PREFACE:There is a tradition of epidemiology in the former Soviet Union that is hardly traceable today in Western languages and libraries. This is due in part to the political isolation of the USSR, but may also reflect the fact that for many years, the challenges facing Soviet epidemiologists were different from those found in the West. For much of the early years of the Soviet Union, infectious diseases that had mostly retreated in the West were still ravaging the USSR. Epidemic typhus is a telling example.
Typhus is caused by Rickettsia prowazekii and transmitted in humans by body lice. It apparently arrived in Europe in the 15th century and was a major killer (and a major factor in warfare) until the 18th century.1By 1900, typhus had become rare in Western Europe, but it continued to be endemic in Eastern Europe. It killed on average 40,000 Russians annually, with peaks of up to 200,000 deaths in a single year.1(p299),2(p120)In 1909, the louse was identified as a key intermediate in the transmission of typhus.3This knowledge provided governments (and armies) with a strategy for preventing massive epidemics. During World War I, soap and bathing became effective public health strategies, and petroleum fuels were used as insecticides.
The big exception was again Russia, the only region in Europe where typhus “attained its medieval ascendancy”1(p299)in the 20th century. There were 20 to 30 million cases of typhus between 1918 and 1922 in the territories controlled by the new Soviet Republic, with a mortality of around 10%.4(cited by 2,p120) These deaths were in addition to the casualties from epidemics of cholera, scarlet fever, and typhoid. In December 1919, Vladimir Lenin, first premier of the USSR, declared: “We are suffering from a desperate crisis…. A scourge is assailing us, lice, and the typhus that is mowing down our troops. Either the lice will defeat socialism, or socialism will defeat the lice!”5
During World War II, mass epidemics of typhus again threatened the USSR. Epidemics of typhus occurred in the Ukraine and in Byelorussia.6(p288)These epidemics could have given a major military advantage to the German army. Indeed, the Soviet Union claimed that the Nazis actively attempted to introduce typhus into the Soviet Union.6(p289)According to the U.S. historian Henry Sigerist, “the Red Army was equipped with special bath trains consisting of 9 cars with all facilities for bathing, washing and disinfection, and they were sent right into the front lines.”2(p122)Of special interest is the creation by the Soviet government of antiepidemic groups at the beginning of 1942.6(p297)The Soviet government selected physicians to identify the specific causes of mass outbreaks and to stop them. Courses lasting approximately 6 months were developed to train these epidemiologists. In 1943, Marcus Klingberg attended the first such course in Moscow.
During the war, disease outbreaks were regarded as military secrets. It was useful for the Nazis to know the nature of the outbreaks occurring in the countries they intended to occupy. For this reason, Soviet epidemiologists were required to send daily reports on new cases of a series of diseases to Moscow by telegraph in code6(p299)(as far as Klingberg remembers, the code for typhus was “number 5”). Judging by the Seuchen Atlas (or “Atlas of Epidemics”) prepared by the University of Berlin between 1942 and 1945, the Soviet Union seems to have been successful in hiding information from the Nazis: the Atlas did not reflect the epidemics going on in the USSR during the war.
Marcus Klingberg was a young medical student when the Nazis occupied Warsaw on 29 September 1939. He escaped from Poland to the Soviet Union, eventually making his way to Minsk, the capital of Soviet Byelorussia, where he resumed his studies at the school of medicine. One and a half years later, he was sent to Lida, Western Byelorussia, to work as an epidemiologist.
On 22 June 1941, the Germans launched their invasion of the Soviet Union by attacking Byelorussia and Ukraine. Klingberg volunteered for the Red Army on the first day of the war and served as a medical officer until he was wounded. He was assigned to Perm in the Urals, where he began his epidemiologic work. In 1943, he attended the postgraduate training course in epidemiology in Moscow. Toward the end of December 1943, the first parts of Byelorussia were liberated and Klingberg became chief epidemiologist of the Byelorussian Republic.
At the end of the war, immediately after the liberation of Poland, Klingberg returned to his homeland. There he served as Acting Chief Epidemiologist at the Polish Ministry of Health. Within a few years, he moved to Israel, where he worked as an epidemiologist for approximately 35 years, initially in the Israeli Army and then in academic settings. He became Professor of Epidemiology in 1969 and Head of the Department of Preventive and Social Medicine in the Medical Faculty of Tel Aviv University from 1978 to 1983.
On 19 January 1983, Marcus Klingberg officially “disappeared.” He had been arrested by the Israeli government and put on trial under highly secret conditions. Even his wife, a virologist, was not permitted to attend the trial. According to worldwide media reports, he was charged with having provided information to the USSR about Israel's biologic and chemical warfare research (he had served as Deputy Scientific Director of the Israel Institute for Biologic Research from 1957 to 1972). He was found guilty and sentenced to 20 years in prison. After almost 16 years in prison, in September 1998, he was allowed to move to a very strict house arrest for the remainder of his sentence. He was released on 18 January 2003, at which time he left Israel.
In this interview, Klingberg discusses his work as an epidemiologist, the events that led to his imprisonment, and his commitment to public health.
AM: How did you become an epidemiologist?
MK: I did not choose. In June 1941, when I had finished medical school in Minsk (Byelorussia), I wanted to study internal medicine. However, the special committee of the Ministry of Health told me that I would be an epidemiologist. I had never considered this option, partly because in Poland, epidemiology and hygiene were government professions and therefore not accessible to Jews.
AM: Can you give us some examples of your activities during these years in the Soviet Union?
MK: As an epidemiologist, my team and I had to investigate one outbreak after the other in very difficult war conditions. Sometimes we lacked electricity, kerosene, medicaments, and even paper to take notes. We often had to write between the lines of old newspapers or on the back of wallpaper. We worked closely with the officials of the local administration and the [Communist] Party, and sometimes the Army, and even with officials of the secret police, known as the People's Commissariat for Internal Affairs. When we arrived in a place, we had to see the medical officer and get firsthand information on the epidemiologic situation in the place. With the help of officials of the local council and the Party organization, we were entitled to make crucial decisions such as, if necessary, closing schools and opening improvised “hospitals,” requisitioning beds from houses, putting sick people in quarantine, etc.
For example, in 1942, epidemic typhus broke out in one of the districts of the Perm region (in the Urals). We went from house to house identifying patients. We grouped them in one place, and disinfected their clothes and the clothes of people with whom they had been in contact.
Then we searched for the causes. We interviewed every possible person: Party activists, teachers, community leaders, relatives, and other citizens. In this particular example, we drew on wallpaper a detailed map of the collective farm (called a kolkhoz), the location of the index case, and the dates of the first symptoms for the subsequent cases to trace the progression of the outbreak. We found out that it could be traced to the house where a recently released prisoner had spent nights in the kolkhoz.
People were poor. They could not afford to give hospitality for more than one or 2 nights. So the prisoner had slept in several houses, contaminated its habitants, and had already left the kolkhoz when we arrived. I went after him on a horse. It took the help of the local militia and the secret police, but we found him and destroyed his clothes. In this way, we succeeded in interrupting the spread of epidemic typhus through the whole district.
We often had to overcome the passive resistance of local villagers when modes of transmission were related to their hygienic or funeral habits and traditions. I recall an outbreak of typhoid fever in a Muslim kolkhoz in the Perm region. This was my first encounter with Muslims. Cases seemed to be related in some way to the recent death of the community leader, the mullah, but people were reluctant to provide details about the funeral rites. Finally the local teacher, who was a Party activist and an atheist, explained that the tradition was that old and respected people cleaned the anus and rectum of the dead with their hands. Some of these people contracted the disease and then contaminated their family members. I also found out that people in this community did not use paper or leaves after defecation as most people did during those years, but used water from a special copper kettle shared by the whole family. This habit encouraged the spread of the disease among family members.
I shall mention a curiosity: when I was imprisoned in Israel, the guard gave me a bed, a mattress, and among other things, a plastic kettle. When I asked him what the kettle was for, he explained that it is a habit in the Muslim community to clean themselves after defecation using water. This particular prison was for Palestinian political prisoners; therefore, all prisoners were provided with a kettle for this purpose. As epidemiologists, we have to learn and investigate the cultural habits of the communities in which we work. It helps a lot to be a social anthropologist of some kind!
AM: Was your activity limited to outbreaks of infectious diseases?
MK: Not always. Doctors in the field called the Department of Health when they suspected an infectious agent to be responsible for a sudden rise of cases or deaths. On one occasion, while I was still working in Perm, our investigation revealed that the disease outbreak was not due to a contagious agent.
At the beginning of spring, I was informed of an outbreak in 2 or 3 kolkhozes of a disease characterized by vomiting, diarrhea, and hemorrhages of unknown cause. I went with my team and found that whole families were severely ill, and many were dying. Affected families were sometimes neighbors of nonaffected families, and sick people from affected families could be in contact with members of nonaffected families. We therefore compared members of affected families with those of unaffected ones.
It turned out that the affected families had used up their reserves of wheat during the winter. When the snow had melted, they had gone to the fields and collected wheat that had not been harvested during the previous summer. (Recruitment for the Red Army had depleted the villages of manpower, and mostly old people and children remained.) In contrast, unaffected families had not eaten the rotten wheat.
We therefore recommended that everyone stop eating the rotten wheat. The epidemic vanished. Clearly, the wheat that had remained under snow during the winter was the cause. It was only in the early 1950s that I learned that the disease was alimentary toxic aleukia or septic angina, a rare form of mycotoxicosis associated with the ingestion of grain that has overwintered in the field and become contaminated with fungi that contain trichothecenes.
AM: Are they other examples?
MK: Yes—simply to show you that this was not exactly a routine job. In 1944, there was an increased incidence of malaria in a particular region of Byelorussia, with a strain of plasmodium never seen there before the war. We speculated that Italian occupation forces staying in the region had imported it.
Epidemiologists were also involved in checking for epidemic typhus, louse infestation, diarrhea, malnutrition, etc, during the evacuation of detention camps. In 1944, these camps were sometimes used by the Nazis before retreating to disseminate epidemic typhus. In the Mozyr region of Byelorussia, the German occupation troops gathered tens of thousands of Soviet citizens and mixed people with epidemic typhus with the rest of the population, thus succeeding in spreading the disease throughout the whole camp. The aim of the German troops was mainly to spread epidemic typhus to the Red Army. We, the epidemiologists, had to identify and isolate the sick people and put their close contacts in quarantine for observation. It was a very hard job. Many of the sick died.
AM: Can you describe your epidemiologic training?
MK: At that time, unlike in recent years, epidemiologists were all medically qualified. They were trained in special institutes for advanced studies in the various Soviet Republics. I was very fortunate. In 1943, I was sent for postgraduate studies to the Central Institute for Specialization of Physicians in Moscow. This first course of epidemiology during the war took place after the victory in Stalingrad. As far as I can remember, there were not more than 25 participants from all over the USSR. I was the only attendee who had not been born in a Soviet republic, and therefore I got a room to myself.
The head of the course was Professor Lev Gromachevski, the father of the Soviet school of epidemiology. The half-year program in Moscow was mostly about the epidemiology of infectious diseases. As far as I remember, there were 2 textbooks: one was General Epidemiology7 by Gromashevski, and the other was Specific Epidemiology (in Russian, Chastnaya Epidemiologia) by Isaac Rogozin, which dealt with typhus, typhoid, malaria, diphtheria, scarlet fever, etc. Rogozin was Professor of Epidemiology and Head of the Department of Epidemiology of the Ministry of Health of the USSR. Later we became good friends when I worked in Byelorussia, and he visited me often.
Professors Gromashevski and Rogozin were the strongest influences in my career. They insisted that the goal of an epidemiologist is to find ways of preventing the spread of disease. Not “art for art's sake,” but epidemiology for the community. Part of this intensive course consisted of discussing examples reported by the students from their previous field experience. Essentially, we improved our methods of outbreak investigation and of preventive measures in the community. We also studied the clinical aspects of various infectious diseases at the famous Botkin Hospital in Moscow. We used some statistics for frequencies, incidences, and simple tests. I graduated with distinction in the epidemiology course, and Gromashevski invited me to join his department, but I declined for personal reasons.
AM: Can you describe your first encounter with Western epidemiology?
MK: Before 1951, I had never heard about the epidemiology of noninfectious diseases. This was introduced into the USSR by Validmir Zdanov only in the 1950s. In 1951, I was working as Chief Epidemiologist and Head of the Department of Preventive Medicine in the Medical Corps of the Israeli Army, and it was during that time that I met John Gordon. Gordon had come to Israel with a public health delegation from the United Nations. He was a colonel and had been the Chief Epidemiologist of the Alien Forces in Eisenhower's army, and then was Head of the Department of Epidemiology at the Harvard School of Public Health.
When Gordon told me that he was studying the epidemiology of traffic accidents, I could not understand what he meant. Then he mentioned several examples of the application of epidemiology to health conditions other than infectious disease such as studies by Donald Reid on the epidemiology of hearing loss in soldiers. (Donald Reid was Director of the Department of Medical Statistics and Epidemiology at the London School of Hygiene and Tropical Medicine from 1961 to 1977.) To me, associating epidemiology with these types of issues seemed nonsense.
It was only in 1962, during a sabbatical at the University of Pennsylvania in the Henry Phipps Institute, that its Director, Theodore Ingalls, familiarized me with noninfectious disease epidemiology. He stimulated my interest in congenital malformations, which I studied until the end of my professional life. This is how I was “converted” to noninfectious disease epidemiology.
AM: What do you consider as your contribution to epidemiology?
MK: In infectious disease epidemiology, our work on West Nile Fever. We were the first to describe its natural history, epidemiologic distribution, clinical presentation, laboratory investigations, etc, in a series of papers published in the American Journal of Hygiene [now the American Journal of Epidemiology] and elsewhere.8,9 This work resulted from investigating an epidemic in Israel, particularly in some military camps, in the early 1950s. In noninfectious disease epidemiology, I made contributions to research on congenital malformations.10,11
AM: These studies cannot have been the source of the confidential information you transmitted to the USSR while you were an Israeli citizen. What happened?
MK: This is very simple. Thanks to the USSR, I was the only person in my entire family, except for one cousin, who survived the Nazi invasion and occupation of Poland. I am especially grateful that the Soviet Union gave me the opportunity to fight fascism as a physician in the Red Army and as an epidemiologist. I witnessed the tremendous suffering of the people in the Soviet Republics during the war, and I am deeply convinced that it is primarily thanks to the incredible resistance of these populations and of the Red Army that the Nazis were defeated. I feel I have a moral debt to them.
When the Russians contacted me in the 1950s, I could not see any grounds on which I could refuse to provide them with the information they were asking. It was a personal decision, for which I am not seeking understanding at all and for which I paid heavily. However, this never influenced my scientific work. I was not even directly involved with work connected with the information I was asked to provide. I believed that if both superpowers were in possession of scientific information, it would be in the interest of humankind. Although passing information to the Soviet Union was an illegal act, I am convinced that it has not caused any damage to Israel's security.
AM: What are your interests apart from epidemiology?
MK: Literature. I read a lot of novels. I am from a reading family. At home, our library contained books in several languages: German and Polish, and biblical, Talmudic and modern Hebrew. I am happy that my daughter and my grandson read a lot. My wife died with a book in her hand. Theater comes second. In Russia, even during the war, there was still opera and ballet. I was fortunate that during the war, the famous Kirov Ballet was evacuated from Leningrad to Perm. I knew Aram Khachaturian and sat close to him for the prepremiere of the ballet Gaiane.
CODA:In conducting this interview, I was struck by Professor Klingberg's strong commitment to public health, which in many respects parallels that of other Eastern European refugees whose journeys brought them to the West. Although the “West Side Story” to which those immigrants contributed may be a more familiar history of our profession, it is not our whole history.
I am indebted to Iain Chalmers, Oxford, and Jens Reich, Berlin, for their comments and advice, and to Dr. Tatiana Sacroug, Geneva, for her summaries and translation of the book by Lotova and Idelcik. Professor Klingberg lives in Paris, where he graciously agreed to provide this interview.
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© 2006 Lippincott Williams & Wilkins, Inc.
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