Tracking disease with laptops and dial-up modems

Monday, January 15, 2007

DOĞUBAYAZIT ? Turkish Daily News

Twice along the 170 kilometer road from Van to Doğubayazıt, military checkpoints stopped the minibus. The soldier opened the bus's side door and said politely, �İyi bayramlar.� At the second stop, a similar soldier, a similar greeting, �İyi g?nler.� Both checkpoints collected ID cards.
�This is normal for us,� said Baram, a local businessman and translator in Doğubayazıt. Still, at each checkpoint, the men in the bus fidgeted in their seats and sat up straight.
Epidemiology and public health demands detailed information and communication. Otherwise, understanding how a disease spreads through a community is little more than guesswork. Where there is censorship and suppression of information, scientists can't get a clear picture of what is happening during a disease outbreak and people are at risk. Too often there is political interference with vital information during an outbreak.
�We live in an open prison,� said Mukkades Kubilay, mayor of Doğubayazıt, sitting in her very comfortable living room. The discussion of last year's bird flu outbreak had quickly turned to politics. �The officials in Ankara do not care about eastern Turkey,� she continued. Properly, as mayor Kubilay represents the very pro-Kurdish Democratic Society Party (DTP), all her reminiscences of last year's bird flu outbreak were presented in terms of the area's larger Turkish and Kurdish politics.
Almost everyone interviewed in Doğubayazıt said mutual suspicion and lack of trust between a predominantly Kurdish population and the Turkish state got in the way of the public health response to the bird flu outbreak. One year ago, this month, four children died in the outbreak. Around the world, the information revolution has changed how diseases are monitored and reported. The Internet has empowered people to get around government attempts to suppress information of a disease outbreak. But this power is still limited by government controls on information and communication.
Ali, a young IT whiz who worked in a Doğubayazıt Internet caf?, spoke about the beginning of the bird flu outbreak, when the H5N1 virus had begun to infect chickens. �I can say that 80 percent [of local people] didn't care about [the government's warnings about sick birds]. They didn't believe it. In the villages, not in Doğubayazıt, but in the villages, when the government came to cull the chickens, people killed and cooked their chickens so the government wouldn't get them.�

�Most people here thought it was a political subject about Kurdish people,� said Ali's colleague Hasan, �And so they didn't believe and continued to eat their chickens. At first we thought that, but then the three [Ko?yiğit] children died, and people stopped eating the chicken. We saw on television that in China and Indonesia people had also died, so we believed.�

Public awareness during a public health emergency depends on getting credible information to people. Health officials around the world cite the Chinese experience with SARS. In 2002 when SARS began to infect people in southern China, the Chinese government initially tried to suppress information about the disease, displaying the same instinct some Turkish officials had during the bird flu outbreak. The Internet and SMS text-messaging allowed Chinese civilians to overcome the censorship and get the word out, both within China and to the world, that an unknown disease was killing people.

�SARS was only acted on after it received high exposure through the Internet. Indeed, Internet attention was the only reaction possible until the Government of China was willing to recognize it. So this was a case of the government and especially local officials not just being ignorant of matters, but of suppressing matters,� said Dr. John Read, Director-General of Dangerous Goods and a lead pandemic influenza planner for the Canadian government. He continued: �To make progress there must be reports and the reports must be checked. If either of these two does not happen, that could be called a failure of the authorities. In such an instance the population can become informed [through the] Internet and blogs and the resulting attention can affect what authorities do. It is almost direct democracy, which provides for a more responsible and responsive �government.'�

A black humorist named his business the Vir?s Internet Caf?. It is located down a side street in Doğubayazıt, and is heated by a woodstove; still, everybody keeps his winter jacket on. Trying to log onto Kurdish Web sites such as,, or undertaking a Wikipedia search for �Kurdistan� all generate the following message: �Bu Sayfa Yasak Siteler Listesinde Kayıtlı ve Bloklandı.� Translation: �This site is listed as forbidden and has been blocked.�

Reporters sans Fronti?res, the independent advocacy group that campaigns for and monitors freedom of the press, reports that in Turkey �Cybercaf? owners were ordered in December 2003 to install filters to block access to pornographic Web sites and to prevent their premises being used to promote gambling, pornography, political separatism or any challenge to the structure of the state. Two-thirds of Internet activity in Turkey occurs through the country's 15,000 or so cybercaf?s.�

At mayor Kubilay's house, DTP officials demonstrated how satellite television signals from Kurdish channels ROJ and Mesopotamia were blocked. �But not in the villages, only in the cities,� a DTP official said. �Because people in the cities know what they can do,� he explained, somewhat conspiratorially. The Turkish, EU, U.K., and U.S. governments allege that Danish-based ROJ is a �mouthpiece� of the illegal Kurdistan Workers' Party (PKK), an issue that made headlines in 2005 when Turkish Prime Minister Recep Tayyip Erdoğan boycotted a news conference with Danish Prime Minister Anders Fogh Rasmussen because a reporter from ROJ would be attending.

A new and important type of epidemiology is being carried out on the internet - one that depends on access to media information and suffers when information is censored. �Blogs and online forums are part of the new sources if communication and information,� explained the Editors of The Effect Measure Blog in an email exchange. �They have a widely distributed cadre of subject specialist �stringers' all over the world, obsessively combing local newspapers and net sites for information. ? In that sense they can be more timely than most local or even national news outlets. Few, however, do original reporting, so they are limited to existing sources of information. They can pull disparate pieces together, stimulate further inquiry and alert authorities wise enough to use them as an additional information source. I know that our blog is read in health departments at all levels, including the highest levels of the U.S. health establishment and CDC [Centers for Disease Control]. In our case, its major effect may be to change the conversation, directing it to places it wouldn't otherwise go or to highlight a fact that would otherwise have escaped notice of a busy health official. It also can put pressure on them for greater transparency and make them more circumspect in how they �spin' things because they know it will be examined by knowledgeable people. Blogs and online forums like Flu Wiki, then, are �just' another source of information to be used with judgment but also an unusually powerful one that has never existed before.�

Laws that kept the Kurdish language out of public institutions, such as hospitals, are being slowly relaxed. A few years ago, Hasan said: �I had to translate if my mother went to the hospital. Even if the doctor is Kurdish and speaks Kurdish, he couldn't speak it to my mother because hospitals are state institutions. For all Kurdish women who didn't speak Turkish someone would have to translate for them. But now people are allowed to speak Kurdish. It's become something normal.� And Ali said: �My nephew Uğur didn't know Kurdish until last year, so I taught him. My mother can't speak Turkish. And my niece and nephews can't speak Kurdish. It is a problem.�

Kurds in Turkey have done well by abiding by Atat?rk's famous formulation �Happy is he who says, �I'm a Turk.'� İsmet İn?n?, Atat?rk's right-hand man and Prime Minister (1923-1937, 1961-1965) and President (1938-1950), was a Turkish nationalist with Kurdish origins. In an interview, a young man said, �Find me one Kurd who was also an Arab nationalist,� implying the dual identity was only possible in Turkey. It is no coincidence that Atat?rk's phrase is painted in huge, white, haphazard letters on a cliff face that overlooks Van.

During the bird flu outbreak, Kurdish speaking doctors were enlisted to help and Kurdish was spoken in the hospitals in Doğubayazıt and Van. �It was quite effective,� said Dr. Nikki Shindo, from the World Health Organization headquarters in Geneva. Dr. Shindo was part of the international response team sent to Van during the outbreak. Others have said these measures did not overcome the language barriers well enough to satisfy a first principle of public health: that information be accessible to those it is intended to help.

In a Doğubayazıt restaurant, on hearing �Sağ ol,� the owner said: �Sipass, sipass, don't speak Turkish, only police and soldiers speak Turkish.� But not just police and soldiers it turns out. Earlier in the same day, a few blocks away, there was a DTP-sponsored Bayram concert of Kurdish films, songs and amateur theater. Some 12 year-old girls waved �V for Victory� fingers to a song that a translator said was about Abdullah ?calan, theimprisoned leader of the PKK. But Mukkades Kubilay, the DTP mayor of Doğubayazıt who had earlier called eastern Turkey an �open prison,� made her address in Turkish.

On Jan. 1, 2007, Zeki and Marifet Ko?yiğit were standing in the snow at Doğubayazıt cemetery and praying at the graves of their three children, Mehmet Ali, Fatma and H?lya, who each died of the bird flu. It was the one year anniversary of Mehmet Ali's death. Around the same time on the same day, mayor Kubilay was across town opening a new picnic park that covered a large traffic island. Snow covered in winter, it would be a green space in summer. The municipality had named the park after Ehmed? Xane (1651-1707), a Kurdish philosopher from the area. (In Doğubayazıt, Xane's picture is more conspicuous than Atat?rk's.) But as there is no �X' in the Turkish alphabet, �Xane� is clearly a Kurdish name. Ms. Kubilay said the police insisted that the sign installed over the entrance to the park be re-spelled (and rebuilt) as �Hane.� That night the police took the sign down for Ms. Kubilay at no charge. But on a neighboring traffic island there was a seated statue of the same philosopher. A poem in Turkish on the plaque embedded on the statue base was attributed to �Filozof Xani.�
At the park, Baran, the local businessman who translated for the mayor, suggested not to take too many pictures because the �secret police� might be watching. And later, when shown an article from a major western magazine about the Turkish military's conflict with the PKK, Baran took the article, wrapped it in newspaper, and hid it in a desk at the front of the restaurant. Were these sincere expressions of caution or a bit of playing-up for a journalist? The most likely answer is both. In 1999, the Bulletin of the Atomic Scientists ran a report with the following passage about police surveillance in ?izre (in next door Şırnak province). �The hotel clerk complained that he had to inform the police of all movements by reporters: �When you get up, when you go out, and when you return. It's incredible,' he said. �We have to telephone three different places each time: the Army, MİT (military intelligence), and the regular police. Why can't we just call one place, and let them handle the rest?' What he really wanted was a sort of clearinghouse for the surveillance of the press?�
Leaving Doğubayazıt, on the way back to Van, the minibus passed through the two military checkpoints without being stopped; the driver waved to the soldiers. A tank overlooked one checkpoint, its turret aimed at the rock face of a cliff.
Note: At their request, people identified by only first names have been given pseudonyms.
Tomorrow: What if we all take Tamiflu?

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