A recent study published in Science Advances shows us how a series of interventions can make a real difference when managing a pandemic. Given the impact of Covid-19 in recent times there’s much we can learn from history...
Following the outbreak of war in September 1939, Jews from many areas of Poland were forced to resettle in their country's capital. The small patch of land they were allocated - no more than 1.3 square miles - became known as the Warsaw Ghetto. In November 1940 a brick wall, some 3m high and 18km long, was built to encircle the Ghetto and the 400,000 Jewish residents were forbidden from leaving. Conditions soon deteriorated and deaths from disease and starvation started to multiply rapidly. Chillingly, the authors noted, "the situation progressively worsened until human corpses covered with newspapers were a common sight on the streets". As the summer of 1941 arrived, it became clear that typhus was becoming a major problem. In August, the disease was reported to be responsible for 63% of all deaths. But then, just a few months later, something completely unexpected happened. Rather than continue to climb through the winter months as expected, deaths from typhus started to fall. What happened?
Typhus is a bacterium (Rickettsia prowazzekii) spread by bites from the human body louse (Pedicus humanus humanus). According to the authors, the louse multiplies, "prolifically under conditions of poor hygiene, filth, overcrowding, and cold weather — exactly the conditions of the ghetto". Following an incubation period of 7 to 14 days patients typically develop a high fever, headache, muscle pain and an extensive rash. As the disease progresses, weakness and delirium develop. Left untreated, typhus is often fatal. The WHO estimates that the disease is still responsible for approximately 5 million deaths per year
To answer this question the researchers used contemporary data to model the monthly reproductive number (R) from January 1941 until the Ghetto was finally "liquidated" more than a year later. Over the course of the first 12 months, the number of infections generated from each case fell from a mean of more than 2 to a value below 1. As a result, deaths from typhus peaked in November 1941 and quickly began to fall.The authors attributed the decline in R value to 3 key factors:
(1) A significant increase in the availability of food rations. In the early months of the ghetto the German authorities set out to deliberately starve residents. However in May 1941 this changed as it became apparent that the Jews could be set to work if they were adequately fed. Large numbers of community kitchens appeared throughout the ghetto and the new daily calorie intake ranged from 784 to 1665kCal per day depending upon wealth and social status.
(2) Improvements in sanitation. The allied bombings in 1939 resulted in enormous damage to the sewerage system of Warsaw. Work by the ghetto's Health Department and Council led to meaningful improvements and focused upon eradicating typhus.
(3) A network of medical organisations emerged that were able to educate large sections of the community in the prevention of typhus. The authors cite the example of courses on sanitation sometimes attracting more than 900 attendees. Whilst social distancing and self isolation were not enforced, they were widely encouraged and practised wherever possible. Such a collective effort shows what can be done, even with limited resources, when a community works closely together. As Warsaw Ghetto survivor and celebrated historian Yisrael Gutman later wrote, “whilst almost 100,000 ghetto residents died mostly from starvation and disease in the period up until July 1942, a similar or greater number were saved thanks to the dedicated relief workers and self-help relief agencies operating.”
A series of typhus epidemics spread throughout Germany in the decades prior to the rise of Adolf Hitler and the National Socialist German Worker's Party. Jews were blamed for the spread of the disease and this was subsequently used to justify their internment. However the outbreak of typhus in the Warsaw Ghetto was not the fault of the Jews. As the eminent bacteriologist Ludwik Hirszfeld later wrote, “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. In this war, typhus is the work of the Germans"
Critics argue that an important factor missing from the study’s analysis was the role of immunity. Given the high levels of infection some argue that the fall in November 1941 was due to the resistance built up in those who were previously exposed. However resistance in this highly malnourished population may have been limited. 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 believes that the Warsaw Ghetto experience has much to teach the world as it struggles 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," he says. "If you don't take things seriously enough and don't have the desire to beat it, people will die."
For more on the recent typhoid vaccination programme in Nepal take a look at this.