Lost Lessons of the Strangling Angel
Europe’s diphtheria outbreaks in the 1940s provide a sobering context for modern anti-vaccination claims.
When the Strangling Angel was at her strongest in Norway and Germany, 715 people each day were infected. She took refuge in the throats and hearts of the unprepared. The Strangling Angel—diphtheria—found comfort on the boots of German soldiers as they marched across Europe in the 1940s. Even though she visited over one million people in Europe at the time, she was forgotten and her lessons were lost.
The merciless lessons of diphtheria are drowned out today by the echo chamber of anti-vaccine activists trying to convince parents not to vaccinate their children and to discourage people from vaccinating themselves. An online collection of factoids meant to support the anti-vaccination position reverberates around the Internet, cut from one website and pasted onto another without fact checking or context. Two of these anti-vaccination echoes are: “In Germany, compulsory mass vaccination against diphtheria commenced in 1940 and by 1945 diphtheria cases were up from 40,000 to 250,000” (Allen 1985), and its usual sidekick, “In nearby Norway, which refused vaccinations, there were 50 cases of diphtheria.”
The truth about the relationship between diphtheria and vaccines in the 1940s cannot be expressed as a shout against hard walls while standing at the bottom of a canyon. A higher vantage point is needed to see the truth about vaccines in Europe in the 1940s.
Most industrialized westerners are blissfully ignorant of diphtheria today. To understand how it spread across Europe, we must first understand the basics of the disease.
Diphtheria is a highly contagious bacterial disease of two types: respiratory and skin (cutaneous). Skin diphtheria can cause redness, sores, and ulcers. Mild fever, sore throat, and chills are the first symptoms of respiratory diphtheria. Diphtheria then creates a toxin that makes a blue or gray-green coating that sticks to the throat and nose. The coating thickens in the throat, making it hard to swallow and robbing the patient of breath. Some patients’ necks swell, sometimes to the width of the head, a condition called Bull Neck. The toxin can also travel to the nervous system, causing paralysis, and to the heart causing heart failure. Diphtheria was once called the “Strangling Angel” because of how it kills.
The bacteria that cause diphtheria reside in the upper respiratory system. It is spread by close contact with an infected person or contact with droplets of saliva, the toxin, or other bodily fluids. Occasionally objects soiled by an infected person can spread the disease. Susceptibility increases in overcrowded, unsanitary, and poor socioeconomic conditions. Research also indicates that stress and starvation make a person more likely to contract diphtheria. Between 5 and 20 percent of people who get diphtheria die, depending on age. Children are at the highest risk of death.
Diphtheria was a scourge on Europe’s residents during World War II. Europe saw more than one million recorded diphtheria cases in 1943, not counting Russia (Stowman 1945).
“Don’t Get Stuck”
Don’t Get Stuck! asserts: “Vaccination was made compulsory [in Germany] at the beginning of the Second World War; and the diphtheria rate soared up to 150,000 cases, while in unvaccinated Norway, there were only 50 cases” (Allen 1985). Allen offers no sources for this information. Allen is the past president of the natural medicine advocacy group American Natural Hygiene Society.
In 1945, the United Nations Relief and Rehabilitation Administration1 released diphtheria numbers for several European countries over several years, including Norway and Germany (UNRRA 1945).
• In 1940, Germany had 143,585 cases and Norway had 149.
• In 1943 (the last year in the report), Germany had 238,409 cases and Norway had 22,787.
Allen’s numbers are reflective of only about one-third of the total cases recorded in Norway and Germany.
Diphtheria’s Dark History
In the 1920s and 1930s, diphtheria killed thousands of people every year in Europe, but not all countries were equally affected (Rosen 1948). Diphtheria was one of the top three killers of people under age fifteen in England and Wales in the 1930s. Germany wrestled with exponential increases in diphtheria infection rates between 1920 and 1940 from about 50 to over 200 per 100,000 people (Baten and Wagner 2003). Norway escaped being ravaged by diphtheria and had a long-term steady decline in the numbers of diphtheria cases.
Due to the small number of cases in Norway, no national program for diphtheria vaccinations was instated. Epidemiologists of the time described Norway as almost completely non-immunized (Anderson 1947).
Allen’s claims do not include other European countries, but England is essential to note. England implemented a mass diphtheria vaccination program in 1940 in response to the outbreaks. The value of vaccines was made clear to the public. In 1940, England had 47,683 cases of diphtheria and in 1944, the number had dramatically dropped to 29,446 (UNRRA 1945).
Germany did not follow England’s lead, but neither did it go the way of Norway. In 1945, Dr. G. Stuart of the European Regional office of the United Nations Relief and Rehabilitation Administration summarized the German vaccine program:
The reason underlying the high morbidity in Germany and its incorporated territories is largely determined by the absence of any nation-wide policy of immunization comparable to that so successfully applied in Great Britain. On the other hand, a large-scale campaign was introduced in the pre-war period in Western Germany, while an increase in diphtheria morbidity and mortality has since led the Reich and Prussian Ministry of the Interior to approve immunization in those parts of Germany particularly affected. Moreover, immunization is compulsory for all youths at the beginning of their Landjahr—i.e., their year of agricultural service. (Stuart 1945)
(Landjahr was a voluntary program for all youngsters except university students, who were required to participate.)
Germany had an incomplete, noncompulsory diphtheria vaccination program. A large percentage of, maybe even most, citizens were not vaccinated against diphtheria. Even though the original claim and Allen’s claim have been fully discredited, the numbers have not yet been put in appropriate context to shed light on the larger issue of vaccine effectiveness. We need to understand why Germany and Norway’s numbers went up at such a high rate.
There are two obvious factors that have yet gone unexplored: World War II and the Holocaust.
Sardines and Sanitation
In September 1935, Germany passed the Nuremburg Laws, depriving Jews of many of the rights and protections of citizenship. In October 1935, the laws were extended to cover Roma (gypsies), blacks, and other “undesirables.” Between 1933 and 1939, new laws banned Jews from municipal hospitals, forced them out of schools at all levels, and severely limited Jewish doctors’ ability to practice medicine. This is not a comprehensive list, but it does demonstrate how restricted health care was for Jewish and other “undesirable” Germans.
In October 1939, the German-occupied territory of Piotrków Trybunalski in Poland opened the first ghetto specifically for Jews. Also in 1939, Germany greatly expanded its use of concentration camps. The number of people held in concentration camps quadrupled from 1939 to 1942. Undesirables from all over Europe—Jews, the mentally ill, Roma, communists, gay people, political dissidents—were also imprisoned in the camps. The estimated number of camps ranges greatly, some estimate up to 15,000 by the end of the war. Some were temporary, others existed for several years.
(There were several different types of concentration camps, including labor camps and extermination or death camps. For the purposes of examining diphtheria in Germany during this time, the specific type of camp is not important, so all the different types of camps will be referred to as concentration camps.)
The Nazis packed people into concentration camps at an even higher rate than they did in the ghettos and further restricted access to clothes, shoes, soap, food, medicine, and clean water. Many camps used prisoners for slave labor. The clothing was inadequate to protect from the cold. Camp prisoners had to contend with starvation, unending stress, exhaustion, and exposure. From a germ’s point of view, it was a perfect place to reproduce. Unrelenting tidal waves of disease swept through the camps without conscience or mercy.
“Quite aside from hard-to-measure traumas such as the drawn-out anticipation of an impending catastrophe, the incarceration itself, the dehumanization, the sustained fear of death, I could point to some very tangible assaults upon my health in the concentration camp,” Jewish linguist Werner Weinberg recalled about his experience in Westerbrock Camp and Bergen-Belsen Concentration Camp. “Among them were prolonged starvation and exposure; being worked beyond my endurance and strength; every cut and bruise turning into festering wounds accompanied by high fever; diphtheria, dysentery, hepatitis, and a bout with typhus that very nearly killed me” (Weinberg 1984).
Bergen-Belsen Concentration Camp was located in northern Germany near Calle. Housed in Bergen-Belsen were Jews, Roma, criminals, Jehovah’s Witnesses, homosexuals, prisoners of war, and political prisoners. In July 1944, approximately 7,300 prisoners lived in Bergen-Belsen. By April 1945, the number rose to 60,000. Many of those people were evacuated from other camps or regions in the German occupied territories. Food rations did not rise proportionally.
Bergen-Belsen was liberated on April 15, 1945, by the British Army. The liberators were shocked by what they found: more than 60,000 prisoners in various stages of starvation and almost all suffering from disease.
Lieutenant Colonel M.W. Conin of the Royal Medical Corps at Belsen was one of the first medics from the Allied Forces to enter Bergen-Belsen Concentration Camp. Said Conin, “One had to get used early to the idea that the individual just did not count. One knew that 500 a day were dying and that 500 a day were going to go on dying before anything we could do would have the slightest effect. It was, however, not easy to watch a child choking to death from diphtheria when you knew a tracheotomy and nursing would save it” (Reilly et al. 1997).
Prison block infirmaries and camp hospitals were short of all medical supplies including cots, life-saving drugs, sterile supplies, diagnostic tools, staff, and anesthesia. Prisoners had to share beds even if their diseases were contagious. The block infirmaries were often staffed by other prisoners without medical training, who were left to administer treatment, diagnose problems, and even perform surgery. The infirmary staff would often try to hide advanced illness from Nazi doctors who would come to check on the patients because the Nazi doctors were usually performing “selection.” When patients were “selected” it usually meant they were chosen to be put to death. According to numerous accounts, prisoners resisted going to the camp doctors. The infirmaries were called “waiting rooms for the crematoria” in some camps.
Just an Experiment
In some camps prisoners were subjected to deadly medical experiments, including new vaccine development. Research on typhus, smallpox, cholera, malaria, yellow fever, tuberculosis, paratyphoid, and diphtheria was conducted on the prisoners.
In written testimony given for the International Auschwitz Committee, former prisoner Dr. Stanislaw Klodzinski described the medical experiments he saw performed by SS doctors and pharmaceutical company representatives: “These preparations, he tried out on prisoners of the Auschwitz camp for experimental purpose regarding typhus, typhoid fever, and various para-typhoid diseases, diarrhoea [sic], tuberculosis of the lungs, erysipelas, scarlet fever and other diseases” (International Auschwitz Committee 1986).
When disease levels got too low in the camps where research was taking place, Nazi doctors intentionally injected prisoners with disease and sent them out into the populations at the camps to re-infect the prisoners and keep diseases active in the camps. By having a lasting infection, they could study the effectiveness of vaccines as well as the long-term effects of the diseases (Baumslag 2005, 145).
Lieutenant William Smith of the Canadian Army explains death on the front in World War II in his online account of Operation Infatuate (an amphibious landing to take Walcheren, a Dutch Island). “There in early December, outside Groesbeek, on the edge of the Reichswald Forest, I was wounded on patrol. Brown was killed, shot in the kidneys by a sniper, and Doakes died of diphtheria in a hospital somewhere in Holland” (Smith 1944).
Smith’s story was common. Soldiers killed each other; diphtheria and other diseases killed soldiers. Soldiers, especially those on the front lines and in prisoner of war (POW) camps, underfed, under-dressed, packed together in tight groups and exhausted, were vulnerable to disease. Every aspect of war made the soldiers and civilians more vulnerable to disease.
Conditions for POWs during World War II varied depending on rank, circumstance, and the country in which they were captured. In Germany, some POWs were kept in castles, others were forced to work as slave laborers. Many lived in concentration camps or in conditions similar to them.
In January 1945, tens of thousands (numbers vary between 30,000–120,000) malnourished Allied prisoners of war were forced to march in groups of up to 300 across Poland and Germany in what came to be known as The Long March. Temperatures dipped to a biting -13 degrees Fahrenheit. The prisoners were given inadequate water and food. They had to resort to drinking from ditches and scavenging for food, including eating rats. They were forced to sleep on the ground in the freezing conditions, which resulted in amputations due to frostbite. POWs died from exposure, dysentery, exhaustion, pneumonia, typhus, and diphtheria. Between 1,121 and 2,200 POWs died during the three-month winter march.
Diphtheria on the March
Germany’s policy of slave labor, concentration camps, ghettos, and a lack of vaccines made it a festering pustule of disease. As Germany marched across Europe, disease became a second army, a wake of death behind the tanks and guns.
The European countries with the greatest increases in diphtheria during 1940–1944 were Norway, Belgium, the Netherlands, France, and Denmark. The Netherlands saw a whopping forty-fold increase in diphtheria cases, which was dwarfed by Norway’s 112-fold increase in cases (Stuart 1945). The increases in diphtheria rates all followed the German occupations in those countries. Germany’s official numbers did not even double (UNRRA 1945).
Belgium was invaded by Germany in May 1940, and with the invaders came a considerable increase in diphtheria. In 1939, Belgium had 2,419 cases of diphtheria. By 1941, the number had skyrocketed to 4,271. Even worse was 1943 at 16,072 or about 1,340 cases per month (UNRRA 1945). In September 1944, the Canadians pushed into Belgium and started to shove Germany out. In early November, the Germans were forced out of Belgium. In November, the cases were down to 447 (Stuart 1945).
The Netherlands was also invaded by Germany in May 1940. In 1939, they had 1,273 cases of diphtheria. 1940 had a shocking 5,501 cases. The exponential growth continued for the next two years, with 1942 seeing 19,527 and 1943 seeing 56,603. In August 1944 the number of cases was up to 60,226. The Germans were booted from the Netherlands in early 1945. In 1945, diphtheria rates in the Netherlands dropped faster than they gained the year before, to 49,730 cases (Stuart 1945; Anderson 1947; UNRRA 1945).
The Netherlands and Belgium had one significant commonality—incomplete vaccine programs. The Netherlands stopped their previously widespread but not comprehensive diphtheria vaccine program during the war. Belgium attempted widespread vaccinations but did not make it mandatory.
Norway Was Different
Unlike the Netherlands and Belgium, Norway was completely undefended against diphtheria. The rates of diphtheria dipped so low the country had little natural resistance and there was no national or compulsory vaccination program. When Norway was invaded in April of 1940, it set in motion an astronomical spread of diphtheria.
In 1939, Norway had 71 cases of diphtheria. By 1943 it was up to 22,787 (UNRRA 1945). Norway was caught totally unprepared. With no inoculations and no natural immunities, the population was at the mercy of the troop movements and the disease’s course. Norway’s decision to have an unvaccinated populace was a deadly mistake.
Allen was on to something—diphtheria in Europe during the 1940s is a compelling anecdote in the current debate over the safety and effectiveness of vaccines. Unfortunately for the original online assertion, Allen’s position, and the anti-vaccination position, the vaccination programs in Norway and Germany argue in favor of mass, compulsory vaccinations and show the dangers of the anti-vaccination movements to the health of all people.
In countries without complete vaccination programs, when the disease was introduced, it spread at an almost inconceivable rate. Norway’s mistake—be it a result of hubris or ignorance—was its belief it could control a disease without vaccines and its failure to adequately consider changing conditions outside its control.
Europe in the 1940s is a case study that demonstrates the importance of paying attention to the health of all countries and helping them eradicate their diseases. The world is a smaller place than it was during WWII. All people are just a short plane ride from the next continent. A person infected with diphtheria can take between two to five days to show symptoms. In that time an infected person can travel thousands of miles by plane and potentially contact thousands of people.
Germany and Norway in the 1940s also teach us that human rights abuses are not just matters of morality for the persons directly involved. Altruism is not the only reason to help people in conditions like those in ghettos and camps; enlightened self-interest may be necessary to protect from outbreaks of disease. The take away from World War II Europe diphtheria rates and the effectiveness of vaccines would be most clearly stated as:
In the 1930s and 1940s, Germany created a breeding ground for diphtheria. They did not implement a comprehensive, compulsory vaccine program. They restricted medical care for large sections of the population, and crowded those people into concentration camps and ghettos. That concentration and the accompanying war conditions led to outbreaks of disease in Germany. As a consequence, diphtheria could be found in the footsteps of German soldiers in countries they invaded during World War II. After being invaded by Germany, Norway, which had no diphtheria vaccine program, saw unimaginable increases of diphtheria (149 cases in 1940 to 22,787 in 1943). Other countries with incomplete inoculations, like Belgium, the Netherlands, France, and Denmark also had huge increases. England had an extensive vaccination program and the incidents of diphtheria during World War II declined. Vaccinations are essential to protecting people from disease and merely controlling it by other means is not sufficient.
The anti-vaccination movement in America today uses Hannah Allen’s claims about Germany and Norway to try to discourage vaccinations in children and adults. As a result of their efforts, nearly ten percent of children in America are not fully vaccinated. The number of parents filing for exemptions to school vaccine requirements is increasing steadily. America is having outbreaks of diseases previously controlled through vaccinations, like whooping cough and measles. America may soon be as vulnerable as Belgium was in the 1940s. If anti-vaccination proponents see their goal accomplished, America risks becoming another Norway.
Dr. Paul Offit, developer of the rotavirus vaccine, summarized his objection to the anti-vaccination claims about vaccines in 1940s Germany plainly: “I can’t believe we are still discussing this in the 21st century. There is no debate. Look at the history of vaccinations in the world and you come away with the following conclusion: immunization rates increase, disease decreases. It is just that simple.”
For research assistance I thank: Kristian Frøland, student at Norwegian University of Science & Technology, and Timothy Binga of Center for Inquiry Libraries.
1. United Nations Relief and Rehabilitation Administration was the branch of the United Nations tasked with planning and coordinating relief efforts for WWII war victims.
Allen, Hannah.1985. Don’t Get Stuck! The Case Against Vaccinations and Injections, revised edition. Natural Hygiene Press, 28.
Anderson, Gaylord. 1947. Foreign and domestic trends in diphtheria. The American Journal of Public Health 37(1): 1–6.
Baten, Jörg, and Andrea Wagner. 2003. Autarchy, market Disintegration, and health: The mortality and nutritional crisis in Nazi Germany 1933–1937. Economics and Human Biology 1: 1–18.
Baumslag, Naomi. 2005. Murderous Medicine: Nazi Doctors, Human Experimentation, and Typhus. Praeger.
International Auschwitz Committee. 1986. Nazi Medicine: Doctors, Victims and Medicine in Auschwitz. Howard Fertig.
Reilly, Jo, David Cesarani, Tony Kushner, et al. 1997. Belsen in History and Memory. Routledge.
Rosen, George. 1948. Public health in foreign periodicals. American Journal of Public Health 38: 1158–1160.
Smith, William. Operation Infatuate–Walchren 1 to 8 Nov 1944. Online at http://bit.ly/VIFDWg.
Stowman, Knud. 1945. The epidemic outlook in Europe. The British Medical Journal 1(4403): 742–744.
Stuart, G. 1945. A note on diphtheria incidence in certain European countries. The British Medical Journal 2(4426): 613–615.
United Nations Relief and Rehabilitation Administration (UNRRA). 1945. Epidemiological Information Bulletin: 241–246.
Weinberg, Werner. 1984. Survivor of the first degree. Christian Century (October 10). Online at http://bit.ly/Wa0dPT.
For Further Reading
Baker, Jeffery, Artur M. Galazka, Susan E. Robertson, et al. 1995. Resurgence of diphtheria. European Journal of Epidemiology 11(1): 95–105.
Collins, Selwin D. 1946. Diphtheria incidence and trends in relation to artificial immunization, with some comparative data for scarlet fever. Public Health Reports 61(7): 203–250.
Galazka, Artur. 2000. The changing epidemiology of diphtheria in the vaccine era. Journal of Infectious Diseases 181(1): S2–S9.