This article examines how mainstream Turkish political actors have perceived, discussed, and responded to the uneven geographical distribution of physicians, a chronic problem in the state health care provision since the early years of the Republic of Turkey. The physicians, both general practitioners and medical specialists, have been—and still are—concentrated in the major urban areas of western Anatolia, like Istanbul, Ankara, and Izmir at the cost of rural areas and the east, especially the predominantly Kurdish southeast region (Taylor, Dirican, and Deuschle Reference Taylor, Dirican and Deuschle1968; Vujicic, Sparkes, and Mollahaliloğlu Reference Vujicic, Sparkes and Mollahaliloglu2009; Cörüt Reference Cörüt2023).
Compulsory public service (CPS) has been one of the major policy tools used by Turkish governments to tackle this distribution problem (as also for other groups of state employees, for example, judges, teachers, and nurses). Five CPS laws posting physicians in areas of shortage have been issued in the history of the Republic, the first when it was founded, in 1923, and the last, still in force, in 2005. Discussions around the issue go beyond the logistical problem of health care provision, however. They involve the idea of a unitary Turkey, the Turkish nation, and how to close the gap between the idealized imaginary of these and defective reality; they raise concerns about the model citizen, rights and duties, and how individual and national interests should be reconciled.
In other words, given that the subject of politics is “the subject of the lack,” committed to the filling of lack in a process of identification (Laclau and Zac Reference Laclau, Zac and Laclau1994), the legislative work and discourse of the legislators of the CPS laws, insofar as they have been—are—oriented to defining a “lack” (in Turkish national order) and fixing it, directly pertain to “interpellating” (Althusser Reference Althusser1971, 170) Turks as subjects acting with full national consciousness and responsibility. Thus, this article on the legislative works and discourses around physicians’ CPS provides new insights into Turkish nationalism(s) and enriches our understanding of how Turkish nationalism(s) shapes social policy process, about which we know very little. It presents a detailed historical review of the issue through legal documents (reports, bills, and laws) and deputies’ justifications and disputes, and it examines the discursive strategies through which CPS has been forwarded, legitimized, and delegitimized in Turkish mainstream politics. First, a theoretical framework for the analysis of the politics of CPS is outlined. Then, the history is recounted—through four periodizing, chronological sections—named Kemalist, Democratic Party, Military Dictatorship, and AKP—before a brief conclusion.
Theoretical Framework
Mode of Exchanges: State, Nation, and Nationalism
The theory framing this analysis centers on Kojin Karatani’s (Reference Karatani2014) novel approach to (modern) social formations named “Capital–Nation–State.”Footnote 1 Karatani reinterprets a Marxian model of base and superstructure by retaining the determination by economic level but without limiting the economic base to capital, and he makes a distinction between different forms of economic base, or “modes of exchange.”
Karatani (Reference Karatani2014, 10) accounts for the autonomous realities of state and nation, two of the most important so-called superstructural elements, with reference to their being “rooted” in their “own distinct mode[s] of exchange.” Even the state, which one may easily identify with a one-sided imposition of sovereignty (enforcement, oppression), is based on a form of exchange (plunder and redistribution). That is, plunder (e.g., income forcibly gained through taxation, etc.) cannot be sustained in the long term unless it is at least partly redistributed: “[T]he dominant community cannot simply carry out acts of plunder but must also give something to its targets: it must protect the dominated community from other aggressors, as well as foster it through public works, such as irrigation systems. Herein lies the prototype for the state” (Karatani Reference Karatani2014, 6).
Nation, as well as state, according to Karatani (Reference Karatani2014, 209–16), is based on a mode of exchange: gift- and counter-gift reciprocity. This reciprocity, which is discussed in detail by Marcel Mauss ([Reference Mauss1954] 2002), forms the material skeleton of community. When the communitarian structures in a society, from autonomous village economies to neighborhoods and moral economies, are targeted and dissolved—by the collaboration of capital, the modern form of commodity exchange, and the bureaucratic state (the modern form of plunder and redistribution)—the reciprocity principle of community asserts itself in a new form, as nation, to reproduce itself, albeit as an imaginary.Footnote 2 Against this conceptual background, Karatani (Reference Karatani2014, xiv) defines the modern social formation as a capital-nation-state trinity dominated by capital (commodity exchange):
This is a mutually complementary apparatus. For example, a capitalist economy allowed to take its own course will inevitably result in economic inequality and conflict. But the nation, as something that intends communality and equality, will seek to resolve the various contradictions and inequalities introduced by the capitalist system. The state, in turn, realizes this intention through such measures as taxation, redistribution, and various regulations. Capital, nation, and state are distinct entities, each operating according to its own principles, but like a Borromean knot, they are linked in such a manner that all will fall apart if any of the three is missing.
This understanding of modern social formation as an articulation of mode of exchanges is particularly useful for identifying and addressing three stages of CPS as a social policy. First, there is the problem: an uneven geographical distribution of physicians, which is an outcome of supply and demand dynamics (here, of the health-sector labor force market). This is the level of commodity exchange and economy. In response, “intend[ing] communality and equality,” nation comes to the fore and calls for the imbalance to be corrected (not directly, for example, through the pressure of mass action from below but mainly through the national-sovereignty-centered political system built on the competitive claims of the parties to represent the nation).Footnote 3 This is the stage of reciprocity and community. In response, the state intervenes (here, by redistributing physicians according to national geography to correct the imbalance via CPS laws). This is the stage of plunder and redistribution.
The present article thus explores the nature of this egalitarianism of nationalism at work in CPS for physicians in Turkey to get to the nub of the national identity issues involved. The questions addressed here are thus these: what is specifically nationalist about the egalitarian moment of Turkish CPS laws imposed on physicians, and how does this nationalist egalitarianism manifest discursively? The answer to these questions requires a detailed focus on the nature of the redistributive mechanism at work in the CPS laws. In the following subsections, therefore, I introduce first the agency and problematic of the relevant laws, next, their legitimacy, and then the variants of Turkish nationalism shaping them.
Agency and Problem
Although the shortage of physicians in certain parts of Turkey—simplified as “the East”—has always been on the agenda in local and national newspaper, radio, and television coverage, one cannot convincingly demonstrate any mass organization around the issue pressuring policy makers. Therefore, consideration is required of the concrete mechanism through which the egalitarian dynamic of nation has affected political elites such that they have perceived the unequal geographical distribution of physicians to be a serious problem. Given that the pressure from below has not been excessive, the reason why Turkish political elites have needed to openly address an uneven development issue is far from self-evident.
The answer seems to reside not in grassroots agitation but in the legislative timing of those elites. When looking at the dates of the enactment of the CPS laws, one observes that they were all enacted by the then government at critical junctures in the political history of the Turkish Republic, many of which we can call “passive revolutions” (Yalman Reference Yalman2002; Tuğal Reference Tuğal2009). The first CPS law was enacted in 1923, the year of the promulgation of the Turkish Republic by Kemalists, Turkish nationalist modernizers replacing the Sultanate and Caliphate. The second CPS law was enacted in 1932, in the wake of the government’s establishment and closure of an opposition political party for the 1930 election, which thus constituted a democratic limit and implicit challenge to its legitimacy, as well as the subsequent transition to statism as a socioeconomic strategy. The third CPS law was enacted by the center-right Democratic Party in 1952, shortly after its 1950 election victory, which marked the end of the Kemalist one-party system (1925–1946) and the start of the multiparty period. The fourth CPS law was enacted by the military council in 1981, following the (September 12) 1980 coup d’état. And the final, most recent CPS law, still in force, was enacted in 2005, two years after the coming to power of the present conservative-Islamist government of the Justice and Development Party (Adalet ve Kalkınma Partisi, AKP) when it was still vulnerable to the Kemalist military and judiciary and required continuing mass support to establish its authority.
Legitimacy
To define the nature of redistributive justice of the nation-state that has been operative in the CPS laws, one is led directly to the question of legitimacy because what are forcibly redistributed via CPS laws are not goods but physicians, some of whose fundamental constitutional rights are thereby restricted. This restriction cannot be arbitrary. It needs to be somehow justified in a political system built on the principle of popular sovereignty. Therefore, it is the specific form of the justification that shapes this nationalist egalitarianism.
When examining the legislative attempts to legitimize CPS by framing it as a fair exchange between the obliged physicians and the nation-state (and not just the simple imposition of sovereign power from above), one can detect two main ways used by legislators (in different periods and sometimes simultaneously) to charge the physicians with a debt to the nation-state, in return for which CPS is fairly asked. One involves the market and freedom of contract, and the other is paternalistic authority.
In practice, the market mechanism method means obliging medical students via a contract they sign of their free will—to do CPS for a certain period following their graduation at places designated by the health ministry (henceforth, “the Ministry”Footnote 4) in return for free accommodation and other resources provided to them as such. In fact, this contract-based model does involve a coercive dimension, as the students signing the contract prepared by the state have few options. The most promising and brightest students in Anatolia coming from unprivileged (middle/lower-class) backgrounds and seeking a channel of upward social mobility through a commitment to the medical service as physicians cannot afford the expenses of studying in the metropolis. Thus, they have had to sign the contract through which the state, requiring the necessary workforce for peripheral stations (hospitals, health centers, etc.), exploits their economic incapacity.
The legitimacy based on paternalistic authority is based essentially on plunder and redistribution. In practice, this means the imposition of sanctions on newly qualified general practitioners and medical specialists refusing a post in an underdeveloped region—by preventing them from following their profession in Turkey and/or imposing a financial penalty. Citing the redistributive expenditures of the nation-state—specifically, the gap between (public) medical school tuition fees and the actual cost of medical students to the public budget—along with parallel cases—in other countries or in other professions—this argument recognizes the state medical system’s paternalistic authority over new graduates.
In Turkey, higher education has never been entirely commodified, but neither has it been determined that citizens have the right to it free of charge. Rather, students have to pay a limited part of its cost, resulting in an ambiguity concerning the status of the state funding. If it is not exactly a commodity sold or citizenship right satisfied, then a reasonable explanation for this surplus is to see it as a gift by the nation-state that needs to be adequately reciprocated. Medical students are thus implicitly constituted as indebted to the nation-state. It is this debt that newly qualified physicians are called on to pay by the demand of CPS.
What these two legitimizing strategies have in common is their foundation on a negation of social citizenship. Were citizens granted access to tuition-free high education as their citizenship right, both these legitimizing strategies would cease to work. It would no longer be possible for the state to extract nation-building compulsory labor from the children of unprivileged families under the guise of freedom of contract or to charge the medical graduates with the debt of education incurred and demand reciprocity for the generous gift bestowed.
Variants of Turkish Nationalism
Turkish nationalism practiced through policy formulation on the uneven geographical distribution of physicians can be analyzed as having two main variants, whose distinguishing features are demonstrated in Table 1 below. In the first—Turkish nationalism centered on commodity exchange, or TNCCE—the egalitarian moment of nationalism is mediated by commodity exchange. This operates both at the level of reality and normativity. The adherents of this variant are well aware of the structural factors behind the uneven geographical distribution of physicians and employ a political economic perspective in the way they perceive and respond to the problem. From this point of view, the uneven distribution is not a moral issue that can be remedied by prohibitions and punishing physicians. Rather, it is an outcome of the supply-and-demand realities of the health labor force market that require intervention through political economic knowledge of these mechanisms and in the least costly way possible.
Table 1. Comparison of Fundamental Features of TNCCE and TNCPR
Normatively, as Karatani (Reference Karatani2014, 6) puts it, commodity exchange occurs between free individuals: it is “neither constrained by the obligations inherent in gift giving … nor imposed through violence.” In commodity exchange “the participants mutually recognize each other as free beings.” Adherents of this variant of Turkish nationalism have a normative commitment to the notion of the autonomous, self-sufficient individual. This commitment is manifest mainly in two attitudes. First, for the adherents of this variant, CPS is not necessarily the only available or most desirable instrument to remedy the uneven geographical distribution of physicians but rather an exception to the rule, at most a temporary instrument to be carefully deployed as a necessity, reinforced by incentives, and removed as soon as possible due not only to its deterring pressure on the supply side of health labor force market but also to the normative assumptions of its adherents. Second, the adherents of this variant always opt for a contract-based model of CPS for the redistribution of physicians instead of a plunder-like version based on sovereign deduction.
There are two subtypes of TNCCE, which share the same structure but differ slightly in their flexibility. One of them is pragmatic and regards CPS as an exceptional, short-term solution to a specific problem. The other is strict and closed to concessions on individual autonomy and the rights of physicians.
In the second variant of Turkish nationalism—Turkish nationalism centered on state or plunder and redistribution (TNCPR)Footnote 5—the redistribution of physicians, the egalitarian moment of nationalism, is based on plunder and redistribution involving the threat of seizure (rescinding the new graduates’ certificates) in cases of noncompliance (to take up their posting as determined by geographical need).
The adherents of TNCPR are guided by a juridical vision in which problems can be surmounted by sovereign power (prohibition, imposition, deduction). The immediate implication of this is a kind of state-centered voluntarism that denies any impersonal or structural immunity to sovereign intervention. From this perspective, in which commodity exchange/economy does not have any autonomous reality, there is a general lack of any political economic understanding and thus of the uneven distribution of physicians. Consequently, the iniquity is individualized, reduced to a matter of morality, culture, and choice and attributed to selfish physicians lacking patriotism and avoiding self-sacrifice.
TNCPR also has a normative component. The denial of impersonal/structural immunity to sovereign intervention is part of the normative investment made in a national imaginary that conceives of social reality as a transparent moral universe encompassing all actions (exchanges, transactions, etc.). Recognizing commodity exchange or market as an impersonal level of reality, and thus working through the impersonal, self-interested subjectivities of the market to have an influence on it, would be in conflict with this national imagination and its subjectivities. This does not imply a struggle against the impersonal order of market relations but is rather indifference to it and thus implicit compromise and nonconfrontation.Footnote 6
The culturalist voluntarism inherent to TNCPR has two interrelated implications for policy formulation. First, devoid of any political economic perspective, its adherents seek to solve the problem of the moment without longer-term calculations of whether the short-term solution would result in a middle- or long-term, say, decrease of students in medical schools, acceleration of the emigration of physicians, or increase of the resignation of physicians employed by the Ministry. Second, TNCPR adherents design CPS laws not only as a distribution remedy but also as an instrument of punishing culturally spoiled and ethically empty physicians. This manifests an anti-intellectualist ressentiment expressed, for example, in attempts to set the duration of CPS as long as possible, not at an optimum period; in the unwillingness to encourage the physicians to be subjected to compulsory public service laws with incentives and extra payments; in the insults targeting physicians as unpatriotic; and in the proposals ranging from seizure of the certificates of the newly qualified physicians not fulfilling CPS to the denaturalization of Turkish physicians working abroad.
Nationalist anger toward allegedly selfish young physicians also reflects discontent with their relative social status. Most TNCPR adherents in parliament have come from professional backgrounds, deriving their status and privileges from the plunder-redistribution economy of state sovereignty. These have included professional populist politicians (with careers built on the accumulation, mobilization, and redistribution of national emotions of sacrifice) and retired soldiers, governors, and judges (who have variously wielded state power). For these legislators—whose performance of sovereignty is, in their eyes, of the greatest value—offering physicians higher salaries than those offered to juridical and military sections of the state bureaucracy is not an acceptable way to ensure a balanced geographical distribution of physicians.
TNCPR is centered on plunder and redistribution also because of its particular conception of the relationship between state, nation, and individual. Fundamentally disregarding the independent reality and normative presuppositions of commodity exchange, it does not address the individual as an autonomous, self-sufficient, rights-bearing entity but only as (indirectly) through their (unequal) role in relationship with the nation-state. The individual as conceived by TNCPR is presumed to owe a debt to nation and/or state.
CPS Laws
The Kemalist Period
In addition to Enlightenment liberalism, according to standard scholarly argument, a solidarist conception of society supported Kemalist Turkish nationalism from the very beginning and gradually prevailed over the liberal component in parallel with the establishment of authoritarian, single-party rule after 1925. Solidarism had been transferred from Durkheimian sociology in the Second Constitutional Era (1908–18), especially through Ziya Gökalp, before evolving into populism (halkçılık), one of the six arrows of Kemalism, the official ideology of the Republic (Toprak Reference Toprak1977; Parla Reference Parla1985).
The core idea of solidarism is that society is a harmonic unity of mutually dependent professional groups organized in a systemic division of labor. Thus, people are “not free individuals” because all are “indebted to others” (Rabinow Reference Rabinow1995, 185)—and the Turkish citizen was more duty-burdened than rights-bearing (Üstel Reference Üstel2008). The CPS laws enacted by Kemalists for newly qualified physicians in 1923 and 1932 seem to confirm this argument, as they defined national duties. On closer inspection, however, the notion of the self-sufficient and autonomous individual is observed as central.
State centeredness is another fundamental characteristic attributed to Kemalism (İnsel Reference İnsel1996; Keyder Reference Keyder, Bozdogan and Kasaba1997; Kadioglu Reference Kadioglu1998). This, it is argued, manifested in a kind of voluntarism based on the misleading belief that society can be shaped by the top-down, modernizing interventions of the state elites. The CPS legislation during the Kemalist period may thus be taken as voluntarist attempts to resolve a socioeconomic problem by coercive instruments. At the same time, however, the reality on the ground is more complicated than it appears and does not allow easy generalizations. As shown below, the justification and design of the first CPS laws were mainly centered on commodity exchange, not the state, and based on political economy calculations, not on voluntarism and a moralistic mobilization of national emotions.
The 1923 Law
The first CPS law of the Turkish Republic—the “Law on Compulsory Service of Physicians”Footnote 7—was enacted in November 1923, just four months after the elections when the Kemalists swept away their opponents from the assembly and acquired an overwhelming majority. Despite the split that emerged within the governing People’s Party (Halk Fırkası) shortly after the proclamation of the Republic in October 1923, the people drafting the law and participating in parliamentary discussions were all loyal Kemalists. The design of the law, support, and opposition thus revealed the parameters and inner tensions of the Kemalist stance on the issue.
The story of this law dates back to October 1922, when Health Minister Dr. Rıza Nur submitted a note to the Council of Ministers including a bill on the CPS of physicians in the eastern provinces.Footnote 8 The justification for the bill referred to the chronic reluctance of civil servants to serve there, stating that only 24 of 135 districts had a government physician. The main articles of the bill were as follows:
Article 1 – Civilian physicians graduating from medical school are obliged to do three years of state service.
Article 2 – Two years of compulsory service shall be performed in the Eastern region.Footnote 9
Article 3 – Medical licenses shall not be approved by the government unless the compulsory service is fulfilled.
Article 4 – Apart from salary and extraordinary funds, all physicians fulfilling their compulsory service in the eastern region shall receive an extra 25 liras per month. This amount does not apply to those physicians in the eastern region who fulfill their service in their hometowns. (TBMM 1923a, 31).Footnote 10
The bill was negotiated by the health and social assistance commission in September 1923 and subjected to some essential amendments before the legislative process. Below, these amendments are brought into focus. It is argued that the differences between the bill prepared by Rıza Nur, who resigned from his government post on the first day of the negotiations and did not take up any position in the subsequent Kemalist governments (developing into an uncompromising adversary as one of the leading figures of the racist wing of Turkish nationalism), and the amended final version of the bill offered by the commission, headed by Dr. Refik Saydam, a card-carrying member of the Kemalist leadership, who replaced Dr. Rıza Nur as minister, show the divergence of the TNCPR and TNCCE perspectives.
In the amended version of the first article, the method of appointment of physicians and the commencing date of CPS were specified and the duration of service reduced from three to two years:
Article 1 – Those physicians who will graduate from medical school as of 1923 are obliged to fulfill two years of compulsory service. They will be appointed by drawing lots; all vacant posts must be included in the list to be drawn from. (TBMM 1923a, 32)
The second article in the new version introduced a new provision for physicians: a free boarding system. The commission considered that the supply of physicians already available and graduating in the next few years would be insufficient to meet demand. A free boarding system was thus necessary—both as a general service (inducement) and so that a separate class of physicians could be trained for the task at hand—but a three-year CPS requirement was placed on this:
Article 2 – The government shall cover the free-boarding expenses for students who currently study medicine or will enroll in medical school from 1339 [1923] onwards, provided they undertake to serve for three years in the locations designated by the government. (TBMM 1923a, 32)
The third article of the amended bill adjusted the CPS remuneration to a relative as opposed to fixed-rate increase, and it refrained from categorizing the deprived regions as the eastern provinces, diagnosing as the main problem that physicians usually applied for places with better living conditions (şeraiti hayatiyesi binnisbe iyi)—the vacant posts were in places with hard living conditions (şeraiti hayatiyesi müşkül mahaller), postings to which would routinely result in resignation. Thus, the commission recommended that the Ministry identify all places with hard living conditions, regardless of location, and better recompense physicians serving there (effectively, by at least 100 liras monthly) to increase the uptake and completion of CPS:
Article 3 – The Ministry of Health is authorized to grant an increase of not less than one-half … and not more than the total amount of the salaries and allowances of the physicians to be appointed to the locations to be designated and announced. … (TBMM 1923a, 32–33)
Article 4 of the amended version was the sanction against physicians not fulfilling their obligations. Previously, physicians faced permanent withholding of their certification. On the grounds that only the medical inadequacy of a physician authorized the government to withhold their certification, the re-formulated article employed a temporary sanction, thus converting it to the deterrence of an economic cost:
Article 4 – Those physicians who fail to fulfill their obligations as prescribed in the first and second articles are banned from practicing their profession for five years. (TBMM 1923a, 33)
The differences between the two texts largely corresponded to the differences between the TNCPR and TNCCE approaches to the issue of the uneven geographical distribution of physicians. These differences can be traced at two levels: the level of political economy and of legitimacy and normative foundations.
The original text prepared under Rıza Nur largely lacked a political economic perspective. It was directed at bringing a short-term solution to the chronic shortage of physicians in more than a hundred districts of the eastern region, primarily based on the threat of preventing recalcitrant new graduates from ever practicing their profession (ameliorated by a small monthly payment). The amended text, on the other hand, sought a balance between the cost of a short-term fix and the possibility of achieving longer-term solutions. Essentially, the juridical measures restricting individual autonomy were redefined by a structural perspective on the health labor force market. Restrictions were eased to maintain the demand for medical school, while the reduction from three to two years (for nonboarders), conversion of the permanent prohibition to a temporary suspension of the right to practice, and increased additional payment all evidence a political economic perspective to prevent a short-term solution (the CPS) from undermining the longer-term health labor force supply.
Striving to eliminate the deterrent effects of the urgent solution (CPS) that would eventually be harmful, the commission formulated a long-term solution, a free-boarding system. An innovation on the original text, this took into account the simple economic fact that, in the post–First World War and Independence War conditions at the time, most families simply could not afford to send even one child to the Istanbul University medical school (the only such [nonmilitary] facility in Turkey until another was opened in Ankara in 1945). This support was expected to increase the demand for the medical school both because the contract offered was very attractive and because the deterrent effects of the CPS imposed on day students would disappear once the number of free-boarding graduates reached a level at which the need to impose CPS on the day students became unnecessary.
As well as an outcome of a delicate political economic analysis of the health labor force market, the free-boarding system can be analyzed as a normative commitment of the TNCCE version of Kemalism to the self-sufficient, autonomous individual concept of Enlightenment liberalism—per the 1924 Constitution recognizing the basic civic and political rights of the citizenry (Özbudun Reference Özbudun2012). Given that CPS was the only available tool for the correction of the uneven distribution of physicians, Kemalists, as Turkish nationalists, were ready to suspend constitutional rights to impose it. However, for the Kemalist leadership, which placed a heavy emphasis on cultural modernization and enlightenment, suspending the constitutional liberties of one of the most educated groups in the country had normative limitations. It was much more acceptable to oblige physicians to fulfill their CPS in Anatolia by charging them with a debt through a contract they would sign by their free will.
The less statist character of the amended bill can even be seen in the term used for CPS. In the first bill promoted by Rıza Nur, it was called “state service” (hizmeti Devlet), reflecting a mentality identifying nation with state or, worse, subsuming nation under state. This term was not used in the bill promoted by Refik Saydam or in his speeches in parliament. The points of agreements and disagreements within and between the TNCPR and TNCCE approaches manifested in the polemical exchanges that took place in the national assembly.
The objections to the amended bill negotiated in the assembly were twofold. One questioned its political economic rationality and the other its legitimacy. The political economic objection had to do with the deterrent effects of CPS imposed on all newly qualified physicians. A socioeconomic problem requires a socioeconomic solution, argued Dr. Mazhar Germen, ex-military physician and later health minister (for three months in 1924–25), adding that an attempt to tackle the issue using coercive methods would backfire:
In the face of such a simple and material difficulty, they [the government] are trying to … [use] force and coercion without thinking about taking measures that are more scientific and logical and in line with the spirit of the issue. While no other profession in our country is subjected to such treatment, they want to inflict it only on physicians. Should the children of the country boycott such unfair treatment and stop going to the medical school? … It is necessary to encourage everybody and increase the demand to study medicine… . Gentlemen, arouse enthusiasm and desire, do not discourage, instead! (TBMM 1923a, 34–35; emphasis added)
Regarding the legitimacy of the first article, in return for what, it was asked, was the state imposing CPS? According to this criticism, the debt of an individual could only be based on a contract signed by their free will. For example, those who raised this question, like Dr. Fikret Onuralp, did not object to the second article of the bill, which recognized physicians as equal parties to a contract and offered CPS in exchange of state support:
How do you oblige those men who have completed their education to be self-employed physicians using their own means to fulfill the compulsory service? [Shouting: “In the name of public interest” (Menafi amme için)]. … [The Ministry] can announce that it will admit students [to the medical school] with special conditions as defined by the second article. Then, those students accepting the conditions make a contract with the government and fulfill the compulsory service following their graduation. Otherwise, how do you oblige him to go? (TBMM 1923a, 37; emphasis added)
Questing both the legitimacy and the political economic basis of the bill, especially its first article, this objection reflected what may be regarded as a TNCCE split between those pragmatically regarding CPS acceptable as an exceptional, short-term solution and those in absolute opposition to it in principle. Against this objection, the proponents of the more pragmatic version of TNCCE and the proponents of TNCPR defended the bill in their own specific ways. The TNCPR approach was embodied in the words of Dr. Mustafa Cantekin.
Cantekin drew on the notion of the individual indebted to the nation-state and a culturalist reductionism. He argued for the legitimacy of the first article of the bill, drawing implicit inspiration from Durkheim, the favorite sociologist of the early Republican period (1920s) (Toprak Reference Toprak2012, 183), specifically with reference to his notion of organic solidarity (la solidarité organique, hayatı içtimaiye ve umumiye); thus,
[e]ven if they [student physicians] were educated with their own money—if there were no such thing as social and public life [hayatı içtimaiye ve umumiye] in the country—would they be able to become physicians? Does a physician not serve the well-being of his country? I think physicians are more willing than anyone to make this sacrifice and recognize what the country needs first and foremost. (TBMM 1923a, 37–38; emphasis added)
This drew a sharp response from Mazhar Germen: “Nothing can be done by relying on emotions. You don’t have the right to monopolize patriotism” (TBMM 1923a, 38). According to Cantekin, national feelings, a felt indebtedness to the nation, were strong enough sources of motivation for physicians to act selflessly. He called on such feelings not only to legitimize CPS but also to avoid discussing and to even deny the possible negative influence of CPS on the supply side of the health labor force market:
It is said that the demand for the profession would fall if we imposed compulsory service. No, gentlemen! The medical school … became the vanguard, full of patriotism, … against the autocracy in 1305 (1889)… . Why not those coming from the same faculty serve for two years for the health of the country? … The medical school … would fulfill the duty at stake proudly, for the well-being of the country without any hesitation, not for two years but even for five years. (TBMM 1923b, 86)
The proponents of the pragmatist version of TNCCE, who were the drafters of the bill, defended it, just like the proponents of TNCPR against the objection. However, their disagreement with the objection was not a disagreement on principles. Unlike TNCPR, seeking to prove the legitimacy of imposing CPS on all graduates of medical school with reference to “individual indebted to nation-state,” the proponents of the pragmatist version of TNCCE did not emphasize CPS as a fair exchange between the new graduates and the state. For example, when answering the objection to the law, Health Minister Saydam acknowledged that “the objection might be true in principle.” In his view, which fairly reflected that of the Kemalist leadership, the CPS restriction of physicians’ autonomy was a sovereign exception suspending the “principle” and thus its confirmation as rule or norm: “Some deputies oppose the two-year compulsory service. Their objection might be true in principle, but if the needs of people and country conflict with imtiyazat Footnote 11 of the individual, we certainly have to opt for the former over the latter” (TBMM 1923b, 88).
The government’s nonreliance on the conception of individual indebted to the nation-state when imposing the two-year CPS found its most crystallized expression in the government order expounding the law (Türkiye Cumhuriyeti 1925, 4), which clarified that even those physicians who had graduated from medical schools abroad without any state support were still subject to the CPS requirement.
The Kemalist leadership did not essentially disagree with the political economic aspect of the objection to the bill, either, as can be seen in the disagreement between Kemalist leadership and TNCPR over the second article imposing a three-year CPS on free-boarding students. TNCPR advocates found this period too short to pay off the expenses incurred by the state. Ahmet Remzi Güres, for example, suggested “at least five years” on the basis that the CPS difference of one year between day students (who would do two years) and free boarders (to do three) was “not adequate” (TBMM 1923d, 310). Süleyman Sırrı Aral proposed that “a similar case” be considered:
While we oblige the new [medical] graduates to do two years compulsory service … by relying on force and compulsion that can be deemed despotism, the government is very lenient to the free-boarders. … I propose that those students must be obliged to do two years compulsory service in return of each year they study thanks to the accommodation and provisioning provided. (TBMM 1923c, 108; emphasis added)
These extensions were not promoted from a political economy perspective, such as taking into account their possible effect on the demand for free-boarding places or distinguishing between different professional groups and comparing the anticipated surplus labor with potentially lost labor. Rather, the proposals were guided by and adopted the terminology of a juridical-legal conception of power, especially uniformity and homogeneity.
Saydam’s response to these TNCPR arguments revealed a quite different way of reasoning, one that considered the possible effects of the extensions on the supply and demand dynamics of the health labor force market: “That we fixed it as three years in the Commission was a result of our goal to increase demand. Five years would be seen as excessive, and applications would be very low” (TBMM 1923c, 108; emphasis added).
The text offered by the commission was accepted without any amendment and passed into law, to remain in force until 1932, when the CPS imposed on day students was abolished and the free-boarding system was systematized.
The 1932 Law
The predominance of TNCCE over TNCPR in the way the Kemalist leadership handled the uneven geographical distribution of physicians was not limited to the period preceding the full-fledged establishment of the single-party rule by 1925. It persisted in the law enacted in 1932, namely, the “Law on the Abolition of the Compulsory Service of Physicians Who Will Graduate from the Medical School and on the Obligations of Free-Boarding Students.”Footnote 12 This law was essentially just a revision of the 1923 law, as it mainly just abolished the CPS obligation of day students and gave a more systematic and detailed shape to the CPS obligation of free-boarding students.
The decisive role of TNCCE thinking in the 1932 law can be seen first in the removal of the CPS obligation for day students, which already did not have long-term legitimacy from that perspective. Kemalist leadership did not insist on maintaining the CPS obligation of day students when the emergency situation was over and day-student CPS was no longer necessary. As mentioned in the justification of the 1932 bill, it was due to the opening of a dormitory for free boarders in 1924 that the number of medical students had increased sufficiently to fill the vacant posts for government physicians. There were 350 free-boarding students, and there had been no significant change in the overall number of day students because of the deterrent effect of CPS. Thus, the government was “convinced that it was time to abolish the CPS for day students” (TBMM 1932).
A second TNCCE influence on the 1932 law can be seen in the way that CPS duration was calculated in the report of the budget commission. This sought to establish the best equilibrium between the level of support provided to the student, the length of CPS expected in return, and securing the demand for free boarding in the medical school:
In view of the fact that all the expenses of the students in the medical students’ dormitory … are borne by the state, and in comparison with the two years of compulsory service imposed … on those who are funded to study in Europe … for each year of study, … it seems appropriate and logical to impose on them … at least one year of compulsory service for each year they spend in the dormitory. Because … imposing a compulsory service of six years would … lead to a decrease in the demand for the dormitory, our committee has found it appropriate to accept the compulsory service period as two-thirds of the time spent in the dormitory. (TBMM 1932; emphasis added)
A third striking indicator of the influence of TNCCE in the 1932 law can be observed in its third article. The original version of the new bill read as follows:
Article 3 – Those physicians who fail to fulfill their obligations prescribed in the second article shall be banned from carrying out their profession for five years and shall be made to reimburse the expenses incurred by the state for them. (TBMM 1932; emphasis added)
This was amended on the grounds this would not serve the goal of increasing the overall number of physicians; thus,
Article 3 – Those who fail … or [only] partly fulfill the compulsory service are obliged to pay double the dormitory expenses incurred for them. (TBMM 1932; emphasis added)
The new bill passed into law on June 1932 without much resistance, thus ending the requirement of CPS for day students.
Although the emergency situation had been dealt with, the shortage of physicians in the East persisted. This triggered subsequent opposition to the law in the following years, mostly with TNCPR-informed arguments and specifically to the provision enabling physicians to discharge their CPS obligation by paying a fine.
In 1945, Ahmet Hamit Selgil, a military physician and Deputy of Afyonkarahisar, requested the removal of Article 3. He did not concern himself, however, with whether this would reduce demand for the free-boarding medical schools or how to coerce obliged physicians who, without the option of paying a fine, would still refuse to fulfill their obligation. Instead, his assessment centered exclusively on the legitimacy problem, as may be expected from a typical TNCPR perspective structured by juridical-legal conception of power, which is evident in his judging the fair CPS duration on the basis of a comparison with another profession and a detailed description of the relative advantages that free-boarding students enjoyed:
The Ministry of Health operates a dormitory for the students of medical faculty … [which] is of great benefit to them. Following their graduation, they are obliged to fulfill a compulsory service of only two-thirds of the time they have spent in the dorm, whereas free-boarding law students are obliged to do compulsory service for eight years in return for four years of free boarding. Moreover, in recent years … young physicians educated by virtue of the sacrifices of this country for the sake of sending physicians to its far, remote, and deserted corners, unfortunately, have not been fulfilling their duty. After completing their military service obligation, they make a financial payment instead of doing compulsory service.
I saw some statistics. In 1932, one out of 23 graduates, in 1936, two out of 92 graduates … in 1941, 28 out of 118 graduates, and in 1942, 36 out of 135 graduates were released from this compulsory service by making a payment. These students … should not have this right … [Voices: Very true]. (TBMM 1945, 421; emphasis added)
Deputy Dr. Niyazi İsmet Gözcü, another military physician, reasoned similarly in support of withdrawing the option for new graduates to make a payment in lieu of CPS. Gözcü argued for the maximum duration that could be extracted without being unfair and unjust—which he judged by comparing the length of CPS of physicians (four years) with that of military school graduates (15 years) (TBMM 1945, 426).
Despite the objections made from within Republican People’s Party (Cumhuriyet Halk Partisi, CHP) with TNCPR arguments, however, the law was not changed (again) during the 1930s and 40s. Therefore, it can be concluded that the Kemalist leadership took a determined and consistent TNCCE stance in its approach to the uneven geographical distribution of physicians from the 1923 law and through the 1932 revision and later defense.
The Democratic Party Period
I learnt that … some physicians migrated to foreign countries, making contracts with foreign institutions. [Voices: Good luck to them!] No, I do not say “Good luck” to them, they can go to hell for all I care! [Voices: Bravo!] Let them go… . I believe that this nation and the people of the deprived regions will curse them! [Voices: Amen!] (TBMM 1954a, 193)
—Deputy Arif Nihat Asya, Democratic Party
The 1952 Law
The third CPS law—on the Requirements of the Recruitment of Medical Personnel in the State OrganizationFootnote 13—was issued by the center-right Democratic Party (Demokrat Parti, DP), winners of the momentous 1950 general election over the Kemalist party, CHP. In 1952, the Council of Ministers prepared a bill requiring CPS of physicians to be employed in public sector. The reason given was the insurmountable conflict between the reluctance of physicians to work in certain regions and the necessity to staff new health institutions that were to be opened there. The dormitory, the single tool that the government could use in dealing with the problem, had been effectively closed in 1950 (transferred to the Ministry of Education),Footnote 14 the country’s post–Second World War financial situation did not allow the financing needed to make posts in the deprived regions attractive, and physicians had alternatives like private practice and working in semiautonomous public enterprises for higher wages. There was “no way available but speaking to national sentiments to send physicians to the places where they are needed” (TBMM 1952).
The most relevant articles of the bill were as follows:
Article 2 – Turkish physicians who have received their diplomas from the medical schools in Turkey or abroad and who wish to take up a position as a physician in the Ministry of Health shall be obliged to serve for two years in those areas designated … due to their remoteness or special situation for sanitary, administrative, and economic reasons.
Article 5 – Those physicians not fulfilling compulsory service cannot be appointed to any medical post in any medical establishment or organization managed by the national budget, supplementary budget, special provincial administrations, municipalities, or public economic enterprises. (TBMM 1952)
The bill was negotiated by the health and social assistance commission and then by the budget commission. In the final version, prepared by the budget commission, the first article read as follows:
Article 1– Those Turkish physicians (including medical specialists), dentists, and pharmacists, who are to be employed in offices governed by national, supplementary, and special budgets, in public economic enterprises, in those enterprises of which all or more than half of the capital belongs to the state, and in workers’ insurance shall be obliged to serve for a period of two years in those areas classified … due to geographical, economic, social, and administrative reasons. Their assignment locations shall be determined by lot. The appointed personnel shall not be employed in the aforementioned offices, institutions, or enterprises unless they fulfill their compulsory service. (TBMM 1952)
At first sight, the bill seems to be guided by TNCCE, in the sense that it designed CPS as a clause in a labor contract offered by an employer, the state, for applicants, the physicians to be employed in the public sector. Democratic Party (DC) deputies defending the bill, such as Mazhar Şener (Giresun), speaking for the budget commission, compared the state to an enterpriser:
Some of our friends, who oppose the law, tried to depict it as a compulsory service law. As the name of the law shows, this is neither a compulsory service nor an obligation law. The law just includes the conditions of recruitment of physicians, dentists, and pharmacists by the state.
Is not the state authorized, like an owner of an enterprise, to expect an applicant to satisfy the requirements of recruitment? It is not correct to call the law compulsory service. For the law does not restrict the professional activities of those physicians who prefer to be self-employed. (TBMM 1952, 392; emphasis added)
Deputy Natık Poyrazoğlu (Muğla) explained further: “We do not restrict the liberty of anyone. We just stipulate a condition for those physicians seeking to work for the state. As far as I know, even a shopkeeper says to an applicant that “this is what I demand. You can start working if you accept it. Otherwise, I can’t do anything” (TBMM 1952, 393; emphasis added).
This was a contract, but its sides were not equally free to engage in it or not, as happened in the contract offered by the state to free-boarding medical students under the Kemalist party. The strategy that the drafters of the bill used to impose CPS involved intervening in and restructuring the oligopsonistic health labor force market as the dominant purchaser to have physicians act in accordance with market realities and sign the contract offered to applicants by the government as employer.
In a nutshell, the difference between the old and new contract-based CPS systems for extracting CPS from physicians was that between unequal exchange and plunder. In fact, nothing is immediately unfair in the CPS free-boarding system, which was not a sovereign imposition from above. It operated on the agreement of both parties, extracted from free-boarding students in return for various provisions (tuition-free education, free accommodation, etc.). That is why Kemalist physicians, intellectuals, and politicians have tended not to regard the free-boarding system as part of the CPS arrangement and rather reserved the term for the requirement introduced by the military in 1981 and the AKP in 2005. For instance, Dr. Füsun Sayek (Reference Sayek2008, 49), head of the left-Kemalist Turkish Medical Association between 1996 and 2006, concluded that “compulsory service in the employment of physicians was not used from 1932 to 1981” and that it was reintroduced “nearly 50 years later … by Law No. 2514, which came into force on August 25, 1981.”
The compulsory nature of the contract between free-boarding students and the Ministry—that is, unequal exchange—is implicit: a free-boarding system uses the economic incapacity of middle- and lower-class families to charge them with a debt to the nation-state in such a way that the burden of CPS, a specific form of nation-building labor expended at the margins of the nation, which should in principle be equally divided among all newly qualified physicians irrespective of social position, is exclusively left over the shoulders of physicians with lower- and middle-class backgrounds. Nevertheless, this unevenness does not invalidate it as a commodity exchange. Ultimately, per Marxian theory of surplus value, labor power is an exceptional commodity in that it can produce more than it costs, so inequality becomes integral to any commodity exchange involving it. However, the contract-based CPS introduced by the DP was different, characterized by plunder, not by unequal exchange, as CPS imposed via the DP contract was in return for nothing. Other than the specific professional requirements being expected to be met adequately, the prerequisites of being recruited into the state institutions were legally fixed for all Turkish citizens and did not involve the fulfillment of CPS. Therefore, the contract that made being hired by the state health care institutions conditional on the fulfillment of CPS covered up what was really a case of plunder.
This is a clear instance of TNCPR, but of a special type that one can name “Turkish nationalism centered on simple commodity exchange” (TNCSCE) to better express its exact nature. The reasoning behind the DP contract-based CPS system cannot be thought independently of the party’s “simple market society ideal” (Keyder Reference Keyder, Pamuk and Toprak1988). This was an idealization of the reality on the ground, according to which mainly rural but also urban petty producers, the majority of the population at that time, should be incorporated into the market as owners of private property and thus be given an autonomous room for initiative against top-down state interventionism; meanwhile, the full commodification of society should be strictly avoided to prevent the simple market society from evolving into a bourgeois society (with its normative conception of the individual as an autonomous, rights-bearing entity and the political economy view of economy as an autonomous domain immune to any intervention of a sovereign type).
Modeled on the simple market society ideal, DP populism tended to organize the state as if the party was its owner—both as the embodiment of the national will and as a petty entrepreneur not yet absorbed into capitalist abstraction and thus likely to think they have the right to enjoy an absolute authority over their small-scale private property (without restriction by value [economy] or right [individual autonomy]). This accounts for the prima facie ambiguity of the DP contract-based CPS system regarding TNCCE and TNCPR—which led some deputies to question the sovereign violence hidden behind the freedom of contract.
Was the government legally authorized to fix the requirements of the recruitment of physicians in state institutions as it chose? According to some, the requirements for the recruitment in the state were legally fixed and applied to all Turkish citizens equally. Therefore, the government could not act as though it were an ordinary employer in an unregulated market and free to determine the labor contract. For example, Arif Hikmet Pamukoğlu, a Nation Party (Millet Partisi) deputy, demanded the negotiation of the bill by the constitution commission thus: “We cannot violate the principle of equality. When a duty is assigned for the first time, the obligations to be imposed on those who will undertake public service are the same, they are equal. For example, any civil servant must be an adult Turkish citizen and is obliged to submit a certificate of good conduct and several photos. One cannot impose any extra liability” (TBMM 1952, 401; emphasis added).
CHP deputy Hikmet Fırat opposed the bill with similar words: “We have a Civil Servant Law that details who is eligible to be a civil servant and who not. To assert that one cannot be recruited by the state in the institutions in which it has a share or in autonomous institutions unless one works in places designated by the state is irreconcilable with prevailing legal principles” (TBMM 1952, 386; emphasis added).
The answer given by the health minister to such questioning of the legitimacy of the imposition of CPS would not be unexpected unless one were to mistakenly identify the CPS system of the DP with TNCCE due to its basis on contract. The DP CPS system called for a conception of the individual’s relationship to the state and nation that was different from that posited by TNCCE. Thus, the minister legitimized CPS with reference to the publicly funded education system and the notion of the individual as indebted to the nation-state, per TNCPR: “It must be taken into account that these young people are raised from primary school to the end of university through the sacrifices of this state and nation. In return, they are, of course, charged with a duty to be fulfilled. … Yet this duty is not imposed on everybody. … It is brought only for those who would like to work in the Ministry” (TBMM 1952, 386; emphasis added).
The TNCPR of the DP contract-based CPS system was not limited to the issue of legitimacy and the conception of the individual’s relationship to the state and nation. The bill lacked a political economic understanding of the health labor force market, failing to formulate incentives to counteract any discouraging effects of CPS on the supply side of this market and relying exclusively on threatening physicians with unemployment.
The complete lack of a political economy perspective on the part of the DP leadership was crystallized in the budget commission’s response to the draft proposal prepared by the health commission. This proposal questioned the attainability of the intended goal, correcting the uneven geographical distribution of physicians only by restrictions and compulsion, and asserted the need for incentives:
It has been agreed … that it is necessary to provide some incentives to the members of the profession of medicine, who are already obliged to carry out public service under the most severe conditions, to impose on them compulsions that are not imposed on other professionals. In this respect, it has been accepted that those who undertake CPS will be given a preferential right … to assistantships and extra payment of up to half of their salary. Only under these conditions is it possible for the members of the profession to carry out their civic duty with maximum efficiency. … Otherwise, it has been concluded, the law cannot be implemented efficiently. (TBMM 1952; emphasis added)
The budget commission did not take the suggestions of the health commission into account and rejected the health commission’s suggestions. One can see all the characteristic elements of TNCPR in the noncompromising stance of the budget commission, as expressed by Mazhar Şener, the representative of the budget commission:
The Head of the Health Commission has complained that the Budget Commission has annulled the 50% premium. This issue was … removed from the bill, first, in principle, and then, economically. As a principle, if the method of paying premiums to the physicians to be appointed to the east and deprived regions is adopted … then all engineers, teachers, judges, physicians, etc. appointed to these regions need to be paid premiums. … As for the second point, there is no available allocation. (TBMM 1952, 392–93; emphasis added)
Approaching the extra-payment issue through the conceptual lens of a juridical-legal conception of power, the budget commission made an assessment limited to the equality of civil servants and uniformity of their working conditions. Thus, it did not concern itself with the encouraging effects of the extra payment in terms of its possible effects on the health labor-force market and geographical imbalance of the distribution of physicians. Finance Minister Hasan Polatkan voiced a similar argument, concluding that the extra payment was impossible “in principle” (TBMM 1952, 407).
However, it would be naive to account for the noncompromising stance of the budget commission as a kind of short-sightedness that could not see the whole picture due to a juridical fetishism. This was not a failure, lack, or incapacity. If the issues were just related to a budgetary principle of equality and the burden on the public budget, the budget commission would not have canceled the nonmonetary incentive in the health commission’s draft proposal (of giving priority to obliged physicians in assistantship appointments). This involved more than juridical fetishism, and reference to the equality principle covered up what could not be declared explicitly: CPS law, as understood by the budget commission, was not only a remedy for the uneven geographical distribution of physicians but also an instrument of populist (anti-intellectualist) ressentiment, a punishment meted out to the supposedly culturally alienated and morally spoiled physicians.
DP deputy Natık Poyrazoğlu was not a member of the budget commission, but his words pointed to culturalist voluntarism, another TNCPR characteristic, that might have played a role in the unwillingness of the budget commission to provide incentives: “One of our friends, on the one hand, asserted the holiness of this profession and, on the other, questioned whether this duty is performed in return for such a small salary. In my opinion, materialism and spirituality cannot co-exist [Voices: Bravo!]” (TBMM 1952, 394).
Poyrazoğlu made no calculation for additional costs here but rather a distinction between the domains of the spiritual and material as corresponding to the national subjectivity and the self-interested individual, respectively. What he was actually refusing was not a financial payment but the political economic perspective itself and policy making from within its materialistic way of reasoning. Seeking a political economic solution to the physician shortage in the countryside and eastern (mainly Kurdish) region would mean trying to overcome a national question with nonnational means.
Completely sidelined by the budget commission, the members of the health commission, most of whom were physicians and DP deputies, engaged in heated polemics against the budget commission, which itself largely reflected the attitude of the DP leadership and the main body of DP deputies. The head of health and social assistance commission, Dr. Talat Vasfi Öz, was adamantly opposed to the two-year CPS imposition unless it was supported by an extra payment, which was couched as “economic opportunities that might enable [a physician] to advance his scientific knowledge” (TBMM 1952, 391).
Deputy Dr. Esat Oktay argued similarly:
The health commission offers … an extra payment up to half of the salary. However, in the justification of the [bill of] Budget commission there is no mention to this; the article was completely removed from the bill… . Reward is proportional to burden. We designate a place as a deprived region and send someone there, where he cannot even find a house to live in. Worse, he is deprived of an extra-payment… . The Budget Commission canceling the allocation has nullified the bill. (TBMM 1952, 389)
This insistence on the need for incentives cannot be reduced to a matter of professional solidarity among physicians. Rather, the responses of several members of the health commission converged on a TNCCE position and directly targeted the reasoning at work in the budget commission’s draft proposal. We can see this in the sarcastic criticism made by DP deputy Dr. Burhanettin Onat, as if society could be shaped by the top-down interventions of the state elites, when really, what was being proposed was more an instrument of punishment:
The government is telling us, “The physicians we send to some places do not go there. Adopt the law we have brought so that they will be obliged to go.” So, we have found the easy way, friends, we have found the easy way. I congratulate you all. Let’s say a road is to be built and we cannot find laborers, then issue a law and mobilize the people. Or if we have difficulty in providing a service, pass a law and get it done. … We have no right to exile the members of a sacred profession under the pretext of CPS. (TBMM 1952, 385; emphasis added)
The bill was passed into law without any amendments in spite of those criticisms and remained in effect until March 1954, when the government realized that the physicians’ unwillingness to serve in deprived areas could not be overcome just by coercive mechanisms effected through state power in the health labor force market (TBMM 1954b).
The Military Dictatorship Period
The enactment of a new CPS law,Footnote 15 which had been attempted several times after 1954 from a TNCPR position, became possible in 1981 under military rule. Bülent Ulusu, the then prime minister, submitted the “Bill Regarding the Compulsory Duty Obligation of Certain Health Personnel” prepared by the Ministry to the legislative body, which now consisted of the members of the junta acting as the Presidency of the National Security Council (1980–1983). In addition to the geographical distribution issue, there was a general need for more physicians (with a Ministry shortfall of some 6,300). For the prime minister, “The Law Regarding the Full-time Employment of Health Personnel” (1978), which mainly relied on economic incentives to hire physicians, had proved to be dysfunctional.
The 1981 Law
The bill was negotiated by the expert commission to be given its final shape. The basic articles of the bill regarding CPS were as follows:
Article 3 – Physicians are obliged to perform four years of state service (two in general practice and two years in medical specialty) in the institutions and organizations where the Ministry of Health and Social Assistance (MHSA) is legally obliged to appoint physicians and in MHSA approved positions of other ministries, higher education institutions and other organizations.
Those who complete four years of state service in the general practice shall be deemed to have performed the service specified in the first paragraph.
Article 5 – Persons within the scope of the law are not allowed to perform their profession without fulfilling their state service obligation. … (MGK 1981)
The bill was an outcome of a full-fledged state-centered variant of Turkish nationalism. It was exclusively based on punitive and juridical measures restricting the liberties of the physicians, and there was no mention of economic or other incentives in the articles of the bill or subsequent regulations on how the law would be executed. Two of the provisions in the bill prepared by the Ministry, later removed by the expert commission, show how far the military regime was ready to go in suspending the basic liberties of physicians (their freedoms of movement and work):
Physicians and other health care personnel not fulfilling their compulsory service as prescribed by the law are not allowed to go abroad beginning from the date of their graduation from medical faculty and during their compulsory service, except for personal or family health reasons.
The diplomas of physicians and other health care personnel who cannot prove their fulfillment of compulsory service with official documents … are retained by the Ministry. … until the end of the period specified in the above paragraph. (MGK 1981)
Again, beyond the nonprovision of incentives and exclusive reliance instead on coercive mechanisms to correct uneven geographical distribution of physicians, the TNCPR approach was revealed in the juridical-legal conception of power centered on unity, uniformity, order, and affiliated notions of homogenizing authority and state sovereignty. As Kenan Evren, head of the junta and National Security Council, made clear in a response to the Ministry on the possibility of supplying CPS physicians with housing, any idea of special working conditions for physicians that could not be generalizable to other groups of public servants working in eastern Turkey was a nonstarter for the junta; moreover, it was not normatively acceptable because it could undermine established hierarchies among public servants, which designated the judiciary and military as the most privileged:
Because the personnel we send [to deprived regions] are not only physicians but also engineers, census officers, teachers, administrators, and judges, if we provide [public housing] to physicians only, will not the others ask, “Why do not you give us public housing as well?” Consequently, if this is to be provided, it should be provided to all of them, for compulsory service applies to them, too. We appoint judges to these places, but we cannot give them [public housing]. (MGK 1981, 298)
Note the special emphasis Evren placed on judges in his response. This echoes the case of the (1978) “Law Regarding the Full-Time Employment of Health Personnel,” which had provided high salaries to physicians to attract them to work in the public sector and thus improve the perennial distribution problem, leading to discontent in the military as the salaries of low-rank military physicians exceeded those of many high-rank officers. Thus, one of the main reasons why the junta annulled the law just a few months after the coup was because it had “resulted in extreme financial disparities, causing discontent among public servants” (MGK 1980).
The TNCPR approach of the bill also manifested itself in the culturalist and moralist negation of political economy and its self-interested subject. We can observe this in a speech Evren delivered shortly after the coup in the predominantly Kurdish city of Ağrı, one of the poorest cities in Turkey. Promising to enact a CPS law, he identified the fulfillment of duties in deprived regions with patriotism: “We will also impose compulsory service on our physicians, engineers, teachers, district governors, and governors. Everybody should come here and serve in every inch of this homeland. Fulfilling one’s duty is not a matter of money. We, who love this homeland and grew up in it, are obliged to do our duty all over this homeland” (Evren Reference Evren1991, 88; emphasis added).
The law reflected the TNCPR reasoning also in the way it legitimized the imposition of CPS on physicians for four years, as based on the notion of the individual indebted to the nation-state and imposed as if a collection of this debt. This can be seen in a part of the law defining who would be exempted from CPS: “Health personnel who complete their education or specialization abroad without receiving foreign currency from the state by studying on their own behalf and account are not subject to state service obligation” (MGK 1981).
The assumption behind this exemption is obvious: those who study medicine at public universities largely funded by the state owe a debt to the state, and those who study medicine abroad without having any public fund do not. The assumption is openly mentioned in the justification for the bill: “It is not seen in almost any of the countries in the world that education and training related to medicine and medical branches are provided free of charge. As all the burden of free medical education, which is still applied, is covered by the state, it is a fair requirement and a … national duty … to meet the needs of our country” (MGK 1980).
Referring to the ratio of tuition fee for medical school to the total expenses made by the state to train a physician, Evren depicted CPS as a fair obligation:
Why did we bring this state service obligation? Because the guys studying medicine here study it free of charge. The state spends nearly 10 million within six-seven years for training him. What he pays is not even a tenth of that, the rest is paid by the state. In that case, we say that in return for the aid provided by the state, this person should fulfill state service obligation… . If someone who studies medicine abroad without using any public fund comes to Turkey to work as a physician and we tell him “ok, fulfill compulsory service”, then he refrains from coming here. And moreover, we have no right to say that. (MGK 1980, 296)
The 1981 law was structured by an extremely statist version of TNCPR, clearly apparent in the (adjusted) title of the law naming CPS a “state service” (devlet hizmeti). When compared with the terms civic duty or national duty, which imply that obligation is initially to the nation and that the state, as a nation-state, as organized will of the nation, merely regulates the conditions for the fulfillment of this obligation, state service is the product of a state fetishist absorption of the nation into the state making the state an end in itself.
The negotiations were finished in a day, and the bill passed into law on August 21, 1981. It remained in force with some interruptions and amendments until 2003, when the AKP returned to a contract-based system.
AKP Period
In 2003, the newly elected AKP removed the CPS law issued by the military regime in 1981, which had been suspended in 1995 and reintroduced in 2002, on the grounds that it had patently failed to establish a geographically balanced distribution of physicians. Initially, the government readopted a contract-based recruitment of physicians and offered higher salaries to overcome the shortage of physicians in deprived areas—but this was also unsuccessful. For 3,524 general practitioners’ posts and 1,081 posts announced by the Ministry for medical specialists, only 1,565 and 136, respectively, were applied for (TBMM 2005). With reference to the shortage of physicians in “Regions of Priority in Development,”Footnote 16 in June 2005, the AKP amended the Basic Law on Health Services to make CPS obligatory for all newly qualified physiciansFootnote 17 (Türkiye Cumhuriyeti 2005).
The 2005 Law
Based on the justification and articles of the bill and negotiations during the enactment process, the CPS introduced by the AKP may be described as ambivalent in terms of the TNCCE-versus-TNCPR alternative. On the one hand, there was a solid political economy perspective and distance from culturalist/moralist voluntarism, but on the other hand, the notion of the individual indebted to the nation-state was maintained. This ambivalence was not the earlier ambivalence of the DP’s CPS scheme, however. The latter was only a prima facie ambivalence and can be covered by a concept (TNCSCE), but the former cannot. It was a manifestation of a deeper split, an incoherence, and thus a coexistence of two conceptually different frameworks of nationalism.
In many respects, the AKP’s CPS is similar to that imposed by the Kemalist leadership in 1923. The drafters of the bill established a clear distance from culturalist/moralist voluntarism and avoided reducing the problem to an individual issue of a lack of patriotism and self-sacrifice on the part of physicians. This is evident in the words of Recep Akdağ, then Minister of Health:
It is clear that the solution to this problem, in the long run, is to increase the number of physicians in the country… . There are 52 countries in the European region of the World Health Organization, and among these 52 countries, unfortunately, we are bottom in terms of the number of physicians per capita… . The current supply of physicians in Turkey is not enough for our needs. Therefore, no matter how much we encourage and try to ensure recruitment on a voluntary basis, our two years of experience have shown us that … our physicians never come to the public [sector]. (TBMM 2005, 562; emphasis added)
From this point of view, the failure of market incentives meant that CPS was the only alternative available to fix the problem in the short and middle term, if not in the long term. In other words, CPS was reintroduced in 2005 not as an outcome of a culturalist or moralist voluntarism that has no toolbox other than sovereign violence. The bill was based on political economy considerations. This is most evident in the way the duration of CPS was calculated. Borrowing the classification of the State Planning Organization, which divides all the country’s districts into six groups based on a socioeconomic development index (Dinçer and Özaslan Reference Dinçer and Özaslan2004), the bill assigned different service durations to each on a sliding scale. Thus, CPS in the least developed group of districts was set at 300 days, whereas in the most developed places, it was 600 days (TBMM 2005).
Specifying different service durations for different areas in this way was intended to maintain the motivation and efficiency of the obligated physicians. For the same reason, moreover, physicians were given the option of fulfilling CPS on a contract-based employment scheme offering higher salaries (TBMM 2005).
Another major difference in the reasoning behind the law from TNCPR concerned the emphasis placed on the notion of the rights-bearing individual. When the AKP abolished the military regime’s CPS law and substituted it with a contract-based recruitment scheme in 2003, one of the government’s main arguments was that the CPS law had violated the basic rights of the physicians, as expressed by Minister Akdağ: “Today, together, we are eliminating a practice that is not appropriate in the 21st century. As a result of the 22-year-long implementation of this law, it has been understood that the balanced and just distribution of physicians throughout the country cannot be achieved by coercion” (TBMM 2003, 45; emphasis added).
And even when they had to bring CPS back in 2005, they did it with reference to the citizens’ right to health care services and felt the need to clarify that the imposition could not be deemed a violation of the rule that no one can be forced to work. This is how the issue was articulated in the justification of the law:
The right to a healthy life and access to health care is one of the most fundamental rights that human beings are born with. … The health service that the state is obliged to provide, due to the nature of the health service, cannot be delayed, postponed, or substituted. Therefore, recruitment of the personnel required by the importance and priority of health services is essential.
Article 13 of the Constitution stipulates that fundamental rights and freedoms can only be limited by law without affecting their essence, and only for the reasons outlined in the relevant sections of the Constitution; Article 18, having mentioned that no one shall be subjected to forced labor, clarifies that working in the fields necessitated by the needs of the country as a civic duty shall not be considered forced labor. (TBMM 2005)
That being said, there was a certain prevarication in the argument presented: The pertinent question that arises in this appeal to the “civic obligation” of Article 18 of the 1982 Constitution is whether the imposition is an exceptional suspension of the liberal rule that nobody can be forced to work or whether it involves more than that and calls for another form of relationship between individual and state. To answer this, we need to examine the Article 18: “No one may be required to perform forced labor. Unpaid compulsory work is prohibited. The term forced labor does not include work required of an individual while serving a court sentence or under detention, services required from citizens during a state of emergency, and physical or intellectual work necessitated by the requirements of the country as a civic obligation, provided that the form and conditions of such labor are prescribed by law” (Yasar, Reference Yasar1997).
In fact, Article 18 involves two interpellations of two different subjects: the autonomous, self-sufficient, individual citizen, who belongs to the order of TNCCE, and the individual indebted to the nation-state, who belongs to the order of TNCPR. As a rule, the former cannot be forced to work: “No one may be required to perform forced labor. Unpaid compulsory work is prohibited.” And this must and can only be regulated as a sovereign exception during a state of emergency. This is a liberal intolerance of any ordinary limitation of free labor and dates back to the 1924 Constitution, the first constitution of the Republic. In the latter case, however, the individual is indebted to the nation-state and may be required to fulfill civic duty when necessary.
Civic duty in Turkey is a legacy of the 1961 Constitution, which introduced the concept as a reflection of its “solidarist-corporatist” conception (Parla Reference Parla1991) of the individual as indebted to nation-state. When justifying CPS with reference to civic duty per Article 18 but without explicating an emergency situation or state of exception, the AKP interpellated the obliged physicians as individuals indebted to nation-state. So, CPS was not forced labor when it was a civic duty—which seems suspiciously close to a backdoor entry of TNCPR by another name.
Thus, the 2005 law exempted from CPS those individuals who had gained their medical education abroad. The wording of the relevant article in the new law indicates that it was just transferred from the relevant article of the CPS law enacted by the military regime. In this view, it is the fact that educational expenses at Turkish medical schools are met by the state that makes these students indebted to the nation-state, which thereby acquires a legitimate ground to require the graduates to reciprocate when necessary. The article was annulled by the Constitutional Court in 2006 on the grounds that it violated the constitutional principle of equality; however, the main body of the law is still in force.Footnote 18
The polemical exchange between Mustafa Özyurt (CHP) and Osman Kılıç (AKP) also reveals that the AKP did not legitimize CPS as a case of exception to the rule. The legitimacy was rather grounded in an aspect of TNCPR, where the individual is indebted to nation-state, pointing to the public expenses made for training physicians:
Özyurt: There is … a distinction between those who study abroad and those who study at home; I mean, are they the children of different countries? You say to them [those who study abroad] that you are not obliged to fulfill CPS, whereas you say to others [who study at home] that you are obliged to fulfill CPS.
Kılıç: Ok, but how much does it cost to train a physician?
Özyurt: What about those [who study abroad]?
Kılıç: They are funded by their parents. (TBMM 2005, 578)
The continuity of the CPS of the AKP with that of the military regime of the 1980s was not limited to their both relying on the conception of the individual indebted to the nation-state. The civic-duty conception of the AKP CPS law was informed more by the 1982 Constitution than the 1961 Constitution, insofar as civic duty is to the state (Parla Reference Parla1991, 37). Again, the 2005 CPS law refers to it as a “state service.” This reveals an understanding of the individual’s relationship to state and nation that denies the autonomous reality of gift- and counter-gift reciprocity of nation and instead subsumes it to the plunder and redistribution mechanics of the state. One can see this most clearly in one aspect of the AKP style of redistribution through social policy, whereby redistribution is treated not as a matter of national solidarity financed by the national budget but rather enacted as a paternalistic way to “portray an image of Erdoğan as the protector of and provider for Turkish society” (Aslan Reference Aslan and Tezcür2022, 400).
Conclusion
The findings of this article can be extended to many directions and discussions. Here, I will briefly touch on only two of these. As mentioned in the introduction, our knowledge of the influence of Turkish nationalism on social policy is very limited. Undoubtedly, the well-established scholarly conviction that Turkish nationalism has an extremist ideopolitical orientation and adopts an aggressive and assimilative form of identity politics that has nothing to do with mundane politics of redistribution has had a major part in this neglect in the context of social policy. The general criticism leveled by Billig (Reference Billig1995) at nationalism scholars concerning their indifference to everyday, not immediately political forms of nationalism also applies to the Turkish case.
Concomitantly, when classifying variants of Turkish nationalism, the standard procedure is to focus on the explicit political content of discourses on belonging, citizenship, rights, and sovereignty to identify the elements on which emphasis is placed. Then, distinctions are made between civic, ethnic, racist, Islamic, and Kemalist versions of Turkish nationalism (Bora Reference Bora, Kadıoğlu and Keyman2011).
One of the main contributions of this article is movement beyond this descriptivism/politicism and provision of more substantive and deeper distinctions—namely, TNCCE and TNCPR. Established through analysis of the discourses at work in the redistribution of resources, these variants of nationalism are substantive in the sense that their discursive formations have a material foundation; they owe their conceptual consistency and specificity to being rooted in a specific mode of exchange (plunder and redistribution or commodity exchange). They are also deeper and more analytical distinctions because they pierce the veil and help us see the beyond. Most strikingly, the perspectives enabled by these distinctions provide for an analysis of the DP and AKP as, even in the heyday of their liberalism, harboring authoritarian potentials in their ideopolitical formation. Their subsequent authoritarian turns, the findings suggest, may have not been deviations from their original positions and can rather be seen as the actulization of authoritarian potentials already present from the beginning. It is also shown that despite the Kemalist rhetoric around solidarist corporatism, including the notion of the individual indebted to the nation, Kemalist leadership consistently attached normative importance to the notion of the rights-bearing individual when responding to a critical social policy issue. This means that, rather than a guiding principle, the solidarist corporatist notion of the indebted individual may have been a rhetorical device legitimizing the sovereign gesture of suspending individual rights when they conflicted with the Kemalist project of nation-state modernity.
This analysis also contributes to our understanding of the weakness of social citizenship in Turkey (Buğra Reference Buğra2007). Social citizenship refers to a form of claim to redistribution (entitlements, provisions, public services) made by rights-bearing individual citizens with reference to their legally defined rights. Turkish nationalism, however—specifically its state-centered version, which has been the prevalent form of Turkish nationalism throughout the history of the Republic—relies on plunder-redistribution mechanics and necessarily produces and operates through the individual’s indebtedness to the nation-state. In the plunder-redistribution mechanics of TNCPR, the redistributive expenses of the state reflect a unilateral, top-down, benevolent gesture and institute the recipients as potentially indebted to the state (to which they should be submissive, including ready to be plundered when necessary) in return for what is bestowed. Therefore, TNCPR can be considered as an anditode to social citizenship, hindering the development of the notion of the rights-bearing citizen.
Disclosure
None.
Open access
