DECEMBER 29, 2020
“PREVENT THE EPIDEMIC, for heaven’s sake, wash hands, wash hands, disinfect, yes? Look after the nurses, so that it does not spread. […] Vaccinate, of course.” These words were not uttered yesterday, but in fact were spoken by Franz Hahn, a Viennese Jewish doctor, recalling his two years — from 1942 to 1944 — practicing medicine in Theresienstadt. This Central European ghetto, known in Czech as Terezín, was in a walled city in the present-day Czech Republic and held a population of 143,000 inmates at its height. The Nazis deported a disproportionate number of elderly Jews to Theresienstadt and, as part of a propaganda campaign, painted it as a retirement community; in fact, for many, it was a stopping point on the way to concentration camps. It was remarkable for its artistic creativity (theater, cabaret, concerts, poetry, and music compositions) as well as its childcare. Less well-known is that in many ways the practice of medicine in the ghetto was on a par with its cultural achievements, and quite possibly superior to medical treatments elsewhere in Nazi-occupied Europe. Some of the reasons why were anomalous. For instance, the SS members who ran the ghetto were so scared of “Jewish infection” that they gave it medical supplies. But other explanations are just as important and offer us tools for thinking about relations among the state, medicine, and society.
Theresienstadt was just like other Nazi camps and ghettos in being rife with illness. Accommodations were absurdly crowded, heating and food were insufficient, and hygiene impossible. But the massive spread of infection seen in other ghettos was avoided thanks to the management techniques of the prisoner physicians. Their pivotal role is part of a larger story worth retelling now in our current COVID-19 context.
When Theresienstadt was set up in November 1941 as a transit ghetto for all Czech and some Central and Western European Jews, the Nazis left the everyday running of the place to a Jewish administration. In other words, the ghetto was self-run. After the war, the Jewish Councils would be scornfully denounced for their cooperation with the Nazis, but that response is too reflexively easy and ignores the ghetto’s moral complexities. More recently, scholars such as Doron Rabinovici and Beate Meyer have started to address the details of how the Jewish functionaries used long-range planning to improve the welfare and manage the people who, by edict, had become their responsibility. They made it a point to focus not on those sent away on transports to the East but on those who remained. (Of the 143,000 imprisoned in the Theresienstadt ghetto, 87,000 people were deported, of whom 4,000 survived.) Organized medicine was a crucial part of their enterprise — a way of maintaining some semblance of a livable society.
What made the administration so effective in this regard was its understanding of the ghetto as a public health problem above all else, demanding a robust organizational response. Over its three-and-a-half-year existence, Theresienstadt proactively built up its “Health Services” department with a vast apparatus of hospitals and clinics. For comparison’s sake: Theresienstadt had between 14 to 16 hospital beds per thousand inhabitants while the US today has about 2.5. There were 18.1 physicians per 10,000 inhabitants, which was almost three times more than the number in the United States at the same time. (Today, the numbers are not much higher than they were in Theresienstadt: 28.1 for the United Kingdom and 24.5 for the United States, while Austria has 48.) These are impressive numbers even if we take into account that the population in Theresienstadt was disproportionately old — in part because many young people were able to emigrate before being captured but also because of the Nazis making it a point to deport the Jewish elderly from Germany and Austria to Theresienstadt as part of their propaganda campaign. They called Theresienstadt a preferential camp (Vorzugsghetto) for the elderly as well as so-called exception groups — for instance, Jews who were World War I veterans or had citizenship in neutral countries. By February 1943, almost a third of the inmates were ill, half of them elderly patients with chronic conditions.
The Jewish doctors’ prescription was, in essence, prevention. Consider their approach to tuberculosis. Before the discovery of antibiotics and a vaccine, TB was quite often deadly. Lilly Pokorná, who headed the ghetto’s radiology unit, was startled by how often she was diagnosing tuberculosis, which led her to wonder if, on the X-rays, she was in fact seeing the residue of sulfa drugs instead. It wasn’t residue: the ghetto population had an extraordinarily high 7.8 percent infection rate. Its Health Services therefore decreed that all inhabitants be sent for X-rays. Those who were sick were then put into a separate TB hospital and treated with the kind of interventions available before antibiotics: therapeutic pneumothorax, rest, and better nourishment. The Transport Committee of the Jewish administration, whom the SS tasked with setting up the transport lists to the camps and annihilation sites in the East, was also able to protect those who were gravely ill from being deported. Of those who were transported, some had recovered enough to pass the selection at Auschwitz and survive months of forced labor. To be sure, many struggled with ill health and died of the effects, but the extraordinary fact is that others went on to live long, fulfilling lives after being liberated, thanks precisely to those preventative public health measures implemented by the Theresienstadt doctors.
Children in Theresienstadt were housed apart from their parents in dormitories that afforded them preferential accommodation, food, hygiene, and even a secret education. In January 1943, another epidemic — typhoid — broke out in these youth homes. Youth Care functionaries reacted with alacrity. As a result, less than 500 of them fell ill, and the mortality rate stayed under 10 percent. In fact, only 13 died. In the epidemic’s aftermath, the doctors systematically immunized all new arrivals. Franz Hahn explained how he and his colleagues went about their work: “[T]here was always a serum for typhoid — not 100 percent effective or at least not as effective by far as the one we have today, which you take orally. Back then we injected it, which hurt, but we had no mercy: the entire camp was vaccinated lock, stock and barrel; there was no other way.”
This standard of medical care did not exist at the outset. It developed over time, which makes it worth studying today. Just a few days after the Nazis sent the first inmates to Theresienstadt, in December 1941, one man was already ill with appendicitis. Having no instruments to operate with, the attending doctor could do little else than helplessly watch. The Jewish administration, however, wasted no time. It went to the SS and asked that physicians as well as medical supplies be prioritized in deportations heading to Theresienstadt. By 1943, the Health Services had become the most effective, and second largest, department in the ghetto. It had smartly exploited the Germans’ fear of Jewish-derived infections among local non-Jewish populations — Leitmeritz, the regional center in the annexed Reichsgau Sudetenland, was only two miles away, while a Wehrmacht hospital for convalescents was just outside the ghetto. The Germans, as mentioned earlier, were also under pressure to keep up a certain image of this camp for propaganda purposes. The SS thus allowed for, and financed, deliveries of medication. In the summer of 1944, the monthly delivery, which was billed at half a million crowns, included all the essential medications used for patient care between 1940 and 1945 — for pain, dysentery, paratyphoid, as well as heart medications and sulfa drugs. This advantage obviously sets Theresienstadt apart from other major ghettos such as Warsaw, Minsk, or Lodz. Operations were modern and complex, according to Harro Jenß’s reading of the operation diary of Erich Springer, the head of surgery. Still, the fact remains that the inmates had to work to exploit their advantages. By December 1942, unnecessary deaths from appendicitis were a thing of the past.
Not everyone in Theresienstadt received the same treatment, though: incarceration was much more difficult for elderly prisoners. Of almost 34,000 people who died in the ghetto, 92 percent were over 60 years of age. This was not by chance. Food access was regulated by labor category, with non-workers receiving the smallest and least nutritious food rations. Female inmates no longer had to work after age 60, and the majority of the elderly were in fact female. (For men, the cutoff was 65.) The weakened elderly thus disproportionately fell victim to infectious enteritis, an intestinal inflammation. Almost all prisoners in Theresienstadt became infected, but for the elderly it could be fatal, due to malnutrition and age. While the doctors performed pneumothorax on TB patients and gave young pneumonia patients expensive sulfa drugs, tens of thousands of elderly inmates died of a banal, preventable disease. Enteritis in the elderly went untreated as part of an unwritten triage system that treated the elderly in general as less valuable. The Health Services department reserved their thousands of hospital beds for more “important” diseases.
While thousands of old people died, many young Czech Jews, who constituted the social elite of the ghetto, were able to take on desirable positions as cooks, butchers, and bakers, and so had access to food with which to fund their social life. For instance, Theresienstadt had a large soccer scene with much celebrated matches. The food to support the players was an illegal “gift” from their friends, the cooks, who took it out of the non-worker rations. Aware of the official and unofficial bias in food distribution, the elderly bitterly protested. Ernst Michaelis, a 72-year-old Berliner, did not mince words: “People steal in order to deal in cigarettes and then they hoard golden watches and jewels and they have the prettiest girlfriends. People from bakeries get two or three loaves a day and even boast about it.” The Jewish self-administration paid scant attention.
These differences may strike us as grossly unfair, and indeed they were. However, to the Terezín doctors, human nature was what it was — in the ghetto as elsewhere — and triage seemed their only option. Erich Springer recalled that “the cooperation of the departments was exemplary, certainly much better than in civilian hospitals, perhaps because we had no long distances [to travel] and then the physicians shared the same fate; for us, there were only moral duties and successes, in no way financial ones.” The doctors had opinions on everything and could at times seem tyrannical. But their approach mostly worked, at least within the boundaries of what they could accomplish. Rather than being “just doctors,” the leading physicians in the ghetto saw themselves as moral and practical leaders; they worked with the Jewish functionaries, and they thought in both medical and political terms about how judiciously to allocate scarce resources.
Geographically well-placed to evoke fears of infection among the Nazis, Theresienstadt’s Jewish leaders were savvy enough to take full advantage of those fears to demand more medical resources. The key point here is that the Health Services took a long view from the outset, as opposed to simply reacting impulsively or with only short-term aims in mind. In addition, medical personnel received somewhat better food rations, had access to showers, and even had some protection from being transported to the East. Equally important, prisoners admired the doctors and nurses and followed their orders; the Health Services department not only had credibility but the sort of support that enabled it to improve over time.
Access to medical care was free in the ghetto, as was accommodation and food, however paltry those might have been. With the notable exception of the elderly ill with enteritis, all patients, regardless of status, were brought to the same hospital beds, operated on by the same doctors, and received the same food rations. If the Health Services ordered collective X-rays, everyone complied, because this policy was their only hope of isolating and treating tuberculosis. By and large, prisoners behaved as responsibly as did the Jewish administration, acutely aware of imminent danger, not just the threat of mass annihilation in “the East” (though this surely had a role to play in their sense of solidarity) but of fatal diseases they could encounter at any moment.
Health policy in the Nazi ghettos and concentration camps helps us understand the broader societal meaning of medicine as more than just healing. Our medical institutions are a measure of our humanity — we can consider ourselves a functioning society only so long as these institutions work; when they fail, it’s a clear sign our societies have failed.
Anna Hájková is associate professor of modern central European history at the University of Warwick and the author of The Last Ghetto: An Everyday History of Theresienstadt (2020).
Michael Beckerman is chair of the Music department at New York University. The author of seven books and more than a hundred scholarly articles, he has written most recently about musical composition in Terezín.