The mass killing of Jews during World War II did not happen only in gas chambers. Starvation and disease ravaged incarcerated Jews, who lacked adequate food and medical care. Perhaps the most well-known Holocaust victim, Anne Frank, died at Bergen-Belsen concentration camp — not in a gas chamber, but of typhus.

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Jews were forcibly interned in Holocaust-era ghettos where diseases ravaged the population. The ghettos they were crammed into averaged four to eight people per room, and offered inadequate access to sanitation facilities, medicine and food. These conditions left them particularly vulnerable to epidemics of deadly communicable illnesses. The yellow stars on their clothing were not a choice. They were forced to wear them, and to live in horrific conditions that bred infectious disease.

When outbreaks occurred, the Nazis dealt with them ruthlessly. In the Kaunas ghetto, they burned down the hospital for infectious diseases with patients and doctors inside. In the Lodz ghetto, when typhus ravaged the Roma, they were herded into cattle cars and became the first victims of the gas vans at the Chelmno extermination camp. People were scared to go to the hospital with an infectious disease for fear of being killed there or deported to an extermination camp.

Those not killed by the Germans while seeking medical care had a poor prognosis. The hospital death records of the Lodz ghetto list the names and ages of thousands who died of disease: Hinda Calel, 8, died of chickenpox; Eliezer Rusek, 4, died of whooping cough; Esther Rosenbaum, 5, died of tuberculosis.

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In his Lvov ghetto diary, David Kahane recorded that the bodies of the dead were “carted off to the graveyard every day, sometimes even several times a day,” and noted that few of the deceased were being ritually prepared for burial. This work had been done by rabbis, but all the rabbis in Lvov had either been deported or died of disease or violence at the hands of the Nazis. Instead, bodies of the dead were piled high in the cemetery, becoming a spectacle for Nazi visitors, who took pictures of the horrific site.

The death toll from infectious disease was so high because Jews were stripped of basic resources including medical equipment, medicine and food. They were even denied quality soap. Doctors and other care providers helped fight disease in terrible conditions with scant supplies, many succumbing to disease themselves. Starving people traded food for medicine to help family members survive.

Vaccines emerged as a powerful, if expensive, tool for resistance. Smugglers found ways to bring medicine and even nascent vaccines into the ghetto. Those few who could obtain a vial of vaccine on the black market paid more than 100 times their weight in gold to obtain them. The going rate for a vaccine in the Warsaw ghetto could buy 30,000 bowls of soup — an astronomical amount in a place where people perished of hunger in the streets.

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Smuggling vaccines into ghettos was one of the ways in which Jews and the Polish underground worked together. Irena Sendler, a Polish social worker, smuggled 2,500 Jewish children out of the ghetto. When Irena came into the ghetto, she was able to get vaccines to her former colleagues Ewa Rechtman, who worked in a ghetto orphanage, and Ala Golab-Grynberg, a nurse in the ghetto.

In addition to smuggling vaccines, Ludwig Fleck developed an early test for typhus and a vaccine for the disease in the Lvov ghetto. Working in a ghetto laboratory, he developed a means to create a vaccine from urine. He eventually used it to inoculate himself, his family and 500 ghetto inmates.