The Report on

Climate Change
and
Public Health in Turkey

Editors:
Prof. Dr. Muzaffer Şeker
Prof. Dr. İsmail Koyuncu
Prof. Dr. İzzet Öztürk

Contributors to the Report:

Prof. Dr. Hasan Hüseyin Eker
Prof. Dr. Ali Özer
Prof. Dr. Mehmet Emin Aydın
Prof. Dr. Ali Deniz
Assoc. Prof. Fatih Kara

July 2020 / ANKARA

The Report on Climate Change and Public Health in Turkey
Turkish Academy of Sciences Publications
TÜBA Report No: 38

ISBN: 978-605-2249-50-5

Graphic Designer
Ece Yavuz

Redaction
Mürsel Doğrul

1th. Edition / July 2020

1000 pcs.

Publisher:
Turkish Academy of Sciences
Piyade Sokak No: 27, 06690
Çankaya – Ankara TÜRKİYE
Phone: +90 312 442 29 03
www.tuba.gov.tr

Printed in Berk Matbaacılık, Ankara

 Contents

Never-Ending Demands of Humankind and Ecological Damages ................ 5

1. Introduction .................................................................................................. 7
1.1. Sustainable Development, Climate Change and Public Health ...................... 7
1.2. Climate Change and Health Expectations .................................................... 8
1.3. Purpose and Scope of this Report .................................................................. 9

2. Studies on Climate Change and Public Health .......................................... 11

2.1. Previous Publications on Climate Change and Public Health ............................... 11
2.2. Turkey’s General Situation and Climate Change Projections ............................. 11
2.2.1. Geographical Location, Demographic Structure and Population ......... 11
2.2.2. Energy Consumption and Greenhouse Gas Emissions ....................... 13
2.3. Climate Change and Projections .................................................................... 14
2.3.1. Meteorological Parameters ........................................................................ 14
2.3.2. Impacts of Climate Change on Turkey Water Resources ...................... 16
2.4. Current Situation and Infrastructure of Health in Turkey ........................ 20
2.4.1. Current Situation of Health Services ......................................................... 20
2.4.2. Preventive Health Services .......................................................................... 26
2.4.3. The Budget Allocated to Health from Turkey’s National Income .......... 29
2.4.4. Actions on COVID-19 ............................................................................ 29

3. Climate Change and Its Impacts on Public Health .................................... 31

3.1. Heat Effects ..................................................................................................... 31
3.2. Extreme Weather Events, Floods and Effects ............................................. 33
3.3. Infectious Diseases ......................................................................................... 35
3.3.1. Vector Source Diseases ................................................................................ 35
3.3.2. Waterborne Diseases ................................................................................... 40
3.3.3. Foodborne Diseases ................................................................................... 41
3.4. Mental Diseases ................................................................................................ 42
3.5. Chronic Diseases ............................................................................................... 43

3
 3.6. Acute Diseases and Allergies ........................................................................... 43
3.7. Air Pollution, Pollutants and Effects ............................................................... 44
3.8. Food, Nutritional Safety, Agriculture and Effects ........................................... 45
3.9. Forest Fires and Effects ..................................................................................... 46
3.10. Migrations, Vulnerable Groups and Effects ...................................................... 47

4. Compliance and Mitigation Policies ............................................................. 49

4.1. National Adaptation Plans for Climate Change and Public Health ........................ 49
4.2. Adaptation and Mitigation Approaches ............................................................... 53
4.3. Mitigation and Common Benefits ...................................................................... 54
4.4. Case Studies for Adaptation and Mitigation ....................................................... 55
4.5. Economic and Development Results .................................................................. 56

5. Results and Recommendations ................................................................... 59

5.1. Concerns about Climate Change and Public Health ........................................... 59
5.2. Things to be able to done about Climate Change and Health .................. 60

REFERENCES .................................................................................................. 63

4
Never-Ending Demands of Humankind and Ecological Damages

The perspective of homo-economicus, which is profit-maximization centered,

and gain-oriented, implies that all human activities are based on rational
thinking and cost-benefit analysis, emerging from the periods of Mercantilism,
Capitalism, and rapid industrialization. The spread of this perspective led to
the artificialization of natural life with destruction and causes environmental
pollution such as air, soil, and water. Humankind is forming a habitat that
affects biodiversity negatively with an ambition of earning more and more. As a
result of excessive and uncontrolled production, the increase in carbon dioxide
emissions and the direct disposal of industrial wastes without the necessary
treatment processes divest the rights of future generations to live in a clean world.
Humankind has consumed and wasted the natural resources heritage of their
ancestors unconsciously and inefficiently until today. Therefore, the resources
left to the next generations have higher processing costs and threaten the future
of human beings.

The dimension of destruction caused by developed countries is understood in

the last global epidemic process. It has clearly observed that environmental
problems have been significantly reduced by people staying in homes, decreasing
production, and minimizing transportation during the global epidemic of
COVID-19. This is a striking indicator of the impact of people’s destruction on
nature. All stakeholders and countries must work together for a more livable
world and sustainable resource management. The effect of the struggle on this
issue will be increased with projects such as “Zero Waste” project conducted by
Turkey and spreading similar initiatives all over the world.

It is necessary to underline with the awareness that climate change, environmental

problems, and public areas are interconnected. Public health problems are
related to so many different multidisciplinary aspects but mostly considered
climate change, environmental issues, and economic situations. The purpose of
such reports, which is valuable for human beings, is to leave a livable world to
future generations. It should not be forgotten that we have only one world that
we can protect and live on.

Prof. Dr. Muzaffer ŞEKER

TÜBA President

5
1. Introduction

1.1. Sustainable Development, Climate Change and Public Health

Sustainable development, which aims to make it possible to meet the needs of
future generations along with the needs of today’s generations, took its place on
the world agenda in the late 20th century. One of the 17 Sustainable Development
Goals adopted at the United Nations summit in 2015 is to combat climate change
and its impact.

The increase in greenhouse gases in the atmosphere is expected to cause regional

and global changes in climate and climate related variables such as temperature,
precipitation, air and soil moisture. In addition to the significant temperature
increase observed in the global climate, according to the projections made with
advanced climate models, an increase in global surface temperatures is expected
between 2-4,5 oC in the period 1990-2100. Depending on the increase in global
surface temperatures, the change of hydrological cycle, melting of land and sea
glaciers, narrowing of glacial areas, especially in polar regions, rising sea levels,
shifting climate belts, changing dynamic processes in the atmosphere, heat waves
are more severe and frequent. In some regions, excessive precipitation and
floods and in some regions droughts are more severe and frequent, and drought
epidemics and pests due to high temperatures may occur. The predicted effects
of climate change are given in Table 1.

Table 1: The predicted effects of climate change

7
These changes are expected to directly affect socioeconomic sectors, ecological
systems, human life and other living creatures on a global scale (TÜBA, 2010). In
addition, due to the fact that climate changes are not at an equal level globally,
they will react differently in different ways in relation to the impact of individuals
and countries. As a result of these effects, an average of 1.2 million people every
year due to urban air pollution, 2.2 million people due to inability to access
safe drinking water resources and diarrhea caused by poor hygiene, 3.5 million
people due to malnutrition and 60 thousand people due to natural disasters are
losing their lives.

As a result of global warming and its other components affecting human health,
studies on this subject have been accelerated. In this context, the World Health
Organization has determined the 2008 World Health Day theme as the effects
of global warming and climate change on health and creating awareness in this
regard (TÜBA, 2010).

1.2. Climate Change and Health Expectations

Situations that arise as a result of climate change are among the biggest
problems facing humanity in the 21st century. This situation has taken the first
place in the international agenda in recent years. If the progress of the current
industrialization and the related energy consumption are not controlled by the
global and regional policies, the temperature increase will continue and reach
critical levels. To keep the temperature rise at 2 °C, it is necessary to stabilize the
atmospheric intensity of carbon emissions at 450 ppm and to reduce the existing
carbon dioxide emissions by 80% till 2050.

The impact of climate change on human health occurs in various ways, including
direct and indirect impacts (TÜBA, 2010). The direct impacts of this change are
seen as a result of extreme changes in weather events. As a result of these changes,
the weather being too cold, too hot, too humid or too dry affects human health
negatively. For example, excessive heat exposure can lead to physiological stress,
illness, and even death of the individual. As a result of the indirect effects of climate
change, infectious diseases and vector-borne diseases occur due to the increase
in temperature. In the third evaluation report of the IPCC (Intergovernmental
Panel on Climate Change), it is stated that the effects of climate change on
human health will be more common in tropical and subtropical countries and
low-income countries, although it is all over the world (IPCC, 2001).

Globally, all countries are at varying degrees of risk against the negative health
effects of climate change. This effect is expected to occur most intensively in low-
income countries. In addition, disadvantaged groups such as those living in the
cities, the poor, the elders, the children, those who earn their living by farming
and those living in the coastal area are at higher risk. The level of economic
development is the most important indicator of countries’ adaptation to climate

8
change and its impacts. However, even countries with high levels of economic
development cannot fully protect themselves from the situations caused by
climate change and its effects. Factors such as the level of economic development
and the reflection of this situation on the society, the creation of education and
health infrastructure play an important role in shaping public health (SB, 2015).

1.3. Purpose and Scope of this Report

This report is prepared at the request of the Association of Asian Science Academies
and Communities (AASSA), to contribute to the report to be prepared to address
the health effects of climate change in countries in the Asian Region. The aim
of this report is to address the effects of climate change on health in Turkey.
Within the scope of the report, the first section covers the introduction part, the
second section covers a country scale of the current climate change situation,
future projections, and current situation of health and health infrastructure in
Turkey, the third section covers climate change impact on health, the fourth
section covers the climate change adaptation and impact reduction studies on
health, and in the fifth section results and recommendations are presented.

9
2. Studies on Climate Change and Public Health

2.1. Previous Publications on Climate Change and Public Health

The possible effects of climate change have been addressed by many institutions
and organizations. “Assembly Research Commission Report on the Effects
of Global Warming and Sustainable Management of Water Resources” was
completed in 2008 by Grand National Assembly of Turkey and drawn attention
to the impact of climate change on health (TBMM, 2008).

TUBA (Turkey Academy of Sciences) published “Turkey in the world in terms

of Climate Change” report in 2010 and it contains extensive information about
climate change and its impacts on health (TUBA, 2010).

A report titled “The Impact of Climate Change on Health” was prepared by the
General Directorate of Meteorology of the Ministry of Forestry and Water Affairs
in 2012 and the subject was discussed in detail in this report. With the “National
Program and Action Plan for Reducing the Negative Effects of Climate Change”
prepared by the General Directorate of Public Health of the Ministry of Health in
2015, studies, meetings and symposia on the impact of climate change on health
have increased. The “Climate Change Education Modules Series” prepared by
the Ministry of Environment and Urbanization in 2019 also includes the issue of
the impact of climate change on human health.

The relationship between climate change and health is increasingly being

investigated and researched in universities. This report is expected to contribute
to the studies to be carried out in the field of climate change and health.

2.2. Turkey’s General Situation and Climate Change Projections

2.2.1. Geographical Location, Demographic Structure and Population

Turkey is located between the eastern and western cultures in a location where the
continents of Asia, Europe and Africa approach each other (Figure 1). Located
on the southwest tip of the Asian continent, Turkey is on the Anatolian peninsula.
Some of its territory is on Thrace, which forms part of the Balkan peninsula in
the southeast of Europe. Turkey is therefore both Asian and European country.
Turkey is also a country of the Middle East and as some of the Middle East

11
countries are a part of African countries therefore for Turkey “a country that is in
contact with the African continent” designation would be correct.

Figure 1. Turkey Location on the World

Turkey is among the subtropical zone and temperate zone. Turkey is surrounded
by sea on three sides, extension of the mountains and the variety of landforms;
causes different types of climate to be experienced. While temperate climate is
seen in coastal areas due to effects of seas, the sea influence is prevented by the
North Anatolian Mountains and Taurus to enter the inner part of the country
(Figure 2). Therefore, continental climate features are seen in the inner parts.
According to climate classification Mediterranean, Marmara (transition) and
Black Sea climate types are found in Turkey (Atalay, Rel., 1997, Şensoy et al,
2020).

Figure 2. Turkey Geographical Map

12
According to TSI 2020 data, the population of Turkey is 83,154,997 as of
December 31, 2019. 50.2% of the population is male and 49.8% are female. The
0-14 age group population constitutes 23.4 percent of the total population. In
demography of Turkey, urbanization rate is the most important changes that
occurred over the years. In 1927, while 75.8 percent of the population lived in
rural areas and 24.2 percent in urban areas, today this ratio has been reversed.
Since year 2011, 23.2 percent of Turkey’s population live in rural areas, 76.8
percent of them live in urban areas (TSI, 2020).

2.2.2. Energy Consumption and Greenhouse Gas Emissions

Turkey is the eighth largest economy among the OECD countries and is in the
position of a fast-growing country. According to the OECD report of 2019, fossil
fuels make the largest portion of energy consumption in Turkey between the
years 2005-2017. As of 2017, fossil fuels represent 88% of the total primary
energy supply (Figure 3). Turkey meets its energy supply mostly with imported
energy (oil and natural gas). Turkey has a large number of renewable energy
sources and can minimize its foreign dependence on the result of the effective
use of these resources. Turkey has an energy self-sufficiency rate of 25%. In
order to reduce the greenhouse gas emission accumulated in the atmosphere, it
is aimed to switch to renewable energy, especially by increasing the production
capacity through energy production, solar and wind energy and by using
hydroelectric, geothermal energy potential more efficiently. Recently, there has
been a decrease in greenhouse gas emissions rates contrary to economic growth
(Figure 4) (OECD, 2019).

Figure 3. Distribution of energy resources (OECD, 2019)

13
 Figure 4. Annual change of greenhouse gas emissions (OECD, 2019)

2.3. Climate Change and Projections

2.3.1. Meteorological Parameters

Worldwide, particularly in Europe and in most of the countries adjacent to the
Mediterranean basin and Turkey in many regions, especially in spring and
summer seasons, a statistically and climatologically significant increase trend was
found in the minimum temperature values measured at night. The change in
climate of Turkey is stated to be related to widespread, rapid and increasing
urbanization in our country. Asymmetrical or symmetrical fluctuations in different
magnitude on the maximum and minimum values of the measured temperature
during the night is an important indicator of climate changes in Turkey (Figure
5). The increasing tendency of the daily average air temperatures is considered
as a natural result of the reflection of the significant increase observed especially
in the night hours after 1992 (Türkeş et al., 2002). As seen in Figure 6, in recent
years in Turkey the number of hot days has been increasing. In 2019, an average
temperature of 14.7 °C is obtained in Turkey and this value is 1.2 °C higher than
the normal 1981-2010 (13.5 °C) temperature. In addition, 2018 was the second
and 2019 was the fourth hottest year since 1971 (Figure 7) (MGM, 2019).

14
 Figure5.5.Annual;
Figure Annual;A)
A)Maximum,
Maximum, B)
B) Minimum,
Minimum, AndAnd C)
C) Tmax-Tmin;
Tmax-Tmin;Spatial
SpatialDistribution
Distribution
Models of Temperature Trends of 70 Stations in Turkey (TÜBA, 2010; Türkeş et al, 2002)
Models of Temperature Trends of 70 Stations in Turkey (TÜBA, 2010; Türkeş et al, 2002)

15
 Figure 6. The annual average temperature deviations in Turkey (MGM, 2019)

Figure 7. Turkey Annual Average Temperature Rankings (MGM, 2019)

Drought, starting in the 1970s, has effect in subtropical zone in some part of
the Mediterranean basin including Turkey. Due to drought tendency, the
most effected regions are Aegean, Mediterranean, Marmara and Southeastern
Anatolia Regions (Figure 8). In studies on climate change it is indicated that in
Turkey, along with many other countries in the Mediterranean basin significant
climate change has been seen and Turkey will be adversely affected by future
climate change (TÜBA, 2010).

2.3.2. Impacts of Climate Change on Turkey Water Resources

The most comprehensive study on climate change and its impacts on water
resources in Turkey is “Impacts of Climate Change on Water Resources Project”
(OSIBE, 2016). As part of the climate projections, the first stage of projection
works, outcomes of three global models selected from CMIP5 (Coupled Model
Intercomparison Project 5) archive (HadGEM2-ES, MPI-ESM-MR ve CNRM-
5.1) and RCP4.5 and RCP8.5 release scenarios and RegCM4.3 regional climate

16
model forming the basis of the 5th Evaluation Report of Intergovernmental
Panel on Climate Change (IPCC) were studied including whole Turkey. Total 8
parameters and projections of 17 climate indices representing extreme conditions
were formed in river basin scales (25 river basin) through model simulations, and
the differences of the studied parameters until 2010 were calculated as seasonal
and annual averages for 10 and 30 years periods based on the reference period
accepted as the simulations of 1971-2000. For the first time with this project, 3
global climate model with 10x10 km resolution results were obtained for Turkey
(OSİB, 2016).

b
Figure 8. Geographic Distribution of Long Term Rainfall Trends in A) Winter, B) Summer
for Turkey (TÜBA, 2010; Türkeş et al., 2007)

17
Climate simulations at 50x50 km first and then 10x10 km resolution were
obtained by using start and limit conditions (ERA-40 reanalysis data) (Uppala et.
al., 2005) for the reference period within the scope of climate change projections.
Afterwards, reference period climate simulations were performed with 10x10
km resolution of HadGEM2-ES, MPI-ESM-MR and CNRM-5.1 global climate
models selected from the CMIP5 database. Comparisons were made with the
simulations performed by using reference period simulation observation data of
the global model, and the bias of the global model in the climate simulations was
examined. Every three global models, simulations based on RCP4.5 and RCP8.5
representational concentration routes against the 4.5 W/m2 and 8.5 W/m2 climate
forces in 2100, and climate simulations at 10x10 km resolution between 2015-
2010 with RegCM4.3 regional climate model were obtained (OSİB, 2016).

As part of the hydrologic projections, the second stage of the projection works,
for the first time in Turkey, the water potentials of all river basin in Turkey
were calculated using SWAT (Soil and Water Assessment Tool) hydrologic model
supported by WEAP (Water Evaluation and Planning System). Using hydrologic
models with the outcomes of the climate models, precipitation values were
converted to flow values, and water potential modeling/calculation study was
carried out considering the current situation of surface water and groundwater
sources and the estimated situation for projected periods.

In the simulations performed with the outcomes of climate models using with
WEAP supported SWAT hydrologic model, the status of the median gross
water potentials forecasted for 3 sub-projection periods is compared with the
median value of the reference period (Tables 1 and 2). As can be seen in Table
1, the lowest gross water potential estimates were obtained with the HadGEM2-
ES climate model outputs in both scenarios (RCP4.5 and RCP8.5) and 3 sub-
projection periods. Although the gross water potentials obtained as a result of
hydrological modeling based on the outputs of the other 2 climate models (MPI-
MSM-MR and CNRM-CM5.1), the results are quite close to each other, they
remained below the reference period values for all 3 periods (OSİB, 2016).

As can also be seen from Table 2, the median water potential estimated for the
period 2041-2070 with hydrological modeling for the HadGEM2-ES RCP4.5
scenario is expected to be equal to or less than 111,000 million m3, with a 50%
probability. According to Table 3, with the hydrologic modelling base on the
outcomes of HadGEM2-ES climate model, it is anticipated that the median gross
water potentials for 3 sub-periods in the 2015-2100 period will decrease 40-
45% compared to the median value of the reference period. Under the same
conditions, it is forecasted that the decrease ratio of the median gross water
potential obtained from the hydrologic model projections performed by the
outcomes of the MPI-MSM-MR climate model will remain at the range of 15-
20%(OSİB, 2016).

18
 Table 2. Probability of occurrence of gross water potential obtained using hydrological
modeling for Turkey in accordance to climate projections (OSİB, 2016).

Projection Probability Gross Water Potential (million m3/year)

Period of
Occurrence Reference HADGEM HADGEM MPI MPI CNRM CNRM
(%) Period RCP4.5 RCP8.5 RCP4.5 RCP8.5 RCP4.5 RCP8.5

2015-2040 50 193.499 117.508 118.864 169.903 174.607 169.353 156.950

90 271.307 141.081 142.539 196.715 215.517 220.161 187.847
2041-2070 50 193.499 111.015 95.687 162.900 147.515 168.470 142.114
90 271.307 140.465 132.900 212.991 219.495 215.963 178.743
2071-2100 50 193.499 117.363 107.045 153.613 135.158 161.939 156.869
90 271.307 147.596 136.372 181.192 213.077 200.876 176.317

Table 3. The median values* deviation of gross water potential obtained using hydrological
modeling for Turkey in accordance to climate projections for from reference** period
median (OSİB, 2016).

Projection Gross Water Potential (million m3/year)

Period
Reference HAD- HAD- MPI MPI CNRM CNRM
Period GEM2-ES GEM2-ES RCP4.5 RCP8.5 RCP4.5 RCP8.5
RCP4.5 RCP8.5
2015-2040 193.499 117.508 118.864 169.903 174.607 169.353 156.950
(-39%)** (-39%) (-12%) (-10%) (-12%) (-19%)
2041-2070 193.499 111.015 95.687 162.900 147.515 168.470 142.114
(-43%) (-51%) (-16%) (-24%) (-13%) (-27%)
2071-2100 193.499 117.363 107.045 153.613 135.158 161.939 156.869
(-39%) (-45%) (-21%) (-30%) (–16%) (-19%)
* 50% probability of occurrence

** Values in parentheses indicate relative deviation rates from the reference period value.

The net water deficit/excess situation of the river basins in Turkey for the 2015-
2100 period has been prepared in thematic map format for three models and
two scenarios separately (Figure 9). The thematic maps showing the water excess/
deficit may also be used in the future to determine the possible water transfer
between the neighboring basins. In Fırat-Dicle Basin, East Mediterranean Basin
and Konya Closed Basin, significant water deficit is observed in all period (OSİB,
2016).

The amounts of water that Turkey undertakes to release to the countries located at
the river mouths from Fırat-Dicle Basin are taken into consideration for thematic
maps. The outcomes of each three models show that in Fırat-Dicle Basin, water
deficit levels of up to 2-12 billion m3/year are expected in the 2015-2100 period.
These data show that a new evaluation is required to be made regarding the
amounts of water that Turkey has undertaken to release to the countries located
at the river mouths of the basins.

19
 Figure 9. Thematic Map Showing the Basin Based Water Excess/Deficit According to the
MPI-ESM-MR RCP4.5 scenarios of Climate Projections for Turkey (2041-2070) (OSİB, 2016)
(For Fırat River Basin, the amount of 500 m3/s that Turkey undertakes to release to the countries located at the river mouths
are taken into consideration. For Dicle River Basin, the average flowrate value of 342 m3/s that releases to the river mouths
between the years 2011-2015 is taken into consideration (DSİ).)

2.4. Current Situation and Infrastructure of Public Health in Turkey

2.4.1. Current Situation of Public Health Services

In our country, there has been an improvement in many health indicators as
a result of changes in health care professionals and infrastructure and health
management in recent years. For example, the increase in immunization rates,
increase in follow-up of pregnant, child and puerperium, decrease in maternal
mortality and infant mortality rates, and increase in hospital and health care
professionals developments in health services and health care in Turkey will be
discussed in three different categories.

a) Demographic and Public Health Indicators

In this section important indicators of Turkey’s population and the potential
future changes in these indicators are given. In 2019 Turkey’s population
is approximately 83.1 million, while the population growth rate is 13.9%. TSI
(Turkey Statistics Institute) estimates, the population of Turkey is expected to
be 83.9 million in 2023. Along with the total population, the distribution of the
population by age groups is more important. Until recent past in Turkey, as a result
of high fertility rates and rapid population growth it can be said to have a young
population. According to TUIK data, as of 2019, the working age population in
the 15-64 age group constitutes 67.8% of the total population. In addition, 23.1%
of the population is in the 0-14 age group and 9.1% is in the 65 and above age
group. When the future predictions of TUIK are analyzed, it is thought that while
the young population size decreases, the older population will increase (Figure

20
 total population, the distribution of the population by age groups is more important. Until
recent past in Turkey, as a result of high fertility rates and rapid population growth it can
be said to have a young population. According to TUIK data, as of 2019, the working age
population in the 15-64 age group constitutes 67.8% of the total population. In addition,
23.1% of the population is in the 0-14 age group and 9.1% is in the 65 and above age
group. When the future predictions of TUIK are analyzed, it is thought that while the
young population size decreases, the older population will increase (Figure 10). The
10). The population ratio above the age of 65, which was 5.7% in 2000, increased
population ratio above the age of 65, which was 5.7% in 2000, increased to 9.1% (with an
to 9.1% (with an increase 59%)
increase of approximately of approximately 59%)
in 2019 and reached in 2019
10.2% and
in 2023 andreached 10.2% in
20.8% in 2050.
2023Itand 20.8% to
is estimated inreach
2050. It isinestimated
27.7% 2075 (TÜİKto reach 27.7% in 2075 (TÜİK 2019).
2019).

40
35
35
29,8
30 26,4
23,4
25

20
%

15
8,8
10 7,1
5,7
4,3
5

0
1985 1990 1995 2000 2005 2010 2015 2020
Year
0-14 Age Population Rate 65 and over 65 Population Rate

FigureFigure
10. Annual rates rates
10. Annual of 0-14 Age Age
of 0-14 Population
Populationandand
65 65
andandolder Population
older Population (%)
(%)(SB,
(SB,2018)
2018)
According to TSI estimates, the total fertility rate, which was 2.17 as of 2002, will decrease
According
to 1.85 to TSI estimates,
in 2023 the
(Figure 11). If thistotal
valuefertility rate,
falls below 2.1,which wasthat
it means 2.17 aswill
there of 2002,
be no will
decrease to 1.85
population in 2023 (Figure 11). If this value falls below 2.1, it means that
increase.
there will be no population increase.
2,50

2,38
2,40

2,30
Number of Children

2,17 2,18
2,20 2,16 2,15
2,12 2,11
2,09 2,10
2,1511 2,07
2,10 2,05
2,11 2,12 2,11 2,11
2,08
2,00

1,90
2011

2012

2013

2014

2017
2005

2015
2000

2006

2008

2009

2010

2016

2018
2001

2002

2003

2004

2007

Year

Figure 11. Annual fertility rate (TÜİK, 2018)

Figure 11. Annual fertility rate (TÜİK, 2018)
When all these demographic changes are evaluated, it can be said that the aging
population will significantly affect the demand for health services, it will also have
When allsignificant
these demographic changes
effects on the burden arethat
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that the aging
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will will significantly
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Another important the demand for health
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(KB, 2018).
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While the
crude birth rate was 18.6 per thousand in 2002, it was 16.1 per thousand in 2017 (Figure
services 12)
are(TUIK,
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there is a decrease in crude birth rate and this downward trend is expected to
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in thethefuture.
most important criteria used in evaluating a country's health status are
(KB, 2018). Crude birth rate refers to the number of live
average life expectancy, infant mortality rate, child mortality rate under 5, and maternal
births per thousand
mortality population.
rate. The While the
average life expectancy crudewas
in Turkey birth rate inwas
72.5 years 18.6
2002. per
In the thousand
year
in 2002, 2018 it has
it was 16.1increased to 78.3 years.
per thousand inIn2017
general, women 12)
(Figure live longer
(TUIK, than2018).
men and the
difference in life expectancy at birth is 5.4 years in 2018 (Figure 13).

While in 2002 the infant mortality rate, 21 child mortality rate under 5, and maternal
mortality rate were 31.5, 42, and 64, respectively, in 2018 these rates declined to 9.2, 11.3,
and 13.6, respectively. Consequently, it is observed from the Table 3 that life expectancy
has increased and death rates have decreased significantly in 16 years period (SB, 2018).
Among the most important criteria used in evaluating a country’s health status
are average life expectancy, infant mortality rate, child mortality rate under 5,
and maternal mortality rate. The average life expectancy in Turkey was 72.5
years in 2002. In the year 2018 it has increased to 78.3 years. In general, women
live longer than men and the difference in life expectancy at birth is 5.4 years in
2018 (Figure 13).

While in 2002 the infant mortality rate, child mortality rate under 5, and maternal
mortality rate were 31.5, 42, and 64, respectively, in 2018 these rates declined to
9.2, 11.3, and 13.6, respectively. Consequently, it is observed from the Table 4
that life expectancy has increased and death rates have decreased significantly in
16 years period (SB, 2018).
Per Thousand
Per Thousand

24,0
24,0

21,0 20,3
21,0 20,3

18,2 18,4
17,9
18,2 18,4 17,6
18,0 18,6 17,9 17,0 17,1
18,1 18,1 18,2 17,6 16,9
18,0 18,6 17,017,5 17,1 16,1
18,1 18,1 18,2 17,2 16,9 17,2
17,2 17,2 17,5 16,5 16,1
15,0 16,5
15,0

12,0
2015
2010 2010

2016

2018
2001

2002
20032003

20042004

20072007

2011 2011

2012 2012

2013 2013
2014

2017
20052005
2000

20062006

20082008

20092009

12,0
2015

2016

2018
2001

2002

2014

2017
2000

Figure 12. Annual Crude birth rate (TÜİK, 2018)

Figure 12. Annual Crude birth rate (TÜİK, 2018)
Figure 12. Annual Crude birth rate (TÜİK, 2018)
82 81

8280 78,7 81
78,3
8078 76,6 78,7
76,4 78,3
75,6
7876 74,7 76,6
74,4 76,4
74,2
Age

75,6
7674 74,7
72,5 74,4
72,2 74,2
Age

7472 70,5
72,5 72,2
7270 70,5
68
70
2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020
68 Year
2000 2002 2004 2006Male2008 2010
Female 2012 Total
2014 2016 2018 2020
Year
Figure 13. Life expectancy
Male
byFemale
gender andTotal
age (TÜİK, 2018)

Table 3. Infant mortality,

Figure 13. child under 5 mortality and maternal mortality rates in
Turkey between the years 2002 and 2018 (SB 2018)
Figure 13. Life expectancy by gender and age (TÜİK, 2002 2018)2018
Table 3. Infant mortality, child under 5 mortality and maternal mortality rates in
Infantbetween
Turkey mortalitythe
rateyears
(per 1000
2002live births)
and 2018 (SB 2018) 31,5 9,2
Child under 5 mortality rate (per 1000 live births) 42
2002 11,3
2018
Maternal mortality rate (100 000 live births) 64 13,6
Infant mortality rate (per 1000 live births) 31,5 9,2
Child under 5 mortality rate (per 1000 live births) 42 11,3
b) Health Transformation Program
Maternal mortality rate (100 000 live births) 64 13,6
Between the years 2003 and 2011 Turkey Health Transformation Program have been
b) Health Transformation Program
established. according to the World Health Organization, the health system of a country
should be designed in a way to ensure the high quality of the necessary health care for
Between theThis
everyone. years 2003 should
service and 2011
be Turkey
effective,Health Transformation Program have been
22affordable and socially acceptable. It is
established. according to the World Health Organization, the health system of a country
should be designed in a way to ensure the 13 high quality of the necessary health care for
everyone. This service should be effective, affordable and socially acceptable. It is
 Table 4. Infant mortality, child under 5 mortality and maternal mortality rates in Turkey
between the years 2002 and 2018 (SB 2018)

2002 2018
Infant mortality rate (per 1000 live births) 31,5 9,2
Child under 5 mortality rate (per 1000 live births) 42 11,3
Maternal mortality rate (100 000 live births) 64 13,6

b) Health Transformation Program

Between the years 2003 and 2011 Turkey Health Transformation Program have
been established. according to the World Health Organization, the health system
of a country should be designed in a way to ensure the high quality of the necessary
health care for everyone. This service should be effective, affordable and socially
acceptable. It is recommended that each country develop its own unique health
system by considering these factors. The situation of the Turkish health system
at the end of 2002 required radical changes in many areas from service delivery
to financing, from health care professionals to information system. For this
purpose, Health Transformation Program was launched in 2003. The program
was inspired by past knowledge and experience, particularly the socialization
of health services, recent health reform studies and successful examples from
around the world. In this period, hospitals of other public institutions, especially
SSK hospitals, were transferred to the Ministry of Health. The VAT rate on the
drug has been reduced and the drug pricing system has been changed. These
regulations played an important role in promoting access to medication. Not
only in cities but also in villages, “112 Emergency Health” service has started
to be offered, the number of stations has been increased and ambulances are
equipped with the latest technologies. Air and sea transport vehicles were also
added to the system. Primary health care services, especially preventive health
and maternal and child health services have been strengthened, family medicine
practice, which is one of the basic elements of modern health understanding,
has been started and spread to the whole country. Comprehensive programs
have been implemented to prevent deterioration of health and premature deaths
due to noncommunicable diseases. In this context, national programs have
been planned and implemented for certain diseases, especially cardiovascular
diseases, cancer, diabetes, chronic respiratory diseases, stroke, kidney failure.
Indicators in infectious diseases have reached the level of developed countries
after the implementation of the Health Transformation Program. Regions where
buildings, equipment and health personnel are lacking are considered to be a
priority, and imbalances in this regard have been largely eliminated (SB, 2012).

23
 c) Health Care Professionals and Health Infrastructure

The total number of physicians, which was 91.449 in 2002, increased to 153.128
in 2018. Likewise, the number of nurses increased from 72393 to 190499
between 2002 and 2018. In the same period, the number of midwives increased
to approximately 15000, the number of pharmacists to 10000 and dentists to
14000. While the total number of physicians per 100 thousand people in 2002 was
138, it has been increased to 187 in 2018 (Figure 14). The number of physicians,
dentists, pharmacists, nurses, midwives (Public + Private Sector) per 100000
people are shown in Table 5.

In addition, the number of applications per physicians have increased over time.
For example, in 2002, while a patient was applying to the physician with an
average of 3.1 times a year, this number reached 9.5 in 2018.

A total of 1534 hospitals, including 577 in private sector, 68 in universities and

889 in the Ministry of Health exist in Turkey as of 2018. The Ministry of Health
owns the greatest number of hospitals in Turkey and plays a decisive role in the
medical and therapeutic services (Figure 15).

Table 5. Health care professionals in Years (SB, 2018).

Hospitals Family Other Total

Medicine Institutions
Unity
Specialist Physician 40,541 1,814 992 43,347
Practitioner 10,719 22,268 6,455 39,442
Physician Associate 8,770 0 0 8,770
Total Physician 60,030 24,082 7,447 91,559
Total Dentist 4.642 0 6.172 10.814
Pharmacist 2,747 0 317 3,064
Nurse 113,641 7,448 5,802 126,891
Midwife 27,028 13,299 12,168 52,495
Other medical staff 73.226 1.874 46.106 121.206
Recruitment of 193,787 17,614 24,754 236,155
Other Staff and
Services
Total Staff 475,101 64,317 102,766 642,184

24
 Nurse 113,641 7,448 5,802 126,891
Midwife 27,028 13,299 12,168 52,495
Other medical staff 73.226 1.874 46.106 121.206
Recruitment of 193,787 17,614 24,754 236,155
Other Staff and
Services
Total Staff 475,101 64,317 102,766 642,184

200

190 186 187

181
179
180
174 175
Number of Physicians 172
169
170 167
164
158
160
154
150
150 146
143
141
138
140

130

2011

2014

2017
2015
2000

2010

2016

2018

2019
2012

2013
2001

2002

2003

2004

2007
2005

2006

2008

2009
Year

Figure 14. Total Number of Physicians Per 100,000 People in Years (SB, 2018)

Figure 14. Total Number of Physicians Per 100,000 People in Years (SB, 2018)
Table 5. Number of health labor force per 100000 people in 2002 and 2018 (SB, 2018).
Number of health personnel 2002 2018
Table 6. Number of health
per 100,000 people care professionals per 100000 people in 2002 and 2018
All Physicians 138 187
Dentist (SB, 2018).
5 13
Pharmacist 34 39
Nurses and Midwives 171 301
Number of health personnel 2002 2018
per 100,000 people
All Physicians 138 187
Dentist 5
15 13
Pharmacist 34 39
Nurses and Midwives 171 301

2002 2018

1.534

1.156

889
774
577

271

50 68 61
-

Ministry of University Private Other Total

Health

Figure 15. Total number of hospitals by sector in years (SB, 2018)

Figure 15. Total number of hospitals by sector in years (SB, 2018)
Within the scope of the second leg of the health transformation, the first city hospital in
Turkey was put into service in February 2017 in Mersin. As of 2020, 11 city hospitals
continue to serve. By the end of 2021, the number of city hospitals is planned to reach 18.
While the total actual bed capacity in our country was 164471 in 2002, it reached 231913
as of 2018 (Figure 16). In 2002 the number of intensive care units was 2214, in 2018, this
has reached to 38098 in Turkey (SB 2018). When the graphics are considered; It can be
said that the number of hospitals, intensive care bed capacity and increased health labor
force play a major role in combating the Covid-19 pandemic.
25
2002 2018
 577

271

50 68 61
-

Ministry of University Private Other Total

Within the scope Health of the second leg of the health transformation, the first city
hospital in Turkey
Figurewas15. put
Totalinto service
number in February
of hospitals 2017
by sector in Mersin.
in years (SB, 2018)As of 2020, 11
city hospitals continue to serve. By the end of 2021, the number of city hospitals
Within the scope of the second leg of the health transformation, the first city hospital in
is planned
Turkey wasto reach
put into18. While
service the total
in February 2017actual bed As
in Mersin. capacity
of 2020,in11our
city country
hospitals was
164471 in 2002, it reached 231913 as of 2018 (Figure 16). In 2002
continue to serve. By the end of 2021, the number of city hospitals is planned to reach the number
18.
of intensive care units was 2214, in 2018, this has reached to 38098231913
While the total actual bed capacity in our country was 164471 in 2002, it reached in Turkey
as of 2018 (Figure 16). In 2002 the number of intensive care units was 2214, in 2018, this
(SB 2018). When the graphics are considered; It can be said that the number
has reached to 38098 in Turkey (SB 2018). When the graphics are considered; It can be
of hospitals, intensive
said that the number of care bed capacity
hospitals, andbed
intensive care increased
capacity andhealth carehealth
increased professionals
labor
play force
a major
play arole
major inrole
combating thethe
in combating Covid-19 pandemic.
Covid-19 pandemic.

2002 2018

231.913

164.471
139.651
107.394

42.066 50.196
26.341 19.349
12.387
-

Ministry of University Private Other Total

Health

Figure 16. Total actual bed capacity in 2002 and 2018 (SB, 2018)
Figure 16. Total actual bed capacity in 2002 and 2018 (SB, 2018)

2002 2018

38.098

16

16.086 15.973

6.039
992 2.214
869 353

Ministry of Health University Private Total

Figure 17. Total Number of Intensive Care Beds by Sectors in Years (SB, 2018)
Figure 17. Total Number of Intensive Care Beds by Sectors in Years (SB, 2018)

2.4.2. Protective Health Services

Protective
2.4.2. health services
Preventive Healthare health services provided to protect people from getting sick,
Services
injured, disabled and premature death. Protective health services are within the scope of
Preventive
primary Health Services
health care services.are
As health services
a result of provided
the Health to protect
Transformation people
Program of thefrom
Ministry
getting sick,ofinjured,
Health, community
disabled and healthpremature
centers anddeath.
family health centers,Health
Preventive and centers
Services
where babies, children, women's health, elderly health, cancer screening programs and
are within the scope of primary health care services. As
many protective health services are provided have been established.
a result of the Health

a) Family medicine
26
The family physician is obliged to provide preventive health services and primary care,
primary diagnosis, treatment and rehabilitative health services to each person in a certain
and continuous manner, regardless of age, gender and disease, providing mobile health
Transformation Program of the Ministry of Health, community health centers
and family health centers, and centers where babies, children, women’s health,
elderly health, cancer screening programs and many Preventive Health Services
are provided have been established.

a) Family medicine

The family physician is obliged to provide preventive health services and

primary care, primary diagnosis, treatment and rehabilitative health services to
each person in a certain and continuous manner, regardless of age, gender and
disease, providing mobile health services to the extent necessary and working on
a full-day basis. The family physician is a medical practitioner or a specialist who
receives the training prescribed by the Ministry of Health.

The pilot implementation of the family medicine model started in Düzce Province
in 2006. As of the year 2010 in Turkey, all health centers have been transformed
into family medicine unit. The family physician is responsible for the health of
all members of the family including fetus and the elders, and all kinds of health
problems. The family physician is obliged to take care of a maximum of 4000
people.

Family physicians cooperates with the community health center of the region
in the planning of the health service in the region they work. They provide
preventive health services and primary diagnosis, treatment, rehabilitation and
consultancy services for each patient. Family physicians provide guidance for
their patients regarding health and provide health-promoting and preventive
services. They also provide mother-child health and family planning services.
They make follow-up and scans for their patients regarding their age, gender
and disease groups (cancer, chronic diseases, pregnant, maternity, newborn,
infant, child health, adolescent, adult, elderly health and so on).

As shown in Figure 18 as a result of the increase in the number of family

physicians, the population per family physician also decreased. In Turkey, as
in 2016, a family physician serves an average of 3267 people. The target of the
Ministry of Health is to gradually decrease this number over the years and for
each family physician to serve to 2000 people in 2023.

One of the biggest reasons for the transition to the family physician system is
to increase the rate of immunization in the society and to better follow up the
pregnant, puerperant, baby and child. The data of these criteria between 2002
and 2016 are shown in Table 7. It is seen that the number of the follow-up have
increased significantly when 2002 and 2016 years are compared.

27
 in 2023.

One of the biggest reasons for the transition to the family physician system is to increase
the rate of immunization in the society and to better follow up the pregnant, puerperant,
baby and child. The data of these criteria between 2002 and 2016 are shown in Table Z. It
is seen that the number of the follow-up have increased significantly when 2002 and 2016
years are compared.

3800
3696
3700
3634 3621 3633 3629

3600

3500

3400

3300 3267

3200

3100

3000
2011

2014

2017
2010

2015

2016
2012

2013
Figure 18. Population per family physician in years (SB, 2016)

Figure
Table18. Population
6. Population per family
per family physician
physician in2016)
in years (SB, years (SB, 2016)
2002 2016
Immunization percentage (DaBT3, BCG, HBV, KKK) 77,3 97,5
Average number of follow-ups per pregnant 1,7 4,7
Average number of follow-ups per child 0,7 2,1
Table
Average 7. Population
number of follow-ups per family physician
per puerperant in0,7
years (SB,3,0
2016)
Average number of follow-ups per baby 3,4 8,4
2002 2016
Immunization percentage
b) Community Health(DaBT3, BCG, HBV, KKK)
Center Services 77,3 97,5
Average
Communitynumber of follow-ups
Health Center is defined asper pregnant
the health 1,7improving
institution that; focusses on 4,7
and protecting the health of the community living, determine health risks and problems,
Average number of follow-ups per child 0,7 2,1
18
Average number of follow-ups per puerperant 0,7 3,0
Average number of follow-ups per baby 3,4 8,4

b) Community Health Center Services

Community Health Center is defined as the health institution that; focusses on

improving and protecting the health of the community living, determine health
risks and problems, makes plans overcome these problems and implementing
these plans, organizes primary preventive, curative and rehabilitative health
services in the referral and administration of the directorate, monitors,
evaluates and supports the efficient delivery of these services, and ensures the
coordination between the health institutions in the region and other institutions
and organizations.

In order to establish a community health center in a compound, the population

must consist of at least 100,000 people. The community health center carries out
activities such as registration and statistics, planning and scheduling, monitoring
and evaluation, control of infectious and non-infectious diseases, tuberculosis and
malaria combat services, and reproductive health services. As of 2018, Turkey has
776 community health centers (Table 8) (ITO, 2010).

28
 of the directorate, monitors, evaluates and supports the efficient delivery of these
services, and ensures the coordination between the health institutions in the region and
other institutions and organizations.

In order to establish a community health center in a compound, the population must

consist of at least 100,000 people. The community health center carries out activities such
as registration
Table and statistics,ofplanning
8. Number Primaryand scheduling,
Level monitoring
Establishments and evaluation,
in Years control
(SB, 2018).
of infectious and non-infectious diseases, tuberculosis and malaria combat services, and
reproductive health services. 2002 As of 2018,2014
Turkey has
2015776 community
2016 health
2017centers2018
(Table 7) (ITO, 2010).
Primary Health Care Center 5.055 - - - - -
Family Physicians Unity - 21.384 21.696 24.428 25.198 26.252
Table 7. Number of Primary Level Establishments in Years (SB, 2018).
Family Health Center - 6.829 6.902 7.636 7.774 7.979
2002 2014 2015 2016 2017 2018
Community Health Center
Primary Health Care -
5.055 970- 970
- - 970 - 972 - 776
Center
Family Physicians Unity - 21.384 21.696 24.428 25.198 26.252
Family Health Center - 6.829 6.902 7.636 7.774 7.979
c) Satisfaction
Community Health Level in Health
- Services970
970 970 972 776
Center

In Terms of level of
c) Satisfaction satisfaction,
Level according to the results of “Life Satisfaction
in Health Services
Survey” done by Turkey Statistical Institute (TUIK), over the years, citizens in
In Terms
general sayofthat
level of
thesatisfaction, according
satisfaction leveltoof
thehealth
results ofservices
"Life Satisfaction
tends to Survey" done The
increase.
by Turkey Statistical Institute (TUIK), over the years, citizens in general say that the
level of satisfaction in health services, which was 39.5% in 2003, increased to
satisfaction level of health services tends to increase. The level of satisfaction in health
70.4% by 2018
services, which(Figure
was 39.5% 19) (TÜİK,
in 2003, 2018).
increased to 70.4% by 2018 (Figure 19) (TÜİK, 2018).

2003 2018

70,4

39,5 39,3

21,2
13,9 15,1

0,5
-

Satisfied Moderate Not Satisfied No Idea

Figure 19. Annual Health Services General Satisfaction Rate in Years (%) (TÜİK,
Figure 19. Annual Health Services General Satisfaction Rate in Years (%) (TÜİK, 2018)
2018)

2.4.3. The Budget Allocated to Health19 from Turkey’s National Income

In 2002 in Turkey, total health expenditure per capita was $ 187, in 2018,
was realized as $ 430 (SB, 2018). Gross domestic product ratio of total health
expenditure in Turkey (GDP) was 4.4%.

2.4.4. Actions on COVID-19

Within the scope of the fight against the epidemic, it was carried out under
the leadership of the Presidency in our country, it was implemented by taking
fast, effective and frequently updated decisions. In conclusion; After the first
case was detected in China on 31.12.2019, the Coronavirus Scientific Board
was established by the Ministry of Health on 10.01.2020. During the process,
Wuhan-Istanbul flights were stopped on 24.01.2020 and all flights from China on

29
05.02.2020 were stopped. The land border gates between Turkey and Iran was
closed on 02.23.2020. The first case was seen in our country on 11.03.2020 and
one day later, on 12.03.2020, education was interrupted in primary, secondary
education institutions and universities. On 13.03.2020, the cancellation of public
activities and the temporary closure of collectively gathering places started to be
implemented. In order to prevent the spread of the virus, flexible working in the
public has been initiated, and curfew has been introduced at different dates for
people over the age of 65 and under 20. Curfew restrictions have been applied
on weekends and long-term holidays. As of 03.04.2020, entrance and exits to 30
Metropolitan and Zonguldak provinces have been subjected to special permit
(Travel permit), and it has been made compulsory to wear masks in places of
work, süper markets and marketplaces. On 06.05.2020, the Minister of Health
announced that the 1st Period has been completed in the fight against the
epidemic. As of 29.05.2020, the worship in the mosques, which were interrupted,
was allowed within the scope of limited times and Friday prayers were started
to be performed again in accordance with the social distance and mask rule in
the open area. As of 01.06.2020, the travel restriction of metropolitan cities
was removed and the transition to controlled social life was started within the
framework of the previously announced calendar (TÜBA, 2020).

During the epidemic of Covid-19, arrangements have been made in order to

provide healthcare services free of charge to patients in both private sector
and public institutions by social security institution (SSI). Cooperation with the
relevant ministries has been realized to present various incentive and support
packages including deferral in tax payments and discount for the businesses that
have been suspended due to the epidemic and continue to produce and employ
personnel within the scope of obligation or volunteering. In this context, with the
“We Are Enough For Us” campaign and the support of all segments of the society,
contribution was made to the social benefits planned to be made to households.
The needs of individuals over the age of 65, people with disabilities and chronic
illness who were curfewed, were fulfilled through teams established with the
support of local governments, security forces and various non-governmental
organizations (TÜBA, 2020).

In this process, Turkey has launched the production of its medical supplies as
well as the personal protective equipment of the health personnel. In addition,
It provided medical equipment and protective equipment to various countries
(USA, UK, Italy, Spain, Serbia, China, Pakistan, Syria, Sudan, Somalia, Bosnia
and Herzegovina, Libya, Iran) within the scope of international solidarity. This
attitude of our country is very important in terms of economic and political
relations (TÜBA, 2020).

30
3. Climate Change and Its Impacts on Public Health

Turkey is one of the countries in that are at risk in terms of potential effects
due to the global climate change. Due to the decrease in water resources, forest
fires, erosion, change in agricultural productivity, drought and ecological
deterioration, deaths due to heat waves and increases in vector-borne diseases,
floods and related diseases or deaths and urban air pollution as a result of the
observed and expected change in climate, chronic respiratory diseases are
expected to increase. The chances of catching health risks caused by climate
change are higher in low-income countries and regions with poor health care. In
this context, preparation plans are needed to provide safe drinking and utility
water in both cities and rural areas, to prevent and fight bad weather events that
may affect health services (SB, 2015). The possible effects of climate change are of
interest not only by the Ministry of Health but also in many different institutions
and the relationship between climate change and health has been increasingly
investigated in recent years. In this section, climate change and health effects in
Turkey are discussed.

3.1. Heat Effects

The change in temperatures can directly affect human health and life. These
effects are mostly seen acutely and often cause casualties (Atay et al., 2012). These
effects can be examined in two groups as hot and cold air waves.

Especially in cities, the effect of the hot air waves is important. The effect of
hot weather and temperature waves on human health depends on the level
of exposure to hot air, the density of the population (frequency, degree and
duration) exposed and the sensitivity of the population. The direct effects of high
temperature on health appear as sunburn, heat cramp, heat fatigue, heat stroke
or sunstroke. In addition, it can lead to worsening or even death of the person’s
health. Individuals with chronic diseases such as hypertension and coronary
artery disease, asthma, respiratory system diseases such as chronic obstructive
pulmonary disease, diabetes, and vulnerable groups such as the elderly, pregnant
women and children are particularly at risk. Due to the climate zone in which
our country is located, the probability of seeing hot air waves is very high. In
this respect, the Southeastern Anatolia Region is at a higher risk regionally than
the Marmara Region. However, since the population of the Marmara Region is
denser, it is likely that the effects of hot air waves are higher (SB, 2015).

31
The maximum temperatures in June 2006 and 2007 and the daily mortality rates
for the same months are given in Figure 20. It can be said that there is a parallel
between high temperatures and the increase of mortality rates (SB, 2015). In
another study, three hot air wave events in Istanbul in 2015, 2016 and 2017
showed an increase in the risk of death by 11%, 6% and 21%, respectively. The
highest risk rate was seen in the summer of 2017. People are less tolerant of
extreme temperature in the first weeks of summer. The second heat wave in 2017
did not increase mortality rates (Can et al, 2019).

Figure Figure 20. High

20. High temperature and
temperature and death
deathrelationship in İzmirinprovince
relationship İzmir between Junebetween
province
2006 - 2007 (SB, 2015) (The Same Figure is taken)
June of2006
The Ministry - 2007
Health (SB,its2015)
continues efforts(The Same
to inform theFigure is taken)
public against hot air and
temperature waves, especially in the summer months. With regard to chronic diseases,
ministry is carrying out Prevention of Cardiovascular Disease and Control Program,
The Ministry ofChronic
Turkey Health continues
Respiratory its efforts
Disease (asthma toPrevention
and COPD) informandthe public
Control Programagainst hot
Action Plan and Turkey Diabetes Control Program Strategic and Action Plan programs (SB
air and temperature
2015). waves, especially in the summer months. With regard to
chronic diseases, ministry is carrying out Prevention of Cardiovascular Disease
Cold weather continues to be a problem in the northern regions of the world, where cold
and ControlairProgram, Turkey
is suddenly formed Chronic
and the Respiratory
air reaches Diseasefor(asthma
very low temperatures a long time.and COPD)
Prevention Exposure
and to cold weather is more problematic among those who work outside, homeless
Control Program Action Plan and Turkey Diabetes Control
people and similar social conditions and the elderly. In countries that have adapted to cold
Program Strategic
weather andand Action
cold air Plan
waves, there mayprograms
be an increase(SB
in the2015).
death rates from cold if there
is a problem in the electricity and heating system (SB, 2015). There is no statistical
information regarding the impact of cold wave in Turkey.
Cold weather continues
As previously to beinathe
mentioned problem in theof northern
future scenarios climate change,regions of the world,
the average
temperature is expected to increase between 2-3.5oC and 4-6oC for two different pollution
where cold emission
air is suddenly
scenarios (Rcpformed and
4.5 and 8.5). Thethe airtemperature
highest reachesincrease
very low temperatures
is expected in for
South East Anatolia and Mediterranean Regions. Especially, summer and autumn months
a long time. Exposure to cold weather is more problematic among
are the most sensitive period during the year (Öztürk, 2019). Along with these estimates,
those who
work outside, homeless
the groups people
that are more and
sensitive similar social
to temperature increasesconditions
may be affected and the
more by the elderly. In
effects of climate change.
countries that have adapted to cold weather and cold air waves, there may be
an increase3.2.
in the death
Extreme rates
Weather from
Events, Floodscold
and if there is a problem in the electricity
Effects
and heatingThesystem (SB, experienced
most frequently 2015). There is no statistical
natural disasters information
in Turkey are storms, regarding the
floods, droughts
impact of cold wave
and forest inThese
fires. Turkey.
disasters can often cause injury to individuals and sometimes even

22
As previously mentioned in the future scenarios of climate change, the average
temperature is expected to increase between 2-3.5oC and 4-6oC for two different
pollution emission scenarios (Rcp 4.5 and 8.5). The highest temperature increase
is expected in South East Anatolia and Mediterranean Regions. Especially,

32
summer and autumn months are the most sensitive period during the year
(Öztürk, 2019). Along with these estimates, the groups that are more sensitive
to temperature increases may be affected more by the effects of climate change.

3.2. Extreme Weather Events, Floods and Effects

The most frequently experienced natural disasters in Turkey are storms, floods,
droughts and forest fires. These disasters can often cause injury to individuals
and sometimes even death. 2019 was the year with the most extreme events with
935 extreme events. There is an upward trend in extreme event trends, especially
in the last two decades (Figure 21). Most of the extreme events recorded in 2019
were heavy precipitation/flooding with 36% and a storm with 27%. Other incidents
were hail with 18%, lightning with 7%, heavy snow with 5%, landslide with 3%,
and avalanches of the
death. 2019 was 1%year
andwith
to the
a lesser extentevents
most extreme avalanche,
with 935wildfire, sandstorm
extreme events. There and
is an upward trend in extreme
fog (Figure 22) (MGM, 2019). event trends, especially in the last two decades (Figure 21).
Most of the extreme events recorded in 2019 were heavy precipitation/flooding with 36%
and a storm with 27%. Other incidents were hail with 18%, lightning with 7%, heavy snow
with 5%, landslide with 3%, and avalanches of 1% and to a lesser extent avalanche,
wildfire, sandstorm and fog (Figure 22) (MGM, 2019).

Figure 21. Number of Annual Extreme Events in Turkey (MGM, 2019) (The Same Figure is Taken)
Figure 21. Number of Annual Extreme Events in Turkey (MGM, 2019) (The Same Figure
is Taken)

Rates of Meteorological Disasters (2019)

1% 0% 1%
Heavy Rain/Flood
1% 3% 1% 0%
Storm
5% 7%
36% Hail
Snow
18% Lightning
Frost

27% Landslide
Avalanche
Forest Fire
Sand Storm

Figure 22. Distribution

Figure of Extreme
22. Distribution of Events
Extremein Events
TurkeyinofTurkey
the Year
of2019 (MGM,
the Year 2019) (The
2019
Same Figure is Taken)
(MGM, 2019) (The Same Figure is Taken)
As one of the extreme events in the most common type of natural disaster, floods, has led
to significant loss of life and property during
33 the historical period for Turkey. Floods have
started to have devastating results at higher rates with their incidence and severity,
especially in the last 10 years (Akay, 2019). In Table 8, the list of floods that led to death
of at least 10 people between 1995-2004 in Turkey are given. When the causes of deaths
As one of the extreme events in the most common type of natural disaster, floods,
has led to significant loss of life and property during the historical period for
Turkey. Floods have started to have devastating results at higher rates with their
incidence and severity, especially in the last 10 years (Akay, 2019). In Table 9,
the list of floods that led to death of at least 10 people between 1995-2004 in
Turkey are given. When the causes of deaths due to floods were investigated,
the causes of death were found to be drowning, injury and hypothermia. Stress
and psychological trauma are also the most important effects of individuals as
a result of floods (TÜBA, 2010). In addition, excessive rainfall, stagnant water
or overflow of rivers cause increases in infectious diseases due to the increasing
number of flies. Until the end of the 21st century, Turkey is expected to be the
most effected country from extreme weather conditions among the Eastern
Europe, the Balkans, Eurasia and the Turkic States (Figure 23) (Baettig et al,
2007).

Table 9. Floods that happened between 1995-2004 years in Turkey and led to death of at least 10
people (TÜBA, 2010).

Year Place Number of Influences (Loss / million USD)

March 2004 Erzurun, Batman, Bitlis, 15 deaths
Konya, Silifke
June 2002 Rize 39 deaths
August 1999 Trabzon (Beşköy) 60 deaths, 1000 affected people
June 1998 Diyabakır 22 deaths
May 1998 Zonguldak, Karabük, Bartın 10 deaths, 47 injuries, 1200000 affected people
(Loss:1000000000 million US dolar)
July 1995 Ankara, İstanbul, Isparta 74 deaths, 10000 affected people

Figure 23. 21. Near Geography Countries where the biggest increases will be experienced in
extreme climatic conditions until the end of the 21st century (Baettig et al., 2007)

34
3.3. Infectious Diseases

3.3.1. Vector Source Diseases

While the changes in climate conditions affect ecology and biodiversity, they also
change the pattern of disease, the source of the disease, the variety, structure,
amount, strength of the disease factors, the means of transmission of the factors,
the carriers, the living and inanimate places where the factors reside, and the
environmental features in which they live. Carriers that mediate the transmission
of diseases to humans and animals are called vectors. Changes in temperature and
humidity, excessive precipitation, changes in winter temperatures, urbanization,
increase in vegetation, decrease, structural changes may cause vectors to be seen
in a different place than expected, to increase or to increase more than expected
(Kiraz, 2019).

Due to the increase in temperature with climate change, animals with

miscellaneous dimensions on land and at sea tend towards cooler places to get
out of the hot zone. Also in addition to climate change, deforestation, habitat
change or the destruction of some ecosystems can indirectly cause the movement
of animals to different places and the spread of diseases. With the movement
of animals to different regions, it creates an opportunity for them to come
into contact with other animals they do not normally live with, and in this case
pathogens enter new environments. Pathogens can transform with mutations in
their new environment. For example, the bird flu virus found in wild water birds
can spread to wider areas with birds forced to migrate with the destruction of
wetlands (Tolunay, 2020). Findings revealed as a result of studies on the effects
of climate change on human health show that hot climate belts will shift to the
north and cause the distribution of some infectious disease vectors to change (SB,
2015). As a result of rising temperatures and uneven distribution of precipitation,
there has been an increase in vector-borne diseases such as avian influenza, tick-
borne diseases, cholera, ebola, parasitic diseases, plague, lyme, harmful seaweeds,
scarlet fever, sleep sickness, tuberculosis, yellow fever, malaria, western nile virus,
chikungunya and dengue fever (Kiraz, 2019).

a) Malaria

Malaria is the most susceptible to long-term climate change among the vector-
borne diseases. The increase in average temperature in the external environment
will affect the mosquito-mediated vector distribution. In the coming years, it is
expected that it will be seen in tropical and subtropical regions where malaria
has not been seen yet and it will increase in the regions where the disease is seen.
European countries are an endemic region for some of the vector-borne diseases.
Malaria is endemic in some Eastern European countries, including Turkey (SB
2015).

35
In the past 30 years, there have been two periods associated with a high number
of malaria cases (Figure 24). These are the periods between 1977-1987 and 1993-
1998. The average temperature in Adana between 1977 and 1987 was found to be
significantly higher than the average temperature between 1930 and 2004. This
is an important result that shows a parallelism between high temperature and
malaria cases in the period between 1977 and 1987. Distribution of malaria cases
varies according to different regions. The average temperature in Sanliurfa and
Mardin was found to be significantly higher than the sum of the years examined
in the 1993-1988 period. This finding may be related to the high number of
malaria cases in the region (Atay et al, 2012).

140000

120000

100000

80000

60000

40000

20000

0
1974

1981

1987

1991

1997

2001
1975
1976

1978
1979
1980

1982
1983
1984

1992
1993

2000

2002
2003
2004
1988
1989
1990

1994
1971

1977

1985
1986

1995
1996

1998
1999

2005
1972
1973

Figure 24. Number of Malaria Cases in Turkey Since 1971 (Atay et al, 2012).
Figure 24. Number of Malaria Cases in Turkey Since 1971 (Atay et al, 2012).
Within the scope of the studies carried out within the scope of Malaria Elimination
WithinProgram
the being
scopeimplemented in Turkey,
of the studies very successful
carried results the
out within have scope
been obtained. In
of Malaria
2010 and 2011, no new domestic malaria cases were reported, only overseas malaria case
Elimination Program
reports were made being implemented
(CSB, 2013). Turkey isinone
Turkey,
of the very successful
16 countries thatresults
has not have
been encountered
obtained. In with2010 andcases
malaria 2011, for 3no new domestic
consecutive malaria2007
years between cases
andwere
2017 reported,
(WHO,
2018) (Figure
only overseas 25). The
malaria primary
case reports malaria
wereagent,
madefalciparum
(CSB, malaria
2013). parasite,
Turkeyisisprojected
one of the
to spread to new areas by 2050, as shown in Figure 26 . According to the light of this data,
16 countries that has not encountered with malaria cases for 3 consecutive years
the incidence of malaria in Turkey can be increased by 2050 (UN, 2019).
between 2007 and 2017 (WHO, 2018) (Figure 25). The primary malaria agent,
falciparum
Mankindmalaria parasite,
has struggled with thisispest
projected todifferent
by applying spreadmethods
to newin areas
order tobyget2050,
rid of as
shown theindisturbing
Figure 26 and.disease bearing
According toeffects of malaria
the light vector
of this from
data, theincidence
the beginning ofofhismalaria
life
until today. Today, we can gather the techniques used to combat vectors under the
in Turkey
headingscanof be increased
chemical, by 2050
biological, (UN, cultural
mechanical, 2019).and integrated struggle. In the fight
against pests, the type of struggle that enables to reach the result in the shortest time and
in the has
Mankind moststruggled
effective way is thethis
with chemical
pest struggle. Biological
by applying strugglemethods
different is a sustainable pest to
in order
management method that takes place as a natural phenomenon and does not harm the
get rid of the disturbing
environment and
with little or diseasemanipulation.
no careful bearing effects of malaria
The definition madevector from the
as mechanical
beginning
struggleof his
can alsolife until physical
be called today. struggle.
Today,The wemain
can aim
gather
in thisthe techniques
struggle used to
is to eliminate
combat vectors and
the breeding under thehabitats
feeding headingsof theofvectors
chemical, biological,
by improving mechanical,
the physical cultural
infrastructure.
Cultural struggle,
and integrated which constitutes
struggle. In the fightone of the important
against pests, components
the type of of the strugglethat
struggle
against vectors, is raising awareness of employees and practitioners in education and
enables to reach
arguments, the result
especially in local
for the the shortest
people who time and
live in thein the (Alten
region most and
effective
Çağlar,way is the
1998).
chemical struggle. Biological struggle is a sustainable pest management method
that takes place as a natural phenomenon and does not harm the environment
with little or no careful manipulation. The definition made as mechanical
struggle can also be called physical struggle. The main aim in this struggle is
to eliminate the breeding and feeding habitats of the vectors by improving the

36
physical infrastructure. Cultural struggle, which constitutes one of the important
components of the struggle against vectors, is raising awareness of employees
and practitioners in education and arguments, especially for the local people who
live in the region (Alten and Çağlar, 1998).

5
4,2 4,2
4

3 2,7

2 1,8 1,8
1,5
1,2 1,2
0,9
1
0,3
0,1
0
United Kingdom

Germany

Greece

Turkey
Switzerland

Belgium

Other WHO / European

Spain

Holland
France

Sweden

Region Countries
Figure 25. International comparison of cases of malaria (100000 population, 2017
Figure 25. International
data, this numbercomparison
has been of
setcases of malaria
to zero (100000
for Turkey population,
in 2018.) 2017
(General data, this number
Directorate of
has been set to zero forPublic
TurkeyHealth,
in 2018.)
the(General Directorate
World Malaria of Public
Report 2018, Health,
UNDP) the World Malaria
Report 2018, UNDP)

Figure 26. Distribution of Malaria Parasites in the World until 2050 (UN, 2019)

b) Crimean-Congo Haemorrhagic Fever (CCHF)

Crimean Congo Hemorrhagic Fever (CCHF) is usually caused by a virus transmitted by

ticks. Ticks
Figureare
26.sensitive to climate
Distribution andParasites
of Malaria seasonal in changes.
the WorldTherefore,
until 2050 it is necessary
(UN, 2019) to
control the disease seasonally and take precautions when the disease is common (CSB,
2013). Figure 27 shows the geographical distribution of CCHF cases in the world limited
to Asia - Europe - Africa. Although the disease shows seasonal characteristics, it generally
starts with spring, reaches the highest level in summer and decreasingly disappear in
autumn.
27
37
 b) Crimean-Congo Haemorrhagic Fever (CCHF)

Crimean Congo Hemorrhagic Fever (CCHF) is usually caused by a virus

transmitted by ticks. Ticks are sensitive to climate and seasonal changes. Therefore,
it is necessary to control the disease seasonally and take precautions when the
disease is common (CSB, 2013). Figure 27 shows the geographical distribution of
CCHF cases in the world limited to Asia - Europe - Africa. Although the disease
shows seasonal characteristics, it generally starts with spring, reaches the highest
level in summer and decreasingly disappear in autumn.

One of the tick-borne infectious diseases, CCHF is a deadly viral infection that
occurs in parts of Africa, Asia, Eastern Europe and the Middle East. The first viral
hemorrhagic fever (VHF) detected in our country until today is CCHF. Since 2002,
a large number of patients started to be registered. To date, 10562 cases have
been recorded by 2017, mainly from Tokat, Yozgat, Corum, Sivas, Kastamonu,
Karabuk, Gumushane, Erzurum, Amasya, Cankırı, Giresun and Samsun, 501
(5%) of them resulted in death (Figure 28). Deaths are most common in the 50-
70 age group and 66% with the most engaged in farming and animal husbandry
(THSK, 2016).

Figure 27. Crimea-Congo Hemorrhagic Fever Distribution Map (THSK, 2016)

38
 Figure 27. Crimea-Congo Hemorrhagic Fever Distribution Map (THSK, 2016)

1400
Number of cases
1200
Death
1000
800
600
400
200
0
2004

2005

2007
2003

2006

2008

2009

2010

2011

2014

2015
2012

2013

2016
Figure 28.28.
Figure Crimean-Congo
Crimean-CongoHemorrhagic
Hemorrhagic Fever Casesand
Fever Cases andDeath
DeathNumbers
Numbers (THSK,
(THSK, 2016)
2016)

c) Tularemia
c) Tularemia
Tularemia is a disease caused by the bacterium of Franscisella Tularensis, which is
transmitted to humans by direct contact with infected animals, contaminated water or
Tularemia is a disease
food entering caused
the body, by the
tick bite, bitingbacterium of Franscisella
flies or mosquitoes, Tularensis,
which
or inhalation of infected
is transmitted to humans by direct contact with infected animals, contaminated
28
water or food entering the body, tick bite, biting flies or mosquitoes, or
inhalation of infected powders or sprays. Population movements, poverty, wars
and migrations facilitate the spread of various disasters. The increase in cases of
tularemia in Turkey in recent years, is attempted to be explained due to changes
in some of the ecological balances. It is thought that the increase in the rodent
population, especially after rainy seasons, has increased the number of tularemia
cases (CSB, 2013). However, the contact of rodents with the water resources is
seen as the most factor in clustering tendency of tularemia cases in Turkey and in
general being seen as small-scale water-borne epidemics. Before 1998, very few
cases of tularemia were seen in Turkey. However, many cases have been reported
since 1998. The source of all these epidemics is polluted drinking water. While
Tularemia was widespread in the Marmara and Western Black Sea Regions before
2005, new cases were also reported in the first half of 2009-2010, especially in the
Central Anatolia and Black Sea regions (TSHGM, 2011).

d) Sandfly Fever

Sandfly fever is caused by a virus transmitted from sandfly (Phlebotumus

papatasi). Sandflies are sensitive to climate and seasonal changes. The disease
is transmitted to people by bite of sandflies. The sandfly feeds at night and is
found in dark places during the day, such as wall cracks, caves, houses, and tree
burrows. Therefore, it is important to monitor the disease seasonally and take
the necessary measures when the disease is seen. Sand fly malaria is observed
frequently in the Turkish Republic of Northern Cyprus, the Balkans and in
Turkey’s southeastern neighbors (Iran, Iraq). In Turkey, in the studies in the
Aegean and Cukurova regions, especially in Adana, disease-related antibodies
have been identified. In Izmir, Ankara and Adana Over 106 patient study carried
out, and SFCV SFSV type antibodies have been identified and Turkey-type virus
(sandfly fever virus Turkey, SFTV) was isolated (CSB, 2013).
39
 e) Leishmaniasis

Leishmaniasis is a disease transmitted by vectors affected by climate change.

Climate change facilitates the spread of both infectious vectors and disease.
Increases in temperature and humidity can spread the disease to the northern
regions. Unplanned urbanization and poor infrastructure can facilitate the
spread of sand flies carrying this disease. Leishmaniasis has been reported in
all countries adjacent to the Mediterranean. The cutaneous form (Cutaneous
Leishmaniasis) of Leishmaniasis is endemic in our country, especially in the
Sanlıurfa and Cukurova regions, in the Southeast provinces. Migration and
urbanization are important risk factors for cutaneous leishmaniasis. According to
reports, with the increased agricultural irrigation due to the GAP (Southeastern
Anatolia Project), the habitat of the infected flies will expand and the cutaneous
leishmaniasis may increase.

f) Cutaneous Leishmaniasis

Cutaneous Leishmaniasis is known in Turkey since 1833. In the 1950s, it has

decreased due to the fight against malaria and pesticides affecting the sand
flies, but it started to spread again due to irrigation agriculture, unplanned
urbanization and migrations. In all infectious diseases, control measures play an
important role in reducing effects. In this context, health personnel should be
trained and awareness of health personnel should be increased in the diagnosis
and treatment of these diseases affected by climate change.

g) Dengue

Dengue is the world’s most important vector-borne disease. It was seen in only
9 countries in the world until 1970, and since 1995, it became problematic
in countries more than 4 times than the countries in the previous period and
continued to increase. It is stated that 40% of the world’s population is at risk
for this disease. There are many studies investigating the relationship between
climate and occurrence of dengue disease. In these studies, this reported
relationship did not fully reveal the complex effects of climate change and other
factors on transition. While excessive rains and high temperatures can cause
an increase in transmission, studies have shown that drought can also cause it.
The climate-based (temperature, rain, clouding) intensity maps of Aegypti, the
main dengue fire vector Stegomyia (previously called Aedes), match the observed
disease distribution. Approximately one third of the world’s population lives in
suitable places for the spread of dengue disease (SB, 2015).

40
3.3.2. Waterborne diseases

Studies have found that there is a relationship between the time of occurrence of
waterborne diseases and epidemics and the dates of heavy rains and floods. In
both of them, the incidence of water-borne diseases increases due to secondary
reasons such as excessive thirst and drought, poor hygiene conditions and
weaknesses of immune system. It is estimated that water-borne diseases will
increase over time with climate change (Atay et al., 2012).

Waterborne diseases can be transmitted by drinking polluted water, eating foods

that have come into contact with these waters, and using polluted waters in green
areas irrigation. Conditions such as temperature changes, extreme weather
events, floods, increases in precipitation can increase waterborne diseases (TÜBA,
2010). Campylobacter, Salmonella and Shigella are the most common water and
foodborne diseases. While infections caused by Salmonella and Shigella have
been decreasing in recent years, an increase in Campylobacter infection, which
is associated with high temperatures, has been shown. In cases where excessive
precipitation was observed but drinking water chlorination was not performed, an
increase in tularemia cases was observed. Chlorination of waters is very important
in the tackling of Tularemi (CSB, 2013).

Sewerage and flood waters management is important in low income urban

communities. Because the clogging of the sewage system is one of the most
important reasons for the spread of diseases. Extreme weather events affect
the water system both physically and administratively. Due to the decrease in
precipitation, low flow occurs and thus, pathogens increase. Impairment of water
quality increases the number of diseases such as cholera, typhoid, paratyphoid
and childhood diarrhea and the incidence of related deaths (SB, 2015). As a result
of climate change, it is expected that it will adversely affect water resources and
water quality and that drinking water resources will decrease in these regions. It
is expected that there will be an increase in diarrhea in the future due to the use
of poor quality river waters or unsafe waters (TÜBA, 2010).

3.3.3. Foodborne Diseases

Changes in climate and severe weather events have an impact on human nutrition
from different perspectives. The reasons such as regional lack of water, increase
in salt rate in agricultural areas, damage of crops from disasters such as flood and
plant diseases affect nutrition. Drought reduces the diversity of food and food
consumption. This causes an increase in mortality in malnutrition and diarrheal
diseases. One of the most important factors affecting this is the outdoor temperature.
Foodborne diseases increase especially in summer months (TÜBA, 2010). Many
studies confirm that high temperature affects salmonellosis food poisoning. These
studies have shown that there is a linear increase in poisoning in each degree of
temperature increase weekly and monthly. It is stated that the increase of the
temperature in Campylobacterin spreads most in Europe (SB, 2015).

41
In addition to extreme temperatures, excessive precipitation and strong winds
can also increase foodborne illness. It is estimated that foodborne diseases will
increase by 5-20% by 2050. Microorganisms are generally transmitted to humans
through eggs, chicken and veal. The relationship between food and infectious
species especially affects the susceptibility of heat carriers such as flying, rodent
and cockroaches to heat. Flying insects are largely affected by ambient temperature
rather than biotic factors. Warm weather and mild winter months increase flying
insects in warmer countries. Other species that normally appear in the summer
have begun to appear in the early spring months (SB, 2015),(TÜBA, 2010).

3.4. Mental Diseases

Psychological effects of global warming can range from simple stress issues to
chronic stress or other mental disorders. Many of these problems are thought to
be related to extreme weather events and heat waves (IWGCCH 2010). The effects
of stress caused by extreme heat cause many health problems, from heart attacks,
temporary loss of consciousness to traffic accidents. The broader effects of floods,
forest fires, which occurred after extreme weather events such as hurricanes
arries from the social trauma. In such a situation, people who lose their homes,
jobs, relatives and social environments face many psychological problems (Yüksel
et al., 2018). In particular, it can have negative effects in maintaining jobs that
require attention. Increases in air temperature can often cause anxiety disorders
among mental health diseases.

In addition, increases in humidity can create a feeling of restlessness for those

with panic disorder, and the frequency of attacks may increase. While summer
means relaxation, sea or vacation for most people, it is also a time when anger
control problems can increase. Research has shown that many social-fact events
coincide with summer or hot weather, and crime rates also increase. Many people
can increase alcohol or drug use while going on holiday, and the holiday season
can be risky for addicts or patients who are still being treated for easy access to
alcohol or drug (Denizgil, 2018).

A study published in the Journal of the American National Academy of Sciences

revealed that experiences at higher temperatures and additional precipitation
were directly related to poor mental health. As people are exposed to these
factors, their condition gets worse. Therefore, events related to climate change
are expected to become more frequent and intense in the coming years. Women
and low-income individuals were found to be the most affected by the link between
temperatures and mental health. When the global temperature rise increases to
the range above 2 degrees above average, it can have serious effects on human
well-being, including mental health. It has also shows that climate change can
increase suicide rates, causing tens of thousands of people to kill themselves in
the middle of the 21st century, especially in the USA and Mexico (Obradovicha
et al., 2018). Berry H.L. et al. (2018), 208 publications were reported in 9,672

42
publication searches produced with the terms “climate change and mental
health” between 2007-2016. This number is very low and studies on the mental
health of climate change should be increased.

In a study conducted in Bartın, it has been stated that climate change has various
effects on people and it has been revealed by various researches (Akdağ, 2011). It
has been seen 33 cases of depression in 2009 and 24 cases of depression in 2010.
These depressions occurred in summer and autumn in 2009, while in 2010 they
occurred in spring and autumn. This situation is important in terms of showing
that people can be affected in a constantly changing climate environment. Located
in the hottest region of Turkey a survey was conducted for high school students
and teachers in Sanliurfa. According to this study, the effect of air temperature
on teaching and learning was investigated. The most appropriate working time
for students and their teachers was determined as “sunny weather in winter”. In
the summer months, students think that dusty air negatively affects the desire to
work by 80.7%, while teachers think that hot air negatively affects the desire to
teach 95.05% (Mollazade & Sahinalp, 2019).

3.5. Chronic Diseases

As a result of the additional burden of chronic diseases on the human body,

the body gets weak. Individuals with chronic diseases are easily affected, even
if climate change has mild effects (SB, 2015). Therefore, the group that is
expected to be most affected by climate change is the group with chronic disease.
With climate change, those with chronic diseases such as cancer, hypertension,
cardiovascular diseases, blood-borne diseases, asthma, neurological diseases and
disorders will be most affected.

The depletion of the ozone layer in the stratosphere causes the increase of
ultraviolet rays reaching the earth. The increase in ultraviolet rays reaching
the earth causes an increase in the tendency to catch infections and an increase
in cancer tendency due to the weakening of the human immune system. The
increase in ultraviolet rays also results in the occurrence of sunburn, early signs of
aging due to a decrease in photosensitivity and skin elasticity (Çimen & Öztürk,
2010).

3.6. Acute Diseases and Allergies

Respiratory system disease, defined as “Metropolitan Disease”, is an important

health problem in cities where crowded masses live together, especially in big
cities. The number of individuals affected by this disease, which can also be
defined as “Metropolitan Bronchitis”, is quite large.

Despite the fact that a large number of people living in crowded cities every year,
especially children do not have a significant respiratory system disease such as

43
asthma, chronic bronchitis, pneumonia, allergic disease development, etc. they
get sick and this reveals the importance of this problem (Çimen & Öztürk, 2010).

Temperature variations and increases affected all living species and changes
occurred in plants and pollen scattering. Storms were found to increase pollen-
related asthma attacks. Air pollution increases the allergen properties of pollens.
It is known that high temperatures and precipitation increase pollen production
of many trees and herbaceous plants. According to a study conducted in North
America, the pollen period of the Ambrosia plant extends seriously as it moves
towards the northern regions. There are many studies indicating that this is also
true for other plant species (SB, 2015). The main diseases caused by pollen can
be listed as hay fever, asthma and eczema.

Some studies have been made in Turkey in this regard. In a study covering
14 provinces and conducted on 25,843 people, it was shown that the average
annual temperature was associated with the prevalence of asthma and wheezing
in both genders, and also linked to eczema in women (Metintaş & Kurt, 2010).
It was determined that the amount of moisture was also effective on asthma in
women and there was a relationship between the number of annual snowy days
and wheezing in both gender. Due to the climate change the increase in the
number of cockroaches, mites etc. in the houses and the increase of pollen and
air pollutants in the external environment, diseases such as asthma are expected
to increase (TÜBA, 2010). Treatment expenses and economic job losses caused
by pollen and similar allergens that cause allergic reactions will cause billions of
dollars of damage to the national economies.

3.7. Air Pollution, Pollutants and Effects

Carbon dioxide is the biggest factor in global warming and climate change.
Besides, many compounds containing gas or particles known as ‘Climate
Compeller’ have a significant impact on the amount of solar energy (including
heat) that the earth retains and the amount it reflects back into space. These
climatic compellers include air pollutants such as ozone, methane, particulate
matter (PM) and nitrous oxide.

Depending on the particulate matter composition, it may have a cooling or heating

effect on the local and global climate. For example, black carbon, which is one of
the fine PM components and formed as a result of incomplete combustion of fuels,
has a heating effect in the atmosphere as it absorbs solar rays and infrared rays in
the atmosphere. Other PM types, which contain sulfur or nitrogen compounds,
have the opposite effect. They acting as small mirrors, tend to reflect the energy
of the sun into space and thus lead to cooling tendency. Simply stated, this
situation depends on the color of the particle. Generally, “white” particles reflect
daylight, while “black” and “brown” particles tend to absorb daylight. A similar
phenomenon takes place in the soil. Some of the particles descend to the surface

44
of the earth due to rain, snow and gravity. Black carbon, can be moved relatively
away from the source, achieve the level of the snow and ice cover. In recent years,
black carbon accumulations in the Arctic have gradually darkened white surfaces
and reduced their reflective properties. This causes our planet to retain heat
more. With the additional heat, the size of the white surfaces shrinks much faster
in the North Pole.

Interestingly, many climate processes are controlled not only by the major
components of our atmosphere, but only by some very small amounts of gases.
The most common of these gases, called trace gases, is carbon dioxide, making
up only 0.0391% of the air. Any changes in these very small quantities have the
power to influence and change our climate.

Evidence for the health effects of particulate matter is stronger than ozone.
Particulate matter seriously affects the number of deaths and diseases. Therefore,
increased concentration increases negative effects on health (SB, 2015).

In a study investigating the effect of air pollution on respiratory system diseases

in Istanbul province, it was found that outdoor air pollution in Istanbul increased
hospital admissions due to respiratory system diseases, especially adverse impact
in the elderly (> 65 years) and women (Çapraz et al. ., 2017). Another study
investigating the effect of air pollution on deaths in Istanbul revealed a significant
relationship between air pollution and deaths caused by respiratory and heart
diseases (Çapraz et al. ., 2017).

The greatest risk for deaths from cardiovascular diseases generally occurs four
days after exposure to pollution. The greatest risk for deaths caused by respiratory
diseases generally occurs five days after exposure to pollution. The greatest risk
for deaths caused by non-accidental causes show up is ten days after exposure
to pollution for PM10 and two days for SO2 (sulfur dioxide). The serious risk is
experienced when pollutant concentrations are well above normal levels. In such
cases, the risk of death increases exponentially (Çapraz, 2013).

In 2013-2015, the relationship between hospital admissions and air pollution was
investigated due to respiratory diseases from different age groups in Istanbul. The
highest relationship was found between PM2.5, NO2(Nitrogen Dioxide) and PM10
parameters, respectively, and hospital admissions. In addition, in the number of
hospital applications in Istanbul, short-term exposure to these parameters has
increased this number (Çapraz et al. ., 2017).

3.8. Food, Nutritional Safety, Agriculture and Effects

It is estimated that due to climate change in the Mediterranean Basin where

Turkey located in, the temperature will increase, heat waves will be more intense,

45
up to 20% reductions would be in precipitation, soil moisture will decrease and
sea level will rise. In the report prepared on this subject, it is reported that the
temperature increases and changes in the precipitation regime will be more in
semi-arid and tropical areas in the Mediterranean Region, and extreme weather
events such as floods and droughts will be more intense and frequent. It is
estimated that these changes will cause losses and destructions in agricultural
areas and decrease in product yields. The report also reports that temperature
increases of 2 and 4 ° C worldwide will result in a 5% and 10% reduction in grain
yields, while a decrease in yield will reach 25-35% in the Mediterranean region
(CSB, 2013).

Turkey is estimated to be one of the countries most affected by climate change. A

study conducted in seven geographical regions and national scales in Turkey, it
was found that as a result of precipitation and temperature changes in the regions
during the production periods of plants covering 85% of the production areas,
changes in yields, and this change of Turkey’s agricultural production, inter-
regional pattern of products, agricultural products prices, exports and imports
of consumer, producer and social welfare effects have been identified (Dellal
et al., 2011). As seen in Table 10, it has been determined that the production
amount will decrease by 8,18% in wheat, 2,24% in barley, 9,11% in corn, 4,53% in
cotton and 12,89% in sunflower. There will be changes in the production pattern
by regions, exports in wheat and sunflower will decrease , imports in corn and
cotton will increase , product prices will increase by 6.3% in wheat, 7.1% in barley,
12.6% in corn and 0.1% in sunflower. In the face of the increase in product prices
it is estimated that producer welfare will increase by 8.3%, whereas consumer
welfare will decrease by 1.7% and total welfare will decrease by 0.7% (CSB, 2013).

Table 10. Effect on the yield of agricultural products in seven regions in Turkey of climate
change, % (Dellal et al., 2011).

Wheat Barley Corn Cotton Sunflower

Black Sea -6,0 -7,0 -7,4 -5,0
Marmara -10,3 -8,5 -7,9 -5,0 -5,9
Aegean -7,2 -7,2 -11,0 -3,6 -6,6
Mediterranean Sea -6,5 -6,0 -10,9 -2,8 -6,8
Central Anatolia -7,4 -8,2 -12,5 -7,3
Eastern Anatolia -8,3 -8,5 -12,1 -7,9
Southeastern Anatolia -7,2 -7,5 -9,2 -4,0 -6,3
Turkey -7,6 -7,6 -10,1 -3,8 -6,5

3.9. Forest Fires and Effects

Meteorological factors that decrease the relative humidity and increase the
temperature are particularly effective in the formation of forest fires, which are

46
closely related to drought (MGM, 2018). As a result of 30188 forest fires between
the years 2005-2018 a total of 106 650 hectares of forest has burnt out in Turkey.
According to annual statistics, an average of 2388 forest fires occurred annually.
An average of 6665 hectares of forest were damaged annually in these fires.
While 2167 forest fires occurred in 2018, 5644 hectares in total were damaged.
According to 2018 statistics for Turkey, it has been introduced that 81% of forest
fires originating from human intent and omission. Fires caused by natural causes
are only 19% (OGM, 2018). These are fires caused by energy transmission lines,
mostly due to lightning and storms (MGM, 2018). The year of the biggest fire was
2008, which makes up almost 27% of the burning areas in the last 10 years. The
fact that 2008 was a dry year had a great impact on this. In 2008, largest forest
fire in Turkey’s history has occurred in Antalya-Taşağıl (MGM, 2018).

The area damaged by fires decreases every year. Developing technology and
increasing measures have a big share in this decrease (OGM, 2018). Protection and
improvement of forest ecosystems, which have a very important role in combating
climate change, have a special place. In Turkey, many studies are performed to
preserve existing forests and rehabilitate deteriorated forest ecosystems. Many
collaborations are carried out such as early warning and alarm systems (Akay,
2019). Forest fires cause burns and smoke inhalation and other injuries (e.g.
accident while avoiding fire areas). Major fires lead to an increase in the number
of patients in emergency departments. Toxic gases and particles are dispersed
into the atmosphere, and these cause an increase in acute and chronic respiratory
diseases, especially in children and the elderly, lung infection, upper respiratory
tract diseases, asthma and COPD. Pollutants from forest fires negatively affect air
quality even thousands of kilometers away (SB, 2015).

3.10. Migrations, Vulnerable Groups and Effects

Today, beginning with the rise in the number of asylum seekers coming to Turkey
in excess of millions, notably economical many respects causes them to produce
new policies in Turkey. Increasing disasters caused by climate change will lead
to further increase in these waves of migration in all aspects (Akay, 2019). The
absence of a legal framework makes it difficult to determine the protection status
of these people called climate refugees. Climate refugees, whose legal status
is uncertain, can cause social tensions due to resource shortages and indirect
security problems (Yılmaz & Navruz, 2019).

The United Nations Human Rights Committee has taken a decision that
governments cannot force people to return because of the climate crisis (Vatandaş,
2019). The decision in question is a first and it can also be an “entrance door” for
people who are under threat due to global warming.

Since 2008, an average of 21.5 million people have been forced to migrate each
year due to disasters such as floods and droughts. It is stated that millions of people

47
will demand asylum from Europe every year, even due to climate change, without
political and economic factors. A study showed that citizens of countries with a
temperature above 20 degrees demand more asylum than citizens of countries
with less temperatures (EKOIQ, 2019). The top 10 migration movements in 2016
were due to the climate. The countries most affected by these migrations were the
Philippines, China and India. Due to the climate and disasters in Turkey last 10
years, 275 313 people have emigrated (UNDP Turkey, 2019).

Turkey, especially refugees who escaped from the war and refugees in the camps
where these can be classified as sensitive areas. While there were 58 thousand
refugees in Turkey in 2011, the official number of Syrian refugees with only
nominal August 2019 is 3.64387 million. According to unofficial data, this number
is over 5 million. 89% of refugees in Turkey from Syria, 4% from Afghanistan,
3% from Iraq, 1% from Iran and remaining 3% from other countries. Most of
these refugees live in camps in Southeast Anatolia and are vulnerable to climate
change and epidemic diseases. In these camps, there is an increase in cases
such as tuberculosis and measles. In addition, the incidence of some infectious
diseases, such as aftosa disease, which is more common in immigrants, is gradually
increasing.

Five important risk factors such as the number of daily smokers, consuming
less than 5 servings of fruits and/or vegetables per day, not meeting physical
activity recommendations, the presence of overweight or obesity, and high blood
pressure were examined for Syrian refugees. While only 0.3% of Syrian refugees
in the 18-69 age group are in the low-risk group for non-communicable diseases,
the proportion of those in the medium-risk group (1-2 risk factors) is 41.1% and
the proportion of those in the high-risk group (3-5 risk factors) it is 58.7%. 45.7%
of men in the 18-44 age group and 46.1% of women are in the high risk group. A
striking finding is that men (81.7%) and women (87.1%) in the 45-69 age group
are exposed to high combined risk (more than 3 risk factors) (Balcılar, 2016).

48
4. Compliance and Mitigation Policies

4.1. National Adaptation Plans for Climate Change and Public Health
Studies spread over a large area on climate change in Turkey in 2004 has begun
with the signing of the Framework Convention on Climate Change in 2008,
it has gained momentum with the signing of the Kyoto Protocol. In line with
these agreements, some national documents have been prepared and these
documents have directed the work to be done. In our country, there is a Climate
Change Coordination Board (CBCC) under the coordination of the Ministry of
Environment and Urbanization, which was established to carry out studies in this
field. All policy work is coordinated by this board. The first document examining
the effects of climate change on health is the First National Communication on
Climate Change prepared in 2007 (TİDUB, 2007). In the first communication, it
was decided to implement certain adaptation tools, such as identifying hazardous
areas related to health, raising public awareness, creating risk maps related to
diseases affected by climate change, and warning health units (TİDUB, 2007).

Grand National Assembly of Turkey basic document that examined the health
effects of climate change in a systematic way (TBMM), Parliamentary Investigation
Commission’s report was drafted in 2008 (TBMM, 2008). In the report, the
interaction points of health and climate change are touched on and the health
problems caused by the country’s climate change are mentioned. The most
obvious of these are shown as health problems caused by heat waves, problems
occurring due to the effects of changes in temperature and precipitation on
epidemics such as malaria, CCHF and their vectors. In the report, a series of
suggestions were made on reducing the effects of climate change on health.

Another document addressing the effects of climate change on health is the

Climate Change 2010-2020 National Strategy Document published in 2010 (CSB,
2010). In this document, the effects of climate change are analyzed by sectors.
Health is not considered as a sector. In the harmonization part of the document,
the factors to be used in reducing the effects of climate change on health in
the short, medium and long term are listed. In the short term, it is aimed to
raise the awareness of the public against natural disasters caused by climate, to
train the health personnel against the health risks of the climate change and to
raise awareness among the health personnel. Although there are no direct health
adaptation tools in the medium term, indirect applications in water resources,

49
agricultural production, energy efficiency and similar fields that can indirectly
reduce the effects of climate change on health are also mentioned. In the long
term, direct health compliance instruments such as monitoring WHO indicated
(World Health Organization) disease and its vectors and reducing their effects,
and minimizing the effects of extreme weather events on public health, have
been specified.

The Climate Change Action Plan prepared in 2011 was prepared with a
participatory approach under the coordination of the Ministry of Environment
and Urbanization between 2009-2011 and was adopted by the Climate Change
Coordination Board (CBCC) in May 2011 (CSB, 2011). The interaction between
climate change and health exists as a harmonious topic. There are two aims in
this title and four goals under these objectives. Under the first objective, the
objectives of the extreme air events to investigate the effects on human health
and the interaction between infectious diseases and health risks have been
determined. The second objective includes capacity-oriented targets such as
strengthening the infrastructure of risky areas and strengthening the capacities
of health institutions. Detailed planning for these two purposes is detailed in
Table 11.

The Ministry of Health General Directorate of Public Health (GDPH) is

responsible for the impact of climate change on health. Ministry of Health
(GDPH) contributed to the climate change action plan. In order to support the
climate change action plan, the Ministry of Health has started to prepare an action
plan to reduce the effects of climate change on health. Two preparatory meetings
were held in Ankara in 2010 and 2011 with the financial support of WHO.
WHO and stakeholder institutions (Ministry of Environment and Urbanization,
Ministry of Education, Ministry of Food, Agriculture and Livestock, Directorate
of Disaster and Emergency Management (AFAD), Ministry of Energy, Ministry
of Forestry and Water Affairs, Universities and other relevant public institutions
and organizations) have supported this study. GDPH organized a workshop with
all stakeholders in Ankara on 5-6 December 2013.

The National Program and Action Plan for Reducing the Negative Effects of
Climate Change on Health were launched in 2010 and approved on 21 January
2015. The report has been prepared in Turkish and is 122 pages.

It is planned to carry out studies under the following topics related to the things
to be done in the field of climate change and health in the national program and
action plan (SB, 2015):

50
Table 11. Climate Change and Health Issues in the Climate Change Action Plan (CSB, 2011).
Goal 1. Determination of Threats and Risks for the Management of Natural Disasters Caused by Climate Change
Target 1.1 Investigation of the effects of extreme weather events on human health
Actions Period Outputs and Responsible / Related Organi-
Performance Coordinating zations
indicators Organization
1.1.1. Monitoring and evaluating 2011-2020 Impact assessment MOH Governorships
the effects and risks of extreme reports and
weather events such as heat waves, monitoring
hurricanes, floods and drought on systems
human health based on current and
future climate projections.
1.1.2. Establishing and extending 2011-2020 Emergency Governorates SB, Universities
early warning systems and making warning reports,
emergency warnings to reduce the Early warning
effects of extreme weather events systems
on human health.
Target 1.2. Investigating and monitoring the link between climate change, contagious diseases and health
risks and identifying possible measures
1.2.1. Investigation and follow-up of 2011-2015 Research reports MOH MFAL, MFWM,
the current and future relationship Governorships
between infectious diseases and
climate change
1.2.2. Identifying risky areas and 2011-2015 Public health MOH LG
measures to be taken in terms of risk map due to
public health climate change
1.2.3. Establishment of Tropical 2011-2015 Reinforced MOH Governorships
Disease Diagnosis Laboratories diagnostic and
regionally or strengthening the response infra-
infrastructures of Hygiene Laboratories structure
in some provinces for this purpose.
Target 2. Enhancing the Capacity of Combating Risks from Climate Change in the National Health System
Objective 2.1. Establishing emergency response action plans in risky areas and providing the necessary infra-
structure
2.1.1. Creation and implementation 2011-2015 Repeatable and MOH Governorships
of pilot programs in the areas of ep- scalable case
idemic and emergency health risk studies
2.1.2. Raising awareness of 2011-2013 Reinforced MOH Governorships
“National Medical Rescue Teams emergency response
teams in the area of ​​
(UMKE)” in the field of adaptation
climate change risks,
to climate change impacts including disasters
and infectious
diseases

2.1.3. Increasing the authority 2011-2015 Reducing infec- MOH Governorships

and enforcement skills of mobile tious disease risks
health teams affiliated to Provincial on a local scale
Health Directorates in risky areas
in terms of infectious diseases
2.1.4. Cooperation with 2011-2015 Experience and MOH International
international organizations and knowledge sharing Organizations
countries working on the effects of through joint
climate change on human health projects / events
2.1.5. To prepare and distribute 2011-2023 Public health MOH Governorships,
guidelines explaining what citizens guidelines LG, Universities,
and institutions should do in case public and private
of possible infectious diseases, hospitals, univer-
extreme weather events and sity hospitals
periodic training.

51
Table 11. (Continued) Issues on climate change and health in the climate change action plan
(CSB, 2011)

Target 2.2. Strengthening the capacities of health sector organizations against health risks due to climate
change
2.2.1. Carrying out capacity building 2011-2015 Capacity building MOH MFWM,GDF,
activities on health risks due to climate activities Governorships
change for preventive healthcare /
family health system employees
2.2.2. Announcement of ‘Ministry of 2011-2013 Communication MOH MFWM,GDF,
Health - Climate Change Adaptation campaigns Governorships
Program’ across the country
2.2.3. Establishment of the “Disaster 2011-2015 Effective health MOH Governorships
Coordination Center” of the Ministry of coordination
Health in regions affected by climate infrastructure
2.2.4. Ensuring coordination and 2011-2015 Ortaklıklar, Ortak MOH AFAD,
cooperation between related institutions projeler Governorships,
and organizations regarding climate Universities,
sensitive disasters and health risks NGO’s, Public
and Private
Hospitals,
2.2.5. Strengthening of vector (carrier) 2011-2020 Strengthened MOH Public and
mediated and zoonotic (from animals public health Private Hospitals,
to humans) diseases, evidence-based monitoring and University
protection, and treatment and control decision making Hospitals
of infectious diseases (including vaccine system
programs, vector control), including
integrated disease monitoring and
monitoring
2.2.6. Investigation / monitoring the 2011-2020 Strengthened MOH Public and
effectiveness of possible adaptation public health Private Hospitals,
measures to be taken in the health sector, monitoring and University
including early warning, strengthened decision making Hospitals
disease observation, information systems system
and other public health measures to
protect against the effects of climate
change
2.2.7. Benefits of mitigation / compliance 2011-2020 Strengthened MOH MEU, Universities
measures as well as the common public health
investigation / monitoring of losses and monitoring and
compliance costs decision making
system
2.2.8. Strengthening the observation 2011-2015 Water and hygiene MOH Governorships,
and preparedness of water availability, monitoring system, Municipalities
water quality and hygiene in rural and precaution and
urban areas information guides
2.2.9. Determining the health risks that 2011-2015 Research reports, MOH Governorships,
may occur due to the increase of the Capacity building Universities,
population and increasing the capacities activities International
of the institutions in the region, which Organizations
may be affected by the climate and in the
areas of migration movements.
2.2.10. Cooperation with national 2011-2015 Possible disease MOH Governorships,
and international organizations and spreads on a Universities,
countries working on issues such as regional scale, International
migration movements, international sharing knowledge Organizations
trade and tourism that will affect human and experience,
health due to climate change. developing
international
measures

52
 • Reducing the impact of extreme weather events and the resulting natural
disasters on human health and social life
• Strengthening the institutional infrastructure and increasing cooperation
within and outside the institution for the follow-up of diseases seen in our
country as a result of climate change.
• Ensuring water and food safety, combating water and foodborne diseases.
• Necessary studies to prevent vulnerable groups from being affected by
the adverse effects of climate change.
• Reducing the negative contribution of health institutions to climate
change.
• Raising public awareness for more effective protection from the negative
effects of climate change on health.
• Conducting monitoring and evaluation studies.

4.2. Adaptation and Mitigation Approaches

After the adoption of the National Program and Action Plan on Reducing the
Negative Effects of Climate Change on Health, on 21 January 2015, the National
Program and Action Plan started to be adapted as follows:

• The Ministry of Health PHGD organized a workshop on January 12,

2016 and received the opinions of the institutions and academicians
on the “National Program and Action Plan for Reducing the Negative
Effects of Climate Change on Health”.
• The Ministry of Health General Directorate of Public Health organized a
second workshop on “5-6 April 2016” on “National Program and Action
Plan for Reducing the Negative Effects of Climate Change on Health”
in order to establish implementation commissions. Commissions were
created in this workshop. The commissions formed and their duties are
given in Table 12.
• In line with the work of the commissions: targets are set, strategies are set
and activities are listed.
• In addition to technical and scientific developments, it is time to create
general / special models that will respond to awareness, and warnings in
national, regional, local, city, neighborhood scales.
• Training meetings on National Program and Action Plan to Reduce the
Negative Effects of Climate Change on Health were held in Bursa on
April 19, 2016 and in Ankara on September 13-14, 2017.
• Water and Health Congresses were held in 2015, 2017 and 2019.
• City, Environment and Health Congresses were held in 2016 and 2018.

53
 • Climate change training modules were prepared in 2019. These training
modules include 17 training modules on climate change. 14 of these
modules examine the effects of climate change on health.
• In 2019 TUBITAK (The Scientific and Technological Research Council of
Turkey) Climate, Environment and issued calls for bilateral cooperation
projects related to health.
• Trainings and other activities continue within the framework of the
action plan.

4.3. Mitigation and Common Benefits

Turkey, due in part to the introduction of feed-in tariff renewable energy targets
(30%) set for 2023 reached.Turkey has made enormous progress in reducing
CO2 emissions while increasing the number of forests. It is important to reduce
both emissions from agriculture and integrate compliance and promote low-cost
climate-friendly measures (OECD, 2019).

Increasing energy efficiency and renewable energy use, supporting low emission
clean transportation in public transportation, increasing the short-term renewable
energy target and setting longer-term targets, promoting the use of renewable
energy sources in transportation will both reduce emissions and reduce the
impact of climate change. With all these studies, air quality will improve and
cause less breathing-heart conditions. Thanks to the reduction of extreme
weather phenomena, epidemics transmitted by water will be reduced and will
also provide less spread of vector-borne diseases. Thanks to the reduction of
extreme weather phenomena, epidemics transmitted by water will be reduced
and will also provide less spread of vector-borne diseases.

Table 12. Duties of the Commissions (Kiraz, 2019b).

Commissions Health indicators Early warning Research - orien- Risk management

commission and intervention tation - planning commission
commission commission

• Determination • Determination • Literature re- • Identification of

of diseases that of parameters search risk maps
can be affect- affecting health • Data Bank • Determination of
ed by climate for early warning • Determination intervention and
change and their • Determining the of research pri- information meth-
demographic in- capacity of the orities ods for adaptation
dicators by con- health system to • Preparation of of vulnerable
sidering ICD-10 respond to cli- training material groups to climate
codes and other mate change change
Tasks related health • Determination
indicators and follow-up of
the relationship
between meteoro-
logical data and
health
• Identifying poten-
tial health risks
54
4.4. Case Studies for Adaptation and Mitigation
A number of studies have been carried out by the Ministry of Health to reduce
the effects of climate change, various teams have been formed and some systems
have been put into operation. Details of these are given below (SB, 2015; CSB,
2013):

• National Medical Rescue Teams (UMKE) have been established within the
Ministry of Health to respond to natural disasters and unusual situations.
The staff working at UMKEs are trained and certified by the ministry
to respond to disasters and unusual situations. UMKEs are coordinated
regionally. It has structuring in 81 provinces including 21 regions. It
has the necessary tools, equipment, mobile hospital, equipment and
personnel, including the air ambulances system, for a possible disaster
situation.
• The Health Disaster Coordination Center (SAKOM) has been established
within the Ministry of Health, and the computer system installed at the
center is continuously monitored for possible disaster situations.
• Emergency health services have sufficient capacity to prevent the possible
effects of climate change. The existence of this capacity was also observed
in the Covid-19 process.
• In cooperation with meteorology and other relevant institutions,
planning is made to establish an early warning system and to alert the
public in regions where disasters are likely to occur and to create a more
effective and faster response.
• Studies on informing health personnel and the public about the possible
effects of climate change, what to do and developing the right behavior
continue.
• In-service training meetings are organized at the central and local level
for healthcare workers related to infectious diseases.
• Educational materials, booklets, brochures and posters for infectious
diseases were prepared by the Ministry of Health.
• Infectious diseases are monitored every month by the Ministry of Health.

The establishment of an early warning system is one of the most important studies
in terms of compliance and impact reduction. In this context, a pilot scale study
was carried out by Aydın Adnan Menderes University. The details of this study
are given below (Kiraz, 2019):

• The thesis titled “Early Warning Model for Air Variables in Primary
Protection”, conducted by Aydın Adnan Menderes University in Aydın,
is the most recent climate and health study (Doğan & Kiraz, 2016).

55
 • In this study, “Local Early Warning System Model” is planned in order to
protect, raise and prepare the society about air variables.
• It is foreseen that the awareness and attitude-behaviors of the participants
in the intervention group will increase by sending sms, e-mails, warnings
and informative messages for the determined air variables.
• The research is an intervention study aimed at determining the
change in the level of awareness before and after the intervention in
the intervention and control groups determined in the Central Efeler
District of Aydın province.
• The research was conducted between June 2014 and August 2016.
• All public information was made available on the website www.
aydinerkenuyari.com.
• In this context, the awareness, attitude and behaviors of the intervention
and control groups were determined with the first survey.
• When the threshold values ​​determined for the air temperature, UV index
and air quality index (air temperature: 27oC, UV index: 6 and air quality
index: 101) are exceeded by the prepared computer program, a warning
and SMS and e-mail informative messages were sent for one year.

4.5. Economic and Development Results

The effects of climate change, which take place as a result of long processes,
appear at the end of many years due to the nature of the climate. Climate change
affects the economy in this system and creates some reflections. In this context, it
is seen that climate change has important impacts on employment and economic
growth and sectors such as agriculture, tourism,energy. Climate change has
serious effects on economies, especially as a result of temperature fluctuations
and excessive fluctuations in precipitation regime. It is seen that the global net
effect of climate change is negative. This negative picture reveals the necessity of
an effective and urgent struggle with climate change.

Undoubtedly, reducing energy and water consumption is a more environmentally

friendly action, and the demand is some of the things that can be done
individually as part of combating climate change (Başoğlu, 2014). It is stated
that the greenhouse gas emissions due to industrial processes and the use of
fossil fuels will double in 2060 will bring a 5% slowdown in the growth rate of
Asian countries. Similarly, it is estimated that the average annual growth rate
of the world economy will decrease to 3.6% for 2014-2030 and 2.7% for 2030-
2060. Behind these pessimistic projections are agricultural yield reduction, water
scarcity, increase of new bacteria, spread of various diseases and similar climate
change factors. According to the estimates, the expected effects on climate
change will reduce the global real product in the world by more than 7% in 2100.
However, complying with the Paris Agreement and limiting the temperature

56
increase to 0.01 ° C annually may limit the fall in global real product to around
1% (Acar, 2020).

Extreme events, Turkey’s Gross National Product in (GNP) leads to direct

economic losses of 3% each year. This is expected to increase gradually. Turkey is
one of the countries that will suffer the most water stress. This will put the risk of
both livability in our country, food systems related to drought and the availability
of natural resources together with agricultural lands (Acar, 2020). The yields of
products in all regions of Turkey were estimated to decrease (Dellal et al., 2011).
Due to the decrease in yield, it has been determined that the production amount
will decrease by 8,18% in wheat, 2,24% in barley, 9,11% in corn, 4,53% in cotton
and 12,89% in sunflower (CSB, 2013).

57
5. Results and Recommendations

5.1. Concerns about Climate Change and Health

The following concerns are raised with regard to climate change and health:

• In addition to the significant warming observed in the global climate,

an increase in global average surface temperatures is expected between
2-4.5 oC in the 1990-2100 period, according to the most advanced
climate models.
• Depending on the increase in global temperatures important changes are
expected to occur such as the change of hydrological cycle, melting of
land and sea glaciers, narrowing in glacier areas, rising sea level, sliding
of climate zones, more frequent and waxier heat waves, extreme rains,
floods and droughts in some regions will directly affect the socioeconomic
sectors, ecological systems and worldwide human life , because of the
increase in epidemics and pests due to high temperatures.
• Hot air waves can increase the risk of unexpected death. With the risk of
increasing UVB (Ultraviolet B), an increase in skin cancer, cataracts and
blindness cases is expected.
• They will be directly affected by climate change, and will be indirectly
affected by changes in water quality, food quality, ecosystem, agriculture,
industry, settlements and the economy.
• Climate change also adversely affects many health needs. Among
them are fresh air, clean water, adequate nutrition and healthy shelter
requirements. Climate change will negatively affect water quality and
accessibility. In some regions, in countries where food is cooked with
biomass, nutritional deficiencies can be seen more due to famine, lack of
access to healthy water as a result of desertification.
• The decrease or disappearance of transportation potential directly and
indirectly affects human health.
• All these effects are expected to be felt in a wide area, affect a large
number of people and occur over a wide period of time.

59
 • All countries (even if not the same) are at risk against the negative
health effects of climate change. Low-income countries will face this risk
intensely.
• Those living in cities, the poor, the elderly, children, traditional societies,
those who make their living with farming and those living in the coastal
area are particularly at risk.
• It is not possible to fully protect even the economically developed
countries from diseases and injuries caused by climate change.

5.2. Things to be able to done about Climate Change and Health

Below are the points that will reduce the health effects of climate change and
eliminate worries:

• Monitoring studies should be conducted for food, temperature and

waterborne diseases.
• Immigrants and asylum-seekers who are considered as vulnerable groups
should be followed up with a good monitoring program.
• Trainings should be accelerated, trained manpower capacity in the
field of climate change and health should be increased and a common
language should be established on impacts.
• Studies should be made to reduce the vulnerability of vulnerable groups.
• The Ministry of Health should mobilize existing infrastructure to identify
and implement early warning components of the effects of climate
change on health.
• Database should be developed to reveal the relationship between climate
change and health.
• Awareness-raising activities should be carried out at the social and
individual level in order to avoid the negative effects of climate change
on health.
• Healthcare physicians and other healthcare professionals should know
the acute and chronic effects of climate change on health, and precautions
should be taken with the approach of preventive medicine.
• In order to be protected from allergens caused by global warming
and climate change, it is necessary to stay away from substances such
as cigarette smoke, chemicals, aerosols in closed living places such as
homes, schools and workplaces.
• Drinking and potable water tanks should be constructed to prevent
contamination. Unsuitable ones must be improved.
• Decision makers should focus their attention on protecting human health
against a high level of climate change.
60
 • While producing solutions to the negative effects of climate change on
health, solutions covering global health risks and all segments of the
society should be produced.
• Cooperation between all parties should be developed and capacity
should be increased. Interdisciplinary and cross-sectoral studies should
accelerate.
• Continuous data collection and monitoring infrastructure should be
strengthened to monitor the climate change process more actively and
to develop action plans.
• All industry leaders who are parties to the subject should prepare their
action plans for possible situations related to their fields.
• Emergency response mechanism should be developed in a more
integrated way.

Ministry of Health General Directorate of Public Health and Head of Turkey

Institutes of Health, is doing very serious study and projects on climate change
and health effects. It is very important to have scientific studies, projects and
dissertation done in the following periods and take it to a much higher level:

• Economic dimension of climate effects on health

• Monitoring studies and evaluation of data for climatic diseases
• Public health infrastructure and development studies
• Early warning systems and disasters preparedness
• Emergency response systems
• Sustainable conservation programs
• Diseases related to travels
• Diseases transmitted by vectors
• Cancer cases and climate relations

In addition, a separate AFAD-like structure should be established within the

Ministry of Health to address these and similar issues more strongly, to plan,
monitor, supervise and manage action plans.

As a result, Turkey has made very serious efforts in the process of adaptation
to climate change in the last 15 years and continues to do so. A National Action
Plan on the effects of climate change on health has been prepared by the Ministry
of Health and studies are being carried out in line with this action plan. As
seen in the Covid-19 process, Turkey’s health infrastructure is much better level
of health infrastructure in many developed countries and increasingly being

61
developed. Thanks to having a strong health infrastructure in the disaster and
epidemic situation can take an active and fast-paced action, because of trained
human capacity, the effects of climate change on health are expected to be felt in
the minimum level of Turkey.

62
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 TÜBA COVID-19 GLOBAL OUTBREAK
ASSESSMENT REPORT
TÜBA - COVID-19 Global Outbreak Assessment Report,
which has been presented as open source on April 17, 2020
and published with the recent data on June 4, 2020, can be
accessed from libraries and TÜBA internet site (www.tuba.
gov.tr/en). The report, consisting of 5 parts, is prepared with
an interdisciplinary approach.

i. Terminology, Definitions, History and Current Situation

in Turkey

ii. Process Management of Pandemic, Interaction of

Science Disciplines, and Information Technologies

iii. Social and Economic Projection in the Post-Pandemic

Period

iv. COVID-19 Data Tracking Platforms

v. COVID-19: Scientific Approaches

 ANATOMY OF THE PANDEMIC
THE FUTURE OF HUMAN and SOCIETY
Editors:
1) Prof. Dr. Muzaffer Şeker
TÜBA President
2) Prof. Dr. Ali Özer
Ministry of Health, Scientific Committee Member
3) Asst. Prof. Cem Korkut
Ankara Yıldırım Beyazıt University

The book consists of 49 thematic articles. There are

projections for a wide range of post-epidemic periods, from
healthcare to education, information technologies to political
science, economics to international relations, trade to
philosophy, artificial intelligence studies, sociological analysis,
environment and agriculture, space, and polar studies.

The publication status for English version: In press