The present volume focuses on the process by which state healthcare and sanitation systems were introduced to the provinces of the modern Ottoman Empire. It aims to overcome the limitations of Orientalist frameworks, such as the concepts of “delayed modernization” and “insufficiency arguments,” by emphasizing the continuity of healthcare and sanitation policies with those of the Republic of Turkey. Whereas previous studies primarily analyzed central government healthcare policies, the most significant contribution of this research lies in its concrete analysis of how central state healthcare unfolded in provincial cities, using Izmir – the second-largest port city after the capital, Istanbul – as a case study. Consequently, Chapters 1 through 5 discuss five themes: the implementation of central policies, their application to urban administration, cholera countermeasures, the duties of municipal physicians, and the professionalization of healthcare.

Chapter 1 offers a comprehensive survey of the pertinent legislation, organizational frameworks, and personnel training systems for local medical and sanitary administration. It establishes that municipal administrative physicians were appointed as medical professionals following the reorganization of local administrative systems in the late nineteenth century and beyond, with Izmir receiving a relatively larger number of such appointments compared to other regions. Moreover, it is noted that the turn of the twentieth century signified a pivotal moment for the dissemination of the national healthcare system to the provinces. In order to address the shortage of private physicians, civilian medical schools were established. These institutions systematically provided medical education in Turkish, graduating hundreds of students who were appointed as municipal administrative physicians in local governments.

Chapter 2 examines public health measures implemented by the urban municipality of Izmir, discussing the expansion of water and sewer systems, the strengthening of city cleaning efforts, and interventions in the living conditions of the poor. While the collection and disposal of rags and bones have been viewed primarily as fiscal issues, the author concludes that this alone does not fully explain the relationship between residents and the municipality regarding Izmir’s sanitation problems. As evidenced by the movement demanding the extension of the water supply system, “grassroots movements” toward modern sanitation facilities were also crucial. The author emphasizes these “bottom-up” demands, evaluating that sanitation administration unfolded not only through unilateral policy promotion from the central government to localities but also in a manner that accommodated demands from local residents.

Chapter 3 examines the cholera pandemic and the countermeasures implemented, exploring how Izmir’s infectious disease policies underwent a transformation “through the adoption of medical knowledge in bacteriology.” The study posits that these measures were not wholly supplanted by novel approaches, but rather “repositioned within a novel intellectual framework for disease and health incorporating bacteriology.” The threat of cholera and the subsequent epidemic prevention measures not only led to the maintenance of urban administration and infrastructure development but also compelled residents to adopt new lifestyle habits and prioritize physical health.

Chapter 4 examines “the specific duties and roles of municipal physicians employed by city governments who served as the core of local medical and sanitary services.” It is evident that these medical professionals made substantial contributions to the maintenance of community health. Their contributions encompassed not only the treatment of patients but also the implementation of smallpox vaccination programs, the management of food safety, and the dissemination of public health education. Notwithstanding the elevated demand for medical care experienced by the local population, the financial burden of medical expenses relative to personal income levels was considerable. This development subsequently gave rise to the concept of “separation of medical and pharmaceutical services,” which entailed the delineation of roles and responsibilities between physicians and pharmacies. However, physicians’ practice of medicine within pharmacies was subsequently prohibited.

Chapter 5 delves into the manner in which municipal administrative physicians, confronted with a plethora of responsibilities, proactively pursued the “medical professionalization” process to establish their social standing as “legitimate” physicians. Concurrent with government crackdowns on non-legitimate physicians, municipal administrative physicians actively advocated for medical professionalization as “caretakers of national medical and sanitary administration.” In this sense, the professionalization of medicine in modern Turkey can also be attributed to the economic demands of municipal administrative physicians, who, in response to competition from non-regular practitioners and the resulting employment insecurity, advocated for fair treatment.

As previously mentioned, the objective of this book is to examine the reality of the Ottoman Empire’s national healthcare system. This system was centered on municipal administrative physicians. These physicians were graduates of civilian medical schools. They were employed by urban municipalities and became the foundation of national medical services. Previous studies have focused on the adoption of modern medical and hygienic knowledge, emphasizing either the progress made or the stagnation caused by bureaucratic misunderstanding, public ignorance, financial difficulties, unpaid salaries, and physician shortages. This research is noteworthy for its ability to transcend these binary oppositions and re-examine the history of state healthcare from the regional perspective of Izmir. In light of the aforementioned points, it is essential to acknowledge the limitations of the present review, which, it should be noted, was conducted by a reviewer with a primary focus on the economic history of East Asia. This perspective inevitably gives rise to a number of questions regarding the medical and sanitary systems studied.

Initially, the author identifies the “germ” or “birth” of state healthcare. The early Turkish Republic’s local medical and sanitary administration, which was based on the appointment and assignment of public physicians, is regarded as having continuity from the Ottoman period. The dispatch of “local physicians” from the central government to the provinces is another indication of continuity with the Turkish Republic period. The author’s argument is supported by an observation made by Erdem Aydin. According to Aydin, municipal administrative physicians “promoted public health administration in the provinces in cooperation with health personnel such as vaccination officers and chemical analysts.” These physicians, therefore, represent the “germ” or “birth” of state healthcare. This conclusion is derived from an institutional history approach, and while the research methodology appears valid, the question of whether the diverse policies implemented by the state were effective remains an area to be examined within policy history.

Pursuing this point entails the risk of inevitably arriving at the “insufficiency argument,” which the author critiques. Nevertheless, a discussion of health transformations over the long term necessitates the use of objective metrics, such as morbidity and mortality rates. The utilization of newspaper articles as a primary source for the reconstruction of public health conditions in Izmir is indicative of the absence of systematically preserved policy documents and municipal medical officer reports. Nevertheless, ex post facto evaluations of specific policies remain indispensable. Even if institutional measures were introduced, if they proved entirely ineffective, they cannot be considered a genuine implementation. In such cases, they must be evaluated as the “historical preconditions” for the Turkish Republic’s national healthcare system.

The subsequent issue to be addressed is the conflict between “official” municipal physicians and “unofficial” or “unlicensed” medical practitioners. As modern medical education, including military medical schools, developed, a qualification system was established. This system prohibited “medical practice by physicians” without a diploma from specialized medical schools within or outside the empire. Nonetheless, in actuality, despite the continuous escalation in medical demand, physician shortages have led to the central government’s tolerance of unlicensed practice and local communities’ petitioning for the employment of unqualified practitioners. This has resulted in a substantial number of “unlicensed” medical providers. This development led to a situation of “competition with unlicensed practitioners” for municipal administrative physicians. In order to ensure that patients are regarded as “customers” and to safeguard their rights as licensed practitioners, professional interest groups were established.

Consequently, while endeavoring to portray history through the prism of “licensed versus unlicensed,” the most contentious aspect of modern medicine’s proliferation in East Asia pertained to the establishment of relationships with “traditional medicine.” With the establishment of government-run medical schools and hospitals, traditional practitioners were marginalized and ousted from the core of medical practice. Consequently, the establishment of medical schools and the subsequent training of physicians in Western medicine led to the development of a medical system that is centered on Western medicine. This resulted in the relegation of traditional medicine to a supplementary role. Consequently, traditional practitioners assumed the role of transitional alternative medical practitioners in rural areas where Western medical services were unavailable. In response, practitioners of traditional medicine moved beyond a passive stance of seeking to justify their existence by subordinating themselves to the hegemony of Western medicine. They initiated a movement to revive traditional medicine.

The author posits that the professionalization of medicine was not so much a conflict stemming from discrepancies in treatment methodologies between modern and traditional medicine, but rather, a discord surrounding the valuation of specialized knowledge and the remuneration thereof (p. 185). The indigenous nature of healthcare is the focus of this study. It is well-documented that traditional practitioners who fulfilled the role of physicians long before the advent of “official doctors” trained in modern medicine were inevitably categorized as “unofficial doctors.” In this sense, the conflict with unlicensed practitioners may not have merely signified opposition to physicians lacking proper modern training but also represented a broader process of reevaluating medical knowledge. When examining the subject through the lens of not only medical knowledge but also technology, it becomes evident that when novel technological advancements are introduced and disseminated, they ultimately replace existing technologies and become the standard for a specific era and geographic region. Consequently, the process of professionalization in the field of medicine is often interpreted as a significant disconnection from traditional medical practices.

Conversely, the explicit adoption of an analytical framework centered on the medical market has the potential to facilitate a more comprehensive evaluation. In essence, while general practitioners were at liberty to offer medical services in accordance with market principles, municipal administrative physicians were formally barred from receiving remuneration directly from patients. As a result, patients were able to receive medical services free of charge. Confronted with financial constraints, municipal physicians sought to augment their incomes by establishing arrangements with pharmacies and implementing a streamlined medical insurance system. Conversely, unlicensed practitioners, though operating illegally, were effectively tolerated within local communities, thereby enabling them to provide low-cost medical services. In light of the limited financial resources available to municipalities, there have been instances where unlicensed practitioners have effectively served as municipal administrative physicians. The professionalization of medicine in response to this situation has been shown to have the effect of excluding competitors from the healthcare market. Consequently, the reviewer is compelled to conclude that the definition of “unlicensed practitioners” likely encompasses “traditional practitioners.”

These inquiries represent merely marginal reservations raised in the face of the author’s substantial endeavor to surmount linguistic barriers and documentary limitations in an effort to elucidate a particular aspect of the medical institutionalization of the Ottoman Empire from a local vantage point. It is the intention of future research to use the biographical documents of municipal administrative physicians to clarify their origins and educational backgrounds. The image of the modern Ottoman Empire as a vast bureaucratic organization will thus be illuminated further.