Special Report

Figure: Turkish police fire tear gas at protesters marching against new construction in Gezi Park.The Turkish Medical Association lists in its founding pledge a series of statements familiar to anyone acquainted with the Hippocratic Oath. And that's no surprise: the Greek father of modern medicine was born on Turkish soil. Now the very principles upon which most physicians in Turkey practice — to protect and improve public health, to preserve the moral and spiritual core of the medical profession — are under fire. A new law allows prosecution of anyone who administers “unauthorized” medical aid in the wake of a demonstration, a measure aimed squarely at the country's emergency physicians. Almost immediately after it was passed, the American Academy of Emergency Medicine (AAEM) issued a statement opposing the Turkish law. “It penalizes physicians for doing what they are supposed to do in emergency situations. And that is to take care of the sick and the hurt,” said Mark Reiter MD, the president of the AAEM. The academy joined 11 other organizations in registering a collective objection, including Physicians for Human Rights (PHR), the World Medical Association, the International Federation for Emergency Medicine, and the British Medical Association. The letter, sent in early March, calls on the Turkish Prime Minister to “immediately and unconditionally” drop the legal actions against members of the Turkish Medical Association, Turk Tabipleri Birligi (TTB). “The hope is that this becomes more visible,” Dr. Reiter said. The Turkish law is not the first to make emergency treatment a personal risk for patients and health care providers, he pointed out. Gay men who are ridiculed and beaten for their sexual orientation in some African nations can face serious legal consequences if they are identified during treatment: laws prohibit same-gender attraction. Women in some countries who receive aid after rape can risk execution by family members seeking to rectify the shame from an acknowledged sexual assault. But the law in Turkey is different. “This is a blanket law for political reasons,” Dr. Reiter said. It was enacted in the aftermath of anti-government demonstrations beginning last May when a broad cross-section of the country's citizens staged sit-ins and made public demands for rights, such as freedom of expression. The catalyst occurred at Taksim Gezi Park, an urban green space in central Istanbul where trees were being felled to allow new construction, in part to house a shopping mall. What began as a peaceful demonstration gave way to upheaval — and mass injury. Doctors served in makeshift clinics to care for those hurt in the protest, clinics that were hastily convened in mosques or under tents. In doing so, the doctors were perceived as abetting enemies of the state, according to news accounts, including those in the city's newspaper, Zaman. More than 8,000 were injured in the Gezi Park uprising, and more than 70 journalists lost their jobs for covering the demonstration. (NY Times, Nov. 14, 2013; http://nyti.ms/1ftv3gj.) Actions taken by several governments over the past few years — Syria, Bahrain, and now Turkey — have sought to “inhibit the ethical duty of physicians,” said Vincent Iacopino, MD, PhD, a senior medical advisor to PHR. It's too soon to tell whether governmental clamp-downs on emergency medical care will spread from Turkey to other nations, Dr. Iacopino said, but some medics who helped injured protesters in Bahrain are in prison three years after demonstrations started there. Syrian medical personnel, including physicians and nurses, have been arrested and tortured for providing treatment during a civil war in that began in 2011. “It is possible that this could spread,” Dr. Reiter agreed. The new Turkish health law states that emergency services provided by authorized personnel would only be allowed “until the arrival of formal health services and health service becomes continuous.” These “vague and unnecessary conditions regarding who can provide medical care and when will result in the arbitrary arrest and punishment of emergency medical responders,” Dr. Iacopino predicted, adding that international standards in human rights and medical ethics “make it clear that doctors, nurses, paramedics, and other health workers must be able to carry out their professional responsibilities to provide emergency medical care to those in need without interference or fear of reprisal.” But reprisal is just what seems to have been initiated shortly after the park-based protests. The Istanbul branch of TTB was singled out, accused of delivering illegal emergency care during protests against the planned razing. The Turkish Ministry of Health has filed a civil suit against the association, requesting the removal of members from office for organizing medical relief efforts. “This shows real contempt for ethical medical practices and the right to emergency medical care,” said Dr. Iacopino, adding that the case against members of the association could have a chilling effect on any medical assistance during relief efforts. Previous efforts by representatives of the international medical community to meet with the Minister of Health failed, noted Dr. Iacopino, who also is a senior research fellow at the Human Rights Center at the University of California, Berkeley. The support and concern expressed by the international medical community, including AAEM and PHR, reportedly has been met with gratitude by emergency physicians across Turkey. Emails indicating that Turkish medical colleagues appreciate the actions began popping up in his inbox almost as soon as AAEM took a public stance against the new Turkish law, said William Durkin Jr., MD, MBA, who was AAEM's president at the time the protests began. (Read Dr. Durkin's editorial on the Turkish law in EMN's iPad app on May 5 and on www.EM-News.com on May 12.) So far, however, AAEM's protest hasn't had a discernible impact on the move by the government, which has asked for the names of physicians, medical students, other health workers involved in providing medical help, and those who received medical care. (BMJ 2012; 344:e529.) Dr. Durkin said one of the most disappointing aspects of the law — besides its imperiling emergency doctors and nurses — is that it has been passed in a country that has made such great strides in emergency care. “We are talking about a place that is pretty much up-to-date,” Dr. Durkin noted, adding that emergency medicine training is a separate, well-recognized field of practice in Turkey. (www.healthobservatory.eu.) Turkey has specialized training programs for physicians in the field, separate practice facilities linked to hospitals, standards of care closely aligned to the United Kingdom, and emergency infirmaries that function as the same kind of safety net seen in the United States.Figure: A man is treated at an Istanbul mosque serving as a makeshift medical clinic after clashes in Gezi Park.Some countries have been at the forefront of emergency medicine — Canada, Hong Kong, Singapore, Australia, New Zealand, the United Kingdom, and the United States — but there is an emerging “intermediate group” of countries in emergency care about to break through to that top echelon, said Terry Mulligan, DO, MPH, an associate professor at the University of Maryland School of Medicine. Turkey has been one of them, said Dr. Mulligan, an emergency physician who has been involved in global health care issues for more than 15 years following a fellowship in international medicine at George Washington University in Washington, DC. He said he met Turkish physicians while on that fellowship who trained at Pennsylvania State University in Hershey, PA, which also had a program for the study of international health. “There wasn't much more than a handful of us then, and we'd done cross-projects together,” Dr. Mulligan explained. They became a tightly-knit cohort that remained friends, he said. This core group not only formed sustaining relationships, some of them began traveling to Turkey to assist in organizing an emergency medicine association there, which is affiliated with the TTB. They also helped their Turkish counterparts plan conferences for continuing medical education and set standards for care. Then they watched as emergency medicine grew there. But it wasn't one-sided; they've learned from colleagues in Turkey as well, Dr. Mulligan said. “Now we are working together, society to society,” he said, noting that the professional bond easily extends across oceans and borders. Turkey has had an emergency medicine specialty since the 1990s when the president of the country died from a heart attack after a delay in diagnosis and treatment. “This country has been a real leader in emergency medicine, and now this happens,” Dr. Mulligan said, adding that, like Dr. Durkin, he has been in contact with his colleagues in Turkey who could be affected by the law. “We are offering our support, but why is there even a need to do that? Certain human rights — the right to medical care — should be unassailable,” he said. Physicians in Turkey contacted for this article declined to respond; repeated efforts to reach the Turkish Minister of Health were unsuccessful. A PHR report released recently has documented the ways in which Turkish authorities violated international laws, cracking down on what started as peaceful protests at the end of May. The police actions included tear gas, rubber bullets, water cannons, beatings, and live ammunition, according to the report. (http://bit.ly/1pMfkfs.) The encroachment of politics into emergency medicine could have particularly devastating consequences in the years ahead. The greatest need for urgent treatment over the past half century has shifted from communicable disease to physical conditions such as heart disease, stroke, and trauma. (http://bit.ly/1lCe7bq.) Increasingly, vehicle crash injuries are topping the list. (Emerg Med Internatl 2014; http://bit.ly/1pMihN7.) The latter — traumatic injury — is now almost universally among the top 10 causes of morbidity and mortality across the world, and it has reached the top five in many cases, Dr. Mulligan said. Insistence on equality in health care has been a part of medical practice almost since it formally began in Europe, particularly medical care associated with relief efforts. George Guthrie, a famous 19th Century surgeon who served in the British military, is credited with resisting authority by treating injured enemy soldiers along with his own men following battle. British physicians also volunteered their time and used their own medicines to serve the poor, often by visiting clinics that had been financed by private donors. Health care in recent years, however, hasn't just been a national policy concern but a global one. Control of health care in some countries — through its proffering or denial — has been used to gain control of local populations. (Epidemiol Rev 2010;32[1]:82.) Outbreaks of unrest can lead to scarce resources, and these situations have demonstrated that control of health and social services can influence the degree of loyalty to a cause. The shared experience of a resistance effort can forge new alliances as well, as two feminist scholars observed in the Gezi Park demonstration. A large group remained for a period of time after the protests abated, and the result was “tayyip,” a new connection of people, they reported. (Open Citizenship 2013;4[2]: 88; http://bit.ly/1pRpxFI.) The concept of “tayyip” seems to extend beyond Turkey, as some American physicians have promised to keep their focus on the new Turkish law with continual pressure for support of the TTB, particularly its contingent of emergency physicians. “This is a political intrusion and an unethical restriction that needs an organized, international response,” Dr. Mulligan said. Click and Connect!Access the links in EMN by reading this issue on our website or in our iPad app atwww.EM-News.com. Comments about this article?Write to us at[email protected]. Speak Out for Turkish EPs William T. Durkin Jr., MD, MBA, said emergency physicians must speak out on behalf of their colleagues in Turkey before the same thing happens elsewhere. Read his editorial on the Turkish law on May 5 in the EMN iPad app and on May 12 in the Breaking News blog on www.EM-News.com, where the EMN app can also be downloaded for free.

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