Ghetto doctors and Jewish council members successfully curtailed a typhus epidemic in occupied Poland's Warsaw Ghetto — the largest Nazi ghetto during World War II — through measures that included social distancing, self-isolation, public lectures, and an underground university to train medical students, according to a new study published in the July 24 issue of Science Advances.
Using mathematical modeling and drawing from historical records, researchers concluded that the epidemic did not naturally recede before the arrival of winter 1941-1942, but instead was cut short through community actions carried out under exceedingly difficult conditions.
These interventions may have prevented more than 100,000 residents from falling ill and likely averted tens of thousands of deaths from the disease.
"My greatest surprise was realizing that the typhus epidemic died out at the very beginning of winter, just when I would have expected it to accelerate," said Lewi Stone, a professor of biomathematics at Tel Aviv University in Israel and RMIT University in Melbourne, Australia and the first author on the study. "For a year, I thought this was likely just a corrupted dataset. I checked with the diary of [Polish historian Emanuel] Ringelblum, who documented daily events in the ghetto, and he himself corroborated what I had seen."
Typhus — a deadly disease that is spread by lice and causes fever, headaches, and a rash — has long added to the misery of wars and other crises. Researchers have traced its influence on the War of Spanish Succession (1710-1712), the Napoleonic Wars (1812), and both World War I and World War II, sending many to their graves at the moments in history when humanity was most vulnerable. The spread of typhus in Germany during World War II was weaponized by the Nazis as one pretext for genocide, with anti-Semitic beliefs that Jewish people carried diseases used to justify the isolation of many thousands of Jewish people in ghettos. With as many as 450,000 people crammed together in a 3.4 square kilometer (1.3 square mile) space, starving from meager 200 calorie-per-day food rations and lacking soap and water to keep clean, the Warsaw Ghetto inevitably formed the perfect incubator for the typhus bacterium.
Despite their contributions to the death tolls of human conflicts such as World War II, the social and political ramifications of such infectious disease epidemics often remain underexplored. After decades of modeling diseases in his work as a mathematical biologist, Stone was largely unaware of the role disease played in the Holocaust until he stumbled upon an article that mentioned typhus in World War II.
"Before I began the project, I was reasonably informed about Nazi anti-Semitism and its racial policies, including eugenics, in the lead up to World War II," said Stone. "But I was shocked to uncover the degree to which disease and epidemics played [a role] in the initial stages of the Holocaust. I would come across allegations from top Nazi officials that the genocidal murder of 3 million Jews in Poland was 'unavoidable for reasons of public health.'"
Stone began hunting for more information, finally uncovering a small amount of data on typhus in the Warsaw Ghetto. However, he needed more — and data capturing the numbers of typhus cases in the population was not easy to come by.
"The ghetto inmates did not like to report their disease, as it could easily mean punitive actions from the authorities," said Stone. "I learned, for example, of hospitals being burnt to the ground, patients and all, by the Nazis simply because of the presence of typhus. Or, phenol injections to the heart to immediately kill anyone who was sick."
To mathematically model the progression and halt of the epidemic in the Warsaw Ghetto, Stone and colleagues referenced month-to-month changes in food ration cards (used by ghetto statisticians to maintain a census of the population) as a proxy for the death rate. The researchers soon realized their model indicated that the disease's transmissibility mysteriously plummeted in late October of 1941, even though only about 10% of the population had been infected. Since an epidemic would only naturally collapse when there is a lack of susceptible people left to infect — and clearly many remained in the Warsaw Ghetto — Stone and his team knew human efforts must have contributed to the disease's downfall.
"We could see from this drop that something had to be blocking disease transmission pathways," Stone said. "For modelers, this is the tell-tale sign of behavioral interventions."
To learn what anti-epidemic activities the ghetto community may have undertaken, Stone drew from the written testimonies of ghetto doctors who survived to tell their stories. He spent hours poring over rare documents in libraries around the world, finding that the community combatted typhus through a myriad of measures. It deployed its network of social welfare and media organizations, initiated sanitary courses on public hygiene that were sometimes attended by more than 900 people, and developed sanitation programs through the ghetto's Health Department and Council. Social distancing and home self-isolation were widely practiced and encouraged.
Stone and colleagues modeled how the typhus epidemic would have progressed in the ghetto if these measures had not been taken. Their findings were stark — two to three times as many people would have been infected, with the outbreak ultimately peaking in January.
"We know that in other towns of the region, typhus continued on through the winter unabated," said Stone. "So, it was odd that just in the Warsaw Ghetto the disease should die out before winter when it was expected to accelerate. Thus, we are fairly confident that the intervention succeeded."
Just as community adherence to basic mitigation methods was key to eradicating typhus in the Warsaw Ghetto before more lives could be lost, the researchers said it is central to current efforts to contain COVID-19.
"I find what happened in the Warsaw Ghetto a microcosm of COVID-19 days, or rather like a parallel universe, at least in terms of contagion and its outcomes," Stone said. "The methods perfected by infectious disease experts from centuries of dealing with these pandemic-like events are our best defense."