Crowds of Jews in the Warsaw ghetto, Poland, 1942. The crowded conditions were conducive to the spread of typhus, but the number of cases dropped dramatically in the winter of 1941. A new study tries to determine the reasons for this public health success in the most dire of circumstances. Photo 12/Universal Images Group via Getty
Alex Hershaft remembers the special comb.
He and his family were living in the Warsaw Ghetto. It was 1940. He was a little boy, about 6 years old.
A disease known as epidemic typhus was spreading among the close to half a million Jews confined in 1.3 square miles of Warsaw, Poland, in what became known as the Warsaw Ghetto.
Records kept by ghetto leaders and unearthed after the war show six or more people lived in a single room in some apartments. Many homes had no running water and there were few public baths, according to records from the U.S. Memorial Holocaust Museum in Washington, D.C., and Yad Vashem, the World Holocaust Remembrance Center in Jerusalem.
Typhus is a highly contagious bacterial disease carried by body lice, which thrive in cramped and unsanitary conditions. It can cause fever, chills, body aches, coughs, nausea and confusion. In outbreaks during World War I, the death rate was 10% to 40%. And there was no antibiotic treatment until the development doxycycline was approved for marketing by the Food and Drug Administration in 1967.
But the Jews of the Warsaw ghetto beat back typhus. And the comb was one of their weapons.
The comb has "very fine teeth to comb out your hair" – and catch any lice, says Hershaft, now 86 and living in Bethesda, Maryland.
The squelching of that outbreak of epidemic typhus in the Warsaw Ghetto is the subject of a new study, which is especially relevant in a world battling a pandemic.
The study, published in July, suggests that public health measures such as social distancing, hygiene and food supplies to supplement the meager rations provided by the Nazis could have been responsible for an unexpected drop in typhus cases in the winter of 1941.
The Nazis established the ghetto within the city of Warsaw in November 1940 and began herding in both Polish and refugee Jews.
Forced resettlement of Jews from villages and small cities in Warsaw District to the Warsaw Ghetto. Picture taken near crossing of Żelazna and Solidarności Streets. Wikimedia Commons Image
According to the study, "...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."
Even though that pretext was false, typhus did in fact sweep through the Warsaw ghetto, sparked by the living conditions and worsened by the lack of food. By 1941 official food rations for Jews were under 200 calories per day, according to a 1992 book, Courage Under Siege: Disease, Starvation and Death in the Warsaw Ghettoby Charles G. Roland, a physician and historian. A lack of nutrition can make it harder for a person's immune system to fight off disease.
Alex Hershaft says he remembers people in the ghetto looking for food, and neighbors giving clothes and other possessions to his grandparent's Russian housekeeper, who remained with his family during their time in the ghetto. Unlike the Jewish residents of the ghetto, she could leave its confines – and would exchange the goods for food she would bring back.
Alex Hershaft, now 86, was a boy when the Jews of Warsaw were confined to the ghetto by the Nazis. Through boiling of clothes, hair combing and the ability of the family's Russian-born housekeeper, Julianna, to trade valuables for food outside the ghetto, the Hershaft family did not contract typhus. Julianna was able to smuggle Alex out of the ghetto, saving him from its liquidation in 1943. Max Posner/NPR
Two major waves of the typhus epidemic hit the Warsaw ghetto. One in 1940 soon after the enclave was erected and another in early 1941. "The official number of monthly reported new typhus cases for both epidemic waves sums to a total of 20,160 reported cases," write the authors of the study. "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."
But that number may have amounted to only 20% to 25% of actual cases, according to the study, "likely because many of the Jews may not have reported having typhus for fear they'd be killed by the Nazis or otherwise punished."
Lewi Stone, the study's lead author and a professor of biomathematics at RMIT University in Melbourne as well as at Tel Aviv University, says the discrepancy can be seen from referring to documents collected in the ghetto, particularly those from what was is known as the Ringelblum Archive, a treasure trove of documents gathered and hidden during the ghetto years and named for Emanuel Ringelblum, a social activist and historian who created and led the archive project. Ringelblum's archives were hidden in metal cases and milk cans beneath the streets of the ghetto; two of the three troves were discovered after the war.
Stone says to learn more he "spent many, many hours in libraries around the world seeking rare documents or publications to find details about the interventions employed." Among the works he consulted were the records and memoirs of Ludwik Hirszfeld, a well-known bacteriologist who, with his family, was sent to the ghetto in 1941, where he was involved in medical care. He escaped in 1943 and died in 1954.
According to the study, an unexpected development occurred during the second typhus wave, and "unusually, in late October 1941, just at the onset of winter, the typhus epidemic rapidly began to curtail and collapse.
"The epidemic's turnaround was completely unexpected since typhus infection normally accelerates during winter," say the study authors. Ringelblum was the source of that information. They quote him as saying: "The typhus epidemic has diminished somewhat—just in the winter when it generally gets worse. The epidemic rate has fallen some 40 per cent. I heard this from the apothecaries, and the same thing from doctors and the hospital."
The study authors used mathematical modeling techniques to investigate whether that drop came because the typhus outbreak "burnt itself out" naturally or whether these external interventions assisted, says Stone.
"We could see from this drop that something had to be blocking disease transmission pathways," says Stone. "For modelers, this is the tell-tale sign of behavioral interventions. Indeed, we know that in other towns of the region, typhus continued on through the winter unabated."
The study's conclusion, according to Stone: "It was odd that just in the Warsaw Ghetto the disease should die out before winter when it was expected to accelerate," said Stone. "Thus, we are fairly confident that the [public health] intervention succeeded."
What specific measures could account for the drop? The study ticks off several:
More food. The Nazis began seeing some ghetto residents as potential workers and increased food aid in the ghetto and briefly allowed food smugglers to bring in rations. In addition, community soup kitchens were set up and provided food for some 100,000 residents, funded with money smuggled into the ghetto by an American Jewish aid group, the Joint Distribution Committee, and coordinated by ghetto leaders including Emanuel Ringenblum.
Public health efforts. The community's network of social, self-help and medical organizations was intensely involved in fighting the epidemic, with public courses on public hygiene and infectious diseases often attended by more than 900 people at a time. There were also home-cleaning programs by self-governing bodies in the ghetto with the goal of eradicating typhus. In addition, an underground university was set up to train medical students, and scientific studies on the phenomenon of starvation and epidemics were conducted.
Personal Responsibility: Building and apartment cleanliness was encouraged and often enforced through inspections by members of the Jewish council in the ghetto.
The impact of social intervention is plausible to Patricia Heberer-Rice, director of the division of the senior historians at the U.S. Memorial Holocaust Museum in Washington, D.C., who says that both the Warsaw and Lodz ghettos, also established by the Nazis, "had strong social organizations, public health campaigns, lectures on hygiene and policing themselves for lice."
But at least two historians of the ghetto are not completely convinced of the study's conclusions that hygiene, food and public health efforts could have been the key reason why cases of typhus dropped in the Warsaw ghetto in 1941. "I don't think social distancing measures could have played a major role because of the extreme overcrowding of the ghetto streets," says Samuel Kassow, a professor of history at Trinity College and author of Who Will Write Our History about Emanuel Ringelblum's archive.
A Footbridge over Chłodna Street in the Warsaw Ghetto, Poland, 1942. Overcrowding in the ghetto meant the population had to negotiate tight passages, where contact with others increased the likelihood of spreading lice and ultimately typhus. Wikimedia Commons Image
"But a drive to improve sanitation in buildings may have played a role," says Kassow. He quotes the leading epidemiologist in the ghetto Dr. Ludwik Hirszfeld, who survived the war and wrote: "We tried to ensure that outbreaks centered in specific buildings and apartments ebbed spontaneously. We didn't spread the epidemic by taking totally inappropriate measures. I don't think however that this was the only reason for the decline. But public opinion ascribed the improvement to the new leadership and the new spirit in the Health department."
Professor Miriam Offer, a prominent researcher on medicine in the Warsaw Ghetto and a lecturer at Western Galilee College and Tel Aviv University on medicine during the Holocaust, also questions whether the number of typhus cases could have just simply fallen so steeply. In her book, White Coats in the Ghetto, Offer says it is likely that there were reasons beyond the public health measures that the numbers of typhus cases drop – including herd immunity. So many people contracted typhus that its ability to spread diminished, she theorizes, drawing from the writings of Hirszfeld.
But the value of the study, especially as it may relate to the coronavirus, may not lie in whether the authors can prove irrefutably how typhus was brought under control. "For people living in the ghetto, despite so many odds stacked against them, the will to live was very strong, so to take measures to try to prevent typhus, to keep the population as healthy as possible, is fabulous," says Heberer-Rice.
Aaron Glatt, chief of infectious diseases at Mount Sinai South Nassau hospital on Long Island and a spokesman for the Infectious Diseases Society of America, says he suspects "that a combination of many factors, including both efforts to actively prevent spread coupled with many people being immune by the virtue of having had disease and getting better both played a role in the sudden arrest of the spread of disease."
Glatt, the associate rabbi of a synagogue on Long Island, has a personal connection to the Warsaw ghetto and to typhus. His paternal grandmother died in the Warsaw ghetto, he says, and "my aunt died of typhus in my mother's arms on the day Auschwitz was liberated."
Glatt believes that the Warsaw ghetto experience has much to teach the world as it struggles to deal with COVID-19. "The level of desire and commitment to address a public health issue is the most important characteristic as to whether you will be successful," says Glatt. "If you don't take things seriously enough and don't have the desire to beat it, people will die."
Jewish Children in the Warsaw Ghetto around 1940. Food was in short supply. Imagno/Getty Images
Alex Hershaft has a similar perspective. His own family, he says, was "somewhat fortunate" because his maternal grandparents had a large home in the ghetto where his family moved, and money and goods of value to trade for food outside the ghetto.
"I don't think anyone in my family contracted lice," said Hershaft, who says he sees parallels with the coronavirus now. "People who could afford to stay home and had enough to eat were okay, and people who had to mingle with others and didn't have enough to eat were the most likely victims."
And like Glatt, Hershaft speaks of the strong will to live in the ghetto: "People were keenly aware of their mortality which is what made them go to such lengths to try to prevent typhus."
"Now," says Hershaft, "some people don't take COVID seriously because the concept of contracting a deadly disease is so foreign to us, while in the ghetto, we were so conscious that the next day could be our last."
Fran Kritz is a health policy reporter based in Washington, D.C. Her work has appeared in The Washington Post and Kaiser Health News. Find her on Twitter: @fkritz.
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