Turkey has been contact tracing for a century. That offers lessons and perils.

Istanbul — On a sticky summer morning, the air thick with haze, Seher Odabaşı starts her work day in her office with the windows open. She turns on her computer and studies the screen, which displays row after row of names. Today’s chart contains about 50 cases, nearly 10 times as many as there were a couple months ago.

For Odabaşı, the list fills her with anticipation and uncertainty about what the day will bring because she must track down these people who are scattered throughout their neighborhood. It’s her job to keep COVID-19 from spreading.

As she heads out into the thrumming streets in the city’s Kadıköy District, Odabaşı scans the names on her electronic tablet, the connections, and the addresses. Before each visit, she pulls a white protective suit over her cat-print scrubs, trades her thick-rimmed glasses for goggles, and grabs her medical kit with her gloved hand.

Odabaşı is a contact tracer, a member of one of roughly 9,300 teams that the Turkish government has deployed during the outbreak. Situated at the crossroads of Europe, the Caucasus, and the Middle East, Turkey seemed a likely hotspot for a disease spread by international travel and social mixing. But five months after a modest early surge, daily cases remain low and steady, and the nation doesn’t make the list of the top 100 in cases per capita.

Part of this success stems from Turkey’s long legacy of contact tracing, one of the main tools public health officials use to contain outbreaks. While countries such as the United States have struggled to implement effective programs and often depend on volunteers, the contact tracing system in Turkey dates back nearly a century, when it was developed to fight measles and tuberculosis.

“There were able physicians working in the Ministry of Health responsible for controlling infectious diseases since the foundation of the Republic [in the] 1920s,” says Necati Dedeoğlu, a retired professor from the country’s School of Public Health, which was originally attached to the Ministry of Health.

(Related: The magnitude of America’s contact tracing crisis is hard to overstate.)

These medical detectives not only track down the contacts of a person who has tested positive for COVID-19—testing and isolating the exposed to prevent the further spread of the disease—but also become the first point of reference for care. They bring medicine to people required to stay at home and call them daily to check on their health and to make sure they are abiding by the quarantine rules.

Despite that highly professional approach, the authoritarian tendencies of Turkey’s current leadership can be a double-edged sword, with the influence of politics sometimes overshadowing the recommendations of public health officials. Some doctors question the official tally of 340,000 cases and 9,000 deaths, and police enforcement of stay-at-home orders has become a regular tool for contract tracers, at times to the dismay of the average citizen.

Odabaşı takes pride in her new job, but it can feel risky at times. Many citizens value the contact tracers, but recently some have responded with hostility.

“In some other parts of Istanbul, people got physically attacked—so many times. Someone had their nose bleeding after an attack,” Odabaşı says. “People [are] getting angry for no reason.”

Tracing and policing

Turkey’s ability to manage the pandemic has its roots in American training initiatives and institutions, a small irony given the struggles in the United States. American expertise helped build the first School of Public Health in Turkey, which was funded in part by the Rockefeller Foundation.

Between 1923 and 1937, protective public health services—such as contact tracing—were codified into Turkish law. Many of the early epidemiologists in Turkey were trained in England and the United States, and they joined the School of Public Health when it opened in 1941. Equipment, training, and teaching staff flowed from the U.S. into Turkey. A decade later, some Turkish public health specialists visited America to train at Johns Hopkins University in Baltimore or with the U.S. Centers for Disease Control and Prevention.

“After the 1970s, all epidemics were attended by public health specialists from the School of Public Health,” says Dedeoğlu, who is also the former deputy head of the Ankara Health Ministry. “I was one of them.”

After the school closed in 1983, the Ministry of Health took on the duties of tracing disease outbreaks. About a decade later, it launched a department dedicated to emerging epidemics, which started two-year training courses for field epidemiologists with the help of the CDC and the World Health Organization.

“Your CDC is an institution which every country is looking up to...You have all the specialized manpower to be able to control it,” Dedeoğlu says. For example, the CDC has deployed about 25 percent fewer staff during the COVID-19 pandemic relative to the 2014-2016 Ebola outbreak in West Africa.

But even in a country where fighting infectious diseases has long been a national priority, the COVID-19 pandemic has required additional tactics.

In the beginning, the Turkish government set up a scientific committee of clinical doctors and infectious disease specialists to advise the Ministry of Health.

“This science committee published national guides for hospitals, for passengers in the planes, and for morgues,” says Neslihan Uyar, the head of the Kadıköy District Health Ministry. “All the treatments and the medicines that are given to the patients had to be done according to the guides. Throughout Turkey, these guides were being implemented.”

Limited contact tracing began in January after COVID-19 broke out, but Turkey’s established contact tracing system had to quickly adjust once the scale of the pandemic became clear. By March, the government reassigned doctors, dentists, and other medical professionals and trained them for contact tracing duties to cope with the increased demand. With certain medical professionals such as dentists in lower demand while people sheltered at home, it made sense to shift them to contact tracing duty.

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Odabaşı’s team in Istanbul’s Kadıköy neighborhood consists of mostly young doctors and dentists working in daily shifts to trace and test residents. Turkey’s centralized health-care system allowed doctors like Odabaşı to be rapidly reassigned to contact tracing duty.

The 26-year-old Odabaşı graduated from medical school just two years ago. Until recently, she worked with city health inspectors to make sure the food in school cafeterias met nutritional guidelines. But in March, she was reassigned. “I felt like a baby being thrown into a pool to learn how to swim,” she says.

“We are doing contact tracing at a much larger scale for COVID-19 with many more health workers assigned than we used to do for other infectious diseases,” says Binnur Erdem, the head of contact tracing in the Kadıköy District Health Ministry.

A computer network supports these activities by connecting hospitals and testing centers to the contact tracing divisions in the local health ministries. This system also pulls information from the Turkish social security programs and a new registry to track travel. All Turkish citizens who want to travel must sign up through an app or text their information to a government phone number. Similar to digital contact tracing in democracies like South Korea, the Turkish government uses the information to pinpoint anyone that may have interacted with an infected person on a plane, at work, or in their apartment building.

As the pandemic drags on, though, the work has become harder. One day, Odabaşı called a woman in Kadıköy as part of a daily checkup and to schedule a time to drop off medicine. But the woman wasn’t at home.

“You shouldn’t go to the market!” exclaimed Odabaşı when she finally reached the woman by phone. “You were in contact with someone! You’re under quarantine!”

This lack of compliance has become more common as people become fatigued with coronavirus restrictions. Odabaşı says she has uncovered such absenteeism at least 10 to 15 times over the summer. When that happens, Odabaşı files a report with the police, who then issue a fine.

Odabaşı sometimes uses the threat of law enforcement to keep people in line. “Having an authoritarian regime, the police card always works. Unfortunately. That's the only positive side,” says Odabaşı. “[People are] very afraid of the police force, or getting in trouble with the police.”

Learnable lessons

While other countries could learn from Turkey’s successes with contact tracing, they should also heed its struggles to cope with the pandemic. Dedeoğlu believes it’s essential for political leaders to listen to the experts.

Government oversight has, at times, complicated Turkey’s tracing process. Early on, the Ministry of Health only accepted COVID-19 tests conducted by their own facilities, so other positive tests from universities and laboratories were not tracked by the contact tracers. There have been suspicions since early in the pandemic that the government has been keeping the case count artificially low, and on October 1, the Health MInister Fahrettin Koca said that Turkey has only been accounting for symptomatic cases since late July rather than also including symptom-free people who test positive. A leaked document from September 10 indicated that the case count was 19 times higher than the official numbers released that day.

(Related: How the Nagorno-Karabakh conflict has been shaped by past empires.)

“[The Ministry] does not always do what the scientific board says,” says Dedeoğlu. “More than that, the Ministry is not transparent. They do not provide us, public health specialists, with data. We don't know how many cases exactly there are in Turkey.”

In a country that is deeply politicized, sometimes decisions about public health are made based on political expediency instead of scientific data. On Friday, April 10, the government announced late in the day that the first lockdown would go into effect over the weekend and all shops would be closed. Panicking, thousands of people flooded onto the streets and into their bakeries and markets to stock up, creating a spike a few weeks later in the number of cases. That decision, and its ill-advised rollout, was made without input from the ministry’s scientific committee. Politics also trumped public health advice when a world-renowned museum—the Hagia Sophia—was reverted to a mosque with great fanfare on July 24, a decision made by the government to appeal to its religious base. More than 350,000 people attended the opening ceremony, many of them unmasked, and official cases spiked soon after. And early in the summer, the committee’s recommendation not to “normalize,” or reopen, on June 1 was disregarded, and much of the country resumed business on that date.

(Related: Hagia Sophia stripped of museum status, paving its return to a mosque.)

“The ministry doesn’t like us, the public health specialists, because we speak the truth,” says Dedeoğlu.

For now, Turkey’s contact tracers continue to work diligently, often without much appreciation for their role, as the cases in the country creep up. At 8 a.m. on a Sunday morning, few people stir in the neighborhood of Fikirtepe, as two women in white hazmat suits arrive on the quiet streets. Walking past apartments that seem to lean into each other and ignoring the steady gaze of an inquisitive woman peering out between strung-up laundry, the contact tracers are there to swab two generations of women in one family. As the mother holds her daughters steady, they squirm and cry after the swab goes up their noses. The youngest, tear-stained, glares at the contact tracers. But this is their job, and it’s necessary to keep the coronavirus in check.

“I enjoy it. I never thought about quitting,” says Odabaşı. For every difficult situation, there are the people who appreciate the demanding job the contact tracers perform.

“I love when people are like, Oh, thank you for doing this for us. Thank you for coming to our house and taking care of us.”