In just over three square kilometers, the Nazi troops crowded 450,000 people in Warsaw, representing about a third of its total population. It happened at the end of 1940 and with this gesture they constituted the largest Jewish ghetto in the Europe of the Second World War.
Located in the center of the Polish capital, poor sanitation, famine and a population density five to ten times greater than any current city were the perfect breeding ground for a typhus epidemic to spread like wildfire.
An estimated 120,000 people in the ghetto contracted the disease and more than 30,000 died, adding to the deaths from food shortages. However, in the autumn of 1941, when the population experienced the highest rate of infection and the cold winter was approaching, the epidemic curve began to fall until it died out. How did they get around the curve inside the ghetto?
The answer seems to lie in the preventive measures implemented by the epidemiologists and the rest of the doctors incarcerated in the neighborhood and who its inhabitants strictly followed. This is what concludes an international research published in the journal Science Advances and led by the biomathematician Lewi Stone, who has been modeling diseases for decades.
The measures ranged from social distancing to domestic quarantine. General hygiene, cleaning of the apartments were also promoted, and soup kitchens were set up to stop the famine.
Another of the strategies that could be key was training, with training courses on public hygiene and infectious diseases, in addition to hundreds of public conferences on how to fight typhus and even an underground medical university for young students.
On the trail of ration cards
Stone found written records of these initiatives in numerous documentary sources. The researcher explains to SINC that he has been able to have a very approximate idea of what happened in the ghetto, especially thanks to two sources: the survivors and the written records and diaries that were hidden and that today make up the Warsaw Ghetto Archives.
“My best sources were the records of specialist epidemiologists within the ghetto. Professor Jacob Penson, chief of the infectious disease ward, published several records on this issue,” says Stone, who is a researcher at the Biomathematics Unit at the University of Tel Aviv (Israel).
In addition to the testimonies, ration cards have been a fundamental part of the investigation. Imposed by the Nazis to limit what the Jews ate, they were distributed monthly and have served to give a rough idea of the population in the ghetto.
“As the number of ration cards decreased rapidly after March 1941, we can reasonably assume that much of that change was due to a high mortality rate,” says the biomathematician.
As research shows, the numbers on the cards and the number of cases agree: the drop in these cards coincided with the highest number of deaths from typhus between April and October 1941.
In fact, according to these cards, the number of deaths from the typhoid epidemic in the ghetto and famine could have been much higher than reflected in official records and could reach 100,000 deaths in 1941 – almost a quarter of the inhabitants of the neighborhood -, according to scientists.
Unfortunately, although preventive measures saved countless lives, most of the survivors died in the death camps to which they were deported.
Typhus in the city of Valencia
Typhus encompasses a group of bacterial diseases spread by lice and fleas. In the case of the Warsaw ghetto, its population suffered from exanthematous typhus, which is caused by the bacteria Rickettsia prowazekii transmitted by the body louse. This disease had an epidemic character in the Europe of the Second World War and in cities like Valencia, when in the Warsaw ghetto they tried to bend the curve, they did the same in the middle of the Spanish post-war period.
“The common denominator of both scenarios was the epidemiological situation, that is, the convergence of the ideal coordinates for the eruption and development of exanthematous typhus and other acute infectious diseases: hunger, overcrowding and lack of hygiene,” they point out to SINC. Xavier García-Ferrandis and Àlvar Martínez-Vidal, professors from the Catholic University of Valencia “San Vicente Mártir” and from the University of Valencia, respectively.
The two experts in the history of medicine have studied the typhus epidemic that Valencia suffered between 1941 and 1943. The difference between what happened in Poland and in the capital of Turia was the context that caused both health crises. “The case of the Warsaw ghetto was forced confinement for criminal purposes. The Spanish case was a direct consequence of almost three years of war and a policy of repression against losers in the immediate post-war period,” they distinguish.
When confronting the epidemic, confinement measures were also implemented in Valencia but, as the researchers say, these only affected the segment of the population that corresponded to the most disadvantaged social class, by being associated with overcrowding and poor hygiene .
“On occasions, the confinement was carried out against the will of those affected, a negative justified because the hygienic-sanitary conditions of the places of isolation were so poor that on some occasion an outbreak of exanthematous typhus was declared in the interior of those infamous facilities “, explain the teachers. In addition, thousands of people living in the ruins of buildings bombed during the Civil War were also deported to their places of origin.
Confinement in other epidemics
Typhus epidemics are an example of the importance of prevention and control to stop its transmission. But they are not the only ones. Diego Ramiro, head of the Population Department of the CSIC Institute of Economics, Geography and Demography, recalls that measures to reduce the effect of pandemics, such as quarantines, have been adopted in almost all pandemics.
“This is the case of plague epidemics, while alternative measures against the spread of the disease such as the closure of schools, theaters or the prohibition of public events are normal measures in pandemics such as the 1918 flu or the Russian flu of 1889 -1890 “, the sociologist describes to SINC.
The lazarettos – isolated hospital centers to treat infectious diseases – were aimed at patients who had to quarantine for diseases such as plague or yellow fever, and can still be seen on our shores today, Ramiro says.
“Confinement in all its forms, that is, quarantines, lazarets, sanitary cords, removal or flight from infected areas, has been the main measure with which societies have faced epidemics throughout history, taking into account that the Microbial theory and the existence of vaccines and antibiotics are relatively recent milestones in the history of medicine, “comment García-Ferrandis and Martínez-Vidal.
The researchers highlight the successive waves of plague between the 14th and 18th centuries. As for the cholera epidemics of the 19th century, there was a rejection of isolation measures because they impeded communications and commerce in the framework of the Industrial Revolution.
“In the case of some chronic infectious diseases, confinement took place by confining the patients to leprosariums and anti-tuberculosis sanatoriums. Sometimes this isolation was obligatory and sometimes for life,” they add.
COVID-19 prevention works
This brief review of the history of medicine serves to check how common these types of preventive measures have been to fight infectious diseases. Some of them, such as quarantines or distancing, are being implemented in the COVID-19 pandemic.
Research published in PLoS MEDICINE shows that actions work. Which? A combination of them. Handwashing, facemasking, and social distancing – so-called self-imposed measures – along with confinement policies – such as closing schools, workplaces, or banning meetings – imposed by governments, can help mitigate and delay the peak of the pandemic.
Using a computational model of disease spread, scientists studied the estimated effect of these prevention measures on COVID-19 cases. As for self-imposed actions, if they are taken quickly and carried out by a large number of people, with an efficiency exceeding 50%, a great epidemic can be prevented, depending on the model. But if they are slow, they can only reduce the number of cases, without delaying the peak.
In contrast, early implementation of government-imposed containment measures delays, but does not reduce the peak of the COVID-19 epidemic. This is why the authors conclude that the combination of individual measures, especially if they are adopted quickly and by a large part of the citizenry, together with the social distancing imposed by governments, have the potential to delay and reduce the peak of the epidemic.
“Self-protection measures work well if enough people follow them and practice them over time,” says Alexandra Teslya, lead author of the study and researcher at the University Medical Center in Utrecht, the Netherlands.
In the event that such adherence is difficult to achieve, according to the epidemiologist, the benefits to slow down the transmission of the disease will be limited, since infected people and the size of the beak will decrease, but this will not be delayed. “In this case, government-imposed short-term confinement may be better as it may delay the peak,” Teslya maintains.
Going back to past health crises, the scientist recalls that confinement measures imposed by the authorities had already been used in the 1918 flu and were effective: the epidemics in the cities that carried them out were greatly reduced. The problem was what came next. “Once these measurements were relaxed, second waves were often observed,” he alleges. History can repeat itself if we let our guard down.