The importance of associations in the struggle against tuberculosis in Turkey

İnsanlık tarihi kadar eski bir hastalık olan ve insanoğlunun yaşamını her alanda etkileyen tüberküloza karşı verilen mücadele dünyada sivil toplum örgütleri tarafından başlatılmış ve bu mücadele ikinci dünya savaşı sonrasında başarıya ulaşmıştır. Tüm dünyada olduğu gibi Anadolu’da da tüberkülozla mücadele tıp çevrelerinde önde gelen isimlerin girişimleriyle Osmanlı Devleti döneminde başlamıştır. Sonraki yıllarda mücadelenin yürütücü kadrolarını içinde barındıran İstanbul Verem Savaş Derneği 1918 yılında kurulmuştur. Yaşanan siyasi gelişmeler nedeniyle kısa süre sonra duran dernek çalışmaları, 1923 yılında Türkiye Cumhuriyeti döneminde İzmir’de yeniden başlamıştır. Tıp çevrelerinin 1925 ve 1927 yıllarında düzenlediği ulusal tıp kongrelerinde tüberkülozun ana konu olarak seçilmesi ve sonrasında 1928 yılında İstanbul Verem Savaş Derneğinin yeniden faaliyete geçmesiyle mücadelede dernek çalışmaları belirleyici rol üstlenmeye başlamıştır. 1953-1973 yılları arasında UNICEF, Sağlık Bakanlığı ve Ulusal Verem Savaş Derneğinin ortaklaşa yürüttüğü çalışmalar sonrasında tüberküloz mücadelesinde önemli sonuçlar elde edilmiştir. Bu olumlu tablonun verdiği rehavet ortamı, ekonomik ve siyasi krizlerle geçen 10 yıl içinde tüberkülozda tüm dünyada yaşanan artışa paralel olarak Türkiye’de de bir artış söz konusu olmuştur. 1990’lı yıllara gelindiğinde derneklerin katılımıyla oluşan Ulusal Verem Savaşı Dernekleri Federasyonu’nun (1986) çalışmaları sonucunda tüberküloz mücadelesinde doğrudan gözetimli tedavi stratejisi uygulamasına Türkiye genelinde 2005 yılında geçilmiştir. Sonuç olarak; başlangıcından günümüze kadar geçen süre içinde Türkiye’de yürütülen tüberküloz mücadelesinde verem savaş derneklerinin önemli rolü olduğu değerlendirilmektedir.

Tuberculosis (TB) is one of the oldest diseases to humankind and it affects every aspect of human life as well is the most common cause of infection-related death worldwide.One in every three people in the world is believed to be infected with Mycobacterium tuberculosis.More than eight million new cases of TB develop annually and three million people die from the disease (1).
Our knowledge about TB relies on fragments of bones from Egyptian mummies and ancient written.Although the disease become a major health problem for humanity, disease has been loaded into all the metaphors, however, were disappeared by Robert Koch determination of the tuberculosis agent, and understanding the pathogenesis of the diseases.After the discovery of Koch, the fight against TB has accelerated in the last quarter 19 th century.As of this period, the struggle against TB has been carried out by non-governmental organizations (NGOs) and successful results were achieved after the second world war (2).
In our country, we know learning from daily and archive documents that TB was the most common cause of death in the Ottoman period.Despite all the negative statements, NGOs and State could not be exhibited sufficient efforts to fight against TB in that time (2).

THE TUBERCULOSIS STRUGGLE in OTTOMAN PERIOD
The earliest official document about the struggle against TB in Anatolia was in 1898.It was a report prepared to Sultan Abdulhamid by the "Cemiyeti Tıbbiye-i Şahane", which was the first Medical Society in Ottoman Empire.The report contained knowledge about the infectivity of TB and its protection, as well as the sanatorium system and the constitution of a TB association.Despite the great efforts, only a few sanatoriums were established because of the period's economic and social the difficulties (3,4).
In Ottoman Empire, TB mortality increased during the Trablusgarp war, the Balkan wars and the first world war.At the same time, improvements in the treatment at abroad triggered a new movement about TB, new dispensaries, sanatorium and organizations against the disease.The "Ottoman Association for Combating TB" was founded by the efforts of some well known medical doctors in 1918 in Istanbul.Later on, this association was accepted as the predecessor of the Turkish National Anti-TB Association (5)(6)(7)(8).But this first period of the association did not last long since its functions had to be postponed because of the occupation of Istanbul (2,7,9).
After the War of Independence (1919)(1920)(1921)(1922), the Republic of Turkey was established in 1923.Although TB was one of the priorities of the new republic the resources were too limited, the government focused on the treatment of malaria and syphilis, which would be more cost-effective.At this point, nongovernmental organizations were considered as a necessity in order to struggle against TB (2,10).The first nongovernmental organizations were founded in Izmir in 1923 by Dr. Behcet Uz and other associations followed up.These organizations had achieved significant improvements on health promotion.We can evaluate these efforts as highly significant for starting point (2,7,8).
The importance of associations in the struggle against tuberculosis in Turkey

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Tuberk Toraks 2012; 60(3): 291-294 Tuberculosis is a disease as old as human history and has affected every area of human life.The struggle against tuberculosis had been started by non-governmental organizations and achieved success after second world war.In Anatolia as well as all over the world fight against tuberculosis, with the leading names in medicine, started during the Ottoman Empire.
In the following years of struggle within the executive team will host association

THE TUBERCULOSIS STRUGGLE in REPUBLIC of TURKEY
In 1925 and 1927, the medical community, which participated at the Turkish Medical Congresses, stated that the number of associations and its functions had to be increased by the civil initiative and described the technical aspects of the struggle against TB (2).By the end of these congresses in 1927, the struggle against TB association in Istanbul, which had been a successful model for the entire country in Ottoman period, was again activated (11).The new association worked as a local association during the construction period in Istanbul, and then it was supported by the government after 1932 (2).At the same time, BCG vaccine was produced by the Ministry of Health (MoH) in Ankara by means of the lobby efforts of the Istanbul association and the government gave a special importance to TB struggle in the "Law of General Hygiene" (2,12).As a consequence of these civil and governmental efforts, the TB struggle in Turkey has established awareness and a legal foundation in early 1930s.This decade can be entitled as a structuring period of the struggle against TB (7).
During the years of the second world war, although Turkey did not join the war, TB cases increased due to the global conditions.Despite the poor conditions related to the war, the Istanbul Association continued its achievements and got organized in Istanbul and around and the "Turkish TB Specialists Association" was constructed in 1939 (2).
In the years following the war, the Turkish Government set up its relations with the new world and its organizations, such as World Health Organization (WHO) and UNICEF.Dr. Behcet Uz, the founder of the Izmir Association, became the MoH and played a significant role in the struggle against TB by his early local experience.In his ministry period of 5 years, the number of the TB associations increased from 3 to 65 in Turkey (13,14).
In 1948, "Turkish National Anti-TB Association" was founded by 36 members in the First TB Information Commission Meeting, held by the MoH, Istanbul and Ankara (1946) associations.After a year, the National Anti-TB Association was accepted as a member by the "International Union against TB and Lung Disease".
Following the participation at this union, the struggle against TB was affected positively (2,8,15).
At the same year, as a consequence of the efforts of the national association as well as the MoH, the legislation about TB struggle was accepted in 1949.We can actually say that this legislation supported a partnership between the government and the associations for the TB struggle (2,9).
In 1950, the MoH, the national and Istanbul associations contacted with UNICEF and WHO.By this cooperation, the campaign of BCG vaccination was started in 1953 and due to the satisfying results, this campaign was presented as a successful example by the WHO.In the same year, the first TB congress was held by the efforts of the Turkish TB Association.Additionally, a Consultation Meeting was held by the national association and the MoH in order to evaluate all these positive achievements and to point out to the new policies (2,9).
In 1954, the success of the TB struggle in Turkey was positively affected the international positions of the Turkish specialists.For example, Dr. Tevfik Saglam, who was the president of the national and Istanbul associations, became the president of the Middle East Union Association, founded in Lebanon (8).
In 1964, the general directorate of the TB struggle was founded in the MoH.Now, we realize that this novelty was a reform in the struggle process because the TB struggle was extended to the entire country by means of this general directorate (2,9).The improvement has to be attributed to the efforts of the TB Information Commission by the associations' pressure on the MoH.
At the beginning of the 1970s, the TB struggle had a great success all over the world and the TB cases considerably decreased.In the same year in Turkey, the state of TB showed a parallelism with the world.In 1973, the signed collaboration treaty with the UNICEF had ended (2,9).After that, in 1975-1976, the medical community had a false opinion that the TB struggle had completed its duty.In 1980, this "negligence" perspective and the 1980s' economic and social difficulties were negatively affected and the drug-resistant cases increased dramatically in Turkey and all over the world.Additionally, the special situation of Turkey, caused by the temporary military government, postponed the functions of all the civil organizations including the "unfortunate" TB associations (2).
Results of the multicentric investigations in 1981 revealed the increased tendency of the TB; however, in contrast, the TB struggle general directorate was reduced to a department formation despite the oppositions of the TB struggle association and the Information Commission.After the school providing technical personnel to TB struggle was shut down by the MoH in 1984, the association tried to supply adequate number of personnel for the struggle's maintenance (13).Then, the department and the national association suggested that more chronic and drug-resistant cases would be seen.Therefore, they postulated that the patients had to be kept under control (9).
In 1986, after the reconstruction of the related law, the national association was switched to the national TB association federation (2).From 1985 to 1995, the continuity of the department management could not be maintained because of the political reasons and this situation caused insufficient budget of the ministry for the TB struggle (16).After 1990, the TB federation and the Information commission hardly made an effort to put DOTS (directly observed treatment strategy) program into practice advised by the WHO in the new global system since there was an increase in the tendency of TB.In spite of all the efforts, DOTS program could not be performed (17).Besides, in 1998, tax allowances of TB associations were expired and associations' autonomy was wounded (2).

CONCLUSION
Finally, at the beginning of the 2000s, after all of these processes, the TB struggle has arrived at a new level by the results of the efforts of the TB struggle department of the ministry, the federation and the 188 TB struggle associations.After a long work of the national federation, the associations and the persons related with the TB, the DOTS program has been performing since June 2006 in all cities in Turkey (9).
When the Istanbul TB association was founded, not only the individual efforts to construct a TB struggle for Turkey was demonstrated, but also the associational and the federational efforts were put together in order to establish suitable circumstances for the TB struggle.
The process itself has integrated the governmental forces, as well.We think that this can be accepted as a highly appreciable endeavor of all of these individuals.

CONFLICT of INTEREST
None declared.
(Istanbul Anti-tuberculosis Association) was founded in 1918.Due to political developments that occurred shortly after standing association studies, in 1923, the Republic of Turkey in Izmir during the re-started.In the 1925 and 1927 a national medical congress, tuberculosis as the main election issue, was organized, and then in 1928 in Istanbul Tuberculosis Association again take action in the fight against decisive role in association studies have begun to undertake.In the years 1953-1973, UNICEF, Ministry of Health and later efforts Turkish National Anti-tuberculosis Association jointly significant results were obtained in the fight against tuberculosis.These positive statements given the lethargy environment, economic and political crises in the last 10 years, in parallel with the increase of tuberculosis around the world experiencing, there was an increase in Turkey.In 1986, the National Anti-Tuberculosis Federation was founded by Anti-Tuberculosis Associations.The Anti-Tuberculosis Federation has put in practice DOTS programme in 2005 in Turkey.In conclusion, we evaluate that the Anti-Tuberculosis Associations in Turkey have played a major role in struggle against tuberculosis in Turkey since the last century.