The German experiment: Health care without female or Jewish doctors.

Jewish and female doctors were not allowed to practice medicine in Germany during Hitler's rule from 1933 to 1945. Data about the consequences of this on the health service are difficult to come by, but what information can be gathered demonstrates a detrimental effect on the nation's health. These data, however, must be interpreted with consideration to the morbidity and mortality from violence, death camps, slave labor, and the privations of war. The article summarizes the history of German health care during this period and also compares Germany to other nations at that time.

Introduction

The Third Reich (1933–1945), the period when Adolf Hitler was chancellor of Germany, was a time of great violence, discrimination, and medical upheaval. Data about the quality of the German health service are difficult to come by, but what information can be gathered demonstrates a detrimental effect on the country’s health. This is to be expected during the war years, but may also represent the loss of so many trained physicians (i.e. Jewish and female practitioners) who were not allowed to practice during these years. This article will argue that preventing women and Jews from practicing adversely affected Germany’s health.

Pre-Nazi period

Germany had an advanced history concerning women’s rights. The first-ever female doctor in Europe was a German woman named Frau Dorothea Lepavin-Erxleben, who, in 1754, was admitted to the University of Halle and graduated from the medical faculty by the favor of Frederick the Great (Lovejoy, 1957). Like most, if not all, early German female doctors, she became an obstetrician. Queen Victoria of Britain, for example, was delivered by a female German obstetrician named Dr. Charlotte von Siebald in 1819 (Lovejoy, 1957). Women training to be doctors in Germany still faced a struggle, however, and in 1869, female doctors could only practice in Germany if their medical diplomas were from a different country. Women were not admitted to medical schools in Germany until 1888 (Lovejoy, 1957), compared to 1849 in the United States, 1875 in France, 1876 in England, 1878 in The Netherlands, and 1882 in Spain.

Germany also led the way with social policies, including, in 1883, Otto von Bismarck’s state health insurance system (Berg and Cocks, 1997). The move towards a social policy of health met with great criticism from doctors, but also led to greater unification. In 1873, the National Medical Association, DÄVB, was founded. This was largely a Jewish-friendly organization, perhaps because so many of its members and leading figures were Jewish (Berg and Cocks, 1997).

The 20th century led to greater recognition of both female and Jewish medical practitioners. The First World War had been an opportunity for female doctors to prove their skill manning hospital and research units while their male colleagues signed up for active service. The First World War also marked the first time Jewish male doctors received field commissions, but, in general, Jewish doctors of both sexes had been forced into less glamorous areas of medicine, such as internal medicine and dermatology. These fields, however, were becoming highly developed, perhaps under their influence. Still, Jews could not join university medical faculties unless they converted (Berg and Cocks, 1997).

The Wall Street crash of 1929 and resulting depression caused a collapse across many developed countries. Germany was particularly affected, as it was paying reparations after the Great War. Doctors suffered along with all other professions; this helped foster anti-Semitism, as Jewish doctors were academically influential in large metropolitan areas such as Berlin, Frankfurt, and Hamburg (Berg and Cocks, 1997). The national health insurance system meant that doctors had to wait to fill vacancies in national services and could not start private practices. This, with encouragement from the National Socialist Party (Nazi Party), led to the formation of the National Socialist Medical Association (NSDÄB) to rival the DÄVB. Initially, the NSDÄB was not a powerful or influential organization, but things changed in 1933 when Hitler rose to power. The Nazi Party ideals were also anti-feminist, with rules as early as 1921 stating that no woman could have a position or role in the Nazi Party. In 1933, there were 4,367 female German doctors (Lovejoy, 1957), 587 of whom were Jewish (Hutton, 2001). This can be compared to figures from France, a country of similar size, where in 1928 only 556 women were practicing medicine in France across all specialties (Lipinska and Thomas, 1930). Jews represented 16% of doctors in Prussia and 25% of dermatologists in Germany, which is equal to 566 total (compared to being less than 1% of the population) (Yesudian et al., 2010). Another figure quoted is that, of the 2078 dermatologists in Germany in January 1933, 569 were Jewish dermatologists (Scholz and Eppinger, 1999).

Hitler’s rule in Germany

On January 30, 1933, Adolf Hitler was elected Chancellor of the Reichstag, the governing body of Germany. The Enabling Act was subsequently passed in March 1933, effectively giving Hitler total power. Hitler then set about with his programs of “social Darwinism” and “racial hygiene,” which included the removal of all Jewish and female doctors from their posts in April and June of 1933, often replacing them with medical students (Weindling, 1989). While female doctors might still be allowed to work in midwifery, Jewish doctors could not work at all and many emigrated. After Hitler’s ascension, most other medical practitioners decided to join the NSDÄB (membership rose from 2,786 members in January 1933, to 11,000 members in October 1933 and 42,000 members in 1942) (Weindling, 1989) and income for doctors rose from a rather poor 9,300 marks in 1933 to 15,000 marks in 1938 (Berg and Cocks, 1997). In addition, in 1933, women were dismissed from their positions as solicitors, civil servants, and other professional posts; as of 1936, women were no longer allowed to sit on juries (nor be judges or prosecutors), as they were deemed to be ruled by their emotions.

Hitler’s policies also featured eugenics, a term first proposed by Francis Galton, a cousin of Charles Darwin (Cuerda et al., 2011). Eugenics was first implemented in the United States in the early 1900s, and is reportedly still occurring there via the sterilization of female prisoners (Johnson, 2014). With the rise of Nazism in 1933, those chosen for sterilization included racial and ethnic groups such as blacks, Gypsies, Poles, and Jews. One figure suggested that, of the 400,000 people who had been forcibly sterilized by 1945, approximately 5,000 women died of either postoperative complications, as a result of their resistance to the procedure, or of subsequent suicide (Berg and Cocks, 1997). (Men were also being sterilized, but suffered fewer postoperative complications.) The surgeons, however, were being dubbed “masculine heroes of the scalpel.” In 1934, a doctor was required by law to denounce any of his patients who were disabled (Berg and Cocks, 1997). In 1935, the Blood Protection Law prohibited marriage and sexual intercourse between Jews; later that year, the Marital Health Law prohibited the marriage of a Jew (or a member of any other classified unsavory group) to an Aryan (Berg and Cocks, 1997). Abortion was either encouraged or refused depending on the woman’s race/ethnicity, and a woman’s role in society was seen as purely reproductive. One example of this is the “Lebensborn,” an initiative where “racially pure” women were encouraged to procreate with Aryan men, such as SS officers; the children would then be adopted out, while the mothers continued in their duty to provide more members of the “master race” (International Tracing Service, n.d.).

With the advent of war in 1939, “Action T4” started in earnest, which was a program to exterminate all mentally and physically handicapped and chronically ill patients (Berg and Cocks, 1997). Relatives, convents, and monasteries had to give up their charges. Special children’s wards were created for the observation (and eventual death, usually from starvation until they moved to faster methods) of chronically ill children from the epileptic to the handicapped. Towards the end of the Second World War, as German supplies became scarce, those who had been kept in concentration camps or used as slave labor were exterminated.

Morbidity and mortality figures have to be interpreted amongst this setting of increased violence and extermination programs. Not only were Jewish and female doctors prevented from practicing medicine, but members of the German intelligentsia, which included many physicians as well as politicians and university staff, who refused to submit to Nazi doctrine also lost their jobs. With the loss of a good proportion of experienced medical practitioners, one would expect that the quality of the nation’s health care would deteriorate.

The diphtheria death rate is one indicator that medical care was suffering, as it shows 77,340 deaths in 1933, increasing to 146,733 in 1937 (Weindling, 1989). A doubling of the death rate in a pre-war Germany, which was ostensibly flourishing under Hitler (if you were Aryan), suggests that good propaganda underlay a very different reality of a healthcare system bereft of experienced practitioners. Records also demonstrate increasing trends in scarlet fever, spinal meningitis, infantile paralysis, typhoid, and paratyphoid (Weindling, 1989). Hospital mortality figures rose by 16%5 and life expectancy declined but, again, whether this was due to violence or lack of medical care is difficult to extract (Gapminder, 2013). Research into the detection and treatment of sexually transmitted diseases stopped (Weindling, 1994). Figures from one German dermatology center showed a tripling of cases of syphilis, from 275 to 859, and gonorrhea cases increasing from 127 to 1675 between 1933 to 1938 and 1939 to 1945 (Kapp and Bondio, 2011). Maternal mortality figures are not available for Germany until 1952, when the maternal mortality rate per 100,000 was 184; compare this to the rates of the United Kingdom (67 per 100,000) and the United States (68 per 100,000) for the same year, which demonstrates that the German health service still had not recovered by that point (Table 1) (Gapminder, 2013).

Table 1

Historical Maternal Mortality Figures from Selected Developed Countries.

Country	Maternal mortality rate per 100,000
	1933	1945	1952
Germany	N/A	N/A	184
United States	619	207	68
United Kingdom	453	196	67
Sweden	307	133	52
Netherlands	317	194	76
Finland	251	402	125
Belgium	515	343	90

N/A, not available.

The Jewish doctors who remained worked mainly amongst their own people. Some did what they could to help their fellow Jews in the Warsaw ghetto in 1940, while also providing useful research data. The Germans had decided to exterminate the occupants of the Warsaw ghetto by starvation by providing fewer than 800 calories a day to residents (Gratzer, 2005). Dr. Milejokowksi and 5 out of 28 medical staff living in the ghetto decided to record the effects of this starvation, understanding that they would all die, but that the data they collected would mean that non omnis moriar (not everything of us will die) (Medawar and Pyke, 2001). Dr. Milejokowski and colleagues in the ghetto set about recording clinical assessments, physiological readings, and data collected from postmortems regarding the consequences of starvation (Gratzer, 2005). Documentation stopped in 1942 when the remaining people were transported to death camps (note that 43,000 people had already died at this point), but almost one half of the reports were smuggled out and entrusted to Professor Orlowski, the non-Jewish director of the Department of Medicine of Warsaw University. The surviving reports were published in English in the US in 1979 and were seen as an impressive observation on the consequences of malnutrition (Gratzer, 2005).

Not all Jewish doctors were persecuted. Eduard Bloch, an Austrian Jew, was granted special protection and allowed to immigrate to the United States in 1940 because he had cared for Hitler and his family during Hitler’s childhood.

Refugees

In 1933, many Jews fled Germany before they were dismissed from their positions, or worse. Within weeks of Hitler’s ascension, hundreds of Jews had left. Britain was a welcoming destination for many, as it saw the advantage and benefit of accepting so many skilled people, especially in regards to medicine, physics, and chemistry. The United Kingdom, therefore, set up the Academic Assistance Council (AAC), which was tasked with finding these refugee scientists and physicians posts and payment. U.S. policy was still largely anti-Semitic; as such, only 30 Jewish scientists and physicians fleeing Nazi Germany in 1933 were admitted (Medawar and Pyke, 2001). The United States remained prejudiced in this regard, never accepting more than 100 Jewish academics in a year, the highest being only 97 in 1939 (most of those made up of physicians, as they had better international contacts) (Medawar and Pyke, 2001). Often, those who were allowed entry into the United States had already been accepted into the United Kingdom (e.g., Edward Teller, known as the father of the hydrogen bomb). In 1935, a U.S. envoy was sent to Britain to tell the AAC that it could take no more academic refugees (Britain ignored the request and continued to send Jewish academics to the United States) (Medawar and Pyke, 2001).

Not all of the United States was anti-Semitic; for example, Princeton University donated 5% of all of their salaries to the AAC (Medawar and Pyke, 2001). In the 1930s and 1940s, polls of the nation’s attitudes demonstrated that 70% to 80% of the U.S. population opposed raising the quotas for Jewish refugees (Medawar and Pyke, 2001). In 1939, the Wagner–Rogers Bill was proposed, asking that 20,000 refugee children be allowed admittance into the United States, but it was so unpopular that it failed to reach the floor of Congress. At the same time, the already stretched Britain received 10,000 child refugees as war began (known as the Kinder transport) (Medawar and Pyke, 2001).

Postwar

In 1945, the population of postwar Germany faced starvation and was suffering from the destruction of its major cities, a displaced population, and a defeated government. The Allies, comprising France, United Kingdom, United States, and Russia, decided the fate of the country, which was split between them. East Germany remained separate until the fall of the Berlin Wall, while the United States and the United Kingdom still maintain a military presence in what was once West Germany. The splitting of Germany makes it difficult to compare German health statistics pre- and postwar, as they were two very different entities. Of the Jewish doctors who had not left Germany, most were dead from suicide, starvation, violence, or the concentration camps. Using Jewish dermatologists as an example, 50% had emigrated (with 107 going to the United States), 10% died in concentration camps (including Karl Herxheimer and Abraham Buschke), 10% died of natural causes, 2% committed suicide, 4% survived and 24% remain unaccounted for (Burgdorf and Bickers, 2013, Eppinger et al., 2003). German female doctors who remained started reclaiming for themselves a position in medicine. Belatedly, in March 1950, the German Female Doctors Association finally reacquired a legal footing and figures show that of 64,104 doctors, 6,400 were women (Lovejoy, 1957).

Concluding comments

The beginning of the 20th Century was a difficult time to practice medicine as a woman or a Jew. The Nazi Party legalized prejudices (i.e., anti-Semitic and misogynistic) that reflected many people’s opinions at that time. These opinions were not specific to Germany nor are they only relevant to the past. The influx of so many talented people into Britain and the United States represented a huge advance in academia and medicine, and we still benefit from their discoveries and descendants today. Those who remained made every effort to ensure that their work would be remembered and that lessons were learned from the atrocities inflicted upon them. The health care of Germany suffered as a consequence of the loss of so many learned individuals, as evidenced by the maternal mortality rates.

Doctors have been political pawns for centuries, and Jewish doctors have been expelled from their homelands on multiple occasions (e.g., the expulsion of Jewish doctors from Malta in 1492). Recent conflicts have led to an exodus of doctors and their families to safer regime; this includes female doctors who are no longer allowed to practice in Islamic states. One can never fully quantify the detrimental effects the loss of female doctors have on the vulnerable groups they historically and religiously care for.