Public health measures alone can be enough to combat pandemics, study shows

Public health measures alone can be enough to combat pandemics, study shows
Street in Warsaw ghetto, 1941, credit: Yad Vashem Photo Archive, Jerusalem

An epidemic can be contained and even beaten by behavioral measures without access to any vaccine. A new research paper shows how typhus was ravaging in Warsaw ghetto during WWII and miraculously eradicated during the worst possible conditions in war time.

The study, published last week (24 July) in Sciences Advances, was carried out by professor Lewi Stone, a biomathematician from Tel Aviv University and RMIT University in Melbourne, together with scientists from Amsterdam, Berlin and Hong Kong.

Using mathematical modelling and relying on historical source material, the authors highlight the importance of public health measures and social distancing practices in eradicating an infectious disease.

“Our study sits at the intersection of health, history and politics and may have some parallels with the COVID-19 crisis today,” he told The Brussels Times.  “The same themes reappear, only in an updated form for the 21st century, with the way minority groups are treated. They are, in fact, the true victims of COVID-19.”

COVID-19 and typhus are two very different diseases. While COVID- 19 is a viral disease, typhus is spread by bacteria transmitted by the human body louse, which becomes infected by feeding on the blood of patients with acute typhus fever. WHO explains that the onset is variable but often sudden, with headache, chills, high fever, prostration, coughing and severe muscular pain.

Compared to COVID-19, typhus is less contagious but much more deadly. The former has a case fatality rate (CFR) of 1-2% while the rate for typhus is about 20% or even higher without treatment, according to WHO. Nowadays, epidemic typhus is treated with the antibiotic doxycycline, which was developed in 1960ies.

Before and during WWII, a vaccine was developed by Polish and Jewish scientists but it was hard to get and had limited success. Towards the end of the war, the pesticide DDT, which since then has been banned, was used against the lice. Nazi Germany was desperate for a vaccine but weaponised typhus in the Holocaust and used it as pretext for genocide.

The Nazis feared the spread of typhus 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 Nazi Germany for the relocation of Jewish victims into closed ghettos and camps in occupied Europe. However, the same fear of epidemics was also a pretext to liquidate the ghettos and those confined there.

The report draws attentions to previous epidemics. In times of war and famine, the presence of infectious diseases magnifies existing hazards, often resulting in catastrophes of extreme proportions. Thus, the Spanish influenza pandemic at the end of WWI killed more than 50 million people. When the Americas was colonized, the introduction of smallpox almost eliminated its indigenous peoples.

From outbreak to turning point

The Warsaw ghetto was the biggest ghetto established by the Nazis in their murderous plan to exterminate the Jews by all means, diseases, starvation, forced labor, shooting and gassing in the death camps. For Nazi Germany, the genocide of the Jews became more important than winning the war.

A first smaller outbreak happened in September 1939 during the siege of Warsaw after Nazi aerial bombing had severely damaged the city’s sewage system and contaminated the water supply. Simultaneously, large numbers of refugees and exiles streamed into Warsaw, increasing the likelihood of an infection. The first typhus epidemic over the winter ended naturally during the summer season.

In October 1940, Jews were forbidden to leave the ghetto. After 15 November 1940, a brick wall was built that surrounded an area of 3.4 km2 and all of Warsaw’s then about 400,000 Jewish inhabitants were confined in the ghetto. The density in the ghetto was some 5- to 10-fold higher than the densest city in the world. The sealing was an extreme form of “quarantine”.

In January to March 1941, the Germans forced 66,000 displaced refugees into the ghetto. Initially, new arrivals were quarantined for 14 days to prevent typhus spread, but the practice was soon abandoned. From this moment, the epidemic was unstoppable. The spread of typhus followed quickly on the heels of a horrific starvation phase. The official food ration was often no higher than 200 calories per day.

Ludwik Herzfeld, a Polish – Jewish bacteriologist and Nobel Prize nominee, who survived the war, had no doubt: “In the case of WWII, 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.”

“We established that approximately 100,000 were infected in a population of 450,000, which is about 22%,” Professor Stone explains. “This rate is consistent with reports of epidemiologists and historians in the ghetto and our modelling. The reproductive factor –the average number of people who become infected by an infectious person – varied in the first phase between 1.2 and 2.”

The transmission dynamics of typhus in the ghetto was usually through contact or close proximity to an already infected individual, as this allowed lice to pass from one host to another in the densely crowded ghetto. The mathematical modeling shows that the end outcome would have been a massive outbreak through the whole winter of 1942 – 1943.

In fact, the epidemic peaked in October 1942. With a case fatality rate of 20 – 25 % or even more in some pockets of the ghetto, the direct death toll was at least 20,000 but the effect of starvation and typhus accounts for the large number of deaths in 1941–1942, approximately 100,000.

The epidemic’s “turnaround” was completely unexpected since typhus infection normally accelerates during winter. Emanuel Ringelblum, the ghetto’s historian who documented events in a diary which was discovered after the war, wrote in November 1941:

“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 pharmacists, and the same thing from doctors and the hospital.”

Lessons learned for COVID-19

The modelling in the research paper predicted that many more people should have been infected and died in typhus. This did not happen and the only possible explanation, besides a miracle, is the public health measures implemented by the confined in the ghetto.

Sanitary courses and lectures were initiated, covering public hygiene and infectious diseases. An underground university was set up to train young medical students, and scientific studies on the phenomenon of starvation and of epidemics were undertaken. Building and apartment cleanliness was encouraged and often enforced.

Social distancing was considered basic common sense by all, although not enforced. Home self-isolation was put in practice, although not comprehensively. Last, complex and highly elaborate sanitation programs and measures were developed by the Jewish Health Department and Council in the ghetto.

What lessons learned can we draw today when it comes to fighting the coronavirus? If the Warsaw ghetto, under such terrible conditions, could stop an epidemic, shouldn’t we also be able to stop Covid-19?

“At a basic level though, we learn how communities can use simple public health measures designed to beat infectious diseases”, Professor Stone replied.  “Education, hygiene, social distancing, motivation and cooperation are incredibly important in trying to beat a pandemic. That said, I think there is consensus that a vaccine is essential to truly eradicate COVID-19.”

“These public health measures have been designed and used by infectious disease specialists for centuries in dealing with pandemics, and they worked effectively in the Warsaw ghetto and should also work today with COVID-19. There was a limit that social isolation could achieve in an overcrowded ghetto like Warsaw.”

Nutrition, as opposed to starvation, is also of utmost importance, Stone added. The epidemic in the ghetto may have crashed in part due to the availability of extra food to keep the labour force alive a little longer. Self-help soup kitchens with limited and meagre food became available in the period before the epidemic crashed.  But it was better than the earlier complete starvation conditions.

The story does not end here. Those who survived the typhus epidemic would be deported the following year to the gas hambers of the Treblinka extermination camp. In April 1943, the few surviving Jews in the ghetto launched a desperate uprising against the Nazi murder machine, the first revolt in any occupied city in Europe.

With all heroic efforts in the ghetto, culminating in the uprising in April 1943, do you and your co-writers see the fight against typhus in the ghetto as an expression of the human will to survive against all odds?

“Most definitely,” Lewi Stone replied.  “There were many highly skilled doctors and specialists in the ghetto who were working 24/7 with huge motivation to fight off the epidemic. One of them remarked that at a very minimum all these efforts were necessary if only to show future generations that the Jews did not sit back under these conditions of indirect extermination but fought back at full strength.”

M. Apelblat
The Brussels Times

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