Life and Death in Besieged Leningrad, 1941-44 (Studies in Russian & Eastern European History)

1403_901422_01_pre.qxd

10/6/2004

4:55 PM

Page i

Studies in Russian and East European History and Society Series Editors: R. W. Davies, E. A. Rees, M. J. Ilic ˇ and J. R. Smith at the Centre for Russian and East European Studies, University of Birmingham

Recent titles include: Lynne Attwood CREATING THE NEW SOVIET WOMAN Edwin Bacon and Mark Sandle (editors) BREZHNEV RECONSIDERED John Barber and Andrei Dzeniskevich (editors) LIFE AND DEATH IN BESIEGED LENINGRAD, 1941–44 John Barber and Mark Harrison (editors) THE SOVIET DEFENCE-INDUSTRY COMPLEX FROM STALIN TO KHRUSHCHEV Vincent Barnett KONDRATIEV AND THE DYNAMICS OF ECONOMIC DEVELOPMENT R. W. Davies SOVIET HISTORY IN THE YELTSIN ERA Linda Edmondson (editor) GENDER IN RUSSIAN HISTORY AND CULTURE James Hughes STALINISM IN A RUSSIAN PROVINCE Melanie Ilicˇ WOMEN WORKERS IN THE SOVIET INTERWAR ECONOMY Melanie Ilicˇ (editor) WOMEN IN THE STALIN ERA Peter Kirkow RUSSIA’S PROVINCES Maureen Perrie THE CULT OF IVAN THE TERRIBLE IN STALIN’S RUSSIA E. A. Rees (editor) DECISION-MAKING IN THE STALINIST COMMAND ECONOMY CENTRE–LOCAL RELATIONS IN THE STALINIST STATE, 1928–1941 THE NATURE OF STALIN’S DICTATORSHIP Lennart Samuelson PLANS FOR STALIN’S WAR MACHINE Tukhachevskii and Military-Economic Planning, 1925–1941 Vera Tolz RUSSIAN ACADEMICIANS AND THE REVOLUTION

1403_901422_01_pre.qxd

10/6/2004

4:55 PM

Page ii

J. N. Westwood SOVIET RAILWAYS TO RUSSIAN RAILWAYS Stephen G. Wheatcroft (editor) CHALLENGING TRADITIONAL VIEWS OF RUSSIAN HISTORY Galina M. Yemelianova RUSSIA AND ISLAM

Studies in Russian and East European History and Society Series Standing Order ISBN 0–333–71239–0 (outside North America only) You can receive future titles in this series as they are published by placing a standing order. Please contact your bookseller or, in case of difficulty, write to us at the address below with your name and address, the title of the series and the ISBN quoted above. Customer Services Department, Macmillan Distribution Ltd, Houndmills, Basingstoke, Hampshire RG21 6XS, England

1403_901422_01_pre.qxd

10/6/2004

4:55 PM

Page iii

Life and Death in Besieged Leningrad, 1941–44 Edited by

John Barber Fellow of King’s College, Cambridge

and

Andrei Dzeniskevich Senior Research Fellow, Institute of History Russian Academy of Sciences, St Petersburg

1403_901422_01_pre.qxd

10/6/2004

4:55 PM

Page iv

Editorial matter and selection © John Barber and Andrei Dzeniskevich 2005 Introduction © John Barber 2005 Chapter 4 © Andrei Dzeniskevich 2005 Translator’s Note © David Fry 2005 Chapters 1–3, 5–9 © Palgrave Macmillan Ltd 2005 All rights reserved. No reproduction, copy or transmission of this publication may be made without written permission. No paragraph of this publication may be reproduced, copied or transmitted save with written permission or in accordance with the provisions of the Copyright, Designs and Patents Act 1988, or under the terms of any licence permitting limited copying issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London W1T 4LP. Any person who does any unauthorized act in relation to this publication may be liable to criminal prosecution and civil claims for damages. The authors have asserted their rights to be identified as the authors of this work in accordance with the Copyright, Designs and Patents Act 1988. First published 2005 by PALGRAVE MACMILLAN Houndmills, Basingstoke, Hampshire RG21 6XS and 175 Fifth Avenue, New York, N.Y. 10010 Companies and representatives throughout the world PALGRAVE MACMILLAN is the global academic imprint of the Palgrave Macmillan division of St. Martin’s Press, LLC and of Palgrave Macmillan Ltd. Macmillan® is a registered trademark in the United States, United Kingdom and other countries. Palgrave is a registered trademark in the European Union and other countries. ISBN 1–4039–0142–2 This book is printed on paper suitable for recycling and made from fully managed and sustained forest sources. A catalogue record for this book is available from the British Library. Library of Congress Cataloging-in-Publication Data Life and death in besieged Leningrad, 1941–44 / edited by John Barber and Andrei Dzeniskevich. p. cm. – (Studies in Russian and East European history and society) Includes bibliographical references and index. ISBN 1–4039–0142–2 (cloth) 1. Saint Petersburg (Russia) – History – Siege, 1941–1944. 2. World War, 1939–1945 – Campaigns – Soviet Union. 3. World War, 1939–1945 – Food supply – Russia (Federation) – Saint Petersburg. I. Barber, John, 1944– II. Dzeniskevich, Andrei Rostislavovich. III. Series. D764.3.L4L54 2003 940.53¢4721 – dc21 2003056403 10 14

9 8 7 13 12 11

6 10

5 09

4 08

3 07

2 06

1 05

Printed and bound in Great Britain by Antony Rowe Ltd, Chippenham and Eastbourne

1403_901422_01_pre.qxd

10/6/2004

4:55 PM

Page v

Contents List of Tables

vii

List of Figures

ix

Preface

x

Notes on the Contributors

xiii

Translator’s Note

xv

Glossary of Russian Terms

xvii

Glossary of Medical Terms

xxiii

Introduction: Leningrad’s Place in the History of Famine John Barber

1

1 The Demographic Situation and Healthcare on the Eve of War Nadezhda Cherepenina

13

2 Assessing the Scale of Famine and Death in the Besieged City Nadezhda Cherepenina

28

3 Evacuation from Leningrad to Kostroma in 1941–42 Mikhail Frolov

71

4 Medical Research Institutes during the Siege Andrei Dzeniskevich

86

5 Physiological and Psychosomatic Prerequisites for Survival and Recovery Svetlana Magaeva 6 The Work of Civilian and Military Pathologists Vadim Chirsky 7 The Impact of the Siege on the Physical Development of Children Igor Kozlov and Alla Samsonova v

123

160

174

1403_901422_01_pre.qxd

vi

10/6/2004

4:55 PM

Page vi

Contents

8 Long-Term Effects of Lengthy Starvation in Childhood among Survivors of the Siege Lidiya Khoroshinina

197

9 Crime during the Siege Boris Belozerov

213

Bibliography

229

Index

239

1403_901422_01_pre.qxd

10/6/2004

4:55 PM

Page vii

List of Tables 1.1 1.2 1.3 1.4 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 4.1 4.2 7.1 7.2 7.3 7.4 7.5

Natural population changes in Leningrad and four satellite towns (19 registry offices) Natural population changes in Leningrad (15 registry offices) Deaths from social diseases and external causes per 10,000 people Epidemic sickness and mortality rates per 10,000 people Data on food ration cards issued to the population of Leningrad in 1941–42 Mortality by age group in autumn 1940 and 1941 for Leningrad Daily per capita supply of food products (in grams) in January and February 1942 Deaths of men and women registered in February–May 1942 Mortality in Health Department hospitals in Leningrad in the first quarter of 1942 Mortality in Leningrad, Kolpino and Kronstadt in 1942 (17 registry offices) Mortality by age group in 1942 (17 registry offices) Births, marriages and divorces in Leningrad in 1942 (17 registry offices) Distribution of disabled in Leningrad by sex, July 1945–July 1946 Distribution of disabled in Leningrad by age, July 1945–July 1946 Growth of children who suffered starvation in the Crimea in 1922–23 Data on the height of children of pre-school age in Moscow and Leningrad, 1936–37 Height of children of pre-school age in Moscow (1936) and Leningrad (1945) Trunk length of children of pre-school age in Moscow (1936) and Leningrad (1945) Weight of children of pre-school age in Moscow (1936) and Leningrad (1945) vii

15 16 17 17 36 39 45 46 48 59 60 61 112 112 175 178 180 181 184

1403_901422_01_pre.qxd

10/6/2004

4:55 PM

Page viii

viii List of Tables

7.6

Chest circumference of children of pre-school age in Moscow (1936) and Leningrad (1945) 7.7 Height of children aged 7–18 in Leningrad, 1937 and 1945 7.8 Weight of schoolchildren aged 7–18 in Leningrad, 1937 and 1945 7.9 Chest circumference of schoolchildren aged 7–18 in Leningrad, 1937 and 1945 7.10 Ages of crossover of height and weight of girls and boys in Moscow and Leningrad 8.1 Main causes of death of patients born in 1927–41 who died in the St Petersburg Hospital for War Veterans in 1989–2000 8.2 Relative number of patients (%) in different stages of atherosclerotic damage to the arteries 8.3 Relative number of patients with a different area of atherosclerotic damage to the arteries 8.4 Frequency of illnesses in patients

185 187 190 191 192

202 204 205 207

1403_901422_01_pre.qxd

10/6/2004

4:55 PM

Page ix

List of Figures 7.1 Alteration in body proportions with age of girls in Moscow (1936) and Leningrad (1945) 7.2 Alteration in body proportions with age of boys in Moscow (1936) and Leningrad (1945) 7.3 Growth of girls aged 7–18 in Leningrad, 1936–37 and 1945 7.4 Growth of boys aged 7–18 in Leningrad, 1936–37 and 1945 7.5 Height of girls aged 8–15 in Glukhovo settlement, 1934 and 1945 7.6 Height of boys aged 8–15 in Glukhovo settlement, 1934 and 1945 7.7 Relationship of height and age in Leningrad schoolchildren aged 7–18 (1945) 7.8 Relationship of weight and age in Leningrad schoolchildren aged 7–18 (1945) 8.1 Percentage retardation in the height of Leningrad children of pre-school age in 1945 compared with 1927–28 8.2 Percentage reduction in the weight of Leningrad children of pre-school age in 1945 compared with 1934

ix

182 183 187 188 188 189 192 193 199 199

1403_901422_01_pre.qxd

10/6/2004

4:55 PM

Page x

Preface The siege of Leningrad in the Second World War was one of the most dramatic episodes in the history of modern warfare, and has not surprisingly been the subject of much writing. Military, political and social historians have analysed the events that took place in and around the city between August 1941 and January 1944; novelists, poets and essayists have described the suffering and heroism of the population; and many eyewitness accounts are to be found in diaries and memoirs. What has been relatively little studied, however, is the medical history of the Leningrad siege – the impact of the siege, immediate and longterm, on the life and the health of the population. During the war, it is true, medical researchers in the besieged city studied the effects of starvation, often in appallingly difficult circumstances and not infrequently dying in the course of their work. Such research continued for a time after the war. But within a few years it had largely ceased, partly because of other demands on the limited resources available for medical research, partly under the influence of the Leningrad Affair of 1949–50, in the course of which many who had played a leading role in wartime were purged and much of the memory of the siege was suppressed. Over the following decades barely a handful of works were published on the medical history and consequences of the siege. Yet it remained and remains a subject of major significance, and not only for historical reasons. The effects of starvation and extreme malnutrition experienced during the siege were long-lasting, and they are present in St Petersburg to this day – in the ill-health of surviving veterans of the siege and, as some research suggests, that of their children as well. The importance of analysing the lessons of the Leningrad siege, however, is not limited to the Russian context. In a world where millions of people continue to be subject to the scourges of hunger and disease, understanding of the factors making for survival in conditions apparently incompatible with life is of the greatest practical importance. The famine to which Leningrad’s population was exposed in the hungry winter of 1941–42 was unique in the volume and quality of the data collected at the time. After decades in closed archives, much has now been declassified and constitutes a resource of enormous value for researchers. Together with the possibility of interviewing survivors, declining every year in number, but still capable of providing clear and x

1403_901422_01_pre.qxd

10/6/2004

4:55 PM

Page xi

Preface xi

vivid accounts of conditions during the siege, they gave the authors of this book both the motive and the opportunity to undertake the research presented in the following pages. Aware as they are that the subject of this book is larger and more complex than can be adequately dealt with in a single volume, they hope none the less that it will illuminate one of the darker areas of the history of the Leningrad siege, and in turn stimulate others to further study of it. The editors wish to record their thanks to various organizations and individuals, first and foremost to the Wellcome Trust. Grants from its History of Medicine Programme between 1998 and 2001 funded the project that resulted in this book. They are grateful to the directors of the programme, Dr John Malin and Dr Anthony Woods, for their support and encouragement. Thanks are also due to the University of Cambridge and King’s College, Cambridge, for financial support; to the Archival Administration of St Petersburg and the Leningrad Region for hosting the Conference on ‘Life and Death in Besieged Leningrad – the Medical History’ in April 2001 at which the results of the project were first presented; and to the directors and staff of the following archives for the invaluable assistance they rendered to the authors: in Moscow, the State Archive of the Russian Federation, the Russian State Archive of Social–Political History, the Russian State Archive of the Economy, the Central Archive of the Ministry of Defence, and the Central State Military Archive; in St Petersburg, the Central State Archive, the Central State Archive of Historical–Political Documents, the Central State Archive of Scientific–Technical Documentation, the Information Centre of the Main Administration of Internal Affairs, and the Archive of the Administration of the Federal Security Service; and to the Vologda Regional Archive of Modern History, the State Archive of Vologda Region, the State Archive of the Yaroslav Region, and the Centre of Documentation of Modern History of the Yaroslav Region. The editors also wish to thank the many individuals who provided advice at different stages of the project, including Rashid Bakhtyarev, Daniel Beer, Richard Bidlack, R. W. Davies, D. B. Gusarov, Mark Harrison, Melanie Ilicˇ, Y. I. Kolosov, Ashley Moffett, B. M. Rachkov, D. B. Shestov, Sarah Stanner, Boris Starkov and John Yudkin. A particular debt of gratitude is owed to Svetlana Roubtsova for her assistance on numerous occasions. Members of seminars on Russian history at the Centre for Russian and East European Studies, Birmingham University; the Cambridge Committee for Russian and East European Studies; St Antony’s College, Oxford; and the European University

1403_901422_01_pre.qxd

10/6/2004

4:55 PM

Page xii

xii Preface

Institute in Florence contributed valuable comments, as did participants in the conference in St Petersburg in April 2001 mentioned earlier. To all the above the editors are most grateful; responsibility for any errors of fact or interpretation, however, remains theirs alone. John Barber Andrei Dzeniskevich

1403_901422_01_pre.qxd

10/6/2004

4:55 PM

Page xiii

Notes on the Contributors John Barber is a Fellow of King’s College, Cambridge, Senior Lecturer in Politics at Cambridge University, author of Soviet Historians in Crisis, 1928–1932 (Macmillan, 1981), co-author (with Mark Harrison) of The Soviet Home Front, 1941–45: A Social and Economic History of the USSR in World War II (Longman, 1991), and co-editor (with Mark Harrison) of The Soviet Defence-Industry Complex from Stalin to Khrushchev (Macmillan, 2000). Boris Belozerov is a Professor of History at the University of the Ministry of Internal Affairs, St Petersburg. Nadezhda Cherepenina is a Senior Archivist at the Central State Archive of St Petersburg. Vadim Chirskii is a Lecturer at the Military–Medical Academy, St Petersburg. Andrei Dzeniskevich is a Senior Research Fellow at the St Petersburg Institute of History of the Russian Academy of Sciences, author of Nakanune i v dni ispytanii: Leningradskie rabochie v 1938–1945gg. [On the eve and during the days of ordeal: Leningrad workers in 1938–1945] (St Petersburg, 1990), Blokada i politika: oborona Leningrad v politicheskoi kon’yunkture [The siege and politics: the defence of Leningrad at the political conjuncture] (Nestor, St Petersburg, 1998), Front u zavodskikh sten: maloizuchennye problemy oborony Leningrada [The front at the factory gates: little-studied problems of the defence of Leningrad, 1941–45] (Nestor, St Petersburg, 1998), Na grani zhizni i smerti: rabota medikov-issledovatelei v osazhdennom Leningrade [On the border of life and death: the work of medical researchers in besieged Leningrad] (Nestor, St Petersburg, 2002), and editor of Leningrad v osade: sbornik dokumentov [Besieged Leningrad: a collection of documents] (LIKI Rossii, St Petersburg, 1995). Mikhail Frolov is a Professor of History at the University of the Leningrad Region. xiii

1403_901422_01_pre.qxd

10/6/2004

4:55 PM

Page xiv

xiv Notes on the Contributors

David Fry is a freelance translator/reviser at the European office of the United Nation Geneva, as formerly worked for the World Health Organization. Lidiya Khoroshinina is a Research Associate at the Department of Geriatrics of the Medical Academy of Postgraduate Studies, St Petersburg. Igor Kozlov is Professor of Biomechanics at the P. F. Lesgaft Academy of Physical Culture, St Petersburg. Svetlana Magaeva is a Senior Research Fellow at the Institute of Pathology and Pathophysiology of the Russian Academy of Medical Sciences, Moscow, and author of Blokadnye lyudi [Siege people] (Izdatel’stvo RUDN, 1999) and Leningradskaya blokada: psikhosomaticheskie aspekty [The siege of Leningrad: psychosomatic aspects] (Izdatel’stvo ABTs, Moscow, 2001). Alla Samsonova is an Assistant Professor of Biomechanics at the P. F. Lesgaft Academy of Physical Culture, St Petersburg.

1403_901422_01_pre.qxd

10/6/2004

4:55 PM

Page xv

Translator’s Note At the risk of stating the seemingly obvious, the task of a technical translator working for publication is to combine readability with respect for the technical or scientific subject matter. Many decisions may have to be taken on the most appropriate terms and shades of meaning. The present book is no exception in that respect. It is a product of the postSoviet period in the history of Russia, but it deals with the most tragic human story of Leningrad under siege, largely in terms of the effects of malnutrition, semi-starvation and outright famine on the human body. The onset and duration of hunger and its effects are considered in relation to exposure to the stress factors of bombing and shelling, the cold of a winter of Arctic severity in unheated and frequently unlit buildings, and the mental anguish of bereavement within families and many deaths of friends, acquaintances and total strangers. Many hundreds of thousands of Leningraders died, while those who survived were variously, but profoundly, affected. In addition the book contains accounts of the work of the public services of the city of Leningrad, especially the health services, the evacuation of a considerable part of the population, and the research work of the city’s medical institutes, which continued under almost unbelievable conditions. The Russian term alimentarnaya distrofiya, here rendered throughout as ‘nutritional dystrophy’ (the translation ‘alimentary dystrophy’ previously used seems less appropriate and probably stemmed from the medical Latin distrophiya alimentaria), is a key concept throughout the narrative. I have not been able to establish whether it is a term coined by the Russian medical profession, but the only definition found for it is contained in Volume 1 of a Russian encyclopaedic dictionary of medical terms published in 1982 (Entsiklopedicheskii slovar’ meditsinskikh terminov), which states: ‘a disease that develops as a result of lengthy inadequate consumption of food; characterized by cachexia, oedema (dropsy), progressive disorders of all forms of metabolism, and dystrophy and malfunctioning of organs and tissues’ (my translation). The synonyms offered in this brief entry include hunger oedema, famine oedema, nutritional marasmus, nutritional oedema and war oedema, from which it may be deduced that the emphasis is on the presence of oedematous states. However, the picture of nutritional dystrophy developed by the authors on the basis of research carried out at the time and xv

1403_901422_01_pre.qxd

10/6/2004

4:55 PM

Page xvi

xvi Translator’s Note

on autopsy records surviving in the archives is one of a condition developing through a series of stages and not necessarily accompanied by oedema. The exposition also challenges the established opinion of a critical loss of body weight beyond which recovery is impossible. The author of the chapter on the physiological and psychological prerequisites for survival and recovery was herself, as a young girl, taken apparently lifeless from a trolley on the way to the mortuary, was revived by intravenous glucose injection and subsequently recovered. The point of this account is that while we may accept the term ‘nutritional dystrophy’ as a valid translation, it does have to be understood, as a result of this book, in a rather broader sense than that contained in the original dictionary definition. In that wider sense it should be very relevant to the experience of famine relief workers and refugee agencies in the post-war world. Another translation problem is the difficulty, on occasion, of finding suitable equivalents for medical establishments. One example is the Russian statsionar, which is given as ‘hospital’ in Russian–English general and medical dictionaries, but is very definitely a facility of lesser rank, although provided with beds for patients. Such facilities were provided along the evacuation routes from Leningrad. In the same context, when medical treatment establishments are listed in terms of their various subordinations (civil, military, academic, etc.) it may be difficult and largely pointless to attempt a full translation, and it is in that sense that terms such as ‘facilities’ and ‘treatment establishments’ have been used. One final example, the Russian zhiznedeyatelnost’, rendered as ‘vital activity’, is a term used very frequently by Russian biologists and medical researchers. Its original, now archaic, meaning was ‘life’s work’, but in the biological and medical sense it means activities or functions essential to life, and it frequently appeared either as ‘vital activity’ or as ‘vital functions’ in the many biological and medical journals published in the post-war period in the Anglo-American-sponsored journals translation programme. David Fry

1403_901422_01_pre.qxd

10/6/2004

4:55 PM

Page xvii

Glossary of Russian Terms AMN SSSR ASSR

AUFSB

EG

FZU GARF GAVO GAYaO GKO Gorispolkom Gorkom Gosplan SSSR

Gosstrakh

Akademiya meditsinskikh USSR Academy of nauk SSSR Medicine Avtonomnaya sovetskaya Autonomous Soviet sotsialisticheskaya Socialist Republic, respublika ASSR Arkhiv upravleniya Archives of the federal
noi sluzhby Department of the bezopasnosti Federal Security Service (for St Petersburg and Leningrad Region) Evakuatsionnyi gospital
Evacuation hospital, casualty clearing station Fabrichno-zavodskoe Factory/works school uchilishche Gosudarstvennyi arkhiv State Archives of the rossiskoi federatsii Russian Federation Gosudarstvennyi arkhiv State Archives of Vologda Vologodskoi oblasti oblast Gosudarstvennyi arkhiv State Archives of Yaroslavskoi oblasti Yaroslavl oblast Gosudarstvennyi Komitet State Defence Committee Oborony Gorodskoi ispolnitel
nyi City Executive komitet Committee Gorodskoi komitet City Committee (of Communist Party) Gosudarstvennaya State Planning planovaya Commission of the komissiya Soveta USSR Council of Narodnykh Komissarov People’s Commissars SSSR Kontora/otdel
State Insurance Office gosudarstvennogo strakhovaniya

xvii

1403_901422_01_pre.qxd

10/6/2004

4:55 PM

Page xviii

xviii Glossary of Russian Terms

GUVD

Glavnoe upravlenie vnutrennikh del

IVS

Institut vaktsin i syvorotok Komsomol Kommunisticheskii Soyuz Moleodezhi Lengorispolkom Leningradskii gorodskoi ispolnitel
nyi komitet Lengorsovet Leningradskii gorodskoi sovet Lengorzdravotdel Leningradskoe zdravookhranitel
noe otdelenie LF Leningradskii filial

LIETTIN

LIKhT

LIPK

LNIIGTiPZ

LNI

Leningradskii nauchnoissledovatel
skii institut ekspertizy trudosposobnosti i trudoustroistva invalidov Leningradskii nauchnoissledovatel
skii institut khirurgicheskogo tuberkuleza i kostnosustavnykh zabolevanii Leningradskii nauchnoissledovatel
skii institut perelivaniya krovi Leningradskii nauchnoissledovatel
skii institut gigieny trudy i profzabolevanii Leningradskii nevrokhirurgicheskii institut

Directorate of Internal Affairs (of St Petersburg and Leningrad oblast) Institute of Vaccines and Sera Communist League of Youth, Komsomol Leningrad City Executive Committee Leningrad City Council Leningrad Health Department Leningrad Branch (e.g. of an institute of the Academy of Sciences of the USSR) Leningrad Research Institute of Fitness for Work and the Organization of Work for the Disabled Leningrad Surgical and Osteo-articular Tuberculosis Research Institute Leningrad Institute of Blood Transfusion Leningrad Research Institute of Occupational Hygiene and Diseases Leningrad Neurosurgical Institute

1403_901422_01_pre.qxd

10/6/2004

4:55 PM

Page xix

Glossary of Russian Terms xix

LNISGI

LNITI

LVO

Leningradskii nauchnoissledovatel
skii sanitarno-gigienicheskii institut Leningradskii nauchnoissledovatel
skii tekhnologicheskii institut Leningradskii voennyi okrug

Narkomat NKVD

Narodnyi komissariat Narodnyi komissariat vnutrennikh del

OAGS

Otdel
aktov grazhdanskogo sostoyaniya Otdel
borby s banditizmom

OBB

OBKhSS

Obkom

ORUD

Otdel
borby s khishcheniem sotsialisticheskoi sobstvennosti Oblastnoi komitet Oblast


Okrug Otdel
regulirovaniya ulichnogo dvizheniya

Leningrad Sanitation and Hygiene Research Institute Leningrad Technological Research Institute

Leningrad Military District, Leningrad MD People’s Commissariat People’s Commissariat for Internal Affairs, NKVD Registrar’s Department

Department (of UNKVD LO) for combating banditry Department (of UNKVD LO) for combating theft of socialist property Regional Committee oblast or region: usually oblast when referring to a major administrative area, e.g. Kostroma oblast; region when the sense is more general area, district Street traffic control section (of UNKVD LO)

1403_901422_01_pre.qxd

xx

10/6/2004

Page xx

Glossary of Russian Terms

OSFR Its GUVD SPb i LO

PAL PAO PribVO Raiispolkom Raikom RAMN RGAE RGASPI

RSFSR

SNK/Sovnarkom SPb GVV SSSR

SZF

4:55 PM

Otdel
spetsialnykh fondov i repressii informatsionnogo tsentra GUVD SPb i LO

Department of Special Funds and Repressive Measures of the Information Centre of the Directorate of Internal Affairs of St Petersburg and Leningrad oblast Patalogoanatomicheskaya Anatomical pathology laboratoriya laboratory, APL Patalogoanatomicheskoe Anatomical pathology otdelenie department Pribaltiiskii voennyi Baltic Military District, okrug Baltic MD Raionnyi ispolnitel
nyi district executive komitet committee Raionnyi komitet district committee Raion district Rossiiskaya Akademiya Russian Medical meditsinskikh nauk Academy, RMA Rossiiskii gosudarstvennyi Russian State Economic arkiv ekonomiki Archives Rossiiskii gosudarstvennyi Russian State Archives of arkhiv sotsial
noSocial and Political politicheskoi History istorii Rossiiskaya Sovetskaya Russian Soviet Federative Federativnaya Socialist Republic Sotsialisticheskaya Respublika Sovet Narodnykh Council of People’s Komissarov Commissars Sankt-Peterburgskii Saint Petersburg Hospital gospital
veteranov voin for War Veterans Soyuz Sovetskikh Union of Soviet Socialist Sotsialisticheskikh Republics, USSR Respublik Severo-Zapadnyi Front North-Western Front, NWF

1403_901422_01_pre.qxd

10/6/2004

4:55 PM

Page xxi

Glossary of Russian Terms xxi

TsAMO RF

TsDNIYaO

TsGA SPb

TsGAIPD SPb

TsGANTD SPb

TsSU SSSR

TsUNKhU

UK

UNKhU

UNKVD LO

Tsentral
nyi akhiv ministerstva oborony Rossiiskoi Federatsii Tsentral
nyi dom narodnokhozyaistvennoi informatsii Yaroslavskoi oblasti Tsentral
nyi gosudarstvennyi arkhiv SanktPeterburga Tsentral
nyi gosudarstvennyi arkhiv istoricheskikh i politicheskikh dokumentov Sankt-Peterburga Tsentral
nyi gosudarstvennyi arkhiv nauchnotekhnicheskoi dokumentatsii Sankt-Peterburga Tsentral
noe statisticheskoe upravlenie SSSR Tsentral
noe upravlenie narodnokhozyaistvennogo ucheta Ugolovnyi Kodeks

Central Archives of the Ministry of Defence of the Russian Federation Central Repository of Economic Information of Yaroslavl oblast Saint Petersburg Central State Archives

Saint Petersburg Central State Archives of Historical and Political Documents

Saint Petersburg Central State Archives of Scientific and Technical Documentation USSR Central Statistical Office

Central Board of Economic Statistics Records Criminal Code/Penal Code (of USSR, RSFSR, etc.) Upravlenie Board of Economic narodnokhozyaistvennogo Statistics Records (of ucheta Leningrad) Upravlenie narodnogo Leningrad Regional komissariata Office of the People’s vnutrennikh del Commissariat for leningradskoi oblasti Internal Affairs

1403_901422_01_pre.qxd

10/6/2004

4:55 PM

Page xxii

xxii Glossary of Russian Terms

UPKO

VIEM

VKP(b)

VMA VMM VOANPI

VSLF

VTEK

VTsIK ZAGS

Upravlenie predpriyatiyami kommunal
nogo obsluzhivaniya Vsesoyuznyi nauchnoissledovatel
skii institut eksperimental
noi meditsiny Vsesoyuznaya kommunisticheskaya partiya (bol
shevikov) Voenno-meditsinskaya akademiya Voenno-meditsinskii muzei Vologodskii oblastnoi arkhiv narodnokhozyaistvennoi i politicheskoi informatsii Voennyi sovet leningradskogo fronta Vrachebno-trudovaya ekspertnaya komissiya Vserossiiskii tsentral
nyi ispol
nitel
nyi komitet (Otdel
/Byuro) zapisi grazhdanskogo sostoyaniya

Leningrad Municipal Services Department

All-Union Research Institute of Experimental Medicine

All-Union Communist Party (Bolsheviks) – referred to throughout as Communist Party Military Medical Academy Military Medical Museum Archives of economic and political information of Vologda oblast Military Council of Leningrad Front Commission of Medical Referees for Industrial Disability All-Russian Central Executive Committee Registry Office

1403_901422_01_pre.qxd

10/6/2004

4:55 PM

Page xxiii

Glossary of Medical Terms aetiology amenorrhoea anaemia antigen aorta arteriosclerosis

ascorbic acid atheromatosis avitaminosis basal bradycardia bronchopulmonary cachexia cancerous intoxication carotene cardiology climatotherapy

colloid coxitis cortex cytokines diabetes mellitus

study of the causes and origins of diseases absence or abnormal stoppage of menstrual periods shortage of red blood cells in the bloodstream substances such as toxins or bacteria capable of inducing an immune response the main artery in the body conducting blood from the heart to all parts of the body disorder of arteries, particularly hardening due to fibrosis or calcium deposits (synonym for atherosclerosis) vitamin C a diffuse disease of the arteries a condition caused by a deficiency of one or more essential vitamins pertaining to or near a base slowness of the heart beat pertaining to the lungs and their air passages severe ill-health accompanied by constitutional disorder and malnutrition poisoning caused by a cancer precursor of vitamin A study of diseases affecting the heart and blood vessels treatment of disease by removal of the patient to a region with climate more favourable for recovery microscopic particles suspended in a liquid medium inflammation of the hip the outer layer of an organ non-antibody proteins produced by tissue or cell types relative or absolute lack of insulin leading to uncontrolled carbohydrate metabolism xxiii

1403_901422_01_pre.qxd

10/6/2004

4:55 PM

Page xxiv

xxiv Glossary of Medical Terms

dystrophy E. coli emphysema

empyema endothelial cells

epidemiology

erythrocyte erythropoiesis fibrous plaque fusospirochaetel gastro-enteritis

haematogenic haemoglobin

homeostasis hypoglycaemia hypoproteinaemia histology hypercoagulation hypertension hypofunction hypothalamus

hypertrophy

a disorder resulting from defective nutrition a bacillus abundant in the colon accumulation of air in the lungs, causing breathlessness and ultimately damage to the heart accumulation of pus in the chest cavity a layer of cells lining the inside surfaces of body cavities, blood vessels and lymph vessels, making up the endothelium study of the distribution and determinants of health-related conditions; study of epidemic diseases a red blood cell process of production of erythrocytes in the marrow of adult mammals thickened area of arterial intima produced by fat-laden smooth muscle cells bacteria acute inflammation of the lining of the stomach and intestines, caused by food poisoning, consumption of irritating food or drink, or psychological factors such as anger, stress and fear originating from blood oxygen-carrying pigment of red blood corpuscles; a low level in the blood signifies anaemia a tendency to stability in the normal body states of the organism deficiency of glucose in the blood abnormally small amounts of protein in blood plasma study of cells and bodily tissues under the microscope abnormally increased coagulation persistently high blood pressure reduced, low or inadequate function portion of the brain secreting substances which control metabolism through influence on the pituitary gland enlargement or overgrowth of an organ or body

1403_901422_01_pre.qxd

10/6/2004

4:55 PM

Page xxv

Glossary of Medical Terms xxv

hypovitaminoses ileus immunobiology

infarction insult interferon interstitial intima involution ischaemia leptospirosis

leukocyte lipid

lipofuscin macrophages

microflora mitosis monocytes morbidity morphology mortality mucosa

part due to an increase in the size of its constituent cells condition due to a deficiency of one or more essential vitamins obstruction of the intestine with severe pain study of the immune factors that affect the growth, development and health of biological organisms formation of an area of tissue death due to a local lack of oxygen attack, injury, trauma (e.g. heart attack) proteins derived from human cells which normally fight viral infections pertaining to or situated between parts or in the interspaces of a tissue inner layer of blood vessel rolling or turning inward a low oxygen state usually due to obstruction of the blood supply Weil’s disease; a type of jaundice, caused by infection with bacteria transmitted by infected urine or water white blood cell fats and fatlike substances which are stored in the body, serve as a source of fuel and are an important constituent of cell structure brown pigment characteristic of ageing. cells which play an important part in killing some bacteria and tumour cells, releasing substances that stimulate other cells of the immune system bacteria and fungi inhabiting an area the process of cell division by which the body grows and replaces cells one of three types of white blood cells the incidence of disease or diseases in a population study of the structure of animals and plants the death rate; ratio of total number of deaths to total population a mucous membrane

1403_901422_01_pre.qxd

10/6/2004

4:55 PM

Page xxvi

xxvi Glossary of Medical Terms

myelopoiesis myocardium nasolabial necrosis neuralgia neurogenic neuropeptides neuropsychology

neuroretinitis nosology oedema osteomyelitis

paraesthesia paraneural pathogenesis pathology pellagra

phago-cytosis psychomotor

psychoprophylaxis

formation of tissue elements of or types of blood cells derived from bone marrow the middle layer of the heart wall (heart muscle) relating to the nose and upper lip changes indicative of cell death paroxysmal pain extending along the course of one or more nerves arising from or caused by the nervous system constituent parts of proteins which have effects on the nervous system study of the correlation between experience or behaviour and basic neurophysiological processes inflammation affecting the optic nerve head and posterior pole of the retina classification of diseases, or the study of their treatment abnormal accumulation of fluid in the body tissues or cavities inflammation of bone, characterized by severe pain, tenderness in the affected part and high temperature abnormal sensation such as burning or prickling near or alongside a nerve the origin and development of disease study of disease and its effects on the structure and functions of the body a vitamin B deficiency disease caused by inadequate diet, characterized by wasting, inflammation of the mouth and tongue, skin lesions, gastrointestinal disturbances and nervous manifestations including depression and dementia eating or devouring movement produced by action of the mind or will; pertaining to motor effects of cerebral or psychic activity psychotherapy aimed at the prevention of emotional disorders and the maintenance of mental health

1403_901422_01_pre.qxd

10/6/2004

4:55 PM

Page xxvii

Glossary of Medical Terms xxvii

psychosomatic

pulmonary renal rickets

scurvy

spondylitis

stomatology thorax

Von Willebrand’s disease

pertaining to the mind body relationship, having bodily symptoms of psychic, emotional or mental origins pertaining to the lungs pertaining to the kidney condition caused by deficiency of vitamin D, especially in infancy and childhood, causing weak muscle development and bone deformities deficiency disease due to lack of vitamin C, due to inadequate diet; symptoms include severe anaemia, weakness, lethargy, bruising, and swelling and bleeding of gums, with loss of teeth inflammation of the vertebrae, often leading to permanent stiffness and deformity of the spine study of the structures, functions and diseases of the mouth chest, bony cage containing the heart and lungs, subject to deformity in sufferers from rickets congenital disease caused by a deficiency of blood factor that promotes platelet adhesion, and characterized by prolonged bleeding and poor blood coagulation

1403_901422_01_pre.qxd

10/6/2004

4:55 PM

Page xxviii

1403_901422_02_intr.qxd

10/6/2004

4:57 PM

Page 1

Introduction: Leningrad’s Place in the History of Famine John Barber

During the Second World War Leningrad suffered the greatest demographic catastrophe ever experienced by one city in the history of mankind. Estimates of its scale vary widely and the exact number of dead will never be known; but the data examined in the present volume show that there were at least three-quarters of a million civilian deaths in Leningrad during the siege, with half a million people dying in the winter of 1941–42 alone. When to these are added military deaths in nearly three years of fighting near Leningrad, the total death toll is well over a million.1 Devastated though other cities were in the course of the war – Dresden and Hamburg, Hiroshima and Nagasaki, Stalingrad and Warsaw – none saw death on such a scale as Leningrad. And unlike these, Leningrad did not suffer its huge loss of life in the course of military action. It was not combat, bombing or shelling which caused the massive number of deaths. The great majority of those who perished in Leningrad died directly or indirectly of hunger. They were victims of the German blockade which Hitler ordered in September 1941 to force the city’s capitulation by denying its population the means of survival – by starving it into surrender. Cut off from land contact with the rest of the country, and with food reserves and supplies catastrophically reduced, Leningrad was subjected to famine in the winter of 1941–42 on a scale unprecedented in a modern urban society. Though the worst of the crisis had passed by summer 1942, conditions would remain grave for many months more. By the time the siege of Leningrad ended after 872 days in January 1944, a third of its population had perished, a third had been evacuated, a third had remained in the city. Death for most was not the sudden and violent consequence of war, but the painful, often agonizing and protracted result of starvation. And the price paid by many survivors would be serious and lasting damage to their health, even to the present day. 1

1403_901422_02_intr.qxd

2

10/6/2004

4:57 PM

Page 2

Introduction

The ordeal, tragedy and heroism of Leningrad and its population during the siege have been vividly described in hundreds of works published in the Soviet Union and post-Soviet Russia2 – histories, memoirs, collections of documents, works of literature – and in a small number of books and articles published in the West.3 The extremes of suffering, the enormous death toll, the collective determination to survive, the extraordinary capacity to improvise food substitutes are all well-known. What has been much less investigated, mainly because of the lack of sources, has been what made the difference between life and death in the besieged city, what were the factors determining life and death – in the broadest sense, the medical history of the siege. This was the focus of the three-year project funded by the Welcome Trust’s History of Medicine Programme, and it is the subject of this book. The single most important factor determining the fate of the people of Leningrad in the Second World War was hunger. From late November 1941 their rations were reduced to what was literally starvation level (with a calorific value for workers, as Chapter 2 shows, of 707 compared with a norm of 3,500, and for dependants of 423 compared with 2,800). While rations would be gradually increased from the end of December, it would not be until April 1942 that they would regain minimum subsistence level. This study of life and death in the city during the siege therefore begins by situating it in a broad historical context, by identifying the main issues and hypotheses which study of the history of hunger and famine has raised. By so doing it hopes to show the significance of such an analysis for understanding how individuals and societies respond to the extreme threat to life posed by starvation. The spectre of hunger has haunted mankind throughout its history. From the beginning of time, the world’s inhabitants lived with the fear of starvation. Their most basic need was always to secure food in order to sustain life, and in the struggle for survival many were unsuccessful. It is not accidental that Thomas Malthus, when he identified the three main regulators of population growth, placed famine in first place, before war and pestilence.4 Throughout the centuries shortage of food has threatened the well-being and the very existence of individuals and communities; and at the beginning of the twenty-first century it still does so. While the advanced countries produce large surpluses of food and possess the capacity to generate even more, huge numbers of people throughout the world experience continuous hunger – 500 million in the early 1990s, it has been estimated.5 Hunger remains a central feature of the human condition.6 While its consequences are all too visible, hunger is not easily defin-

1403_901422_02_intr.qxd

10/6/2004

4:57 PM

Page 3

John Barber 3

able. It takes a variety of forms and affects people in different ways. There are no exact criteria to measure degrees of hunger. In English a distinction is drawn between hunger resulting from food scarcity and a situation of widespread and acute food deficit, namely famine. In Russian, on the other hand, one word, golod, covers the whole spectrum of conditions caused by the shortage of food. To some extent the distinction is a subjective one: the same situation may be described by different observers as one of food scarcity or famine. Nonetheless it well reflects the consequences of different degrees of hunger. A serious decline in the amount of available food will certainly cause suffering to those affected and deterioration of their health, and it may well do lasting damage. But there is a major difference between this and a situation of food shortage so acute and protracted that it produces widespread starvation, disease and death. It is above all the last of these, with a dramatic increase in mortality, with masses of emaciated people waiting helplessly to die or already dead, which is the unmistakable sign of famine. There is no doubt that Leningrad in the winter of 1941–42 experienced a full-scale famine. With rations at starvation level and with most people having little opportunity of supplementing them from unofficial sources, the death rate rose to terrible levels. Between November 1941 and May 1942 the city’s population was in the grip of a famine on a scale and of a severity unprecedented in a modern urban setting. In his classic study of the impact of famine on mortality, P. A. Sorokin wrote that the annualized death rate in areas affected by famine might reach 200, 500, even 800 for every 1,000 people, compared with normal rates of 10–30.7 In Leningrad, as Chapter 2 shows, it was 600 in the first quarter of 1942, reaching a peak of 787 in February. Leningrad’s hungry winter belongs in the same category as other major famines of modern history: Ireland in 1846–51, India in 1868–70, 1876–79, 1896–97, China in 1876–79, 1928–29, 1958–61, Bengal in 1943, Ethiopia in 1973 and 1982, Bangladesh in 1974 – and the Soviet Union itself in 1921–22, 1932–33 and 1946–47.8 While by summer 1942 Leningrad’s agony had passed, the increased supply of food would come too late to save thousands whose organisms had been fatally damaged in the preceding months; not until the end of the year would the death rate fall to normal levels. There are many causes of hunger as a mass phenomenon. Well over a century ago Cornelius Walford listed twelve reasons for the breakdown of the processes of production, distribution and acquisition of food. He divided them into natural and artificial categories, the former beyond

1403_901422_02_intr.qxd

4

10/6/2004

4:57 PM

Page 4

Introduction

human influence, the latter the result of human action.9 Among natural causes were drought, floods, extremes of rain, wind, heat or cold, the effects of vermin or insects, and diseases affecting plants or animals; among artificial causes were political and military conflict, administrative incompetence or corruption, and economic crisis. These categories are still analytically relevant. Study of particular famines, however, shows that nature and human action (or inaction) may interact to turn a potentially critical situation into a catastrophe. This underlies A. K. Sen’s challenge to the traditional focus on food availability decline (FAD) in explaining the causation of famines. He argued that famines often resulted from problems of demand rather than supply, from deterioration in people’s ‘exchange entitlement’ to the purchase of food.10 When deprived of resources enabling them to obtain an adequate amount of food, they starved and died. In most twentieth-century famines the supply of food at a regional or national level had been adequate; the problem was its unavailability for large numbers of the population for economic and/or administrative reasons. Sen’s study of the 1943 Bengal famine showed that there had been no significant decline in food availability per head of the population. The famine had primarily resulted from British maladministration. Other examples of this pattern of causation had been the famines in Ethiopia in 1973 and 1982, and Bangladesh in 1974. Sen’s entitlement approach has been challenged by, among others, Peter Nolan. He has argued that in some of the largest-scale famines of the twentieth century, such as in the Soviet Union during collectivization and China during the Great Leap Forward, a sharp decline in food output, resulting from policies pursued by these countries’ rulers, was the prime factor responsible for mass starvation and the death of millions.11 It is reasonable to conclude that different famines have different causes. But Sen’s approach remains a valuable means of understanding the interaction of natural and artificial causes of famine. It has led Michael Ellman to draw a distinction between famines in which FAD was unavoidable, in which there was little or nothing that could have been done to reduce their impact significantly (FAD1), and those in which natural causes seriously reduced food availability, but where action by governments deleteriously affected the outcome (FAD2). If governments in the latter category had had different priorities or if they had acted in different ways, famine could have been avoided or at least its impact greatly lessened.12 If famines frequently result from the interaction of natural and artificial factors, the major exception is those which result from war; here

1403_901422_02_intr.qxd

10/6/2004

4:57 PM

Page 5

John Barber 5

hunger is likely to be a wholly man-made phenomenon. In wartime, even a well-organized society, with an efficient administrative system and a modern health service, may be unable to defend its population from the ravages of hunger. In the twentieth century, Nolan argues, war was the prime cause of the major famines.13 In some cases these resulted from the general destruction of resources, in others from the deliberate employment of hunger as a weapon. The latter tactic, it is true, has a long ancestry. The ancient Chinese military strategist Sun-tze advocated the destruction of an enemy’s grain supplies as a reliable way of defeating it; and many theorists and practitioners of war have followed in his footsteps.14 Destroying the enemy’s means of production and distribution of food, or curtailing its supply by means of a siege, may or may not be effective. What is certain is that it is a particularly brutal weapon. Those who suffer most are least likely to be combatants – women, children, the elderly and infirm – while the actual combatants tend to be relatively well-provided and least likely to suffer starvation. There can be no doubt as to the prime cause of Leningrad’s famine in the winter of 1941–42 or of its population’s continuing suffering in the months that followed. The German blockade was expressly aimed at starving the city into surrender in order to achieve a major strategic advantage in the war. That, despite the huge number of victims of this policy, it did not fall and the front held does not negate the fact that the Leningrad famine was deliberately caused as an act of war. It is, however, worth asking whether it comes into the category of FAD1 or FAD2. Could the suffering of Leningrad’s population have been avoided or significantly reduced had the actions of either the national or local authorities been other than they were? Theoretically the option of a military withdrawal and the surrender of Leningrad (or declaring it an open city, in the euphemism of the time) existed for the Soviet government in autumn 1941; but not in reality. Had Leningrad fallen, Moscow would have been in even greater danger of capture, and the prospect of Nazi conquest of the Soviet Union substantially increased. For the people of Leningrad, given German treatment of the population of occupied territories, not to mention Hitler’s declared intention of razing the city to the ground, there is no reason to suppose that its condition after surrender would have been preferable to its actual fate, however tragic for many this was. In the context of the Soviet Union’s struggle for survival, there was no way for its government to prevent the weapon of hunger being used against the population of Leningrad, if a merciless enemy was bent on using it. Were there steps that the city’s leaders could take to reduce the impact of

1403_901422_02_intr.qxd

6

10/6/2004

4:57 PM

Page 6

Introduction

famine on the population? Certainly, and many were taken, ranging from the strictest rationing of what food there was to the improvisation of innumerable food surrogates, from the establishment of a network of clinics providing supplementary diets for the desperately sick to the harnessing of medical research to the maintenance of life. In numerous ways Leningrad provides valuable lessons in the management of famine by the authorities, and in the coping practices adopted by individuals, families and small groups. Undoubtedly more could have been done. With greater foresight many more children and dependants could have been evacuated in the first weeks of the war. Larger food reserves could and should have been accumulated, and stored securely. Rations could have been reduced earlier, thus preserving the dwindling stocks longer. The ice road across Lake Ladoga could have been brought into full operation sooner. Higher priority could, theoretically, have been given to the transport of food supplies and evacuees, less to that of industrial goods and materials. But whether these and other measures would have significantly reduced the scale of the famine, let alone prevented it, is doubtful. The death toll would still have been huge. The Leningrad famine unquestionably belongs in the FAD1 category. When we turn from explanation of the causes of hunger to study of its effects on individuals and communities, we enter an area of even greater complexity and variety. Beginning with Sorokin’s seminal study, social effects of mass starvation, including food riots, theft, murder, even cannibalism, have been subjects of analysis, as they are in Chapter 9 of this book. But the main focus of research, reflected in Chapters 5–8 of the present volume, has been on the effects of food deprivation on the health, mortality and demography of the communities affected. Given the variable pattern of food availability throughout history, it is not surprising that human beings have developed the capacity to tolerate food shortages, that within limits the human body is capable of adapting to situations of dearth. In parts of the third world millions of people manage to live on a diet 10–20 per cent less than the minimum normally required for subsistence. It appears that compensatory mechanisms allow them to survive on an inadequate calorific intake. They do so by reducing their level of physical activity or they use energy more economically; their metabolism may be able to work more efficiently. This enables them to survive without being reduced to a skeletal condition or dying of starvation. But prolonged malnutrition inevitably has its costs, ranging from low birth weight, higher infant mortality, stunted growth, defective vision and slower cognitive development to reduced resistance to a wide range of diseases, including tuberculosis, influenza and malaria. Protein and vitamin deficiency is

1403_901422_02_intr.qxd

10/6/2004

4:57 PM

Page 7

John Barber 7

particularly associated with weakening of the immune system, leading to significantly higher levels of diseases such as scurvy, beriberi, pellagra and rickets. And in famine conditions the likelihood of increased incidence of epidemic disease is high – in Europe typically typhus, in Asia cholera and smallpox, although any endemic infection may give rise to an epidemic. At the same time, the assumption that malnutrition necessarily results in increased vulnerability to infection has been questioned in recent research. Diseases range from being very influenced by food intake to being unaffected by it.15 As already stated, a defining characteristic of famine is the high level of mortality. Much debate has focused on the question of what people die of in famines. Do they die mainly of starvation, as the typical image of famine with its emaciated victims suggests, or of disease? The evidence is conflicting, and probably reflects the different conditions in which famine occurs. Death from starvation occurs when the reduction of protein and fats in the body causes systemic atrophy, particularly of the heart muscle. It also often takes the form of oedema, swellings caused by the accumulation of fluid, or in young children marasmus. In Leningrad, the main cause of death during the winter of 1941–42 was the direct result of starvation. ‘Dystrophy’ was first reported in November; by the end of the year it had reached epidemic proportions, with innumerable reports of people simply collapsing and dying – at home or at work, in shops or in the streets – although as shown in Chapter 2 it would be many months before this was reflected in official medical statistics. Death from starvation was also prevalent in the Greek famine of 1941–42 and the Dutch famine in the hunger winter of 1944–45. In other famines, however, infectious diseases accounted for the majority of deaths. A detailed study of the Irish famine of 1845–51 shows the main causes of death as dysentery and diarrhoea, typhus and typhoid, tuberculosis, cholera and gastroenteritis.16 A key question here concerns the exact relationship between malnutrition and infectious diseases. Most accounts of mortality in famines take a biological link between them for granted. It is not self-evident, however, and needs to be empirically established. Two possible explanations of high mortality from disease during famines suggest themselves, both of which may be true. The first would see it as directly linked to acute food shortage, and explain it as the consequence of malnutrition lowering immunity and resistance to infection, or the consumption of contaminated or unfamiliar foods causing poisoning. The second would see it as indirectly linked to famine, and attributing it to a worsening of social conditions and behaviour. The decline of support networks and medical care, lower productivity and income due

1403_901422_02_intr.qxd

8

10/6/2004

4:57 PM

Page 8

Introduction

to reduced physical capacity, a mood of resignation and lethargy, migration in search of food, may all create conditions in which disease flourishes. A detailed study of mortality and morbidity during periods of food scarcity in late eighteenth-century England, for example, suggests that epidemic deaths then mainly resulted from lower standards of public hygiene and sanitation caused by general impoverishment.17 Again, Leningrad casts valuable light on this question. While deaths from infectious diseases increased, in contrast to many other famines there were no major epidemics during the siege, even though hygiene in winter 1941–2 was at a much lower level than normal due to the breakdown of sewerage and running water. The explanation would appear to lie in a combination of unfavourable climatic conditions for the spread of epidemic diseases, namely the unusually severe weather that winter, and the preventative measures taken by the Leningrad authorities, most notably their mobilization of an exhausted population in spring 1942 to cleanse the city of the filth accumulated over the winter. Who dies in famines? Which sections of the population are most vulnerable? The conventional answer is the youngest and oldest, the sick and infirm, those dependent on the able-bodied and employed. Other things being equal this is often the case; but much depends on the food distribution policies in operation at the time and how these relate to nutritional needs. In Leningrad, for example, as data cited in Chapter 2 suggest, the death rate among male adolescents in technical schools and some groups of workers was higher than among dependants. What is also generally and not surprisingly the case is that in famines, class affects mortality. The poor die in greater numbers than the better-off, for the simple reason that, in Sen’s terms, they have the least entitlement to food. In Leningrad, however, the situation was rather different. While being poor obviously had negative consequences for access to supplementary food that could still be purchased at the market, the crucial factor determining food entitlement was possession of a ration card. After this, other factors such as the place of employment, or simply connections with food production and distribution, were likely to be of greater significance for survival than income. In Leningrad the most disadvantaged section of society consisted of refugees who had entered the city without permission and who had no entitlement to ration cards. It is not accidental that they comprised the largest group among those arrested for cannibalism. A major obstacle to establishing patterns of mortality and morbidity in famines, and to showing the connection between starvation and disease, is the inadequacy of available medical and demographic data.

1403_901422_02_intr.qxd

10/6/2004

4:57 PM

Page 9

John Barber 9

This can make it difficult if not impossible to distinguish deaths from starvation and deaths from disease, or to establish with any degree of precision the number of excess deaths, those in addition to the number which would normally have occurred, during a famine. This is not surprising, since most famines occur in societies lacking the developed administrative structures, let alone health services, needed for the systematic collection of such data. It is not accidental that much detailed study has been made of the Dutch famine of winter 1944–45. The number of excess deaths, some 20,000 in a population of approximately three million, was low compared with the major famines of the twentieth century. In Leningrad as many deaths were recorded every week in January and February 1942. But the detailed statistics available have greatly facilitated analysis of human responses to extreme hunger.18 In this respect the siege of Leningrad provides a unique opportunity for analysing the nature and effects of famine. The records kept by government and Party organizations, statistical bureaux, hospitals, medical research institutes and other bodies throughout the blockade, now declassified and available to scholars, are an exceptionally valuable source for research. Their comprehensiveness and reliability, it is true, should not be exaggerated. The appalling conditions in which statistics were collected, the desperate state of the officials registering deaths or recording details of disease and themselves often dying in the process, the incentive that some might have to exaggerate the totals of dead (cemetery personnel, for example, paid by the quantity of bodies disposed of ), and the unnoticed and unreported decease of those whose family or neighbours had predeceased them, all inevitably left their mark on the quality of the data obtained. It is certain that there was both underreporting and overreporting of deaths. Nonetheless, the information available for analysing the medical history of Leningrad during the siege is far greater than that available to historians of any other major famine. Until recently such analysis was impossible. Though much has been written about the siege of Leningrad, relatively little attention had been given to its medical aspects. Until now only one book, by P. E. Gladkikh, was wholly devoted to the subject of health in the besieged city.19 In Western literature only three books deal more than perfunctorily with this subject. Leon Goure’s The Siege of Leningrad (1962) devoted some pages to it. Using Soviet memoirs and diaries, he described how ‘Hunger caused weakness, dizziness, swelling of the hands and legs, and painfulness of the joints; moreover it made people increasingly susceptible to various diseases’. He went on to relate how

1403_901422_02_intr.qxd

10/6/2004

4:57 PM

Page 10

10 Introduction

‘weakness caused by vitamin deficiency and lack of food became a general phenomenon that few Leningraders escaped’, and quoted figures for deaths from dystrophy. He took an extremely negative view of the health service in Leningrad: ‘the medical facilities were completely unequal to this situation . . . medical services by mid-January were completely swamped’, and drew a dire picture of conditions in the hospitals. Goure also quoted evidence of cannibalism (at a time when any mention of the subject in the USSR was taboo), though it was not known, he said, how common this was.20 As to how many had died, this was ‘a matter of conjecture’, though basing himself on Soviet sources he suggested between 1 and 1.25 million. In his celebrated book The 900 Days: The Siege of Leningrad (1969), Harrison Salisbury used newly published Soviet sources to give a vivid picture of conditions in the besieged city. ‘A certain order of starvation emerged’, he wrote. ‘It was not the old who went first. It was the young, especially those fourteen to eighteen, who lived on the smallest rations. Men died before women. Healthy, strong people sank before chronic invalids.’ He compared different estimates of the death toll, noting that ‘almost all these deaths were due to starvation-related diseases’, and that ‘the death rate of all diseases jumped astronomically’ (though this was not in fact the case). Scurvy, he said, was ‘universal’, and he described the city authorities’ measures to combat it and other diseases. When it came to estimating the total number of dead, he also recognized the inexact nature of any calculation. A total of ‘something over 1 million deaths attributable to hunger’ seemed to him reasonable.21 Two decades later, William Moskoff devoted a chapter of his study of food supply in the USSR during the Second World War, The Bread of Affliction (1990), to Leningrad. He examined the impact of hunger on the birth rate and infant mortality, and described the prophylactic measures taken by the government, but otherwise he added little to his predecessors’ accounts.22 Besides these books, a small number of specialist articles on specific medical themes relating to the siege of Leningrad have appeared in the West; but these have been few and far between.23 To a large degree the medical history of the siege has until now remained unwritten. The persistence of hunger in a world of plenty is one of the great contradictions of our time. In the fight to overcome it, the study of history has a key role – and research into the Leningrad famine, informed by the mass of newly available data and benefiting from international collaboration, has much to offer. In the following chapters numerous medical aspects of the siege will be examined. But the wider purpose of this book is to contribute to a greater understanding of the nature of

1403_901422_02_intr.qxd

10/6/2004

4:57 PM

Page 11

John Barber 11

hunger and famine, and of effective ways of combating them. In this way its authors hope that knowledge resulting from the study of Leningrad’s tragedy in the Second World War will be of benefit to present and future generations worldwide. Notes 1. The often-quoted figure of one million dead in besieged Leningrad is almost certainly an overestimate of deaths in the city itself, although with military casualties the figure for total Soviet deaths resulting from the siege was considerably higher. See G. L. Sobelev, ‘Blokada Leningrada v svete perestroiki istoricheskoi nauki (Ob osveshchenii nekotorykh voprosov istorii blokady Leningrada v knigakh D. V. Pavlova)’, in A. P. Kryukovskikh et al. (eds), Voprosy istorii i istoriografii Velikoi Otechestvennoi voiny (Leningrad, 1989), pp. 74–5; G. F. Krivosheev (ed.), Grif sekretnostic sniat: poteri vooruzhennykh sil SSSR v voinakh, boevykh deistviyakh i voennykh konfliktakh deistviyakh (Moscow, 1993), 167, 172, 184, 199, 247. 2. See V. P. Gridnev, Istoriografiya oborony Leningrada (1941–1944) (St Petersburg, 1995); A. R. Dzeniskevich, Blokada i politika. Oborona Leningrada v politicheskoi kon
yunkture (St Petersburg, 1998). Among the most revealing sources on conditions in the besieged city are the reminiscences of survivors, such as those cited in A. Adamovich and D. Granin, A Book of the Blockade (Moscow, 1983), and collections of archival documents, notably A. R. Dzeniskevich (ed.), Leningrad v osade (St Petersburg, 1995) and N. A. Lomagin (ed.), Neizvestnaya blokada, 2 vols (St Petersburg, 2002). 3. Leon Goure, The Siege of Leningrad (Stanford, 1962), Alexander Werth, Russia at War, Part 3: The Leningrad Story’ (New York 1954) and Harrison Salisbury, The 900 Days: The Siege of Leningrad (New York, 1969) were the major Western studies of the Leningrad siege based on sources available during the Cold War. Among recent works are John Barber, ‘War, Public Opinion and the Struggle for Survival 1941–45: The Case of Leningrad’, in Silvio Pons and Andrea Romano (eds), Russia in the Age of Wars (Milan, 2000); Richard Bidlack, ‘Survival Strategies in Leningrad’, in Robert W. Thurston and Bernd Bonwetsch (eds), The People’s War: Responses to World II War in the Soviet Union (Urbana and Chicago, 2000); Richard Bidlack, ‘Historical Background to the Siege of Leningrad’, Foreword to Cynthia Simmons and Nina Perlina, Writing the Siege of Leningrad: Women’s Diaries, Memoirs and Documentary Prose (Pittsburgh, 2002). 4. Alan Macfarlane, The Savage Wars of Peace: England, Japan and the Malthusian Trap (Oxford, 1997), iii. 5. Brian Murton, ‘Famine’, Part 4, Chapter VI, The Cambridge World History of Food (Cambridge, 2000), 1411. 6. David Arnold, Famine, Social Crisis and Historical Change (Oxford, 1988); Stephen Devereux, Theories of Famine (London, 1993): G. Ainsworth Harrison (ed.) Famine (Oxford, 1988); Lucile F. Newman (ed.), Hunger in History: Food Shortage, Hunger and Deprivation (Oxford, 1990); Murton (2000), 1411–27. 7. Pitirim Sorokin, Man and Society in Calamity: The Effects of War, Revolution,

1403_901422_02_intr.qxd 10/7/04 06:11 PM Page 12

12 Introduction

8.

9.

10. 11. 12. 13. 14. 15.

16. 17. 18.

19.

20. 21. 22. 23.

Famine ad Pestilence upon Human Mind, Behaviour, Social Organization and Cultural Life (New York, 1922), cited in Murton (2000), 1415. For the major famines in world history, see J. R. K. Robson (ed.) Famine: Its Causes, Effects and Management (London, 1981), 21–3. For Russian famines, see William Dando, The Geography of Famine (London, 1980), Chapter 9, ‘A Millenium of Russian Famines’, and S. G. Wheatcroft, ‘Famine and Factors Affecting Mortality in the USSR: The Demographic Crises of 1914–22 and 1930–33’, CREES Discussion Papers 20 and 21 (Birmingham, 1981). C. Walford, ‘The Famines of the World: Past and Present’, Journal of the Royal Statistical Society, 41 and 42 (1878–9), cited in International Encyclopaedia of Social Sciences, Vol. 5 (London, 1970), 322. A. K. Sen, Poverty and Famines (Oxford, 1981). Peter Nolan, ‘The Causation and Prevention of Famines: A Critique of A. K. Sen’, Journal of Peasant Studies, vol. 21, no. 1 (October 1993). Michael Ellman, ‘The 1947 Soviet Famine and the Entitlement Approach to Famines’, Cambridge Journal of Economics, vol. 24 (2000), 603–4. Nolan (1993), 21. Newman (1990), 162. R. Dirks, ‘Famine and Disease’, in Kenneth F. Kiple (ed.) The Cambridge World History of Human Disease (Cambridge, 1993), cited in J. Mokyr and C. Ó Gráda, ‘Famine Disease as Famine Mortality: Lessons from the Irish Experience, 1845–50’, in T. Dyson and C. Ó Gráda (ed.), Famine Demography: Perspectives from the Past as Present (Oxford, 2002). Mokyr and Ó Gráda (2002), 30–3. John D. Post, ‘Nutritional Status and Mortality in Eighteenth-Century England’, in Newman (1990). See Zena Stein, Mervyn Susser, Gerhart Saenger and Francis Marolla, Famine and Human Development: The Dutch Hunger Winter of 1944–1945 (London, 1975); Henri A. van der Zee, The Hunger Winter: Occupied Holland 1944–5 (London, 1982); A. Brown, E. Susser et al. ‘Increased Risk for Affective Disorders in Males after Second Trimester Prenatal Exposure to the Dutch Hunger Winter of 1944–45’, British Journal of Psychiatry, vol. 166 (1995), 601–6; L. H. Lumey, ‘Reproductive Outcomes in Women Prenatally Exposed to Undernutrition: A Review of Findings from the Dutch Famine Birth Cohort’, Proceedings of the Nutritional Society, vol. 57 (1998), 129–35. P. E. Gladkikh, Zdravokhranenie blokirovannogo Leningrada (Leningrad, 1980). Mention should also be made of a pioneering study, unfortunately never published, by A. V. Sveshnikov: ‘Zdravokhranenie Leningrada v gody Velikoi Otechestvennoi Voiny, 1941–1945gg.’, kandidatskaya dissertatsiya (Leningrad, 1963). Goure (1962), 160–3, 216, 223. Salisbury (1986 edition), 376, 507, 514–16. William Moskoff, The Bread of Affliction (Cambridge, 1990), 199–200. See for example Josef Brozek, Samuel Wells and Ancel Keys, ‘Medical Aspects of Semistarvation in Leningrad (Siege 1941–42)’, American Review of Soviet Medicine, vol. IV, no. 1 (October 1945); and S. A. Stanner, K. Bulmer et al. ‘Does Malnutrition in utero Determine Diabetes and Coronary Heart Disease in Adulthood? Results from the Leningrad Siege Survey’, British Medical Journal, vol. 315 (1997), 1342–9.

1403_901422_03_cha01.qxd

10/6/2004

4:58 PM

Page 13

1 The Demographic Situation and Healthcare on the Eve of War Nadezhda Cherepenina

While analysis of the tragedy of the siege and its causes has to begin with an account of the pre-war situation of the northern capital, many aspects of the history of Leningrad on the eve of the war are poorly reflected in contemporary historiography. There are hardly any works on the demographic situation in the city and public health.1 And there has been even less study of the preparation of Leningrad for possible military operations – despite the fact that in 1939–40 it was the only city of the Soviet Union in the immediate vicinity of a front line and that it had some experience of mobilization operations. The explanation for this state of affairs is mainly the inaccessibility of many sources, especially statistical sources, until recently and even up to the present. The materials of the 1939 census have yet to be published in their entirety, the pattern of subsequent demographic trends is unknown, and the mobilization plans of the city and of individual branches of government are not available. Study of documents which have been declassified does however modify views on the pre-war life of Leningrad in some important respects. The All-Union census of 1939 is the starting point for all wartime population statistics.2 Although the census has been justifiably criticized for distortions, it provides the only source of information on the population structure of Leningrad by sex, age, nationality, family status and other categories two and a half years before the war. The official census results were the basis for all statisticians’ calculations during the siege, and were also used by the authorities for particular measures (for example, to evacuate people of German and Finnish nationality from the city). It has now been established that the ‘special contingents’ separately registered in the civilian population of Leningrad numbered 75,801 people (59,732 men and 16,069 women), that is, 2.4 per cent of 13

1403_901422_03_cha01.qxd

10/6/2004

4:58 PM

Page 14

14 Healthcare on the Eve of War

the published total.3 It should also be noted that detailed processing of the census materials was carried out for only 19 districts of Leningrad (15 urban districts and the four towns of Kolpino, Kronstadt, Pushkin and Peterhof administered by the Leningrad Soviet), and that the contingents were not apportioned between them.4 On 17 January 1939 there were 1,454,783 men (45.6 per cent) and 1,736,521 women (55.4 per cent), a total of 3,191,304 people in the 19 districts of Leningrad; of these 3,015,188 people (1,372,928 men and 1,642,260 women) lived in the 15 urban districts.5 On the whole the age composition of the population in Leningrad, one of the country’s largest industrial centres, did not differ greatly from that for the country as a whole, which was typical of a traditional society.6 Children and young people up to the age of 19 accounted for 37.2 per cent of the Leningrad population (44.9 per cent for the USSR), people over 50 for 13.8 per cent (13 per cent for the USSR). There was a cluster of young people born in 1937–39 (5 per cent of all citizens) as a result of the 1936 Act banning abortion. There were 11 men and 34 women aged over 100. Out of every 1,000 Leningraders over 15 years old, 564 were married. The number of family units 783,145 totalled; one third of these (31.9 per cent) had two members, another third (32.1 per cent) had three and only 20.9 per cent had four. There were few traditional families with several generations and many children in Leningrad: 9.5 per cent of families had five members, 3.7 per cent had six, 1.3 per cent had seven, 0.4 per cent had eight, 0.1 per cent had nine and 0.l per cent had more than ten. Members of more than 30 nationalities lived in Leningrad, but the overwhelming majority (86.99 per cent) were Russians. Jews comprised 6.3 per cent, Ukrainians 1.7 per cent, Belorussians 1 per cent and Tatars 0.99 per cent. Leningraders of other nationalities ranged in numbers from 0.01 per cent (Swedes, Chinese etc.) to 0.65 per cent (Poles), and there were 10,104 Germans and 7,923 Finns in the city. The 1939 census recorded only 206 ‘unemployed’, but there were more than 1.2 million dependants (children, housewives, pensioners, invalids etc.) comprising 38.3 per cent of the population. Most of the employed were in industry (51.9 per cent), building (6.2 per cent), transport and communications (6.0 per cent), trade and public catering (8.3 per cent). More than 73,000 people (4.2 per cent of the workforce) were in the public health system. Women constituted nearly half (46.2 per cent) of those in employment. There were 64,898 managerial employees at various levels, including 1,802 heads of All-Union Party, govern-

1403_901422_03_cha01.qxd

10/6/2004

4:58 PM

Page 15

Nadezhda Cherepenina 15

ment and public organizations (18.3 per cent of them women) and 2,134 heads at city and district level (28.2 per cent women). There were also 3,482 full-time leaders of primary Party, Komsomol, trade union and other public organizations. The population of Leningrad changed in size and structure during the two years following the census. Demographic processes were significantly affected by the Soviet–Finnish war of 1939–40. The Leningrad military commissariat sent more than 147,000 reservists and new recruits to army, navy and NKVD units in September 1939,7 which sharply increased the imbalance between the male and female population. Migration was greatly reduced by the close proximity of the front: whereas 479,300 people on average had come to Leningrad annually in 1935–38 (and 456,200 had departed), this flow was reduced by a factor of 1.7 times in 1939–40. In 1939 departures exceeded arrivals by 101,054, and the increased migration in 1940 (51,021) did not make good the difference.8 A considerable proportion of those who settled in Leningrad in late 1940–early 1941 were young people directed into occupational training establishments set up by the decree of the Presidium of the USSR Supreme Soviet of 2 October 1940 ‘On labour reserves’. By the end of 1940 there were 82 occupational training colleges, three railway training colleges and 21 industrial training schools for labour reserves in Leningrad attended by more than 81,000 boys and girls (13–18 years old), of whom about 50,000 were not native to Leningrad and lived in hostels.9 The statistics on natural population changes of Leningraders (marriages, births, deaths) also changed in 1939–40 and not for the better (Tables 1.1 and 1.2). Table 1.1 Natural population changes in Leningrad and four satellite towns (19 registry offices)

Live births All deaths Deaths below 1 year Marriages Divorces

TsUNKhU* data 1939

TsUNKhU* data 1940

Registry Office data 1939

Registry Office data 1940

86,243 48,446 12,676

72,645 53,976 14,337

86,106 51,715 13,746

72,845 57,583 15,487

40,317 11,139

38,781 10,913

40,259 11,148

38,916 10,918

* TsUNKhU – Central Board of Economic Statistics Records. Source: RGAE, 1562/329/261, 68; 1562/329/394, 67; TsGA SPb, 7384/3/13, 82.

1403_901422_03_cha01.qxd

10/6/2004

4:58 PM

Page 16

16 Healthcare on the Eve of War Table 1.2 Natural population changes in Leningrad (15 registry offices)

Live births All deaths Deaths below 1 year Marriages Divorces

1939

1940

79,411 44,942 11,581 37,943 10,507

66,604 50,118 13,047 36,445 10,248

Source: RGAE, 1562/329/261, 68; 1562/329/262, 5; 1562/329/394, 67; 1562/329/396, 4.

There were fewer weddings and births in 1940 than in 1939. The reduction in the birth rate was especially apparent in the latter half of 1940, because of men departing to the army. Whereas an average of 6,392 babies were born every month in January–June 1940, the monthly figure for July–December was only 4,771, 25 per cent less. Conversely, the death rate, especially infant deaths, increased. Babies dying in the first year of life accounted for 26 per cent of all Leningrad deaths in 1940. Whereas the death rate per thousand live births was 157.2 in 1939, it was 200.3 in 1940. The statisticians commented: ‘There had not been such high mortality since 1922, and [infant] mortality was especially high in March (269.6) and July (348.0).’10 Neonate sick rates and death rates were higher in Leningrad than in other large cities of the Soviet Union. Death was from pneumonia in 35.4 per cent of cases, from gastrointestinal disorders in 33.7 per cent, and from ordinary children’s diseases (measles, whooping cough, diphtheria) in only 7 per cent. Pneumonia also became a main cause of death in adult Leningraders (18 per cent of all deaths), and accounted for 2,000 more deaths in 1940 than in 1939. The statistics of deaths from so-called social diseases and from external causes also underwent changes (Table 1.3), in connection with the departure of men into the army. Deaths from alcoholism were considerably reduced, while deaths from syphilis increased slightly. Deaths from tuberculosis continued to fall steadily. The suicide rate fell sharply throughout the period of military operations (last quarter of 1939, first quarter of 1940), but attempted suicides became more frequent from April 1940. The highest death rates in Leningrad were recorded in March and July 1940, when 5,662 and 5,646 people died, whereas monthly deaths

1403_901422_03_cha01.qxd

10/6/2004

4:58 PM

Page 17

Nadezhda Cherepenina 17 Table 1.3 Deaths from social diseases and external causes per 10,000 people Cause of death

1938

1939

1940

Tuberculosis Syphilis Alcoholism Suicide Murder Industrial injury Other injuries

22.0 1.0 2.1 2.6 0.6 0.4 7.0

20.7 0.9 2.0 2.2 0.7 0.4 6.9

19.7 1.2 1.2 2.2 0.5 0.5 7.0

Source: TsGA SPb, 7384/3/13, 87.

Table 1.4 Epidemic sickness and mortality rates per 10,000 people

Typhoid Typhus Measles Influenza Dysentery and colitis Cerebrospinal meningitis

Cases 1939

Cases 1940

Deaths 1939

Deaths 1940

3.2 1.4 101.8 2,951.4 68.5 1.5

3.3 2.0 198.9 2,767.8 137.9 31.8

0.2 0.002 3.4 1.4 3.8 0.5

0.3 0.006 6.4 1.2 4.8 1.2

Source: TsGA SPb., 7384/3/13, 86.

did not otherwise exceed 5,000.11 The statisticians stressed: ‘The July increase in deaths was so considerable that there was negative population growth in a number of Leningrad districts.’12 Adverse trends were also seen when infectious disease rates were analysed (Table 1.4). The general conclusion reported in January 1941 by the City Board of Economic Statistics Records to P. S. Popkov, chairman of the Leningrad Executive Committee (gorispolkom), was depressing: ‘The information recorded in 1940 is considerably worse as regards medical demographic statistics than in 1938 and 1939.’13 Whereas births per 1,000 of the population were 28.4 in 1939, they were 23.6 in 1940, and deaths were respectively 16.0 and 17.5. Natural population growth was halved from 12.4 per 1,000 in 1939 to 6.1 in 1940.14 The population of Leningrad had ceased to increase for the first time since the Revolution

1403_901422_03_cha01.qxd

10/6/2004

4:58 PM

Page 18

18 Healthcare on the Eve of War

and the Civil War, and had even slightly declined. The population of the 15 urban districts was estimated at 2,920,000 on 1 January 1940.15 Little reference is made in contemporary documents to the causes of the adverse demographic development of Leningrad in 1940, ascribed to ‘known difficulties arising from military operations against the White Finns’.16 The departure of able-bodied men to the army reflected in fewer marriages and births also indirectly contributed to the increase in infant mortality. Women entering industry placed their children in nurseries and kindergartens17 where sickness rates were higher. Employment also led to a worsening in the feeding of infants. ‘Many mothers begin weaning their children too early, resulting in reduced resistance to infections and to a shift of infectious diseases into the first six months of life, i.e. the age at which the death rate increases sharply.’18 In addition, the winter of 1939–40 was extremely harsh, with temperatures falling to -40 °C, and shortages of electricity and fuel led to failures in the heating of municipal buildings, including medical facilities. In the maternity ward of the Peterhof hospital, for example, the temperature did not rise above 7–12 °C, and the walls of the maternity home in Pushkin froze.19 The cold contributed to children’s and adults’ illness, and especially to pneumonia. Although the worsening of demographic processes in 1939–40 was a nationwide phenomenon20 it was acutely felt in Leningrad, above all because the city had some of the best and largest public health services. Apart from the facilities of the Leningrad Health Department, there were the clinics of medical research and teaching institutes, administered by the RSFSR and USSR Health Commissariats. Large military medical establishments, including two medical academies (the Military Medical and the Naval Medical), also operated in the city, and military doctors contributed to the solution of many scientific and practical problems, although their activity was not funded by the Health Department. In 1940 there were in Leningrad 73 hospitals (including two psychiatric colonies), 18 clinical institutes, 131 polyclinics and outpatient clinics, 59 treatment centres (for tuberculosis, venereal diseases, psychoneurological illnesses), 47 women’s clinics, 20 maternity homes and 384 first-aid stations in enterprises.21 There were 1.2 beds available per 1,000 of the population for general treatment, 1.1 for surgical cases, 1.1 for the treatment of infectious diseases, and 0.3 each for tuberculosis and neurological illnesses. Before the war an annual average of more than 420,000 patients had been treated as in-patients. In 1940 the hospital death rate (deaths as a proportion of admissions) had averaged 7.8 per

1403_901422_03_cha01.qxd

10/6/2004

4:58 PM

Page 19

Nadezhda Cherepenina 19

cent in city hospitals (excluding psychiatric and maternity beds), which was slightly above the 1939 figure (7.3 per cent). The Health Department calculated that there were on average 9.3 beds per doctor and 3.1 per nurse, a high figure, which led management to consider ‘the rational workload of doctors’. Leningrad doctors had achieved much. The foci of many dangerous infectious diseases had been eradicated, there was active disease prevention and effective mother and child care, and great attention was paid to prompt admission of patients.22 The well-organized machine was, however, unable to cope with the increased load in 1939–40. Many health service facilities were directly involved in serving the front. Up to 2,500 Leningrad medical workers were drafted into the army23 and some large hospitals were switched to the treatment of military personnel. The result was that admission of civilian patients in January–May 1940 ‘was very difficult’.24 Owing to the ‘unusual working conditions of the hospitals’, 10,000 fewer Leningraders were admitted in 1940 than in 1939. The ambulance and emergency services were switched almost entirely to meeting the tasks of the front, that is, to transporting the wounded and to transferring patients from medical premises attached to the hospital. The war did not end in March 1940 for doctors. Treatment and evacuation of the wounded and the closing of military hospitals continued for several more months.25 The switchover to peaceful, civilian public health was slow and difficult. Some matters traditionally of importance to the medical profession in Leningrad were therefore overlooked. For example, preventive medical measures in preparation for taking children to summer holiday camps could not be properly carried out, with the result that there were more gastrointestinal complaints. Healthcare managers in Leningrad were taken completely by surprise by the alarming information on the poor medical demographic situation of the city. Early in August 1940 the City Health Department received a stern circular from the Health Commissariat on the inadmissibility of the high mortality in maternity homes and wards, and a report from the City Board of Economic Statistics Records (UNKhU) giving figures of birth, death and sickness rates was presented in the Department on 28 August. The acting head of the Department reacted with dismay: ‘this information goes so far beyond what could be expected that we must work out a policy to deal with this question’.26 Early in October 1940 the RSFSR People’s Commissar for Health visited Leningrad to see the situation, and the main item on the agenda of the Leningrad Soviet on 18–19 October was measures to improve the

1403_901422_03_cha01.qxd

10/6/2004

4:58 PM

Page 20

20 Healthcare on the Eve of War

provision of healthcare to workers. A report by L. A. Emdin, head of the Health Department, noted that the medical profession had succeeded neither in reducing gastrointestinal diseases and infant pneumonia, nor in arranging for health workers to visit newborn babies and provide full inoculation coverage against diphtheria for children, nor in synchronizing external treatment and hospitalization. This was mainly because ‘a large part of the medical team had been sent to serve the front in the last quarter of 1939 and the first half of 1940. A period of complacency followed in which the interests of the civilian population were neglected.’27 In Popkov’s view ‘an absolute majority of the shortcomings referred to by the deputies . . . [were] a result of the complacency of healthcare managers’.28 The main defects were the poor discipline of medical workers, a lack of clear guidance from the City Health Department, and the aloofness of research institutes from the practical needs of urban healthcare. Energetic measures taken by the city authorities and by doctors themselves were aimed mainly at reducing sickness and deaths among newborn children. In November 1940 commissions consisting of an obstetrician, a paediatrician and a pathologist were set up in every maternity home and ward to monitor treatment. Autopsies on all babies that died were made compulsory and had to include patho-anatomical and histological investigations. As information was collected and analysed the commissions made specific proposals to both the managements of medical establishments and the Central TreatmentMonitoring Commission of the City Health Department. Steps were taken to improve heating conditions. Early in December 1940 3,000 hot-water bottles and 123 incubators were supplied to maternity homes and wards, and supplies of sulphanilamides were organized. The City Health Department issued an order prohibiting the discharge of premature babies, who could stay in maternity homes for up to two months. Premature babies were accompanied on discharge by a nurse, were conveyed in a motor vehicle where possible, and were placed in special ‘trunks’ heated by hot-water bottles. Further training was arranged for medical personnel.29 Results were not long in coming: infant mortality had already declined sharply in the first quarter of 1941. The death rate (per thousand live births) for babies in the first year of life, 197 in February 1940, fell to 100 in February 1941.30 Reorganization of women’s clinics, which provided all care for pregnant women, was begun late in 1940. Steps were taken to combat illegal abortions, the number of which had risen sharply: 385 had been recorded in 1938, more than a thousand in 1939–40, and 325 in the

1403_901422_03_cha01.qxd

10/6/2004

4:58 PM

Page 21

Nadezhda Cherepenina 21

first quarter of 1941 alone. The post of lawyer was instituted in the three largest hospitals, with a job description that included ‘all contacts with the procurator’s office and assistance in discovering criminal abortions by hospital doctors’. Great attention was paid to strengthening relationships between polyclinics and hospitals to ensure prompt hospitalization. As regards control of widespread gastrointestinal complaints, what could be done by the medical profession was limited by the state of the urban infrastructure.31 By 1941 the Leningrad housing stock comprised 16.6 million cubic metres, there were 27,624 properties in the city, and the average living space per person was 6–6.5 square metres. Nearly 8 per cent of the entire population (242,351 people) lived in the 2,129 hostels, more than 200 of which were regarded as ‘unsatisfactory because infested with lice’. It was there that outbreaks of typhoid occurred in late 1940 and February 1941. There was piped water in 95 per cent of houses, drainage in 92.7 per cent and electric light in 99.5 per cent. Only 16.7 per cent of dwellings had central heating and most houses were heated by stoves. Provision of piped gas was just beginning (25,000 apartments had a gas supply), and cooking was done mainly with paraffin and primus stoves. Doctors were most alarmed by what they regarded as the unsatisfactory sanitary condition of the city, especially the inadequate capacity of the drainage system and piped water, and the shortcomings of the refuse-clearing and cleaning system. The State Sanitary Inspectorate brought many charges against street trading in unpackaged foodstuffs and against the state of many canteens. Extension of psychiatric care became a pressing problem. On 1 March 1941 there were 6,485 patients in all the mental hospitals (apart from those for children), but there was a catastrophic shortage of places, with some patients even having to sleep on the floor. Between 1938 and early 1941 more than 3,000 patients were evacuated from Leningrad to the suburbs and other regions, but there was no solution to the problem of organizing a systematic outflow of the chronically sick to psychiatric colonies and social security establishments. Early in 1941 the medical demographic state of Leningrad improved considerably, as was noted in the regular reports of UNKhU to Popkov.32 The birth rate was up on the second half of 1940 (by 25 per cent in absolute terms, although the 1939 level was not reached), and the death rate was down (by 11 per cent), especially the infant rate (which was halved). The rapidity with which the demographic situation improved showed the effectiveness of the established health services and the high professionalism of the doctors. Even so, the experience of 1939–40 had

1403_901422_03_cha01.qxd

10/6/2004

4:58 PM

Page 22

22 Healthcare on the Eve of War

shown that many aspects of ensuring the life and safety of the civilian population had been neglected. At the beginning of 1939 Popkov had already received a ‘Memorandum on mobilization matters for the city of Leningrad’33 signed by F. F. Rastorguev, the City Military Commissar, which set out the most difficult problems of Leningrad’s preparedness for a possible war. It is evident from this short document that the legal basis of preparation for war was completely lacking throughout the country, since the old laws (for example on compulsory labour service) that came into force when mobilization was announced had in fact been scrapped. As early as May 1937 the secretary of the RSFSR Council of People’s Commissars (Sovnarkom), responding to repeated requests from the presidium of the gorispolkom, had stated that ‘there is no clarity on the question of laws in time of war’. Following this the Leningrad authorities approached the government six times in 1937–38, but to no avail. No general mobilization plan was ever prepared by the gorispolkom: ‘the question of the need to prepare one was raised with the RSFSR Sovnarkom but, as ever, without any result’, and the headquarters of the Leningrad military district did not recommend the civilian authorities to prepare a general plan in the interests of state and military secrecy. All that was produced was an internal plan for the presidium of the gorispolkom. The main result of such an approach to mobilization was the ‘almost total’ lack of agreement between the plans of the various administrations and departments. The offices of the city committee (gorkom) and the district committees (raikomy) of the Communist Party were not involved in planning, and their representatives were not even included in the meetings of executive committees (ispolkomy) concerned with this work. Nothing was done on a number of fundamental questions, especially the abolition, scaling down or merging of organizations and institutions in time of war, the use of all forms of transport as goods vehicles to supply the population with food and fuel, and the safeguarding of the possessions of conscripted persons. The state of readiness for mobilization was never once tested by the RSFSR Sovnarkom, the Defence Commissariat, the Defence Committee of the USSR Sovnarkom or the headquarters of the Leningrad military district in the 1930s. As a result the authorities and those working in mobilization departments lacked knowledge and experience, and their ‘illiteracy over mobilization’, in the words of the City Military Commissar, was a ‘huge brake’ on the work. The vulnerable military and strategic position of Leningrad (close to the frontier and separated from raw material and fuel bases), its popu-

1403_901422_03_cha01.qxd

10/6/2004

4:58 PM

Page 23

Nadezhda Cherepenina 23

lation structure (considerable numbers of children and dependants), and the presence of large defence industry enterprises, required the efficient and timely evacuation of substantial numbers of people and a large volume of equipment. The plan for the ‘emptying’ of the city prepared in 1932–34 had envisaged three stages of evacuation: 1. Automatically on announcement of mobilization there was to be the removal of currency and museum treasures, and valuable imports and exports. Nineteen premises were to be evacuated and 26,037 tons of freight were to be loaded, along with 294 people, for which purpose 2,210 freight wagons were needed. The first stage was to last for between one and ten days. 2. By special government order particular enterprises and institutions working on defence were to be evacuated. Forty-five premises were to be ‘emptied’, and 25,974 tons of freight and 23,547 people removed (in 4,008 freight wagons). The time allocated was 20 days from the date indicated in the special order. 3. Should Leningrad be directly threatened, 118 defence industry enterprises were to be evacuated. This plan was largely out of date by 1939, but changes to it were made, in Rastorguev’s words, ‘in an amateurish way, using local resources, without any input from governmental bodies. All these points have made the plan a completely unsatisfactory document, and it does not, in its existing form, meet the stated objectives.’ In 1937–38 the presidium of the gorispolkom approached the USSR and RSFSR Sovnarkoms and the Defence Commissariat about this matter on four occasions, and representatives went to Moscow several times, but once again fruitlessly, although it was known there that ‘Leningrad will not evacuate itself independently without an order from the government’. Despite the war with Finland, many aspects of the mobilization and defence of Leningrad had not been dealt with even in 1939–40. Figures on the building of shelters and various installations, and the conversion of schools to hospitals, were approved at meetings of the gorispolkom, but no overall document was prepared.34 No independent decision could be taken by the city on many matters. For example, the 1939 mobilization plan of the Leningrad Education Department provided for expansion of children’s homes by 890 places and kindergartens by 2,000 places, and for evacuation of the children and staff of children’s homes (12,122 people). In July 1939 the chairman of the gorispolkom requested the RSFSR Education Commissariat and

1403_901422_03_cha01.qxd

10/6/2004

4:58 PM

Page 24

24 Healthcare on the Eve of War

Sovnarkom to designate the regions, districts and site locations for the children’s establishments to be moved deep into the country.35 When the Leningrad authorities attempted to evacuate some children in late 1939–early 1940, however, their initiative started a fruitless correspondence with departments in Moscow. The situation did not change until the spring of 1941. On 5 March 1941 the Defence Commissariat approved ‘Instructions for the mobilization work of offices of the military administration’.36 Shortly afterwards meetings of the gorispolkom began to examine the new mobilization plans of its departments and boards. On 14 March 1941, for example, the Public Utilities Board was instructed to prepare a new plan, to include expansion of the existing cemeteries, preparation of new trenched plots for burials (for about 45,000 people), organization of special corpse-collecting teams and extension of special premises for their use.37 In May 1941 new plots were designated for cemeteries, but trenches were not dug until after the war had started, and only on 26 August did the Public Utilities Board inform the district Soviets of the allocation of plots to them ‘for the burial of those killed by air attacks’.38 The mobilization plan of the Health Department was not approved at the meeting of the Executive Committee, but the medical services were continuously supervised by the city authorities and the Health Commissariat. The Health Department and its establishments were given major mobilization tasks: (a) to give medical and sanitary assistance in troop mobilization; (b) to ensure normal healthcare for the civilian population under wartime conditions; (c) to transfer surgical beds to the Defence Commissariat within the brief mobilization period; and (d) to organize new facilities (hospitals, laundries and sanitary units). The draft plan for provision of health services to the civilian population prepared in 1940 was twice sent back for revision by the Health Commissariat and finally submitted to a special meeting of the Health Commissariat in mid-December 1940.39 Its main provisions were further hospital beds (replacing those made available to the Red Army), retention of medical personnel, redistribution of staff between medical establishments and reclassification of some establishments. Those who drafted the plan thought that the most difficult question was the number of doctors to be drafted into the army,40 but the City Health Department lacked the necessary information about this even in May 1941. Nineteen decisions on the creation and storage of mobilization stores of medical equipment and on premises for future military hospitals were taken at meetings of the gorispolkom in 1940, and these matters were returned to five times between January and May 1941. The first sector

1403_901422_03_cha01.qxd

10/6/2004

4:58 PM

Page 25

Nadezhda Cherepenina 25

of the Health Department, the office responsible for readiness for mobilization, was inspected six times (!); and inspectors from the Medical Department of Leningrad Military District, the RSFSR People’s Commissariat of Health and Sovnarkom spent a total of 57 days in Leningrad. The last inspection was on 21–28 April 1941, when the head of the War Department of the RSFSR People’s Commissariat of Health spent a whole week examining the readiness of Leningrad doctors for mobilization.41 On 10 May 1941 a meeting of the gorispolkom adopted a resolution on ‘Results of verification of the readiness of the Health department for mobilization and the financial and material activity of the department on defence measures in 1939–1941’. On the basis of this resolution, the head of the Health Department issued an order on 23 May 1941 instructing the managers of treatment facilities to complete revision of the 1940 mobilization plan by 1 June, and of the 1941 mobilization plan by 1 July. They were to pay special attention to the allocation of qualified doctors to military hospitals and involvement of the heads of the future hospitals in the work. The order ended ‘I give notice that I shall take the harshest measures, going as far as suspension from work and committal for trial, for any underestimation of mobilization work, failure to create the conditions in which mobilization stores are properly safeguarded, and failure to keep records of mobilization stores.’42 On 21 May 1941 the RSFSR Sovnarkom passed a resolution on the preparedness of the evacuation hospitals being set up by the Health Department and the quality of technical documentation on the buildings for conversion to hospitals. It was critical of the activity of Leningrad medical personnel, a view categorically rejected by the city authorities, who drafted a sharp letter in reply. This fault-finding approach to the provision of health services did bear fruit: subsequent events showed that the medical services of the city were generally better prepared than other departments for wartime.43 The fact however remains that the mass evacuation of the population was never discussed before the war at meetings of the gorispolkom, which was undoubtedly due to the extremely adverse attitude of the country’s leaders to the plans involved.44 In general by 1941 the population structure of Leningrad was little changed from that shown by the 1939 census. The population of the city on 1 January 1941 was estimated at 2,992,000.45 During the five months before the war natural population growth had been about 10,000, but the migration balance was negative – the number of departures from the city was approximately 11,000 greater than the number of arrivals.46 Consequently, there were around three million people in

1403_901422_03_cha01.qxd

10/6/2004

4:58 PM

Page 26

26 Healthcare on the Eve of War

the 15 urban districts by the start of the war. The number of men can be assumed to have declined, as some had remained in the army after the Finnish campaign. There were still large numbers of children and dependants in the city; the records of cards issued in July indicate that they constituted 45.8 per cent of the population, which would be a serious problem in the besieged city. The health services were well prepared for war – but nobody had expected Leningrad to be under siege for a long time, and for this the city was not prepared. Notes 1. Very general information on demographic processes in Leningrad in the late 1930s may be found in an article by Chistyakova (1997), 164–75. 2. For further information see Vsesoyuznaya perepis’ naseleniya 1939 goda (1992); Zhiromskaya (1995), 28–35. 3. RGAE, 1562/329/280, 80. See also Zhiromskaya (1995), 30. 4. Dokumenty s osnovnymi itogami perepisi 1939 g. po Leningradu (26 tablits): see RGAE, 1562/336/305. 5. Kolpino had a population of 37,648 (18,601 men and 19,047 women), Kronstadt 44,261 (20,186 and 24,075), Pushkin had 56,136 (25,528 and 30,608): TsGA SPb, 4965/3/13, 3–4. 6. Naselenie Rossii (2000), vol. 1, 374. 7. TsGA SPb, 7384/4/23, 657–8. 8. TsGA SPb, 4965/8/738, 9. 9. TsGA SPb, 5016/2/120, 2. 10. TsGA SPb, 7384/3/13, 83. 11. TsGA SPb, 7384/3/45, 273. 12. TsGA SPb, 7384/3/13, 88. 13. TsGA SPb, 7384/3/13, 82. 14. TsGA SPb, 4965/8/738, 11. According to other data the natural growth was 10.8 in 1939 and only 4.8 in 1940, i.e. more than halved (7384/3/13, 82). 15. TsGA SPb, 4965/8/738, 7. The City Registrar’s Office estimated the population of Leningrad on 1 January 1941 as 2,802,413 (TsGA SPb, 4904/1/5, 26–7). The city’s leaders were not worried by the reduction in the population; on the contrary, it fitted in with plans to limit the total size of the population. Speaking at the combined 9th Regional and 7th City Leningrad Party Conference (April 1940), A. A. Zhdanov commented that the Party Central Committee had set a limit of 3.5 million for the population of Leningrad over the ensuing decade. The increase would come mainly from the birth rate, and it was proposed to establish ‘some barrier along the migration path to prevent excessive arrivals’. See RGASPI, 77/1/751, 91; 77/1/752, 30. 16. TsGA SPb, 9156/4/82, 49. 17. The report of the children’s section of the Health Department for 1940 noted that Leningrad had experienced ‘an acute need’ for nurseries early in 1940 (TsGA SPb, 9156/4/792, 17). 18. TsGA SPb, 7384/3/13, 85. 19. TsGA SPb, 9156/4/82, 116.

1403_901422_03_cha01.qxd

10/6/2004

4:58 PM

Page 27

Nadezhda Cherepenina 27 20. Isupov (2000), 125–37. 21. The information on the number and state of medical establishments comes from the status report on assumption of office given to the head of the Health Department on 5 June 1941; most statistical data relate to the position on 1 January and 1 April 1941: TsGA SPb, 9156/4/82. 22. For more information see Emdin (1939); Khromov and Sveshnikov (1969). 23. Ocherki istorii Leningrada (1964), vol. 4, 416. 24. TsGA SPb, 9156/4/82, 82. 25. Twelve hospitals with a capacity of 6,300 beds were moved from Moscow to Leningrad during the Soviet–Finnish war; when military operations ceased their property was left at the disposal of the Health Department as mobilization stores (TsGA SPb, 7384/4/36, 192). 26. TsGA SPb, 9156/4/63, 150. 27. TsGA SPb, 9156/4/62, 1. This phrase was differently worded in the draft of L. A. Emdin’s speech: ‘The entire staff . . . was directed exclusively to serving the needs of the front.’ 28. TsGA SPb, 7384/18/1102, 50–68. 29. TsGS SPb, 9156/4/82, 118–19, 123, 124. 30. TsGA SPb, 7384/3/13, 151–3, 169–73. 31. See TsGA SPb, 9156/4/82, 33, 57, 127; 2076/4/65, 5–6. 32. TsGA SPb, 7384/3/13, 151–3, 169–73. 33. TsGA SPb, 7384/4/25, 652–5. 34. Work on the draft 1935 Provisions on mobilization and defence work was completed in the gorispolkom in summer 1940. TsGA SPb, 7384/4/36, 78. 35. TsGA SPb, 7384/4/23, 186; 7384/4/35, 22–33. 36. Russkii arkhiv (1994), vol. 2(1), 246–7. This document replaced the Temporary Instructions prepared in 1930. 37. TsGA SPb, 3200/5/18, 83. 38. TsGA SPb, 3200/5/19, 25. 39. TsGA SPb, 7384/4/37, 7–8. 40. TsGA SPb, 9156/6/2, 177. 41. TsGA SPb, 9156/6/2, 208, 210. 42. TsGA SPb, 9156/6/2, 203–4. 43. See Gladkikh (1985). See also the speech by F. I. Mashanskii, head of the Health Department, to the staff of the RSFSR People’s Commissariat for Health on 17 December 1942 when presenting a report on the work done. GARF, A-482/47/409, 135–6. 44. See, for example, Stalin’s reaction to plans for the partial evacuation of the population of Moscow. On 5 June 1941 he wrote the following on the draft of the accompanying decree, addressing it to V. P. Pronin, Chairman of the Moscow Soviet: ‘I regard your proposal on the “partial” evacuation of the population of Moscow ‘in time of war’ as premature. I ask you to disband the evacuation commission and discontinue discussion of evacuation. The Central Committee and Sovnarkom will inform you when and if it should be necessary to prepare for evacuation.’ Cited in Kumanev (2000), 245. 45. TsGA SPb, 4965/8/738, 7. The City Registrar’s Office estimated the population of Leningrad on 1 January 1941 as 2,802,413: TsGA SPb, 4904/1/5, 26; 9156/6/35, 85. 46. TsGA SPb, 7384/3/45, 273; Leningrad v osade (1995), 350.

1403_901422_04_cha02.qxd

10/6/2004

4:59 PM

Page 28

2 Assessing the Scale of Famine and Death in the Besieged City Nadezhda Cherepenina

Quantifying the victims of the siege of Leningrad is one element of the complicated problem of assessing the total losses of the USSR during the Great Patriotic War over which professional historians and the general public still disagree.1 Estimates of civilian losses in Leningrad range between 649,000 and 1,200,000, and even a figure of two million has been given.2 Until recently it was assumed that the true number of dead Leningraders would be found documented in the secret archives, but thorough searches have dashed these expectations and shown the need for a meticulous source study of the materials discovered.3 Disputes over the numbers that perished have unfortunately diverted attention from such important questions as the dynamics of the death rate (in general and by population groups), the numbers and ages of males and females among the dead, and the demographic consequences of the siege. These interdisciplinary matters (involving history, source studies, demography and medical statistics) have been disregarded by specialists.4 Various circumstances complicate the study of demographic processes in Leningrad during the siege. In the first place, the administrative arrangements of the city were unusual: in 1936 the towns of Kolpino, Kronstadt, Peterhof and Pushkin were added to the 15 city districts administered by the Leningrad City Executive Committee ( gorispolkom) (a decision officially ratified by the presidium of the AllSoviet Central Executive Committee [VTsIK] on 5 July 1938). From 1939 onward natural population changes were therefore recorded by the statistical services for two groups: data of the 15 city registry offices of Leningrad and of the 19 registry offices of the gorispolkom (17 in the period September 1941–February 1944). Second, close interaction developed between military and civilian bodies in the city during the siege. ‘Front-line city’ was no empty phrase for Leningrad: the line of defence, 28

1403_901422_04_cha02.qxd

10/6/2004

4:59 PM

Page 29

Nadezhda Cherepenina 29

the front in the literal sense, extended in part through the suburbs closest to the city. Within it there were many military organizations, commands, rear services5 and military hospitals that were served by and employed many citizens; decisions by the Military Soviet of the Leningrad Front were binding on the local authorities at all levels. Under these conditions it is very difficult to arrive at purely ‘civilian’ statistics. Finally, part of the territory of the Leningrad region was within the area under siege: the districts of Vesvolozhskii, Pargolovo, Oranienbaum (in part) and Slutsk, the inhabitants of which were actively involved in the defence of Leningrad, but not formally included in the statistical returns. Little allowance was made for these factors in the drafting of all kinds of returns, summaries and reports, especially regarding evacuation, conscription and so on. The reporting systems of other organizations also deviated from the principles for public records of population movements. The boards of the Oktyabr
skaya Railway and the Northwestern Inland Steam Navigation Company reported the numbers of passengers carried, but were not concerned with who those passengers were (evacuees or people on assignments, residents of the city or the region). Such statistics should therefore be treated with caution.6

Statistical sources The official statistical services of Leningrad were in a very difficult position under wartime and siege conditions: there was neither the time nor the resources to process vast amounts of information, often incomplete and confused, irregularly received and delayed for months. Some part was also played by the pre-war falsification of statistics: the ‘unallocated’ quota,7 fictitious individuals who could not be drafted into the army or into defence work. The administrators of Leningrad did not moreover need rough calculations (estimates) of the size of the population, but real figures, as accurate as possible, by sex, age, district of residence and other indicators. Such statistical data are obtainable only from a population census – a highly complicated and painstaking measure unthinkable under wartime conditions. Recourse was therefore had to untraditional methods of enumeration, especially the returns of the City Administration on the Registration and Issuing of Food Ration Cards. From the spring of 1941 that department became the chief source of information on the size of the population for Party and Soviet departments. The population count based on cards issued was always fairly approximate,8 and moreover the cards themselves became one of the

1403_901422_04_cha02.qxd

10/6/2004

4:59 PM

Page 30

30 The Scale of Famine in the Besieged City

main objects of illegal and criminal activity during the siege. Nevertheless, throughout the war, and especially during the first year, the Leningrad leadership established and maintained strict control over these documents by rigorous reporting: the regulations for their granting were repeatedly tightened, reregistration was frequent (almost monthly), and delivery, storage and issuing were under armed guard from November 1941.9 Another point is that the ‘ration card statistics’ (like all other statistics) could not fully reflect the ever-changing situation. The cards were issued for a month, but up to 3,500 people were dying every day in January–February 1942, and many others were evacuated. In addition, the city authorities made widespread use of a ‘kitchen supply’ system for some categories of individuals, under which the cards were not presented in shops but in canteens. This gave rise to a great discrepancy between the number of issued and reregistered cards, as high, for example, as 24 per cent in January 1942. This difference cannot be ascribed solely to illegal machinations. It emerges from an explanatory note from I. G. Stozhilov, head of the City Administration on the Registration and the Issuing of Food Ration Cards, that a large part of it was accounted for by canteens, hospitals, crèches and nurseries, and that only about 1 per cent was ‘unaccounted for’.10 It may be suggested from the checks carried out by the Administration of the People’s Commissariat of the Interior of Leningrad Region (UNKVD) and from the consolidated NKVD data that up to 4 per cent of cards in circulation were illegal, and that the main abuses related to acquiring cards of a higher than permitted category.11 Given that some cards were illegally obtained and others were not used (unused cards were returned to district ration card offices), it seems reasonable to assume that the figures for ration cards issued were far greater than the actual size of the population, but is that so? Under the regulations then in force cards were not issued to persons ‘wholly maintained by the state’ nor, from summer 1942, to Leningraders conscripted to work in the forests and peat fields. In addition, the overall statistics included inhabitants of the region working in city enterprises and their dependants. These categories reached a total of 58,000 (in June 1942), but the usual figure was 30,000. Therefore the figure for the total population in the monthly returns of the city administration was invariably greater from August 1942 than the number of ration cards issued. During the initial months of the siege (until the end of January 1942), after the scale of migration by Leningraders had declined, the statistics of natural population changes – births and deaths – recorded by the registry offices acquired decisive importance. The registry offices of

1403_901422_04_cha02.qxd

10/6/2004

4:59 PM

Page 31

Nadezhda Cherepenina 31

Leningrad were among the few public bodies that continued to operate throughout the siege. Their work became difficult in the late autumn of 1941, and by the end of November death certificates were being issued on the day of application only to private individuals, whereas the certification of deaths in public and military hospitals took two or three days. On 10 December a regulation issued by the chairman of the gorispolkom allocated additional workers to the registry offices (two for each office), and external registry offices were established to issue death certificates at ten of the largest hospitals.12 As a ‘temporary measure’ the gorispolkom decided on 25 December 1941 to authorize the burial of corpses from civilian and military hospitals on the basis of lists compiled by each hospital and the subsequent processing of the lists by the registry offices.13 The same decision authorized the establishment of district mortuaries to receive corpses from the neighbouring quarters. The mortuaries were instructed to take in corpses accompanied by death certificates issued by housing departments, usually by the local police officers.14 Lists of corpses taken from mortuaries to cemeteries were subsequently sent to the registry offices. A new decision of the gorispolkom on 4 January 1942 stressed the need to allocate registry office staff to all civilian and military hospitals.15 In 1942 the registry offices were open seven days a week, but for a shorter time on Sunday, and shift working was introduced to avoid meal breaks. Death certificates issued totalled 766 on 1 January and 1,664 on 1 May, but on the harshest days in January, the 24th and 25th, when it was -34 °C, the total was 5,369. From December 1941 the Leningrad Registrar’s Department produced two kinds of reports (at ten-day or five-day intervals) from data of the 15 district offices: the number of deaths for each day and each district, and the numbers and ages of deceased males and females (by district). These reports, which listed only deaths recorded daily, were the basis for reports from UNKVD to the city leadership and to the NKVD, that is, to L. P. Beria. How complete the registry office data were and how accurately they recorded mortality during the siege is one of the most difficult questions in Russian historiography. Most authors assume that the registry offices recorded only a proportion of the deaths, and even the lesser part.16 Be that as it may, no documentary evidence has been found in the archives to suggest that the authorities doubted the truthfulness of the registry office figures. The only organization to state categorically that ‘a negligible proportion of the population went to the registry offices to register deaths’ was the Leningrad Municipal Services Depart-

1403_901422_04_cha02.qxd

10/6/2004

4:59 PM

Page 32

32 The Scale of Famine in the Besieged City

ment, which managed the Funeral Trust.17 However, neither the Department nor the Trust had full access to confidential information on population numbers and movements, since their work did not require it.18 Moreover, the reporting of the Department and the Trust was not noteworthy for accuracy, and when the daily record of the number of deaths registered and the number of corpses in hospital mortuaries and cemeteries was introduced at the end of December the workers of the municipal services were incapable of complying with that regulation. The gorispolkom obtained information on the state of the cemeteries and mortuaries from the police and the sanitary inspectorate through personal visits by its staff, but lacked any precise regular information from cemetery workers on numbers buried. The registry offices were not, of course, able to record all deaths in the winter of 1941–42: entire families and all the inhabitants of some flats perished, and many people lost contact with their relatives, friends and neighbours through evacuation, call-up or moving out of damaged buildings, and so on. Many enterprises and institutions were unable to monitor fully the movements of their staff; not until April 1942 was there a new inventory of industrial staff in Leningrad.19 It should, however, be remembered that the deaths of those who perished in that terrible winter continued to be registered in the ensuing months and years. Throughout 1942–45 registry offices received so-called consolidated verification reports, which were initially lengthy. In February 1943 alone there were 239 additional births and 32,982 additional deaths registered. The Leningrad Statistical Office noted in the commentary to a report on natural population changes during 1945: The discrepancy between the number of deaths by date of registration and actual date of death may be explained by the fact that the city registry offices are continuing to register deaths during the siege years from the executive listings. Most were deaths promptly registered on the basis of mortuary and cemetery listings, but without surnames, because they were lists of dead people found outside the home and without identity papers. Now, as evacuees return they present themselves to the district registry offices to register the death of relatives who perished during the siege years.20 Deaths continued to be registered for many years. For example, 1,432 certificates recording death during the war were issued in 1949, 956 in 1950, 338 in 1956 and 61 in 1959.21 It should also be recalled that a high degree of bureaucratization was a feature of Soviet society and that many everyday matters, including registration for employment, job

1403_901422_04_cha02.qxd

10/6/2004

4:59 PM

Page 33

Nadezhda Cherepenina 33

placement, education and training, and pension provision, could not be dealt with in the absence of documents, certificates and other ‘papers’. Even in the winter of 1941–42 many people needed death certificates for their relatives. Evidence to that effect is provided, in particular, by a memorandum on the work of offices of notaries (March 1942) in connection with the ‘increased mortality and payments by the State Insurance Office to legatees’.22 The absence of distortions was an important feature of registry office statistics in besieged Leningrad. The practice throughout the country from the mid-1930s onward was that deaths in custody were not recorded by where death occurred (prison, camp, penal colony), but in the registry office of the town (region) where the deceased had lived before arrest. Therefore, someone arrested in Leningrad who died, say, in Vorkuta, figured in the mortality statistics for the place of arrest. Such a practice, regularized by NKVD edict No. 00674 of 11 June 1939,23 ceased to be effective in Leningrad in the last quarter of 1941 and was not reinstated until August 1943. It was stated in the report of the Leningrad Registrar’s Department for August 1943 that a total of 1,698 deaths of inhabitants of Leningrad, Kolpino and Kronstadt had been registered, of whom 147 had died in NKVD camps, and mention was made of ‘the high mortality from pellagra among prisoners in the Rybinsk camp’. This distorted the true figures for mortality in the city, as was noted in the report for December 1943: ‘the number of deaths increased, although actual mortality was continuing to decline, and the increase in the absolute figures was accounted for by the deaths of prisoners in the camps’.24 Leningrad statisticians were also dissatisfied with this situation. In May 1944 the head of the Leningrad Statistical Office proposed, when sending information to Moscow on deaths among imprisoned Leningraders during 1941–43, that such material should be processed separately. His arguments were quite convincing: 22 per cent of all death certificates issued in 1943 listed as the cause of death diseases not found among the inhabitants of Leningrad. The reply from the USSR Central Statistical Office on 16 May 1944 stated: ‘All certificates obtained from the registry offices must be included in the general city statistics.’25 As the official statistical body the Leningrad Statistical Office produced tables of natural population changes from the duplicate copies of certificates (top copies during the siege). Its figures did not usually tally with the data of the registry offices because of features in the recording procedures in each of the agencies.26 A reason had to be given for the discrepancy, and this was usually done in commentaries sent to the statistical offices of the RSFSR and the USSR. Because the Leningrad Statistical Office ceased to function at the end of December and did not

1403_901422_04_cha02.qxd

10/6/2004

4:59 PM

Page 34

34 The Scale of Famine in the Besieged City

resume until the following spring, the health services, the planning committee and other city services found themselves without essential statistical information. Doctors who regularly produced medical demographic reports on health status for the city administration reacted very quickly. As early as the middle of December 1941 V. S. Nikitskii, head of the Health Department, wrote a letter to the gorispolkom stating, in particular, that ‘the recent organization of the production of mortality statistics cannot satisfy the needs and requirements of the Health Department and is contrary to the interests of healthcare’.27 He considered that what was needed was, first, to modify the list of causes of death and, second, to speed up the processing of medical death certificates to enable the Statistical Office to send them directly to the Health Department. The doctors’ suggestions were only partly implemented. To detect the groups particularly affected by dystrophy a Health Statistics Methodology Office established at the end of 1941 made sampling studies on special assignments in the first half of 1942 using material on the mortality (for January and May) of various age groups.28 In the spring of 1942 the Statistical Office began to process material from the registry offices for the end of 1941 and the early months of 1942 with the assistance of staff of the Health Statistics Methodology Office, two representatives of the staffing department of the Health Department and four seconded students from the Military Medical Academy.29 The handling of information on the causes of death occasioned the greatest difficulties. The Health Statistics Methodology Office recommended that ‘preference should be given to the actual nosological terms when different diagnoses are combined with dystrophy and scurvy’.30 The records of meetings of the Office show that such statistical handling problems were taken up on several occasions; the 1942 data were not finally processed and sent to Moscow until May 1943. It is likely that the data on natural changes in the population of Leningrad were never tabulated since no traces of them have been found in the St Petersburg or Moscow archives. This detailed account of the sources of information on the size of the population and natural population changes is essential in order to understand why the statistical data are so patchy and why caution is needed in evaluating the material of the various departments.

Demographic changes 1941–42 The beginning of the siege of Leningrad is traditionally taken to have been 8 September 1941, when German forces seized Shlisselburg, sev-

1403_901422_04_cha02.qxd

10/6/2004

4:59 PM

Page 35

Nadezhda Cherepenina 35

ering the land link between Leningrad and the rest of the country. In reality, however, Leningraders had ceased to be able to leave their city nearly two weeks earlier. Rail communication was interrupted on 27 August, and tens of thousands of people congregated in the station buildings and on trains at suburban stations awaiting a possible breakout to the east. The miracle failed to happen, and halfway through September Leningraders began to return home and transit passengers were put up in hostels in the city and nearby suburbs. In September –November 1941 the identity card office registered 79,345 arrivals in the town, most of whom were apparently refugees from the Baltic region and Karelia.31 Changes in the size and structure of the population may be seen in Table 2.1, based on data on food ration cards issued. The first striking feature of Table 2.1 is the high percentage of the non-employed population. Until summer 1942 dependants were 31–32 per cent of the total population, and children up to 12 years old were about 20 per cent, that is, nearly 50 per cent of the population were not employed in production or in other establishments. The number of dependants began to decline sharply from July 1942, and had fallen to 7.4 per cent in December, but the number of children remained high, despite mass evacuation. The Leningrad Registrar’s Department also had information on the total size of the city’s population. Unfortunately, we still do not know how this information was arrived at. Registry Office statistics did not usually tally with the official statistics (this was also true in time of peace) and were intended solely for internal use, both at the city level and the national level.32 According to the Registry Office calculations the population of Leningrad was 2,450,639 in September 1941, increased in October to 2,915,169, but once again declined in November to 2,485,947. No explanation for such a vast increase, nearly half a million, in the city population and the equally sharp decline is given either in the Registry Office documents or in the work of Z. Z. Shnitnikova, former head of the Leningrad Health Statistics Methodology Office, who used these figures.33

Autumn 1941: the approach of famine Mortality in Leningrad began to increase from July 1941. If we take the mean number of deaths in the first half of 1941 (3,738, data from the 15 registry offices) as 100 per cent, the figure was 111 per cent in July, 143.6 per cent in August, 182 per cent in September and 196.7 per cent

2,652.5 2,621.8 2,377.6 2,371.3 2,384.4 2,330.3

2,281.8 2,151.9 1,912.4 1,612.4 1,306.4 1,211.7 1,060.5 773.0 700.4 670.6 657.9 643.3

1941 July Aug. Sept.* Oct.* Nov. Dec.

1942 Jan. Feb. Mar. Apr. May June July Aug. Sept. Oct. Nov. Dec. 802.6 754.5 686.0 611.1 554.4 568.3 550.6 457.5 439.6 437.5 441.9 435.4

921.7 898.6 834.5 817.7 822.3 805.7

Workers

287.6 249.8 216.6 167.0 137.6 137.3 117.5 85.4 83.0 78.2 73.2 70.0

515.9 487.8 437.3 396.3 372.1 341.3

Office staff

738.3 704.6 615.4 505.7 351.0 266.3 194.8 108.2 70.5 59.1 50.4 47.7

747.9 743.4 672.2 716.7 738.7 729.6

Dependants

453.3 443.0 394.4 328.4 263.4 239.8 197.6 121.9 107.3 95.8 92.4 90.2

467.0 492.0 433.6 440.6 451.3 453.7

Children

35.2 35.1 35.9 37.9 42.4 46.9 51.9 59.2 62.8 65.2 67.2 67.7

34.8 34.3 35.1 34.5 34.5 34.6

Workers, %

12.6 11.6 11.3 10.4 10.5 11.3 11.1 11.0 12.0 11.7 11.0 10.9

19.4 18.6 18.4 16.7 15.6 14.6

Office staff %

32.3 32.7 32.2 31.3 26.9 22.0 18.4 14.0 10.0 8.8 7.8 7.4

28.2 28.4 28.3 30.2 31.0 31.3

Dependants, %

19.9 20.6 20.6 20.4 20.2 19.8 18.6 15.8 15.2 14.3 14.0 14.0

17.6 18.6 18.2 18.6 18.9 19.5

Children, %

782.6 714.8 687.7 660.4 649.8

Estimated population

4:59 PM

20.0 59.0

21.2

Returnees

10/6/2004

* There is also information to the effect that 2,489,400 sets of ration cards were issued to the population of Leningrad and the four towns administered by Leningrad (2,345,100 to the 15 city districts) on 6 September, and 2,443,400 (17 registry offices) and 2,370,300 (15 districts) on 6 October. Source: TsGAIPD SPb, 24/2v/5082, 24/2v/6187; TsGA SPb, 7384/17/410, 7384/17/21.

Cards issued

Year, month

Table 2.1 Data on food ration cards issued to the population of Leningrad in 1941–42

1403_901422_04_cha02.qxd Page 36

36

1403_901422_04_cha02.qxd

10/6/2004

4:59 PM

Page 37

Nadezhda Cherepenina 37

in October, that is, a doubling.34 The causes of death changed in September, with the appearance of the first air-raid casualties, who accounted for 23 per cent of all deaths of citizens: in October this statistic declined to 17 per cent. The catastrophic food supply situation, which the city’s leaders had already surmised at the end of August, but about which they were informed in detail on 12 September after an inventory of edible stores, was kept secret from most citizens.35 The amounts of food issued on the ration began to be reduced early in September 1941, and the free sale of foodstuffs was banned on 1 September.36 On 13 September the UNKVD sent its first report to Zhdanov on food difficulties, concerning not Leningrad, but Sestroretsk, where large numbers of refugees had congregated.37 In October A. A. Kuznetsov, a member of the Military Soviet, received a report on ‘the poor organization of feeding in industrial enterprises and institutions’. It was noted that the largest factories (the Kirov, Bol
shevik, Lenin, Krasnyi Treugolnik and other plants) were experiencing a shortfall of up to 70 per cent in essential products, that meals were of poor quality, often with only first-course dishes on offer, and that waiting time in the large queues was 1–2 hours. The workers were naturally dissatisfied.38 In November when, as people who were doctors at the time put it, ‘conditions were approaching complete starvation’,39 illness occasioned by emaciation reached epidemic proportions. Calls to the emergency medical services increased markedly in the second half of the month: doctors and ambulances were called to flats to see patients who were incapable of attending to be seen, and also to enterprises and polyclinics to take away members of staff and callers ‘suddenly’ taken ill. Whereas the emergency services had 20 such calls on 17 November, the figure on 1 December was 6.5 times greater (131). The comment was ‘emaciation’ on 80 cases and ‘acute cardiasthenia’ on 51.40 Attendance at polyclinics increased sharply, reaching 200 patients a day at some. In one week (21–28 November) one polyclinic in the Kirov district saw 1,626 patients complaining of illness due to poor diet, and the doctors diagnosed 206 of them as ‘emaciated’. This diagnosis was made on 423 out of 4,375 patients at the polyclinic of the Dzerzhinskii district.41 The first deaths from emaciation were recorded. One patient in the Perovskaya hospital died in the first half of November, while at the end of the month 19 patients there died of starvation. In the Erisman hospital, one of the largest in the city, a 40-year-old patient died suddenly in the middle of November (two weeks after admission);

1403_901422_04_cha02.qxd

10/6/2004

4:59 PM

Page 38

38 The Scale of Famine in the Besieged City

the anatomical diagnosis was ‘nutritional dystrophy complicated by broncho-pneumonia’.42 Cases of fainting from hunger at work and in the street became more common at the end of November. It was mainly men in the age range 29–59 years on workers’ rations who lost consciousness. As a rule they died soon after reaching the treatment centre. It was stated in a report of the Petrograd district health department that ‘the first deaths from dystrophy appeared in November, and those who died first were men without any marked pathological changes apart from quiet heart tones and bradycardia [slowness of the heart beat]. There were cases of workers dying just after clocking on.’ Doctors in the Frunze district noted: ‘One striking feature is the considerable number of “acute” deaths or, more correctly, deaths that seem inexplicable at first sight. The patient came [to the treatment centre] independently, seemed to feel reasonably well, but was found dead in bed after a few hours or days.’43 References to hunger in the letters and statements of Leningraders were increasingly linked with the topic of death, seen as a means of escape from painful suffering. ‘Death from bombs or shells is no longer so terrible. The hunger that we are experiencing is far worse’, ‘we shall be glad if they kill us . . . I am sick of suffering from hunger. Life has become worse than hard labour’ are words quoted by the secret services as examples of the ‘decadent outlooks’ prevalent in the population, especially among housewives.44 The naïve and terrified thoughts committed to her diary by a schoolgirl in the 9th class on 13 November testify to the impossibility of existing on the rations of a dependant: ‘Perhaps people will start to eat cats, dogs and even their own children. I am afraid to think about the future.’45 Her fears were justified. Starving people were already eating cats and dogs, but such actions were still regarded as antisocial. However, during the night of 15 November a mother suffocated her 6-week-old daughter in order to feed her other three children. The lowest ration of bread, up to half consisting of additives, was introduced in Leningrad on 20 November 1941. The supply situation for other products on the ration – flour, cereals, meat and fats – became much worse at the same time. Hungry people had to queue from 4 or 5 o’clock in the morning, or even all night, at the shops to get anything else that was going. By the second ‘decade’ [ten days] of November, canteens were not allowed to provide bread with a meal unless they took bread coupons from the ration cards. On 26 November the gorispolkom, having routinely reviewed the ‘Instructions on dividing the population into groups by supply norms’, reduced the numbers of people in receipt

1403_901422_04_cha02.qxd

10/6/2004

4:59 PM

Page 39

Nadezhda Cherepenina 39 Table 2.2 Mortality by age group in autumn 1940 and 1941 for Leningrad

Year

Total

Up to 1 year

1 year

2 year

3–4 years

5–7 years

8–14 years

15 years and above

1940 1941

100% 100%

16.6 17.5

9.3 9.0

2.3 3.5

1.9 2.0

0.8 0.8

1.2 1.7

67.9 65.5

Source: TsGA SPb, 7384/3/45, 277.

of a ‘worker’s’ ration card. The same decision obliged Leningraders to use their ration cards at specified shops.46 Death from starvation was still not a mass phenomenon. It was stated in the reports of the UNKVD to the city leadership (Zhdanov and Kuznetsov) and to Moscow (Beria): ‘There are recorded instances of illness conditioned by lack of food having a fatal outcome.’47 The Leningrad death toll in November was 11,085, nearly three times the number of deaths in the peaceful six months of 1941 and 1.5 times the figure for the autumn months (an average of 7,080 people died in September and October).48 The explanation given for such a sharp rise was ‘the appearance of a new cause of death – dystrophy (emaciation)’.49 A fair proportion of the dead (17 per cent, 1,903 people) were victims of bombing and shelling. Most of the dead were young men (2,082) and members of the able-bodied group more than 40 years old. On the whole, however, there was little significant difference in mortality by age groups; the increase was more or less the same from group to group, as is shown by the table compiled by the Health Department on 5 January 1942 (Table 2.2).

Defining dystrophy In November the doctors of Leningrad were faced with what seemed to be purely a terminological question: dystrophy did not appear as a disease and cause of death in the classifications of the People’s Commissariat of Health and the Central Statistical Office of the USSR State Planning Commission. The specialists of the northern capital had encountered ‘emaciation through starvation’ and ‘death from starvation’ only in the first few years after the Revolution. In 1917–23 in Petrograd 19,516 people died of starvation.50 The eminent Russian demographer S. A. Novosel
skii wrote in 1920, ‘Starvation and cold are the main causes . . . of the exceptionally high mortality . . . because they elicited and created a massive

1403_901422_04_cha02.qxd

10/6/2004

4:59 PM

Page 40

40 The Scale of Famine in the Besieged City

reduction in the vitality and viability of people, and minimized the resistance of the organism.’51 By 1941, most Leningrad doctors, having been educated in the Soviet period, had a very weak and largely theoretical grasp of dystrophy and the diseases that it occasioned.52 The recording of a disease new to Leningrad – emaciation ‘occasioned by inadequate diet and intensified work’53 – began in the last decade of November. On 7 December 1941 the Health Department approved proposals by Professors M. G. Danilevich, M. I. Khvalitskaya and M. D. Tushinskii ‘On the terminology and treatment of nutritional disorders’. The document stated in particular that ‘the term “nutritional dystrophy” is proposed for the clinical syndrome currently being seen in connection with malnutrition. When oedema is present the words “oedematous form” are to be added to the diagnosis. When there is acute emaciation . . . physical and mental debility, “cachectic form” should be added.’54 The term ‘nutritional dystrophy’ was accepted throughout the treatment network and in the scientific institutes of Leningrad. ‘Nutritional emaciation’ was preferred by the Military Medical Office of the Leningrad Front and by army doctors.55 Nutritional dystrophy was not included in the classification of causes of death, however, until the summer of 1942, and then not at the instigation of Leningrad doctors. On 16 May 1942 the demographic department of the Central Statistical Office of the USSR State Planning Commission wrote a letter to the People’s Commissariat of Health of the USSR, referring to a query from the Molotov (Perm) statistical office, stating that statisticians were putting death from emaciation under the heading ‘other cause of death’ (entry 83). The letter went on, ‘Because this diagnosis is frequently made, especially in recent months, we ask whether we are correctly situating it?’56 The question was repeated on 6 June, this time with reference to a letter from Vologda. The Health Commissariat replied on 10 July 1942, and on 20 July the Central Statistical Office proposed that all republican statistical offices should ‘when processing the copies of death certificates and compiling monthly returns and quarterly and annual reports, distinguish as cause of death (1) Wartime traumas among the civilian population – entry 40-A; (2) Avitaminoses and dystrophy – entry 83-A’.57 This circular did not apparently reach Leningrad. At all events, dystrophy was not distinguished as a cause of death during 1941–42.58

December 1941: mass starvation Not only illness but also death due to starvation became massive in Leningrad in December. Daily deaths averaged 954 during the first

1403_901422_04_cha02.qxd

10/6/2004

4:59 PM

Page 41

Nadezhda Cherepenina 41

decade, and by the end of the month the figure had risen to 2,340 a day. The sudden death of passers-by became an ordinary occurrence: 841 corpses were delivered to mortuaries between 6 and 13 December, and in the middle of the month at least 160 corpses a day were picked up in the streets.59 Calls to the information line of the emergency services were up by a factor of 2.4 times (from 1,418 in November to 3,396 in December) – Leningraders were calling for information about relatives who had not returned home.60 Because hospital dissecting rooms could not cope with the increased volume of work, the Leningrad Police Department cancelled from 20 December the compulsory autopsy on persons found dead in the street without signs of a violent death.61 In December the registry offices of Leningrad (15 districts), Kolpino and Kronstadt recorded 53,843 deaths,62 including 5,671 infants in the first year of life. Most of the dead were men, 71 per cent of deaths registered in the first decade of the month. When, on 5 January 1942, the doctors sent a report on the medical demographic status of the population during 1941 to the gorispolkom, they wrote of sharp quantitative and qualitative shifts in natural population changes. In their opinion, 75 per cent of Leningrad deaths were from dystrophy: Dystrophy, which is a result of systematic inadequate intake of the nutrients (protein, fats, carbohydrates) essential for replacement of the energy expended, under conditions of the known disturbance to the normal functioning of the neuro-psychic and cardiovascular systems as a result of prolonged aerial and artillery bombardment, rapidly exerts a destructive effect on the organism.63 The second main cause of death was inflammation of the lungs resulting from overcooling and complications after an infectious disease. In third place were diseases of the gastrointestinal tract caused by consumption of substitutes and poor quality foods, and by aggravated chronic diseases. Deaths from bombing and shelling (there were fewer air attacks in December) were relatively few (1,038) by comparison with all deaths. Cold became an important factor in mortality. The city’s fuel stocks were used up and electricity generation was only 16.5 per cent of the pre-war (June) level. On 11 December the authorities took the harsh decision to take the coal remaining in the boilerhouses of dwellings and hospitals for the No. 2 Power Station,64 but the situation continued to worsen. District heating of dwellings was discontinued, factories and works came to a halt, public utilities (bath houses, laundries and hairdressers) shut, and life in many of the city’s institutions stopped. Even

1403_901422_04_cha02.qxd

10/6/2004

4:59 PM

Page 42

42 The Scale of Famine in the Besieged City

those people who turned up to work were unable to do so, not only from physical weakness, but also from lack of heat and light. Winter came early in 1941 and the city froze up. The temperature fell to -20 °C on some days (14–15 December), although in the main it was between -5 °C and -15 °C throughout the month.65 In any case, any degree of cold was terrible for weakened people. ‘The cold was somehow internalized. It went right through everything. The body generated insufficient heat’.66 Movement of pedestrians and transport was impeded by heavy snow that fell on 8 December and formed drifts. An attempt by the gorispolkom through its decision of 11 December to make snow clearance compulsory (between three and eight hours a day) was short-lived.67 Trams soon stopped running for lack of electricity. This event was noted by almost all authors of those years as contributing to the increased mortality. Z. M. Shnitnikova wrote, in particular, When the stopping of the trams added to the daily workload a further two or three hours walking (often carrying fuel) to and from home and work, that necessitated an additional expenditure . . . of calories. After the reserves of the organism (subcutaneous fat) had been used up, the additional burden of walking resulted in weakening of the muscular system, including weakening of the myocardium, and frequently to a denouement, death from heart failure, cardioplegia, fainting and freezing when out and about.68 ‘The candle was being burnt at both ends’ – a quotation not from a volume of poems but from a basic scholarly work69 – expressively characterizes the situation of a besieged Leningrader, between the Scylla of starvation and the Charybdis of vast physical and mental burdens.

January–February 1942: the height of the famine A ‘total blockade regime’ was established early in 1942. An increase in the bread ration (which now contained 60 per cent of additives) from 25 December 1941, greeted with rapture by production teams and brigades, was of a symbolic nature. Despite the opening of the Ladoga route, the general food supply situation in the city worsened. It was noted in the returns of the UNKVD that ‘Since the third decade of December 1941 ration cards are not being honoured. Apart from bread (350 g for worker and 200 g for office staff) people are not receiving any other products.’70 ‘We began January boldly, with very great joyous expectation. Who,

1403_901422_04_cha02.qxd

10/6/2004

4:59 PM

Page 43

Nadezhda Cherepenina 43

whether fortune teller or prophet, could have known what terrible inhuman calamities history had in store for us?’ – these lines from a diary71 express one of the main tragedies of the first months of 1942 – the crushing of the hope that Leningrad would be freed rapidly and radically from the sufferings of the siege. It became obvious by the middle of January that the operation to lift the siege ordered on 17 December 1941 had been unsuccessful.72 Interruptions in supply became greater in January. A report of the UNKVD noted on 28 January 1942 that except for flour, no food products reached Leningrad in the first half of January. Deliveries that began only on 16 January were insufficient for the amounts due on the ration cards to be fully met. The increase in the bread ration from 24 January (to 400 g for workers, 300 g for office staff, 250 g for dependants and children) and the limited delivery of other rationed foodstuffs did not improve the situation of the people.73 This information was made more specific in the report of 10 February: the January allocations on the ration cards were not met regarding meat, fats and confectionery, and the people did not get 889 tons of fats (out of a specified 1,362 tons), 1,095 tons of meat (out of 1,932 tons) and 1,373 tons of confectionery (out of 2,369 tons). Possibly the only positive aspect of the January supply was an improvement in the quality of the bread, because additives were reduced to 5.6 per cent on account of exhaustion of the stocks of additives and an improvement in deliveries of flour.74 There were heavy frosts as the year began. The mean monthly January air temperature was -18.7 °C, whereas the temperature did not normally fall below -7.6 °C. On eight days (12–14, 20–21, 24–25, 27) the thermometer reading was -30 °C or lower.75 Drainage and the piped water supply broke down almost everywhere. Drinking water was in very short supply and any deliveries to dwellings and institutions were heroic deeds. By the end of January water was reaching only 85 apartment buildings, 95 per cent of standpipes were frozen, and there were 80 per cent more fires than in December on account of ‘careless handling of fire’, while electricity generation was only 4.3 per cent of the pre-war level.76 The number of victims of starvation rose inexorably: in the first decade of January (incomplete data) registry offices recorded 28,028 deaths of Leningraders, greater by a factor of 2.9 times than for the same period in December. More than 3,000 deaths, practically the monthly

1403_901422_04_cha02.qxd

10/6/2004

4:59 PM

Page 44

44 The Scale of Famine in the Besieged City

death toll in peacetime, were recorded every day in January. The UNKVD calculated that 4.06 per cent of the entire population perished in January.77 Among the dead were 7,267 infants less than one year old (there were 4,265 births). Children up to the age of 14 accounted for 12.9 per cent of all deaths, adolescents (15–19 years) of both sexes for 6.3 per cent and persons more than 50 years old for 35.8 per cent. There were 2,734 corpses collected from the streets of Leningrad, and the airraid defence service took to hospital nearly as many people exhausted by starvation.78 Increasing mortality in the suburbs was a feature of January, especially among people evacuated from Karelia to the Vsevolod and Pargolovo districts of Leningrad Region. In January 313 of the inhabitants of Peterhof taken to Oranienbaum died, whereas only nine had died in December. Owing to difficulties in supply through Kronstadt, the rations in Oranienbaum on some days in January were lower than in Leningrad – only 100 g of bread were given on a dependant’s card.79 The city population continued dying in February, when the registry offices recorded 108,029 deaths (roughly 5 per cent of the total population) – the highest figure in the entire siege. The largest numbers of death certificates were issued on 6 and 7 February – 4,719 and 4,720. The frosts continued; mean air temperature for the month was -12.4 °C (not the usual -7.7 °C). Coal stocks ran out at the beginning of February and total power generation was only 2.4 per cent of the pre-war level. The situation began to change in the second decade of February. New bread rations were introduced on 11 February (500 g of bread for workers, 400 g for office staff, 300 g for children and dependants), and canteens began to provide cereal dishes for which only half a coupon was taken (formerly a whole coupon). The most important thing was that supply became regular, with the result that queues vanished, and ration cards were honoured promptly and almost in their entirety. Good quality meat, frozen beef and mutton, was even supplied on 16 February.80 The ration cards for cereals, supply of which was slightly less than laid down, were fully honoured in February and meat products were issued. The supply situation was worst for sugar and fats. The shortfall was 227 tons of sugar and 770 tons of oil and fats. The amount of fat supplied on a worker’s card was 150 g, instead of the 800 g laid down.81 After the siege had been lifted Leningrad specialists calculated the daily per capita supply of food products in January and February 1942, shown in Table 2.3. These are, of course, only calculations, but even these ‘theoretical’ norms were staggeringly low and insufficient for the normal vital activity of the human organism. In reality, as already noted, produce reached

1403_901422_04_cha02.qxd

10/6/2004

4:59 PM

Page 45

Nadezhda Cherepenina 45 Table 2.3 Daily per capita supply of food products (in grams) in January and February 1942

Month

Bread

Flour

Cereals

Pasta

Meat

Sugar

Confectionery

Dried fruit

Vegetables

Jan. Feb.

306 363

11 4

46 73

26 41

10 23

16 15

5 13

1 4

47 33

Source: TsGA SPb, 2076/4/70, 7–8.

the city shops irregularly and it was not until the beginning of February that most of the January norms were met. Even the miserly rations did not always reach the intended recipients because of misappropriation and abuses. Professor D. I. Kargin gives a telling example in his memoirs: an inquisitive academic in his laboratory evaporated soup given to him in the canteen of the Scientists’ Club and found that it contained only 8.1 g of cereal mixed with flour instead of the 25 g laid down.82 The death total remained high in February 1942, although with a noticeable tendency to decline. There were 37,296 deaths recorded in the first decade of February (provisional data), 34,852 in the second, and only 23,867 in the last seven days of the month, that is, 36 per cent less than at its beginning. The number of deaths in the streets began to decline especially rapidly: 1,060 in the first decade, 679 in the second, 366 in the third (almost 75 per cent lower). The rate of development of nutritional dystrophy and its clinical picture also changed in late February–March 1942, but other conditions became prevalent: avitaminoses (scurvy, pellagra), hypertension, tuberculosis and so on.83 During the initial period (November 1941–February 1942) of the development of nutritional dystrophy84 doctors observed three forms of death: 1. Slow death, gradual extinction of life. 2. Accelerated death, with death occurring several days after the beginning of a deterioration in the general condition for whatever reason (usually from an associated complication). 3. Sudden or rapid death against a background of ‘relative well-being’.85 The majority of those who died were adult males.

Spring–summer 1942: the famine recedes In the spring the number of sudden deaths fell considerably: 667 died suddenly in the streets in March, 262 in April, and only nine in May.86

1403_901422_04_cha02.qxd

10/6/2004

4:59 PM

Page 46

46 The Scale of Famine in the Besieged City Table 2.4 Deaths of men and women registered in February–May 1942

Died

February

March, 1st decade

March, 2nd decade

March, 3rd decade

April

May

Men Women

57,990 38,025

14,175 13,106

13,175 15,084

11,301 14,726

25,409 30,885

17,567 32,227

Source: TsGA SPb, 4904/1/4, 18, 23, 25, 33–5, 37–41, 43, 45, 47.

For the first time since the beginning of the war the number of women to die in March (absolute figures) was higher than the number of men, a fact immediately noticed not only in the registry offices, but also at the domestic level. Thus, the unknown author of a letter wrote, ‘Men and youths have all died, only women have remained’. The change in the established proportion may be seen from the deaths registered at the time (Table 2.4). It should be remembered that only one-third of the city’s population were men and that therefore their death rate was considerably higher than that of women. The theme of death by starvation continued to take first place in the reports of the UNKVD on the mood of the public, but the feeling of doom was gradually disappearing from the reported conversations. Attitudes towards hunger became more general, and fears that supplies would be cut off in the spring were overtaken by rumours that the city was to be taken under the ‘guardianship’ of Britain or of neutral countries.87 After living conditions improved considerably in April (municipal services began to be restored, trams were running, better canteens were organized and so on) it was mainly office workers and dependants, on small rations, who continued to talk of lack of food and death. In the summer, in July 1942, starvation was replaced as a topic of public discussion by abuses in the communal feeding and trading system.

Hospital mortality Special mention should be made of hospital mortality in Leningrad. Although most civilian deaths in the winter of 1941–42 occurred outside medical establishments, the study of hospital mortality enabled doctors to define the main characteristics and stages of mortality in the siege. A more or less reliable record of general city mortality was not established in the Health Department until April 1942,88 before which doctors had data only for individual hospitals. Nor was there a unified

1403_901422_04_cha02.qxd

10/6/2004

4:59 PM

Page 47

Nadezhda Cherepenina 47

recording procedure, as may be seen from the verbatim record of an academic council meeting of the Pavlov First Medical Institute on 22 July 1942,89 where there was discussion of reports by research assistants Ya. N. Dashkevich and O. D. Isserson on death rates at the Erisman and Karl Marx hospitals.90 Asked how they defined the mortality percentage, the authors replied that it was the number of dead patients as a proportion of admissions. The chairman, Professor I. D. Strashun, then stated that the Health Department calculated the percentage differently, in relation to the number of patients registered (not admissions). A retort from the floor (‘Now they will take [the number of] admissions plus discharges divided by two’) angered the professor, who commented that the discrepancy in the calculations had almost led to criminal proceedings. What had been normal in peacetime was, in Strashun’s words, ‘heresy’ under wartime siege conditions. In fact, in winter 1941–42 the discharging of patients from hospitals practically ceased. Nor was documentation promptly prepared on the dead, whose corpses were stored initially in the mortuaries, and subsequently in cellars and elsewhere. In January–February 1942 the mortuaries of large hospitals were taking in a daily average of 566 corpses, not only of patients, but also persons brought in dead from the streets and others who died in the waiting room. Corpses of members of the armed forces were also brought to the mortuaries of civilian hospitals from nearby military hospitals. Doctors also disagreed on whether to include in the returns persons who died in the first few days after being brought to hospital, and some hospitals did not. The lack of a common recording procedure and the incompleteness of the data were responsible for the significant diversity of figures in different reports and returns. In March 1942 the Health Department sent Zhdanov a return on mortality in the city hospitals in January–March 1942. This was one of the first reports on hospital mortality and, perhaps, the only one to compare mortality among the civilian population and military personnel (Table 2.5). It is noteworthy that mortality was appreciably lower among military personnel, who received higher rations, than among ‘civilian’ patients. Data on mortality in subsequent reports and returns of the Health Department fluctuated between 39.3 and 40.8 per cent in the first quarter of 1942, between 28.9 and 31.1 per cent in the second, between 15.9 and 28.9 per cent in the third, and between 3.7 and 9.8 per cent in the fourth.91 According to A. P. Sveshnikov, mean hospital mortality in 1942 was 24.43 per cent.92

1403_901422_04_cha02.qxd

10/6/2004

4:59 PM

Page 48

48 The Scale of Famine in the Besieged City Table 2.5 Mortality in Health Department hospitals in Leningrad in the first quarter of 1942

Departments

Mortality among civilian population

Mortality among wounded and sick troops

Therapeutic Surgical Tuberculosis* Infectious (dysentery) Infectious (other) For dystrophics Psychiatric*

20–25% 12% – 20–25% 7–10% 60–70% –

4.5–6% 4.5% 5% 22% 6–7% – 9%

* No information given on mortality; calculation method not explained. Source: RGASPI, 17/121/176, 68.

Mortality varied greatly from hospital to hospital. It was stated at the academic council meeting referred to above that up to 84 per cent of patients admitted to the Karl Marx Hospital in January 1942 died. When the Chief Physician of the Botkin Hospital heard this figure he commented in astonishment that mortality had not exceeded 50 per cent in the wooden barracks of his hospital, where conditions ‘were not good – cold and dark’. An appreciable difference in mortality level was also found in the statistics of children’s hospitals: 12 per cent in the Second Children’s Hospital of the Oktyabr
skii district, 50 per cent in the Raukhfus Hospital.93 It should be commented that hospital mortality was not a subject of special research and is little reflected in the medical and historical literature.94 The explanation lies not only in the difficulty of gathering information, but also in the impossibility of publishing research, since the statistics were ‘secret’95 and there was real danger of arrest for ‘divulgence’. For example, early in 1942 the doctor in charge of one district sector was arrested and charged that ‘being in possession of actual data on morbidity and mortality data arising from starvation, he used the information for anti-Soviet propaganda’.96 The psychological factor also undoubtedly played a part. To quote I. F. Mashinskii, speaking in summer 1943 at a meeting on the twenty-fifth anniversary of Soviet healthcare, ‘the high hospital mortality of those days placed a heavy burden on doctors, nurses and orderlies, at a time when all hospital staff had, through their behaviour, to maintain cheerfulness in patients and belief in a better future close at hand’.97 The impossibility of assisting dying patients, the vast scale of mortality and the starvation of the

1403_901422_04_cha02.qxd

10/6/2004

4:59 PM

Page 49

Nadezhda Cherepenina 49

medical staff themselves made hospital mortality an unattractive research topic. Comparison of the data of treatment facilities and other organizations (especially registry offices) shows that the pattern of hospital mortality in the first stage of the development of nutritional dystrophy was, on the whole, the same as in the city in general. Only later, when it became possible to hospitalize most patients, including sufferers from dystrophy (the task given to doctors in summer 1942), did hospital mortality exceed that in the city in general.

The Leningrad authorities and the famine The city leaders were undoubtedly fully informed about the scale of the depopulation. Given that the Leningrad Statistical Office ceased functioning at the end of 1941, the UNKVD, which included the registry offices, became the main if not the only source of comparatively accurate data on current mortality statistics. Very few people received the special reports of the UNKVD: Zhdanov, M. S. Khozin, Kuznetsov and, less often, Popkov. A daily report was produced of the number of corpses in hospital mortuaries and at cemeteries from the middle of December. As already noted, the Funeral Trust was incapable of performing this task. However, the largest city hospitals reported the number of corpses in the mortuaries, specifying how many had been taken in and how many removed, daily by telephone to the Health Department (which passed the information on to the gorispolkom).98 For example, there were 5,322 corpses in 14 mortuaries on 28 January 1942, 395 were removed and 531 taken in, leaving a total of 5,458, including 2,790 for whom the documentation had not been processed. This means of collecting information was strictly followed until January 1944. However, because the subject of mass deaths among the civilian population was absolutely secret, it was completely omitted from official public information.99 As already mentioned, doctors at the time were inadequately informed about the effect of starvation on the human organism. Therefore, in the opinion of E. E. Ben, in the winter of 1941–42 the health services and most of the medical profession had formed ‘a one-sided and simplified idea’ of dystrophy ‘as a phenomenon of social pathology’. ‘Dystrophy sufferers were looked upon as people in need of food but not treatment. At the same time, it was precisely lengthy starvation that caused or aggravated a number of pathological processes for which a therapeutic and qualified solution should have been found in healthcare facilities.’100 In a book summarizing a study of nutritional

1403_901422_04_cha02.qxd

10/6/2004

4:59 PM

Page 50

50 The Scale of Famine in the Besieged City

dystrophy, Professor M. V. Chernorutskii also noted that medical workers had not spotted the ‘precursors’ of the disease, ‘a latent kind of incubation period’ characterized by such symptoms as amenorrhoea, hypothermia and a tendency toward bradycardia and oedema.101 The city authorities, who could only assist certain categories of the population under siege conditions, knew even less about the serious consequences of mass starvation. Priority was given to defence workers carrying out the extremely important assignments of the Military Soviet of the Leningrad Front, and to creative and scientific intellectuals and Party workers. In accordance with decisions of the gorispolkom, with effect from October 1941 some departmental canteens did not take all the coupons for some foodstuffs (apart from bread), which increased the allocations to these categories.102 Thus, by a decision of 1 November 1941, only half the meat coupons were taken for dinners in the canteen of the newspaper Leningradskaya Pravda, and no coupons at all for cereals. Similar privileges were extended by a decision of 5 November to workers and engineers directly engaged in the defence industry, in a list of more than 100 enterprises. There were also additional distributions of products. In December 1941–January 1942, for example, it was decided to issue vodka to people recruited to bury corpses. The category of those entitled to additional feeding was extended at the very end of 1941. A secret decision of the gorispolkom of 29 December 1941 ‘On measures for the medical care of sufferers from dystrophy (emaciation)’ instructed the Health Department to develop a network of treatment and nutrition facilities, for which rusks, tea, cocoa, sugar and chocolate were allocated for distribution off the ration; on 30 December dietary norms were laid down for these establishments.103 By 8 January 1942 the network had already been considerably enlarged, and district executive committees had been authorized to set them up (each for 200–300 people), as had 17 enterprises (1,440 places). The Health Department itself was required to set up only one facility serving the whole city and based on No. 108 Hospital.104 Mass support for surviving Leningraders began in the spring of 1942, when closed canteens providing increased nutrition for 100,000 people were organized by decision of the gorispolkom and the City Committee of the Communist Party (gorkom).105 In the spring of 1942 the Leningrad medical profession was required to explain the high mortality in the city. On 31 March a lengthy memorandum was sent to the chairman of the gorispolkom and to the USSR Sovnarkom (to A. N. Kosygin), which demonstrated that ‘the main, if not the sole cause of the high mortality in the first quarter of 1942 is dystrophy (emaciation)’.106 However, the city leadership was clearly

1403_901422_04_cha02.qxd

10/6/2004

4:59 PM

Page 51

Nadezhda Cherepenina 51

dissatisfied with the work of the medical profession. Nikitskii, the head of the Health Department, was removed from his post in April 1942 and F. I. Mashanskii appointed in his place. When Popkov addressed a meeting of medical workers on 25 May, he made sharp criticisms of the work of the Health Department. In particular, analysing shortcomings in the work of medical establishments, with specific examples (naming organizations and persons), he stated: If you read the newspapers regularly, they speak a lot about innovations and inventions in armaments and explosives, and many other matters. The situation as regards medical affairs in Leningrad is very bad . . . I wish to express to this meeting of medical workers the dissatisfaction of the City Party Committee and the City Executive Committee and also of Comrade Zhdanov personally . . . I tried to call meetings in my office. We wanted to halt deaths from starvation as quickly as possible. We raised the question several times, asking to be told what would be best, but we never got any answer. Only after we ourselves discussed this matter were canteens to provide additional nutrition for 100,000 opened on the initiative of Comrade Zhdanov. But that was not done on the initiative of doctors. I consider that reflects badly on our medical establishments, and especially our institutes here in Leningrad, particularly on those people who devote much of their time to so-called scientific medical questions. Had this matter been raised earlier, had appropriate material assistance been requested, it would have been given sooner. But what was manifested here was some sort of timidity or, perhaps, unwillingness to work. The profession was given the task of reducing mortality by ‘approximately eight times, if not more’.107

The Soviet leadership and the Leningrad famine How much was known outside Leningrad about its tragedy? This question is reduced in Soviet historiography to the formula ‘People of Leningrad, the whole country is with you’, but study of the sources shows that information from the besieged city was carefully controlled. No information on the starvation and high mortality appeared in the national mass media (newspapers and radio), and letters from Leningrad containing ‘negative’ material were held back by the military censorship. The leadership of the country was undoubtedly aware of the tragic

1403_901422_04_cha02.qxd

10/6/2004

4:59 PM

Page 52

52 The Scale of Famine in the Besieged City

situation in the city. However, it should be remembered that Zhdanov, a Secretary of the Party Central Committee who, even with the tight centralization of those years, possessed (or thought that he possessed) some independence of action over many questions, was repeatedly subjected to fierce criticism, if not to downright dressing down, at the hands of Stalin. Historians are well aware of one such fact: on 22 August 1941, when the struggle for the city was most intense, Stalin (in the presence of Molotov, Malenkov, Mikoyan and others) sharply reprimanded the Leningrad leader over the organization of the Military Soviet for the Defence of Leningrad. It is worth quoting a paragraph from a known, but never published, document. Having characterized the decision of the Leningraders to elect commanders in the workers’ battalions as ‘a serious political error’, Stalin declared: We have never known of your plans and undertakings. We always learn by chance that something or other is intended, that something or other is planned, and then there is a gap. We cannot put up with this. You are not children and you well know that there is no need for forgiveness. Your justification of being overworked is laughable. We are no less overworked than you. You are simply disorganized and you feel no responsibility for your acts, as a result of which you act as if you were on an isolated island, without considering anyone.108 On 1 December 1941 there was another acrimonious conversation over the government telegraph apparatus between Zhdanov, Khozin and Moscow. Stalin (with Molotov also present) said in his typically harsh and expressive manner: It is very strange that Comrade Zhdanov never feels the need to come to the machine and ask at least one of us for reciprocal information in such a difficult moment for Leningrad. If we, the Muscovites, had not summoned you, perhaps Comrade Zhdanov would have forgotten about Moscow and the Muscovites, who might have given assistance to Leningrad. We might imagine that Leningrad under the leadership of Comrade Zhdanov is not in the USSR, but somewhere on an island in the Pacific Ocean. Tell us what you are doing and how you are thinking of getting out of the present situation, everything.109 Soon after this discussion Zhdanov flew to Moscow and was received by Stalin on 17 December 1941. Not until 17 June 1942 did he visit the Kremlin again.110

1403_901422_04_cha02.qxd

10/6/2004

4:59 PM

Page 53

Nadezhda Cherepenina 53

It is evident from the documents now available that the chairman of the State Defence Committee was concerned mainly with the military aspects of the siege of Leningrad and the defence potential of its industry. The main gamble was on lifting the siege, and therefore Stalin, in the words of Mikoyan, was sceptical about the possibility of an ice road across Lake Ladoga.111 But, while the city was surrounded, it followed that everything usable for war against the enemy should be got out, above all the plants making tanks and other munitions. The pragmatism of Stalinist policy is clearly seen in the airborne evacuation of Leningrad in autumn 1941: the priority was to take out the workers of the Kirov and Izhora plants so that they could be used for organizing tank production in the Urals. Information on the situation in the city reached the highest leadership of the country mainly through the NKVD. An order of the NKVD of 7 June 1941112 confirmed a list of events (19 items) about which the People’s Commissariat of the Interior was to be promptly informed (by special communication or by telephone). This order was strictly adhered to throughout the war by everyone, including the Leningraders. P. N. Kubatkin, the head of the Leningrad UNKVD, regularly sent special communications (every five or 14 days from 13 September 1941) on the food situation in the city, starvation, mortality and starvation-related crime to members of the Military Soviet of the Leningrad Front – Zhdanov, Kuznetsov and Khozin (and later L. A. Govorov) – and to Beria, his immediate superior in Moscow. More detail was given on supply matters in the communications sent to Moscow than in the similar documents for the Leningrad leadership. A different situation arose in the Party’s Central Committee, the technical office of which required major Party organizations to submit quarterly reports. Information from Leningrad was sent from the office of Zhdanov. That is why, for example, a memorandum from V. M. Reshkin to Popkov on burial problems and other matters concerning Soviet (but not Party) bodies may be found in the files of Zhdanov in the Central Committee Archives, but not reports of the Leningrad City and Regional Party Committees.113 Many central departments, especially the Central Statistical Office of the USSR State Planning Commission (Gosplan USSR), also lacked accurate information about Leningrad, which was left out of national statistics between the third quarter of 1941 and May 1943. Thus, for example, no Leningrad information appears in returns on population changes in 1942 sent to Sovnarkom. The explanation for such an ‘exception’ is that the Leningrad Statistical Office did not submit its report

1403_901422_04_cha02.qxd

10/6/2004

4:59 PM

Page 54

54 The Scale of Famine in the Besieged City

until May 1943, but even thereafter the vast losses ‘spoiled’ the general picture. The phrase ‘No information for Leningrad, where the siege conditions resulted in an extremely high level of mortality and a reduction in birth rate, is included in the figures for the territory covered’ was deleted from a memorandum of the Central Statistical Office on population changes in 1943, prepared in April 1944.114 Nor were the health commissariats of the USSR and the RSFSR in possession of complete information up to 1943.115 The sending of doctors to Leningrad on assignments and the evacuation and transfer of a number of specialists to Moscow undoubtedly gave workers in the central apparatus a broader view of the situation in the city. However, when G. A. Miterev, the USSR People’s Commissar for Health, came to the city in October he acknowledged that he had for a long time failed to understand the problem of dystrophy, and that only being in the city had convinced him that ‘a sufferer from dystrophy cannot be regarded as someone who only needs feeding. A dystrophy patient needs treatment as well as feeding.’116 Only after the evacuation began in January 1942 did the general public and republican and regional authorities learn about the scale of starvation in Leningrad.

Evacuation The mass evacuation of city dwellers also had an appreciable effect on the size and composition of the population of besieged Leningrad. The effect of this factor fluctuated at different periods during the siege, but was strongest in the summer of 1942. Despite a good legal basis (a procedure for evacuation and draft documentation was already prepared in July 1941) and a clear organizational system (establishment of evacuation commissions, evacuation points and arrangements for authorized agents), the statistics of the evacuation are confused and contradictory. It is not only present-day researchers who have great difficulty in making calculations. As early as April 1942, when a report on the evacuation of 500,000 Leningraders was being prepared for Stalin, the members of the City Evacuation Commission had difficulty in finding the information required, as is evident from their drafts. Documentation of the evacuation statistics before February 1942 is especially weak, but even thereafter the record gave, at best, only the number of people who left, without any details on sex and age. The figures of the Statistical Office on departures are very incomplete and reflect scarcely half of the actual movements, since no prompt record was kept of those who departed in the winter of 1941–42.

1403_901422_04_cha02.qxd

10/6/2004

4:59 PM

Page 55

Nadezhda Cherepenina 55

This is shown, in particular, by a verification of entries in housing registers made in accordance with a resolution of the gorispolkom of 3 May 1942. A memorandum from the City Police Department sent to Popkov on 7 June 1942 stated that a check on 45,945 dwelling houses and 1,179 hostels had discovered 241,687 former residents who had not been entered in the housing registers. Of that number, 112,757 had been evacuated, 33,029 had entered the Red Army, 81,305 had died, 2,959 had been arrested and 11,637 had gone away for other reasons.117 Unorganized departure from Leningrad was forbidden, and from 8 September 1941 special documents had to be produced even to purchase suburban train tickets.118 Checks were made at stations by special police teams. Police at the Lake Ladoga station held and returned to Leningrad 1,750 people in October, 278 in November and 891 in December.119 There was little evacuation in the autumn of 1941. Between 33,000 and 41,000 people crossed Lake Ladoga on ships of the Northwestern Inland Steam Navigation Company and the Ladoga flotilla.120 In a report on naval transport across Lake Ladoga from 11 September (before that time no precise record had been kept), the naval authorities themselves admittedly asserted that up to 29 November 1941 26,332 passengers (850 in September, 15,658 in October, 9,814 in November) had been carried from Osinovets to Novaya Ladoga, but gave no details. One barge carrying about 300 passengers sank in a heavy storm on 17 September.121 There is no information in the documents of the City Evacuation Commission on losses during the autumn navigation season or during the summer season of 1942. Between 35,000 and 43,600 people left Leningrad by air between 22 September and mid-December. According to one report, 36,700 Leningraders were evacuated in the autumn and early winter of 1941, among them many creative and scientific intellectuals and workers from the Kirov and Izhora plants. The ice route across Lake Ladoga, the celebrated ‘Road of Life’, began to operate on 22 November. It was intended from the very beginning to provide for the mass exodus of Leningraders from the starving city, as is shown by a decision of the Military Soviet of the Leningrad Front on 19 November 1941 to establish an evacuation commission headed by Popkov. Already on 26 November three troop trains arrived at the Lake Ladoga station and their passengers were shipped across to the eastern shore. On 27 November two special trains set out from the Finland station carrying 2,200 students of the Military Medical Academy, and a further train left on the following day. A thaw on 30 November and a severe storm on 1 December briefly interrupted movement along the route, but intensified preparation for evacuation continued. On 2 December an evacuation point was established at the

1403_901422_04_cha02.qxd

10/6/2004

4:59 PM

Page 56

56 The Scale of Famine in the Besieged City

Borisova Griva station, at which 1,120 pupils of trade schools, workers from the Kirov plant and members of their families assembled by 5 December. On 6 December, when the Military Soviet decided to transport up to 5,000 people a day, workers of the Vulkan, Krasnaya Zvezda and Leninskaya Iskra plants were already on the way. The first death among the evacuees, that of 18-month-old Natasha Fedorova, was recorded on the same day.122 However, the evacuation was halted on 8 December and on 12 December the Military Soviet of the Leningrad Front decided to postpone it while awaiting a special ruling. No reason has as yet been established for this decision, and no mention is even made of the 11-day evacuation of November–December 1941 in the many memoranda and reports of those years, although this delay may have sacrificed huge numbers of people. Suggestions about the danger of travel and the unfinished state of the bases on the eastern shore of Lake Ladoga are well-founded, but they are equally applicable to the January ‘exodus’ of the besieged, whose physical condition worsened appreciably over the two winter months. Moreover the January evacuation was begun at a time of intense cold that killed at least as many as starvation did. The conviction of the USSR Supreme Command that the siege would be lifted, if not in December 1941, then in January 1942, without fail, especially in the light of the successful offensive in the Moscow region, probably played the decisive role in the delay. This was a gamble on the most radical and comprehensive way of helping Leningrad: lifting the siege would automatically end all the supply problems of the population and the army. This may also explain why the ice route was used mainly in December–January to transport munitions. Four days were set aside to prepare for the mass evacuation of people from Leningrad: on 18 January the USSR Sovnarkom took the decision and designated ten authorized agents123 in built-up areas along the railway route, on 21 January the Military Soviet of the Leningrad Front laid down the order of evacuation, on 22 January the State Defence Committee decreed the evacuation of at least 500,000 people, and the evacuation began on the same day. On 26 January the first trainload of exhausted victims of the siege reached Vologda. The opening up of the route continued until 1 February 1942 and 630 people a day, on average, left the city. ‘Relatively normal’ evacuation began on 1 February, and by the end of the month 4,283 people on average were leaving every day, after which the number increased to 7,734.124 From 8 February 1942 the Emergency Services were made responsible for medical services along the route; their exhaustive report125 gives a vivid and detailed picture of the exodus of a vast mass of people from the starving city. More than

1403_901422_04_cha02.qxd

10/6/2004

4:59 PM

Page 57

Nadezhda Cherepenina 57

800,000 civilians left Leningrad in 1942, and the total number of evacuees to break out of the encirclement, including those from the Leningrad Region, wounded servicemen, collective farmers from Karelia and refugees from the Baltic republics, exceeded a million.126 The winter and spring evacuation of 1942 did not appreciably affect the structure of the city population (see Table 2.1) and the percentage of dependants and children up to the age of 12 years was scarcely altered.127 The summer evacuation, which began on 27 May 1942, was of a different kind, its main purpose being not only to save people dying of starvation, but to convert Leningrad into a military city ‘with the essential minimum of a non-military population’. It is clear from a statement by Zhdanov to the gorkom buro that this idea had originated in Moscow.128 The people who left in the summer of 1942 were mainly unfit for work. During July–September 105,000 women with children, 34,000 inmates of children’s homes and 22,000 pensioners left the city. Able-bodied workers and office staff (40,000) were 13 per cent of the evacuees. Also evacuated were 72,000 workers and office staff ‘temporarily unfit for work’.129 The plan of establishing a military city could not be fully implemented, although the number of dependants was reduced to almost a quarter by the end of the year, and the number of children up to 12 years old to 5–6 per cent. Official reports stated that there were 2,922 deaths en route from Leningrad to Tikhvin in 1942, of whom 553 died during the summer evacuation.130 The figures in the report of the Emergency Services are also inexact. According to their information, 239 people died in February–September 1942 in the medical post at the Finland station, seven in July–November in the post at the Moscow station and the following numbers in other medical posts and sanitary units: 306 at Lavrovo (25 February–10 April), 506 at Zhikharevo (21 January–10 April), 62 at Borisova Griva (27 May–31 December) and 355 at KobonaLavrovo (28 May–31 December), a total of 1,475. The report of the Emergency Services does not give figures for the sanitary units at Vagonovo, Borisova Griva and Kobona before 28 May, because those in charge had left without sending complete information.131 It follows that the report of the Emergency Services, through whose hands more than 100,000 evacuees passed, contains information only about those who died actually in the medical posts and sanitary units. The same report states, for example, ‘there was great mortality among the evacuees’; between January and April 2,200 funerals were registered at Borisova Griva.132 The extent to which information on those who died in the region is reflected in the general death statistics of Leningrad remains a mystery.

1403_901422_04_cha02.qxd

10/6/2004

4:59 PM

Page 58

58 The Scale of Famine in the Besieged City

Leningrad’s population in July 1942 The actual size of the population of besieged Leningrad was established in July–August 1942, following reregistration of the identity cards of its inhabitants, a measure carried out following a decision of the State Defence Committee of 21 February 1942 ‘On identity card reregistration for the inhabitants of regulated localities, restricted areas and the frontier zone of the USSR and the insertion of control pages in them’. This decision was taken because enemy troops had seized large quantities of unused pages and seals during offensives and were busily using them to falsify Soviet documents. A total of 12,795,928 people had their identity cards verified in districts of the USSR close to the front in 1942.133 It was planned that reregistration in Leningrad should last from 15 April to 1 July, but it was only on 3 July that the gorispolkom took the decision ordering the City Police Department to carry out the verification from 5 to 22 July, and at the same time (which is very important) the Leningrad Statistical Office was instructed to process the reregistration records. The verification began on 8 July and ended on 30 July 1942, and on 31 July a memorandum on the size of the city population signed by Popkov and Kubatkin was sent to the Leningrad obkom.134 According to that document, there were 807,288 inhabitants in Leningrad, Kolpino and Kronstadt, of which 17.95 per cent (144,927) were children up to 16 years old. Included in the total were 9,813 people who had not been given identity papers (patients, invalids, air-raid defence service fighters and persons who arrived after mobilization from other regions, and so on), as well as children in the care of the state (8,128). In the districts of Leningrad proper there were 775,364 people (640,750 adults and 134,614 children up to 16 years old), in Kronstadt 9,566 (7,653 adults and 1,913 children), and in Kolpino 4,417 (4,145 adults and 272 children). It was noted in the memorandum that there were workers and office staff from surrounding districts (26,000) receiving supplies in Leningrad, and 3,500 servicemen. The total number of people receiving supplies in Leningrad was 836,788. A memorandum was then prepared on the number of families with children; it was established that 72,922 women had one child, 14,965 had two and 3,096 had three or more.135 The final results of this reregistration were assembled by the Statistical Office in October 1942, but unfortunately the full set of final tables (shown by nationality and length of residence in Leningrad) has not survived. A breakdown by age and sex was produced for 790,024 people.136 The results of this ‘mini-census’ revealed the catastrophic devastation of the city by the summer of 1942. The population was only

1403_901422_04_cha02.qxd

10/6/2004

4:59 PM

Page 59

Nadezhda Cherepenina 59

a quarter of that in the 1939 census, the number of men was reduced to one-seventh and of women to one-third. The balance between the sexes was greatly affected: there were 291 women to 100 men, and at the most propitious age for childbearing this imbalance was even greater. In August 1942 there were only 4,247 men 20–24 years old in Leningrad. The number of children in the first year of life was 30 times less than in 1939, and the number of children 1–4 years old was less by a factor of 4.5 times. Out of the large number of children born in 1937–38 (more than 180,000) only slightly more than 32,000 remained in the city. The size of the population established from the identity card reregistration was the starting point for subsequent Leningrad statistics.

Mortality in 1941– 42 The effects of the tragic year 1942 on changes in the population of Leningrad were summed up in 1943.137 According to the official data 520,550 people died in the city and in Kolpino and Kronstadt, 513,529 of them in the 15 city districts. Of the dead 49.2 per cent were male and 50.8 per cent female. Bearing in mind that the proportion of males in the total population was considerably less, these figures show that the ‘strong’ sex died off significantly more intensively than did women. Table 2.6 summarizes the monthly pattern of deaths.

Table 2.6 Mortality in Leningrad, Kolpino and Kronstadt in 1942 (17 registry offices) Month January February March April May June July August September October November December Total

Men

Women

Total

Men, %

Women %

89,151 67,448 41,404 24,854 14,044 7,511 4,378 2,214 1,354 1,028 1,032 1,602

37,838 55,232 57,077 41,511 29,083 17,161 10,788 5,398 3,160 2,490 2,349 2,433

126,989 122,680 98,481 66,365 43,127 24,672 15,176 7,612 4,514 3,518 3,381 4,035

70.2 55.0 42.0 37.5 32.6 30.4 28.8 29.1 30.0 29.2 30.5 39.7

29.8 45.0 58.0 62.5 67.4 69.6 71.2 70.9 70.0 70.8 69.5 60.3

256,020

264,530

520,550

49.2

50.8

Source: RGAE, 1562/329/1024, 80 ob; GARF, A-374/32/112, 49 ob.

1403_901422_04_cha02.qxd

10/6/2004

4:59 PM

Page 60

60 The Scale of Famine in the Besieged City Table 2.7 Mortality by age group in 1942 (17 registry offices) Up to 1 year

1–4 years

Men Women

12,513 11,552

16,067 14,457

Total

24,065

30,524

20–24 years

25–29 years

Men Women

5–9 years

10–14 years

15–19 years

9,282 6,488

13,808 7,994

23,166 10,180

15,770

21,802

33,346

35–39 years

40–44 years

30–34 years

5,308 9,406

10,131 11,444

15,721 16,858

17,476 18,294

17,958 21,946

14,714

21,575

32,579

35,770

39,904

45–49 years

50–54 years

60–64 years

65–69 years

Men Women

20,636 20,625

23,774 20,206

20,772 19,153

15,925 19,355

11,023 16,985

Total

41,261

43,980

39,925

35,280

28,008

70–74 years

75–79 years

90–94 years

95–99 years

Total

55–59 years

80–89 years

Men Women

5,855 13,447

2,301 7,737

766 3,435

224 983

46 264

Total

19,302

10,038

4,201

1,207

310

100 years

Unknown

Totals

Men Women

4 14

13,229 13,621

256,020 264,530

Total

18

26,850

520,550

Source: RGAE, 1562/329/1,024, 108; GARF, A-374/32/112, 37.

Table 2.6 shows that absolute mortality declined nearly thirty-fold (29.4 times) over the year. However, relative to the total population of the city the decline was slower. The monthly death rate (per 1,000 of the population) fell by 7–10 times (depending on the calculation) during the year and was three times the pre-war level in December 1942.138 The mean annual death rate, from the official statistics, was 332.4 per 1,000.139 Table 2.7 shows the mortality by age group. Infants in the first year of life comprised 4.5 per cent of all deaths,140 children up to 14 years old 13.1 per cent and adolescents 15–19 years old 6.4 per cent, that is, 24 per cent of the dead Leningraders were young people. People more than 60

1403_901422_04_cha02.qxd

10/6/2004

4:59 PM

Page 61

Nadezhda Cherepenina 61 Table 2.8 Births, marriages and divorces in Leningrad in 1942 (17 registry offices) Month

Boys born

Girls born

All births

Weddings

Divorces

January February March April May June July August September October November December

2,134 1,449 825 545 508 398 354 148 64 32 34 49

2,095 1,434 815 560 525 376 326 151 46 30 29 60

4,229 2,883 1,640 1,105 1,033 774 680 299 110 62 63 109

302 254 255 200 264 283 367 279 224 205 292 313

58 54 88 55 51 60 60 45 40 47 33 61

Total

6,540

6,447

12,987

3,238

652

Source: RGAE, 1562/329/1024, 80; GARF, A-374/32/37, 49.

years old accounted for 19 per cent. Male mortality (absolute figures) predominated mainly in the groups below the age of conscription (there were considerably fewer men than women in the older age groups). The difference was most marked in the 10–19-year age groups: the number of dead boys and youths was nearly double the number of dead girls. The birth rate and other population indicators are reflected in the Table 2.8. The birth rate contracted by a factor of 67 times in 1942, reaching its lowest point in October, when only 62 babies, including two sets of twins, were born. Stillbirths in 1942 were a relatively small percentage (262 recorded, or 2 per cent of all births), largely because of the special attention paid to pregnant women, who received a higher ration and additional products. The general birth rate per 1,000 in 1942 was only 8.3, the lowest figure in the first half of the twentieth century. The reduction in the number of marriages (12 times lower in absolute terms than in the pre-war period) and divorces (17 times lower) shows how profoundly the natural population pattern was disturbed. The data submitted by the Leningrad Statistical Office to the Central Statistical Office of the USSR differed from information supplied by the Leningrad Registrar’s Department, which sent Zhdanov a certificate of 528,830 deaths in April 1944. The Central Statistical Office, which asked the Leningrad statisticians to explain the discrepancy, received a detailed statistical memorandum on 15 April 1944.141 The explanation

1403_901422_04_cha02.qxd

10/6/2004

4:59 PM

Page 62

62 The Scale of Famine in the Besieged City

given was ‘the poor state of registration in the registry offices in the first half of 1942; duplicate copies [certificates] were received without accompanying information, for several months at a time, and with confused numbering . . . many instances of duplicated registration were found’. In addition, the deaths of more than 4,000 people who died in December 1941 were recorded in January–April 1942. The explanation was taken into consideration, and the figure of 520,000 dead was accepted as the official statistic. The composite data on the causes of death compiled by the Leningrad statisticians seem a historical curiosity: dystrophy, avitaminoses and war wounds do not figure in the general table, but are lumped together under ‘other causes of death’ (the explanation for this astonishing fact has been given above). ‘Other causes’ accounted for 271,771 deaths (52.2 per cent) in 1942, heart disease for 108,939 (21 per cent), gastroenteritis for 44,290 (8.5 per cent), pneumonia and other pulmonary diseases for 25,790 (5 per cent) and tuberculosis for 10,257 (2 per cent). There were 587 recorded murders and 318 suicides. The natural population balance remained negative in 1943, mainly because of a very low birth rate (21,493 deaths, 7,613 births). The mean annual population of Leningrad, Kolpino and Kronstadt in 1943 was 579,400, and the death rate remained high at 36.1 per 1,000, 2.2 times the 1939 figure.142 On 1 January 1944 there were 557,760 people living in Leningrad, 77.5 per cent of whom were female and 22.5 per cent male. The population began to rise from 1944, when the natural increment was more than 10,000, while the mechanical increment (in connection with the start of return from evacuation) was 371,900, and the death rate returned to the pre-war level of 17.0 per 1,000.143 On 1 July 1945 Leningrad had more than a million inhabitants, the overwhelming majority of whom were female.

Estimates of total deaths The catastrophe that had befallen the population of Leningrad was fully recognized by the wartime demographers and the medical profession, who understood the need to study all aspects of the demography of the besieged city. The compilation of a medical demographic review of the first year of the war was raised as early as July 1942 at a meeting of the Health Statistics Technology Office, and it was planned to involve several people in the work, including Professors Ben and Novoselskii. Special attention was to be paid to the causes of death. This assignment had been partly completed by October 1942, and Ben produced a review

1403_901422_04_cha02.qxd

10/6/2004

4:59 PM

Page 63

Nadezhda Cherepenina 63

based on provisional data (the statisticians had not completed the processing of the data), but the manuscript has not so far been found. When this review was discussed on 7 October 1942, it was proposed to set up a special commission headed by a responsible staff member of the Health Department to coordinate and unify the work of the various institutions and departments that had studied the effect of the siege on the life of the city. However, there was opposition from some leading members of the medical profession (especially the director of the Paediatric Institute, Ya. A. Mendelev). A special commission on the history of medicine during the war years was set up in the First Leningrad Medical Institute, but it did not work actively.144 Committees to study the diseases of the siege (including nutritional dystrophy), set up under the aegis of the Health Department in 1943, paid scarcely any attention to the demographic aspects and medical statistics. Early in 1945 the Leningrad City Commission set up to establish and examine the crimes of the German fascist invaders and their accomplices145 busied itself with calculating the victims of the siege from the information of the city and district registry offices. Nothing has been found concerning the calculation methodology and the principles applied to the selection of this information in the archives of the commissions (national and Leningrad), the City Registrar’s Office and the Identity Card Office of the Main NKVD Administration of Police. Very many questions are raised, in particular, by the data in the centralized record of the City Registrar’s Office (191,427 people), for which there are no supporting lists of the dead.146 A centralized record could have been made of deaths reported after some delay, prisoners who died both in Leningrad and elsewhere, evacuated Leningraders who died en route and so on. All of this is conjecture, as no documentary interpretation of the figure given has been found. If we disregard the quite erroneous assertion of D. V. Pavlov that the commission was scrupulous in its work in May 1943,147 the lack of explanation has helped to create and spread doubts about the accuracy of the calculations and, in the final analysis, has discredited the data of the commission.148 However, the present state of the sources does not allow us to reject the calculations of those years. If we consider that the population statistics after the reregistration of identity cards are fairly reliable, we can attempt to establish the change in the population between October 1941 and 1 August 1942. (It is difficult to begin the record with September, since there was very considerable and poorly recorded migration at that time.) According to the information on identity cards issued, there were 2,371,300 people under siege (the number was increased to 2,374,300

1403_901422_04_cha02.qxd

10/6/2004

4:59 PM

Page 64

64 The Scale of Famine in the Besieged City

in November through the registration of newcomers). Let us repeat that the identity card statistics are not precise, but can only be an overstatement of the actual population through defects in recording, deliberate deception and so on. The number of ‘cardless’ people is a conscious omission, because they were few at the time and were offset by the number of residents of Leningrad Region who had obtained identity cards in the city. On 1 August there were 807,300 people living in Leningrad; thus the population had shrunk by 1,564,000 in ten months. During that time 573,235 deaths had been registered, approximately 100,000 men had gone into the army and, according to the official figures, some 813,000 people had been evacuated, leaving aside inhabitants of the region, wounded Red Army men and collective farmers from the Karelian isthmus.149 It may therefore be assumed, with some reservations on the incompleteness of the statistical material, that the unrecorded mortality did not exceed 80,000, and that approximately 653,000 Leningraders perished in the first eleven months of the siege. The death toll in the whole period of the siege, from September 1941 to January 1944, was around 700,000. The last attempt to quantify the victims of the siege by the direct calculation of deaths was undertaken early in the 1990s.150 The presidiums of the City and Regional Soviets of People’s Deputies adopted a resolution on 7 May 1991 ‘On the perpetuation of the memory of those who died during the Great Patriotic War and the heroic defence of Leningrad and the establishment of a Leningrad Memorial Book’, but work was delayed for lack of finance.151 Not until 9 November 1992 did the Mayor of Leningrad order the setting of an editorial commission and the creation of a working group of the Social Security Committee. Collection of the information required was based on proposals from the Moscow district office of the International Association of Victims of the Siege, drafted by the working party of I. N. Lyubich in 1992, to record all the inhabitants of the besieged city (not only the dead). The procedure approved by the Social Security Committee in October 1993 proposed the use of 13 sources, including some of highly questionable reliability, such as publications in the media, information from published memoirs and the recollections of citizens. The main sources for the Memorial Book (listed in order of importance in the approved procedure) were to be information from the population, registry office archives and information from burial grounds. It was originally assumed that all information sources would be indicated in the compilation of card indexes, but this requirement was not observed, and that greatly detracted from the historical value of the material, which was why the draft card

1403_901422_04_cha02.qxd

10/6/2004

4:59 PM

Page 65

Nadezhda Cherepenina 65

indexes, which were in a fairly chaotic state, were not sent to be deposited in the state archives. An electronic version of the Memorial Book has now been sent to the memorial at the Piskarëv Cemetery, and a printed version of the book is being published, but the statistics have not been published. Nevertheless, it is premature to say that the question of the number of siege victims is finally settled. Losses among the population of Leningrad Region within the ring of starvation remain uninvestigated, and no figures have yet been published for servicemen who died in Leningrad hospitals and were buried there.152 Only a comprehensive examination of these matters will fully illuminate the tragedy of this city. Notes 1. For information on calculations of people lost see Lyudskie poteri SSSR (1995); Rybakovskii (1999) (also published in Sotsiologicheskie issledovaniya (2000) issues 6 and 8). 2. For a detailed account of attempts to calculate civilian losses in Leningrad, see Dzeniskevich (1998), 45–68. The figure of two million is given in Zima (2000), 31. 3. Critical assessment of the figures given in official documents is difficult because, strange as it may seem, there are no source studies in Russian historiography on the nature of documents from the war years. 4. Medical statistics, including mortality data, have been studied by, inter alia, E. E. Ben, L. S. Kaminskii, E. P. Natanson-Sokolova, S. A. Novosel
skii, Z. G. Frenkel and Z. Z. Shnitnikova. (See also the bibliography by staff of the Health Statistics Technology Office: TsGA SPb, 9713/1/201.) Unfortunately, by far the greater part of the research during and shortly after the war was not published for reasons of secrecy, and little of it remains in the archives. Much statistical material was put together in the postgraduate thesis of Sveshnikov (1964), published in part in Gladkikh (1985). 5. The ‘evacuation’ of food from Leningrad in summer 1944 is largely explained by the activities of army quartermasters’ departments, especially those of the Northern Front, who removed food earmarked for military units from state reserve stores in Leningrad. See Mironov (2000), 13–19, on differences between the city leadership and the quartermasters’ departments. 6. It is not therefore surprising that the figures on evacuated victims of the siege produced by different departments do not coincide. See Koval
chuk (2000), 22–4. 7. For detail on the disposition of units of the armed forces, NKVD staff and prisoners see Isupov (1994). 8. See, for example, what has been written by the leading Russian statistician Novoselskii (1920), 9. Concerning the unreliability of a calculation based on ration cards during the siege see Koval
chuk (1998), 363. 9. A detailed account of how the ration card system worked is beyond the scope of this chapter. Briefly, ration cards were introduced in Leningrad on

1403_901422_04_cha02.qxd

10/6/2004

4:59 PM

Page 66

66 The Scale of Famine in the Besieged City

10. 11.

12. 13. 14. 15. 16. 17. 18. 19. 20. 21.

22. 23. 24. 25. 26. 27. 28. 29. 30. 31.

32.

33. 34. 35. 36. 37.

18 July 1941, and on 26 July the gorispolkom approved four standard documents on the issuing procedure and 12 return forms to ensure strict record keeping (TsGA SPb, 7384/18/1442, 95–109). Between then and July 1942, when the issuing procedure was changed, the Committee adopted 11 resolutions on making verification stricter (not including the resolutions announcing reregistration). TsGAIPD SPb, 24/2v/6187, 7; 24/2v/5932, 12–13. It was a different matter when, by agreement with traders, the ration book counterfoils were used, but the total number of cards was not affected thereby. TsGA SPb, 9156/4/311, 13. TsGA SPb, 9156/6/5, 197. For an example see Boldyrev (1999), 43–4. TsGA SPb, 7384/18/1436, 80–1. For detail see Dzeniskevich (1998), 57. Leningrad v osade (1995), 339. This is evident from surviving documents of the head office of the Department. Leningrad v osade (1995), 60–161. TsGA SPb, 4094/1/7, 19; 4965/3/209, 38. TsGA SPb, 4965/3/ 404, 15; 4965/3/ 492, 2; 4965/3/845, 49, 91, 121, 158; 4965/4/668, 6. Unfortunately, the reports of the Leningrad Statistical Office do not always give figures for deaths of civilians registered during the war. The 1951 report, for example, merely states ‘there were many’ (4965/3/521, 6). Leningrad v osade (1995), 424. GARF, R-f. 9401/1a/34, 35. TsGA SPb, 4904/1/6, 90, 116, 207. RGAE, 1562/329/1471, 22, 23; TsGA SPb, 4965/3/105, 5–5ob. Leningrad v osade (1995), 593. TsGA SPb, 9156/4/76, 61. TsGA SPb, 9713/1/111, 8–13. Unfortunately, these studies have not been found in the archives. TsGA SPb, 9713/1/98, 402. TsGA SPb, 9713/1/98, 410. Leningrad v osade (1995), 350, 590. Few indigenous Leningraders had succeeded in arranging their departure by the end of August, because the evacuation was conducted in a great hurry. See, for example, reports on the work of the Leningrad Registrar’s Department of the NKVD and the City Police Department for the war years. GARF, R-9415/3/1396, 1405, 1406, 1410. TsGA SPb, 4904/1/5, 26–7; Shnitnikova (1999), 83. TsGA SPb, 4904/1/5, 26. However, it follows from published memoirs that the inevitability of famine in Leningrad was understood by some. See Likhachev (1999), 446. See Leningrad v osade (1995), 261–2 for details of the amounts. Archives of the Department of the Federal Security Service of the Russian Federation for St Petersburg and Leningrad Region (hereinafter AUFSB), 12/2/19, 1–2. Some special communications of the UNKVD have been published by Lomagin (1996) and V tiskakh goloda (2000).

1403_901422_04_cha02.qxd

10/6/2004

4:59 PM

Page 67

Nadezhda Cherepenina 67 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52.

53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65.

66. 67. 68. 69. 70.

AUFSB, 12/2/19, 9–15. Chernorutskii (1947), 193. TsGA SPb, 9156/6/5, 154. AUFSB, 12/2/19, 66. Chernorutskii (1947), 195. TsGA SPb, 9156/4/333, 28, 58. AUFSB, 12/2/19, 67. Pamyat’ (1987), 187. TsGA SPb, 7384/18/1429, 247–65, 287–8. AUFSB, 12/2/19, 66. TsGA SPb, 4904/1/7, 19. The original figure was 11,419 (ibid., 4904/1/2, 178). TsGA SPb, 7384/3/45, 277. Materialy po statistike Leningrada (1925), 217–23. At that time ‘death from malnutrition’ was denoted by the number 192 in the ICD classification. Novoselskii (1920), 37. It is a curious fact that Leningrad doctors studying nutritional dystrophy in Leningrad during the siege turned to the works of German authors on its prevalence during the First World War and in post-war Germany. See the bibliography to Alimentarnaya distrofiya (1947). Leningrad v osade (1995), 276. TsGA SPb, 9156/4/317, 4–5. See Alimentarnaya distrofiya (1947), 37. RGAE, 1562/329/805, 143. RGAE, 1562/329/805, 161, 165. See Leningrad v osade (1995), 314–15; RGAE, 1562/329/1021, 119ob. AUFSB, 12/2/19, 76. GARF, A-482/47/52, 62–3. TsGA SPb, 9156/4/311, 13. TsGA SPb, 4. 4904/ 1/7, 119. These Registry Office figures were understated by 4,412 people (RGAE, 1562/329/1024, 22). TsGA SPb, 7384/3/45, 284. TsGA SPb, 2076/4/70, 5. Unfortunately, Meteorological Office information on the weather in Leningrad during the siege has still not been published. Reliance must therefore be placed on other, less reliable sources and especially diaries kept at the time. The diary of N. P. Gorshkov, published in 1993, is of particular interest in that respect. Likhachev (1999), 485. See Iyun
1941 – Mai 1945 (1989), 118; Gorshkov (1993), 31–2. TsGA SPb, 9713/1/136, 34. See Alimentarnaya distrofiya (1947), 43. AUFSB, 12/2/19, 115. Special issues of food were discontinued in December, with the exception of New Year gifts to individual categories of people. Thus, in November, holders of adult ration cards received tea (125 g), powdered egg (150 g for workers and office staff), chocolate (100–200 g), salted tomatoes (200 g), and holders of children’s cards received ten eggs, 200 g of soured cream, 100 g each of dried fruit, salted tomatoes and juices. In December adults received only salt (400 g), vodka, wine (0.5 l) and beer 1.5–2 l), and children 200 g of dried fruit and 400 g of juices. TsGA SPb, 2076/4/54, 46.

1403_901422_04_cha02.qxd

10/6/2004

4:59 PM

Page 68

68 The Scale of Famine in the Besieged City 71. Freidenberg (1991), 18. 72. See Voenno-istoricheskii zhurnal (1999), 18. For an account of the importance attached to this operation by Army Headquarters and the Commander-inChief see Lyubanskaya nastupatel
naya (1994), 8, 11, 13. 73. AUFSB, 12/2/19, 137, 166. 74. TsGA SPb, 2076/4/70, 6ob. 75. Gorshkov (1993), 37–50. 76. TsGA SPb, 2076/4/70, 7; Leningrad v osade (1995), 370–1; O podvige Leningrada (1989), 149. 77. RGASPI, 17/121/177, 4. The calculations were based on data of the Leningrad Registrar’s Department: the total population in January was 2,383,853, and 96,571 had died. If we take the size of the population on the basis of the food ration cards issued – 2,281,800 – and the number of deaths from the final registry office figures – 101,825 – then 4.5 per cent of the population of Leningrad died in January 1942. 78. AUFSB, 12/2/19, 157, 215. 79. TsGA SPb, 7179/53/59, 24. 80. Gorshkov (1993), 53, 56. 81. AUFSB, 12/2/19, 220. 82. Kargin (2000), 62. 83. Alimentarnaya distrofiya (1947), 196–7. 84. The Leningrad doctors finally distinguished four periods in the development of nutritional dystrophy: November 1941–February 1942, March– August 1942, September 1942–April 1943, May–June 1943 (see Alimentarnaya distrofiya (1947), 194–202). A more detailed periodization, each stage of which lasted two months, was proposed by M. V. Chernorutskii in an earlier work (see Chernorutskii (1943), 7–9). 85. Alimentarnaya distrofiya (1947), 195. 86. AUFSB, 12/2/19, 251, 267, 282. 87. AUFSB, 12/2/19, 256, 257. 88. The Health Department kept a special statistical record book of deaths in its own treatment facilities and in the clinics of research institutes and organizations of the USSR and RSFSR Health Commissariats. The book recorded admissions (by diagnosis) to each facility, discharges and deaths, including deaths on the day of admission. This information was processed and mortality percentage tables were compiled by types of hospital and of illness. See TsGA SPb, 9156/4/1516. 89. TsGA SPb, 3132/4/181. 90. O. D. Isserson’s work was published. See Alimentarnaya distrofiya i avitaminozy (1944), 96–100. This is one of the few works on mortality in besieged Leningrad. See also Ben (1958), 65–87. 91. TsGA SPb, 9156/6/18. 92. Sveshnikov (1963), vol. 2, 62. 93. TsGA SPb, 3132/4/181, 45. 94. All that we can mention is Gladkikh (1985), in which he gives data obtained by A. V. Shveshnikov. Unfortunately, although Shveshnikov gives extensive statistical material in his postgraduate thesis, he neither explains the calculation procedure nor analyses his sources. 95. Ya. N. Darshkevich began his report with the words ‘The statistics on deaths

1403_901422_04_cha02.qxd

10/6/2004

4:59 PM

Page 69

Nadezhda Cherepenina 69

96. 97. 98. 99.

100. 101. 102. 103.

104. 105. 106. 107. 108. 109. 110. 111. 112. 113. 114. 115.

116. 117. 118. 119. 120. 121. 122. 123. 124. 125. 126.

127. 128.

from dystrophy are based on absolute figures and are therefore not actually confidential’. TsGA SPb, 3132/4/181, 26. A UFSB, 12/2/19, 164. TsGA SPb, 9156/4/108, 80. TsGA SPb, 9156/6/17, 29, 30, 33. See, for example, a report of the Leningrad gorkom drafted by Kuznetsov in summer 1943 (RGASPI, 17/122/29) and the drafts of Zhdanov (RGASPI, 77/3/126, 101). TsGA SPb, 9156/6/18, 12. Alimentarnaya distrofiya (1947), 196. TsGA SPb, 7384/36/55, 21, 22, 28, 30ff. The decision of the gorispolkom of 30 December 1941 stipulated bread 350 g (including 50 per cent wheat), 50 g meat and meat products, 31 g fats, 15 eggs (a month), 50 g sugar, 18 g tea (a month), 50 g cereals and pasta, 16 g flour, 50 ml grape wine, 20 g raw coffee, 100 g vegetables. TsGA SPb, 7384/36/56, 113. TsGA SPb, 7384/36/71, 35. TsGA SPb, 7384/36/68, 119–32. Leningrad v osade (1995), 297. TsGA SPb, 9156/4/93, 18ob, 19ob, 23ob, 26. RGASPI, 77/3/165, 168. RGASPI, 77/3/165, 86. Istoricheskii arkhiv (1998), issue 4. Posetiteli kremlevskogo kabineta I. V. Stalina. Mikoyan (1999), 432. GARF, R-9401/1a/69, 151. RGASPI, 17/121/130, 176, 177, 178, 179ff. These files have still not been deposited in the archives and are available only on microfilm. RGAE, 1562/329/1449, 18. Unfortunately, the documents of the first department of the USSR Health Commisariat for the war years remain classified and those of the RSFSR Health Commissariat have been saved only from 1943. TsGA SPb, 9156/4/89, 13. TsGA SPb, 7384/4/67, 113. TsGA SPb, 2275/10/5, 111. TsGA SPb, 2275/7/873. Leningrad v osade (1995), 301; RGASPI, 17/121/130, 42. TsGA SPb, 2141/39/5, 139. TsGA SPb, 2275/7/783, 163–86. GARF, R-5446/59/7, 10–19. RGASPI, 17/121/176, 79; TsGA SPb, 2076/4/95, 2–4. GARF, A-482/52/47. Consolidated statistics on evacuees have been saved in the regular reports of the Urban Evacuation Commision and are well-represented in the archives of the Secretariat of the Central Committee, the gorispolkom, the Leningrad Planning Commission etc. For information on the numbers of evacuated Leningraders see also Koval
chuk (1998), 358–9. With, of course, every proviso concerning the imprecision of the ration card system and the scope for abuse, especially with children’s ration cards. See Leningrad v osade (1995), 95.

1403_901422_04_cha02.qxd

10/6/2004

4:59 PM

Page 70

70 The Scale of Famine in the Besieged City 129. 130. 131. 132. 133. 134. 135. 136. 137. 138.

139. 140.

141. 142. 143. 144. 145. 146. 147. 148. 149.

150. 151. 152.

RGASPI, 17/121/178, 73. RGASPI, 17/121/178, 4. GARF, A-482/47/52, 186. GARF, A-482/47/52, 164. GARF, R-9415/3/1409, 9. TsGA SPb, 7384/4/76, 7–8; TsGAIPD SPb, 24/2v/5867, 45–6. TsGA SPb, 7384/4/71, 137. See Leningrad v osade (1995), 313; TsGA SPb, 4965/3/298, 1, 2. For the full report data see GARF, A-374/32/112; RGAE, 1562/329/1024. The Statistical Office did not calculate monthly coefficients for 1942 for lack of information on the size of the population. The Leningrad Registrar’s Department did, however, do so on the basis of overstated population totals and understated monthly mortality figures (see TsGA SPb, 4904/1/5, 21). If we take information on ration cards issued for the total population and the final data of the Statistical Office for deaths, the monthly death rates per thousand of the population are: January, 674.5 (Statistical Office figure 512.5); February, 787 (558.1); March, 680 (535.3); April, 535.5 (475.4); May, 403.3 (333); November, 63.2 (59.5). TsGA SPb, 4965/9/738, 12. Specialists regarded the official infant mortality figures as highly dubious (see the minutes of a meeting of the Health Statistics Technology Office of 28 June 1944: TsGA SPb, 9713/1/98, 174–5). It was noted in infant mortality tables compiled by S. A. Novosel
skii that mortality in the first year of life was 70 per cent higher in 1941 than in 1938–39, and 400 per cent higher in 1942. TsGA SPb, 4904/1/7, 33–4, RGAE, 1562/329/1471, 22. RGAE, 1562/329/1014, 3; 1562/329/1015, 5. TsGA SPb, 9156/6/35, 131; 4965/8/738, 12. TsGA SPb, 9713/1/98, 385, 393, 406; 9156/4/116, 63–5. Leningrad v osade (1995), 573–4, 606. These lists were sent from district registry offices to the Leningrad commission, and on to the state archives (now TsGA SPb). Pavlov (1989), 184. Koval
chuk (1998), 358–9. A total of 71,319 deaths were registered in October–December 1941 (to which should be added 4,412 registered in January–April 1942), that is, a total of 75,731 deaths. In January–July 497,490 people died. Total deaths in October 1941–July 1942 were 573,325. The army conscripted 21,352 people in October, 21,238 in November, roughly 27,200 in May–July, and it may be assumed that 5–10,000 a month were recruited in December–April. In the autumn and winter of 1941–42 (to 21 January) roughly 33,000 Leningraders left the city, a further 453,000 between 22 January and 15 April 1942, and about 321,000 during May–June 1942. For detail on calculation methods see Rybakovskii (1999), 28–34. TsGA SPb, 6041/1/1–4. Grif sekretnosti sniat (1994) gives only general information on the irrevocable losses of the Leningrad front and the Baltic Fleet.

1403_901422_05_cha03.qxd

10/6/2004

5:00 PM

Page 71

3 Evacuation from Leningrad to Kostroma in 1941–42 Mikhail Frolov

Two periods may be distinguished in the evacuation of the population from Leningrad during the war: the first before the siege began, between 29 June and 27 August 1941; the second during the siege, and clearly divisible into four stages, lasting until 1 November 1942. Thereafter departure was permitted only exceptionally and on the instructions of the City Evacuation Commission. This chapter examines evacuation to Kostroma and the role of Vologda and Yaroslavl
regions in the evacuation. (Prior to August 1944 present-day Kostroma region was part of Yaroslavl
region.1) These local authorities were the first to receive and accommodate evacuees from Leningrad and send those who followed deep into the country. Special evacuee trains began to arrive in the Vologda and Yaroslavl
regions in July 1941. On 21 July 30,978 people from Leningrad and other districts near the front line arrived in Vologda region. In addition, 220,000 evacuees came by rail through the Vologda rail junction and 36,000 by water through the Sheksnya and Sukhon Inland Water Steam Navigation companies.2 By a decision of the Vologda Regional Committee of the Communist Party (obkom) of 16 July 1941 two reception points were set up to receive and care for evacuees arriving in the cities of Vologda and Cherepovets, and provision of food and medical care was organized at the landing stages in Vytegra, Belozersk and Vologda and at the Babaevo railway station.3 A fairly detailed picture of the reception of evacuees is provided by a report on the operation of the Cherepovets reception point run by the executive committee of the Vologda City Soviet between June 1941 and early January 1942, which took in two stages of the evacuation during the siege. The evacuation point looked after people arriving by water, rail, motor vehicles and horse carts. On arrival they received medical care, and 71

1403_901422_05_cha03.qxd

10/6/2004

5:00 PM

Page 72

72 Evacuation from Leningrad to Kostroma in 1941–42

those in need of hospitalization were placed in an isolation ward and in the dormitory of the reception point. This had only 100 beds, and the medical personnel had limited capabilities. Before the inland water navigation season ended in November 1941 5,023 people had received medical care. Eighty-seven of the sick (57 of whom had dysentery) were taken from the barges and transferred to the Cherepovets infectious diseases hospital. Some patients whose condition was not highly infectious were admitted to the isolation ward at the reception point.4 Between July and December 1941 650,880 evacuees passed through Cherepovets, 391,659 by rail, 246,789 by water, and 12,422 by motor vehicle and horse-drawn transport.5 Many cases of illness in children and adults were not recorded by the doctors and were missed. That was not always the fault of the doctors. The parents of sick children and sick adults often did not seek medical care and frequently concealed indisposition and illness because they did not want to be left in Cherepovets and interrupt their journey to the rear. In the event there were, of course, more sick people than were admitted to hospital. Between July and December 128 dead (27 adults and 101 children) were taken from the barges.6 A first-aid station was continuously manned at Cherepovets station in conjunction with the railway polyclinic. By the end of December 1941 the first-aid station had treated 2,450 evacuees and the station polyclinic had accepted 2,167.7 Despite shortages of medical equipment, medicines and food for patients, the medical staff of the isolation ward, coping with all kinds of difficulties, satisfied the minimum needs of the evacuees until the middle of December. But the number of patients increased sharply at the end of 1941, which raised the question of the need for new premises, more staff, better food for patients, medicines and medical equipment, the acquisition of transport and so on.8 Documents in the archives show the amount of disorganization in the progress of the special evacuee trains. Some coaches full of people were kept standing for several days at the Cherepovets and Vologda stations. It was cold in the wagons and there were difficulties with feeding and the supply of hot water. People got agitated. The evacuee trains moved slowly, not complying with the instruction to cover 600 km a day.9 The Vologda obkom twice specified what must be done to eliminate shortcomings, but the instructions were not carried out. The head of the political section of the Vologda railway department was relieved of his post, and the head of the Northern Railway was recommended to fire the stationmaster of the Vologda No. 1 station.10

1403_901422_05_cha03.qxd

10/6/2004

5:00 PM

Page 73

Mikhail Frolov 73

Evacuated Leningraders also began to arrive in Yaroslavl
region in July 1941. The local authorities at all levels made great efforts to accept and house the Leningraders, despite material and food supply difficulties. The authorities decided, as a temporary measure, to reduce the per capita living space allocation to 4 square metres, which made it possible to billet and house thousands of Leningrad families. In Kostroma evacuees were given shelter in school No. 29, in the finance and economics technical school and in the buildings of the reception point at Berezovaya roshcha. Evacuees were received by workers in hostels of the Yaroslavl Building Trust, the Chalk Works and other plants. From the start of the evacuation, mainly before August, 67,796 children from children’s homes and 12,030 accompanied by parents, a total of 79,826 children, arrived in Yaroslavl
region.11 Children’s homes and boarding schools were housed in rest homes, sanatoria and schools, and simply in rented premises belonging to collective farms and collective farmers. There were many difficulties over the provision of services and medical care for the children, and especially over feeding, as is shown by communications from the districts to the Yaroslavl
obkom. A memorandum on ‘The placing and feeding of evacuees in Parfenev district’ noted that evacuated children were housed in schools and peasant houses. Many children had no beds and slept on the floor. There were five doctors and eight nurses to 1,305 children. They received scarcely any milk, meat, sugar, butter and eggs.12 Other districts also reported serious difficulties over feeding and medical care. Measures were taken at the region level to rectify the situation, and the tension was additionally eased by the departure of 30,050 children from Yaroslavl
region in August–September 1941. Many were taken back to Leningrad by their parents, while others went to other regions because their parents or their establishments were transferred. On 15 September there were 47,750 Leningrad children remaining in the region. In October 1941 German forces began to advance on Moscow. Yaroslavl
region was at risk of occupation. On 17 October 1941 the Evacuation Soviet of the USSR Sovnarkom decided to move Leningrad children from Yaroslavl
region to other parts of the country. In all, 34,333 children were re-evacuated: 9,582 to Perm (Molotov) region, 10,336 to Chelyabinsk, 10,961 to Omsk region and 2,954 to the Tatar ASSR.13 Also at this time 745,792 people crossed Yaroslavl
region by railway (the Yaroslavl
–Moskovskii and Vspole stations) and by water along the Volga.14 Despite the difficulties, which worsened in mid-November–December 1941, the evacuation of Leningraders to the Vologda and Yaroslavl


1403_901422_05_cha03.qxd

10/6/2004

5:00 PM

Page 74

74 Evacuation from Leningrad to Kostroma in 1941–42

regions and transit through them to the east and north proceeded without serious losses of evacuees and without significant shortcomings. The authorities at regional and district level, and organizations of workers and collective farmers, ensured the minimum conditions essential for medical care and placement. According to available archival data, unfortunately incomplete, no more than 200 bodies were taken from barges and evacuee trains before Vologda station, but several dozen people died during the first days and weeks at the permanent reception points and in hospitals.15 In 1941 35 Leningraders died in Yaroslavl
, six of whom were children less than seven years old, and 257 people, of whom 187 were children less than seven years old, died in districts of the region.16 Thus concluded the first and second stages of the evacuation to Vologda and Yaroslavl
regions and beyond. The experience gained by the authorities at the regional and local levels would be used by them in the third stage. At the same time, the absence of mass outbreaks of illness and, still more, of many deaths among the evacuees would not be of help when the leadership at regional level had to assess correctly the potential difficulties and complexities in the subsequent evacuation of Leningraders who had lived through the first months of the siege. The third stage of evacuation, along the ice road, the Road of Life, which had begun to operate on 22 November 1941, took place from 22 January to the end of April 1942. This would be the most tragic page in the chronicle of evacuation during the siege. On 21 January 1942 a detailed programme for evacuation of the population of Leningrad by rail from the Finland station in Leningrad to Vaganova, and thence by motor vehicle to Zhikharevo station, was announced in a decree of the Military Soviet of the Leningrad Front. The decree specified adequate standards for the feeding of the evacuees, allocated buses for their transportation and ordered the establishment of feeding points and medical posts along the route. Provision was made for all the main requirements for satisfactory evacuation, but many of those being evacuated were in such a serious condition that it was already impossible to save them. The severely emaciated people who left Zhikharevo continued along the Northern Railway. Many were doomed. It was no accident that doctors called dystrophy a time bomb. The first special evacuee train arrived in Vologda on 26 January 1942. By 25 April 1942 215 special trains carrying 486,287 people had passed through Vologda. In addition, 4,000 people had followed the routes Podborove–Chagodosh and Kabozh–Khoinaya and more than 10,000 had settled in districts of Vologda region between its western borders and Vologda itself. During the winter more than 500,000 people passed

1403_901422_05_cha03.qxd

10/6/2004

5:00 PM

Page 75

Mikhail Frolov 75

through the region.17 Following a decree of the USSR Sovnarkom of 18 January 1942, 20,733 Leningraders were settled in the region by 25 April. The number remaining in the region was greater, but some (up to 3,000), when they had recovered their health, continued to their originally designated destinations.18 The people of Vologda had very little time to organize the reception of so many evacuees. On 23 January, only two days after the arrival of the first special train, the Vologda obkom and the regional executive committee (obispolkom) adopted a decree on the reception and accommodation of 20,000 Leningraders. Party bodies and the local authorities were obliged to start the organizing of services without delay for people due to arrive from Leningrad. Later the representative of the Evacuation Board for Vologda region described the measures taken in a memorandum on implementation of the decree of the USSR Sovnarkom ‘On evacuation of the population from the city of Leningrad’. According to the memorandum, four special public catering and medical care centres had been promptly organized at the existing reception centres at the Babaevo, Cherepovets, Vologa 1 and Vologda 2 stations, and had provided first aid and hot food. Two of them, Babaevo and Vologda, had provided rations for the journey. The managers of the reception centres and the public catering and medical care centres had been allocated experienced personnel. Repairs were carried out when necessary to all accommodation allocated for Leningraders, and they were provided with beds and bedding and other essential items, in the light of everything likely to be encountered in the reception of a contingent of weakened people.19 This picture was, to put it mildly, far from reality. True, the representative acknowledges that the arrival of the first special train demonstrated the urgent need to organize special evacuation hospitals and improve the work of the existing first-aid stations in Vologda and at intermediate points. Eyewitnesses of the arrival of the first train recalled that ‘Not only people, but dozens of bodies were taken off the train . . . It had not been realized that things were so bad in Leningrad’.20 The authories in Vologda region were neither materially nor morally ready to receive people, some of whom were on the point of death. The medical facilities were neither intended nor able to take in many hundreds of people for treatment. They lacked premises, equipment, medicines and medical staff. R. V. Turkestanskaya, who had been appointed head of the Hospitals Management Board of the Vologda Health Department, wrote in a report ‘On the hospitalization of evacuees from Leningrad’ on 5 March 1942:

1403_901422_05_cha03.qxd

10/6/2004

5:00 PM

Page 76

76 Evacuation from Leningrad to Kostroma in 1941–42

Around the time that the Board was organizing evacuation hospitals the Health Department had some hostels (more accurately something resembling hospitals) that were reminiscent of a railway station, i.e. several families lived in each room . . . Food was given in bed, patients were not washed in the morning, and there were few ward orderlies. There were no duty doctors, and at night there was only a nurse to look after the patients . . . There were no kitchen and toilet blocks. Food, brought in for the patients from the Catering Trust, got cold in transit, and there was nowhere to heat it. It was usually served irregularly; two meals a day were given, a third could not be managed. There was a great deal of dirt and infestation by lice, and because there was no toilet block there were no washing facilities and nowhere to wash. One change of bed-linen was not enough, because most patients were severe dystrophy cases, and four-fifths were suffering from gastrointestinal complaints (colitis, enterocolitis). There were no disinfection chambers. There was no regular supply of medicines and medical instruments, and no operating theatre, although many patients had frost-bitten limbs and gangrene. The procedure for taking the sick to hospital was to put them on a bus and take them round to the hospitals (making them get off at each hospital) until one took pity on them and accepted them. The food allocations for patients were sugar 20 g, butter 40 g, meat and meat products 125 g, milk 200 ml, cereals 90 g, confectionery 10 g, bread 400 g.21 The plenipotentiaries of the Party bodies dealing with the reception of evacuees reported on the unpreparedness of the reception centres. There are no documents in the archives to indicate how many bodies were taken off the first special trains arriving in Vologda in January, how many bodies had already been removed en route, and how many patients admitted to hospitals and other medical facilities during January died. There is, however, surviving testimony that gives a general indication of this tragic situation. In a memorandum dated 22 February 1942 to P. T. Komarov, chairman of the Vologda City Defence Committee, for example, Police Major Maksimov, deputy head of the Vologda NKVD troops, noted that two piles of corpses delivered from the station had been found in Vologda on 27 January.22 It can be assumed that dozens, possibly hundreds, of bodies had been taken off the special trains. In January, moreover, 61 evacuees from Leningrad died in two evacuation hospitals (38.1 per cent of admissions).23

1403_901422_05_cha03.qxd

10/6/2004

5:00 PM

Page 77

Mikhail Frolov 77

The flow of evacuees into Yaroslavl
region increased sharply in the winter and spring of 1942. Between February and April 1942 alone 167 trains arrived carrying more than 300,000 Leningraders.24 On 20 January 1942 the Yaroslavl
obkom set up a commission to handle the reception and accommodation of evacuees and the provision of services for them. It was decided to settle the evacuees in Yaroslavl, Kostroma, Rybinsk, Tutaev, Rostov and rural settlements along the railway line. Each point of arrival was ordered to prepare accommodation for the evacuees by 26 January: for 1,200 people at Rostov, 2,000 at Tutaev, 2,000 at Kostroma (and a further 2,000 by 1 February), 5,000 at Rybinsk, 2,000 at Danilov, 15,000 at Lyubim and so on. The amounts of accommodation to be prepared for people from Leningrad were also given for some districts of the region.25 Party and governmental bodies reported on their readiness to receive the evacuees. The hospital network of Yaroslavl
Health Department had room for 1,739 patients on 1 December 1941, and was planning an increase of 85 places in 1942 (in a treatment hospital). On 25 January 1942 an order was received from Mikoyan, deputy chairman of the USSR Sovnarkom, for the release of essential supplies from bases in Yaroslavl
region to feed evacuees from Leningrad, without having to wait for authorization from the centre. Special trains carrying evacuees began to arrive in Yaroslavl
region on 27 January 1942. The people of Yaroslavl
received them warmly and strove to assist them with material necessities and food, and to establish conditions for their treatment and recuperation. People arriving were examined by a doctor of the Railway Medical Department. Those who were seriously ill were sent from the coaches to a first-aid post, and thence to hospital as diagnosed. Treatment on the spot was given to those in need and the first-aid boxes of the transit trains were replenished. The evacuees were fed (along the route) at the expense of the state, but housed in hostels and apartments at their own expense. Inpatients were fed at the state’s expense, while the feeding of orphans, before a decision on placing them in orphanages had been taken, was funded by the local authorities. The gratitude of Leningraders to the managers, medical workers and citizens of Yaroslavl
region for their care, concern, and attentive and sympathetic approach was expressed in many letters to Party and governmental organizations and to the editorial board of the newspaper Severnyi rabochii. However, the flow of evacuees increased. In January 1942 3,498 people passed through the region reception centre, between 5 and 14 April the figure had risen to 8,115, and between 15 April and the end of the month it was 21,951, of whom 11,080 went to Yaroslavl
region.26

1403_901422_05_cha03.qxd

10/6/2004

5:00 PM

Page 78

78 Evacuation from Leningrad to Kostroma in 1941–42

Under these conditions serious mistakes and bottlenecks began to be discovered, but sometimes it was just that individual sectors of the public services were simply unprepared for operating under the extremely difficult conditions that arose from February 1942. An instructor in one of the local technical schools, A. Yaroslavets, who was enlisted, like many others, as a medical orderly in 1942, has recalled: ‘What I saw was indescribable. Hundreds of people already beyond the limit of exhaustion lay before us. Their dystrophy was absolute and irreversible, and medicine . . . was powerless. Skeletons in which departing life still flickered lay on beds in the hostel rooms.’27 The numbers of the sick and dead taken off the special trains increased abruptly. In January 1942 185 sick people and seven bodies and in February 712 sick and 109 bodies were taken off. The death rate rose among patients taken to hospitals and other treatment facilities. Whereas 72 were buried in Yaroslavl
in January 1942, the figure had already reached 434 in February. The corresponding figures elsewhere in the region were 66 and 339.28 Leading officials in the Vologda and Yaroslavl
regions were naturally alarmed at such a tragic situation regarding reception and onward routing, and they took a number of measures. By a decision of the executive committee of the Vologda obkom new quotas were fixed for the food products allocated to provide dinner for evacuees: cereals 85 g, meat or fish 75 g, fats 15 g, sugar 10 g, bread (daily ration) 500 g.29 On 17 February the executive committee further decided to settle in Vologda 1,250 sick people from the special trains in transit from Leningrad. For this purpose it was proposed to use a part of the premises of the Northern Railway Board, the buildings of the Vologda Forestry Trust and the Young Spectators’ Theatre, part of the Central City Library, and part of the offices of the Transtorgpit Trust. Sixty medical school students and doctors were allocated to care for the patients.30 On 27 February the committee decided to provide all evacuees passing through Vologda in transit with the following dry rations: bread 500 g, butter 100 g, condensed milk 200 g.31 All this undoubtedly helped to improve the reception of refugees, to provide them with food and to treat the sick. A report (no earlier than 25 April) by Turkestanskaya, head of the Evacuation Hospitals Board, stated that six hospitals had ‘now’ been organized, of which five with 1,210 beds provided treatment and one (160 beds) was a surgical hospital. Each hospital had its own hospital kitchen, a reception room with a small disinfestation station, a disinfecting chamber, and basic domestic and medical equipment; medicines were issued by pharmacies with

1403_901422_05_cha03.qxd

10/6/2004

5:00 PM

Page 79

Mikhail Frolov 79

which the hospitals were registered, and there were two changes of bedlinen (some hospitals had more). Food was provided regularly and on time – three times a day. The rations per patient were sugar 25 g, meat and meat products 125 g, butter 40 g, milk 200 ml, cereals 90 g, bread 500 g, potatoes 200 g, other vegetables (beet, cabbage, onion) 200 g. On top of the ration the patients were given white rusks, condensed milk, bakery products, cranberry extract, rosehips, dried vegetables, spring onions and lettuce.32 Many of the evacuees, however, had already gone beyond the emaciation limit and died on the way. Up to 20 March 1,619 bodies were taken from the special trains on the way to Vologda and 490 in Vologda itself.33 This figure would appear incomplete. There is some information in the archives on evacuation trains passing through the first and second Vologda stations. Daily records were kept of the number of the train, its routing, the number of people, including children, on board, and deaths en route (before Vologda) and in Vologda. According to the data 23 special trains passed through Vologda in the period 1–7 April. In them alone 671 people died on the way and 118 in Vologda, that is, 789 people, approximately half the number in the above-mentioned report covering nearly two months.34 No train on the way to Vologda station was without some dead. At the Cherepovetsk reception centre alone 1,301 bodies were taken off special trains between January and 24 April 1942.35 Even more sick people were taken off the trains. A report of the Evacuation Department of Vologda region on the reception and accommodation of evacuees and provision of services for them states that some 10,000 people were taken off and admitted to hospital between January and April 1942.36 The high death rate among those admitted to evacuation hospitals and other treatment facilities was a calamity. According to information supplied by the head of the City Health Department to the chairman of the Vologda Soviet, 1,495 people died in the city’s medical establishments in March–April 1942 (and most were Leningraders).37 A high proportion of those who reached the reception centres died. More than a third of all patients died in some hospitals (No. 1, No. 4 and No. 5). However, these data are questionable. The author has calculated how many people died in two hospitals (No. 1 and No. 2).38 In February–May 1942 40.2 per cent of the patients admitted died. The death rate was especially high in the first few days. An official report signed by the representative of the Evacuation Board for Vologda region states that the death rate among those hospitalized was ‘very

1403_901422_05_cha03.qxd

10/6/2004

5:00 PM

Page 80

80 Evacuation from Leningrad to Kostroma in 1941–42

high, up to 25 per cent, and highest during the first 2–3 days in hospital’.39 According to the author’s calculations, between 25.8 per cent and 42.4 per cent of those admitted for treatment died in the first four days in the two hospitals. There were many reasons, but the main one was that most of the evacuees were in a very serious condition. Extreme emaciation was accompanied by other illnesses, by oedema and frostbite. There were other causes of the high mortality. A memorandum from the head of the Vologda City Hospitals Board to the obkom (its conclusions based on observations of more than 1,000 people) noted that among patients who had no record of intestinal disease before leaving Leningrad there was massive stomach illness at some point along the evacuation route, and many of them died. What had happened was that when emaciated people who had been undernourished for a long time were given a fortified diet on arriving at Zhikharevo station, it acted like a poison on the emaciated organism. Turkestanskaya proposed changes to the ill-considered diet for evacuees at Zhikharevo and along the way, so as to avoid many cases of illness among extremely weakened people.40 The third stage of the evacuation from Leningrad was completed at the end of April 1942. How many people had died in the territory of Vologda? The figures given above, although obviously incomplete, indicate that 4,717 Leningraders died during the winter stage of the evacuation. At least 2,943 bodies were removed en route to Vologda, and on arrival there, 1,382 died in the evacuation hospitals and 392 in other treatment facilities in Volgoda.41 March and April 1942 were also the most intensive months for Yaroslavl
region, despite the fact that thousands of sick people had been taken off the special trains in Vologda region. During these months up to 200 people a day left the trains, 30–40 from each train. By 5 April there were 15,540 Leningraders in the region, 3,412 of whom were hospitalized for treatment. In April the region took in a further 2,450 people. The number of sick people removed from the trains rose sharply, as did illness among Leningraders already in the region. The medical facilities of Yaroslavl
other than hospitals admitted 1,564 people in April.42 Between February and April 1942, 7,409 people passed through the medical facilities, and a further 863 passed through Yaroslavl hospital. The death rate among patients was high: 46.7 per cent in the neurotherapeutic hospital, 26.5 per cent in the children’s hospital, 45.5 per cent in the Semashko hospital and 30.5 per cent in the infectious diseases hospital.43 Deaths within three days of admission accounted for

1403_901422_05_cha03.qxd

10/6/2004

5:00 PM

Page 81

Mikhail Frolov 81

28.1 per cent of all hospital deaths in March, and deaths within ten days for 62.6 per cent. On 20 April 734 people died in the hospitals and other in-patient facilities of Yaroslavl
alone.44 The numbers dying on the way increased. In March 292 bodies were taken off trains, and a further 135 in the period 1–25 April.45 These figures cannot be regarded as absolutely accurate. There were instances of bodies being thrown from trains at stations and along the line, but these were not recorded in the statistics. A memorandum to the evacuation representative of the USSR Sovnarkom in Yaroslavl
region, signed by the head of the Track Department of the Yaroslavl
Railway, reported that 37 bodies were found between 17 and 20 March in deep snow on the track at Vspole station. A man’s body was found on 17 March 257 km from Moscow, two bodies were found at Koromyslovo station on 18 March, and a further four bodies were thrown from a passing passenger and freight train at the same station on 19 March. On 23 March three bodies were again found on the track at Vspole station and on the same day a body was found on the track between Kotorosl and Vspole. Several bodies had been picked up even earlier at and between stations.46 Most of the special trains arriving at stations in Yaroslavl
region did not have any medical workers on board. Of 76 trains that passed through Vspole station between 4 and 26 April 1942, for example, only 24 had a doctor (three had two doctors) and 24 had a nurse (but only eight of these trains had a doctor and a nurse).47 All 3,000 beds for patients were full by the end of March. Newly opened in-patient facilities were lacking in important respects. Most hospitals and other facilities were short of medicines, bedlinen and junior medical staff, and the food did not meet the therapeutic requirements. Disinfection and delousing were poorly carried out in some hospitals and other facilities, and the sanitary conditions of some in-patient facilities was unsatisfactory.48 After 26 April (the virtual end of the winter–spring evacuation period) the influx of patients decreased sharply, and it was possible to make advance preparations to receive the new batch of evacuees who began to arrive on 1 June 1942. As of 1 May 1942 10,966 people had been admitted to Yaroslavl
in-patient medical facilities and hospitals. A total of 1,405 people had been registered to live in the apartments of relatives and friends or provided with accommodation under the apartment-filling procedure. The in-patient facilities had discharged 6,396 patients who had recovered. Some 5,000 or so Leningraders had died during the evacuation, 1,096 of them in in-patient facilities and hospitals.49 Between 27 April

1403_901422_05_cha03.qxd

10/6/2004

5:00 PM

Page 82

82 Evacuation from Leningrad to Kostroma in 1941–42

and 5 May 4,039 sick Leningraders were hospitalized in districts of the region. The fourth stage of the evacuation, in which 448,649 people were ferried across Lake Ladoga between May and November 1942, was better organized. Between 1 July and 1 August 1942 143 special trains carrying 287,857 people passed through Vologda. Between August and 2 December there were 99 more special trains carrying more than 80,000 people. Conditions for the reception and assistance of the evacuees were better. The flow of people was, moreover, much reduced, and their movement considerably better organized than in the preceding winter. The Leningraders themselves were better physically prepared to withstand the journey. Between 1 June and 1 August 1942, 301 people were taken off the special trains on the way to Vologda and a further 508 on arrival there. There were 71 deaths along the way and 34 in Vologda.50 All medical wagons were stocked with medicines and provided with special first-aid boxes in Vologda. Feeding was well-organized. On the whole the reception centres worked properly. On 1 August there were 515 patients in hospital in Vologda, 198 in Velikii Ustiug, 87 in Babaevo and 67 in Cherepovets, a total of 867. The percentage of hospital deaths, however, remained high. In No. 5 evacuation hospital 86 out of 298 patients admitted (28.9 per cent) died between 1 June and 26 August, 18.6 per cent of them within a day of admission. The death rate (as a percentage of past patients) in No. 2 evacuation hospital was 7.4 per cent in June, 27 per cent in July and 24.4 per cent in August.51 Between 1 August and 2 December a further 99 special trains passed through Vologda carrying 60,522 evacuees. During those three months 18 bodies were removed on the way to Vologda and 13 in Vologda. Hospital admissions were 36 on the way and 37 in Vologda. Evacuation from Leningrad into and through Yaroslavl
region was considerably better organized. A dining room with seating for 400 was opened in Vspole station. In-patient facilities with 1,000 beds were organized to take sick evacuees in the Zavolzhsk district of Yaroslavl
and at least 2,000 beds were retained in the existing in-patient facilities of the city. Facilities with 1,000 beds were temporarily held in reserve. On 24 June there were still 19 in-patient establishments with a capacity of 2,559 beds in six city districts of Yaroslavl
, staffed by 30 doctors, 135 nurses and 215 medical orderlies.52 Archive documents enable us to establish the number of people evacuated to Yaroslavl
region, how many were taken off the special trains and hospitalized in Yaroslavl
, and how many died in the region. Between 3 and 30 June 1942 179 sick evacuees and four bodies were

1403_901422_05_cha03.qxd

10/6/2004

5:00 PM

Page 83

Mikhail Frolov 83

taken off the trains in Yaroslavl
(34 bodies and 87 sick people had been taken off before arrival, but they were probably accounted for by the evacuation bodies of Vologda region). Between 1 and 18 July a further 107 people from the special trains were hospitalized and one body was taken off (before arrival at Yaroslavl
13 bodies and 81 sick people had been taken off).53 The flow of patients into the hospitals and other inpatient facilities declined sharply. Given that the in-patient facilities were not very full (with 1,373 beds vacant out of 2,511), the Yaroslavl
gorkom decided on 24 June 1942 to hold in reserve a number of facilities with a bed capacity of 1,584. This quantity sufficed for the hospitalization of sick Leningraders. On 30 June there were 1,085 in-patients (in facilities capable of taking 1,503), and on 24 August there were 564 patients in facilities with a capacity of 1,081.54 The number of deaths was several times less than in the evacuation of winter and spring. Whereas 2,334 people had died in hospitals and other facilities between the start of the mass evacuation in January 1942 and 3 June 1942, there were 349 deaths between 4 June and 10 September.55 Between 11 January and 1 November 1942 330,594 evacuees passed through Yaroslavl
alone. The city accepted 13,498, 11,600 of whom were sick. From the start of the evacuation to the middle of September 1942 2,683 people died in the hospitals and other in-patient facilities of Yaroslavl
and elsewhere in the region. It is impossible to calculate the mean percentage of patient deaths for lack of information on the total number of Leningraders taken into care. On 10 September 12,776 people from the special trains had been hospitalized, but considerably more patients had been treated in medical establishments. Between 27 January and 5 May 1942 alone 14,583 people were hospitalized and were in hospitals in Yaroslavl
region. It is also difficult to calculate the number of deaths. There is information on evacuees from Leningrad buried in Yaroslavl
region in 1941–44, according to which 8,217 were buried in 1942 and 292 in 1941. It is not clear, however, whether this includes the 590 bodies taken off the trains between January and November 1942, or the bodies thrown from coaches as the trains were moving. And where should the victims of the siege who died in 1943 (831) and 1944 (327) be listed? Between 22 June 1941 and 9 May 1945, 9,704 funerals were registered in Yaroslavl
region. There are grounds for the assumption that about 10,000 people died in Yaroslavl
region while journeying, in hospitals and other in-patient facilities, in hostels and apartments, children’s homes and boarding schools. Early in December 1942 the last trains carrying evacuees from Leningrad passed through the regions of Vologda and Yaroslavl
. During the whole period of the siege at least 15,000 Leningraders died in transit

1403_901422_05_cha03.qxd

10/6/2004

5:00 PM

Page 84

84 Evacuation from Leningrad to Kostroma in 1941–42

through these regions at reception centres, in hospitals and other inpatient facilities, and in hostels for evacuees. They also were victims of the siege because their state of health, serious illnesses and emaciation prevented them from reaching their destination and surviving their first days not under siege. There could have been considerably more victims but for the emergency measures taken by the leaders of the regions, the local authorities, workers’ organizations and collective farmers. These all made great efforts, within the limits imposed upon them by wartime conditions, to receive, accommodate, and provide with medical care and food tens of thousands of emaciated Leningraders. Notes 1. Kostroma region was established in August 1944. It incorporated 15 districts of Yaroslavl
region and three rural Soviets from Lyubimov district, three districts from Ivanovo region, six districts and the town of Sharya from Gorky region and 2 districts from Vologda region. Many districts of Kotroma region, including Kostroma, Bui, Galich and Soligar, and towns, including Kostroma, Bui, Galich and Sharya, were important centres for the reception and accommodation of evacuees from Leningrad. 2. VOANPI, 2522/10/69, 1. 3. VOANPI, 2522/10/17, 27–9. 4. GAVO, 3105/1/28, 130. 5. GAVO, 3105/1/28, 128. 6. GAVO, 3105/1/28, 131. 7. GAVO, 3105/1/28, 131. 8. GAVO, 3105/1/28, 133. 9. VOANPI, 2522/3/400, 33. 10. VOANPI, 2522/3/400, 33–4. 11. Yaroslavtsy (1965), 274. 12. TsDNIYaO, 272/224/313, 30. 13. GAYaO, 2224/224/177, 91. 14. TsDNIYaO, 272/224/177, 91. 15. GAVO, 3105/1/28, 130, 132. 16. Vechnoi pamyati dostoiny (1996), part 2, 507–9. This typewritten manuscript is in the GAYaO (State Archives of Yaroslavl
region). 17. VOANPI, 2522/3/332, 11. 18. VOANPI, 2522/3/332, 11. 19. GAVO, 3105/1/89, 14. 20. Aninkov (1997), 7. 21. VOANPI, 1858/5/152, 5. 22. VOANPI, 3868/1/7, 168–9. 23. Calculated by the author. See GAVO, 1876/4/2, 1–24ob. 24. TsDNIYaO, 272/157/1280, 5. 25. TsDNIYaO, 272/224/203, 25–8. 26. TsDNIYaO, 272/224/203, 128–9. 27. Pamyat’ (1985).

1403_901422_05_cha03.qxd

10/6/2004

5:00 PM

Page 85

Mikhail Frolov 85 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55.

Vechnoi pamyati dostoiny (1996), 507–8. (See note 16.) GAVO, 3105/1/26, 30. GAVO, 1295/2a/10, 17. VOANPI, 1858/5/152, 8, 16ob. VOANPI, 2522/3/332, 4. GAVO, 3105/1/28, 384. Calculated by the author. See VOANPI, 2522/3/333, 38–42. VOANPI, 1858/5/152, 34. GAVO, 3105/2/6, 302–10. An exception is the infectious diseases hospital, where not only Leningraders but also inhabitants of Vologda are included in the number of deaths. Calculated by the author. See GAVO, 1876/4/2, 1–50. VOANPI, 2522/3/332, 11. VOANPI, 2522/3/400, 35–6. Calculated by the author. GAYaO, r.-1269/3/122, 13. GAYaO, r.-358/2/62, 159. GAYaO, r.-1269/3112, 24. Calculated by the author. See TsDNIYaO, 272/224/203, 129–37. TsDNIYaO, 272/224/203, 86. Calculated by the author. See GAYaO, r.-385/2/62, 12–14. GAYaO, r.-1249/1/335, 3; r.-385/2/65, 524. GAYaO, r.-385/2/112, 40. VOANPI, 2522/3/333, 1. GAVO, 3105/2/3a, 83. GAYaO, r.-1269/3/112, 48. Calculated by the author. See GAYaO, r.-1269/3/113, 4–52; r.-1269/8/4, 1–8. GAYaO, r.-1269/3/112, 59, 70, 73. GAYaO, r.-1269/3/112, 59, 70, 73.

1403_901422_06_cha04.qxd

10/6/2004

5:01 PM

Page 86

4 Medical Research Institutes during the Siege Andrei Dzeniskevich

It is difficult to speak too highly of the work carried out by doctors and medical researchers under the hardest conditions of the siege. Their direct observations on the rise of nutritional dystrophy, its development and its effect on other illnesses are of great significance. Work was carried out in research institutes and clinics, by medical researchers and by doctors in civilian and military hospitals. Since it is impossible in a single chapter to cover all the research work of the medical profession in Leningrad during the war, this chapter will examine the main problems of the subject as they emerge from the materials of the research institutes. Their documentation (scientific papers, research and administrative reports) has been preserved, is accessible, and shows both the tasks that the profession was tackling and the conditions in which research was carried out. According to P. F. Gladkikh, there were 22 medical research institutes in Leningrad when the war began.1 The archives of 20 of them are to be found in the St Petersburg Central State Archives of Scientific and Technical Documentation (TsGANTD SPb), but the volume of material is uneven, since some institutes were evacuated at the start of the war. This chapter is therefore based on 17 sets of archive documents that differ in size and in the extent to which they reflect what the research teams were doing, but that give an idea of the work of medical researchers during the siege. The documents are of interest not only because they contain the earliest direct observations and conclusions of specialists, but also because they were intended for official use. (It may be noted that when authors subsequently prepared their conference reports for publication, the content was often significantly modified.) These materials are fortunately supplemented by other documents in the St Petersburg Central State Archives of Historical and Political Docu86

1403_901422_06_cha04.qxd

10/6/2004

5:01 PM

Page 87

Andrei Dzeniskevich 87

mentation (TsGAIPD SPb), decisions of the Central Committee, reports of the Leningrad Health Department, research institutes and hospitals, the records of district Party committees, reports and minutes of Party meetings of institutes and hospitals, all providing a different perspective on events. Sometimes, for example, they refer to the voluntary medical practice of leading scientists, which is not reflected in the official reports of the institutes. All documents in the Party archives were, without exception, internal documents not intended for publication. It is a feature of these sources that they do not contain the ‘settled’ conclusions accepted by most leading scientists. They do not and cannot contain everything published later in the monographs of leading scholars and the proceedings of institutes. Consequently, the collection of sources used has one particularly important feature for the historian, namely that it provides the first observations, conclusions and generalizations of medical workers, without any embroidery, tidying up and editing. By the late 1930s Leningrad was well-provided with medical research institutes. Some were evacuated at the start of the war, and almost all lost many of their specialists through mobilization and evacuation, and were obliged largely to reconstruct their work. Those who remained in Leningrad continued working under siege conditions. Much has already been written concerning their heroism and self-sacrifice, but somewhat less about the practical work of the scientific teams, although it merits praise and a more detailed account of it is long overdue. The position of research institutes was greatly affected by the war, especially by reductions in staffing. By the autumn of 1941 only 12 doctors out of 52 remained in the Ear, Nose, Throat and Speech Research Institute. A quarter of these were partially disabled (disability groups II and III) and two had been transferred to administration.2 Already in 1941 the Leningrad Tuberculosis Institute had lost all its sanatorium facilities, which were largely outside the city, and the urban night sanatoria were beginning to close. Only a small proportion of the staff still remained in the P. F. Lesgaft State Institute of the Natural Sciences, and 50 of its 60 research topics had been deleted from its research plan because those carrying them out had left.3 Work was put on a war footing. It seems that not all institutes had mobilization plans, but when the war began the attention of the overwhelming majority switched to the provision of assistance to the front and to military hospitals. No special plan for assistance to civilian hospitals and polyclinics from research institutes under war conditions had been prepared and considered. Attention was not drawn to this deficiency until after the siege had been lifted. In the autumn of 1944, the

1403_901422_06_cha04.qxd

10/6/2004

5:01 PM

Page 88

88 Medical Research Institutes during the Siege

People’s Commissar for Health, A. F. Tretyakov, made a number of criticisms in a meeting with the directors and heads of research teams of the Leningrad medical research institutes. Among the defects in their work he noted, in particular, that the Leningrad researchers had switched completely to serving the front and had ‘forgotten’ their obligations to the population of the city. It was, as always, those who were doing the work who were blamed. The institutes were in a difficult position at the start of the war. The old plans had been scrapped and there were no new ones. They had to seek and confront the tasks that most corresponded to the needs of the moment and deal with them quickly with their remaining resources. There is no simple answer to the question of whom the Leningrad research institutes were responsible to under siege conditions. They continued to report to the Commissariat for Health, and Leningrad branches of Moscow institutes reported to their parent institute. Tactically and operationally, however, they worked in the besieged city under the orders of the city’s leaders and the Leningrad Health Department. They assisted whoever was most in need of their help at any given time. This was a flexible, manageable and extremely convenient (and unbureaucratic) system for coordination between the various military, Party and governmental authorities. At the same time, this feature of siege conditions was not conducive to the systematic and planned carrying out of scientific work by research workers. Research workers and doctors in the besieged city had their attention concentrated on purely practical and urgent tasks. They were well-aware of the importance of research at this time. A. P. Vishnyakov, who studied the physical, colloidal and chemical state of plasma in victims of the siege, wrote in 1942 that detailed processing of the material would yield a whole series of conclusions both on scientific matters concerning plasma and blood and for a practical solution for diet and living conditions: Over and above its importance for the Soviet Union, this work is undoubtedly of great interest to the international scientific community because there has never been such a deep and comprehensive study anywhere at any time on such a highly topical question as blood and the nutritional regime of the donor under wartime siege conditions as under the conditions now obtaining in our besieged city.4 More than half a century later we can only confirm that opinion. Everything that doctors and scholars did in the war years is scientific-

1403_901422_06_cha04.qxd

10/6/2004

5:01 PM

Page 89

Andrei Dzeniskevich 89

ally very significant. From their work, their papers and reports we can see their views on: (1) the development of nutritional dystrophy and associated illnesses; (2) the effect of nutritional dystrophy on health and mortality; (3) the course of other illnesses against the background of nutritional dystrophy; and (4) the immediate and direct after-effects of famine and siege. The acute need to tackle the most urgent and pressing tasks of preserving life and defending the city was undoubtedly the key feature and driving force of all scientific investigations of that period. Four main approaches may be distinguished. Research arising from the need to save lives of the population and the troops at the front was in the first category. Such research had to be tackled immediately. The second approach involved study of the living and working conditions of the besieged population. The third was research with a bearing on the direct after-effects of war and siege on human health. The fourth concerned the sanitary condition of the city.

Research on saving lives under siege conditions The activity of the staff of the Leningrad Blood Transfusion Research Institute (LIPK) is the clearest and most typical example of such research. By the start of the war the staff already had experience of work for the front. The Institute had been awarded the Order of the Red Banner of Labour for its assistance to the Red Army during the Soviet–Finnish War. Staff of the Blood Bank department came on their own initiative to the Institute as early as 22 June and began to organize a reserve blood bank for the army. The manufacture of blood substitutes was organized under the leadership of senior lecturer A. N. Filatov in the middle of August 1941. On 4 September the Institute was commissioned to establish a special laboratory in which the important No. 3 solution was developed. Filatov’s widely used No. 28 anti-shock solution began to be produced in April 1942.5 The staff of the Institute had to overcome a great many difficulties. For example, the stock of standard bottles for blood donation and storage was very soon exhausted. Special ampoules for banked blood and blood substitutes were initially made by the Kultigrushka cooperative and Plant No. 211, but both ceased work in December. Glass jars were used until March 1942, but when the stock ran out collections were made of returned empties – vodka, wine and milk bottles. Stoppering was a problem with these bottles. What rubber there was in the city was too hard, was perishing and could not withstand the sterilization temperature for bottles filled with blood. In March Vishnyakov and

1403_901422_06_cha04.qxd

10/6/2004

5:01 PM

Page 90

90 Medical Research Institutes during the Siege

Filatov invented a universal stoppering device that fitted all shapes and sizes of bottles and was suitable for sterilization. This was the first and probably the only instance anywhere in the world of the use of wine bottles for blood storage. Stocks of chemical grade sodium chloride needed for the preservation ran out at the same time as the stocks of special containers. Supplies were initially gathered from laboratories and institutions in the city, but the laboratory later organized its own chemically pure production.6 The greatest difficulties, however, began in the winter of 1941–42. There was a heavy influx of volunteer donors. During the first year of the war about 70,000 people approached the Institute to give blood.7 A whole team of doctors had to be organized to medically examine volunteers and many analyses had to be made to determine blood groups and exclude the sick from giving blood. These were not easy tasks in view of the constant threat of bombing and shelling and the lack of heating and piped water. Some doctors’ surgeries had to close. Reception was carried out in the basement and several doctors shared a single room. When electricity was cut off the light went out and the thermostatically controlled cabinet stopped working. In order to continue Wasserman tests, the laboratory staff heated bricks in a stove and lined the cabinet with them to maintain the required temperature. Sterilization of containers, needles, syringes and so on became difficult, but an even more complicated problem had arisen. Under conditions of mass starvation and increasing nutritional dystrophy, the admissibility of using people weakened by hunger as blood donors became an increasingly acute question needing immediate and thorough examination, whatever the difficulties. Studies of the health of donors, methods of preserving and transporting blood and the production of viable blood substitutes had to be continued. Studies on the nutrition of donors had been in progress since 1931, when doctors had concentrated on the question of how the donor should be fed to ensure the most rapid recovery after giving blood. In the cold winter of 1941–42 the question became one of how the composition of the blood was affected and whether it could be transfused to the wounded. Solution of this problem could not be put off. Research was begun on 16 December 1941 and continued until 14 January 1942. Finding the solution to the problem was made easier by the fact that the Military Soviet of the Leningrad Front, which held all the administrative reins of the city, was very interested in the answer. The Military Soviet commissioned the Institute and gave assistance when it was most needed. On 10 December 1941 the Military Soviet, consisting of Khozin,

1403_901422_06_cha04.qxd

10/6/2004

5:01 PM

Page 91

Andrei Dzeniskevich 91

Zhdanov, Kuznetsov and N. V. Solovev, decreed that donors should receive additional food. Those who had given blood at least twice a month were to receive a special donor’s card and were still to be fed as before in the Institute’s canteen on the day when they gave blood. The canteen itself and its staff were put on the same footing as the canteens of defence enterprises and power stations.8 The donors were successfully given a little extra nourishment, but there were difficulties over the research. The staff shortages and the burden of the productive tasks of the remaining staff precluded research during the day. After a full day’s work under pressure they sat down again at the laboratory bench and carried out biochemical tests for research purposes. Between December 1941 and March 1942 they made some 2,000 analyses and determinations of the biochemical and colloidal constants of plasma.9 The first research findings were reported to a meeting of the academic council of LIPK by F. I. Kovshikov on 15 December. Following a full discussion the council members agreed that the composition of blood ‘is dependent on many factors and first and foremost on nutrition’.10 An extensive research plan for the whole year was adopted in January 1942. The four main problems to be tackled were: the donor system; preservation procedures for blood; the treatment of anaemia and dystrophy; and blood groups.11 A total of 36 research topics was planned. All were completed and had a great bearing on the improvement of blood transfusion and blood supply to the city’s hospitals and medical institutes. The content of the research was reported on and discussed at meetings of the academic council, in two conferences in May and June 1942, and thereafter in Moscow in January 1943. The research findings of the Institute’s staff were published in a more definitive form in 1943–47 in the learned transactions of the Institute (Trudy LIPK), in medical journals and in individual monographs. In 1947 Vishnyakov and V. P. Moiseeva wrote in an article on the structural and colloidal state of blood plasma in the inhabitants of Leningrad in 1941–46: ‘Early in 1941 we began extensive chemical studies on the blood of the population of Leningrad in the Leningrad Blood Transfusion Institute that were continued throughout the siege and subsequently down to the present.’12 Much material on changes in the physical and chemical composition of the blood plasma during the siege and after the war was collected in this way. (It may be noted that the staff of the Institute had completed 395 research assignments in the 15 years of its existence down to 1947, 113 of them during the war and the siege.13)

1403_901422_06_cha04.qxd

10/6/2004

5:01 PM

Page 92

92 Medical Research Institutes during the Siege

It was logical to expect that research in this area would have continued and expanded after the siege. Many historians have assumed that such study was discontinued because of the ‘Leningrad Affair’. There is no evidence of this as regards the Institute of Blood Transfusion. The topic of the after-effects of the siege was occasionally taken up after 1949, which would have been impossible had it been prohibited from above. The point is that this topic disappeared from the LIPK research plans in 1946–48, that is, before the start of the ‘Leningrad Affair’. The reason was probably the abrupt change in the international situation. The Cold War and the threat of use of the atomic bomb by the United States obliged the Soviet leadership to take a number of serious measures. Relevant research institutes were switched to in-depth investigations of the problems of radiation, its effects on the human organism and the composition of the blood, and the search for means of protection against radiation sickness and for its treatment, in which the staff of the Institute soon became involved.14 Research plans were reexamined and all the new subject matter was classified as secret. Extreme economies were once again demanded and resources were concentrated on the main and most urgent topic of protection of the population and the army against possible nuclear attack. The switchover to the new subject matter was general and all researchers were mobilized to solve stated assignments. The state maintained the institutes and it called the tune. All this happened late in 1947 and early in 1948. The conclusion, suggested by study of the archives, is that less urgent topics, including the subject of the siege, disappeared from the Institute’s plan. To return to the period of the siege: the Institute’s researchers did not confine themselves to studying changes in the composition of blood under famine conditions. There were useful studies of the activity of the stomach with an inadequate diet, the problem of shock and even the sex life of donors. G. S. Gurevich, one of the Institute’s researchers, drew attention to the fact that the adverse effects of starvation and of ‘the nervous and mental effects’ of the siege period on the stomach of virtually healthy individuals still continued even after 1945, when ‘new pathological trends’ began to be encountered. Ending a series of studies on this topic, he wrote in 1947: ‘The secretory function of the stomach was to some extent affected in all donors, with very few exceptions.’15 Shock was an important problem for the medical profession during the war. Researchers of LIPK examined the aetiology and pathology of traumatic and other kinds of shock, and the treatment of traumatic shock and acute blood loss. In 1946 Professor I. R. Petrov presented a consolidated report on this subject, ‘Results of a 15-year study of the

1403_901422_06_cha04.qxd

10/6/2004

5:01 PM

Page 93

Andrei Dzeniskevich 93

problem of shock’, in which he reached ten main conclusions. We shall quote only the first, because the topic of the siege is clearly brought out in it: There cannot now be any doubt that, in addition to the main cause of the development of shock, neuralgesic trauma, an important and even decisive part is sometimes played by predisposition, i.e. by the reactivity of the organism, which changes in line with constitutional characteristics and under the influence of a set of factors that affected the organism before, at the time of or, ultimately, after the injury. Such factors include neuropsychic trauma, cooling, overheating, nutritional disorder and blood loss. In particular, a marked predisposition arises under the simultaneous influence of a number of these factors.16 This conclusion was of great importance for understanding the extreme seriousness of the position of a victim of the siege, already weakened by hunger and cold, if wounded or burnt. Something must be said briefly about the contribution of other research institutes to saving the population and troops of the Leningrad front. On the eve of the war the Leningrad Branch of the All-Union Institute of Experimental Medicine (LF VIEM) was engaged on profound theoretical research. Its 1941 research plan included almost all important diseases and some major theoretical questions, such as the specifics of living matter in its cellular and tissue manifestations, the comparative pathology of inflammation, metabolism, and the biological effect of physical factors. Conferences on these subjects were scheduled for every month of 1941 except July. By a cruel irony of fate there was to have been a conference on aspects of digestion in December 1941.17 Once the war had begun it was impossible to carry out such an extensive programme. Those specialists who were not drafted into the army were switched to studies of wound healing, frostbite and the relief of pain shock. Purely laboratory experiments had to be abandoned in the winter of 1941–42, the most difficult period in the Institute’s history. Seventy of its scientific workers died of starvation and four of its buildings were destroyed. Research had to be transferred to the Institute’s clinic and made as relevant as possible to the requirements of existing medical practice. From the spring of 1942 work was concentrated on ‘thorough comprehensive study of the pathogenesis of nutritional dystrophy and hypovitaminoses with the aim of developing the most effective means of influencing the course of these pathological processes’.18

1403_901422_06_cha04.qxd

10/6/2004

5:01 PM

Page 94

94 Medical Research Institutes during the Siege

The assignment was to tackle the problem from all sides: physiological, biochemical, microbiological, anatomical and clinical. It was the hope of the compilers of the new work plan that the joint work of clinicians, physiologists, biochemists, morphologists and pathologists on the same group of patients would be the most productive form of all-embracing research. The 16 researchers remaining in the Institute carried out 15 studies. In 1942 the Institute held seven scientific conferences and published two scientific symposia. Work on nutritional dystrophy and its aftereffects continued in 1943. Great importance was attached to this, especially because not all the features of emaciation of the human organism had been discovered and investigated. In one meeting at the end of 1943 Professor V. G. Garshin said that ‘dystrophy now is quite different from dystrophy in 1942’.19 In October 1943 Garshin set out his main conclusions in a paper, ‘Current pathology as revealed by pathological and histological research’. They included the following: 1. In 1943 deaths from nutritional dystrophy were decreasing from month to month. 2. In recent months nutritional dystrophy was being seen only in conjunction with other serious diseases, most often high blood pressure (hypertension). 3. Deaths from hypertension had been on the increase since October 1943. 4. Death from hypertension was due in most cases to heart failure. This meant that death (in hypertension) from brain haemorrhage was less frequent than in peacetime. 5. Cases of renal insufficiency had recently been on the increase, and there had been more cases of malignant arteriosclerosis, which was virtually absent during the initial months of the rise in deaths from hypertension. 6. The influence of nutritional dystrophy was being felt in the course of hypertension. Enlargement of the heart in hypertension did not reach high degrees in dystrophy patients. There were grounds for considering that the preponderance of deaths from heart failure in hypertension was due to weakness of the myocardium in nutritional dystrophy sufferers. 7. Cases of diseases accompanied by jaundice rose sharply in 1942–43. Bacterial and cardiological studies showed that leptospirosis was present in a considerable proportion of these cases.20

1403_901422_06_cha04.qxd

10/6/2004

5:01 PM

Page 95

Andrei Dzeniskevich 95

It is evident that the Institute’s researchers were carrying out very important scientific work during the siege, namely a comprehensive study of the pathogenesis of nutritional dystrophy. A memorandum on the work of the Leningrad Branch states: Study of the forms of basal metabolism in nutritional dystrophy has revealed the chronaximetric mechanism of a slowing of cardiac rhythm by functional shifts in the nervous system, and qualitative aspects of protein, lipid and carbohydrate metabolism have been established; features of the course of certain diseases (tuberculosis) accompanying nutritional dystrophy have been determined.’21 An in-depth study of the ethno-pathogenesis of hypertension following three main approaches was planned in 1944, and the work was begun, but the lifting of the siege of Leningrad appreciably affected its course. The research team was then thinking only of restoring the Institute and its pre-war scientific profile. The question of reestablishing the pre-war lines of research had already been raised in the Institute’s academic council at the very beginning of 1945. As a result it was on the physiology of higher nervous activity that attention was centred in the 1945 plan. The problem of hypertension was relegated to a more general level – the link with the brain, the myocardium and so on. A purely siege topic, ‘Transitory hypertension in Leningrad in 1942–44’, was initially included, but later scrapped in connection with the scrapping of the clinical group in the Leningrad branch. The Institute returned to its deeply theoretical subject matter. The only applied topics were those recommended by the Medical Scientific Council of the Military Medical Board of the Red Army. Ten topics on wounds, infestations, non-healing wounds, concussion, contusions, transplants and so on were included in the list. Matters relating to the siege were not entirely set aside, but were given a more detailed theoretical slant. The subject of the aftereffects of the siege, the effect of starvation and mental trauma on the health of the population, was no longer to be found as an objective in the plans of the Institute in 1946–47, at least not in the archive materials. It is worth pointing out that this was also before the ‘Leningrad Affair’. The war found the research team of the Institute of Vaccines and Sera engaged on detailed research. The Institute planned to investigate 42 scientific topics in 1941, but that plan was not carried out. After some of the staff had been called up for military service, those remaining were

1403_901422_06_cha04.qxd

10/6/2004

5:01 PM

Page 96

96 Medical Research Institutes during the Siege

switched to purely productive work. As the situation in the besieged city deteriorated there were fewer and fewer laboratory animals and it was increasingly difficult to obtain food for them. On the other hand, the need for purely practical work continued to increase. On 25 December a group of researchers were called to a meeting with the head of the Epidemiological Control Board, I. M. Ansheles, who informed them of the danger of a dysentery epidemic. During December 1941 the disease had become increasingly prevalent among older people (over 40 years old) and among children of nursery age. Those present at the meeting said that the situation might prove to be even more complex than the leadership assumed. In particular, they stressed the threatening state of the sewerage system. Following discussion the meeting decided to instruct the Institute to work jointly with the Botkin Hospital on ‘specific immunization and phagoprophylaxis’. The researchers of the Institute were given the task of rapidly increasing the output of suitable medicines. From 27 December 1941 the power supply was cut off and all the equipment needed, including sterilizers, thermostatically controlled cabinets, pumps and centrifuges, was out of action. Some researchers themselves became victims of the famine. The directors requested assistance from the gorkom, and in February 1942 the Institute began to receive a strictly limited power supply. The research team, working under the most difficult conditions, met the needs of troops at the front and the city health services for bacteriological medicines.22 But in these conditions scientific work was reduced to perfecting manufacturing techniques and methods for the production of sera and vaccines. In 1943 the Institute’s reports were little different from those of ordinary industrial enterprises. It was only later, as the situation in the city improved, that the staff began to return to their research. Such topics as A. V. Makarov’s ‘The nature of antibodies and the chemistry of immune sera’ appear in the plans, but by 1945 topics linked to the siege were no longer to be found. The siege also made the work of tuberculosis specialists difficult. The tuberculosis hospitals, external clinics and a very limited amount of hostel care remained within the ring of the siege, but from the start of the war ‘a sharp rise in tuberculosis morbidity and mortality’ was noted almost everywhere in the country, especially in occupied regions and in besieged Leningrad. A considerable increase in morbidity was noted in Leningrad in the latter half of 1941 and in 1942.23 Tuberculosis specialists had to work under unbelievably difficult conditions. Staff numbers at the Tuberculosis Institute were sharply reduced and a large part of the laboratory premises suffered from bombing and

1403_901422_06_cha04.qxd

10/6/2004

5:01 PM

Page 97

Andrei Dzeniskevich 97

shelling. Research was reduced to a minimum and clinical research topics were cut back to ‘the specific aspect of features of the course of tuberculosis’ under the conditions of war and siege. During the war 16 research projects on this subject matter were completed and a volume of articles was prepared for publication. The Institute was not engaged on this topic for long, not only because of the greatly reduced research potential, but also partly because of the topic itself. The point is that the problem was one that had been solved a long time previously as far as tuberculosis specialists were concerned – any war, famine and cold anywhere and at any time increased tuberculosis morbidity among the population. The main task for physicians was the practical work of saving patients and checking the spread of the disease among a population weakened by famine. In 1943 the range of problems tackled was slightly expanded, in the main along two lines, the clinical picture and treatment of tuberculosis under wartime and siege conditions, and the organization of tuberculosis control under wartime conditions. The topics investigated included ‘Clinical and immunobiological characteristics of tuberculosis in children and adolescents against the background of dystrophy and multiple hypovitaminoses’, ‘Legislative, administrative and public measures of tuberculosis control in time of war and in the immediate post-war years’, and ‘Some differences in the social pathology of tuberculosis relative to the pre-war period’. The work of tuberculosis specialists was considerably hindered by lack of demographic data, which simply did not exist in 1942, and later under wartime conditions was treated as highly confidential. There are other works of the period in which doctors complain of the lack of essential statistical data. In 1946 M. L. Goldfarb, the head of the Institute’s department of social hygiene, signed two documents, ‘Tuberculosis morbidity and mortality in Leningrad in 1945’ and ‘A brief survey of tuberculosis morbidity in Leningrad. For official use’. He stressed in both documents that lack of official statistical data on population numbers made it impossible to provide statistics on tuberculosis morbidity and mortality throughout the city.24 Many of Goldfarb’s conclusions were, in his own words, provisional for this reason. Even the absolute figures that he gives, however, are sufficiently interesting to merit being quoted. He states, for example, that deaths from all forms of tuberculosis in Leningrad totalled 1,481 in 1944 (795 men and 686 women), and 2,757 in 1945 (1,620 men, 1,173 women).25 It is not stated whether the increase was accounted for by people returning to Leningrad. At all events, it is noteworthy that, in the opinion of the

1403_901422_06_cha04.qxd

10/6/2004

5:01 PM

Page 98

98 Medical Research Institutes during the Siege

report’s author, there were considerably fewer men than women in Leningrad at this time. Another of his opinions is quite categorical: The increase in non-pulmonary forms of tuberculosis, of which tuberculous meningitis and tuberculosis of the central nervous system are largely a complication of pulmonary tuberculosis and are in general an expression of generalization of the tuberculous process, was largely characteristic of the wartime period . . . It is also possible that the harsh experiences of the war told particularly on women, whose clinical history revealed a particular increase in the gravity of the tuberculous process.26 He noted concurrently that tuberculosis was more severe in 1945 than in 1944, as was confirmed by the ‘high percentage of patients among registered sufferers from pulmonary tuberculosis; the higher hospital death rate in tuberculosis and the lesser number of simultaneously living tubercle excreters and sufferers from active forms of tuberculosis per death from tuberculosis’.27 The general conclusion of his reports was that tuberculosis control in Leningrad after the war remained ‘a most important public duty requiring very intensive activity by the health services’. As is evident, tuberculosis specialists were confronted by a vast, purely practical task. As soon as the war was over the experimental division of the Leningrad Technological Research Institute (LNITI) began a joint study with the Institute’s clinic on the problem of tuberculosis toxaemia. War is always a busy time for all medical institutes in any way concerned with surgery and for all surgeons whatever their special field. The doctors of the Leningrad Surgical and Osteoarticular Tuberculosis Research Institute (LIKhT) were no exception in this respect. Many were enlisted into the army and some were evacuated. There were also changes in the cases being dealt with in the clinic. Already by July 1941 100 beds had been allocated for shell and bomb casualties, and from February 1943 this was changed to 175 ‘surgical beds’ for wounded soldiers from the Leningrad front. Under the extremely harsh conditions of the siege the practical work of saving the lives of the wounded took all the time and energy of the few surgeons. The compilers of a report on the work of the Institute in 1941–43 had to admit that not only research but also the surgical treatment of bone tuberculosis had been relegated to make way for ‘the rendering of the maximum possible assistance to the front and to the ability to defend’ Leningrad.28 All research was concentrated on the main problem, the treatment of war wounds, but even that was no easy matter for the staff of the Insti-

1403_901422_06_cha04.qxd

10/6/2004

5:01 PM

Page 99

Andrei Dzeniskevich 99

tute. Even in 1943, when the situation was relatively favourable, the therapeutic productivity plans of LIKhT were repeatedly changed in response to the military situation and the requirements of the High Command of the Leningrad Front. Even so two conferences were held in the Institute in 1943. The first (which was also the first during the war) was held on 4 July to celebrate ‘25 years of the achievements of Soviet medicine in the field of surgical tuberculosis’. Papers on the subject matter of interest to us were presented at the second, held on 23 September 1943. A. N. Sovetova delivered a report entitled ‘Aspects of the course of tuberculosis of the bones and joints in adults during the siege’. She calculated that the death rate among patients in the clinic was 28 per cent, and was 35 per cent higher during the siege than immediately preceding the war (1939 and 1940). The general condition of the patients monitored was good in 75.5 per cent of cases and bad in 24.2 per cent on 1 July 1944. During the winter of 1941–42 it was good in 10.4 per cent, bad in 89.6 per cent. In the summer of 1942 it was generally bad in 60.3 per cent. During the winter of 1942–43 it was quite satisfactory in 63.9 per cent. On 1 July 1943 75.9 per cent were in an excellent state, and 24.1 per cent were in a bad state.29 Sovetova noted that morbidity increased during January–March 1942, the most severe months of the siege, and that diseases and worsening states were preceded by dystrophy. V. S. Gelikonova delivered a report entitled ‘Features of the course of tuberculosis of the bones and joints in children during the war and the siege’ at the same meeting. When the war began there had been 187 children between 3 and 15 years old being treated in the clinic (most of whom were spondylitis and coxitis cases). Of the 187 sick children 36 (19 per cent) died and 93 (50 per cent) were discharged.30 Consequently, deaths of patients had been increased ‘by a factor of about 2.5 times’ by the siege. Gelikonova considered that the sick children had been provided with roughly the same treatment and warmth as in peacetime, and that the negative factor was poorer nutrition. Climatotherapy and physiotherapy could not be used. Although the general condition of all patients deteriorated during the cold period, it was mainly the weakest and most seriously ill who died. Surgeons refused to operate during the winter so as ‘not to weaken the juvenile organism’. During discussion of the report senior lecturer I. M. Fertig suggested, when referring to the course of pulmonary tuberculosis in children and adults, that death had occurred in both when the pattern of generalization of the disease was similar. Where dystrophy had been superim-

1403_901422_06_cha04.qxd

10/6/2004

5:01 PM

Page 100

100 Medical Research Institutes during the Siege

posed on an old tuberculosis process there had not been any notable worsening in the course of pulmonary tuberculosis. ‘The cause of death in these cases had been dystrophy, not pulmonary tuberculosis.’31 Greater attention was paid to research in 1944. The report on the work of the Institute for that year stated quite definitely that ‘As a consequence of the severe siege conditions, a considerable increase became apparent in tuberculosis in general and tuberculosis of the bones and joints in particular, and a number of distinctive features became apparent in the course of this disease’.32 A new specific research topic had arisen, namely war wound bone and joint disease. The new assignment involved the need for a parallel study of ‘haematogenic and gunshot osteomyelitis and establishment of the distinguishing features of these diseases’. Papers on this topic were presented at conferences in 1945, at which the Leningrad view was opposed. While the conferences were confined to Leningrad clinicians and researchers, the adverse effect of starvation was unquestioningly accepted by all, but in 1945 Muscovites also attended. When they recounted their experience of the treatment of tuberculosis of the bones during the war an interesting fact became apparent. Pakhatinov, one of the Moscow delegates, drew attention to it, saying, ‘It has been stated here that the course of tuberculosis of the bones became serious in Leningrad during the siege . . . In Moscow, where there was no siege, tuberculosis of the bones also took a serious course during the war, and undetected foci present in a waning state in tuberculosis patients reappeared during this period’.33 This view was accepted without qualification and developed by a leading specialist, Professor T. P. Krasnobaev, who said: ‘Our observations reveal extremely interesting facts concerning the serious condition of sufferers from tuberculosis of the bones where nutrition was good and there could be no question of nutritional dystrophy. That is indicative of the major role of the nervous system, namely the autonomic nervous system’.34 In summing up the 14th (wartime) conference, Academician P. G. Kornev said: ‘Today we have heard interesting reports that draw a line under the siege period in Leningrad.’35 His words were not, of course, intended to put an end to the discussion of ‘siege topics’, but the impression was created that answers had already been given to basic questions concerning tuberculosis of the bones and joints raised by the war, and that other more immediate questions had been put on the agenda. One such question, for example, was that of chronic ulcers originating from gunshot wounds that were responsible for a high percentage of invalidity. A republican meeting of the heads of hospitals for war invalids

1403_901422_06_cha04.qxd

10/6/2004

5:01 PM

Page 101

Andrei Dzeniskevich 101

was held as early as May 1945. That meeting heard reports on the work being done and discussed how to organize the most effective means of caring for patients with non-healing wounds. In his opening remarks Kornev spoke of the novelty and importance of the tasks: The importance stems from the need to give effective assistance to war invalids, while the novelty arises from the fact that tuberculosis of the bones was hitherto regarded as a childhood complaint and attention was centred, in the main, on the treatment of children. The war has brought about considerable changes in the age relationship: tubercular conditions of the bones and joints have become more frequent in adults. Thus, 70 per cent of patients in Leningrad before the war were children, and 30 per cent were adults. After the war the proportions were the opposite – 70 per cent adults and 30 per cent children. Roughly the same proportions are apparently to be seen elsewhere.36 The post-war period for the staff of the Institute began with greater attention to the healing of non-healing wounds in war invalids. The war also faced the First Aid Research Institute with new tasks. The composition of patients admitted to its clinic had already begun to change in the latter half of 1941. The most marked changes were in the causes of mechanical damage. Accidents in the home and industrial injuries accounted for a lesser proportion; injuries were now being caused by bombing (37.5 per cent) and shelling (10.6 per cent), which together accounted for 48.1 per cent of all mechanical damage.37 On average 230–240 operations a month were performed in the Institute’s clinic in the first half of 1941. This was routine work. The main difficulty arose and began to increase from November 1941, when more than half the patients being sent for treatment were suffering from varying degrees of dystrophy. Within two months the number of patients already ‘exceeded the official number of beds’ in the hospital. In January 1942, 100 new beds were made available, but ‘the wave of dystrophy cases’ (as stated in the report) filled the whole of the therapeutic department and a considerable part of the surgical department. Nor had their number decreased by the autumn of 1942. When the number of dystrophy cases in the city did start to decline, the First Aid Institute took in a large group of transferred patients, many suffering from dystrophy, from two hospitals which had closed. The few qualified surgeons not enlisted into the army had also to act as therapeutists. Their workload was even further increased when the Erisman Hospital

1403_901422_06_cha04.qxd

10/6/2004

5:01 PM

Page 102

102 Medical Research Institutes during the Siege

discontinued all surgical work and the First Aid Institute had in practice to handle the work of two establishments. The work of the doctors was made even more complicated and difficult because all surgical conditions ‘were progressing against the background’ of severe dystrophy, and mortality from all surgical conditions remained at an unprecedentedly high level in the winter of 1941–42. The prognosis was always uncertain for all patients admitted because ‘even an ordinary phlegm could easily lead to a fatal outcome’. Mortality was especially high following amputations and abdominal and other cavity operations.38 Surgical intervention had to be postponed in some instances to await an improvement in the patient’s general condition. March and April 1942, when patient mortality reached 26.5 per cent, was the most severe period.39 In addition to the changed composition of the patients, there were also changes in the kinds of illnesses and in their course. Thus, the form ‘acute abdomen’, which had been a common emergency, began to disappear from November 1941 and patients with appendicitis were found less and less frequently, to the point of total disappearance. Fewer cases of perforation of the stomach and strangulated hernia requiring surgical intervention were encountered, but conversely there was a very large group of injuries of various kinds. About 20 per cent of patients were suffering from purulent diseases of the soft tissues, complicated by emaciation. Patients of this group exhibited three main characteristics: (1) a sharp reduction in the local resistance of the tissues, (2) a reduction in the general resistance of the organism, and (3) a slowing of regeneration processes. Arising from these characteristics, necrotic states of the skin progressed steadily under famine conditions and reached levels at which the affected limb had to be amputated.40 The treatment of other diseases also proceeded differently under siege conditions than in peacetime. A condition such as a strangulated hernia presented an unexpected surprise to surgeons. Before the war the Institute had handled 200 such cases annually, and the treatment had been quite straightforward. The main element was speed: the operation was performed within a few hours of the patient being admitted to the ward. During the siege the number of strangulated hernia cases was greatly reduced but the course was altered. Lack of transport and the inability of a patient weakened by starvation to get to the hospital independently greatly complicated affairs. There were instances of operations on the ninth to tenth day and even up to 17 days from the onset of the strangulation. Because of the famine and muscular dystrophy ‘it proved possible to operate on a 7–8-day-old hernia without resection of the intestine

1403_901422_06_cha04.qxd

10/6/2004

5:01 PM

Page 103

Andrei Dzeniskevich 103

because of the comparatively satisfactory state of the intestinal wall’.41 In the first half of 1942 there were cases of mechanical ileus following enteritis of dystrophic origin. At this period its clinical picture was so severe as to raise the question of surgical intervention, whereas previously it would have cleared up with conservative treatment. Fortunately, mechanical ileus, like appendicitis, was found only in isolated cases. In the latter half of 1942 this highly unusual form of the illness disappeared as living conditions improved. Ulcerated limbs were another surgical condition noted in the Institute’s reports. All cases resulted from emaciation and oedema. The disease took a very severe course and some patients (four out of 25) died showing symptoms of nutritional dystrophy. Improvement in the condition of patients proceeded slowly. Mean mortality in 1942 was 17.7 per cent of all patients.42 The 13 general surgeons remaining after mobilization were hard put to it to cope with the vast workload. They had neither the energy nor the time for research, nor did the Institute have the appropriate status. It had been set up as a research and service-providing establishment, but such institutes were abolished in 1940. The war began while the fate of the First Aid Institute was under discussion. The Institute began to function as a hospital and nobody required reports on its research work. However, it did have seven staff members with higher postgraduate medical qualifications and experience of research. They continued their research activity and their 1943 research plan contained seven topics, five of which were directly related to the siege. These observations were intended to summarize the practical work carried out in 1942, but the situation changed rapidly. Military operations on the Leningrad front, which became more active in 1943–44, had an effect. The First Aid Institute was given 360 surgical beds and once again became a military hospital. I. I. Dzhanelidze was reappointed as head of the Institute at this time (he had been called to join the fleet and appointed Surgeon-in-Chief of the Navy). Under his leadership the research plan was reviewed and all researchers were switched to the study of gunshot wounds.43 Dzhanelidze’s return strengthened the position of the Institute, which emerged as a research establishment in the post-war period. There were 16 research projects in the 1945–46 plan under the combined general heading of ‘Pathogenesis, clinical picture and treatment of chronic thoracic empyema from gunshot wounds’.44 The subject was highly topical and fairly typical of the surgical establishments of those years. However, to judge by the archival documents, there had been an end to subjects connected with the siege. Other research institutes linked with surgery were also in a difficult position. As mentioned above, only 12 doctors were left in the

1403_901422_06_cha04.qxd

10/6/2004

5:01 PM

Page 104

104 Medical Research Institutes during the Siege

Leningrad Ear, Nose, Throat and Speech Research Institute by the autumn of 1941. On the recommendation of the USSR Health Commissariat, they concentrated on ‘rationalization of means of dealing with the complications and after-effects of ENT injuries’.45 The situation obliged them to move outside their specialist concerns and deal with internal diseases, stomatology, military field surgery, blood transfusion and other matters. They treated patients in the hospital and the polyclinic, cared for dystrophy sufferers, got the wounded back on their feet, and saw patients with ENT diseases in civilian and military hospitals. The Institute’s research director, V. I. Voyachek, was evacuated to the rear in the summer of 1942. As a result of all the changes there was little research in the winter of 1941–42. An attempt to revive it was made in the summer of 1942 but, in the absence of material on the effect of dystrophy on ENT diseases, a scientific conference held on 5–6 December 1942 was devoted to ENT injuries. Eight research projects dealing with the effect of dystrophy on ENT organs were planned for 1943. The doctors noted that hearing, the vestibule of the ear, the sense of smell and speech were sometimes impaired as a result of starvation and emaciation. The work done in 1942 and 1943 was reflected in Volume VII of the Institute’s Transactions (Sbornik trudov LNII po bolezyam ukha, nosa, gorla i rechi) published in 1944. Volume VIII, which did not appear until 1947, was devoted to hearing and speech disorders. Following publication of the above-mentioned volume, the problem of dystrophy and its effects ceased to attract much attention. Judging from the archives, few war invalids suffered injuries to ENT organs. In 1946 they were only 3.8 per cent of the clinic’s patients and the patient mix was little different than before the war. During the immediate post-war years the Institute’s doctors and researchers were increasingly concerned with restorative therapy. The premises of the Leningrad Neurosurgical Institute were destroyed during an air raid in 1941. The Institute lost almost all its laboratory facilities. However, there was a great need for the rare skills of neurosurgeons in the treatment of the wounded, and the Institute’s clinic was moved into an old school that had long been in a state of disrepair. There, despite the unsuitability of the premises, operating theatres were hurriedly set up and wards with just over 500 beds were organized.46 The staff of the Institute were fully engaged on practical work. All scientific work in 1942 was naturally linked to the treatment of gunshot wounds, and only one of the 16 subjects planned, ‘Cases of avitaminotic polyneuritis’, was directly connected with the conditions of the siege.47 This trend also continued in 1943. The Institute’s publishing activity

1403_901422_06_cha04.qxd

10/6/2004

5:01 PM

Page 105

Andrei Dzeniskevich 105

was also connected with practical activity. A textbook, Osnovy prakticheskoi neirokhirurgii (Principles of practical neurosurgery, 600 pp.), was published in 1943, along with Osnovy voenno-polevoi neirokhirurgii (Principles of military field neurosurgery, 400 pp.) and two atlases of damage to and operations on the spinal cord and the brain. It was probably psychiatrists who were in the most difficult position. They too were confronted with the practical tasks of saving their patients, but those patients were not among those most needed for the defence of the city. That was bound to affect the situation of psychiatric hospitals, doctors and researchers. The hard work of these devoted people was thus all the more praiseworthy. What is also astonishing is that the staff of the V. M. Bekhterev State PsychoNeurological Research Institute continued their research under the conditions of the siege. B. E. Maksimov studied patients suffering from depression between May and December 1942. He considered this to be a disease that ‘in its content and symptom pattern most corresponds to the nature of probable mental reactions to the situation in Leningrad’ and he therefore gave it particular attention.48 He noted the seven most fundamental causes of adverse effects on the psyche and nervous system of people in the besieged city, and also three groups of countervailing positive forces and emotions. His main thesis was that ‘A state of mind characterized by belief in the correctness and ultimate triumph of a guiding idea is a factor of great psychophysical content and importance, one capable of maintaining the entire neuro-psychic organization of both the individual and the entire social group in a state of high tone and vital activity’.49 He considered that ‘the siege increased the frequency and, above all, the acuteness of mental disease’, and he was right.50 Professor V. M. Myasishchev gave the problem a wider setting. In the manuscript of an article entitled ‘Mental disorders in nutritional dystrophy under siege conditions’51 he attempted a more general definition of the link between starvation and the mental disorders of the starving. He considered that mental disorders arising as a result of starvation were intensified and ‘acquire special significance and assume a vivid form under wartime conditions’. In his opinion the number of cases of mental disorders against a background of starvation ‘was very small by comparison with the number of emaciated people’ showing no signs of mental disorders. According to his observations, the number of reactive states increased slightly at the start of the siege. He distinguished ‘stages’ in the occurrence and course of mental illness. Asthenia, accompanied by flaccidity and irritability, a combination of mental stress and inade-

1403_901422_06_cha04.qxd

10/6/2004

5:01 PM

Page 106

106 Medical Research Institutes during the Siege

quate nutrition, developed from October 1941. From January 1942 the number of cases of ‘starvation psychosis’ increased, and from the spring onwards multiple vitamin deficiencies were added to starvation. At the beginning of the summer poisoning from eating wild grasses, roots and so on added to the general causes of mental disorders of the siege period. By the early summer of 1942 the external somatic symptoms of emaciation were ceasing to be a mass occurrence, but mental disorders of a dystrophic nature were still prominent. Subsequently, such disorders gave way to psychoses caused by vitamin deficiency states, especially pellagra. From the end of 1943 mass hypertension and excessive corpulence, especially in women, were noted as a recovery phase following dystrophy. Hypertension and related mental disorders were also encountered in 1944: these Myasishchev regarded as consequences of the siege.52 Myasishchev named the six most obvious links between the physical emaciation of the organism and mental disorder: (1) starvation, (2) mental trauma, (3) disturbance of sleep and excessive muscular tension, (4) cold, (5) war injuries and other injuries, and (6) conditions of health and hygiene (infections).53 All, in his opinion, had some influence on the state of the organism. He wrote that ‘Marked changes in organs, especially the alimentary canal, liver, heart and endocrine glands . . . are a source of abnormal activity and morphological changes in the brain.’54 He made the qualification that there was no direct correlation between the degree of dystrophy and mental disorders. It had not been possible to establish the histopathological characteristics of the ‘mental group’ at this time. His main recommendation for the treatment of these conditions was to eliminate dystrophy, and he noted the great part played by mental activity and ‘as active a state as possible’. He wrote: ‘The experience of the siege has shown that, as in freezing to death or in morphine poisoning, it was those who gave way to the urge to rest who died.’55 Very interesting observations were made by medical practitioners and forensic scientists, but their materials must be saved for a special and more detailed work.

Social research on morbidity Doctors concerned with industrial medicine and trade unions had their own specific approach to wartime morbidity. They retained their usual task of establishing the part played by working conditions and their effect on health. But working conditions were radically changed during

1403_901422_06_cha04.qxd

10/6/2004

5:01 PM

Page 107

Andrei Dzeniskevich 107

the war and especially the siege, with the result that the tasks of these doctors became more varied and complicated. Their work is most fully reflected in the archives of the Leningrad Research Institute of Occupational Hygiene and Diseases. At the start of the war the Institute had a staff of 277, four-fifths of whom were lost through enlistment in the army, evacuation and the starving winter of 1941–42.56 The greatly depleted staff concentrated on serving the workers in defence industries. During the hardest times of the siege they dealt with nutrition, heating, water supply and other matters. The situation within enterprises was severe, the work of many of their medical units was unsatisfactory and the staff of the Institute had to take over all provision of medical services for workers in the defence industries. The first thing necessary was to organize mass medical examination of the workers, but it was not easy to begin. Nobody could quantify the ‘volume of requirements’ to be taken as a basis for verification under conditions of mass dystrophy. Procedures had to be devised for initial and periodic medical examinations. It was not until the end of 1942 that some improvement was achieved in recording and analysing morbidity in defence industry workers. The first attempts at understanding what had happened in the starving winter were made in 1943, but research was not really developed until 1944, when it was broadly conducted along several lines. The pattern of morbidity during the siege years was compared with the prewar period. The most prevalent diseases were studied and their special features under siege conditions were established. Special attention was paid to hypertension, cardiovascular diseases, pulmonary tuberculosis, influenza, skin diseases, rheumatism and malaria. Cases of industrial poisoning were studied separately. The bulk of the research was, however, concerned with the working conditions and health of individual groups of workers. Greatest attention was paid to adolescents, followed by working women, with men in third place, and disabled persons in work and pensioners last. It is understandable that the authorities should have paid attention to adolescents. Losses in industry were huge and post-war recovery was largely dependent on the rapid creation of a new qualified workforce. By the end of 1944 there were more than 10,000 adolescents working in the factories and mills of Leningrad, and their numbers were rising rapidly.57 A large research group in the Institute studied their health and physical development. It was found that the structure of morbidity differed noticeably in adolescents from the average morbidity in adults. The main illnesses in adolescents were influenza, tonsillitis, tuberculosis, impetigo, industrial injuries and injuries in the home. These

1403_901422_06_cha04.qxd

10/6/2004

5:01 PM

Page 108

108 Medical Research Institutes during the Siege

accounted for 74 per cent of all illnesses (61 per cent in adults). General morbidity was lower among adolescents in industry than among adults, but industrial injuries were higher. Analysis of the blood of adolescents who had suffered from starvation, dystrophy and vitamin deficiency revealed hypochromic anaemia.58 It should be pointed out that the examinations took place at different times and covered different numbers of adolescent workers. Young employees in enterprises of the chemical industry did not have exactly the same examination as those in the metallurgical industry. M. L. Rylova noted that the blood pressure of the latter was lower than in prewar data, and that this was more apparent in young men than young girls.59 From the 1946 examinations it emerged that the sexual development of young men was two years behind that of young girls. R. I. Verkhovskaya produced a whole series of articles based on the analysis of a considerable amount of material. She concluded that the impaired physical development of young men was due to the health effects of the war. She also noted that retarded development was greatest in orphans who had lived as adolescents through the siege and occupation.60 A study made in 1950 on more extensive material from throughout the country led her to conclude that not only the victims of the siege, but all adolescents who had experienced the stress of war near the front line and in occupied territory, had retarded physical development.61 In 1950 she analysed the records of ‘in-depth’ medical examinations of 22,000 Leningrad adolescents conducted under a uniform procedure between 1945 and 1949. This material once again confirmed her conclusion that most adolescents who had experienced the impact of war lagged behind their coevals of 1940 in all the respects considered.62 The examinations of adolescent workers provided the material needed for a whole series of measures to improve the health and normalize the physical development of the younger generation. The authorities took the same approach to women workers. The health services were concerned to know whether the female organism could withstand the lot of women in wartime and whether women workers would be able to have healthy children after the war. A series of investigations of women workers in foundry shops was conducted in 1944, but they did not yield much material at this time. Many women workers were suffering from amenorrhoea (which was a general occurrence during the siege, irrespective of place of work) and they had no sex life. No significant gynaecological abnormalities were found, and there was scarcely any hypertension among women working in foundry

1403_901422_06_cha04.qxd

10/6/2004

5:01 PM

Page 109

Andrei Dzeniskevich 109

shops. Because factory doctors carefully selected candidates for foundry shops, gave them regular check-ups and promptly transferred any showing signs of cardiovascular disease to lighter work, only the healthiest remained in the foundries. They suffered less from pulmonary tuberculosis and nervous diseases. However, when the health of female foundry workers was compared with that of men and women working elsewhere in metallurgical plants it was found that they suffered more from influenza and acute gastrointestinal complaints, and had a higher injury rate.63 The observations provided further confirmation of the correctness of pre-war legislation prohibiting the use of female labour in metallurgical plants, but it was impossible to rectify the situation before the end of the war. The medical services did not pay as much attention to men as to adolescents and women. It is a fact that industrial illness considerably increased in the years immediately following the war. As people gradually recovered from excessive nervous and physical overloading, they began to fall sick more often; probably they were paying more attention to their health. Times, however, were harsh and industry was being restored. This created new difficulties which had to be promptly overcome. It was essential under these conditions to record and analyse general illness so as to pinpoint ways of reducing it and increasing labour productivity. This was the start of the mass screening that made it possible to compare sickness rates by sex, age and branch of production. It was found that men were ill somewhat more often than women at this time. Men, for example, suffered from peptic ulcers four times more frequently than women and were ill for far longer. Some observations showed that, with regard to the number of cases and the number of days off work, the first place was taken by infectious diseases (mainly influenza), followed by skin diseases, gastrointestinal complaints, respiratory diseases and injuries. These conditions accounted for about 70 per cent of days off through sickness.64 It was clearly established that middle-aged workers were sick 1.5–2 times more often and for longer. E. E. Grigorev, who devoted a series of works to this problem, wrote: ‘The state of general morbidity, i.e. its level and structure, results from the combined influence of a number of factors, such as the sanitary and technical condition of the enterprise, the sex and age composition of the workforce, the quality of healthcare, living conditions and so on.’65 He found that the state of industrial premises and equipment was of great importance in this context. Damaged workshop walls, broken windows, a low level of mechanization, broken equipment and similar factors had a very serious effect on health. In 1950 he wrote that ‘the

1403_901422_06_cha04.qxd

10/6/2004

5:01 PM

Page 110

110 Medical Research Institutes during the Siege

sanitary consequences of the war are not so quickly eliminated . . . The study of matters concerning the sanitary consequences of the war remains topical and of practical importance.’66 During the siege doctors in Leningrad noted considerable deterioration in the composition of the blood of nutritional dystrophy patients, especially in 1942–43. Research in 1944–48 indicated that the greatest deterioration in men was observed in 1943, and in women in 1944–45. Thereafter the composition of blood gradually improved, and in 1948 it had returned practically to the pre-war level. When carrying out the study the normal haemoglobin level in the blood was taken to be between 70 and 80 per cent. In 1941 it was on average 76.5 per cent in men and 70.1 per cent in women. In 1943 it was 65 per cent in men, 64.3 per cent in women; in 1944 it was 68.6 per cent in men, 62.3 per cent in women; in 1948 it was 72.9 per cent in men, 67.3 per cent in women.67 Most members of the medical profession consider that there was also a considerable reduction in the erythrocyte content of the blood in Leningrad inhabitants during the war. According to M. D. Tushinskii, the reduction was most appreciable in 1942. V. A. Svechnikov calculated that only 22 per cent of patients had a normal erythrocyte level in the blood.68 The haemoglobin and erythrocyte content of the blood was thus considerably reduced during the war among Leningraders, and there was an increase in the number of clear cases of anaemia and a sharp reduction in the number of individuals with high haemoglobin and erythrocyte levels. This was natural and understandable. When the blood of a group of patients was examined it was found that their haemoglobin content was little different from that of all healthy workers examined. At the time the doctors were hard put to it to explain this phenomenon. The researchers of the Leningrad Research Institute of Occupational Hygiene and Diseases did a great deal of work, the results of which were evaluated in 1946 in the Institute by I. G. Lipovich and embodied in a manuscript entitled ‘Sanitary consequences of the war in the area of labour hygiene’. This also covered the health of disabled people working in industry, although it had not been a key topic for researchers.

Military and civilian disability One other group of medical workers had a specific approach to the consequences of the war and the siege, namely the many doctors employed by the Commissions of Medical Referees for Industrial Disability (VTEK) and the researchers of the Leningrad Research Institute on Fitness for Work and the Organization of Work for the Disabled (LIETTIN).

1403_901422_06_cha04.qxd

10/6/2004

5:01 PM

Page 111

Andrei Dzeniskevich 111

Whereas previously the focus was on sickness in the civilian population, attention was now turned to war invalids who, on discharge from hospital, again became part of the population whose problems had to be solved by the health and social services. It is not difficult to understand how great these problems were if it is recalled that 94,837 people were officially registered as disabled in Leningrad between June 1945 and June 1946 (of whom 35,498 were war invalids and 59,339 were disabled ‘by general causes’).69 It should be borne in mind that the population of Leningrad was 920,000 early in September 1944 and 1,240,000 on 1 September 1945.70 Consequently, the population of the city, already appreciably diluted by returning evacuees, by September 1945 included 7.8 per cent who were disabled. Moreover, these were only officially recognized invalids; how many other sick people in need of treatment and rest appeared before the VTEK, but were not granted a disability category, is unknown. The number of invalids in the city had been greatly increased by the war and siege – another tragic consequence of the war confronting the health and social services. The invalids had to be treated and helped to find a new trade or profession if their war injury precluded return to their former employment. In addition, there were suicides in hospital of people unable to bear the abrupt change from being healthy to being a cripple. The crippled had to be given timely assistance to prevent depression. It was essential to know how many disabled people there were in the city, and to classify them by type of injury, degree of disability, fitness for work and so on. This work fell largely to the LIETTIN staff and the district commissions of medical referees. The work begun during the siege was greatly stepped up. The Institute drew up a Five-Year Plan for 1946–50.71 The initial premise of the plan was the need to assist war invalids and sufferers from industrial disability who were fit for work to find their place in the ‘national cause of the restoration of the economy’. This was in full accord with the interests of the state, which had to make the fullest possible use of all labour resources in this very difficult period and required a great deal of research. The Institute’s Five-Year Plan set itself three main tasks: 1. To study the numbers, composition and movements of invalids. 2. To organize ongoing medical examination for disability to take account of the long-term consequences of war injuries and other wartime conditions. 3. To improve the provision of employment for the disabled, through an ongoing study (twice during the five years) of the numbers and composition of the disabled.

1403_901422_06_cha04.qxd

10/6/2004

5:01 PM

Page 112

112 Medical Research Institutes during the Siege

In recognition of the importance of the research envisaged, the government gave the Institute assistance with new premises and more staff. It had already been established in the course of research during the war that the difficulties of finding employment for the disabled were largely dependent on the nature of the injury or illness. The work began with the collection and analysis of material. All material on all invalids was under four headings: (1) ‘Sex and age’; (2) ‘Cause of disability (diagnoses)’; (3) ‘Degree of disability (groups)’; (4) ‘Job placement’. The sex composition is quite typical (Table 4.1). The overwhelming majority of the war-wounded were men, but there were appreciably more women among disabled civilians. The ‘war trend’ was equally apparent in composition by age (Table 4.2).

Table 4.1 Distribution of disabled in Leningrad by sex, July 1945–July 1946 (percentages) War invalids Men Women Total

95.8 4.2

Disabled through general causes 41.0 59.0

100.0

100.0 (72)

Source: TsGANTD SPb, 368/1-1/39, 2.

Table 4.2 Distribution of disabled in Leningrad by age, July 1945–July 1946 (percentages) Disabled through general causes

War invalids Age Up to 19 years old 20–29 30–39 40–49 50–59 60–69 70 and over Total

Male

Female

Both

Male

Female

Both

1.9 32.2 40.8 21.9 – 3.2 –

1.8 45.8 25.9 21.2 – 6.3 –

1.9 32.7 40.1 21.9 – 3.4 –

3.5 9.6 22.3 28.0 28.8 6.9 0.9

1.8 7.6 23.3 38.2 24.7 3.8 0.6

2.5 8.4 22.9 34.0 26.4 5.1 0.7

100.0

100.0

100.0

100.0

100.0

100.0

Source: TsGANTD SPb, 368/1-1/39, 2.

1403_901422_06_cha04.qxd

10/6/2004

5:01 PM

Page 113

Andrei Dzeniskevich 113

There were more young people among war invalids. The difference between military personnel and civilians is also apparent in the causes of disability. More than half (51.4 per cent) of the casualties from the front had diseases and injuries affecting the bones, joints and muscles. Only about a fifth (11.3 per cent) of the disabled civilians had such conditions. Conversely, diseases of the cardiovascular system were ten times more frequent as a cause of disability in industrial invalids. The nervous system suffered more among those at the front (26.7 per cent) than among civilians (13.4 per cent). There was, however, nearly five times more mental illness among invalids from general causes.72 The most serious disabilities (group 1) in casualties from the front were amputations and injuries to both upper limbs (23.7 per cent in group 1), while in those disabled from general causes it was mental illness (29.8 per cent in group 1).73 The largest proportion of those in disability group 2 were sufferers from pulmonary tuberculosis (65.3 and 63.4 per cent).74 The degree of disability was lower in all other injuries and diseases. The material on the placement of people in all three disability groups is interesting. According to the figures of the district commissions of medical referees, 59.5 per cent of war invalids were working, 7.4 per cent were studying and 33.1 per cent were unplaced in a job. Among civilian invalids 63.9 per cent were working, 1 per cent studying and 35.1 per cent unplaced. Even 21 per cent of civilians in disability group 1 were listed as working, although in fact this could not have been the case. The explanation is that when patients came to the commissions of medical referees they were still recorded in their documentation as workers. They were not released from work until they had been placed in disability group 1, and thus they were still classified in VTEK materials as ‘working’. The situation was the opposite for war invalids. On leaving hospital they were classified as disabled and recorded as not working, and were later placed in work in so far as they were strong enough and able to work. It is for that reason that we do not have an accurate and complete picture of the job placement of the disabled in the first year after the war. It can, however, be assumed that invalids in disability group 1 did not as a rule work. The certified reports that the administration of the Institute sent to its hierarchical superiors dealt mainly with aspects of the placement of invalids and the use of highly qualified persons. Such information as we have is, however, sufficient to justify our conclusion that disability was one further grave result and legacy of the war and the siege. It distorted the health and the fate of nearly 10 per cent of the population of Leningrad, crippling them for life, and placed a heavy burden on the

1403_901422_06_cha04.qxd

10/6/2004

5:01 PM

Page 114

114 Medical Research Institutes during the Siege

national economy. That is one further facet of the consequences of the war and the siege.

The sanitary state of the city at the end of the siege During the siege this subject had been the concern of three separate laboratories: communal, food and school hygiene. Their uncoordinated efforts were inadequate under the difficult conditions, and by a decision of the USSR Sovnarkom on 5 August 1944 and an order of the RSFSR People’s Commissar of Health on 26 August 1944 they were merged to form the Leningrad Sanitation and Hygiene Research Institute (LNISGI).75 Because of the government’s awareness of the serious sanitary situation in Leningrad after the siege, the Institute was allocated funds for a staff of 295. It was organized into eleven main departments and eight auxiliary sub-departments (workshops, laboratories, etc.), and required to make thorough studies of and monitor air quality and the planning of built-up areas; soils and drainage; water bodies and water supply; dwellings and public buildings; nutritional physiology; prevention of food poisoning; food hygiene; hygiene in the home, personal hygiene, and the hygiene of pre-schoolers and schoolchildren; and finally the bacteriological state of the city.76 When the Institute was created the laboratories were working with a very depleted staff. Some research had been abandoned. No observations were being made about air quality over the city because all monitoring points on the roofs of houses had been closed during the bombing and shelling. Work began to be resumed in 1944. It was planned to carry out 35 studies on 11 problems. During the siege one of the most urgent tasks had been to monitor the condition of water supplies. During the siege certain rivers and canals in the city had become a temporary source of water for the population, although that was precisely the time when they could be contaminated by the considerable quantity of impurities. Sanitary, chemical and bacteriological examination of the Zhdanovka, Moika and Karpovka rivers between May 1943 and February 1944 showed that, although the population was considerably reduced, extensive damage to the sewage system had resulted in the rivers becoming heavily polluted and contaminated to an even greater extent than in the bad year of 1926. The Griboedov and Obvodnyi canals were the most bacteriologically contaminated of all the water sources examined.77 Open sources from which water was drawn for the production needs of factories and plants were the greatest cause of concern to the sanitary services. Roughly 75 per cent of all enterprises had such water

1403_901422_06_cha04.qxd

10/6/2004

5:01 PM

Page 115

Andrei Dzeniskevich 115

supplies, and they were extremely polluted because of improperly constructed sewers.78 When such water bodies were tested for bacteria and E. coli in 1943 they were found to be in a very poor state. The situation improved a little after the lifting of the siege, but bacterial content remained above the permitted levels.79 Piped water was naturally of even greater concern. Extensive damage to the water mains in all districts of the city and repair work had led to a great deterioration in water quality. Systematic monitoring was conducted in ten districts. Samples were taken and analysed daily (except on Sundays) between May 1942 and 31 December 1944. When 1,218 bacteriological analyses were made in 1942, 88 instances of contamination by E. coli were found (7.1 per cent of all samples). The highest incidence of contamination (20 per cent) was in May 1942. Water quality deteriorated in the winter, following heavy frosts and destruction of the piped water network, but improved in the summer. When 3,050 water samples were taken in 1943, E. coli was found in 310 (10.1 per cent). In 1944 the situation had improved and E. coli was found in only 3.7 per cent of 2,892 samples, but the problem of water monitoring and purification remained quite serious.80 The monitoring of air quality was resumed at the same time. Investigations were conducted in five places: in the Petrograd district, in Vyborg district, on Krestovskii Island, and in the Smolnyi and Kirov districts. Air pollution was naturally lowest on the outskirts and increased on approaching the city centre. In the Kirov district air pollution was lower than had been recorded in 1935 because its industrial giant was only just beginning to be restored (eight times lower on Stachek Avenue close to the Kirov Works). Seasonal contamination of the air had also changed. Whereas before the war the situation had deteriorated in the last and first quarters of the year, the greatest atmospheric pollution in 1945 was found in April–August. The explanation was that there had been extensive construction and repair work in the summer, and also that general water spraying of the streets and courtyards of the city had still not been organized. The checkpoint in Starorusskaya Street (apartment block No. 3) was the dustiest and most smoke-laden of all points monitored.81 Another problem of concern to doctors of the Sanitary Inspectorate after the siege was the condition of the soil and soil-cleansing processes. The state of mass burial sites was especially alarming. Specialists were worried about the threat of epidemics. Research was begun in the autumn of 1942, and continued in 1943 and 1944. Three cemeteries were monitored: Serafimovskoe, Piskarevskoe and Bogoslovskoe. The Smolenskoe cemetery was added in 1944. During 1942–44 141 inspection pits were dug and 4,416 primary soil samples were taken, along

1403_901422_06_cha04.qxd

10/6/2004

5:01 PM

Page 116

116 Medical Research Institutes during the Siege

with 48 groundwater samples, 52 samples from ditches and streams, and three from wells in the vicinity of cemeteries. Both the soil and the water were found to be heavily contaminated. Water in the drainage ditches and streams around the Piskarevskoe cemetery did not begin to be cleaner for a distance of 400–600 metres from the burial sites. Water from wells 70–100 metres from the mass grave was in the heavily polluted category. The same result was obtained from analyses of soil and groundwater samples taken 50 metres away from the graves.82 At the end of 1944 researchers of the Institute felt obliged to note that ‘the processes of self-purification and mineralization of the soil surrounding the trenches are still not complete’, were proceeding irregularly and must continue to be monitored for a number of years.83 Space does not permit examination of all 35 research projects on 11 problems, but a few that are most important for an understanding of the effects of the war must be mentioned. An analysis of food poisoning during the siege carried out by Z. A. Ignatovich is particularly interesting. According to his data, only 2–6 per cent of food poisoning before the war was chemical in origin; the rest was bacteriological. Cases of food poisoning of a chemical nature were already 33 per cent of the total in the latter half of 1941, 86 per cent in 1942, and 93 per cent in 1943.84 Most instances of chemical poisoning occurred outside the public catering network and resulted from starvation and the fact that the public was ill-informed. As Ignatovich wrote, most cases were of an isolated nature (henbane roots, tung oil, calabar beans etc.). Bacteriological poisoning usually affected groups. A simultaneous study was made of the connection between inadequate nutrition and changes in the intestinal microflora. This was of importance for its bearing on normalization of the state of people who had survived starvation. Three population groups were studied. The first consisted of workers and office staff who had been given the standard diet; the second had been fed an unspecified diet (ten had returned from Samarkand and were taken as a control group); the third consisted of employees of a dairy plant and the sausage-making section of a meat combine. The data obtained showed that the state of the intestinal flora was clearly dependent on the quality of the diet. The intestinal flora had returned to normal least in workers on the standard diet, was slightly better in those on the unspecified diet, but many times better in workers of the sausage-making section.85 The greatest attention was paid to the diet of children. Even in 1942, when things had been very difficult, the diet of children in nurseries had been constantly monitored by staff of the school sanitary labora-

1403_901422_06_cha04.qxd

10/6/2004

5:01 PM

Page 117

Andrei Dzeniskevich 117

tory. They noted ‘slight’ fluctuations in diet in 1942–44, commenting that in 1943–44 the children had been given more vegetables and thus ‘had been better supplied with vitamins and salts of a basic nature’. The fact that children had, relatively speaking, been ‘properly fed’ was confirmed by school doctors, who did not find vitamin deficiency conditions and increased frequency of common illnesses in groups from the Leningrad nurseries.86 This opinion was widely prevalent during the siege; the situation of the children seemed relatively favourable against the background of general starvation. At this time, however, survival was the main criterion. The after-effects of the systematic feeding of children on poor-quality food had not then been established. The first warning symptoms would appear in 1945. In December 1945 E. T. Fedorova, deputy chair of the Leningrad Soviet, received a detailed memorandum signed by M. Ya. Nikolaev, director of the Leningrad Sanitation and Hygiene Research Institute, and by Professor A. Ya. Gutkin. It sounded the alarm in the opening paragraph: ‘The condition of children of Leningrad investigated in 1945 by LNISGI, the Republican Paediatric Institute and the Turner Institute is a cause for concern.’ The study had in fact revealed that 36.5 per cent of children up to five years of age in five districts of the city centre were suffering from rickets (3,132 children examined). The condition affected 50 per cent of children between 6 and 12 months old, and 51.4 per cent of children in their second year. It was not only children of nursery school age who were suffering; those of pre-school age were also affected. In Kuibyshev district rickets affected 33.4 per cent of threeyear-olds and 32.3 per cent of 4-year-olds.87 It was found that 85.4 per cent of schoolchildren had curvature of the spine (60 per cent before the war), and that the condition needed lengthy therapeutic correction in 9–14 per cent of cases (1–2 per cent before the war). The number of children with dental caries had also increased. In Kuibyshev district only about 5 per cent of the children examined had healthy teeth. The number of bad teeth per child was from two to four. The authors of the memorandum wrote: ‘The condition of the teeth is an indication of the extent to which the organism is provided with essential “building materials” – calcium and phosphorus – and of the overall state of the bone tissue, which is important from the standpoint of the growth functions of the organism.’88 When nearly 500 children in nurseries of the Petrograd district were screened for tuberculosis, between 9 and 18 per cent were found to be infected, as were between 21 and 25 per cent of 314 children in nursery schools. Medical specialists concluded that ‘deficient nutrition and an

1403_901422_06_cha04.qxd

10/6/2004

5:01 PM

Page 118

118 Medical Research Institutes during the Siege

unsatisfactory and undifferentiated hygienic and educational health regime for children of different ages had played the most significant role’. LNISGI studied the food value of the established diet for children and the correctness of the regime in Leningrad schools. There were at the time seven dietary standards for younger children, schoolchildren and older children (in the care of the state). The specialists concluded that ‘the dietary standards are not differentiated’. Up to 12 years of age all children received the same ration – 1,148 calories. Children below school age in children’s homes received 2,318 calories, and boarding school children received 2,353 calories. The doctors also considered that the question was not merely one of calorific content, but of different age-related needs for protein, mineral salts, vitamins and so on. Protein amounts were around the physiological norm in kindergartens and children’s homes, but the diet of other children was deficient in protein by between 10 and 43 per cent. The pattern was the same for mineral salts. There was a deficit of those most essential for the child’s organism – the salts of calcium, phosphorus, iron and magnesium needed to build bone and muscle, that promote the normal composition of the blood, increase resistance to infectious diseases and prevent rickets, dental caries and tuberculosis. None of the wartime diets for children contained sufficient mineral salts: calcium salts were 50–60 per cent below the physiological norm and phosphorus salts 30–50 per cent below.89 Children were seriously lacking in vitamins, especially A and D. The physiological requirement for vitamin A was only 12–25 per cent satisfied, and the situation was worsened by the inadequate amount of fats in the diet, without which even the small amount of vitamin A could not be fully assimilated. In conclusion, the memorandum set out a programme of essential measures to rectify the situation. The main point to be emphasized is that doctors had already at that time established the causes of the diseases and retarded development of children. The work was intensively pursued, and some successes were achieved in protecting the young generation of survivors of the siege. The health of schoolchildren in the age range 7–18 years was investigated in November–December 1945. The planned coverage was 20,000 children, but the final number of medical cards processed was only 11,735 (5,979 boys and 5,756 girls).90 Some cards were not used by the Institute’s researchers because of mistakes or because they had been carelessly completed. When A. Ya. Gutkin reported on the health of schoolchildren at a conference in February 1946 he expressed some disbelief in the materials of the study in connection with ‘the inadequate diag-

1403_901422_06_cha04.qxd

10/6/2004

5:01 PM

Page 119

Andrei Dzeniskevich 119

nostic training of many school doctors’. Even so, some provisional conclusions were drawn. It was found that 89.1 per cent of the schoolchildren surveyed were healthy (80.9 per cent of boys and 94 per cent of girls). Percentage fitness moreover was higher among older children. The conditions especially singled out were heart disease (including organic defects), tuberculosis of the hip and the vertebral column, and anaemia. Abnormalities of sight and hearing were considerably more frequent in boys than in girls. Defective development of the thorax and curvature of the spine were found in boys but were virtually absent in girls. The doctors were particularly disturbed by deformation of the thorax in seven-year-old children, which could have been caused by rickets.91 Specialists concluded that there was a need to keep the same groups of children under ‘dynamic observation’; this was then done fairly systematically. The state of health of the adult population was also a cause of concern. LNISGI researchers therefore tried to monitor the sanitary state of districts and morbidity throughout the city. This, however, required a great deal of statistical information, including the size and composition of the population, natural population movements, sicknesss rates and causes of death, which was precisely the information that doctors did not have for the city as a whole. Although the problem was repeatedly discussed within the Institute, it could not be solved at that level. At a scientific conference in May 1947 Professor Z. G. Frenkel
stated that the work of specialists was made very difficult by the lack of adequate statistics. At that time there were already maps of a general record of sickness rates in Moscow, but none in Leningrad, where they were particularly needed after the siege. The Institute’s researchers were unable to obtain data on deaths with an indication of the causes of death. ‘A sanitary organization ought to know the pattern of morbidity in order to monitor the environment and modify the conditions responsible for sickness’, said Frenkel.92 A paradoxical situation had arisen in which the authorities had created and maintained a large institute with a staff of 300 researchers who were unable to carry out their main duties for lack of the statistical information required. The causes of this situation are beyond the scope of the present study. The important thing to note is that it was impossible under the conditions then obtaining to examine the consequences of the siege and its effect on morbidity. Work continued on particular aspects of the problem. Already in 1943 there was research on ascorbic acid and carotene in the workers and office staff of four enterprises and several institutions: 2,591 tests to detect ascorbic acid in the blood and 1,561 tests for carotene were made

1403_901422_06_cha04.qxd

10/6/2004

5:01 PM

Page 120

120 Medical Research Institutes during the Siege

during the year. In 1947 A. I. Ivanova supervised the screening of 640 people. The work was carried out in the same places as in 1943 and, in the main, on the same people. The 1943 study had shown that ascorbic acid was ‘virtually undetectable’ in the blood of Leningraders throughout the winter and spring, and only began to ‘increase slightly’ in the summer and autumn, following the appearance of fresh vegetables. Standard amounts of ascorbic acid were found in the blood of 42 per cent of those screened in March–June 1947, and in 60 per cent in the autumn (November 1947).93 It had thereby been established that none of those screened a year after the siege had a normal amount of ascorbic acid in their blood, and only in 1947 (i.e. in the fifth year after the winter of starvation!) was the level back to normal in a half of those screened. It is reasonable to assume that such a situation must have affected the restoration of the health and strength of those who had survived the siege and starvation. Some time after the end of the war another observation was made of the state of the soil and ground water in the city cemeteries where mass burials had taken place. Already in 1947, however, there were sharp differences of opinion between specialists on the effect of mass graves on the soil and ground water. Many researchers noted that the ground was far more heavily polluted in the streets and courtyards of the city than in the cemeteries. Physical and chemical studies of the soil showed pollution to be steadily on the increase in the streets and courtyards. L. N. Simanovskii wrote that ‘The main cause of soil and groundwater pollution is the state of the sewage system and of street cleaning. All authors concur that the radical cleansing of the soil of Leningrad requires the provision of a full separate sewage system for the entire city and a reliable refuse-collecting system.’94 Once again study of the consequences of the war was gradually pushed into the background by the acute problems of post-war recovery which had to be solved without delay. Even this brief review of the activity of medical researchers during the war and the siege shows that their work, although not as systematic and planned as before the war, did not cease. Science was mobilized to defend the city, and its main responsibility was to find a rapid solution to the problems constantly arising in the struggle to save the city and its people. Only after the siege had been lifted and the situation in the city stabilized did the work of doctors begin to return to normal. But the war itself had given rise to many problems that came to a head during the first few post-war years. This, combined with the effects of the Cold War, came to dominate the work of medical researchers – which may explain why study of the long-term consequences of siege was not continued as it should have been in the post-war period.

1403_901422_06_cha04.qxd

10/6/2004

5:01 PM

Page 121

Andrei Dzeniskevich 121

Notes 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49.

Gladkikh (1980), 20. TsGAIPD SPb, 4000/10/355, 10. TsGAIPD SPb, 209/1-1/99, 2. TsGANTD SPb, 284/1-3/96, 5. TsGANTD SPb, 284/1-3/104, 14–16. TsGANTD SPb, 284/1-3/104, 17. TsGANTD SPb, 284/1-3/104, 4. Leningrad v osade (1995), 198–9. TsGANTD SPb, 284/1-3/104, 18. TsGANTD SPb, 284/1-3/96, 2. TsGANTD SPb, 284/1-3/100, 1–4. TsGANTD SPb, 284/1-3/200, 1–2. TsGANTD SPb, 284/1-3/118, 9. Leningrad: Entsiklopedicheskii spravochnik (1957), 567. TsGANTD SPb, 284/1-3/190, 1–19. TsGANTD SPb, 284/2-1/872, 9–10. TsGANTD SPb, 182/1-1/752, 12–34. TsGANTD SPb, 182/1-1/787, 4. TsGANTD SPb, 182/1-1/793, 8 ob. TsGANTD SPb, 182/1-1/799, 1-1 ob. TsGANTD SPb, 182/1-1/824, 2. TsGANTD SPb, 211/l-2/57, 1. TsGANTD SPb, 295/2-1/261, 13. TsGANTD SPb, 295/2-1/62, 4. TsGANTD SPb, 295/2-1/62, 9. TsGANTD SPb, 295/2-1/62, 12. TsGANTD SPb, 295/2-1/62, 18–19. TsGANTD SPb, 295/2-1/99 a, 4. TsGANTD SPb, 295/2-1/118 b, 3–4. TsGANTD SPb, 295/2-1/118 b, 5. TsGANTD SPb, 295/2-1/118 b, 8. TsGANTD SPb, 295/2-1/108, 2. TsGANTD SPb, 295/2-1/114, 56. TsGANTD SPb, 295/2-1/114, 58. TsGANTD SPb, 295/2-1/118 b, l72. TsGANTD SPb, 295/2-1/158, 2–3. TsGANTD SPb, 173/1-2/28, 164. TsGANTD SPb, 173/1-2/38, 1 b, 28. TsGANTD SPb, 173/1-2/38, 1 b, 14. TsGANTD SPb, 173/1-2/38, 1 b, 22. TsGANTD SPb, 173/1-2/38, 1 b, 23, 24. TsGANTD SPb, 173/1-2/38, 1 b, 36. TsGANTD SPb, 173/1-2/49, 1. TsGANTD SPb, 173/1-2/56, 1. TsGANTD SPb, 156/1-1/91, 1. TsGANTD SPb, 301/1-1/64, 1. TsGANTD SPb, 301/1-1/61, 2. TsGANTD SPb, 313/2-1/182, 2. TsGANTD SPb, 313/2-1/182, 7.

1403_901422_06_cha04.qxd

10/6/2004

5:01 PM

Page 122

122 Medical Research Institutes during the Siege 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71. 72. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83. 84. 85. 86. 87. 88. 89. 90. 91. 92. 93. 94.

TsGANTD SPb, 313/2-1/182, 28. TsGANTD SPb, 313/2-1/182, 231. TsGANTD SPb, 313/2-1/182, 2. TsGANTD SPb, 313/2-1/182, 9. TsGANTD SPb, 313/2-1/182, 10. TsGANTD SPb, 313/2-1/182, 15. TsGANTD SPb, 221/2-1/79, 1. TsGANTD SPb, 221/2-1/92, 1–2. TsGANTD SPb, 221/2-1/513, 7. TsGANTD SPb, 221/2-1/513, 7–8. TsGANTD SPb, 221/2-1/66, 11. TsGANTD SPb, 221/2-1/68, 1. TsGANTD SPb, 221/2-1/68, 2. TsGANTD SPb, 221/2-1/184, 2. TsGANTD SPb, 221/2-1/133, 13. TsGANTD SPb, 221/2-1/133, 29. TsGANTD SPb, 221/2-1/135, 1. TsGANTD SPb, 221/2-1/135, 3. TsGANTD SPb, 221/2-1/135, 12. TsGANTD SPb, 368/2-2/39, 1. Ocherki istorii Leningrada (1967), vol. 5, 486. TsGANTD SPb, 368/1-1/39, 1–12. TsGANTD SPb, 368/1-1/39, 3. TsGANTD SPb, 368/1-1/39, 6. TsGANTD SPb, 368/1-1/39, 7. TsGANTD SPb, 285/1-1/4, 1. TsGANTD SPb, 285/1-1/4, 1, 1 ob. TsGANTD SPb, 285/1-1/4, 21 ob. TsGANTD SPb, 285/1-1/4, 7 ob. TsGANTD SPb, 285/1-1/4, 8. TsGANTD SPb, 285/1-1/4, 7. TsGANTD SPb, 285/1-1/11, 125. TsGANTD SPb, 285/1-1/4, 14 ob. TsGANTD SPb, 285/1-1/4, 15. TsGANTD SPb, 285/1-1/4, 30. TsGANTD SPb, 285/1-1/4, 32. TsGANTD SPb, 285/1-1/4, 34. TsGANTD SPb, 285/1-1/12, 1. TsGANTD SPb, 285/1-1/12, 1. TsGANTD SPb, 285/1-1/12, 3. TsGANTD SPb, 285/1-1/16, 12. TsGANTD SPb, 285/1-1/16, 7–8. TsGANTD SPb, 285/1-1/23, 25. TsGANTD SPb, 285/1-1/26, 76–7. TsGANTD SPb, 285/1-1/26, 49, 50.

1403_901422_07_cha05.qxd

10/6/2004

5:03 PM

Page 123

5 Physiological and Psychosomatic Prerequisites for Survival and Recovery Svetlana Magaeva

During the war the people of Leningrad had to endure a situation that went far beyond the bounds of anything previously experienced by anyone. Despite the fact that starvation killed more than half a million people, several hundred thousand Leningraders succeeded in surviving under conditions so extreme as to seem incompatible with life, and did so against all scientific opinion on minimum food requirements. Why and how they were able to survive are enigmas that have attracted the attention of biologists and physiologists, doctors and psychologists, historians and writers. Analysis of this question can help to disclose the latent reserves of the organism manifested by some people in extreme situations, and can help explain how and why they survived. The time for finding answers is fast running out. Elderly victims of the siege are passing away, taking with them the secret of the body’s amazing resistance. Children born in the besieged city are now growing old. The time for studying those characteristics of the organism responsible for resistance to the ferocious hunger and the mental and emotional stress of the daily threat to life has passed, but we still have the invaluable writings of eye-witnesses to the tragedy of the siege. Doctors and researchers, themselves exhausted by hunger, made clinical and laboratory observations on the state of the exhausted organism. Medical associations were functioning in the besieged city, discussing urgent problems of assistance to sufferers from nutritional dystrophy and publishing scientific works, all in the name of life. This was heroism on the part of the doctors and scientists of Leningrad, whose thoughts are central to the analysis of survival in the siege. What happened in Leningrad suggests that the human organism possesses reserve capabilities unknown to science that are manifested when the situation is extremely serious. The present author was convinced by her own experience of the 123

1403_901422_07_cha05.qxd

10/6/2004

5:03 PM

Page 124

124 Prerequisites for Survival and Recovery

possibility of surviving critical nutritional dystrophy at the very limit of what has been termed minimal life. Analysis of the prerequisites for survival must start with the individual characteristics of the reactions of the organism under extreme conditions. The state of health of the overwhelming majority in the besieged city was gravely affected by three main factors: ferocious hunger, cold and living daily through the mental and emotional stress of the threat to life. Any one of these factors would in itself have caused partial or complete loss of health, but their interaction was simultaneous and prolonged and their effect mutually intensifying. Hunger and cold seriously affected both soma (body) and psyche (state of mind). The excessive mental and emotional stress modified both, disrupting the innate psychosomatic interactions of the normal organism. Consequently all three pathogenic factors were mutually reinforcing, and this worsened the disruption of vital functions. Starvation resulting in nutritional dystrophy was the decisive factor in the severe, frequently fatal pathology of victims of the siege, but it should be recognized that nutritional dystrophy developed against a background of preceding mental and emotional stress. Starvation developed in the second month of the siege, at a time when life was already under constant threat. In this connection analysis of the survival rate may appropriately begin with the individual characteristics of mental and emotional stress upon which the general state of the organism at the onset of starvation was largely dependent.

Mental and emotional stress resulting from the dangers of war Throughout the siege, that is, for nearly two and a half years, the people of Leningrad were in a chronic state of chronic mental and emotional stress brought about by the ever-present dangers of war, losses of relatives and friends, shelling, bombing and fear for family life. There were 612 air raids between June 1941 and October 1943. Shelling and bombing were responsible for more than 50,000 casualties: 16,747 dead and 33,782 wounded.1 The state of siege, shelling and bombing, hunger and fear for the lives of family and friends and for the fate of the city gave rise to extremely strong and long-lasting mental and emotion stress,2 the severity of which differed, depending on individual predisposition to mental and emotional excitation, the activity of natural stress-limiting systems, and

1403_901422_07_cha05.qxd

10/6/2004

5:03 PM

Page 125

Svetlana Magaeva 125

also the ability of the organism to adapt to stress pressures.3 The severity of stress in response to outwardly identical factors differs markedly according to the individual, ranging from a state of alarm to mental disorders, and reflecting stages of mental and emotional stress that may be physiological, transitional or pathological.4 Physiological stress is accompanied by functional activation of systems and organs in response to changed environmental conditions that require functional effort for physical or mental activity. It increases the capability of the organism to cope with a previously unbearable physical load and mental and emotional stress, and it increases resistance to potentially pathogenic factors by the development of adaptation to the new situation. Will-power, which creates lasting motivation to survive and maintains psychosomatic influences at nearly normal levels, is important in the phenomenon of physiological, mental and emotional stress. In transitional stress states the organism is not fully adapted and resistance to potentially pathogenic factors is inadequate and unreliable. The lack of any appreciable increase in the frequency of mental disorders indicates more or less reliable adaptation to severe mental and emotional effects. Psychiatrists were astonished to note that, despite predictions, there was no such increase in the latter half of 1941 relative to the pre-war period. The number of patients hospitalized in 1942 with various nosological forms of mental illness increased by only a few per cent to 15 per cent, against 11.5 per cent in 1940. Hospitalization for psychopathy increased when shelling and bombing were especially severe, late in 1942 and in the first and second quarters of 1943, respectively to 18.8, 26 and 24 per cent.5 Pathological stress is severe tension affecting adaptation, accompanied by functional disorders of systems and organs essential to life. In pathological stress there is loss of adaptation to the stressor situation. Lack of adaptation to mental and emotional factors results in disturbance to psychosomatic regulatory effects, which worsens accompanying bodily diseases and increases susceptibility to pathogenic factors. Reasoning in terms of the ways in which the mental sphere is protected from stress factors, it may be assumed that the severity of wartime mental and emotional stress was limited to some extent by the activation of natural stress-limiting systems. Prompt activation of these systems limits the stress reaction in strength and duration, and thus prevents or weakens its pathogenic effect.6 As a result of adaptation the organism acquires resistance to extreme environmental factors and is able to exist under conditions, such as those of the blockaded city, pre-

1403_901422_07_cha05.qxd

10/6/2004

5:03 PM

Page 126

126 Prerequisites for Survival and Recovery

viously incompatible with life. There can be no doubt that such adaptation did occur, as follows from the very fact of continued existence even in the worst period of starvation and attack from the air. The survival of several hundred thousand victims of the siege is convincing proof. Life cannot persist under conditions of starvation and excessive mental and emotional stress unless there is quite pronounced adaptation. To remain alive and physically and mentally healthy the people of Leningrad had to adapt to the two pathogenic factors: mental and emotional stress and starvation. Although there may be doubt over adaptation to extreme hunger, some degree of adaptation to an emotional stressor is possible. It is of basic importance that the first of these factors preceded the second by three months, since intensification of protein synthesis is essential for long-term adaptation, and that is impossible under conditions of protein deficiency.7 It may be assumed that many (if not all) of those who survived the siege had adapted to some extent to mental and emotional stress before the onset of severe protein deficiency. Adaptation processes are known to begin immediately after the onset of a stressor effect on the basis, in the early stages, of such existing physiological mechanisms as the redistribution of energy and metabolic resources to the organs and systems undergoing adaptation. This produces so-called immediate adaptation, which arises quite quickly but is not very reliable. It does, however, leave a significant functional and structural trace and may, on repetition of the stressors, be transformed into more perfected long-term adaptation, ensuring fairly reliable resistance to pathogenic effects previously incompatible with life.8 When adaptation is adequate resistance is increased, not only to the factor to which the organism has adapted, but to the pathogenic factors that could previously have had an effect incompatible with life. There are grounds for the assumption that the development of adequate adaptation to mental and emotional stress in the period preceding starvation may have helped to increase resistance to the ensuing extreme situation. It must be assumed that the possibility of survival was largely determined by individual characteristics dependent on various factors, namely: • the state of the psyche and personality traits • a genetic or acquired predisposition to mental and emotional stress • a genetically conditioned or acquired level of activity of the natural stress-limiting systems of the organism

1403_901422_07_cha05.qxd

10/6/2004

5:03 PM

Page 127

Svetlana Magaeva 127

• the degree and reliability of non-specific adaptation to stressor effects. The severity of the mental and emotional stress of a constant threat to life was dependent on individual personality traits: the degree of selfcontrol, the degree of alarm and the development of an exhausting feeling of fear. Those who acutely felt alarm and fear were a group at high risk of developing disturbances of the systems and organs,9 of psychosomatic disorders, against the background of which nutritional dystrophy could take a more severe course.

Psychosomatic disorders The dependence of general bodily state on mental status is conditioned by the existence of a close interaction between the mental and somatic spheres. The somatic systems are the nervous, endocrine and immune systems that ensure the regular functioning of systems and organs and maintain homeostasis, and also the internal organ systems that ensure the vital functions: respiration, circulation, digestion, excretion, motion, motor activity and reproduction. Pathological stress arises if the parameters of mental and emotional stress exceed the physiological measure of the reaction of the organism. Excessive mental and emotional stress may result in disruption of the central nervous regulation of somatic systems and the development of functional organic disorders. Such disorders are connected in origin with changes in mental status, but are essentially psychosomatic.10 Psychosomatic medicine is a developing discipline confronted by the difficult basic problem of how mental influences are transmitted to somatic systems. It is because insufficient attention has been paid to this problem that psychosomatic disorders have not yet been accorded the importance that they merit. That is unjustified, because the mental component may be a significant or even fatal factor in somatic disorders. Changes in mental state are reflected in the functional activity of organs and tissues, and even of the freely moving cells of the immune system. There is convincing evidence for this in the depressed activity of the cells providing the first line of defence against tumours for a few days before a comparatively simple surgical operation (routine herniotomy) or before a first parachute jump.11 The mental and emotional factor may produce a sudden shock resulting in death. Such a shock caused by mental trauma was experienced by several people in Leningrad who

1403_901422_07_cha05.qxd

10/6/2004

5:03 PM

Page 128

128 Prerequisites for Survival and Recovery

were eye-witnesses of death and destruction in the target area of shelling and bombing. Some who suffered no physical injury were so gripped by fear that they died, and medical care was far from always effective. Cases of sudden death associated with acute exposure to seemingly fatal danger are known to peacetime medical practice. Specialists in psychosomatic medicine assume that ‘voodoo deaths’ among African and Australian native peoples, linked to despair and absolute certainty of the irreversibility of violent death for breaking a taboo, are a clear instance of the catastrophic manifestation of mental and emotional stress in the somatic sphere. A similar phenomenon is involved in cases of sudden death in a courtroom upon hearing the death sentence, and of death following erroneous auto-suggestion of mortal danger, or overhearing a doctor’s opinion that a condition is irreversible, that may or may not be confirmed on autopsy. There are known instances of sudden death from the acute mental and emotional impact of the death of relatives and friends.12 Neural mechanisms are involved in the mediation and implementation of mental influences on the somatic system through the neuroregulatory apparatus located in specific structures of the brain and functionally interconnected with the apparatus of the emotions. Mental and emotional influences conveyed by neuromediators, hormones and regulatory neuropeptides are normally transmitted to the appropriate organ system and modify activity qualitatively and quantitatively in line with the environmental influence. Changes in the functioning of somatic systems triggered by positive and negative emotions (palpitations, a ‘sinking’ heart, hurried or slowed breathing etc.) are familiar phenomena. Neuroregulatory pathology is the neurological basis of psychosomatic disorders. Academician G. N. Kryzhanovskii of the Russian Medical Academy coined the term ‘regulatory disease’ for a wide class of diseases caused by disturbance to the neuroregulatory apparatus of organ functioning, contrasting it to another class consequent upon the diseased state of the organ.13 Depending on its localization, the generator forms pathological systems of the neurological and/or somatic syndrome involved. The excessive mental and emotional stress arising from the threat to life created the real prerequisites for the regulatory pathology of visceral systems and organs. The pathogenetic mechanism involved – the generator of pathologically intensified excitation – arises in the parts of the brain responsible for shaping the emotions.14 The key to this system, the hypothalamus, is the main link in the neuroregulatory apparatus of vis-

1403_901422_07_cha05.qxd

10/6/2004

5:03 PM

Page 129

Svetlana Magaeva 129

ceral functions. The neural apparatus that shapes the emotions and the regulatory apparatus of somatic functions are closely interconnected and have some links in common. Limbic–diencephalic influences are mediated by the pituitary–adrenocortical system through which the key mechanism of stress, especially mental and emotional stress, is realized.15 The significance of excessive nervous stress for somatic pathology has been demonstrated in laboratory research on animals by primary modelling of emotional stress from which somatic disorders arise.16 It may assumed that the localization of such disorders will be dependent on an initial individual predisposition for disturbance to the regulation of some given organ. Individuals with a very unbalanced and weak nervous system will be most susceptible to psychosomatic disorders. Hypertension was one of the first such manifestations in the period preceding starvation; that its frequency increased during the first three months of the war, compared with 1940, may be put down to the excessive stress of war dangers.17 Menstrual disorders were also a manifestation of psychosomatic disorders in the period before starvation.18 Almost all (99 per cent) women questioned complained of missed periods (amenorrhoea), usually in August–September 1941, that is, in the early months of the blockade, before the famine. Persistent amenorrhoea among victims of the siege is a clear indication of disturbance to psychosomatic influences and its mass occurrence justifies the view that the early mental and emotional stress adversely affected the organism before the famine. It may be assumed that such disorders were not confined at this time to amenorrhoea, but that they remained unnoticed because there was no special research on the health of the besieged population. The only disorders recorded were those that could not be missed. Neuroregulatory disorders could have contributed to the fainting fits and comatose states that occurred in the initial period of starvation, before emaciation. Particular proneness to such states was a feature of November 1941. People of working age, who were not emaciated, had not previously complained of fatigue and generally felt fairly well, suddenly fainted at work. In some instances fainting gave way to coma, the direct cause of which was found to be an abrupt and sharp decline in blood sugar level, to 20–25 mg per cent. Prompt infusion of large doses of glucose brought the patient out of coma.19 In the absence of prompt attention such patients died, but not from emaciation. The decline in blood sugar level could have been initiated by carbohydrate deficiency in the diet, in conjunction with intensive energy expenditure. In the normal regulation of carbohydrate metabolism an incipient reduction

1403_901422_07_cha05.qxd

10/6/2004

5:03 PM

Page 130

130 Prerequisites for Survival and Recovery

in sugar content is compensated by routine splitting of hepatic glycogen to sugar discharged into the bloodstream, which restores the sugar level in the blood and its consumption by cells of the brain, the heart and other organs. The disruption of psychosomatic influences could have upset the regulation of carbohydrate metabolism, especially in those with hereditary or acquired predisposition to such a state. There are, therefore, grounds for the assumption that the neural regulation of various systems and organs was to some extent affected in many (if not all) Leningraders by the start of the famine. The extent to which psychosomatic disturbances were manifested was determined by the severity of the mental and emotional stress and individual predisposition to the disturbed functioning of any given organ. It may be assumed that those in a state of acute mental and emotional stress when the famine was beginning were a group at high risk of heightened susceptibility to the severe bodily disorders linked to the ensuing starvation. During the famine the mental and emotional factor interacted with the dystrophic factor, affecting the course and outcome of nutritional dystrophy.

The discrepancy between food supplied on the ration and the vital minima Rationing was introduced in the latter half of July 1941. Initially the rations were adequate, at least in amount, to the food requirement, and people did not go hungry, but supplemented their rations with food left over from the pre-war period. The calorific value and quality of the diet declined steadily and by November no longer corresponded to scientific views on vital physiological levels. In the latter half of November the amount of protein in the food of the civilian population had fallen to 10 g a day, and the daily ration in civilian and military hospitals was around 30 and 50 g, whereas the daily protein content to maintain normal vital activity should have been 70–90 g.20 By the standards laid down by the Institute of Nutrition of the USSR Medical Academy, the optimum daily dietary protein intake should have been respectively 100–110 g, 120 g, and 150–160 g to ensure normal vitality with an energy expenditure of 3,000–3,200 kilocalories (kcal), 3,500 kcal and 4,500 kcal. For the growing organism the corresponding amounts per kg of body weight should have been 3.5–4.0 g for children 3–7 years old, 3–3.5 g for children between 7 and 10 years old and 2.5–3 g for children between 10 and 14 years old.21

1403_901422_07_cha05.qxd

10/6/2004

5:03 PM

Page 131

Svetlana Magaeva 131

From 20 November 1941 the calorific content of the food consumed fell to extremely low levels: for workers it fell from 1,087 to 707 kilocalories per day as against a norm of 3,500–4,500. For office staff the fall was to 473 kcal/day as against a norm of 3,000–3,200 kcal/day for non-manual work. For children up to 12+ years and dependants the fall was to 423 kcal irrespective of age, as against a norm of 1,300 kcal for children of up to 18 months, 1,800 kcal for 3–4-year-olds, 2,000 kcal for 5–6-year-olds, 2,400 kcal for 7–10-year-olds and 2,850 kcal for 11–13-year-old adolescents.22 In a discussion of the problems facing Leningrad under siege, Ya. E. Moskalenko states that an adult cannot survive for more than a month on average with an intake of 1,300 kcal/day. The worst famine for Leningraders lasted two to three months. Consequently the population should have been wiped out,23 as was intended by an enemy wellacquainted with acute food shortage in a besieged city. Scientific views on minimum food intake cannot explain the survival of the victims of the siege, but serve merely to forecast death from nutritional dystrophy. We know from medical data and from our own experience that almost everyone suffered some degree of nutritional dystrophy. There was nobody around us who was not starving. Fedor Isaakovich Mashanskii, head of the City Health Department, states that nearly 90 per cent of Leningraders were suffering from nutritional dystrophy by 1942.24 Extreme hunger, almost amounting to total starvation, had begun. People were on the verge of dying.

Nutritional dystrophy as the main cause of death among siege victims The first cases of emaciation were recorded early in November 1941. Patients came to the city clinics with a new nosological form of the disease, which was called nutritional dystrophy, that is, emaciation resulting from a diet insufficient both in quantity and quality, and incompatible with energy expenditure.25 The main aetiological factor of nutritional dystrophy is an appreciable protein deficit, a slightly lesser deficiency of carbohydrates, fats, vitamins and minerals, and a considerable shortfall in calorific intake. Protein metabolism was considerably reduced in severely emaciated patients, and the protein level of the blood and tissues declined.26 The clinical picture of nutritional dystrophy uncomplicated by other illnesses was characterized by rapidly progressing weight loss, increasing muscular debility, weakening cardiac activity, slowing of the heartbeat,

1403_901422_07_cha05.qxd

10/6/2004

5:03 PM

Page 132

132 Prerequisites for Survival and Recovery

increased fatigue, appreciable loss of working capacity, flaccidity, a slowing of speech and movement, and depression or acute overexcitement.27 Professor M. V. Chernorutskii, a leading therapeutician in his day, who lived through the tragedy of the siege, referred to the extreme variant of this state as ‘life at the limit’ (vita minima).28 According to official data, the average weight loss in winter 1941 was 22.7 per cent, but it reached 30–40 per cent and even 50 per cent of initial body weight in some instances.29 The lowest recorded weights were 36.5 kg (a man 169 cm high) and 30.5 kg (a woman 158 cm high).30 The duration, course and outcome of the disease were dependent on the individual characteristics of the organism. In some instances the disease developed gradually. Flaccidity, muscular debility and apathy increased slowly. Patients often gave the impression for a long time of being barely alive, scarcely reacting to external stimuli. In other cases the progression was very fast. Acute nutritional dystrophy, with a tendency towards comatose states, was observed most often in the first period of the famine. The first deaths from the disease were recorded in mid-November.31 With the progressive course of the disease many patients died within a few days of admission. In the acute form, death could occur after 2–7 weeks, depending on the severity of emaciation.32 Starvation was the main cause of death, exceeding deaths from all other diseases and even from bombing and shelling. Emaciation was promoted by all factors that increased energy expenditure: heavy physical labour (construction of defence works, sorting through the rubble of destroyed buildings, procuring firewood, delivering water to multi-storey buildings with lifts out of order, long journeys on foot after the trams stopped running), and the cooling of the body occasioned by the severe cold spells, when temperature fell to -30– 40 °C in the first winter of the siege, in the absence of central heating and stove heating. Paraffin heaters and homemade iron space-heaters gave off too little heat even to warm oneself for a short while. The emaciated organism was unable to maintain body temperature, not only because of the frosts and the inadequate calorific content of the diet, but also because bodily heat regulation was affected. Body temperature fell to 36–35 °C, and in some instances to 34 °C.33 Most victims of the siege were frozen throughout the winter, and some froze to death in unheated apartments and in the streets. Despite conditions seemingly so inimical to life, some sufferers from severe nutritional dystrophy did not die. How was it possible in conditions of extreme hunger lasting for some months? It must be assumed that there was not and could not be adaptation to starvation, as is

1403_901422_07_cha05.qxd

10/6/2004

5:03 PM

Page 133

Svetlana Magaeva 133

shown by the development of nutritional dystrophy in almost everybody under siege, and the high per centage of fatalities. What kind of adaptation is that? Life did, however, continue, and hundreds of thousands of people survived and recovered. Thus there was adaptation, although incomplete and insecure, not to starvation, but to the nutritional dystrophy resulting from it. In an assessment of the adaptive potential of the starving organism when the pathological process took a slow course, Chernorutskii stated his opinion that there was in starvation ‘a process of the gradual adaptation of the organism . . . through a lowering of the main vital functions and transition to a state that could be described as life at the limit’.34 It might be connected with economies in the expenditure of energy and protein, and minimization of the functional activity of organs through use of their own protein, notably the protein of skeletal muscles, to maintain the ebbing life. Adaptation to nutritional dystrophy at the expense of the body’s own protein and a functional lowering of vital organs (heart and liver) could not be either secure or lengthy, because resources of energy and substance were not being renewed. Survival would have become impossible had the ferocious famine continued. It was not adaptation to starvation, but improved nutrition and an easing of the winter cold that enabled some people to hold out until the summer of 1942. What were the characteristics of an organism that was able to remain viable under severe famine conditions? In seeking an answer to this basic question we must examine the pathogenetic mechanisms of nutritional dystrophy and the part played in the outcome by the psychosomatic factor, and we must assess the body’s latent reserves in extremis.

The pathogenesis of nutritional dystrophy The shortage of food and especially the shortage of protein resulted in considerable atrophy of vital organs, associated malfunctioning of almost all somatic systems and a reduction in protein, carbohydrate, lipid, mineral and vitamin metabolism. A reduced level of protein in blood and tissues is one of the main and invariably present indications of nutritional dystrophy.35 In the mild form of the disease blood protein fell to below 5.5 per cent in 54 per cent of cases. In severe forms this indicator of protein metabolism fell to 2.4–2.6 per cent, from the normal 7.5 per cent. The general state of patients in the various stages was found to be correlated with the degree of reduction in blood sugar, which fell to 34–35 mg per 100 ml in the severe state.

1403_901422_07_cha05.qxd

10/6/2004

5:03 PM

Page 134

134 Prerequisites for Survival and Recovery

The main pathogenetic biochemical mechanism of nutritional dystrophy was dissociation of the protein of cells and tissues, and their subsequent atrophy and malfunctioning. Nutritional dystrophy began as a nosological entity from the time when the organism began to consume structural elements of its own cells and tissues.36 There was intensive dissociation of protein in the tissues of the skeletal muscles and internal organs, as is shown by abundant depositing of lipofuscin. In incomplete starvation the lack of food was partly made good by the body using up its own tissues. In total starvation vital activity was maintained exclusively by consumption of the organism’s own resources (endogenous nutrition). The body’s own structures were the sole means of subsistence. Protein deficiency led to incomplete atrophy of organs, tissues and cells. Histological research has revealed considerable atrophic changes in the cells of internal organs and endocrine glands – an appreciable reduction in cell volume but relatively little change in structure (skeletal muscles, myocardium, gastrointestinal mucosa, pancreas, adrenal cortex, thyroid, bone tissue).37 The absence of indications of cell necrosis led histologists to conclude that there were no changes in the quantitative composition of the atrophied cells. Reasoning from modern views on apoptosis – a previously unknown mechanism of cell death in which structures of the dying cell are rapidly used by functioning cells – it may be assumed that some part of the cell population perished in this way in nutritional dystrophy and supplied vitally needed elements to cells that remained viable. In addition to atrophic changes, a reduction in the number of cells was apparent under the microscope in some organs. A reduction in the number of hydrochloric acid-secreting lining cells was found in the gastric mucosa. In late stages of the disease reductions in the size and quantity of precursor cells of formed elements of the blood and of cells of the immune system were found in the bone marrow, spleen and lymph nodes. Progressive atrophy of cells and tissues led to appreciable atrophy of organs, to judge by their reduced weight. The skeletal muscles were most atrophied. Muscle fibres were reduced to between a fifth and a quarter of their original size. Muscle strength, measured by dynamometer, was reduced to 50 per cent in stage I of the disease and to 38 and 25 per cent in stages II and III. Atrophy of skeletal muscle tissues presented a lesser threat to the vital activity of the organism than atrophy of the tissues of other organs. Under normal conditions the weight of skeletal muscle tissues is on average 40 per cent of total body weight and the

1403_901422_07_cha05.qxd

10/6/2004

5:03 PM

Page 135

Svetlana Magaeva 135

protein content is 4,800 g. The vital organs were fed mainly by proteins of the skeletal muscles. In death from nutritional dystrophy uncomplicated by infections, when body weight loss was more than 30 per cent, the weight of the heart was reduced to 174 g and, on occasion, to 90 g. The weight of the liver fell to 860 g. The average weight of the spleen was 55–80 g. The normal weight of these organs is 330 g (without blood), 1,800 g and 180 g. Involution processes in nutritional dystrophy were most marked in children in the period of intensive growth. Thus, the hearts of children 1–3 years old lost on average 46 per cent of their weight, and of children 3–7 years old 31.2 per cent. The figures in the 7–10- and 10–15-year age groups were 28.1 and 39.3 per cent. Liver weight losses in these age ranges were 53 per cent, 44 per cent, 37 per cent and 57 per cent. Atrophy of the thyroid was greatest, to 49.4 per cent of the original weight on average, in children 3–7 years old.38 It follows that the basis for the pathogenesis of nutritional dystrophy is the atrophy of vital organs occasioned by starvation. In the analysis of survival from this standpoint, it may be assumed that survivors had a genetically determined predisposition for the highest resistance to protein starvation and the greatest capacity to redistribute resources of energy and protein to ensure the functional activity of vital organs (brain, kidneys, respiratory organs, heart) to the detriment of other systems (skeletal muscles and the sexual sphere), the functioning of which was not decisive in maintaining the physical existence of the individual. It would appear that atrophy can fully explain the extinction of vital functions and death, but even so the pathogenesis of this disease of the siege was not limited to the atrophic process. Professor Chernorutskii considered that malfunctioning of the neural regulation of vital functions was of key importance in the pathogenesis of nutritional dystrophy. He observed that nutritional dystrophy without complications was the main cause of death under siege only in slow death in extreme emaciation. However, ‘A different explanation must be sought for most cases . . . These [the causes and manner of death] most probably lie in regulatory disorders of the nervous system, in disorganization of the entire regulatory system of the organism as a whole’.39 He applied the term ‘regulatory disease’ to this form of pathology, by which he meant disruption of the ‘regulatory mechanisms’ of vital bodily functions. Academician A. D. Speranskii has demonstrated the significance of the neurogenic factor in the pathogenesis of emaciation.40 He established experimentally that a pathogenic intervention on the hypothal-

1403_901422_07_cha05.qxd

10/6/2004

5:03 PM

Page 136

136 Prerequisites for Survival and Recovery

amus, the seat of the most important structures for the regulation of visceral functions, led to the development of a generalized dystrophic process in the tissues of somatic organs and to cachexia. Although the process of nervous degeneration is considerably different from the atrophic changes that typify nutritional dystrophy, some features of the clinical picture reveal considerable similarity. Subcutaneous fatty tissue disappears, there is weight loss and muscular debility increases. Laboratory animals become flaccid and drowsy. The possibility of modelling cachexia in diencephalic pathology may indicate that malfunctioning of the hypothalamus plays some part in the pathogenesis of nutritional dystrophy. It may be assumed that the accelerated course of nutritional dystrophy promoted a change in the state of the pituitary, which is one of the key central mechanisms mediating the stressor effect.41 In one form of the pathology of the endocrine division of the pituitary (Simmond’s disease), a cachectic state develops, the clinical picture of which is similar to the cachectic form of nutritional dystrophy. It may be assumed from this similarity that the pituitary is involved in the pathogenesis of nutritional dystrophy.42 The change in the state of the pituitary may be due to disruption of hypothalamic–pituitary influences and inadequate synthesis of pituitary hormones linked to protein starvation. In progressive nutritional dystrophy, regulatory disorders connected with modified reception of the regulatory influences of the central apparatus by the atrophied organs and with changes in their responses were combined with modified psychosomatic influences to disrupt adequate feedback between the organ and its central regulatory apparatus. Afferent signalling from the visceral systems on inadequate nutrition was an important factor modifying changes in the neural regulation of the functions of systems and organs. Victims of the siege were acutely and constantly aware of their hunger. Food motivation frequently dominated over other psycho-physiological motivations. We may assume that afferent signalling from the interoceptors of the gastrointestinal tract and other organ systems, the cells of which were not receiving the nutrition essential for normal vital activity, led to the formation of a pathological dominant. Inadequately controllable feeding activity led in some instances to the development of so-called dystrophic psychoses with delusions and hallucinations connected with food. The feeling of hunger disappeared in many sufferers from progressive dystrophy and revulsion against food (anorexia) could arise, indicating profound disorders of psychosomatic and somatopsychic interrelations and disturbed formation of food motivation.

1403_901422_07_cha05.qxd

10/6/2004

5:03 PM

Page 137

Svetlana Magaeva 137

To sum up, the main factors in the pathology of victims of the siege – mental and emotional stress, nutritional dystrophy and associated malfunctioning of the neural and endocrine regulation of the atrophied organs – were mutually reinforcing in a vicious circle. Chernorutskii assumes that ‘the causes and manner of death from starvation . . . are the same as in endogenous diencephalic–pituitary cachexia’.43 M. I. Khvilivitskaya, who rejected a link between a fatal outcome and disturbed cardiac activity, gave examples of the lack of cardiac insufficiency in the dying and suggested that death came in many instances from paralysis of the centre regulating breathing, which disappeared before the heart ceased beating. What is being discussed is the final pathophysiological mechanism of death in nutritional dystrophy. It may be assumed that malfunctioning of the regulatory apparatus of vital functions associated with prolonged starvation and excessive daily mental and emotional stress contributed to the formation of a state beyond which life was impossible. On the basis of autopsy findings Chernorutskii rejects a pulmonary cause of death in individuals lacking indications of uncomplicated extreme emaciation, and assumes that ‘a cerebral cause’ is the most likely, backing his suggestion with the opinion of Professor E. M. Gelshtein: ‘one may think of . . . a central nervous mechanism of death, of . . . paralysis of the autonomic centres’. Such death, in contrast to the slow extinction of life associated with extreme emaciation, occurred abruptly, usually when the patient’s condition was relatively satisfactory, and often when the general condition of the organism was beginning to improve, ‘at the most varied moments in the course of life, but most often . . . in connection with some essentially trivial . . . additional load, such as taking food, moving, experiencing an emotion etc.’. 44 Sudden death was instantaneous (minutes or seconds). These characteristics of the death of the organism may be indicative of the fundamentally important part played by profound disruption of the regulation of vital functions, which might sometimes be connected with a psychogenic factor, especially, as mentioned in the above quotation, with an emotional experience.

The psychosomatic factor in the course and outcome of nutritional dystrophy The modern view of the part played by the neurogenic factor in disturbances to the regulation of somatic functions gives grounds for the assumption that the mental and emotional stress of the starving

1403_901422_07_cha05.qxd

10/6/2004

5:03 PM

Page 138

138 Prerequisites for Survival and Recovery

organism caused malfunctioning of the neural regulation of metabolism, and of the visceral organs and the endocrine and immune systems, which worsened nutritional dystrophy. A psychosomatic factor, which could slow or accelerate the outcome of nutritional dystrophy, bring about sudden death in the absence of emaciation, or contribute to the survival of the severely cachectic in the final stage of the disease, was of definite importance in the fate of victims of the siege. Chernorutskii thought that the outcome of clinical dystrophy was largely determined by the nature of mental and emotional experiences reflected in psychosomatic influences. His conclusion deserves to be quoted for its significance for the problem of survival: We saw quite a few cases in which, when other conditions were equal, a weakening of the will to live, depression and giving up the routine of ordinary living considerably hastened the course of the disease and led to a sharp deterioration in the general condition of the patients, and brought forward an unfavourable outcome. Conversely, a firm and purposeful will to live, cheerfulness, continual optimism and an invariable pattern of organized life and work, seemingly ‘running counter to events’ sustained the weak body and apparently gave it new strength.45 Specialists did not find any direct correlation between the outcome of nutritional dystrophy and the severity of its manifestation. In November 1941 there were some deaths before the development of severe emaciation incompatible with life. Such patients did not have hypoproteinaemia, a main symptom of the severe form of nutritional dystrophy.46 Death could occur in stage I of the disease, when lipid reserves were used up, but before irreversible atrophic changes to organs.47 There is published information on the lack of correlation between the severity of the clinical picture and the disruption of protein metabolism.48 The author has personal experience of the importance of the mental and emotional factor during the siege.49 In a children’s home (to which I was admitted when my mother went into coma in the street), I saw the sudden death of two girls unconnected with emaciation or injury. It was death caused by the acute emotional experience of the terror of an airraid warning. Most of the children remained drowsy during the alert, conserving their strength. So doing was not a display of particular bravery, but a symptom of the fatigue and indifference typical of severe nutritional dystrophy. Our behaviour was also conditioned by the psy-

1403_901422_07_cha05.qxd

10/6/2004

5:03 PM

Page 139

Svetlana Magaeva 139

choprophylaxis that our mothers had practised consciously or unconsciously at the beginning of the war in teaching us not to panic at the danger of air attack. After the first alert I remember my mother being at pains to assure me that a direct hit on our house was unlikely, and that fear could lead to madness and even death. It may be that the mothers of my companions in misfortune taught them the self-control that protected the psyche against traumatization. Calmness during an alert was the unwritten rule of life in the children’s home. Only once was there an exception to this wise rule, and it had stupefying, absurd and terrifying consequences. Two 8–10-year-old sisters, calling themselves Milochka and Polinochka, appeared in the children’s home. They were very different from us. It was as if they had stepped into our dormitory from the good pre-war times. They even still had dimples in their cheeks. Not only could they walk, they could even run and play hide and seek. They were the only children in the home not affected by nutritional dystrophy. I do not know how they had been saved from it. They must have been living in some deep underground shelter and feeding quite well. They had only been with us for a few days and had not begun to starve. Nothing appeared to bode ill and everyone thought that these girls would certainly survive until victory. Soon after they appeared an artillery barrage began. Shells were exploding quite close at hand. The girls gave heart-rending screams and hid under the bed in fright. After the all-clear it was difficult to get them out. During the next alert they both suddenly died. As they had not been starved and they were not emaciated their death must have been connected with fear of death. After this tragedy we came to think that we, the pitiable ‘dystrophics’, might survive the siege because we were not suffering from the cruel terror that killed. Their death was essentially psychosomatic and apparently due to psychogenic ‘paralysis’ of the regulatory centres of vitally important organs. I do not remember where I read about the amazing unity of life and death. A dystrophic mother of three was dying and her children were gathered around the bed pleading with her not to die. As soon as she closed her eyes the children’s voices begged ‘mummy, don’t die’ and the mother returned to life and opened her eyes by an incredible act of will. This happened several times, until the eldest daughter, more keenly aware than the younger ones of the severity of the death-agony, forbade the children to come back, so that the mother could die. And the mother did die, but only then. This sad case convinces us that, even in extremis, there are still hidden reserves to resist death. It seems that one more, almost superhuman effort of will can overcome death, even if only for a while. But it is not given to us to know how to do that.

1403_901422_07_cha05.qxd

10/6/2004

5:03 PM

Page 140

140 Prerequisites for Survival and Recovery

A psychosomatic factor may sustain a fading life. I became convinced of the reality of this factor in preserving life for a short time or even in the gradual weakening of nutritional dystrophy. What is involved is the motivation to survive, which produces an unbelievably strong effort of will to overcome death. This factor was manifested even in children. A girl in the children’s home tried to save her younger brother from dying from starvation. Olya was twelve, Serezha only five. The girl gave all her very small portion of food to her slowly dying brother. On contact with the spoon, the little boy mechanically opened his mouth, without regaining consciousness, and indifferently swallowed his share and hers. The doctor and the nurse tried in vain to persuade Olya to eat, but she would not listen. She was wasting away with every day, but it was Serezha who died first. Olya kissed his shrivelled face and could not be persuaded to part from her brother. When he was taken away, she lay down on the bed, sighed . . . and was no more. It was an adult death, a parting with dignity and a consciousness of a duty carried out. It may be that Olya’s sudden death was connected with the loss of a reason to live. She had nobody left in the world and she ceased to struggle against death. I am convinced that holding on to a reason for living may help in overcoming nutritional dystrophy. No child in the home was more emaciated than eight-year-old Tanya Utkina, whose clinical condition corresponded to stage III of nutritional dystrophy. The disease had made her a walking skeleton. Her eyes were deeply sunk in their large sockets, her cheeks and temples were collapsed, and the nasiolabial folds and zygomatic arches were sharply delineated. The wrinkled face looked elderly, the arms and legs were spindly, the joints seemed greatly out of proportion to the withered body, and the skin was stretched so tightly over the bones as to seem torn in places. Diarrhoea had negated intensive feeding. The doctor was distressed at being unable to inject glucose: the veins had collapsed and the muscles had been converted to flat plates. Nobody thought that she would survive, but she had a real reason for living, to find her younger sister, who had been handed over to a wet nurse after their mother’s death and evacuated shortly afterwards to the mainland. It seemed as though concern for little Sonya was preventing our Tanya from giving up and dying, and so it probably was. The medically improbable happened: death receded and Tanya began to recover. It was quite a while before she was able to eat and then to stand up, but she did and was able to take a few steps. Everyone in the children’s home came to our dormitory to see this miracle. It was incomprehensible and comforting. Every ‘dystrophic’ thought

1403_901422_07_cha05.qxd

10/6/2004

5:03 PM

Page 141

Svetlana Magaeva 141

that if Tanya Utkina could escape death, then so could they, and the fact that some of us did is also due to her. It is difficult to explain survival at the dividing line between life and death. Previously unknown latent reserves in the organism are apparently brought into play in extremis and it becomes possible to avoid death. The observations of victims of the siege, especially those of doctors and medical researchers, provide convincing evidence of the importance of the psychosomatic factor in resistance to nutritional dystrophy. Many are convinced that they survived only because they did not allow themselves to take to their bed (‘to lie down and wait’, as was said at the time) and to reconcile themselves to the sentence of death. Workers, doctors, teachers and young Communists who went through the frozen dwellings in search of orphaned children continued to work with what remained of their energy, and even after. Every morning, with great effort they overcame starvation and debility, got up, rallied their strength and went to get the bread ration for starving children and old people who lacked strength and were emaciated. With unbelievable exertion they overcame the desire to stay in bed and not get up again, and went about their daily work, which was beyond their strength but absolutely necessary because the life of hundreds of thousands depended upon it. The internationally known physiologist Academician Aleksei Alekseevich Ukhtomskii remained in the besieged city until his death, carrying on his research until the end, and refusing to be evacuated although repeatedly urged to go. In the spring of 1942, although physically weakened, he made his way with incredible effort from his home on the 16th line of Vasilevskii Island almost to Strelka to act as examiner for a postgraduate thesis.50 A month before his death he prepared a paper for a meeting marking the anniversary of the birth of I. V. Pavlov, which was published posthumously in September 1942 in the proceedings of the meeting.51 Professor Vladimir Georgievich Garshin, later to be an academician of the Medical Academy, exhausted by hunger and by work in his institute, recalls the weight of his vital work as a pathologist, seeking a strategy for the care of sufferers from nutritional dystrophy: ‘all I had left was my will, and that was what compelled me to work . . . I saw the same thing in others’.52 Valentina Grigorevna Burakova, who worked as a district doctor during the siege, has grounds for her assertion: ‘I found in practice that it was not only nutrition that was conducive to survival, but also high

1403_901422_07_cha05.qxd

10/6/2004

5:03 PM

Page 142

142 Prerequisites for Survival and Recovery

morale.’53 She saw up to 80 patients a day and attempted above all to maintain their cheerfulness. It may be assumed that positive emotions connected with the display of human feeling helped to maintain essential psychosomatic influences on the functions of vital organs or, at least, to prevent their disruption worsening nutritional dystrophy. We know a truly unique example of maternal self-sacrifice. The young Communist members of a household group took to the hospital a mother with a baby in arms whom they had found in a deserted flat. The mother, emaciated by starvation, had bled profusely, having opened a vein in her arm. She had no milk, but had put her baby’s mouth to the wound and it had greedily sucked its mother’s blood. The help had arrived in time, and both mother and baby were saved.54 In the words of the psychiatrist Professor T. Y. Khvilivitskii, many people exhibited ‘genuinely human features of stoic selflessness’.55 There is thus every reason to assume that the greatest humanity of spirit may be manifested under extreme conditions and may be the key to maintaining psychosomatic interrelationships within limits that preclude the development of irreversible disorders.

Changes in reactivity caused by dystrophy and psychosomatic stress The reactivity of the organism differed in the course of the siege, depending on the severity of nutritional dystrophy and mental and emotional stress, and on their reciprocal influence. In comparison with their pre-war structure, the pattern of non-infectious and infectious diseases was considerably altered during the siege.56 The changes in the reactivity of the organism under the combined influence of nutritional dystrophy and mental and emotional stress are the best starting point for an analysis of this phenomenon. Mental and emotional stress preceded starvation and was operative throughout the war and the siege, manifesting itself in various pathological states connected with malfunctioning of the neural regulation of systems and organs. Before nutritional dystrophy developed the disruption of psychosomatic influences was manifested in transitory hypertension, amenorrhoea and malfunctioning of hypoglycaemia compensation mechanisms. When the famine was worst, late in 1941 and early in 1942, the number of patients admitted to hospital with hypertensive disease fell sharply relative to 1940, from 10 per cent to 2 per cent.57 Hypotension

1403_901422_07_cha05.qxd

10/6/2004

5:03 PM

Page 143

Svetlana Magaeva 143

was a feature of this period of nutritional dystrophy, and blood pressure fell appreciably, even in those patients with a pre-war history of hypertensive disease. As the famine abated, hypertensive disease, which was termed ‘Leningrad hypertension’, became more common. Patients suffering from hypertension were 1.5 per cent of admissions to the clinic of the First Leningrad Medical Institute (I LMI) in the second quarter of 1942, compared with the 80 per cent of patients suffering from nutritional dystrophy. These statistics changed to 17.5 and 60 per cent in the third quarter of that year, 27 and 35 per cent in the second quarter of 1943, 45 and 12 per cent in the third quarter of that year and 48 and 6 per cent in the fourth. In 1944 the figures were 30 and 1 per cent in the third quarter, 22 and 0 per cent in the fourth.58 Mass screening in 1942–43 found hypertension in 50 per cent of people in the 40–49 age group, and 65 and 70 per cent respectively in the 50–59 and 60+ age groups. In people below the age of 40, hypertension reached 10–47 per cent whereas the peacetime figure had been 4–7 per cent.59 The raised blood pressure was transitory in 20 per cent of patients and persistent forms developed in 20 per cent. In the other cases there was essential hypertension with marked fluctuations in blood pressure or forms with considerably raised pressure followed by lasting normalization. In patients suffering from the after-effects of nutritional dystrophy hypertensive disease took a severe course, with high mortality which reached 40 per cent of all deaths when admissions were at their highest (data of the I LMI clinic).60 In the majority of cases (78 per cent) death was from heart failure in the absence of compensatory myocardial hypertrophy. The atrophic heart was unable to increase its weight to the extent that occurs with hypertension in a non-emaciated patient. In nutritional dystrophy with accompanying hypertension the heart weighed 370 g, rising to 420–470 g as the emaciation abated, whereas it reached 502 g in sufferers from hypertension without emaciation. The rise in blood pressure was not accompanied by any appreciable worsening in the feeling of well-being of people below the age of 40 whose general condition was satisfactory. Only a few suffered from headaches, dizziness, paraesthesia and deteriorating eyesight. The course of the disease was often without complications and pressure subsequently became normal. The pathogenesis of Leningrad hypertension is linked with mental and emotional stress.61 Chernorutskii defined it as a typically neuroregulatory disease.62 The mental and emotional origin of hypertension is confirmed by figures showing more frequent occurrence (19.4 per

1403_901422_07_cha05.qxd

10/6/2004

5:03 PM

Page 144

144 Prerequisites for Survival and Recovery

cent) of raised blood pressure among fighting men in close proximity to the enemy and among surgeons performing operations than among serving men behind the lines (2.8–4.6 per cent).63 Hypertension among civilians was more often found in those whose work involved great nervous tension than in those employed on physical labour.64 The part played by mental and emotional stress in the pathogenesis of hypertensive disease has been demonstrated in laboratory experiments involving the initial modelling of negative emotions in animals65 and electrical stimulation over a period of hours of the zones of the hypothalamus that produce negative emotions.66 There is a traceable link between the development of hypertension and the after-effects of nutritional dystrophy. There are figures on the higher frequency of hypertension among inadequately fed servicemen than in better-fed troops under similar operational conditions.67 Hypertensive disease was considerably less common among bakery and catering workers, who suffered less from nutritional dystrophy.68 When emaciated hypertension patients were intensively fed their blood pressure fell.69 The link between hypertension and nutritional dystrophy may be explained by the effect of starvation on the mechanism of blood pressure regulation. Chernorutskii assumed that nutritional dystrophy retarded an outbreak of neurogenic hypertensive disease that might, with a normal diet, have arisen considerably earlier under worsening mental and emotional stress.70 The reciprocal influence of the mental, emotional and nutritional factors was manifested in retinal pathology. In the first quarter of 1942 oculists were alarmed by the unusually high frequency of neuroretinitis – inflammatory changes in the retinal membrane – involving seemingly irreversible damage to the retinal blood vessels and cells.71 Varying degrees of atrophy of the optic nerve were found in 25 per cent of neuroretinitis cases. Further cases of neuroretinitis were found in the following period, when diet was improving, and in the early stages of essential hypertension, but no correlation was found with its severity. It may be assumed that malnutrition of the retinal membrane against a background of neurogenic spasm plays a prominent part in the pathogenesis of neuroretinitis. Spasm of the retinal vessels may mainly originate from the mental and emotional factor, since lasting narrowing of blood vessels was found not only in emaciation but also in persons not suffering from nutritional dystrophy.72 When nutritional dystrophy was a mass occurrence, there was a reduction in the frequency of new cases of stenocardia, infarction, stroke, peptic ulcers and allergic diseases. Patients suffering from these

1403_901422_07_cha05.qxd

10/6/2004

5:03 PM

Page 145

Svetlana Magaeva 145

diseases since before the war experienced long remissions.73 This phenomenon may be linked with the development of a special reduced reactivity in patients with the progressive form of nutritional dystrophy who had been in a state of ‘minimum life’.74 Atherosclerotic patches were reduced and so-called ‘milky spots’ on the intima of the aorta disappeared during the famine period.75 The morbidity pattern, which had been greatly altered during the severe famine, reverted to its previous state as nutrition improved. However paradoxical it may seem, nutritional dystrophy prevented the appearance of a neurogenic factor in those diseases whose frequency was reduced during the famine. The reduction of morbidity in only slightly emaciated active people may be connected with a physiological stressor stimulating natural resistance and defence mechanisms. In 1944, following the lifting of the siege, the number of hypertension patients rapidly decreased, but cases of peptic ulcer, bronchial asthma and rheumatism increased, possibly in connection with the ending of the state of hyporeactivity, the appearance of a psychosomatic factor, and the manifestation of a previously asymptomatic pathology, or its commencement. The morbidity of many infections was considerably reduced during the siege, despite a dangerous deterioration of the epidemiological situation. There was refuse everywhere in the ruins of the stricken city. Despite the fact that water supply was non-existent, drains were out of action and there were swarms of insect vectors of dangerous diseases, there were no epidemics in the city, although there were some outbreaks of infections. Leningrad was unique in the history of besieged cities in having no epidemics.76 Had these occurred it would have been the end of the life of the beleaguered city, despite the great efforts of the urban epidemiological services. When nutritional dystrophy was prevalent there were scarcely any streptococcal and staphylococcal infections, or streptococcal complications of other diseases. Cases of scarlet fever, rubella, chicken pox and mumps were far fewer. Measles practically disappeared. Dysentery and typhoid took an atypical course, with the main symptoms frequently absent. There was little intoxication, except for diphtheria. Infectious complications rarely occurred, except for pneumonia with an indistinct clinical pattern and variously located fusospirochaetal lesions with necrotic processes. Focal pneumonia, of imperceptible onset and with a blurred and sparse symptom pattern, was a serious complication of nutritional dystrophy. Pneumonia followed a sluggish and protracted course. Body

1403_901422_07_cha05.qxd

10/6/2004

5:03 PM

Page 146

146 Prerequisites for Survival and Recovery

temperature remained normal in a half of the cases and leukocytosis was absent. In the winter of 1941–42 pneumonia was found on autopsy in 80–85 per cent of cases. The development of pneumonia could be linked with the reduced general resistivity of the dystrophic organism, which might activate a previously non-pathogenic microflora. Lengthy overcooling occasioned by the unusually harsh winter was conducive to the development of pneumonia. The blurred clinical picture of most infections, the reduction of immune reactions and the relative inefficacy of specific therapy were indications of a considerable reduction in the reactivity of the organism suffering from nutritional dystrophy. Indirect evidence of the dependence of reduced sensitivity to the causative agents of these infections on a special state of the organism is provided by the correlation between the period of nutritional dystrophy (November 1941–August 1942) and changes in the structure of infectious morbidity and the course of infections. As nutrition and the general condition of the besieged improved these deviations weakened, and when nutritional dystrophy came to an end infectious morbidity and the course of infections no longer differed from the pre-war picture. There are grounds for the assumption that the absence of mass epidemics when famine was raging may have been connected with the lack of susceptibility of the emaciated organism to infection. The reduction of infectious morbidity in nutritional dystrophy shows some similarities with the absence of disease in hibernating animals, whose life is maintained at a minimum level by drawing upon the body’s reserves (so-called brown fat), with considerable loss of body weight. Body temperature and the activity of all systems and organs are reduced in hibernating rodents. In the hibernating state the animal does not fall sick when infected with virulent causative agents of dangerous infections or when given doses of poisons that would be lethal in the woken state.77 Such a dormant state has been termed areactivity. These findings are evidence of the possibility of not contracting an infection when the level of vital activity is lowered. On coming out of hibernation reactivity is restored, and with it susceptibility to disease vectors. While not attempting in any sense to liken the pathological state of nutritional dystrophy to the biological phenomenon of the adaptation of hibernating animals, we may assume that the way in which the resistance of the organism is altered is, in both instances, the formation of a state of reduced reactivity. Mental and emotional stress is of some importance in the altered susceptibility to infections because of the close interdependence between

1403_901422_07_cha05.qxd

10/6/2004

5:03 PM

Page 147

Svetlana Magaeva 147

the mechanisms of neural regulation of the functions of the immune system and emotional tension. The structures of the central apparatus of neuroimmunal regulation and the apparatus of the formation of emotions are functionally interconnected and have some links in common that make the activity of the immune system dependent on mental and emotional influences. Structures of the hypothalamus, the limbic system and other divisions of the brain are involved in the intricate structure of the central apparatus responsible for neural regulation of the functioning of the immune system. Limbic–diencephalic regulatory influences are received by the pituitary and transmitted by the same effectors also brought into play in mental and emotional stress: the pituitary–adrenocortical, pituitary–thymus and sympatho-adrenal systems. The cells of the immune system have specific receptors for neurotransmitters, neuropeptides and hormones.78 We know that synthesis of antibodies against microbial and viral antigens is activated in physiological stress, that phagocytosis is activated, bactericidal activity is increased, interferon synthesis is intensified and other mechanisms of natural resistance to infection are stimulated, all of which increases resistance to the causative agents of infections. It may be that such a state was formed in those victims of the siege who adapted more or less satisfactorily to mental and emotional stress factors. In malfunctioning of the central neuroregulatory apparatus of the functions of the immune system neuroregulatory diseases develop, and progress to a point of severe immunodeficiency that appreciably increases susceptibility to infection.79 It may be assumed that those most affected by acute mental and emotional stress were a group at high risk of infectious diseases. The suggestion that disease was dependent on a neurogenic factor is strengthened by the fact that the bulk (74 per cent) of those who contracted acute infections had not suffered from the severe form of nutritional dystrophy. Tuberculosis morbidity increased considerably when the famine was raging. The disease assumed an acute and severe form with a tendency to haematogenic dissemination and generalization. It is well-known that the psychosomatic factor is of importance in lowering the resistance of people to the causative agent of tuberculosis. It has been shown in experiments on animals that the organism becomes susceptible even to non-pathogenic strains of M. tuberculosis when in a state of chronic emotional stress. A generalized infection develops with severe and extensive damage to the lungs and other internal organs.

1403_901422_07_cha05.qxd

10/6/2004

5:03 PM

Page 148

148 Prerequisites for Survival and Recovery

Frequently occurring acute and subacute forms of enterocolitis (socalled starvation diarrhoea) were largely of dysenteric aetiology and had an atypical clinical picture. Dysentery could follow a sluggish course, with a blurred clinical picture and a tendency to relapses and transition to a chronic form. Despite the blurred clinical picture, there was an increase in the number of severe forms of infections that made nutritional dystrophy more severe, accelerating the fatal outcome, especially in dystrophy stages II and III. It may be assumed that the increased dysentery morbidity was connected with activation of a potentially pathogenic microflora linked to dysbacteriosis. There were more cases of diphtheria with severe intoxication and frequent neurological complications. To sum up, the structure of non-infectious and infectious morbidity was considerably modified during the siege, due to disturbances to the reactivity of the organism undergoing nutritional dystrophy and mental and emotional stress.

Latent reserves Blasphemous as it may seem, there are grounds for the assumption that not all who died with symptoms of nutritional dystrophy survived to the limit of their potential determined by the degree of emaciation. There were other factors not directly connected to emaciation that determined the outcome: survival followed by recovery or by death. Earlier expert opinion had been that a loss of 40 per cent of initial body weight was irreversible and made a fatal outcome inevitable. The siege prompted reexamination of this hypothesis. It was found that, on average, one-third of patients could lose more than 40 per cent of their weight and recover when hospitalized.80 The data from experimental starvation of laboratory animals show that weight lost can be regained after total starvation for more than 100 days with three breaks. A dog that originally weighed 19.65 kg lost 10.58 kg, that is, more than 50 per cent. The animal was near to death, but recovered to its initial body weight with normal feeding.81 When there was considerable atrophy of cells, tissues and organs, the body protected the brain and kidneys against atrophy, as is shown by the fact that their weight loss, an average of 4–5 and 9 per cent (in the absence of oedema82), was less than that of other organs. The fact that these vital organs maintained their weight until death is evidence of their privileged nutritional status. Fewer changes were found in brain and kidney tissues and cells than in other organs. This was essential first

1403_901422_07_cha05.qxd

10/6/2004

5:03 PM

Page 149

Svetlana Magaeva 149

and foremost in order to maintain the vital activity of the organism dying from nutritional dystrophy. Particular attention should be paid to this when analysing survival mechanisms. The regulatory centres of all functions of the organism, especially the vitally important functions of breathing and cardiac activity, are located in the brain. Paralysis of the regulatory centres will result in death whether or not nutritional dystrophy is present. The organism ‘safeguards’ its neurons for as long as possible by cutting down on the nutrition of other cells. The kidneys excrete toxic metabolic products, and it may be assumed that toxic metabolites were produced in connection with the intensified breaking down of tissues. The blood serum and transudate of nutritional dystrophy sufferers have been shown to be toxic in experiments on mice.83 With the reduction of detoxification processes in the atrophic liver the kidneys had to bear the additional load of excreting the toxic products of metabolism and tissue breakdown. Although the heart is no less important in maintaining the vital activity of the organism, there was considerable myocardial atrophy, with a loss of more than half its weight, but the heart continued to contract, maintaining the sinus rhythm. This suggests that, despite atrophy of the contractile cells, the contractile strength of the myocardium remained adequate to maintain vital activity at the level typical of the emaciated organism. In the opinion of doctors and as recalled by victims of the siege, some extremely emaciated people survived when less emaciated ones died.84 The breaking down of the body’s own tissues, mainly myoprotein, was a reaction to the lack of dietary protein and, at the same time, an important compensatory mechanism. Cell organelles and proteins were used to maintain the functions of the vital organs and thus to ensure the vital activity of the organism.85 This was a key reserve of the emaciated organism. Apoptosis may be assumed to be one of the mechanisms compensating an acute nutritional deficiency at the cellular level. The organism made use of all possible reserves for endogenous nutrition, including the least significant. The lipid components of reduced lipid spots in children and of atherosclerotic plaques in adults were apparently also used for endogenous nutrition. Resorption of lipid from plaques reduced their height and in so doing increased the patency of blood vessels; this may be partly connected with the reduced frequency of infarction in nutritional dystrophy patients.86 Many people remained alive, despite hypoproteinaemia, hypoglycaemia and considerable functional weakening of vital organs. There is information on the slowing of the heart rate at rest to 30–40 beats a

1403_901422_07_cha05.qxd

10/6/2004

5:03 PM

Page 150

150 Prerequisites for Survival and Recovery

minute in 60–82 per cent of victims of the siege. Following physical exertion the heart rate increased, often to above normal, which is evidence of the compensatory nature of changes in the activity of the heart in starvation. In the third stage of dystrophy tachycardia might develop as one of the compensatory mechanisms brought into play in a critical state. The blood flow was reduced in nutritional dystrophy patients, as was indicated by reduction in the volume of the circulating blood to 42 ml/kg of body weight, reduction in maximum blood pressure to 60 mm Hg, and constriction of capillaries.87 Reduction in the functional activity of the thyroid in connection with atrophic changes and lack of proteins for the synthesis of thyroid hormones could have been one important reserve for adaptation of the organism. Reduction of metabolic rate and energy metabolism in hypofunction of the thyroid is an important adaptive mechanism in serious illness.88 It may be assumed that atrophy of the adrenal glands might have been of importance in weakening the reactions of the organism to mental and emotional stress factors. The weight of the adrenal glands was reduced by 60 per cent of the normal in the cachectic form of nutritional dystrophy (data on a group of 10–15-year-old adolescents).89 Thinning of the cortical layer of the adrenals may be indirect evidence of malfunction of the cells secreting so-called ‘stress hormones’ – corticosteroids invariably present at raised levels in a stress reaction. The state of the organism in severe nutritional dystrophy was therefore characterized by minimization of vital functions and energy expenditure, which could have been a distinctive way of economizing resources and manifesting the latent reserve of the organism. Doctors noted that many victims of the siege might hover between life and death for a long time. It was difficult for many hours to say whether the individual was alive or dead. The pocket mirror test was used; if it did not turn cloudy when held up to the face of the dying person the doubt was resolved. I lived through such a state in the children’s home. When the mirror did not turn cloudy a doctor was called. Our doctor was unable to detect the weak heartbeat with the stethoscope. But it was still not death. Life had not been given up immediately, but continued for a little while to combat death and in an instant yielded. When they transferred me to the stretcher I regained consciousness and thought vaguely that I should say that I was still alive, but I had neither the strength nor the desire to speak, and lost consciousness again. As I was later told, the doctor had his doubts on the way to the mortuary and sent the stretcher back to his

1403_901422_07_cha05.qxd

10/6/2004

5:03 PM

Page 151

Svetlana Magaeva 151

office, brought in a paraffin heater to warm the air, injected glucose and, while assuming my fate, looked to see if it was still possible by some miracle to save me. Medical care at the critical point when I was hovering between life and death decided my fate. Had I not been helped at that fateful moment death would have been inevitable. Although the famine continued, I did not become comatose again. There were latent reserves and they were activated by a single glucose injection. Petr Nikolaevich Petrov has related his astonishing recovery. In the winter of 1942 he was dying of emaciation. He was a lanky six-year-old whose weak breathing was scarcely discernible, so that even his mother, a medical worker, was not sure whether he was alive or dead. She went out and exchanged some possessions for a slice of buttered bread with sugar on it. Petr Nikolaevich recalls how he chewed small pieces with very great effort and swallowed them with even greater effort. He could not eat any faster because he lacked the strength. Soon after he had eaten the whole slice it became apparent that death had been vanquished. He survived and came through the siege despite the continuing famine. Nearly sixty years have passed, but I have never ceased to be amazed how very little sufficed to support a life on the point of extinction. A single glucose injection or a single piece of high-calorie food could sustain the fading functions of the heart and the brain, trigger the latent reserves and ensure survival despite the continuing raging famine. Gentle blowing rekindles a dying flame. It may assumed from the foregoing that a one-off stimulus may trigger a whole chain of biochemical and physiological processes that ensure a more or less lasting improvement in the condition of the emaciated organism. Consequently, at least in some instances, not all the reserves of a dying organism had been expended and it was still possible to activate processes that might ensure stable survival. Thousands of people in hospitals, clinics and children’s homes were under roughly the same conditions and as severely ill with nutritional dystrophy. Many, but not all, perished. Doctors note that, despite their serious condition, hospitalized patients with a vanishing pulse who received treatment quite often recovered, whereas others in a relatively satisfactory state and feeling quite well could die suddenly.90 That nutritional dystrophy could have different outcomes under similar conditions suggests that, even when hovering between life and death, individual characteristics of the organism are manifested and that they condition either the inevitability of death or survival under conditions of ongoing starvation.

1403_901422_07_cha05.qxd

10/6/2004

5:03 PM

Page 152

152 Prerequisites for Survival and Recovery

The changes in the above-mentioned indicators of vital activity are individual. The contractile activity of the myocardium and the composition of the blood were not critically affected in some emaciated people even when weight loss was considerable. The latent reserves of the organism were also indicated by the ability of women to continue to give birth. This applies to a clear minority of the least emaciated victims of the siege, since there were considerable atrophic changes in the ovaries and testes in very marked nutritional dystrophy.91 The possibility of the birth and survival of the most vulnerable part of humankind is a manifestation of the latent reserves of mother and child and the care provided by the health services during the siege. Doctors self-sacrificingly carried out domiciliary visits, and ration coupons for products having few calories were exchanged for goodquality nutrition. The city used every opportunity to evacuate its young people. Leningraders born during the siege survived the threat to their existence and are still living after six decades. I became acquainted with one such person, Aleksandr Aleksandrovich Rogozhin, born on 11 June 1943 in the young family of Aleksandr Sergeevich Rogozhin, a battalion commander of the air-raid defence service, and Ekaterina Petrovna Kolokolnikova, who served in the battalion. The baby, who was normal in both weight and growth, and without any subsequent mental or physical retardation, later became a scholar, professor and doctor of science. There is a need for special study of the mechanisms of survival under extreme conditions and the factors of individual resistance to starvation and mental and emotional stress. It may be assumed that the reserves of an organism that survived alimentary dystrophy were: • adaptation to protein deficiency conserving expenditure of the body’s own proteins and ensuring their redistribution • optimum minimization of energy expenditure ensuring the maintenance of vital functions • stability of mental and emotional status within limits ensuring the reversibility of changes of state in the neuroregulatory centres of vital functions and the possibility of subsequent normalization of psychosomatic influences.

Prerequisites for recovery Many researchers and practising doctors were worried whether those who succeeded in living through the siege would survive in the long term. This question was discussed at a press conference for foreign journalists in the Smolnyi Institute in summer 1942 by the chairman of the

1403_901422_07_cha05.qxd

10/6/2004

5:03 PM

Page 153

Svetlana Magaeva 153

Leningrad gorispolkom.92 F. I. Mashinskii, head of the Leningrad Health Department, asserted that the victims of the siege would survive, and he was correct. He was probably convinced intuitively rather than scientifically of the organism’s potential for recovery, so much did he want to believe in the tenacity of Leningraders. The journalists were dubious, and they also had grounds: they had seen the hopeless victims of nutritional dystrophy. Recovery following nutritional dystrophy was one of the most difficult problems during and after the siege.93 Those who had suffered severe dystrophy had little hope of regaining their health. The prognosis was especially harsh for children in the 2–4- and 10–12-year-old age groups. It was suggested that the latter would not live for more than eight to ten years. Fortunately, these prognoses were not borne out. Many of those condemned to a rapid death are still alive today. Thirteen of my adolescent friends survived the siege and ten of them are still alive although we are close to our seventh decade, that is, we have exceeded our forecast life span by nearly sixty years. Consequently, deviations from the norm were reversible and the prerequisites for recovery following nutritional dystrophy and extreme mental and emotional stress did exist. The most fundamentally important physiological basis for recovery was retention of the cell structure of vital organs. Despite considerable atrophy of the tissues and cells of vital organs, those of the haematopoietic, cardiovascular, digestive, endocrinal and immune systems, the structure of the atrophied cells was retained, and that resulted in a considerable reduction of their specific functions. Those changes were reversible. The relative structural integrity of the cells and the anatomical integrity of the organs was an important prerequisite for cell restoration.94 After the ending of the famine the mitotic capacity of somatic cells, and especially of myocytes of the myocardium, depressed in nutritional dystrophy, was restored and cell renewal became possible in the tissues of organs with cells capable of mitosis. In restoration the mass of the cytoplasm increased along with the amount of intracellular protein, and there ensued a normalization of protein level and carbohydrates in the blood, a build-up of lipid and glycogen in those organs (skeletal muscles, myocardium, liver) that had lost weight and volume during the famine, and gradual increase in the number of cells in those organs (spleen, lymph nodes, bone marrow) that had suffered loss of cells and cessation of cell division in addition to cellular atrophy. Recovery was very slow. Erythropoiesis and myelopoiesis were the most rapidly restored functions, preceding restoration of fat deposits. Partial restoration of thin layers of subcutaneous fat did not begin until the fifth

1403_901422_07_cha05.qxd

10/6/2004

5:03 PM

Page 154

154 Prerequisites for Survival and Recovery

month of intensive feeding, but by the eighth month they were appreciably thicker. Even then the cells of various organs had not reached normal size and the continuing breakdown of protein that was a feature of nutritional dystrophy was indicated by the presence of lipofuscin.95 Metabolism remained lowered for many months. Nutrition began to improve in 1943. Nearly a year was needed for restoration of the main metabolic indicators.96 Specialists noted that clinical recovery ran ahead of the restoration of atrophic cells to a normotrophic status. In analysing the problem, consideration should be given to the possible replacement of atrophied cells by new cell generations, in connection with the restoration of mitoses inhibited during protein deficiency. It has been experimentally established that rabbits starved for two months were not completely recovered until a year after normal feeding was resumed. Between the lifting of the siege and midway through 1945 there was at least a transient normalization of blood pressure, indicative of the restoration of normal psychosomatic interactions after lengthy extreme mental and emotional stress. Post-mortem histological findings indicate that the brain and kidneys were the least affected organs. There were structural changes to isolated neurons or neuron clusters (focal changes), but these losses were not quantitatively so great as to exclude compensation with normal nutrition. The fainting fits of the famine were due to inadequate blood supply and nutrition of the brain, especially glucose deficiency. Neurons in cell cultures quickly perish when glucose content is lowered. Nerve cells in the intact organism are capable of restoring impaired or even temporarily lost functions.97 After the lifting of the siege and the ending of bombing and shelling many Leningraders were able to get over the after-effects of the mental and emotional stress, and the psyche and psychosomatic relations returned to normal. The functions of the somatic systems and organs were restored by normalization of the apparatus of their neural and endocrinal regulation. Teachers consider that children who lived through the siege in childhood and adolescence were physically retarded but little different in mental ability to others of the same ages.98 My friends, who lived through the siege at these ages, subsequently went on to higher education and seven out of twelve achieved postgraduate higher degrees. With one exception they all have children and grandchildren. After the siege one of my classmates still had the rare ability to memorize something that she had read only once: the pages of a book were seemingly

1403_901422_07_cha05.qxd

10/6/2004

5:03 PM

Page 155

Svetlana Magaeva 155

‘imprinted’ in her memory, although recollection is one of the most vulnerable functions of the brain. Young survivors of the siege succeeded in retaining and realizing their rare talent, as is demonstrated by the creative activity of many scholars and intellectuals during the siege and after the war. It is common knowledge that former victims of the siege have enriched science, poetry, music, painting and the theatre, but few people realize and remember that they endured starvation and were at risk of losing their talent. An invaluable contribution to saving the lives and restoring the strength of the people of Leningrad was made by the self-sacrificing work of such eminent scholars as Mikhail Vasil’evich Chernorutskii, Petr Andreevich Kupriyanov, Ivan Petrovich Vinogradov, Vladimir Georgievich Garshin, Petr Sergeevich Kornev, Georgy Fedorovich Lang, Vladimir Nikolaevich Myasishchev, Aleksandr Leonidovich Myasnikov, Ioakim Romanovich Petrov, Nikolai Nikolaevich Petrov, Aleksandr Fedorovich Tur, Mikhail Dmitrievich Tushinskii, Zakhar Grigorevich Frenkel and many other medical workers. It is not only somatic functions that can be restored after nutritional dystrophy, but also high manifestations of mental activity in the form of unique talent and inspired creativity. There are, however, grounds for thinking that the organism was not completely restored. There were many who could not recover their health and realize their potential. A trace remained of the severe pathological process and it could be reinstated under the influence of new pathogenic influences.99 Following nutritional dystrophy there were increases in many visceral pathological states and frequent endocrinal disorders brought about by malfunctioning of the hypothalamic– pituitary system.100 Post-war ill health among victims of the siege is apparently largely connected with neuroregulatory diseases. Retarded development of the regulatory systems of the juvenile organism through starvation could have been conducive to the kind of pathology that leaves a trace pathological process. Chernorutskii considered that in many instances there were no grounds for the assertion that there had been complete biological recovery in victims of the siege, despite ‘appearing to be flourishing and plumper than was typical before the war’. As a scientist and doctor he was convinced that there were no grounds for predicting the restoration of stable equilibrium after a severe shock to the organism. And he was correct, to judge by the bitter experience of victims of the siege and of the medical profession following the siege. Some people who had been in the siege did become seriously ill after the war and died

1403_901422_07_cha05.qxd

10/6/2004

5:03 PM

Page 156

156 Prerequisites for Survival and Recovery

prematurely, most often from hypertensive disease. The latter was no longer called Leningrad hypertension, although that was what it was, and it has remained one of the key causes of the poor health of Leningraders who survived the siege. Did any of us recover our health to such an extent as no longer to feel invalids of the siege? To some extent the answer is yes, but only for some. The after-effects of mental and physical traumas poison every post-war day (which is why we divide our biography into ‘life before and after the war’). The life of invalids of the siege is a struggle. Almost all survivors are suffering some after-effects of serious illness during the siege period. We do not differ in our way of life from others of the same age, but the price of a normal, full and useful life is different for us in terms of mental and physical effort. We must therefore acknowledge, despite our optimism, that the recovery of the organism exposed to the combined effects of mental and emotional stress, nutritional dystrophy and excessive cooling of the body has been ‘incomplete and unstable’.101 Adaptation theory gives hope for the retention of a more or less stable non-specific structural trace of processes that may promote adaptation to new pathogenic factors. Thus, the relationship between a trace pathological process and the trainability of adaptation mechanisms determines our state, which will always remain a post-siege state, however much time has passed since the war. Chronic illnesses are usual for people who lived in the siege. Illnesses gripped us during our besieged childhood and multiply as we get older. Directly or indirectly our ailments were caused by the siege: by hunger and mental and emotional stress, but we remain alive, and some of us are long-lived. Our ages justify the assumption that genetically conditioned longevity may be achieved in exceptional instances after severe nutritional dystrophy. The venerable age of survivors of the siege is, in itself, convincing testimony to the real feasibility of adequate recovery of the organism after nutritional dystrophy. The war conducted an experiment of terrible harshness in which more than two million Leningraders were brought to the limit of survival. Under similar extreme conditions the outcome of nutritional dystrophy was different in different people, ranging from survival and subsequently more or less full recovery to death. In analysing data on the pathogenesis of nutritional dystrophy, and the part played by the neurogenic and psychogenic factors in hastening cachexia, we may assume that the following factors were of great significance in the outcome of nutritional dystrophy:

1403_901422_07_cha05.qxd

10/6/2004

5:03 PM

Page 157

Svetlana Magaeva 157

• genetic and individually acquired predisposition to disruption of protein metabolism and mental and emotional stress • the activity of natural stress-limiting systems • the state of the psyche at the outset • the degree of retention of psychosomatic influences • the severity of changes in the state of the nervous system consequent upon nutritional dystrophy • the reliability of adaptation to nutritional dystrophy and the daily threat to life • prompt psychological support and psychoprophylaxis of severe mental and emotional stress • uninvestigated latent reserves of the organism compensating a deficiency of protein synthesis at the molecular level. People have no control over many of these factors, but it is necessary and useful to recognize that self-control and the will to live were not the least important of them, because they ensured the retention of psychosomatic influences at a level that not only did not worsen the severe general state of the organism, but promoted survival. Despite the combined effect of the pathogenic factors of the siege period – protracted severe emaciation and mental and emotional stress – the physiological, structural and psychosomatic foundations of recovery may be retained. It may be assumed that discoveries of fundamental importance to physiology and medicine will be made in the study of survival under extreme conditions, and that they will broaden existing views on the latent reserves of human beings and the mechanisms involved. The results will be of use to people who may find themselves under extreme conditions, but God forbid that anything like the siege of Leningrad should ever happen again to anyone anywhere in the world. Notes 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Mediki i blokada (1997), 256, 257. Khvilivitskii (1988), 130–5. Meerson and Pshennikova (1988). Selye (1982). Khvilivitskii (1988), 131. Meerson and Pshennikova (1988), 101–7. Ibid., 104. Ibid., 111. Zharikov (1986), 19–23. Fedotov (1963), 7–18; Topolianskii and Strukovskaya (1986); Fraiberger and Otte (1999), 117–22.

1403_901422_07_cha05.qxd

10/6/2004

5:03 PM

Page 158

158 Prerequisites for Survival and Recovery 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58.

Meerson and Sukhikh (1985), 23–9. See Topolianskii and Strukovskaya (1986). Kryzhanovskii (1997), 216–29. See Kryzhanovskii (1980). See Selye (1960). See Bykov (1954), vol. 2; Kurtsyn (1973); Airapetyants and Vein (1982). Grotel (1945), 24–8. Khvilivitskaya (1947), 158–9. Khvilivitskaya (1947), 73–6, 143, 144. Khvilivitskaya (1947), 42. Bolshaya meditsinskaya entsiklopediya (1953), vol. 3, 643. Mediki i blokada (1997), 256. Blokada rassekrechennaya (1995), 215. Mediki i blokada (1997), 22. Alimentarnaya distrofiya (1947), 38. Ibid., 53–96; Sveshnikova (1944), 232–9. Myasnikov (1944); Alimentarnaya distrofiya . . . , 128–63. Alimentarnaya distrofiya . . . , 366. Leningrad v osade (1995), 248. Alimentarnaya distrofiya . . . , 132; Opyt sovetskoi meditsiny (1951), vol. 28, 94. Alimentarnaya distrofiya . . . , 37, 194–7. Opyt sovetskoi meditsiny (1951), vol. 28, 56. Alimentarnaya distrofiya . . . , 141. Ibid., 366. Ibid., 58–73. Ibid., 122–3. Ibid., 108–22; Opyt sovetskoi meditsiny (1951), vol. 28, 62, 63. Alimentarnaya distrofiya . . . , 103–28, 256, 257; Chelovek. Mediko-biologicheskie dannye (1977), 233, 275, 338. Alimentarnaya distrofiya . . . , 214. Speranskii (1955), 111–403. Selye (1960). Alimentarnaya distrofiya . . . , 159, 160. Ibid., 214. Ibid. Ibid., 48. Chernorutskii, Gefter and Glinka-Chernorutskii et al. (1944), 54–64. Alimentarnaya distrofiya . . . , 105. See Chernorutskii, Gefter and Glinka-Chernorutskii et al. (1944), 54–64. For further details see Magaeva (1999). Salisbury (1996), 505–6. Grekova, Pinchuk and Anichkova (1990), 104. Garshin (1960), 230. Mediki i blokada (1997), 183. Mediki i blokada (1997), 169. Alimentarnaya distrofiya . . . , 165. Ibid., 332–45, 350–9. Grotel’ (1945), 25. Alimentarnaya distrofiya . . . , 209.

1403_901422_07_cha05.qxd

10/6/2004

5:03 PM

Page 159

Svetlana Magaeva 159 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71. 72. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83. 84. 85. 86. 87. 88. 89. 90. 91. 92. 93. 94. 95. 96. 97. 98. 99. 100. 101.

Teplova (1944), 317. Alimentarnaya distrofiya . . . , 209. See Myasnikov (1945). Alimentarnaya distrofiya . . . , 209. Ibid., 132. Teplova (1944), 318. Airapetyants and Vein (1982). Sudakov (1975), 43. Khvilivitskii (1988), 132. Valdman (1945), 53. Vainberg (1944), 331. Alimentarnaya distrofiya . . . , 210. Maev (1945), 125–39. Maev (1945), 138. Alimentarnaya distrofiya . . . , 322–45. Ibid., 214. Ibid., 127. Mediki i blokada (1997), 14–22. Gaiskii (1938), 174–82; Zabolotskii (1926), 62–3; Kalabukhov (1947). See Korneva, Klimenko and Shkinek (1978); Korneva and Shkinek (1989); Korneva (1993); Ader (ed.) (1981); Ader, Cohen and Felten (1995), 99–103. See Kryzhanovskii, Magaeva and Makarov (1997); Palmblood (1985), 45–63; Solomon (1984), 1–10; Stein (1985), 29–41. Alimentarnaya distrofiya . . . , 132. Ibid., 214. Opyt sovetskoi meditsiny (1951), vol. 28, 62, 63. Opyt sovetskoi meditsiny (1951), vol. 28, 62, 63. Alimentarnaya distrofiya . . . , 201. Martinson, Vladimirov and Korepanova (1944), 42–3. Alimentarnaya distrofiya . . . , 127. Ibid., 128–68; Opyt sovetskoi meditsiny (1951), vol. 28, 86, 87. Zefirova (1999). Alimentarnaya distrofiya . . . , 121. Shulutko (1944), 201–11. Alimentarnaya distrofiya . . . , 121. Mediki i blokada (1997), 28–9. Garshin (1960), 225–39. Alimentarnaya distrofiya . . . , 125; Opyt sovetskoi meditsiny (1951), vol. 28, 86, 87. Opyt sovetskoi meditsiny (1951), vol. 28, 86, 87. Alimentarnaya distrofiya . . . , 101–3. See Kryzhanovskii, Karaban, Magaeva and Karaban (1995). Honoured Teacher of the RSFSR E. I. Ermolenko, teachers E. M. Kots and E. S. Lyubimova. Speranskii (1955), 495–8. Dombrovskaya (1948), 135–44. See Alimentarnaya distrofiya . . . , 365, 366.

1403_901422_08_cha06.qxd

10/6/2004

5:04 PM

Page 160

6 The Work of Civilian and Military Pathologists Vadim Chirsky

The siege of Leningrad ranks in the history of mankind as a monstrous experiment in human survival under conditions of starvation, cold, bombing and shelling. The medical workers of the city gave great assistance to Leningrad’s citizens in overcoming these difficulties, and in the treatment and prevention of disease. Pathologists worked with other kinds of doctors in Leningrad under siege. An outsider, unaware of the problems that had to be tackled, might find it strange and unnecessary in those very difficult times, when there were vast numbers of sick and wounded people and acute shortages of all essentials, that anyone should be carrying out autopsies, dissecting the bodies of dead people. At the same time, it is impossible to overestimate the significance and importance of the work of anatomical pathologists during the siege. The course of many diseases, some of them serious, had been affected by malnutrition, both quantitative and qualitative, excessive cooling of the body, weariness and mental trauma. There was a risk that doctors might make many more errors of diagnosis. Under these conditions the main tasks of pathologists were to: (1) establish the ways in which the course of various diseases had been affected by nutritional dystrophy; (2) analyse the causes of death of patients; and (3) detect and analyse shortcomings in treatment. The success with which Leningrad pathologists tackled these tasks considerably helped to improve diagnosis and treatment, thus contributing to saving many thousands of lives. Anatomical pathology had been well-developed in pre-war Leningrad. Medical schools had active morbid anatomy departments headed by leading specialists in this field, including Academician N. N. Anichkov and Professors V. G. Garshin, F. Ya. Chistovich, M. K. Dal
, G. V. Shor, L. M. Shabad and S. S. Vail
. The city had many research institutes with morbid anatomy laboratories and departments. All large hospitals 160

1403_901422_08_cha06.qxd

10/6/2004

5:04 PM

Page 161

Vadim Chirsky 161

had anatomical pathology departments that worked closely with the medical faculties. The Society of Leningrad Pathologists held regular meetings. The outbreak of the Great Patriotic War disrupted the routine of the city’s pathologists, confronting them with new tasks and the need to switch to the demands of the front. Laboratories of anatomical pathology began to be organized for the various fronts at the very beginning of the war, and that necessitated calling up pathologists for active service (V. D Tsinzerling, M. B. Ariel
, V. V. Rumyantseva, O. I. Bazan and others). The anatomical pathologists remaining in civilian hospitals began additionally to provide services for military hospitals. During the first few months of the war (July–August 1941) the Anatomical Pathology Service of the Northern Front (subsequently the Leningrad Front), headed by Professor Tsinzerling, was assigned the task of carrying out all military pathology of the armies on the front from Murmansk to Vyborg. The mobilization plan for the Northern Front provided for three fully staffed anatomical pathology laboratories (APLs). APL 49 and APL 50 were army laboratories, APL 48 was a frontline laboratory administered by the chief pathologist of the front. APL 48, based in Leningrad, organized and generally supervised anatomical pathology on the Northern Front, examined material sent by the armies (statistical processing, preparation of reports etc.), carried out special laboratory assignments and collected material on the pathology of war injuries (museum work). The anatomical pathology needs of military hospitals and other treatment facilities in and around Leningrad were handled by military pathologists on the staff of some hospitals, and by medical faculties (the Military Medical Academy, 1st and 2nd Leningrad Medical Institutes, Paediatric Institute etc.) and the dissectors of hospitals and scientific institutes in the city. In this period (July–August 1941) conditions for anatomical pathology were extremely favourable in the vicinity of Leningrad. The armies had sufficient pathology teams including qualified specialists, and in Leningrad itself many well-equipped institutes, which had large numbers of qualified workers headed by qualified specialists (university professors etc.), were involved in the work. On the other hand, there were relatively few dead military personnel and civilians. The main tasks of the Anatomical Pathology Service of the Front at this time were to study incoming material, work out a unified approach to its assessment, organize information exchanges between specialists, and direct anatomical pathology towards matters of the most theoretical and practical importance. In addition, great attention was paid to the correct and

1403_901422_08_cha06.qxd

10/6/2004

5:04 PM

Page 162

162 The Work of Civilian and Military Pathologists

full completion of dissection record cards by all anatomical pathologists in the interests of obtaining reliable material for statistical processing (additional instructions were issued), and work was also begun on topical aspects of military pathology and the collection of material for a museum of war injuries. These assignments were partly completed, mainly as regards organization,1 but such work was already disrupted in August by the military situation. A new period in the work of Leningrad’s anatomical pathologists began in that month and continued into October–November. Its features were the approach of the front line to Leningrad and the appearance there of new armies, the increase in the city of the number of hospitals, and as a result a sharp increase in the amount of dissection material. Pathologists were mainly occupied with autopsies and use of the data to make corrections to current medical work. Other aspects (scientific processing of material and museum work) became secondary. The Anatomical Pathology Service of the Front took the following measures at this time: first, two groups of doctors from APL 49, including the laboratory’s most experienced workers (chosen because of the need to work independently), were seconded to military hospitals moving to the rear; second, pathologists were sent to the armies that had arrived in front of Leningrad; third, assistance began to be given to the busiest dissection rooms by seconding groups or individual specialists to them. Such assistance was given to, inter alia, the Military Medical Academy, especially the forensic medicine faculty, the V. V. Kuibyshev Hospital, the No. 1 Evacuation Hospital, and the F. F. Erisman and I. I. Mechnikov hospitals. The APLs were thus enabled to conduct autopsies on all dissection material in Leningrad. Other successfully resolved organizational tasks worthy of mention were: 1. The planned assignment of hospitals lacking their own anatomical pathologists to military and civilian dissection rooms. On 6 November 1941, for example, Order No. 0222 was issued jointly by the Military Medical Board of the Leningrad Front and the Leningrad City Health Department assigning evacuation hospitals to the dissection rooms of civilian hospitals and institutes for autopsies on military personnel dying in them. The volume of work in these dissection rooms may be guessed from the number of evacuation hospitals assigned to each: 11 to the morbid anatomy faculty of the Military Medical Academy, 17 to the dissecting room of the F. F. Erisman Hospital, 17 to the dissecting room of the V. I. Lenin Hospital and so on.

1403_901422_08_cha06.qxd

10/6/2004

5:04 PM

Page 163

Vadim Chirsky 163

2. The establishment of a special military burials team attached to No. 117 Evacuation Hospital, because burials became one of the most important problems at this time – the accumulation of large numbers of bodies in the dissecting rooms made their work very difficult. In November 1941 there were major changes in the working conditions of pathologists on account of the very serious situation in the city. This period lasted until March 1942. The main changes were as follows. First, there was a sharp increase in the amount of dissection material (greatest in February 1942). Second, a number of urban dissecting rooms began to be put out of action in November because they were overloaded with bodies and the central heating had ceased (almost all the urban dissecting rooms stopped working in December 1941). Third, in December some institutes and individuals were evacuated from Leningrad (including Professor Shabad, head of the morbid anatomy faculty in the No. 2 Medical Institute). The departure of the Military Medical Academy, which had done a great deal of dissection of bodies from military hospitals, was of special significance.3 Fourth, a very difficult situation had arisen in those anatomical pathology departments that had not ceased working – lack of water, heating and light, a large influx of the bodies of people who had died from emaciation, and interruptions in the operations of the special team that collected and buried bodies. A report on the work of the anatomical pathology department at the S. P. Botkin Hospital during 1941 stated: from the very first days after war was declared bodies were brought to the department and accepted day and night. The difficulty over these duty periods was that, given the reduction in the number of personnel (before the war Professor Tsinzerling and two doctors, O. L. Vishnevskaya and A. K. Vinokurtseva, had worked here), they came round at daily intervals and worked in the autumn and winter in the dark and cold (the large number of windows and the height of the building made full black-out measures impossible, and the lack of stoves meant that the buildings were cold when the steam heating was not working). All the efforts of the steadily reduced workforce were directed towards the day-to-day work of dissection, the volume of which had been increased by the assignment of a number of military hospitals to our hospital. All teaching and scientific work in the department ceased.4

1403_901422_08_cha06.qxd

10/6/2004

5:04 PM

Page 164

164 The Work of Civilian and Military Pathologists

Because the mortuary was becoming full by 6 September and because of frequent delays in transportation, the basement was filled to overflowing, as was a room on the first floor. People working there literally had to walk over bodies, which was very difficult at night. In December the water supply system failed and the pipes burst, with the results that the basement rooms became partly flooded and then froze (the temperature inside the building fell to -11 °C). Two doctors became ill in the middle of December, leaving on duty only two laboratory workers and one assistant to deal with the documentation on the acceptance and despatch of bodies. All dissection work ceased from that time. Anatomical pathology in the city was then carried out mainly by military pathologists, of whom there were far too few in the treatment facilities of the Leningrad Front (it was impossible to increase their numbers because the call-up of civilian doctors had ceased). The shortage of pathologists became worse, especially in January and February, when there was much sickness among the staff of the hospital anatomical pathology departments and the APLs. Almost all the leading personnel, including the chief pathologist, Professor Tsinzerling, were ill. Many Leningrad anatomical pathologists (O. P. Bykova, I. E. Levin, S. M. Leites, Professor M. E. Mandelshtam, K. D. Lavrova, R. Martynova, L. B. Sheinina and others) died in the besieged city during the war. Among the military pathologists, the head of the hospital pathology department at No. 2222 evacuation hospital, Professor V. M. Gakkel
, died. Professor F. Ya. Chistovich, who refused to be evacuated, continued working in besieged Leningrad until the spring of 1942, was evacuated in June when already seriously ill, and died in hospital in Novosibirsk. T. A. Shtein also perished in the evacuation and M. I. Goremykina was wounded during the shelling of Leningrad. In such a situation a great deal of work fell to APL 48 and APL 49, whose staff continued working in a number of the Leningrad evacuation hospitals. Dissection also continued without interruption, although on a limited scale, in the APL of No. 80 evacuation hospital, where Professor Dal
worked and where satisfactory working conditions were provided by the administration of the hospital, in No. 90 evacuation hospital (APL headed by Ariel
), in evacuation hospital No. 1,015 (APL headed by A. A. Kulikovskaya) and elsewhere. Work also continued in the dissecting rooms of some civilian hospitals. For example, between November 1941 and May 1942 1,023 autopsies were performed (dissector L. M. Linder) in the K. A. Raukhfus Hospital, the largest children’s hospital in the city. The autopsies were performed in the unheated dissecting room, where the instruments froze to the bench. Bodies fre-

1403_901422_08_cha06.qxd

10/6/2004

5:04 PM

Page 165

Vadim Chirsky 165

quently had to be thawed in the dissector’s small room, where she slept at night because she did not have the energy to go home. The work, although very difficult, was essential to clinicians and to the city sanitary and epidemiological service, and it was therefore not interrupted.5 It must be pointed out that there were laboratory assistants working with the doctors in the besieged city (including O. I. Smelova, T. Ya. Sosunova, E. F. Bykova, E. I. Nefedeva, E. N. Maksimova, M. O. Shapchits and A. F. Novitskaya).6 Many Leningrad inhabitants died of starvation and deprivation at home and in the streets. Apart from mortuaries specially organized in some districts to which people took their dead, the bodies of those who had died at home and in hospitals were stored in large numbers in the mortuaries of hospitals. From these they were removed periodically for burial by the Funeral Trust (between 1 December 1941 and 1 December 1942 the City Funeral Trust took 444,182 bodies to the cemetery7). The City Health Department played an active part in organizing this work.8 Because of the impossibility of performing autopsies on all those who died at this time, temporary instructions were issued on compulsory autopsies only for certain categories of corpses. Most were buried without autopsy, and the hospital issued death certificates to the relatives on the basis of details of the history of the illness, the accompanying notes of the polyclinic doctors, the case histories and so on.9 Burying the bodies of servicemen also became a very acute problem between November 1941 and March 1942. The team set up in September to transport bodies to the cemetery was unable to cope, especially because far too few graves were being prepared by the civilian institutions. Despite all the difficulties of this period, city pathologists performed a significant number of autopsies to establish the dysenteric nature of diarrhoea in the emaciated (Ariel
, Dal
); scientific processing of material was carried out in some institutes (T. V. Chaika on emaciation, Dal
on emaciation and dysentery, Ariel on septic complications of wounds); and practical work with students was continued in medical schools.10 Professor Garshin gave the following description of the course in morbid anatomy at the 1st Medical Institute: Lectures and practical work nevertheless continued. There were fewer and fewer students. On approaching the lecture room you did not hear the happy sound of young voices . . . They were huddled in their overcoats and hats around the small stove, and during the lecture they put in wood and gazed pensively at the fire . . . They spoke little,

1403_901422_08_cha06.qxd

10/6/2004

5:04 PM

Page 166

166 The Work of Civilian and Military Pathologists

and did not have the energy to talk even about what always agitated and occupied them. Often they did not have the physical strength to hold out until the end of the lecture . . . The exams are coming. I listen and they reply fairly well! They have assimilated the lecture material. But the examiner – a woman assistant lecturer – interrogates them at times pedantically, at times sympathetically. Where do they get strength from? . . . Life in the faculty continues, come what may. That is the most important thing. Everyone who passed the test of starvation passed their examinations in my course. Some died after my examination.11 Towards March 1942 conditions for anatomical pathology gradually improved, in large measure through the organization of burial and the removal of bodies from the mortuaries of military and civilian hospital anatomical pathology departments. The health of most pathologists also improved. At the beginning of May a further 21 anatomical pathologists began working in the hospitals of the city (nine of them within the anatomical pathology service of the Leningrad Front) after a six-week training course for wartime dissectors. That helped to reduce the shortage of trained staff in hospital dissecting rooms and to improve the qualifications of specialists. Professor Dal
was in overall charge of these courses, with the active assistance of Professor Garshin, Professor Tsinzerling and M. A. Zakharevskaya. O. K. Khmel
nitskii, a future corresponding member of the USSR Academy of Medical Sciences, took one of these courses.12 The improved working conditions in Leningrad made it possible gradually to increase the scope of dissecting room material by autopsies. The task given to anatomical pathologists at that time was complete autopsy coverage for hospitals with their own dissecting rooms, and from May to June 1942 full autopsy coverage was required for all who had died in the assigned hospitals. The task was carried out: autopsy coverage was 20 per cent in March, around 50 per cent in April and approaching 100 per cent in June. Beginning in March 1942 the pathologists of the city and the front were given important research assignments on the complicated and unusual pathology of that time, with the aim of using this scientific knowledge to improve medical care in treatment facilities in the city. All the material was analysed by Professors Tsinzerling and Garshin and in special studies by Professor Dal
, Ariel
, Chaika, Zakharevskaya and others. This work did lead to understanding of the material and of the causes of death of military personnel and civilians.

1403_901422_08_cha06.qxd

10/6/2004

5:04 PM

Page 167

Vadim Chirsky 167

The data obtained by dissecting rooms at this time were regularly brought to the notice of the Military Medical Service of the front, the Leningrad Health Department (from the spring of 1942 Professor Tsinzerling, the chief pathologist of the front, was a consultant on the organization of dissection in the Leningrad Health Department) and many doctors. This was done through reports and communications to conferences of the doctors of the Leningrad Front and the city medical associations (V. V. Rumyantseva and Dal
on chest wounds, Dal
and Garshin on infectious jaundice, Zakharevskaya on hypertension, E. A. Popova and Dal
on emaciation, Tsinzerling on the pathology of emaciation and illnesses connected with it, on work concerning the production of clinical and medical diagnoses, and on especially serious infections, Garshin on peculiarities in the course of tuberculosis).13 In addition, the day-to-day dissection material of the hospitals was systematically gone through with doctors to increase their skills and uncover errors in clinical diagnosis and other shortcomings in the provision of medical care. This was of great importance because most doctors were little acquainted with the pathology of nutritional dystrophy. Anatomical pathologists were given the task of systematically organizing clinical and anatomical conferences and holding them, not only in hospitals that had dissectors on the staff, but in all treatment facilities assigned to them. These conferences dealt mainly with discrepancies between clinical and pathological diagnoses. The increase in the number of such cases by comparison with peacetime was connected with the short time patients were in the wards (sometimes less than one day), their serious condition, the atypical course of the disease, inadequate laboratory investigation, and an increase in the number of doctors with comparatively little experience and length of employment in their special discipline.14 These conferences were especially necessary and useful at this time because they had an appreciable effect on the improvement of diagnosis and reduction of the hospital death rate – one of the main indicators of the quality of therapeutic diagnosis (39.3 per cent in the first quarter of 1942, 32.1 per cent in the second, 15.9 per cent in the third and 9.8 per cent in the fourth).15 Urban district clinical and anatomical conferences for doctors of all kinds began to be held in the city. Subsequently, as clinicians and pathologists gained experience, these conferences took up particular topical subjects: hypertension and epidemic hepatitis (anatomical data presented by Professor Garshin), nutritional dystrophy and dysentery (Tsinzerling), nutrional dystrophy and tuberculosis, nutritional dystrophy in children (M. Linder and others).

1403_901422_08_cha06.qxd

10/6/2004

5:04 PM

Page 168

168 The Work of Civilian and Military Pathologists

It should be pointed out that wartime pathology underwent considerable changes in Leningrad in different periods of the siege. War wounds, which had played the major part at the start of military operations, gave way to a new pathological state – nutritional dystrophy. The first case of death from nutritional dystrophy in the practice of military hospitals was recorded on 14 November 1941, after which such cases began to increase sharply.16 Doctors confronted by the unexpected, little-known and intricate pathology of nutritional dystrophy17 were not initially of one mind on the terminology and treatment of this disease. In December 1941 the Leningrad Health Department had to issue instructions18 in which the clinical symptoms seen when nutrition was impaired were designated ‘nutritional dystrophy’. In addition, the situation was complicated to some extent for doctors by the fact that although the morbid anatomical changes to be noted in nutritional dystrophy in Leningrad in the period 1941–43 were, in general, fairly uniform, they varied in relation to the duration of malnutrition and the combination of nutritional dystrophy with various other illnesses (pneumonia, dysentery, tuberculosis etc.), which complicated the course of the disease and noticeably influenced the morphological picture. These illnesses had such a bearing on the course of nutritional dystrophy that the Leningrad nutritional dystrophy ‘epidemic’ was divided into periods, mainly in accordance with the observed complications.19 Tsinzerling distinguished the following three periods. The first, from November 1941 to January 1942, he characterized by the complication of dystrophy by pneumonia, which was found in 83 per cent of autopsies (only 17 per cent of cases were classified as ‘pure’ nutritional dystrophy). In the second period, which began in January and lasted until April 1942, nutritional dystrophy was accompanied by gastrointestinal complications, mainly enterocolitis and dysentery. Dysentery worsened the course of nutritional dystrophy, maintained it and caused secondary emaciation.20 In March nutritional dystrophy without complications was found in only 4 per cent of autopsies, complication by pneumonia alone in 21 per cent, but complication by dysentery in 70 per cent. Dysentery remained the leading complication in the third period (April to June) – anatomical changes were noted in the intestines in 73 per cent, but new features began to appear in the pathology of nutritional dystrophy from the middle of March, with the emergence of tuberculosis and scurvy. According to the composite data of the dissecting rooms of Leningrad, the uncomplicated form of nutritional dystrophy was seen in 15.4 per cent of cases in 1942.21 This form of nutritional dystrophy may be accompanied by oedema,

1403_901422_08_cha06.qxd

10/6/2004

5:04 PM

Page 169

Vadim Chirsky 169

but not necessarily. During the siege doctors were faced with the question of the extent to which these two variants of the disease could in fact be distinguished as separate forms. The research of anatomical pathologists (including Chaika) showed that the morphological changes were basically the same in both variants of nutritional dystrophy, and that a cachectic and an oedematous form might be distinguished only in acute stages of the disease, when there was marked cachexia or oedema. Such a separation subsequently becomes very difficult. Chaika noted that transitions from the cachectic to the oedematous form could be observed from March onward – a negligible quantity of fluid appeared in the abdominal cavity, but under the microscope the organs revealed all the changes identifiable as stages of latent oedema. The research demonstrated that oedema was invariably to be found, sometimes markedly so, but sometimes only in puffiness of the feet and shins, if the illness was protracted. When autopsies were performed on non-oedematous corpses the former presence of such signs was quite often found, as was indicated by thickening of the epidermis, flaking of the skin, and ‘scars’ from stretching on the thighs and stomach. All this prompted the conclusion that cachectic and oedematous forms should not be distinguished, but that the reference should be to nutritional dystrophy with and without oedema.22 The worsening sanitary and epidemiological situation in the city and the appearance of a large number of emaciated patients led in December 1941–March 1942 to an outbreak of dysentery that was highly unusual both clinically and pathologically: very flaccid, with normal temperature, and a weakly expressed inflammatory reaction in the intestinal wall. This intestinal malfunction in sufferers from nutritional dystrophy was interpreted by clinicians as ‘starvation diarrhoea’ or ‘colitis of the starving’. Joint research by pathologists (Tsinzerling, Ariel) and bacteriologists (E. M. Novgorodskaya and others) demonstrated that the intestinal malfunction in dystrophy patients (children and adults) was due in most instances to dysentery, with Shigella flexneri as the main causative agent. This work, which was of great epidemiological importance, influenced treatment methods. Whereas 20.4 per cent of patients with dysentery as a complication of nutritional dystrophy died in 1942, the figure was only 6 per cent in 1943.23 The course of tuberculosis exhibited the following peculiarities in this period (Garshin, Dal
, Ariel
): (1) caseous lymphadenitis of the root of the lung was frequently observed; (2) haematogenic dissemination was considerably more frequent; and (3) tuberculous pleurisy was more frequent.24

1403_901422_08_cha06.qxd

10/6/2004

5:04 PM

Page 170

170 The Work of Civilian and Military Pathologists

Arterial hypertension was observed among the inhabitants of Leningrad mainly between November 1941 and May 1942. Halfway through 1942 cases of hypertension became much more frequent on account of changes in the arterial wall under conditions of prolonged stress and nutritional dystrophy. Subsequently, the increase in the frequency of this disease was so great that there was talk of a special ‘Leningrad hypertension’.25 The sickness rate was greatest in 1943 (up to 50 per cent of all patients receiving treatment) and the death rate from it was 31.8 per cent in the F. F. Erisman Hospital. Hypertension was somewhat reduced as a cause of death in 1944 (20.7 per cent of all autopsies). The disease affected the same age groups (the average age for men was 60 years in 1942, 54 in 1943 and 57 in 1943; the corresponding ages for women were 47, 57 and 46), but deaths from it at a young age became more frequent (in 1943 16.2 per cent of deaths in the 31–40 age group were from hypertension).26 The combination of hypertension with nutritional dystrophy altered the former’s pathological picture. At the end of 1942 and in the first quarter of 1943 sufferers from hypertension died mainly from cardiac insufficiency (78 per cent in 1942, 88 per cent in the first quarter of 1943) on account of the effect of nutritional dystrophy on the myocardium. Cerebral haemorrhages were considerably less frequent at this period (14 per cent in 1942, 11 per cent in the first quarter of 1943). No renal failure was observed. The picture gradually changed as nutritional dystrophy began to disappear from April 1943. Deaths from heart failure became considerably less frequent (57 per cent), cerebral haemorrhages were more common (18 per cent), and cases of nephrosclerosis with impaired renal function appeared (6 per cent). In 1944 the pathological picture of hypertension gradually returned to normal.27 Late 1942–early 1943 was a time of renewed activity for the Leningrad Health Department. Several commissions were set up to study a wide range of scientific and practical tasks, clinical and anatomical conferences became a regular feature, and autopsies performed on patients who died approached 100 per cent.28 At the start of 1943 the dissecting room commission of the Leningrad Health Department headed by Professor Garshin was reactivated. It produced a new listing of the illnesses connected with dystrophy so as to record the various combinations (nutritional dystrophy with dysentery, tuberculosis and so on). This listing was examined at meetings of dissectors, at which leading therapists of the city were present, in the S. M. Botkin Therapeutic Society, and it was adopted by the Leningrad Health Department.29 On its basis a composite city-wide report was prepared from the reports on anatomical pathology in 1942 (and later in 1943 and 1944), in which

1403_901422_08_cha06.qxd

10/6/2004

5:04 PM

Page 171

Vadim Chirsky 171

such conditions as hypertension, arteriosclerosis, tuberculosis and tumours were dealt with in detail, with special tables. At the same time a committee to study hypertension was set up under the chairmanship of Professor D. M. Grotel
by the Leningrad Health Department. The pathologist Zakharevskaya was a member of this committee, which held several meetings on organization of the study of hypertension in Leningrad. The committee produced and approved a plan of research on hypertension and a draft autopsy record with explanatory notes. It was planned to research five topics concerning the anatomical pathology of hypertension: (a) renal vessels; (b) vessels of the brain; (c) vessels of the heart; (d) vessels of the fundus oculi; (e) vessels of the endocrine glands. The first four studies were supervised by Professor Garshin, with assistance from Zakharevskaya and K. G. Volkova. Detailed instructions on the procedure for completion of autopsy reports on people who died from hypertension were sent to all city hospitals by the hospital office of the Leningrad Health Department.30 By order of the Leningrad Health Department a committee was established in April 1943 to study nutritional dystrophy and hypo- and avitaminoses. The committee was headed by Professor M. V. Chernorutskii, and the representative of the pathologists on it was Professor Garshin. The first meeting was held on 4 May 1943. Because a whole series of research projects on nutritional dystrophy had already been completed when the committee was set up (by the middle of August 1943 109 research projects on nutritional dystrophy had been completed, nine of them on the anatomical pathology of the disease31), and also because nutritional dystrophy was in the final stages of eradication in the middle of 1943, the committee saw its main task as being, on the one hand, to summarize the research and extract the conclusions and, on the other hand, to throw some light on such inadequately investigated problems of this pathology as: • protracted forms of nutritional dystrophy and its long-term consequences • nutritional dystrophy in old age • changes to the endocrine system in nutritional dystrophy • functional changes in the gastrointestinal tract • changes in the liver and kidneys • immunobiological shifts in nutritional dystrophy. The committee planned to publish a symposium entitled Nutritional Dystrophy, which appeared in Leningrad in 1947. The section of Chapter

1403_901422_08_cha06.qxd

10/6/2004

5:04 PM

Page 172

172 The Work of Civilian and Military Pathologists

3 on ‘Anatomical pathology of nutritional dystrophy’ was written by Professor Garshin.32 In addition an educational film for medical students, Nutritional Dystrophy, was produced in 1943 with the direct participation of Professor Garshin. Also in 1943 a scientific committee was established by order of the Leningrad Health Department to study osteomyelitis arising from gunshot wounds. It was headed by Professor P. G. Kornev, and Professor Dal
directed the morphological research. The following research topics were planned in anatomical pathology: • pathogenesis and evolution of osteomyelitis arising from gunshot wounds (Dal
and Kornev) • histotopographic changes in wound osteomyelitis (Dal
and D. M. Krylov) • histopathologic changes in the early stages of gunshot damage to bones (V. M. Nazarov and V. G. Rybina).33 Dissectors contributed greatly to the work of the therapeutic control commissions. A central committee of experts set up to ensure their effective work dealt primarily with hospital death rates, closely examining treatment establishments with high death rates. Their work was especially effective in a number of cases. For example, in the K. A. Raukhfus Hospital (dissector L. M. Lindner), where the death rate was particularly high in winter–spring 1942, the therapeutic control commission established that children suffering from nutritional dystrophy had been incorrectly diagnosed as having toxic dyspepsia. As a result changes were made to treatment and especially to diet. This work led to a considerable reduction in the percentage of discrepancies between clinical and anatomical pathological diagnoses, and made the treatment provided in the hospital more effective. Similar work was also carried out in other hospitals (including the N. K. Krupskaya, S. P. Botkin and V. Slutskaya hospitals).34 The regular working of the Leningrad Society of Pathologists was resumed in 1944 under the presidency of Professor Garshin. There were 18 meetings during the year, at which 16 papers were read and 37 demonstrations were given.35 In summing up the work of anatomical pathologists during the siege of Leningrad, it should be noted that they did much that significantly helped to improve the medical care of the wounded and sick. They clarified views on the causes of death of the wounded, detected shortcomings with regard to in vivo diagnoses and surgical work, and drew

1403_901422_08_cha06.qxd

10/6/2004

5:04 PM

Page 173

Vadim Chirsky 173

attention to shortcomings in documentation, deaths in medical transportation and other matters. Their study of aspects of the pathology of emaciation, a complicated subject little known to doctors in peacetime, was of particular significance. It was largely thanks to their work that the importance of nutritional dystrophy and related illnesses and the dynamics of the entire process were correctly appreciated. Notes 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.

17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35.

VMM, 21/46177/1, 236. TsGA SPb, 9156/ 6/1, 85–7. VMM, 21/46177/1, 237–8. TsGA SPb, 9156/4/342, 1. Vail
(1966), 204–68. Khmel
nitskii (1985), 29–36. Leningrad v osade (1995), 593. TsGA SPb, 9156/6/14, 33–4; 9156/6/21, 2. TsGA SPb, 9156/4/311, 2–17. VMM, 21/46177/1, 237–8. Garshin (1984), 83–8. Khmel
nitskii (1985), 29–36. VMM, 21/5727/3, 148; 21/46178/4, 147. TsGA SPb, 9156/4/342, 44. TsGA SPb, 9156/4/338, 26. Bazan (1997), 74. [Editorial note: The first deaths from nutritional dystrophy in civilian treatment facilities were recorded at the beginning of November. See Chapter 2 of this book.] Tzinzerling (1943), 124–5. TsGA SPb, 9156/4/317, 18. Garshin (1947), 103–28. Chaika (1943), 117–24. Garshin (1947), 103–28. Ibid.; Chaika (1951), 56–87. Ariel
(1943), 112–17; Vail
(1966), 204–68. Garshin (1944), 121–7. TsGA SPb, 9156/4/371, 1–42. Vail
(1966), 204–68. TsGA SPb, 9156/4/371, 1–42. TsGA SPb, 9156/4/338, 1–27. Vail
(1966), 204–68. TsGA SPb, 9156/4/112, 35–41. TsGA SPb, 9156/4/112, 43–5. Garshin (1947), 103–28. TsGA SPb, 9156/4/112, 52. TsGA SPb, 9156/4/338; Vail (1966), 204–68. TsGA SPb, 9156/4/338.

1403_901422_09_cha07.qxd

10/6/2004

5:05 PM

Page 174

7 The Impact of the Siege on the Physical Development of Children Igor Kozlov and Alla Samsonova

Growth studies are very important for what they tell us about vital activity. Individual morphometric differences are genetically and environmentally conditioned. Statistics on the growth and development of children of all ages are of particular significance because they reflect the most intensive period in the establishment of body shape and functions. In addition, many constituents of blood and organs alter along with growth. Great attention was paid to the health of children in the Soviet Union, and the health of the rising generation was also a key problem during the war in besieged Leningrad, as is shown by a series of decrees of the Leningrad Soviet and gorkom.1 Physical development is one of the most important pointers to the state of health of children. A. G. Tsetlin gives the following definition: ‘We take human physical development to be the totality of morphological and functional characters in their interconnection with and dependence on environmental conditions in which the central nervous system plays a determining role.’2

Age-related features of the physical development of children Much has been published on the physical development of various population groups. Standards of the normal physical development of children have been derived from extensive research.3 It has also been established that development is affected by many widely varying factors including living and working conditions and diet.4 The Great Patriotic War greatly changed the living conditions of Soviet people in a way that was bound to affect the physical development of children. Much research has been concerned with the physical development, health and sickness of children during the war.5 It has 174

1403_901422_09_cha07.qxd

10/6/2004

5:05 PM

Page 175

Igor Kozlov and Alla Samsonova 175 Table 7.1 Growth of children who suffered starvation in the Crimea in 1922–23 Boys

Girls

Age, years

n

M (cm)

s (cm)

V (%)

n

M (cm)

s (cm)

V (%)

10 11 12 13 14 15

88 143 101 117 93 64

121.3 127.6 133.8 134.9 142.1 144.2

3.4 3.8 5.0 5.0 3.0 3.0

3.8 2.6 5.8 4.8 3.3 3.0

98 107 152 104 82 –

122.4 128.6 133.8 134.1 141.4 –

4.4 5.4 5.7 5.8 3.4 –

4.4 5.0 3.7 5.5 4.1 –

Note: n is the number screened (sample size); M is the arithmetic mean; s is the standard deviation; V is the coefficient of variation. Source: Shtefko (1925).

been established that the harsh living conditions were reflected in a reduction in general (overall) body size and weight, in chest measurements and in retarded sexual development. Many researchers have concluded that the male body is more affected than the female body by adverse living conditions. Among the very few works dealing with the effects of starvation on the body of the growing child, mention should be made of the classical study by V. G. Shtefko on the physical development of starving Crimean children in 1922–23 (see Table 7.1).6 He established the following features: • girls were taller than boys in the age group 6–11 years • the growth curves of boys and girls were seen to ‘cross over’ for the first time between the ages of 13 and 14 • the characteristic growth spurts of boys and girls at the ages of 8–9 years and 12–13 years were absent • the coefficients of variation of growth were greater in girls (except at the age of 12 years). Analysing these changes Shtefko concluded that ‘the organism of the female is more resistant to the environment than that of the male. On this basis the strikingly apparent greater growth of girls in years when living is hard must be ascribed to the greater resilience of the female organism.’7 His second important conclusion was that ‘starvation has the most pernicious effect on growth between the ages of 12 and 13 and 8 and 9 years’.8

1403_901422_09_cha07.qxd

10/6/2004

5:05 PM

Page 176

176 The Impact on the Physical Development of Children

It may be concluded from analysis of published sources that adverse living conditions have the effect of retarding growth, especially at puberty. Starvation shifts the relationship between the physical development of boys and girls, as well as appreciably reducing the absolute increase in height, weight and chest measurement. The aim of this chapter is to establish how the adverse conditions experienced by children during the siege of Leningrad affected their physical development. Research hypothesis Human physical development and growth are known to be affected by both endogenous (genetic) and exogenous (environmental) factors. The reaction to these conditions in the postnatal period is most intensive during infancy and childhood. It was assumed that comparative analysis of the anthropometric developmental characteristics of children of both sexes who went through the siege of Leningrad and of others of the same age under different conditions would help in solving the problem of ensuring the vital activity of the organism under extreme conditions. What is important is the answer to the question of the nature of the change in the characteristics of physical development under these conditions – whether they are indications of a breakdown in vital activity or of adaptation of the human body to changing environmental factors. The authors used the following methods: 1. Systematization of the anthropological literature on the physical development of children under normal conditions and when affected by adverse living conditions. 2. Retrieval and analysis of archive sources (TsGA SPb, TsGANTD SPb, TsGAIPD SPb) for unpublished data on the physical development of children of pre-school age and children attending general schools and trade schools. Statistical analysis of systematized data Statistical processing is widely used for the analysis of data on human physical development. The most common procedure is to calculate sample characteristics: arithmetic mean, standard deviation, coefficient of variation, and extremes (maximum and minimum values of the characteristic). The arithmetic mean is used to assess the position of the centre of the sample, the standard deviation and the extremes, while the coefficient of variation is used for the extent of variation of the

1403_901422_09_cha07.qxd

10/6/2004

5:05 PM

Page 177

Igor Kozlov and Alla Samsonova 177

character, that is, the deviation of values of the character from the arithmetic mean. The higher the value of the standard deviation and the coefficient of variation, the greater the variation of the character. A definite genetically conditioned trend of a group of physical developmental characters exists when their value is concentrated in the vicinity of certain mean values. As a rule the mean value corresponds to the expression of the attribute most favourable to vital activity, while the greatest and least deviations correspond to the least favourable expression. There is, therefore, a ‘genotypic homeostasis’ that maintains the optimum manifestation of the attribute and its range of variability. Where a constant state is maintained in developing systems this process is known as homeorrhesis. The statistical analysis employed in this research may be characterized as follows: • it is based on data obtained from the scientific literature and from archive records • the Student t-test was calculated to estimate the significance of the arithmetic means of two samples, and the Fisher F-test to estimate the significance of the differences and variation of the characters. It should be stressed that additional statistical analysis is not possible for all published data on human physical development. The minimum set of statistical characteristics should consist of the arithmetic mean, one index of the extent of variation (standard deviation or arithmetic mean error) and sample size. Only then is it possible to use the Student t-test to estimate the significance of the difference of samples. Unfortunately, this requirement is not always observed. Attention should be drawn to a further feature of our statistical analysis. All currently available statistical software packages such as STATIGRAPHICS PLUS, STATISTICA, SPSS or S-PLUS 2000 PRO are based on the processing of input data derived from measurements. However, working with published results entails handling variously preprocessed statistical data to which it may not be possible to apply prepared statistical packages. In that context the Student t-test and the Fisher F-test were calculated in Excel 97 using a specially developed programme. The following symbols have been used in the research: n – sample size; M – arithmetic mean; m – error of arithmetic mean; s – standard deviation; V – coefficient of variation; p – significance level; pt – significance level calculated by the Student t-test; pF – significance level calculated by the Fisher F-test.

1403_901422_09_cha07.qxd

10/6/2004

5:05 PM

Page 178

178 The Impact on the Physical Development of Children

How the siege of Leningrad affected the physical development of children of pre-school age In this research we analysed the generally accepted indicators of the physical development of children of pre-school age: height, trunk length, weight and chest measurement. It should be noted that the literature on the subject is quite extensive. All pre-war sources give complete statistical data: arithmetic mean, standard deviation and sample size. Post-war research results are most often presented as a percentage increment, which precludes assessment of the statistical significance of the measurements given. Before the war juvenile physical development was actively investigated in Leningrad by K. L. Vilenkina and N. I. Krivitskaya.9 Unfortunately, only mean values are given in the 1928 and 1934 research of Vilenkina and the 1936 and 1937 research of Krivitskaya, which precludes complete statistical analysis of the material. There is, however, complete statistical data in M. I. Korsunskaya’s 1936 study of the physical development of Muscovite children of pre-school age10 and in Krivitskaya’s similar 1936–37 study of Leningrad children, comparison of which (Table 7.2) shows good agreement.

Table 7.2 Data on the height of children of pre-school age in Moscow and Leningrad, 1936–37 Moscow, 1936*

Leningrad 1936–37**

Age

n

M (cm)

s (cm)

Girls 3 4 5 6 7 8

77 102 103 106 110 70

91.68 96.82 103.86 110.76 116.52 120.04

3.38 3.84 4.20 5.06 4.38 3.74

–

Boys 3 4 5 6 7 8

84 106 103 114 120 84

91.60 98.50 104.48 111.14 116.36 119.32

3.78 4.10 4.54 4.54 4.52 4.20

–

* Korsunskaya (1938). ** Krivitskaya (1939).

n

M (cm)

97 103 111 116 –

98 104 112 116

s (cm)

1403_901422_09_cha07.qxd

10/6/2004

5:05 PM

Page 179

Igor Kozlov and Alla Samsonova 179

We failed to find any complete statistical data in published sources on the physical development of children who lived through the siege of Leningrad, but such information does exist in the archives, in the material of Z. Z. Shnitnikova.11 A commission was set up in Leningrad on 11 June 1945 to study the health effects of the war and the siege of Leningrad.12 Shnitnikova, the head of the Health Statistics Office, was a member of the first sub-commission. The commission was mainly concerned with the effects of the harsh conditions on the birth rate and death rate in various population groups during successive periods of the siege. Shnitnikova’s material includes screening data on Leningrad children of pre-school age in January 1945 entitled ‘The Childhood Sector.’ The screening covered 3,207 children between the ages of three and eight years in nursery schools: 1,605 boys and 1,602 girls.13 The Second Medical Institute and the Paediatric Institute were involved in the screening. The Health Statistics Office was responsible for the statistical processing of the data on physical development, frequency of illness, stage of sexual development and nutritional status. Some archive material on the physical development of Leningrad children was used in our research. This information is of particular value because it includes complete statistical characteristics and an account of the physical development of children of pre-school age who lived through the siege and evacuation. Thus, we compared data in our work on the physical development of Leningrad children of pre-school age who had lived through the siege and were screened in 1945 with similar information on the screening of Muscovite pre-school children in 1936 by Korsunskaya. Height Statistical analysis of the height of 4–8-year-old boys and girls from Moscow and Leningrad (3-year-olds were excluded because of the small number screened) shows that the height of the Moscow children (1936 data) was significantly greater (p < 0.05) in all age groups than in the Leningrad children (1945 data). The older the children, the greater the difference (Table 7.3). This conclusion is in full agreement with the data of Tsetlin et al., which record changes in the physical development of Muscovite children during the war. Tsetlin wrote: ‘There is a definite pattern to all the indices for children of pre-school age (4–7 years): the older the children, the more marked the retardation, which is greatest in 6–7-year-old children.’14

1403_901422_09_cha07.qxd

10/6/2004

5:05 PM

Page 180

180 The Impact on the Physical Development of Children Table 7.3 Height of pre-school children in Moscow (1936) and Leningrad (1945) Moscow (1936)*

Leningrad (1945)**

Age

n

M (cm)

s (cm)

n

M (cm)

s (cm)

pt

pF

Difference

Girls 3 4 5 6 7 8

77 102 103 106 110 70

91.68 96.82 103.86 110.76 116.52 120.04

3.38 3.84 4.20 5.06 4.38 3.74

15 57 186 270 300 16

92.7 94.8 98.6 104.6 109.7 109.5

6.80 5.50 6.00 5.65 5.95 5.00

>0.05