transmitted diseases until a doctor could verify both full treatment and noncontagious status.72 Increased governmental scrutiny (i.e., compulsory examinations) was mandated for persons working in presumably at-risk occupations (i.e., wet nurses, and those employed in hammam—or baths—and other hygiene-related positions), and associated examinations and treatments would be rendered at no cost.
In its subsequent articles, the 1930 law outlined provisions relevant to brothels and prostitutes as part of its comprehensive plan for Turkey's system of public health. As there were many questions regarding prostitution that were yet to be resolved, the law also indicated that a more detailed regulation specific to brothels and prostitutes would be issued at a later date in order to further define the state's guidelines for each and designate their operational limitations and geographic requirements.73 Given the anticipated regulation that emerged in 1933, the measures in this law detailed simply broad guidelines and rules; it prohibited infected prostitutes from working, mandated their treatment—and detainment (if necessary), forbade alcohol consumption in brothels, and stipulated that municipalities were responsible for financing all measures enacted. To enable municipalities to carry out these requirements, the law also allowed for the taxation of brothel owners. However, it also forbade expressly any collection of taxes from the prostitutes themselves. Furthermore, [End Page 289] to better empower local officials over brothel owners and prostitutes, the law also stipulated in vague terms that both brothel owners and prostitutes could be prosecuted for not only employing minors as prostitutes but also for compromising in any way society's moral standards or violating public order. Finally, equating prostitutes with those carrying infections, foreign prostitutes were banned from entering the country along with all foreign nationals infected with any of a number of listed diseases (including those transmitted sexually).
Connecting State and Populace: Public Health Education
While many works that employ Foucauldian concepts of governmentality focus on the expanding roles and grander ambitions of the state and its officials, a key dimension to Foucault's examination of the expansion of the state which is sometimes neglected entails the actual forging of crucial linkages between rulers and ruled. As he wrote of governmentality, as it developed in the sixteenth century onward, "how to govern oneself, how to be governed, how to govern others, by whom the people will accept being governed, how to become the best possible governor," were all vital concerns within statecraft and for those devoted to its analysis.74 As we see in his own words, the true coercive power of the state—the power to instigate acceptance among the ruled—became far more adroit (and potentially insidious) than under prior schemes more reliant upon mere brute force, or its threatened application.75 As statecraft evolved beyond physical force to the fabrication of an acceptance of being governed, particular practices of states that could instill such loyalties became especially important. Schooling (or "pedagogy"76) thus acquired greater significance as not only one of the many services to be rendered in order to yield a compliant population but also as a [End Page 290] means of directly instilling loyalties.77 In this regard, education as a mechanism not just for state-/nation-building but as an adjunct to other state services (e.g., public health) became essential. As we assess the politics of sickness and health in the early republic, public health education—perhaps even as much as (or more than) the actual application of public health policies and specific regimes of treatment— thus demands greater attention.
In our survey and analysis of public health education initiatives regarding syphilis, we deal broadly with the question—considering not solely those lessons taught to the general public or specifically to those afflicted with the disease but also guidelines and training administered to medical practitioners, as well. Moreover, in view of the lines of discussion that we followed in many of the provincial surveys, we would emphasize that state medical officials were sometimes far more concerned with teaching against particular customs, ideas, and curative practices found throughout Anatolia (in addition to confronting nonmedical cultural traditions) than they were devoted to diffusing sound lessons in preventative health and treatment that reflected contemporary innovations in health and medicine. Indeed, the modernist agendas of the state and its officials were often revealed alongside their own preconceptions and prejudices as they sought to eradicate traditional (i.e., anti-modern/-scientific) approaches to health and wellbeing.
As key agents of a modernist state, Turkish physicians' typical excoriation of the traditional curatives of rural peoples may be interpreted as reflecting not only their own professional inclinations but also various socio-political chauvinisms.78 In their descriptions of healthcare traditions found throughout Anatolia as perceived challenges that the needed to overcome, local medical practitioners were [End Page 291] depicted commonly as adversaries to public health, science, and reason. In this context, the ocak (local individuals or families regarded as experts for particular diseases or conditions), the mutebbib (healers), the hoca (though translated commonly today as "teacher," the term apparently had some application for faith healers who might recite "incantations" in a few local contexts, as well), and other rural healers were portrayed as relying upon superstition, untested (or disproven) medicines, and backward assumptions, diagnoses, and practices.79 In addition to the local cures, one of the most significant therapies that many provincial officials derided as unfounded and primitive was the use mercury fumigation.80 Another therapy for syphilis that had been common from the sixteenth century through the 1930s in parts of Europe, the United States, and elsewhere81 (including Turkey)—but which was also regarded by the provincial medical directors to be so outmoded as to be primitive—was the use of sarsaparilla (or sasparilla).82 Such treatments were depicted as not only ineffective but also dangerous to the patient and society.83 Likewise, local sexual practices and customs were also the objects of scorn, such as the frequenting of "secret" (i.e., non-regulated/-licensed) prostitutes. In these respects, the poor, uneducated, and rural populace of Anatolia was viewed as being at particular risk of syphilis and other diseases as they were assumed to be least likely visit a modern doctor or clinic and instead seemed to avail themselves of the local services of traditional healers.84
While some provincial health directors were advocates of more direct confrontations of traditional practices—either educationally or [End Page 292] legislatively, Ankara director Dr. Muslihiddin Safvet proposed a less direct approach in generating popular acceptance of modern medicine and diminishing the roles played by the ocak, the hoca, the mutebbib, and others. As he wrote, the most expedient means to promote public health policies and associated therapies entailed more effective delivery of state medical services to rural communities. In his opinion, this emphasis on accessibility—both geographic and financial (i.e., through free treatment)—seemed to be a natural means to achieving results and to displacing undesired practices and customs. For syphilis in the region of Ankara, he felt that such expanded efforts toward accessibility of services and the regulation of prostitution (i.e., as an alternative the varied forms of "secret" prostitution) had together yielded appreciable results; a victory for education by example in public health. In his words, the state needed to go to the very doorsteps of the rural poor in order to treat syphilis and other maladies. Doing so, he stipulated, would not only contribute to the triumph of public health (and to the generation of populist consent), it would also mean the very end of those in the countryside who "pretended" to be physicians.85 Though most of his peers were less sanguine about villagers' levels of receptiveness to modern treatment, he felt more optimistic:
[P]eople are positive about medicine. . . . For syphilis there are a few poor villagers who still employ fumigation, but [now] the majority [of them] visit the doctor. Thanks to the work of traveling doctors in villages, it became possible to eliminate the area from this disaster [of syphilis]. With free medicine, free doctors, and especially doctors who travel to the doorsteps of people to cure them, the villagers will show more interest in medicine and doctors than in [mercury] fumigation. The hearths of the local mutebbib [quacks, or literally "pretenders"] will be extinguished by themselves.86
In addition to the aforementioned legislated policies of standardizing medical training, promoting the ongoing education of physicians and health officials through the regular diffusion of professional publications87 and the hosting of nation-wide medical congresses in [End Page 293] Ankara,88 and the extension of medical knowledge to those afflicted with diseases through mandatory counseling and delivery of informational pamphlets, the state also engaged in concerted efforts toward the translation and dissemination of foreign texts on medicine and public health within the wider medical community. Due to limited time and resources in responding to the state's self-defined medical emergencies, doctors and politicians alike relied upon well-received foreign books as they sought to better educate themselves and organize effectively a system of public health. For example, in 1924, the Ministry of Health and Social Assistance initiated its Ottoman Turkish translation of the 1923 text The Elements of Public Health Administration.89 Citing the urgency and limitations of the time, Dr. Refik (Saydam) wrote in his foreword to the translated edition, "We would like to benefit from the experiences of all other nations."90 Because of the popularity of Luckett and Gray's book in the West, its translation was deemed essential—and it became in influential resource. With Luckett and Gray's emphasis on venereal disease as being more dangerous that cancer or tuberculosis, it seemed to speak to the circumstances in Turkey and to the nation-state's concerns over population.91
The tone of the Luckett and Gray text must have had a great deal of appeal in Turkey, as well, as recent matters of concern (i.e., the collection of information and proper surveillance) were dealt with as recent challenges in the West, as well: "until the last six years, although many states were required to report the cases that they discovered, there was almost nothing published about it in the press." Moreover, and perhaps reflecting a far greater challenge in the Victorian-era West than in Turkey, was the matter of social stigma, such that even talking about the disease, unless someone was in the medical profession, was viewed as thoroughly "indecent and immoral." Given elevated concerns about syphilis, however, they indicated how lessons about the [End Page 294] disease began to become integrated into various publications and even elementary and secondary school curricula.92 Moreover, the virtues of taking this state-led "scientific" approach to the disease enabled health professionals to overcome what previously was solely "an occupation of the quacks, of people involved in fumigation and blowing to cure diseases." Thus taking responsibility away from "their dirty hands [to] place it in its rightful place, within medical, health, and social issues."93 People were informed that they were given the opportunity to be examined by the most knowledgeable and able scientists. While a good number of the provincial reports examined in our work were published prior to the publication of Luckett and Gray's Ottoman Turkish translation, it must have been well received as it seemed to affirm many of the suppositions and the scientism (and biases) expressed throughout the provincial surveys.
As the state also sought to promote broader, popular knowledge about syphilis and its appropriate treatment to the wider public, it also had to contend with high rates of illiteracy found throughout the country. Moreover, while both instructional films and traveling museums and displays could help to overcome some of these limitations associated with literacy, they also were limited by geography, finances, and other resources.94 Already engaged in distributing pamphlets to provincial health offices, the state also began to employ informational posters to promote its public health objectives. Employing an artist, Refet Başokçu, the ministry of health presented posters that emphasized clear visual imagery and simple yet memorable lessons in preventive medicine and appropriate healthcare.
In its confrontation of syphilis, the state's 1930s poster used brief warnings and unambiguous imagery to convey their own scientific [End Page 295] authority (note the image of the syphilis microbes, bottom center), the disease's causes and consequences, and opportunities for state-provided treatment (Figure 1). Rendering something of a parable about appropriate behavior, dangers, and potential salvation, the poster warned in bold, red letters: "Be afraid of catching syphilis." In addition to encouraging a sense of alarm for the disease, in general, the poster also suggested unmistakably how the disease could be contracted as it cautioned: "Avoid these types of entertainment." For the Turkish viewer, the chief cause of syphilis would be clear; "secret" (i.e., un-regulated) prostitution—as conveyed by the presence of alcohol (which was outlawed in state-sanctioned brothels) in the associated image of a mixed party (Figure 2). Moreover, the consequences both for the individual and for the family (and nation) of not heeding these warnings were made abundantly clear, as the poster depicted a young man in the secondary stage of his affliction, on the left, and the misfortune of premature and stillborn children, on the right (Figure 1). The consequences for those who would disobey the state's advice (and laws) were portrayed as bleak (i.e., disfigurement and incarceration) (lower right); "The end for those who
Click for larger view
A Turkish public health poster of the 1930s that proclaimed "Frengiye Yakalanmaktan Kork," or "Be Afraid of Catching Syphilis" (Sıhhat ve İçtimai Muavenet Vekaleti; image courtesy of Wellcome Library, London, UK).
[End Page 296]
Click for larger view
A close-up of the central image of the poster. Rendering a modern morality tale, it advises "Böyle eğlencelerde bulunmaktan sakın," or "Avoid these types of entertainment" (Sıhhat ve İçtimai Muavenet Vekaleti; image courtesy of Wellcome Library, London, UK).
go untreated." There were, however, clean, responsible, and free options available at state-sponsored clinics that could save the individual and society (lower left). Far from preaching a morality of good and evil behavior when it came to matters of sexuality and health, the secular state conveyed it own regulationist ethics that contrasted (and communicated the consequences of both) responsible and irresponsible behavior.95
Conclusion
Identified as not only a danger to the citizens of the emergent Turkish republic, syphilis was also viewed and confronted as if it were [End Page 297] a threat to the very nation itself. While this alarm over the disease can be understood, in part, as deriving from both the state's precarious geopolitical contexts amid transition from empire to republic and its associated demographic anxieties, it was also integral to the changing dynamics of public health in a modernist Turkey. As in other modernizing states of the period, in many respects, Turkey prioritized its population as its foremost objective for governance.96 In step with focus of its expression of sovereignty on to its citizenry rather than its territory, physicians and public health officials were also shifting their clinical gaze from the bodies of individual patients to that of the nation at-large. In doing so, their work began to take on statist priorities of surveillance and policing, albeit under the avowed ideals of medicine and science, as they compiled data, assembled statistical measures, and made pronouncements regarding the population.97
In our examination and analysis of the challenge of syphilis, both as framed in and confronted from early republican-era Ankara, we see a disease that was defined more by its ascribed socio-political circumstances than by its biological properties. As such, the measures to confront syphilis in the nation-state were socio-political more than medicinal in nature (i.e., informational, legislative, and educational). Under these circumstances, perhaps one of the most marginal groups of the nation's populace (i.e., that of its prostitutes) were depicted as epidemiological culprits. Prostitutes and brothels, therefore, became the targets of state legislation, surveillance, and policing—thus enduring levels of social and state scrutiny that their many customers evaded entirely. With more than a small measure of irony, however, once regulated as sex workers subordinate not only to their clients but also to the state, they were also idealized as one of the critical means toward overcoming syphilis.98 In this regard, Turkey reveals [End Page 298] another regime of not just regulation but of subordination of women that endures to this day; a practice of marginalization that paradoxically may be seen as having derived, at least in part, from the nation-state's foundational ideals as based upon medical science and public health, liberalism, and nationalism.99
Acknowledgments
We would like to thank both the anonymous reviewers of this article and Margaret Humphreys for their comments and advice. We are also most grateful for the assistance received from staff personnel at the Başbakanlık Cumhuriyet Arşivi, the Türkiye Büyük Millet Meclisi Library, and the Refik Saydam Library, all in Ankara, Turkey, and for permission to reproduce the 1930s propaganda poster held at the Wellcome Library, London, UK.
Funding
Support for this research was awarded by Michigan State University's Center for the Advanced Study of International Development (CASID), Center for Gender in a Global Context (GenCen), and Muslim Studies Program. [End Page 299]
Footnotes
Notes on late Ottoman and early republican sources: Sources from this period sometimes appear with dates from the Hicri (i.e., Ottoman religious) calendar and at other times with dates from the Rumi (i.e., Ottoman fiscal/administrative) calendar. Thus a publication dated to 1924 on the Gregorian (i.e., Western) calendar may vary two years, or so, in the dates on what is assumed to be an "Islamic" calendar. In our bibliography, we include both the original and the Western dates. Also, prior to the universal application of its surname law in the early 1930s, many citizens in Turkey had only one or two names. As this article concerns the 1920s period, both in text and in citations we employ the original names and (when possible) list the surnames that were added later in parentheses—as is customary in Ottoman/Turkish historiography. However, many of the names of the authors listed do not include obvious surnames, so their full (i.e., first or first and second) names are listed with their full name, in addition to their professional title (e.g., Dr. Muslihiddin Safvet, and thereafter as Muslihiddin Safvet).
1. Although Dr. Adnan (Adıvar) occupied this position for only a brief period, until his resignation, the initial public health policies established at this time were relatively constant under the administrative leaderships of other key figures, such as Dr. Refik (Saydam) (1881-1942). On these formative and transitional (i.e., empire to republic) years in the development of Turkish public health, see Osman Gümüşçü, "Osmanli'dan Cumhuriyete Geçiş ve Cumhuriyetin İlk Yıllarında," Atatürk Araştırma Merkezi Dergisi, 2003, 19, 125-46.
2. In addition to syphilis, other diseases identified by the early republic as particularly detrimental were malaria, trachoma, and tuberculosis.
3. Although we will cite sources individually throughout the footnotes of our article, it bears mentioning that this study resulted from our collection and analysis of documents held in the following collections: the Prime Minister's Archive of the Republic (or the Başbakanlık Cumhuriyet Arşivi), the Türkiye Büyük Millet Meclisi Library (for rare books and parliamentary records), and the Refik Saydam Library (for public health-related items), all located in Ankara, Turkey; the Wellcome Library, in London, UK; and the Center for Research Libraries, in Chicago, Illinois.
4. Dr. Muslihiddin Safvet, Türkiye'nin Sıhhî-i İçtimaî Coğrafyası: Ankara Vilayeti (Istanbul: Hilâl Matbaası, 1341/1925).
5. In many regards, the basic organizational structure of each issue of one of the state's primary periodicals, or professional circulars, in public health (i.e., Sıhhiye Mecmuası—from which we cite accordingly in this article) reveals this orientation toward statistics, legislation, and education in the Turkish community of medicine. In each monthly issue, prior to the publication of research articles and other matter, there was an "official section" (or "Resmî kısım") that was often quite substantial (e.g., twenty or more pages) with three categories of information: Kanun, Nizamname, Talimatname ve Tamimler (or "Laws, Regulations, Ordinances and Circulars"); İstatistikler (or, "Statistics"—containing the results of various surveys and other data); and Memurin tebeddülât ve tahavvülâtı (or, approximately, "Civil servants' changes and developments"—a most interesting section that would outline in brief charts the many studies of physicians throughout the country, effectively apprising/educating professionals of the activities of their peers).
6. Such studies on syphilis and associated politics include the following: Allan M. Brandt, No Magic Bullet: A Social History of Venereal Disease in the United States since 1880 (Oxford: Oxford University Press, 1987); Allan M. Brandt, "The Syphilis Epidemic and Its Relation to AIDS," Science, 1988, 239, 375-80; John Parascandola, Sex, Sin, and Science: A History of Syphilis in America (Westport: Praeger, 2008); Claude Quétel, History of Syphilis, trans. Judith Braddock and Brian Pike (Oxford: Polity Press, 1990); Peter Baldwin, Contagion and the State in Europe, 1830-1930 (Cambridge: Cambridge University Press, 1999), 355-523.
7. Foundational for this work was Michel Foucault, "Governmentality," in The Essential Foucault: Selections from Essential Works of Foucault, 1954-1984, ed. Paul Rabinow and Nikolas Rose (New York: The New Press, 2003), 229-45. Also, influential were the following sources, Bryan S. Turner, Medical Power and Social Knowledge (London: Sage Publishers, 1987); Anita Peerson, "Foucault and Modern Medicine," Nurs. Inq., 1995, 2, 106-14; Anthony Pryce, "Governmentality, the Iconography of Sexual Disease and 'Duties' of the STI Clinic," Nurs. Inq., 2001, 8, 151-61; Philip Howell, "Foucault, Sexuality, Geography," in Space, Knowledge, and Power: Foucault and Geography, ed. Jeremy W. Crampton and Stuart Elden (Aldershot: Ashgate Publishing, 2007), 291-315; Gerry Kearns, "The History of Medical Geography after Foucault," in Space, Knowledge, and Power, ed. Crampton and Elden, 205-22; and many of the individual chapters in Colin Jones and Roy Porter, eds. Reassessing Foucault: Power, Medicine, and the Body (London: Routledge, 1994); Alan Petersen and Robin Bunton, eds. Foucault, Health and Medicine (London: Routledge, 1997).
8. This shift from territory to population was entirely in-line with Foucault's description of Western states and their shifting focus in governance from the territorial to the demographic since the eighteenth century, see "Governmentality," 229-45.
9. Indeed, a good number of these surveys actually reached publication even prior to the state's 1923 declaration, such as Dr. Besim Zühtü, Türkiye'nin Sıhhî-i İçtimaî Coğrafyası: Hamidabad (Isparta) Sancağı (Ankara: Öğüd Matbaası, 1338/1922); Dr. Hıfzı Nuri, Türkiye'nin Sıhhî-i İçtimaî Coğrafyası: Kayseri Sancağı (Ankara: Öğüd Matbaası, 1338/1922); Dr. Kemal, Türkiye'nin Sıhhî-i İçtimaî Coğrafyası: Kastamonu Vilayeti (Ankara: Öğüd Matbaası, 1338/1922); and Dr. Nazmi, Türkiye'nin Sıhhî-i İçtimaî Coğrafyası: Konya Vilayeti (Ankara: Öğüd Matbaası, 1338/1922).
10. Such descriptive surveys of the socio-medical geographies were provided by Gümüşçü, "Milli Mücadele Dönemi Türkiye Coğrafyası İçin Bilinmeyen Bir Kaynak, 'Türkiye'nin Sıhhî-i İçtimaî Coğrafyası,'" Atatürk Araştırma Merkezi Dergisi, 1999, 15, 939-69; and M. Sabri Koz, "Türk Halk Kültürün'ün Unutulmuş Kaynaklarından Biri: 'Türkiye'nin Sıhhî-i İçtimaî Coğrafyası,'" in IV. Milletlerarası Türk Halk Kültürü Kongresi Bildirileri (published conference proceedings) (Ankara: Feryal Matbaası, 1992), 37-58.
11. One study, for example, provided details regarding Kırklareli; Türkan Doğruo¨z, "Kırklareli Tarihine Işık Tutacak Bir Eser: Türkiye'nin Sıhhi-i İçtimai Coğrafyası Kırklareli Vilayeti," Hist. Stud., 2011, 3, 275-84.
12. Transcription and translation has been accomplished for some surveys, such as those for Niğde and Çatalca; Dr. Mehmet Hayri, Türkiye'nin Sıhhî-i İçtimaî Coğrafyası: Niğde Sancağı, trans. İlhan Gedik (Niğde: n.p., 1994/1338/1922 original); and Dr. Mehmet Ali, Türkiye'nin Sıhhî-i İçtimaî Coğrafyası: Çatalca Vilayeti, trans. M. Sabri Koz (Istanbul: Çatalca Belediye Başkanlığı, 1991/1341/1922 original).
13. As was the case with the survey for Ankara; Muslihiddin Safvet, Türkiye'nin Sıhhî-i İçtimaî Coğrafyası.
14. The survey for Sivas, for example, was not published until the early 1930s; Dr. Hasan Tahsin, Türkiye'nin Sıhhî-i İçtimaî Coğrafyası: Sivas Vilâyeti (Istanbul: Hilâl Matbaası, 1932).
15. As but one example, we might point to one figure, sometimes referred to as the founder of American medical geography, Jacques M. May. Critiquing this crediting of May from another perspective, see Tim Brown and Graham Moon, "From Siam to New York: Jacques May and the 'Foundation' of Medical Geography," J. Hist. Geoğ, 2004, 30, 747-63.
16. On the juxtaposition of various factors that contribute to the disease ecologies of syphilis, for example, see James C. Thomas, Michele Clark, Jadis Robinson, Martha Monnett, Peter H. Kilmarx, and Thomas A. Peterman, "The Social Ecology of Syphilis," Soc. Sci. Med., 1999, 48, 1081-94.
17. On the origins of Ankara and the early Turkish nation-state, note the following works İlhan Tekeli and Tarık Okyay, "Case Study of a Relocated Capital: Ankara," in Urban Planning Practice in Developing Countries, ed. John L. Taylor and David G. Williams (Oxford: Pergamon, 1982), 123–43; Go¨nül Tankut, Bir Başkentin İmarı, Ankara: 1929–1939 (Istanbul: Anahtar Kitablar, 1993); Kyle T. Evered, "Symbolizing a Modern Anatolia: Ankara as Capital in Turkey's Early Republican Landscape," Comp. Stud. South Asia, Africa, Middle East, 2008, 28, 326–41; and several of the chapters in Erdal Yavuz and ümit Nevzat Uğurel, eds. Tarih İçinde Ankara (Ankara: Orta Doğu Teknik üniversitesi, 1984).
18. We would qualify this generalization by pointing to the notable exception of those studies concerning the state, in general, or the parliament or military, or those devoted to cultural and ethnographic, linguistic, and religious reforms more in keeping with traditional academic inquiries into modernization, nationalism, and secularism.
19. Speaking to these enduring disparities between urban policy formulation and rural policy application in Turkey, one historian wrote, "If we take something like electrification as a measure of modernization, we note that as late as 1953 the total number of villages that had been linked up to the electric grid was ten, or 0.025 per cent of Turkey's 40,000 villages!" Erik J. Zürcher, Turkey: A Modern History (London: I.B. Tauris, 2004), 206.
20. On historical geographies of regulationism (i.e., of prostitution), at least from Britain's Victorian contexts, see Phillip Howell, Geographies of Regulation: Policing Prostitution in Nineteenth-Century Britain and the Empire (Cambridge: Cambridge University Press, 2009).
21. Kemalism refers to the modernist ideology promulgated under the tutelage of Mustafa Kemal (Atatürk) (1881-1938), the founder and leader of the early Turkish republic.
22. For over a decade, critical evaluations of the modernist, state-building Kemalist project have come to characterize a significant body of scholarship on the Turkish republic—to which this article also contributes. Seminal in this body of literature were the studies in Sibel Bozdoğan and Reşat Kasaba, eds. Rethinking Modernity and National Identity in Turkey (Seattle: University ofWashington Press, 1997).
23. For greater analysis of these symbolisms and the planning of Ankara, see K. T. Evered, "Symbolizing a Modern Anatolia."
24. Such contrasts, it should be observed, were inherently ironic, as many of the leading physicians of the new Turkish nation-state had also been doctors working in the Ottoman Empire prior to their realignment with the nationalists.
25. While there were many examples of such accounts of republican triumphs over the shortcomings of the empire that were published by the Ministry of Health and Social Assistance and other governmental bodies—to include photo albums, as examples pertinent to our study, we would point to the two special anniversary issues (one for the tenth year and the other for the twenty-fifth year of the republic) of the Turkish medical journal and circular Sıhhiye Mecmuası (later published as Sağlık); Sıhhiye Mecmuası, Fevkalâde Nüshası: Vekâletin 10 Yıllık Mesaisi (Istanbul: Hilâl Matbaası, 1933); and Sağlık Dergisi, Fevkalâde Nüsha, 1948, 22, no. 10-11.
26. Significant examples of such statements as to the republic's perceived population crisis can be found in the many papers presented at the nation-state's first medical congress, as held in September 1925 in Ankara. The proceedings from this congress were published the following year, see Anon., ed. Birinci Millî Türk Tıb Kongresi (1-3 Eylul 1925) (Istanbul: Kader Matbaası, 1926).
27. For greater analysis of the early republic's "demographic discourse" with regard to Foucault's notions of governance and population, see Kyle T. Evered and Emine Ö. Evered, "Governing Population, Public Health, and Malaria in the Early Turkish Republic," J. Hist. Geoğ, 2011, available online at: doi:10.1016/j.jhg.2011.02.002 (accessed August 16, 2011).
28. Regarding these early histories of the disease in Europe, see Quétel, History of Syphilis, 9-130; J. D. Oriel, The Scars of Venus: A History of Venereology (London: Springer-Verlag, 1994); Peter Lewis Allen, The Wages of Sin: Sex and Disease, Past and Present (Chicago: University of Chicago Press, 2000).
29. On the state of medical knowledge and theory concerning syphilis in nineteenth-century France, for example, see Alex Dracobly, "Theoretical Change and Therapeutic Innovation in the Treatment of Syphilis in Mid-Nineteenth-Century France," J. Hist. Med.Allied Sci., 2004, 59, 522-54.
30. Roy Porter, The Greatest Benefit to Mankind: A Medical History of Humanity (New York: W.W. Norton, 1999), 167.
31. Brandt, No Magic Bullet, 40-47.
32. Porter, Blood and Guts: A Short History of Medicine (New York: W.W. Norton, 2002), 158.
33. Brandt, No Magic Bullet, 40-47.
34. George Rosen, A History of Public Health (Baltimore: Johns Hopkins University Press, 1993), 74.
35. On this matter of choice, or how some construe there to be adverse consequences to free will, note themes from U.S. history that were covered in many of the chapters in Charles E. Rosenberg, Explaining Epidemics and Other Studies in the History of Medicine (Cambridge: Cambridge University Press, 1992).
36. Providing a number of introductory examples of state enforcement involving syphilis and other diseases, see Porter, The Greatest Benefit to Mankind, 420-25. Also, with specific regard to experiences in Victorian Britain, see Judith R. Walkowitz, Prostitution and Victorian Society: Women, Class, and the State (Cambridge: Cambridge University Press, 1980); and Howell, Geographies of Regulation.
37. It should be noted that this inclination toward mediating—rather than prohibiting—particular sexual practices (i.e., prostitution) had precedent in the Ottoman experience and was not merely a republican invention. On the regulation of prostitution in late Ottoman Istanbul, for example, see Müge Özbek, "The Regulation of Prostitutes in Beyoğlu," Mid. East. Stud., 2010, 46, 555-68. For greater discussion of prostitution in contexts of the Ottoman Empire, see Rıfat N. Bali, The Jews and Prostitution in Constantinople, 1854-1922 (Istanbul: Isis Press, 2008); Elyse Semerdjian, Off the Straight Path: Illicit Sex, Law, and Community in Ottoman Aleppo (Syracuse: Syracuse University Press, 2008); and Fariba Zarinebaf, Crime and Punishment in Istanbul, 1700-1800 (Berkeley: University of California Press, 2010).
38. Muslihiddin Safvet, Türkiye'nin Sıhhî-i İçtimaî Coğrafyası, 91.
39. Ibid., 113.
40. Ibid., 51.
41. Although we emphasize in this article more the question of how public health officials promoted a science-based notion of sexual morality, prevailing ideas of social and sexual morality clearly entered into their discourse. Presenting an analysis of changing notions of gender and sexuality in turn of the century Russia, see Laura Engelstein, The Keys to Happiness: Sex and the Search for Modernity in Fin-De-Siècle Russia (Ithaca: Cornell University Press, 1992).
42. Muslihiddin Safvet, Türkiye'nin Sıhhî-i İçtimaî Coğrafyası, 55-56.
43. That these women might be helped out of their circumstances seemed unimaginable to most of the provincial health directors. Though all criticized the conduct of "secret" (i.e., unregulated) prostitution, only one seemed to envision creating an alternative reality through relocation, job training, and other measures to, in his words, "reform their bodies and their morality" (Mehmet Hayri, Türkiye'nin Sıhhî-i İçtimaî Coğrafyası, 171-72).
44. Though tempting to accept Dr. Muslihiddin Safvet's assessment of a recent rise in the incidence of syphilis in Ankara as occasioned by recent conflicts and socioeconomic instabilities, our ongoing examination of nineteenth-century archival documents held in the Ottoman archive in Istanbul is revealing that Ankara experienced significant problems with the disease in the nineteenth century, as well.
45. Muslihiddin Safvet, Türkiye'nin Sıhhî-i İçtimaî Coğrafyası, 55-56.
46. Muslihiddin Safvet, Türkiye'nin Sıhhî-i İçtimaî Coğrafyası.
47. Ibid., 91. Also note that the Kengri (or Çankırı) Gate was not only the site designated for the city's registered brothel. Evidencing from Ankara's history what was, perhaps, a classic example in its municipal leadership's creation of urban disamenity (or, viewed conversely, a case of NIMBY), this gate area was also one of the sites proposed by the city council for the relocation of the city's cemeteries due to concerns over the increased public health hazard posed by cemeteries amid rapid rates of urbanization. Muslihiddin Safvet, Türkiye'nin Sıhhî-i İçtimaî Coğrafyası, 76.
48. Ibid., 55-56.
49. Ibid., 91.
50. Ibid.
51. Ibid.
52. Ibid., 68.
53. Ibid., 91.
54. Ibid., 92.
55. While most provincial directors expressed this perceived need for state-regulated brothels and the licensing of prostitutes on the grounds of public health, it was also detailed with particular attention by the administrators for Kırkkilise, Muğla, and Kayseri; Dr. Ahmet Hamdi, Türkiye'nin Sıhhî-i İçtimaî Coğrafyası: Kırkkilise (Kırklareli) Vilayeti (Istanbul: Kağıçılık ve Matbaacılık Anonim Şirketi, 1341/1925); Dr. Esad, Türkiye'nin Sıhhî-i İçtimaî Coğrafyası: Muğla (Menteşe) Sancağı (Ankara: Öğüd Matbaası, 1339/1923); and Hıfzı Nuri, Türkiye'nin Sıhhî-i İçtimaî Coğrafyası.
56. Muslihiddin Safvet, Türkiye'nin Sıhhî-i İçtimaî Coğrafyası, 92.
57. Ibid.
58. The significant presence of physicians in the parliament of the early republic was observed and discussed in Melih Tınal, "Türkiye Büyük Millet Meclisi Birinci Döneminde Doktor Milletvekilleri," Uluslararası Sosyal Araştırmalar, 2009, 2/6, 617-27. Beyond these examples, we would also note that Dr. Refik (Saydam)—successor to Dr. Adnan (Adıvar) as director of the Ministry of Health and Social Assistance—even rose to become the nation-state's fourth Prime Minister (1939-42).
59. Among imperial efforts to legislate sexual health, we might recall the Ottoman Empire's 1884 Venereal Disease Law as but one example; addressed in Özbek, "The Regulation of Prostitutes in Beyoğlu."
60. Among a few of the many contributions of the republic to the status of women in Anatolia, we would note the 1920s extensions of political, educational, and social rights to women, the legal abolition of polygamy, the early 1930s achievement of suffrage, and other measures to promote equality and inclusion. While critics of these measures often pointed either to the existence of such rights "on paper alone" or to the diminished significance of voting rights in a single-party state, such criticisms could also be made of many similar developments for the inclusion of women that emerged in Western/European states— sometimes years or decades later.
61. Surveying academic and other sources with regard to the detrimental aspects of state endorsements of prostitution—and perspectives that promote it, see Maggie O'Neill, Prostitution and Feminism: Towards a Politics of Feeling (Cambridge: Polity Press, 2001). For additional analysis of the socio-political geographies of regulationist perspectives, past and present, see also Phillip Howell, "Race, Space and the Regulation of Prostitution in Colonial Hong Kong," Urb. Hist., 2004, 31, 229-48, and Howell, Geographies of Regulation. Specific to the French experience with regulation, see Alain Corbin, Women for Hire:Prostitution and Sexuality in France after 1850, trans. Alan Sheridan (Cambridge: Harvard University Press, 1990); Jill Harsin, Policing Prostitution in Nineteenth-Century Paris (Princeton: Princeton University Press, 1985).
62. As restated in the later twenty-fifth anniversary issue of Sağlık Dergisi; "Sağlık İşleri Genel Müdürlüğünün Çalışmaları," Sağlık Dergisi, Fevkalâde Nüsha, 1948, 22, no. 10-11, 10-45, 24.
63. As related in Sıhhiye Mecmuası, Fevkalâde Nüshası, 59.
64. Ibid., 58.
65. Shortly after the law's April 24, 1930, passage, it was published for general distribution in the country in the state's official gazette; Resmî Gazete, May 6, 1930, no. 1489.
66. A number of the law's articles were later translated and provided in English; Sven Christiansen, "A Report on Syphilis Control in Turkey," Bull. World Health Organ., 1954, 10, 627-90. Christiansen's rendering of these articles, however, seemed to derive from information provided at the time by the Turkish state and his text omitted many clauses (e.g., those pertaining to midwives, among others) to the particular articles cited by him and addressed in this article.
67. As revealed through the addition of a subsequent provision, the state's anxieties over physicians' failures to report all cases and required details of each case led to a significant tightening of the law as early as 1933, with greater sanctions outlined for those who would fail to comply; "Vekâletin 12 Teşrinievvel 1933 Tarihli Hıfzısıhha No. 510 Tamimi," Sıhhiye Mecmuası, Vol. 9, no. 65 (Kânunuevvel 1933), 293.
68. Within a year of the passage of the law, the state seemed compelled to issue an additional warning regarding the repercussions of failing to maintain patient confidentiality. Published in its monthly public health journal as a circular Sıhhiye Mecmuası, the state indicated that any health personnel who violated these provisions for confidentiality would be fired from their positions; "Hıfzısıhha No. 382 Tamimi," Sıhhiye Mecmuası, 1932, 8, no. 58 (Ağustos 1932), 229-30.
69. The broad scope of this article, as read, was later specified to come closer to its framers' original intent: to mandate particular measures for those citizens who worked in capacities that would bring them into contexts wherein their disease status might be of concern. Encouraging cautious restraint in its enforcement by public health officials, a subsequent circular from the state warned that it had been applied to peoples that were not envisioned by the framers of the original law. Such errors in application, it was noted, lead to unnecessary (and understandable) complaints, compromised the standing of health officials in their communities, and impugned the standing and reputation of otherwise upstanding citizens; "Hıfzısıhha No. 450 Tamimi," Sıhhiye Mecmuası, 1933, 9, no. 63 (Haziran 1933), 121-22.
70. In the following year (i.e., 1931), each of the provincial directorates of Health and Social Assistance were furnished with 2,000 copies of the document and were reminded that they were required to provide these pamphlets to those patients who suffered from sexually transmitted diseases; "Umumî Hıfzısıhha Kanunun Tatbikine Dair Tamim, No. 22," Sıhhiye Mecmuası, 1931, 7, no. 52 (Ağustos 1931), 277.
71. The specifics of prenuptial examinations—with distinct provisions for men and women—were enacted and disseminated in the following year (i.e., 1931); "Evlenme Muayenesi Hakkında Nizamname, Karar No. 11682," Sıhhiye Mecmuası, 1931, 7, no. 54 (Kânunuevvel 1931), 458-61.
72. Although physicians were required to report the names of all parties seeking prenuptial examinations, state health officials suspected that doctors were only registering the names of those parties who were approved for marriage and dissuading verbally (i.e., not in writing and without entering into a registry that the state could monitor) those who were not approved (i.e., those who tested positive for syphilis) from making a formal application for marriage until they had been treated. As officials were concerned that this suspected practice contributed to inaccuracies in information collection and constituted evasion of state laws on reporting, the expressly forbade such conduct in a circular published the following year; "Hıfzısıhha No. 392 Tamimi," Sıhhiye Mecmuası, 1932, 8, no. 59 (Teşrinievvel 1932), 275-76.
73. This specific article in the law regarding prostitution and prostitution-related diseases was elaborated upon in detail by the state in 1933 and published thereafter in Sıhhiye Mecmuası (i.e., "Fuhuşla ve Fuhuş Yüzünden Bulaşan Zührevî Hastalıklarla Mücadele Nizamnamesi, Kararname No. 15264," Sıhhiye Mecmuası, 1933, 9, no. 65 [Kânunuevvel 1933], 250-82); we address this document, its provisions, and political tensions that might be categorized in Western scholarship as occurring between supporters of regulationism and those of prohibitionism of prostitution in a forthcoming article.
74. Foucault, "Governmentality," 229-30.
75. In this regard, we might note a profound convergence between Foucault's conceptualization of governmentality, on the one hand, and Gramsci's articulation of achieving hegemony through the construction of consent, on the other. On matters of hegemony and social consent, see Antonio Gramsci, Selections from the Prison Notebooks, ed. Quintin Hoare and Geoffrey Nowell Smith (New York: International Publishers, 1971).
76. Foucault, "Governmentality," 229.
77. Beyond our own inquiry into matters of education with regard to governance and public health, there are, however, many other trajectories of study that engage with the role of education and health. For example, we might note those pertaining to sex education. See, Alexandra M. Lord, "Models of Masculinity: Sex Education, the United States Public Health Service, and the YMCA, 1919-1924," J. Hist. Med. Allied Sci., 2003, 58, 123-52.
78. On our description of Turkish public health officials' decidedly modernist orientations, we would not only reference standard works in Turkish studies (e.g., Bozdoğan and Kasaba, Rethinking Modernity and National Identity in Turkey), we also note profound parallels between the politics of Turkish public health and the politics of similar "ultra-modernist" projects for development, as per James C. Scott, Seeing Like a State: How Certain Schemes to Improve the Human Condition Have Failed (New Haven: Yale University Press, 1998)—though we would avoid assessing it in terms of absolute success or failure.
79. As depicted in Nazmi, Türkiye'nin Sıhhî-i İçtimaî Coğrafyası, 20.
80. It was ironic (and hypocritical) that many of the physicians commented so harshly regarding the use of mercury beyond just its physical risks. Indeed, many of them (or their teachers) likely applied mercury as the once-appropriate therapy for syphilis in previous decades. As one historian wrote of nineteenth-century French doctors, "[m]uch as the might wish to avoid it, doctors and their patients understood that mercury was a necessary evil"; Dracobly, "Theoretical Change and Therapeutic Innovation in the Treatment of Syphilis in Mid-Nineteenth-Century France," 552.
81. Parascandola, Sex, Sin, and Science, 80-81.
82. Also noted in, Nazmi, Türkiye'nin Sıhhî-i İçtimaî Coğrafyası, 20.
83. Emphasizing this point through the use of anecdotes of misdiagnosis and inappropriate fumigation, see Ahmet Hamdi, Türkiye'nin Sıhhî-i İçtimaî Coğrafyası, 42-43.
84. Speaking to the profound class dimensions of syphilis in the Turkish populace, note the comments by Dr. İbrahim İsmail; Türkiye'nin Sıhhî-i İçtimaî Coğrafyası: Kırşehri Vilayeti (Istanbul: Kağıçılık ve Matbaacılık Anonim Şirketi, 1341/1925), 49-50.
85. Muslihiddin Safvet, Türkiye'nin Sıhhî-i İçtimaî Coğrafyası, 63-64.
86. Ibid., 64.
87. Such as the state's monthly journal Sıhhiye Mecmuası.
88. Beginning as early as 1925, as documented in Anon., Millî Türk Tıb Kongresi.
89. George S. Luckett and Harold F. Gray, The Elements of Public Health Administration (Philadelphia: P. Blakiston's Son and Company, 1923).
90. Dr. Refik (Saydam), foreword to Luckett and Gray, Sıhhat-i İçtimaîye İdaresi Esasatı, trans. (Istanbul: Hamid Matbaası, 1926), 2.
91. As we cite from the 1926 edition that was translated into Ottoman Turkish, often "it [i.e., syphilis] harms ten percent of the population, and once a person acquires syphilis, it continues to harm the second or third generations." Luckett and Gray, Sıhhat-i İçtimaîye İdaresi Esasatı, 327.
92. Ibid., 327-28.
93. Ibid., 328.
94. By this time, globally, early educational films were emerging as a popular form of public health instruction (and, likely, entertainment), as observed in Jean B. Pinney, "The Motion Picture and Social-Hygiene Education," J. Educ. Sociol., 1936, 10, 158-67. Indeed, one of the French films of 1927 that Pinney includes (though only by its English-language title "The Three Friends," 158). "Il était une fois trios amis," rendered something of a morality tale—not so much about sexuality but about being tested and undergoing proper treatment. This film reportedly was shown in Ankara, though its copy quickly began to break and required frequent splicing (noted in Muslihiddin Safvet, Türkiye'nin Sıhhî-i İçtimaî Coğrafyası). However, most villages were too distant and resources (including power) were too scarce to enable such methods (recall above footnote from Zürcher's Turkey regarding the delayed pace of electrification in the republic).
95. It should be noted that the Ministry of Health and Social Assistance artist, Refet Başokçu, seemed to select and variously re-situate and then re-paint a number of these images of afflicted persons from early republican (or, possibly even late Ottoman) medical photographs and portraits that were contained in a previously issued medical atlas that the ministry issued in the 1920s (T.C. Sıhhiye ve Muavenet-i İçtimaîye Vekaleti, Sıhhî Müze Atlası [n.p., 1926]). In our research for this article, we witnessed one of these early atlases—intended for use throughout the country as a means to educate health professionals and citizens—while working in the parliamentary library (the Türkiye Büyük Millet Meclisi Library) in Ankara. Including a preface by Dr. Refik (Saydam), it provided brief information and abundant pictures relevant to not only syphilis but other priority illnesses, as well.
96. This observation on the priorities of the Turkish state corresponds closely with Foucault's own commentary as to the ways in which population began to emerge "as the ultimate end of government" for modernizing polities, see Foucault, "Governmentality," 241.
97. As a general survey of such engagements with and applications of what might be called scientism—particularly with regard to geographic knowledge (e.g., as with the socio-medical geographies analyzed in this article), see David N. Livingstone, Putting Science in Its Place: Geographies of Scientific Knowledge (Chicago: University of Chicago Press, 2003).
98. In this regard, we might draw strong parallels between how regulated prostitutes were idealized by the state with how pronatalist nation-states also promote idealized (yet profoundly subordinate) notions of motherhood. The connection is even more apparent when we consider how the nation's mothers, as incubators of future generations and as the wives of the prostitutes' potential clients, functioned as states' justifiers for enacting schemes of regulating prostitution.
99. The persistence of prostitution in Turkey may be seen within the country in both its regulated form (i.e., in the so-called genelevs or "brothels") and with respect to Turkey's role as both a destination and transit site for trafficking, see Anti-Slavery International, Forced Prostitution in Turkey: Women in the Genelevs: A Report (London: Anti-Slavery International, 1993); and Sema Erder and Selmin Kaska, Irregular Migration and Trafficking in Women: The Case of Turkey (Geneva: International Organization for Migration, 2003).