1 Introduction

Scarlet fever, one of the infectious diseases, has become an epidemic in some historical periods and caused thousands of people to die [1, 2]. The first scarlet fever was identified in Germany in the sixteenth century, the epidemic was recorded in the early seventeenth century, and the scarlet fever epidemic caused deaths in Germany in 1827 [3]. Between 1820 and 1880, scarlet fever epidemics were reported worldwide, especially in Europe and North America [1]. More than 30,000 people died of scarlet fever in England in 1863s [4] and 12,039 died in Prussia in 1900s [5]. Scarlet fever caused the death of 42% of patient children (between 2 and 8 years of age) between 1958 and 1959s [1]. In 2014s, a scarlet fever epidemic caused by Streptococcus pyogenes was reported in England [6]. In Hong Kong, more than 900 scarlet fever cases were recorded from January to July 2011; six of them developed toxic shock syndrome, and 2 of them died [7]. Scarlet fever was one of the most severe infectious diseases before the 1940s when antibiotics were not widely used. Scarlet fever was once highly prevalent in the global population and was associated with high mortality rates [6, 7]. The disease is transmitted from person to person through droplets of saliva that come out of the mouth during coughing, sneezing and speaking. The disease incubation lasts 3–5 days, and the temperature rises to 39–40 ºC. Although the person may experience sore throat, enlarged lymph nodes, muscle and headache, red rashes in the form of dots appear on the skin [1, 8, 9]. Recent epidemics (such as Covid-19) have shown that epidemics must be kept in mind to successfully identify and track the pathogen, treat patients, and prevent poor outcomes. Scarlet fever can spread rapidly in crowded and closed environments, and considering that people in today’s world stay and live in public spaces more than ever before, it is essential to remember epidemic diseases such as scarlet fever. Research indicated that scarlet fever has invasive potential, which could profoundly impact the future global health burden [10, 11]. Because S. pyogens can adapt well to different environmental conditions [12]. In the Ottoman Empire and the early Republic of Turkey (new international name Turkey), there was not enough literature about the prevalence of the scarlet fever epidemic, the mortality status and the fight against the disease [13]. This study has investigated the incidence of scarlet fever in the Anatolian and Balkan settlements of the Ottoman Empire, its effects on the public and the measures taken for the control of the disease in the documents of the Ottoman Archive (BAO) of the Presidential State Archives of the Republic of Türkiy and the literature. The incidence of scarlet fever in the Republic of Turkey, its effects on the public and the precautions taken in the literature of the early Turkish Republic period (from 1920 to 1930) were also investigated.

2 Materials and methods

BAO is an archive containing notebooks written in the Arabic alphabet and all other documents, where all correspondence and information such as agreements signed by the Ottoman Empire, orders given within the Ottoman Empire, decisions taken, problems encountered from the first years of the Ottoman Empire until its collapse are kept.

At the beginning of the study, which was conducted between 19 March and 12 December 2023, comprehensive literature research on the subject was first conducted. Comprehensive research was carried out in archival documents regarding scarlet fever in the Republic of Turkey Presidency State Archives Ottoman Archives (BOA) and the early Republic Archive (BCA) (except the city of İstanbul). The online research was conducted through the BOA and BCA catalogs about scarlet fever with the words “scarlet”, “scarlatin”, “flower tongue” and “red”. Online research was carried out at https://katalog.devletarsivleri.gov.tr/ using the E-government membership procedures. A fee per document was paid to the Directorate of State Archives for viewing documents online from the Republic Archive and the Ottoman Archive Complex. In addition, scarlet fever was researched within the scope of the subject in the literature. Other diseases identified in the documents in which scarlet fever was identified were also evaluated.

As a result of the scanning, 44 documents from the BAO, and four literature publications regarding scarlet fever and its epidemic were identified. Archive documents written in the Ottoman Arabic alphabet were obtained from the archive and they were transcribed into the modern Turkish language. Examples of archiving documents in the Ottoman Arabic alphabet are given in Fig. 1. Then, the study of scarlet fever in the Ottoman Empire and the early Turkish Republic period (from 1920 to 1930s) was written, supported by the sources obtained from the literature research. The article, written in modern Turkish, was completed in English.

Fig. 1
figure 1

Ottoman Empire archive documents images: a: BAO, 185–18,407 and b: BAO, 8–88

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Identified archive documents The following documents are identified in the BAO: 51–85/MKT.MHM, 1444–10/DH.MKT, 1445–76/DH.MKT, 1745–93/DH.MKT, 1748–49/DH.MKT, 732–113/HR.SFR, 69–84/HR.TO, 817–61,204/BEO, 2526–30/DH.MKT, 2524–85/DH.MKT, 2591–59/DH.MKT, 100–7/İ.HUS, 770–44/DH.MKT, 784–28/DH.MKT, 1037–30/DH.MKT, 161–16,053/TFR.I.SL, 162–16,164/TFR.I.SL, 165–16,466/TFR.I.SL, 182–18,184/TFR.I.KV, 185–18,407/TFR.I.KV, 1255–43/DH.MKT, 2822–20/DH.MKT, 843–60/DH.MKT, 1449–28/DH.MKT, 1756–16/DH.MKT, 1825–81/DH.MKT, 8–88/DH.MKT, 21–45/DH.MKT, 2057–56/DH.MKT, 421–60/MF.MKT, 2131–11/DH.MKT, 2145–75/DH.MKT, 2168–84/DH.MKT, 2169–74/DH.MKT, 2334–20/DH.MKT, 2431–82/DH.MKT, 1130–14/DH.MKT, 1186–91/DH.MKT, 200–57/MF.İBT, 1219–66/DH.MKT, 16–6/DH.MUİ, 225–24/MF.İBT, 9–11/DH.MUİ ve 54–12/DH.MUİ.

3 Results and discussion

The number of documents mentioning scarlet fever in the Ottoman Empire (except İstanbul) was 44 in the Ottoman archive and four from the literature, and two documents were found during the founding years of the Republic of Turkey (Table 1). Scarlet fever was common in the settlements of the Ottoman Empire in the Balkans and Anatolia.

Table 1 Scarlet fever in the Ottoman Empire and during the establishment of the Turkish Republic
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Countries that are now different nations but were under the control of the Ottoman Empire during those periods: (i) Countries under the sovereignty of the Ottoman Empire in the eighteenth century: Hungary. (ii) Countries under the sovereignty of the Ottoman Empire in the nineteenth century: Greece, Bosnia and Herzegovina, Moldova, and Croatia. (iii) Countries under the sovereignty of the Ottoman Empire in the twentieth century: Republic of Turkey (Thrace and Anatolia), Albania, Bulgaria, Kosovo, Macedonia, Romania, Serbia, Montenegro, Palestine, Iraq, Israel, Lebanon, Syria, Saudi Arabia, Jordan, Bahrain, Libya, Southern Cyprus and Northern Cyprus Turkish Republic.

3.1 First recorded scarlet fever

The first scarlet fever was mentioned in the BAO document dated 3 January 1853 (BAO, 51–85). In the document in question, it was stated that there was an epidemic of scarlet fever in Austria and that the necessary precautions were taken to prevent the disease from spreading Austria to the province of Shkodër, but that scarlet fever spread in a short time, caused deaths and that the disease predominantly affected children. Scarlet fever in the Anatolian settlements of the Ottoman Empire was first mentioned in the document dated 20 September 1887 (BAO, 1449–28). In this document, it was stated that a few children died daily from scarlet fever in Kale-i Sultaniye on the Anatolian side of Çanakkale and that the deaths decreased with the measures taken.

3.2 Scarlet fever in archive documents

Scarlet fever in the number of documents and people affected by it was given in Table 1. It was determined that scarlet fever was included in two literature documents during the founding years of the Republic of Turkey. In these documents, scarlet fever was given collectively by year, without distinguishing between children and adults. It was determined that 8843 scarlet fever patients appeared between the 1920s and 1930s, and 1681 (19.0%) of them died (Table 1). The number of archive documents stating scarlet disease in Balkan settlements in the Ottoman Empire was 23 and the number of literature document was one (Özdemir 2009), while the number of archive documents containing scarlet disease in Anatolian settlements was 21 and the number of literature documents was 3 (Trainor et al. 1999; Özdemir 2009). Some of the documents did not specify how many patients were present or died; only scarlet fever (25 documents), epidemic (23 documents), many deaths (10 documents), or several deaths per day (1 document) were specified. The individuals suffering from scarlet fever were also indicated as people in some documents, not differentiated as adults and children. The number of scarlet fever patients in Balkan settlements was 147. It was determined that 36 (24.5%) of them were children and 6 (16.7%) of the children died, while 111 (75.5%) people were sick and 48 (43.2%) of them died. The number of people with scarlet fever in Anatolian settlements was 1225. It was determined that 429 (35.0%) of them were children and 76 (17.7%) of them died, it was determined that 796 (65.0%) people had scarlet fever and 49 (6.2%) of them died. Only one document (BAO, 1756–16) stated that many people had scarlet fever (717 diseases), but deaths from scarlet fever were not noted. As in most other documents, no distinction was made between children, adults, or natioıns.

In Ottoman archive documents, it is indicated that the number of adults who died from scarlet fever is higher compared to children. On the other hand, the number of documents indicating scarlet fever in schools is significantly higher than that of outside schools. It has been determined that the number of people who regained their health after treatment for scarlet fever is significantly higher than those who died.

3.3 Regional differences

While 36.7% of scarlet fever patients died in Balkan settlements, 10.2.7% died in Anatolian settlements (Table 1). The mortality rate from scarlet fever in the Ottoman Empire was 13.0%. Worldwide scarlet fever mortality rate was 15–20% [1, 2]. The number of people who died from scarlet fever in the Ottoman Empire from 1853s, when the first scarlet fever was recorded, to 1919s was 896. It was stated that between 1850 and 1910, there were 227 deaths caused by scarlet fever in four towns in Massachusetts, and 220 of them (96.92%) were children under the age of 16 [1]. Of these, 206 were children between 11 and 16, while 21 were children under 10 [14]. In our study, infant deaths were not mentioned in the documents. In the literature, infant deaths were reported in minimal numbers. It was stated that scarlet fever and deaths in babies were very low, and the reason for this was the antibodies received from the mother [14]. It can be stated that the highest death rate, both in our research and in the world, occurs in children (between the ages of 4–14) [1].

In the archival documents, it is mentioned that other epidemic diseases were also noted when scarlet fever was seen. In the Balkans, three documents mention scarlet fever along with measles; one mentions scarlet fever along with measles and whooping cough; one mentions scarlet fever along with yellow fever; and one mentions scarlet fever along with smallpox. In Anatolia, one documents mention scarlet fever along with measles; one mentions scarlet fever along with measles and cold; one mentions scarlet fever along with rosehip; and one mentions scarlet fever along with diphtheria.

It has been stated in a document that scarlet fever has been eradicated through the measures and treatments taken (school closures, serum administration, isolation of patients, bath application and burning of patient belongings), and quarantine needs to be applied due to the ongoing yellow fever epidemic.

3.4 Precautions taken against infection and the spread of the disease

It has been determined that when scarlet fever is seen and becomes epidemic, the authorities are notified and the health authorities immediately prevent the further spread of the disease and reduce deaths by applying cooling and relaxing procedures such as quarantine in the places where the disease is seen, giving serum to the patients and bathing. In addition, patients burning the items they used effectively prevented the spread of the disease. It has been determined that disinfecting schools and buildings where the disease is seen are important measures to prevent the spread of the disease. It has been determined from archive sources that when scarlet fever patients are treated under the supervision of doctors and paramedics, the patients recover and the deaths decrease. Patients with scarlet fever were given serum by healthcare personnel, and baths were given to the patients at their homes or hospitals. Treatment of patients was carried out in isolation at home or in hospitals. Patients with scarlet fever were given serum by healthcare personnel and they were asked to take baths at their homes or hospitals. The treatment of patients was carried out in isolation at home or in hospitals. The research has determined that when these are applied effectively, the disease can be treated and deaths can be reduced. The public was informed about scarlet fever through newspaper articles and visual posters.

In the Ottoman Empire, people tried to raise awareness by including informative articles about contagious and epidemic diseases in periodicals (such as newspapers and magazines). Especially in primary and secondary schools, articles and texts on healthy living were taught. Recommendations on how to implement and ensure hygiene in schools, at home, or personally were stated in practices and writings [15,16,17,18]. In these articles, articles were written on how to give first aid to the patient before the doctor arrived when symptoms of infectious diseases such as scarlet fever were seen. During the early Turkish Republic period, when communication and communication opportunities were limited, efforts were made to raise public awareness in the fight against infectious diseases. For this purpose, efforts were made to inform the public about contagious and epidemic diseases in schools and places of worship [19, 20]. Hygiene measures recommended against scarlet fever in 1890s were stated as follows [9, 20]. Houses where scarlet fever is first seen should be isolated, and after the patients recover or die, the houses should be cleaned and disinfected. There should be cars and stretchers to be used only for infectious diseases, the bodies of the dead should be carried to the cemetery without being damaged and buried, the coffin in which the dead is carried should be burned and the used covers should be disinfected or burned. Abundant and clean water should be provided primarily to the poor, and the streets should be swept daily and washed occasionally. Crowded old houses should be demolished and replaced with healthy and airy houses, plans for the buildings to be built should be submitted to the sanitary council, and sewers should be cleaned regularly and their flow should be ensured. When information about a disease is received, the authorities should be notified immediately [9]. In the minutes of the Ottoman Parliament in 1914s, it was emphasized that epidemic diseases were spreading and causing deaths by saying that our population was decreasing and people were dying from diseases such as malaria, syphilis, tuberculosis, scarlet fever, measles and smallpox all over the country [9, 21].

In the Ottoman Empire, schools were closed to prevent the spread of scarlet fever in settlements where scarlet fever was detected (BOA, 421–60, BOA, 1219–66 and BOA, 225–24). For disinfection and sterilization processes against epidemic diseases, sterilization machines (“etüv” or “tebhir”) and portable disinfection machines (“pulverizer”) located in buildings (“tebhirhane”) and quarantine places (“tahaffuzhane”) were used (Fig. 2) [13, 22, 23]. Portable disinfection machines (“tebhir”) were used to clean the air of the rooms (hospital, school, home, etc.) where the patient was located, while sterilization machines were used to sterilize the clothes, belongings and bed materials of the patients. Sterilization was done in the “tebhir” for 15 min using a mixture of steam-hot air (110 ºC) or chemicals (phenolic acid and calcium chloride). The air was disinfected by spraying a chemical (mercury-2 chlorine solution) from the portable disinfection machine [13]. It was impossible to establish a disinfection building everywhere in places where there was no disinfection building, the patient’s belongings, clothes and bedding were burned to prevent the transmission and spread of scarlet fever to others [24].

Fig. 2
figure 2

a Portable disinfection machine (“pulverizer”) and b sterilization machine (“etüv” or “tebhir”) [15, 22]

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Quarantine was one of the most effective methods to prevent the spread of epidemic diseases in the Ottoman Empire. However, due to the religious sensitivities of the Ottoman society, there were difficulties in the implementation of quarantine, and it took a long time for the quarantine and disinfectant practices to be adopted by the society. To fight epidemics, the Ottoman Empire established a health organization called the Quarantine Assembly (“Meclis-i Tahaffuz”) in 1838 [25]. In addition, a quarantine building (“Tahaffuzhane”) was established in 1838s to quarantine and treat passengers coming to the Ottoman Empire and people coming from another city or country were hosted for a while and their health checks were carried out [26, 27].

3.5 Public’s approach to the measures taken

When an epidemic disease was detected in the Ottoman Empire, effective measures were taken to prevent the epidemic from spreading. Wherever the disease was detected, quarantine was applied there (27). In some cases, society was insensitive to the measures taken by the Ottoman Empire against epidemic diseases, so it took a long time to implement them. The Ottoman society did not comply with the quarantine rules that the state wanted to implement in 1831 and again resisted the disinfection to be implemented in the 1890s to prevent diseases. People considered “disinfection” a foreign word, understood it as a bad process and did not want to apply disinfection procedures. State officials then preferred to use Arabic words such as “tathir” and “tanzif” (both words mean disinfection) instead of the word disinfection. Therefore, while the Ottoman Empire fulfilled the medical requirements of the period, it also took social reactions into account and took the necessary precautions to not compromise on the control of epidemic diseases [28].

3.6 Effects of war and industrialization on disease

In parallel with industrialization and transportation opportunities in the nineteenth century, the spread of epidemic diseases accelerated, and this situation was experienced in the Ottoman Empire and all over the world [11, 29]. At the end of the first quarter of the twentieth century, when the Anatolian people entered the War of Independence, in terms of epidemics, the people were deprived of all kinds of infrastructure and healthy living conditions, and more than 50% of them fell ill, died or were “disabled” due to cholera, typhus, scarlet fever, and other epidemic and infectious diseases [30]. Epidemic diseases reached high numbers, especially among immigrants who escaped the war and settled in Anatolia. Despite the extraordinary efforts of doctors, diseases were seen as epidemics everywhere starting from 1920 [31]. The poor socioeconomic situation of the people due to the First World War that the Ottoman Empire went through just before the establishment of the Republic and then the Turkish War of Independence, also led to an increase in infectious diseases. Researchers analyzing scarlet fever in England and Wales found that malnutrition increased child mortality [10]. In addition, in the intense wars between the nineteenth century and 1919s (Ottoman-Russian, Balkan and First World Wars) effects such as the loss of too many health personnel and trained people, the death of young and middle-aged people in the wars, malnutrition and failure to take health precautions became factors in the increase in fatalities. During war periods and as a result of the war, the people’s inability to access sufficient food, their inability to provide hygienic conditions and their inability to receive adequate health services were factors in these increases [9]. During the same period, scarlet fever was also seen in Europe. In 1924s, 798 people in Germany and 84,652 people in England suffered scarlet fever, but no deaths occurred [5]. However, in Bulgaria, one of Turkey’s neighbors, 1360 of 7466 patients died. During these years, Scotland, Canada, Austria, Czechoslovakia and Yugoslavia were other countries where scarlet fever caused death. Scarlet fever epidemics were common in Europe in the seventeenth and eighteenth centuries [1]. There were four scarlet fever epidemics in North America between 1520 and 1899s [9]. The first description of scarlet fever was made in 1553 in the world. A complete understanding of the disease was achieved in 1924 [1, 3]. After identifying the scarlet fever causative agent, it took time for countries to take precautions in line with this information. The Republic of Turkey produced a vaccine against scarlet fever for the first time in 1926 and used this vaccine in treating scarlet fever in Konya [32].

3.7 Effect of demographic and socioeconomic structure on the disease

In Ottoman documents, the demographic structure of the society is not as detailed as in the nations. It is only mentioned as adults and school-going children. In a simple document, it is stated that an older woman died of scarlet fever. Ottoman Empire society consisted of different nations. However, when reporting diseases, they were reported without specifying national differences. In most documents, it was determined that scarlet fever was seen among poor people living in villages and cities. Scarlet fever spread, and more deaths occurred in the villages, mainly due to reasons such as unhygienic conditions, separation of people, and lack of medical personnel. The increase in scarlet fever has been caused by poor people in the cities not being able to consult healthcare personnel in a timely manner due to economic reasons and the lack of awareness of the need to take the necessary precautions against the epidemic. Research shows that scarlet fever was much higher among those with inadequate economic power.

In 1899s, it was stated that three doctors were not enough due to the scarlet fever epidemic disease seen in Ankara, that five more doctors were needed for the treatment of poor patients, and that the doctors were sent to Ankara with a monthly salary of 10 thousand kuruş. It was reported that patients were prohibited from selling food or goods, 347 children suffered from scarlet fever, and 42 died. It was stated that a request was made to cover the additional expenses necessary for the burial of those who died of scarlet fever in Ankara (BOA, 2169–74). In 1909, it was stated that there was an epidemic of scarlet fever in Bolu Ereğli; many people died in the hospital, and it was difficult to prevent the epidemic; a doctor was urgently requested to be sent to Ereğli and the necessary measures were continued to be taken (BOA, 16–6).

Providing health services to the society in the Ottoman Empire was not the primary duty of the state. For this reason, the public mostly received health services from self-employed physicians for a fee [18]. However, it was determined that the state covered the treatment expenses of poor people who could not afford their health expenses during the epidemic.38 Providing health services to the community has been accepted as a duty of the state since the establishment of the Republic of Turkey (1920s). It was determined from the archive towns that those who came to the country as tourists or for any other reason in the Ottoman Empire were treated free of charge if they had scarlet fever (BAO, 843–60; BAO, 1745–93). In the Ottoman Empire, personnel were immediately provided when there was a lack of doctors or technical personnel in places where epidemics occurred during the fight against epidemic diseases (BAO, 2169–74; BAO, 1037–30; BAO, 182–18,184). When it was understood that the cause of scarlet fever was wells or stagnant water, it was determined that clean water was provided to the settlement (BAO, 2822–20).

Throughout the historical epidemics such as plague, measles, smallpox, Malaria, Plague, Malaria, Cholera and Chicken Pox in the Ottoman Empire affected both people and the states deeply. Plague epidemics were seen in Anatolia during the Byzantine, Seljuk and Ottoman Empire periods. In the Ottoman Empire. There were many plague epidemics in the century until the nineteenth century and caused the death of many people. In Istanbul, almost two-thirds of the population was exposed to plague epidemics in the eighteenth and nineteenth centuries. Another epidemic disease that was effective in the Ottoman lands was “cholera”. The cholera microbe, which was carried to Anatolia from Russia in 1821, first appeared in Eastern Anatolia, and then over time in Iraq and Syria. Wars, merchant ships coming from India and stopping at ports in Turkey, or pilgrims returning from Medina also played important roles in the transmission and spread of the disease [33]. In 1865, 11,631 people caught cholera in Istanbul in the Ottoman Empire, and 5073 of them. Again, 5314 people died in the cholera epidemic in Tarsus this year [34]. Many measles cases were encountered between 1900 and 1908. Cholera has been a global threat since the first quarter of the nineteenth century. Cholera was first seen in the Ottoman lands in 1822, and from then on it was a constant epidemic in the Ottoman lands, both in significant epidemics and in intermediate epidemics. In this century, when cholera shook the world in epidemics across continents, it was also on a large scale in the Ottoman country, at the intersection of sea and land trade routes. It caused casualties [35]. Syphilis was introduced to the Ottoman Empire in the fifteenth century. The disease was identified in the nineteenth century. In the nineteenth century, it spread as an epidemic within the empire’s borders and caused socioeconomic problems [36].

In the Ottoman Empire, methods such as bathing (BAO, 770–44) and serum administration (BAO, 100–7) were used to reduce the effects of scarlet fever on patients. In the Ottoman Empire, serums for scarlet fever were supplied from other countries (BAO, 2168–84). Scarled fiver epidemics decreased with the measures taken in some villages of the Tirgovishte district of Kosovo. There were no health personnel in Tirgoviş and its villages, and 104 people had scarlet fever and 47 of them died (BAO, 1255–43). An unfortunate situation occurred in Edirne due to scarlet fever during the Second Balkan War (1912–1913). It was stated that hunger and scarlet fever epidemics continued in this city, and the health condition in the city was deplorable and the epidemics of scarlet fever, cholera and dysentery started, and the water of the Arda River, which was full of children’s corpses, was not drinkable [9]. Hamidiye Etfal Hospital was opened in Istanbul in 1899s to treat infectious diseases more quickly and regularly. The hospital had 16 beds for foreigners visiting the Ottoman Empire [26]. In the days following the opening of the Grand National Assembly of Turkey and the establishment of the Turkish Grand National Assembly, the “Ministry of Health and Public Health”, numbered three and dated 2 May 1920, was established [32]. In 1928s, the law establishing the General Hygiene Institution was enacted and chemistry laboratories were established within the scope of this law [37]. Towards the end of the same year, the Mobile Communicable Disease Fighting Organization, consisting of three epidemic disease experts and eight mobile combat medics, was established to carry out infectious disease investigations in local areas and take the necessary precautions. With the field studies of the organization in question, great benefits were achieved in the fight against infectious diseases [32].

It has been identified that population movement and demographic changes in urbanization facilitate the spread of scarlet fever, and an aging population becomes more vulnerable to scarlet fever. Our research has determined that elderly individuals are more prevalent among adults who contract scarlet fever. Archival documents indicate that an older woman who contracted scarlet fever died. Epidemics are likely to arise and persist under conditions created by poverty. First, spreading infectious diseases often requires close and frequent contact between individuals, necessitating crowded living conditions and high (preferably rapid) mobility. Second, poor sanitation and hygiene allow bacteria, viruses, parasites (such as worms and amoebas), and transmission vectors to thrive. Third, weakened bodies are more easily infected and less able to fight infections; epidemics can develop in populations that are malnourished, weakened by other health issues, or have a high proportion of very young or very old members. Fourth, epidemics tend to arise where health systems are weakest and therefore, inadequate in detecting and responding to rapidly developing health threats. Finally, poverty conditions can lead individuals to engage in behaviors that facilitate disease transmission (e.g., sex workers or poor Chinese farmers in Henan province who contracted HIV from selling blood).

Wealth allows people to protect themselves against or mitigate the effects of many of these risk factors. The wealthy generally have less crowded living spaces than the poor, have greater access to healthcare, medications, and vaccines (and can better afford private care where state support is weak), and enjoy better sanitation and nutrition. Moreover, economic downturns frequently trigger the spread of disease. For instance, in Russia in the 1990s, political and economic stress had serious impacts on health systems. Diphtheria became widespread, and tuberculosis and measles reemerged [38].

4 Conclusion

Scarlet fever was an epidemic in the Ottoman Empire and the early Republic of Turkey. Despite scarlet fever, the medical knowledge of the period was applied as far as was known. During the founding phase of the Republic of Turkey, further measures were taken against epidemic diseases, such as providing free health services to the public and producing vaccines and serums. However, it was not possible to take the same precautions everywhere due to the inability to reach all settlements (such as towns and villages) under current conditions in both the Ottoman Empire and the Republic of Turkey. Due to the establishment of more effective disease screening (surveillance) systems in the Republic of Turkey than in the Ottoman Empire and the increasing group A streptococcal disease activity being considered a public health priority, health authorities made more patient notifications and registrations, and as a result, scarlet fever increased in the Republic of Turkey between 1920 and 1930.