When did you first hear about the “hunger disease” study that was conducted in the Warsaw Ghetto?
I visited Poland as part of a delegation from Ichilov Hospital [in Tel Aviv]. Given the composition of the group, our guide, Yaki Gantz, included medical information in his tours. One day, when we were near the Warsaw Children’s Hospital, he told us about the hunger that had existed in the ghetto during World War II. And then he mentioned, in passing, that because the hunger was so acute, a group of Jewish physicians there decided to carry out a study of its effects.
The situation in the Warsaw Ghetto was singular. There is testimony of a meeting of senior Gestapo personnel and Nazi physicians – Eichmann was also in attendance – at which it was decided to liquidate the ghetto by means of starvation. According to their calculations, low-calorie food rationing would wipe it out in nine months.
They calculated a daily ration, just as we dietitians do.
It was racially derived rationing: Germans received more than 2,000 calories; Jews, less than 200.
There was a clear hierarchy [in the occupied countries]. First the Germans, then the Ukrainians, whose ration was about 1,000 calories; the Poles with 600; and the Jews, at the bottom, with 180 calories. As a dietitian, I must say that this is an incomprehensible number – 180 calories a day means one slice of bread, one potato and soup, which was mostly water. I doubt that a portion of soup like that contained more than 10 calories. That’s nothing. My head started to spin.
I said to my colleague, dietitian Dror Ben Noah: ‘Do you understand – 180 calories?’ He too was shocked. I asked whether he had ever heard of the hunger disease study that had been conducted in the ghetto. He said he hadn’t. Google turned up only a few results, referring to the fact that the study had indeed been carried out. The material itself – the data, the findings – simply doesn’t exist on the web. We realized that we had to do something.
We’ll talk about the fate of the manuscript that documented the study shortly, but let’s first consider the story itself. The plan to starve the ghetto’s residents didn’t cause its liquidation, but it definitely took a toll. The bodies lying in the street, which we know all too well from photographs, were those of victims of starvation.
It’s a lethal combination – hunger and disease. The starvation plan mainly took the lives of the most vulnerable: the elderly, children, mothers of small children. It’s also important to emphasize that the ration of 180 calories was provided in return for payment, and most people could not afford it, of course.
But in practice the ghetto inmates managed to obtain additional food, through smuggling, the black market and public kitchens.
The public kitchens of the Joint [the Joint Distribution Committee] gave out soup – and that truly was one of the most amazing and moving things I learned on my trip, in connection with the research study. They declared that from their point of view, the distribution of the soup made it possible to give children in the ghetto an educational experience involving courtesy and cooperation.
The brutal hunger gave rise to horrors, undoubtedly. There was cannibalism. There was violence, people murdered and stole to get food. And yet, on the other hand, a bowl of watery soup could engender values. A social network. Support. You need to see the photographs of the orderly line where everyone is waiting patiently. Of the children sitting at sparkling-clean tables. Those who were fortunate in the ghetto existed on 800 calories a day, but that average consumption also gradually decreased, as time passed and resources dwindled.
In February 1942, a group of Jewish physicians in the ghetto, led by Dr. Israel Milezkowski, decided to conduct an extensive study of the physiology and pathology of hunger there.
Milezkowski thought in practical terms. He wanted to understand how hunger disease could be cured. It was another physician, Dr. Julian Fliederbaum, who saw the potential of such a study, who created the whole research platform. He wrote that this was a singular opportunity to study hunger and that he wanted to do so with the best tools at his disposal, so that the results would have incontrovertible scientific validity.
An impressive research structure was indeed created. The study was divided into several sections, each led by an expert in a particular field. The topics researched included blood circulation, clinical aspects of starvation in children, bone marrow and more.
To begin with, the scale of the research project was immense. More than 100 participants, which is a huge study. By comparison, in clinical studies we conduct today, in a metabolic laboratory, having 10 subjects is considered a dazzling success. The ghetto study was carried out at the highest standards.
How could the researchers know that the subjects’ medical condition was due to hunger and not to a combination of that and other diseases?
The subjects were hospitalized in separate rooms that were strictly off-limits, to avoid infection. They were given medical tests and the results were recorded on the wall. Like a medical chart. The tests they administered were solely for research purposes, irrespective of the subjects’ medical condition.
It’s sad and horrible, and it’s very hard for me to say this, but they also performed autopsies to ascertain that this was in fact the cause of death. Anyone who was found to have been suffering from a different disease was omitted from the study. The most difficult part was to collect the various findings from all sections of the research. The researchers spent the nights in the cemetery’s [ritual] purification structure, collecting, summarizing, performing autopsies and writing up the findings as in a scientific article.
Jews were prohibited from engaging in scientific work. If they’d been caught, they all would have been executed.
The Judenrat [Jewish Council, established by order of the Germans] authorized the research. Its members understood the importance of the study, and also allocated resources to it. Money was needed to smuggle in equipment – blood-test kits, for example. Most of the smugglers were women, because if the authorities caught a male smuggler they could check to see if he was circumcised and know immediately that he was a Jew. Imagine you’re sending a female smuggler to get hold of some piece of medical equipment. She has no idea what it even is. What to ask for. So they draw her a detailed picture. As a professional, I can only admire their thinking.
For example, the researchers wanted to understand what happens to the energy usage of a person who loses weight. That’s a question that occupies the experts in our field even today. We measure it with special equipment and calculators, but they simply calculated it using a pen and paper. The subjects underwent a test for tuberculosis, as the physicians realized that they could draw inferences from this about the immune system. They examined the acidity of the digestive system, hormone levels. What was even known about hormones in the 1940s? Look, at that point in history, the finest medical minds of Central Europe were concentrated in the Warsaw Ghetto. All of them were Jews. It was absolutely a scientific hothouse – horrifying and frightening, but a hothouse. They even did glucose-tolerance tests.
What I wonder is where they got sugar.
They used 75 grams of sugar per subject. Sugar was priceless in such a situation. One cannot imagine how much it was worth.
‘Act of defiance’
Is it even imaginable how the researchers themselves stood up to it? After all, they were hungry themselves.
They were hungry. Picture it: a physician studying the disease he is himself is suffering from and from which he will also likely die. We know the stories about physicians who fell ill with diseases and tried to come up with medication to treat them; some of them succeeded. That is not the case here. They weren’t doing the research in order to save themselves. They did the research in the clear knowledge that they would suffer the identical fate: There were physicians who took part in the project, and died of hunger.
And the study ended with the Grossaktion – the deportation and mass murder of the Jews in the ghetto – during the summer of 1942.
The researchers’ final meeting was apparently held in August 1942, during that Aktion. Dr. Milezkowski informed the group that this would be the last one and announced that the findings had been hidden in the cemetery. Some of the physicians who had taken part in the study were also deported in the Aktion. As far as is known, a week after that meeting most of them were no longer alive.
Of those who led the study, only one survived. The manuscript was successfully smuggled out of the ghetto. Milezkowski himself apparently committed suicide. He wrote an introduction to the study, which is jolting: “I hold my pen in my hand and death stares into my room.”
Yes. He understood this was the end. He understood that if the study would survive and be published, it would perpetuate the memory of all the participants. He writes explicitly that this project is their response to the murderers, adding, “I shall not wholly die.” This is a story of unbelievable heroism. The way they functioned, under those conditions. The self-surrender, the transcendence. I can’t understand where they found the inner fortitude to do all that.
The study gave them meaning.
What is more precious than meaning? The study is their act of defiance, the doctors’ revolt. We should note the courage of Prof. [Witold] Orlovski, the Polish colleague who safeguarded the manuscript. After the war, Dr. Emil Apfelbaum, the only one of the leaders of the study who survived, retrieved the text from Orlovski and passed it on to the Joint Distribution Committee. Because the JDC was then headquartered in France, the manuscript was translated into French and published in France. I don’t know how many copies were printed – probably only dozens.
In 1979, an English-language version was published in book form under the editorship of Dr. Myron Winick, an American expert on nutrition, under the title “Hunger Disease: Studies by the Jewish Physicians in the Warsaw Ghetto.” At the moment, the fate of the original manuscript is unknown.
True. No one knows where it is. By the way, even the Joint didn’t know it had this material. I contacted the organization’s historian and didn’t let up, until one day she called and said, “We have it.” They produced the Polish and French versions, in 1946. The materials are in their archives.
Are copies of the English edition still available?
They exist but are rare. I found a few copies on Amazon and eBay. I bought them, because I think that every copy should be salvaged and preserved. The thing is that, because of our interest, and because we bought a few copies, we drove the price up. The first copy I bought cost $5. Now they’re going for $1,000. We are raising money to buy all the extant copies.
Let’s talk about the study’s relevance for our time. When you declare that you want to save it, the goal is not to place it in a museum. You want to make this body of knowledge available. From your perspective, it’s a textbook.
This study is super-relevant in terms of all the issues we’re dealing with today in the field of nutrition. People don’t realize it, but most of our work in hospitals focuses on malnutrition that’s generated by disease. Because we live in a society of abundance, we find it hard to understand that hunger exists. But such research is relevant also, let’s say, when it comes to the metabolic or biochemical situation of people with advanced cancer – a situation in which, even if there is plenty of food available, the body simply consumes itself. That condition is described in an unprecedented way in the study.
We understand today that a phenomenon like edema stems from hunger. But it wasn’t yet known at the time the ghetto study was conducted. That study examined, proved and effectively diagnosed a disease that is today called the hunger disease. A disease that has various symptoms, and if treated at the relevant stage, if there is timely intervention – can be cured with food.
That is an important point in itself – that there is a point of no return, after which it becomes impossible to save a starving person by means of feeding. Can you describe the stages [development] of hunger disease?
The first stage is a decline in the reserves of fat. The second stage is an accelerated aging of all the body tissues. The final stage, which is relevant for our time, is called cachexia – a sometimes irreversible decline in the mass of body fat and muscle; in children, it also affects the bones. At this stage, in cancer sufferers, for example, in order to help the patient, it’s necessary to treat the source of the cachexia. The tumor itself. The patient is fed, of course, but only if treatment of the cancer is successful will he be able to begin to recover.
The internal organs also respond to hunger with a process of shrinkage and nonfunctioning.
Autopsies performed during the study revealed a small liver, an enlarged spleen and a weakened heart muscle.
Winick writes that the physicians’ most important conclusion was that the rehabilitation process from hunger disease must be gradual. If the medics of the Allied liberation forces had known that, possibly many lives could have been saved. Many survivors died after liberation, simply because they ate.
That is a truly appalling story. Do you know what they were given? Condensed milk. The people who liberated them thought the survivors needed to be given something that would be both imperishable and rich in calories. But condensed milk is actually pure fat. Their body couldn’t handle it. One of our fellow dietitians, Shulamit, second-generation [to Holocaust survivors], told us that when the Allies arrived in the camp where her father was, and distributed food, her father said: Take care of the others, I can wait. And that’s how he was saved. If he’d fallen on the food like all the others, he would have died on the spot.
When a person suffering from anorexia-induced cachexia comes to see me, we feed them very carefully. Ten calories per kilo of body weight, for example. At the same time, we start to correct the deficiencies in micronutrients, because that is what kills them. We add phosphorus, magnesium, vitamins. Without that treatment, all you’re doing is bombarding the patient with calories, and the body just collapses. Only after we see a correction in those values can the caloric value be increased. Death resulting from food intake is a phenomenon we also have see among children in Africa, because of the good intentions of aid organizations, which simply didn’t know what to do.
Generally speaking, it’s more difficult to assist undernourished children, because they need food in order to develop and not just in order to survive. When they don’t receive food, the heart, the liver and the brain don’t develop. It can be clearly seen that the process of collapse, which in adults lasted months, took weeks in children.
Unique point in history
I wonder if among the subjects in the ghetto there were those who were not in a terminal state, and who could possibly have been helped, but whose fate was sealed for the sake of the research.
I don’t know. The findings show that they arrived in different stages of hunger. I find it hard to believe that any of them was in truly initial stages. We’re talking about women who weighed 28 kilos [62 pounds]; elderly people who weighed 34 kilos. That is not a good situation. It’s important to understand: They were given food in the ghetto hospital. Meager food, but still food. They were treated well. They were given painkillers. Their eye infections were treated. But it was impossible to save them.
Yes. Their [suffering] was relieved as much as possible. And additionally, they were subjected to testing. The physicians carried out some of the tests on themselves, to set a reference point. It’s all detailed here in the study. Systematically. With graphs they drew. It’s simply out of the question that we don’t have this material.
Overall, and for obvious reasons, there are very few studies about hunger. The best known of them is the Minnesota Starvation Experiment of 1944-45, which is controversial in itself.
That study was conducted on [draft-age young men]. What sort of malnutrition regime was imposed on them in the project? To consume 1,800 calories a day instead of 3,000 or 4,000. What would have happened if they’d had to subsist on the rationing that existed in the ghetto? God help us. Beyond that, the researchers didn’t reach the achievements of the hunger study in Warsaw. The latter’s findings on how hunger affects the eyes, for example, is unparalleled.
The only way to arrive at such findings is through atrocities. Ethically and practically, there is no way to conduct a study of this kind. It could only have occurred at that point in history.
The doctors in the Warsaw Ghetto could also perform an autopsy to see exactly how hunger affected organs, but that was not an option in the Minnesota experiment. It’s a wild historical drama: That horror is the greatness of the ghetto study; it’s the total opposite of the appalling studies the Nazis carried out in the Holocaust.
We haven’t spoken about the psychological effect of hunger.
At first there is what’s known as hunger madness. People become violent. People are ready to do anything. Anything in order to eat and get food. Cannibalism can occur. Killing. Theft. The Minnesota study dwelt on this stage, because they wanted to understand the behavior of POWs; the study describes how they had to restrain the subjects with force because they were willing to do anything to get food. They wanted to eat everything, including non-foods. After the madness comes a stage of apathy. You’re hungry but you don’t want to eat. Food is no longer of interest. The subjects in the ghetto study were already in that phase. They were apathetic.
That connection, between the study’s historical importance and its scientific relevance, is rare.
Its findings are relevant. The method and the planning are relevant. Even the equipment they used is relevant. You know, I came back from Warsaw obsessed. My children can’t take me any more. They tell me I’m driving everyone crazy. I told the story of the research project to people I met in the supermarket. I just wanted to shout it out to the world. A month ago, I got back from another trip to Poland, this time to a conference in Krakow. It was unbelievable: The lectures revolved around the questions and the findings of the study. The knowledge they’re so proud of in 2019 – it all already existed but no one knows about it. It’s a scientific legacy of the first order.
The physicians in the ghetto had to decide – either to despair of the situation and give up, or to tell themselves: I am a doctor and this is my way to fight back. They have not received sufficient scientific appreciation, certainly not enough for their greatness of spirit. Breakthrough studies like this one, studies that are milestones, are quoted and made use of for years upon years. This study remained in the dark. Today I can find through Google an article that appeared 30 years ago in the Lancet and order it. There is no access to the [text of the original] hunger disease study. Only those with a physical copy of the book can make use of it.
You and your colleagues have a plan.
Absolutely. First, we have to get hold of all the copies of the English-language edition that still exist and distribute them in relevant places: universities, laboratories, nutrition units in hospitals. The second thing I want to do is to get the book retranslated, from the Polish original. I don’t know Polish, but even the superficial comparison I made shows that there are sections missing in the English and French versions. For example, the Polish version has the initials of all the names of the subjects. There are names of doctors who took part in the study and were omitted, and thus not perpetuated. I imagine that other things are also missing.
The aspiration is to translate the whole book anew and make it accessible, digitally, in libraries, in other sources. For people to work with it, study it, quote from it. And, of course, in the end we also want to have a Hebrew version, with notations and commentaries relevant for our time from expert physicians. On all these fronts we are moving ahead slowly but surely. It will all happen. We are goal-motivated. We will not give up.