New modeling of typhus infections in the Warsaw Ghetto during WWII reveals how public health interventions eradicated the disease.
Through state-of-the-art mathematical modeling and historical documents, the study points to community health programs and social distancing practices as the most likely explanations for the epidemic’s sudden and mysterious collapse, which was hailed by survivors at the time as a miracle.
The historical analysis underscores the critical importance of the cooperation and active recruitment of communities in efforts to defeat epidemics and pandemics such as COVID-19, rather than relying too heavily on government regulation.
Mathematician and disease modeler Professor Lewi Stone from RMIT University and Tel Aviv University led the study published in Science Advances, with collaborators from Hong Kong, Amsterdam and Berlin.
In 1941, the Nazi forces in Poland crammed more than 450,000 inmates into a confined 3.4 km2 area known as the Warsaw Ghetto.
“With poor conditions, rampant starvation and a population density five to 10 times higher than any city in the world today, the Warsaw Ghetto presented the perfect breeding ground for bacteria to spread typhus and it ripped through the mainly Jewish population there like a wild fire. Of course, the Nazis were well aware this would happen,” Stone says.
As many as 120,000 ghetto inmates were infected by typhus, with up to 30,000 dying directly from it and many more from starvation or a combination of both.
Stone says it was a historically documented case of disease being used as a weapon of war and as a pretext for genocide.
“Then, in October 1941, as a harsh winter was beginning and just as typhus rates would be expected to skyrocket, the epidemic curve suddenly and unexpectedly nose-dived to extinction,” he says.
“It was inexplicable at the time and many thought it was a miracle or irrational.”
The team’s mathematical modeling designed with theoretical ecologist Dr. Yael Artzy-Randrup (University of Amsterdam) together with modeling and statistical analysis carried out by Dr. Daihai He (Hong Kong Polytechnic University), shows the epidemic was in fact on track to become two to three times larger and peak in the middle of winter, just before it disappeared.
So what happened?
How the Ghetto beat typhus
Stone says the steady decline in disease transmission rates most likely reflects the success of behavioral interventions.
“Fortunately, many of the anti-epidemic activities and interventions are documented, and it turns out that Warsaw Ghetto had many experienced doctors and specialists,” he says.
“To learn more, I spent many, many hours in libraries around the world seeking rare documents or publications to find details about the interventions employed and the actual size of the epidemic itself, which was also poorly recorded.”
Stone found evidence of well organized training courses covering public hygiene and infectious diseases, hundreds of public lectures on the fight against typhus and an underground medical university for young students.
General hygiene and apartment cleanliness were encouraged and sometimes enforced. Social distancing was considered basic common sense, and home quarantining was not uncommon. Many volunteer soup kitchens were opened up in the period before the epidemic’s decline.
“In the end, it appears that the prolonged determined efforts of the ghetto doctors and anti-epidemic efforts of community workers paid off,” Stone says.
“There is no other way we can find to explain the data.”
Holocaust historian Stephan Lenstaedt from Touro College in Berlin assessed the team’s modeling in relation to archival material.
It tallied with primary sources including respected historian, Israel Gutman, who wrote “while almost 100,000 ghetto residents died mostly from starvation and disease in the period up until July 1942, a similar or greater number were saved thanks to the dedicated relief workers and self-help relief agencies operating.”
“The tragedy, of course,” says Stone, “is that almost all of those lives saved through these sacrifices, discipline and community programs would soon end in extermination at the Nazi death camps.”
Typhus – a bacterial disease spread by lice – had pandemic status in Europe. It is less contagious but deadlier than COVID-19.
While the two diseases spread and behave differently, the team says there are still parallels and lessons to be learnt.
“Today, more than ever, society needs to grasp how the damage caused by a tiny virus or bacteria can create utter havoc, dragging humankind to the terminal point of evil as witnessed over the Holocaust,” Stone says.
“As those in the Warsaw Ghetto demonstrated, however,” Artzy-Randrup explains, “the actions of individuals in practicing hygiene, social distancing and self-isolating when sick, can make a huge difference within the community to reduce the spread.
It is the cooperation and active recruitment of communities that beat epidemics and pandemics, not government regulations alone. Only recently have we witnessed at close view how essential community engagement has been in containing and defeating the deadly and horrifying spread of Ebola outbreaks across African countries.
This study is a unique instance where quantitative and qualitative methods could be used for revealing hidden historical processes at the interface of infectious diseases and society, that are directly relevant to the present COVID-19 crisis.
Unquestionably, there are invaluable lessons for us to learn from the past,” says Lehnstaedt.
The study, “Extraordinary curtailment of massive typhus epidemic in the Warsaw Ghetto,” is published in Science Advances.
The Holocaust (9) refers to the Nazi-German annihilation of some 6 million members of European Jewry during WWII (1939–1945). It is not widely known that this genocide was triggered in no small part by alleged public health concerns and Germany’s obsession with disease and fear of epidemics.
More specifically, there was a fanatical fear of typhus spreading to the German people and its army, given its previous impact as the cause of 5 million deaths after WWI. This was the pretense given by the Germans for the relocation of Jewish victims en masse into isolated closed ghettos and camps in wartime Europe (10–14).
However, the same fear of epidemics was also a pretext used by the Germans as justification to liquidate ghettos, including their residents.
Initially, the Germans did not even want to establish ghettos because these were considered to be nourishing ground for infections (10, 12). However, the German discourse on hygiene was very much influenced by the anti-Semitic idea of Jews being notorious bearers of diseases.
In the Nazis’ ideology, this evolved into Jews being the actual disease, so epidemics were to be naturally expected and dealt with, which in the end meant annihilating the Jews (13). Of course, hygiene was only one pretext driving Nazi anti-Semitism; but it played an important part in propaganda efforts to justify anti-Jewish hatred and politics in this period before the industrial killings.
By October 1941, when an epidemic was raging in the Warsaw Ghetto, Jost Walbaum, the Chief Health Officer of the General Government (Occupied Poland) infamously made the accusation: “The Jews are overwhelmingly the carriers and disseminators of typhus infection. … There are only two ways [to solve this].
We sentence the Jews in the ghetto to death by hunger or we shoot them…. We have one and only one responsibility, that the German people are not infected and endangered by these parasites. For that, any means must be right” (14).
These words were followed by applause and clapping from 100 attendees, mostly medical doctors. Previous to this, SS General Heydrich, the main architect of the Final Solution, specifically requested that the chief SS physician initiate an epidemic in Warsaw Ghetto to exterminate the Jews (15).
In addition, the highest German administrative authority in the General Government, Governor General Hans Frank, alleged in 1943 that the genocidal murder of 3 million Jews in Poland “was unavoidable for reasons of public health” (16, 17).
These are obvious cases of disease being used as a weapon of war and pretexts for genocide. Today, more than ever, society needs to grasp how a virus or bacterium can create utter havoc, dragging humankind to this terminal point of evil.
Figure 1 makes clear how several major events in the history of the Warsaw Ghetto over the period 1939–1942 synchronized perfectly with the epidemiological dynamics to help achieve the Nazis’ aim of exterminating the ghetto and its residents. The figure presents a time series of the monthly number of new reported typhus cases over two typhus epidemics that broke out in the ghetto. The first smaller outbreak initiated in September 1939 during Nazi Germany’s siege of Warsaw just after their aerial bombing severely damaged Warsaw’s sewage system and contaminated the water supply. Simultaneously, large numbers of refugees and exiles streamed into Warsaw, increasing the likelihood of an infection invading from the outside, which is exactly what happened (11, 18). The first smaller typhus epidemic over the winter ended naturally during the summer season (~August 1940).
The Germans feared another outbreak of typhus and thus created a Seuchensperrgebiet—literally a restricted disease area, which later would become the ghetto. On 5 October 1940, Jews were forbidden to leave this territory.
After 15 November 1940, a brick wall was built that surrounded the area. It was 3 m tall and 18 km long – the “epidemic wall,” and all of Warsaw’s then ~400,000 Jewish population were confined to remain within (10, 13).
With barbed wire at the top, only the most agile residents could escape, mostly through small gaps in the wall, burrowing underground or via the sewers. The sealing was an extreme form of quarantine.
The Germans prohibited the internees from leaving the ghetto for fear of the possibility that typhus might spread to the external Warsaw population and especially to the occupation personnel. At a certain point, the death penalty was enacted on escapees.
Our main interest is trying to quantify what happened in the so-called “Period of Indirect Extermination” (19) from the time the Warsaw Ghetto was sealed off, until the liquidation of the ghetto began on 22 July 1942 when more than 250,000 residents were quickly deported by train to their deaths in the gas chambers of the Treblinka extermination camp.
To help untangle what occurred, it is important to understand that the population dynamics over this period was largely controlled in two phases.
Phase 1: Starvation
Additional food supplies beyond the small amount the Jewish Council was able to buy were deliberately blocked from entering the ghetto until May 1941, but even later on, the official ration provided by the authorities often was no higher than 200 calories per day (18). Predictably, within a few months, residents began starving to death, leaving the impression of an epidemic of deaths. Mortality rates rapidly increased to large levels with 4000 to 5000 registered deaths per month, as shown in Fig. 2 (blue line). There is reasonable evidence demonstrating that the registered number of deaths is substantially less than the true number, which might be closer to that indicated by the red line in Fig. 2, even exceeding 9000 deaths per month as claimed by Penson (20), the head of the typhus ward of the Czyste Hospital (see section SM5). As described by ghetto commissar Heinz Auerswald: “A quantum leap in deaths for May of this year  showed that the food shortage had already grown into a famine” (11). The situation progressively worsened until human corpses covered with newspapers were a common sight on the streets (21, 22).
Phase 2: Typhus epidemic
The out-of-control rampant spread of typhus followed quickly on the heels of the horrific starvation phase. Typhus is a bacterium (Rickettsia prowazekii) spread by its vector, the human body louse (Pediculus humanus humanus).
The latter multiply prolifically under conditions of poor hygiene, filth, overcrowding, and cold weather – exactly the conditions of the ghetto (section SM2) (23, 24). Given its population density and overall conditions, little wonder that the ghetto was commonly referred to as an “incubator” of disease and “breeder of epidemics.”
Ludwik Hirszfeld, the eminent bacteriologist and Nobel Prize nominee living in the ghetto, had no doubts: “In the case of WW2, typhus was created by the Germans, precipitated by lack of food, soap, and water, and then – when one concentrates 400,000 wretches in one district, takes everything away from them, and gives them nothing, then one creates typhus. In this war, typhus is the work of the Germans” (16).
Lice thrive in large numbers on their human hosts, feed daily on their blood, and have rapid spatial spread, which allowed them to infest the entire cramped ghetto. For those infected, typhus typically has a ~14-day incubation period and results in a high fever, headache, muscle pain, nausea, chills, and extensive body rashes.
As the disease progresses, increasing weakness and delirium develop, and in some cases, loss of consciousness. Death can result within a few days for the worst cases.
Accounts may be found of sufferers jumping through windows in agony to their death. When the human host dies, the vector simply moves to another victim.
Quantifying what actually occurred in these two phases is the goal of this paper. Referring again to Fig. 1, the official number of monthly reported new typhus cases for both epidemic waves sums to a total of 20,160 reported cases.
Yet, according to the scattered reports of leading epidemiologists of the ghetto, there is reasonable consensus that a total of 80,000 to 110,000 residents were infected (19, 20, 25, 26).
This major discrepancy can be seen from referring to many of the reports we have collected and placed in section SM3 (see Supplementary Materials). The time series data in Fig. 1 thus indicate a low reporting rate of ~20 to 25%.
Many infected residents preferred not to report their illness given the potentially horrific punitive actions that might eventuate as a consequence.
The major study of Trunk (17) entitled “Epidemics and Mortality in the Warsaw Ghetto, 1939–1942” is the definitive statistical reference to what occurred in this period.
Yet, Trunk bases most of his conclusions on the very low numbers seen in the official registered data, which results in a misleading representation of what actually took place.
We will be examining these issues in depth as the paper proceeds and begin with a more detailed discussion and analysis of the epidemic dynamics.
THE VILNA GHETTO
Before the war, Vilna was a major European center of Jewish culture, and more than a third of the city’s residents were Jewish. Its erudite, highly organized, and multifaceted Jewish culture earned prewar Vilna the colloquial title “the Lithuanian Jerusalem.”
Setting the Stage for the War on Public Health
The Jewish community of Vilna was all too familiar with crisis. No fewer than nine civilian and military regimes, none of them benevolent, controlled the city between 1914 (when Vilna was part of czarist Russia) and 1923 (when it became part of Poland), all amid violent objections by the Lithuanians, who regarded Vilna as their historic capital.
During the interwar years, Jewish Vilna continued to flourish as a major Jewish center despite mounting anti-Semitism in the 1930s. When the Nazis invaded Poland, Vilna was first occupied by the Soviets, then briefly given to Lithuania, itself soon annexed to the Soviet Union, and then ultimately occupied by German troops.
When the Germans arrived in June 1941, approximately 60 000 Jews resided in the city (including a significant number of Jewish refugees from other parts of Poland).
Another 6500 had emigrated from Vilna to the United States, Palestine, and elsewhere.9a
Although it is clear that ghettoization was anticipated by many of the community leaders, who had weathered countless upheavals, the full truth of what was to come could not have been reasonably anticipated.
Shortly after the Germans occupied Vilna, liquidation of the predominantly poor, old Jewish section of the city commenced, clearing the site of the impending ghettos. Most residents were deported to the nearby Ponary forest and subsequently shot.
In total, 5000–10 000 Jews were killed during this three-day “purge.”10a
The two Jewish ghettos were established in Vilna on September 6, 1941, and the population was divided: those deemed fit for labor – about 30 000 people – were eventually sent to Ghetto I.
The remaining 11 000 people were sorted into Ghetto II, which was liquidated within a few weeks of inception. An additional 6000 Jews never made it into the ghettos but were detained and executed in the following days.10a
This was consistent with the ever-increasing violence of ghettoization in other parts of Europe that preceded the more mechanized killing associated with the Final Solution. Browning presents a more complete discussion of ghettoization preceding the Final Solution.11a
The Jews of Vilna were herded into the ghettos with less than an hour’s notice, bringing with them only what they could carry. As a result, the limited quantities of money, medicine, clean clothes, adequate shoes, and soap quickly vanished.
Wood and coal for heating were also chronically scarce. In the winters, maintaining heat was a constant battle, and indeed cold was among the greatest killers in the ghetto.10a
People were forced into unfamiliar and poorly equipped homes crowded with strangers. This extreme overcrowding immediately threatened health and sanitation. It has been estimated that the population density immediately increased by 7–10 times.10a
As a result, the old sewer systems, which were barely adequate for the poorer neighborhood before the war, were quickly overwhelmed. Most housing complexes had only outdoor privies with two to four seats each, which were originally intended for a population only one tenth the size of the ghetto.
The water supply was also inadequate – particularly in the winter, when the pipes froze in the unheated buildings. These factors made personal hygiene exceedingly difficult to maintain.10a
Just as few resources were allowed into the ghettos, little refuse was allowed out. Proper garbage removal and even burials were extremely limited. As a result, in the beginning, residences became soiled with excrement.
Garbage bins quickly overflowed, sometimes piling as high as second-story windows, with grave impact on both the physical and mental health of inhabitants.10a
A significant threat to the health of the ghetto was the constant influx of individuals from labor camps in the rural areas surrounding Vilna, as the living conditions were generally even worse in the labor camps than in the ghetto.
As these workers were transported to the ghetto, they further taxed the limited resources and infrastructure and were often exhausted, dirty, lice infested, and sick and thus constituted the greatest source of new diseases in the ghetto.10a
These challenges were common among the ghettos of the period.8a Indeed, the death tolls in other major ghettos were staggering: the entire Jewish population would have perished of disease, famine, and cold in a matter of years had the Nazis been willing to wait that long.8a Remarkably, however, such was not the case in the Vilna Ghetto.
Building a Framework for Public Health Resistance
The story of the Vilna Ghetto is exceptional, partly because of a collection of fortuitous circumstances.
Before the war, Vilna had been a key center for Jewish medicine.
In the weeks preceding the creation of the ghetto, the Vilna Jewish doctors met to plan for public health in extremis.
As had been hoped, Ghetto I ultimately encompassed the venerable prewar Jewish hospital and 130 Jewish doctors, who were thus able to facilitate the implementation of their plans.8a
The inclusion of such an invaluable asset within Vilna was unprecedented. Why the Nazis allowed the inclusion of the Jewish hospital is unclear, although it has been proposed that special connections held by persons such as Jacob Gens contributed to this anomaly.9a
Within the first days of the ghetto they created an organized system of public health, the pillars of which were prophylaxis, healing, and child care.8a,10a
At the behest of the Nazis, the Judenrat, or Jewish council, was formed within days of the ghetto’s inception. The Nazis demanded that this Jewish governing body, which was instated in all the ghettos across Europe, act as an intermediary to the Jewish population.
Among their motivations was the desire to gain tighter control of the Jews. The Nazis appointed five-member Judenrats in both Ghettos I and II. The first Judenrat in Ghetto I consisted of known public figures, whereas the appointments to the short-lived Judenrat in Ghetto II were more random.
Of course, the Judenrat was subject at all times to Nazi orders, but in addition it acted to govern many aspects of life in the ghetto, including food, work, housing, education, the Jewish police, and, first and foremost, public health.
To accomplish this, various committees and departments were created by the Judenrat, including the Sanitation Commission and the Epidemiological Section. 8a,10a
Furthermore, by contrast to substantially larger ghettos such as that of Warsaw, the implementation of systematized public health was perhaps made more manageable after the population purges that occurred both before and soon after ghettoization, which resulted in the death of nearly half of the Vilna Jewish population.
In July 1942 the Nazi authorities replaced the Judenrat with what amounted to a police regime led by Jacob Gens, who the Judenrat had appointed as the head of the Jewish police. Gens, who had been an officer in the Lithuanian army, assumed an increasingly active role in the ghetto.
Although this tight control was deeply resented by many ghetto inmates, it did facilitate strict adherence to the system of sanitation and health that had been established by the Judenrat. Although initial access to important medical capital, including health care workers, was not unique to the Vilna Ghetto, this particular confluence of resources must be taken into account when considering the innovation of the Vilna Ghetto with respect to other ghettos of the period.
More information: Community Efforts Halted Typhus Epidemic in Warsaw Ghetto During World War II, Science Advances (2020). advances.sciencemag.org/lookup … .1126/sciadv.abc0927
Supplementary material for this article is available at http://advances.sciencemag.org/cgi/content/full/6/30/eabc0927/DC1
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