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article 21

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European Journal of Population15:241\u2013278, 1999.
\u00a91999Kluwer Academic Publishers. Printed in the Netherlands.
Economic Growth or Survival? The Problematic
Case of ChildMortality inTurkey
Institut national d\u2019\u00e9tudes d\u00e9mographiques, 133 Bd Davout 75980, Paris Cedex 14, France
Received 14 September 1998; accepted in \ufb01nal form13 March 1999
The Sons of Edward sleep in Abraham\u2019s bosom (iv.iii.38)
WilliamShakespeare,The Tragedy of King Richard the III

But who am I?
An infant crying in the night
An infant crying for the light:
And with no language but a cry

AlfredTennyson,Memoriam, xxxvi.
Behar, C., Courbage, Y. andG\u00fcrsoy, A., 1999. Economic Growth or Survival? The Problematic Case
of ChildMortality in Turkey. European Journal of Population15: 241\u2013278.
Abstract.Turkey is a country which is demographically unclassi\ufb01able because its persistently high

infant mortality is out of line with its socio-economic indicators and its low fertility. The rapid modernisation of Turkey over the last three decades, which might have been expected to have had a favourable effect upon infant survival, has not in this respect lived up to expectation. The stresses resulting from economic growth and the high level of female workforce participation have perhaps tended to distract women fromchild care. Also, neither Ottoman nor republican Turkish traditions have encouraged an enhancement of the status of childhood.

Unconventional sources: ethnology, literature, cinema, are deployed here to construct an impres- sion of the cultural environment of the mothers, fathers and families of dead children. Change of attitudes, very slow as far as childhood is concerned, have not yet caught up with the transition in fertility. An infant mortality rate of 53 per 1000, accompanying a total fertility rate scarcely higher than 2, is a combination dif\ufb01cult to \ufb01nd anywhere else.

Behar, C., Courbage, Y. et G\u00fcrsoy, A., 1999. Croissance \u00c9conomique ou Survie? Le Probl\u00e8me de
la Mortalit\u00e9 Infantile en Turquie. Revue Europ\u00e9enne de D\u00e9mographie15: 241\u2013278.
R\u00e9sum\u00e9.La Turquie est un pays inclassable en raison de sa mortalit\u00e9 infantile qui a \u00e9t\u00e9 et continue

\u00e0 \u00eatre tr\u00e8s \u00e9lev\u00e9e, alors que les indicateurs socio-\u00e9conomiques et la f\u00e9condit\u00e9 auraient pr\u00e9sag\u00e9 une meilleure survie. La modernisation rapide de la Turquie depuis trois d\u00e9cennies, que l\u2019on aurait pu croire plus favorable au sort de l\u2019enfant, n\u2019a pas rempli tous les espoirs. Le stress engendr\u00e9 par la croissance \u00e9conomique et la forte participation f\u00e9minine a peut-\u00eatre emp\u00each\u00e9 les femmes de pr\u00eater une attention suf\ufb01sante \u00e0 l\u2019enfant. Mais les traditions ottomane puis r\u00e9publicaine n\u2019ont pas contribu\u00e9 \u00e0 une valorisation suf\ufb01sante de l\u2019enfant.


Le recours \u00e0 des sources non conventionnelles: ethnologie, litt\u00e9rature, cin\u00e9ma ont permis de don- ner une image de l\u2019atmosph\u00e8re culturelle dans laquelle beignent les m\u00e8res, p\u00e8res et familles d\u2019enfants d\u00e9c\u00e9d\u00e9s. Les changements de mentalit\u00e9s, trop lents en ce qui concerne l\u2019enfance, n\u2019ont pas encore rattrap\u00e9 la transition de la f\u00e9condit\u00e9. Un taux de mortalit\u00e9 infantile de 53 pour mille accompagnant une f\u00e9condit\u00e9 \u00e0 peine sup\u00e9rieure \u00e0 2, est une con\ufb01guration qui se rencontre dif\ufb01cilement ailleurs.

1. Introduction

Child mortality in Turkey remains a puzzle. Ever since it became measurable and comparable \u2013 since thirty years \u2013 it has been very high compared to Turkish adult mortality, or child mortality elsewhere. Demographers, doctors and sociologists have failed to explain why, but have repeatedly asserted that it was Turkey\u2019s main demographic and medical challenge (Bulut et al., 1991; Tun\u00e7bilek and Ulusoy, 1988; Behar, 1975).

This high level con\ufb02icts with other demographic and socio-economic indicators. The existence of speci\ufb01c endemic early childhood diseases, climatic variations from the bitterest cold to the most sweltering heat, effective medical care and between-region development gaps have all been unconvincingly offered as explan- ations (Shorter and Macura, 1983). \u201cThe link between income level and mortality during economic development mayvary, but whySri Lanka with a per capita GDP one thirdthat of Turkey should have half its infant mortality remains unexplained\u201d say sociologists (Aksit and Aksit, 1989).

By international organization de\ufb01nitions, Turkey left the \u201cdeveloping\u201d country status behind more than two decades ago. Average annual GDP growth of almost 6% in 30 years, industrial levels of production and exports, place Turkey in the front ranks of South-East European andMiddle Eastern countries. Illiteracy is low among women, very low among men. There is more or less universal primary education, high secondary education enrollment, and decent medical coverage. These are all established facts. The demographic indicators are good and fertility declining so rapidly that the 2-child level will be passed by about the year 2000. Broadly speaking, Turkey seems to have completed its demographic transition (Behar, 1997).

Turkey\u2019s high economic growth and rapid modernization, at whatever pain- ful cost, are undeniable facts. But has this record pace of modernization been suf\ufb01ciently internalized by society? Has it actually worked against the intended purpose, against children? The outcome often perverts or thwarts the aim. The upsurge inIslamism inTurkeyduring the Eighties andNineties was undoubtedly a political backlash against unbridled westernization and of\ufb01cial secularism, as well as re\ufb02ecting a global trendtowards revivalism in religion. One reason whyTurkish infant mortality is so much above the norm may be because modernization has not lived up to expectations. Another may be that children are traditionally paid scant attention. If so, opposing trends would paradoxically have worked to the same end.


Research on the determinants of child mortality has focused chie\ufb02y on their intermediate health variables, through their physiological or medical effects. Vari- ables like dietaryhistory, duration of breastfeeding, infant morbidity, the incidence and role of respiratory, intestinal or other infections and diseases, have all been subjected to detailed statistical and epidemiological analysis (Martorell and Ho, 1984). Socio-economic variables have been compared with the mortality rate, preg- nancy ratio, parity, household size and structure, income, education and occupation (Mosley and Chen, 1984). Despite this, the precise effect of these socio-economic variables on the effective death rate remains unclear.

Also, how these variables articulate with cultural attitudes and practices in the broad sense, as well as with policies and broad ideologies, remains largely unexplained to the extent that these determinants of child mortality, advanced as authoritative explanatory variables, are a kind of black box which has not yet yielded up its secrets (G\u00fcrsoy, 1992). The intangible social environment, that which is not immediately measurable, may be a more promising \ufb01eld of investigation to explain this mortality (Caldwell, 1986).

Infant and child mortality rates have long been regarded as simple statistical indicators, as consequences of a country\u2019s development level andthe effectiveness of its health policy (Rozensweig and Stark, 1997). But child mortality is also and above all a silent and signi\ufb01cant re\ufb02ection of the life styles of the communityunder study, the relative values attached to gender and age, and the cultural norms gov- erning the balance of power between age groups and generations. Often, it re\ufb02ects the parents\u2019 lackof parenting skills and ignorance, the mother or family\u2019s ignoring of instructions in tending a sick child, and even, in some cases, an involuntary but nonetheless fatal neglect (Scrimshaw, 1978). But it could in reality be a matter of shifting gender- and age-speci\ufb01c hierarchies, powers and balances.

Scrimshaw shows in the case of LatinAmerica that there is a degree of \u201cavoid- able infant mortality\u201d attributable to \u201cselective neglect\u201d and that the \u201cdegree of unwantedness\u201d of children is a factor in infant mortality (Scrimshaw, 1978).These attitudes, which are only very remotely and indirectly re\ufb02ected by the of\ufb01cial \ufb01g- ures, are enshrined in a tangle of what maybe nebulous and diffuse values, complex norms and breaches of those norms. With childmortality, too, we enter the realm of the unsaid, the taboo. Surrounded by such silence, how are we able to identify the values, cultural attitudes and practices which may be at the root of this abnormally high mortality?

Silence inTurkey starts with the source data. Vital records are very incomplete. Registration data, even in cities and large towns, cannot be used as they stand to calculate mortality, still less infant mortality (Bulut et al., 1991). We therefore chose a number of usual alternative sources \u2013 censuses, surveys, etc. \u2013 and non- traditional, not to sayunusual, sources for demographers, falling neither within the \ufb01eld of demography nor that of other social sciences strictly speaking. The idea was to delimit a cultural atmosphere, a mesh of diffuse reactions, approaches and attitudes about children and death. Where complex human problems are involved,

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