Xenofobia

Nazism and the Journal

Authors: Joelle M. Abi-Rached, M.D., Ph.D. https://orcid.org/0000-0003-2061-9209, and Allan M. Brandt, Ph.D.Author s

Published March 30, 2024

N Engl J Med 2024; 390:1157-1161

DOI: 10.1056/NEJMp2307319

This article is part of an invited series by independent historians, focused on biases and injustice that the Journal has historically helped to perpetuate. We hope it will enable us to learn from our mistakes and prevent new ones.

Any consideration of the legacy of historical injustices in the Journal must address the rise of National Socialism in Germany, the antisemitism of Adolf Hitler’s Third Reich, and the Holocaust. Hitler was first specifically mentioned in the Journal in 1935, in an article by Michael M. Davis, a noted American health expert and reformer, and his collaborator Gertrud Kroeger, a leading German nurse.1 Yet between this article and 1944, when Nazi war crimes were first explicitly acknowledged in an editorial,2 the Journal remained all but silent regarding the deeply antisemitic and racist motives of Nazi science and medicine and the threat to the “ideals” of civilization, as Albert Einstein put it in an open letter to the Prussian Academy of Sciences. Antisemitism was a critical element of Nazi racial science. The Nazis developed an elaborate ideology based on deeply racist assumptions about Jews and other non-“Aryan” people, whom they considered to be “defective” and “undesirable.”What does this lack of critical attention reveal about the Journal and its engagement with issues of racism and medical science? What is the nature and significance of silence, as we attempt to understand the role that oppression played in the medicine and science of the time?

One explanation could be that the rise of Nazism as a state-sanctioned persecutory regime did not receive editorial attention in the 1930s since it was deemed irrelevant to the Journal’s focus on evolving medical knowledge and therapeutic innovation, as well as to medical practice and policy. Articles on Germany or Nazis in the 1930s and 1940s are overwhelmingly about the compulsory and oversubscribed sickness insurance system, “socialized medicine,” and “quackery, not the persecution and mass extermination of Jews. In fact, when it did address Nazi “medical” practices, the Journal enthusiastically praised German forced sterilization and the restrictive alcohol policies of the Hitler Youth.

But when the Allied powers liberated the concentration camps, it became clear, as the so-called Doctors’ Trial (1946–1947) categorically demonstrated, that the medical profession in Germany embraced Nazism’s antisemitic and eugenic ideology and was deeply complicit in the implementation of mass extermination. The crimes of the Nazi state could no longer be ignored. The first Journal article explicitly damning Nazi medical atrocities is a 1949 article by Leo Alexander, a Viennese-born American neuropsychiatrist, who gathered evidence for the trial of the Nazi doctors at Nuremberg. More articles would be published from the 1960s onward, as scholars started documenting the atrocities committed by medical doctors, and especially after the Declaration of Helsinki of 1964, which established a number of ethical principles regarding human experimentation.

The Journal as Outlier

The argument that not much was known about the persecutory and murderous nature of Nazism as a state ideology before the Nuremberg trials falls short as an explanation. The Journal was in fact an outlier in its sporadic coverage of the rise of Nazi Germany. As soon as the decree of 1933 legalized and institutionalized Nazism as a state ideology, discrimination and antisemitism began to be widely reported in the U.S. press. The decree in effect purged “non-Aryans” and other political opponents of the Nazi regime from all civil service positions and barred them from holding any university or state positions. Significantly, it was drafted by Wilhelm Frick, a Nazi party member and Reich minister of the interior, who was later found guilty of war crimes and executed at Nuremberg. The 1933 decree was followed by several other decrees that excluded anyone of “non-Aryan descent” from all the liberal professions, whether in public or private practice (e.g., law, medicine, pharmacy, and dentistry).

More relevantly, the fact that Jewish physicians were being persecuted was well known in medical circles. The Journal of the Medical Association (JAMA), for instance, which had a “Berlin correspondence,” frequently informed its readership about the detrimental impact of Nazi rule on medical practice. During the first year after Hitler’s accession to power, two to four “letters” per month were written by various JAMA correspondents around the world, including from Berlin. (The Berlin letters would appear every month until 1940.) In 1933, under the new heading “Foreign Medical News,” JAMA published a report entitled “New Regulation of German Medical Practice,” detailing the persecution of Jewish physicians, including the restriction of their practice and access to medical education. The report also described the redrawing of the German medical profession along racialized lines and the way in which insurance organizations (which were major employers of physicians) were affected by the racist decree ordering the dismissal of all Jewish and Marxist-leaning consultants.

Nazi persecution, antisemitism, and the Nazi party’s interference in the reorganization of universities were also covered by Science. In several pertinent and timely articles, that journal addressed the implications of Nazi discriminatory policies and what the National Socialist Party’s subversion of education meant for academic freedom and science. For example, a May 1933 article explained what was at stake in the “Nazi revolutionary supremacy under Herr Hitler,” focusing in particular on the mistreatment of “Jewish learned and professional classes,” which the editors decried as “a relapse” to “crass repression” and “Judenhetze” or active

antisemitism. Science was also alarmed by the Nazi party’s militarization and weaponization of education, as well as the climate of fear, control, and restriction of academic freedom that it had instilled. In contrast, the only explicitly critical piece published in 1933 in the Journal was a short communiqué on “The Abuse of the Jewish Physicians.” The notice, which was included after a tedious article on surgical diathermy, drew heavily on a New York Times dispatch. It noted that the “tightening restrictions against Jewish physicians” concerned a “large” number of non-“Aryan” physicians who were “threatened with loss of living revenue.” The numbers were in fact staggering: 1.5 million civil servants were required to retire immediately. Remarkably, the discrimination against Jewish physicians was viewed by the Journal in purely economic terms. Without providing any details, the notice reported that there was some indication of “a bitter and relentless opposition to the Jewish people.” It concluded with the statement that “evidently, there is no Bill of Rights in Germany for the Jewish physician.”

Praise of German Health Insurance

Precisely because of the Journal’s limited coverage of the crimes of Nazism, the 1935 article by Davis and Kroeger and the exchange it generated are valuable sources for illuminating some of the questions that surfaced in these critical years about the role of the medical profession and its essential responsibilities. This exchange also provides some insight into broader questions of omission and silence, and invisibility and visibility, that are important for understanding how structural and institutional forces may inhibit the ability to explicitly call out discrimination and oppression and how these issues were reflected in the Journal.

In 1935, Davis, who at the time was director for medical services of the Chicago-based Julius Rosenwald Fund, collaborated with Kroeger to assess “in an objective manner” the reorganization of national health insurance in Nazi Germany. Davis and Kroeger praised the changes in sickness insurance introduced by Hitler’s government, specifically its general administrative reorganization (centralization of decision making, prevention, and reassessment of health risks and hence coverage) and the effects of the new insurance scheme on physicians (their number, responsibilities, accreditation, and salaries), characterizing these reforms as a “political revolution” and suggesting that they were worthy of emulation under the “proposed plans for social security for the people of the United States.”

The most disturbing aspect of their article is the detached, uncritical, and decontextualized nature of the analysis. There is no reference to the slew of persecutory and antisemitic laws that had been passed after the Nazis assumed power in January 1933. Davis and Kroeger sympathetically described the requirement that insurance physicians complete 3 months of compulsory service at newly established labor camps in rural areas as an “opportunity to mingle with all sorts of people in everyday life and thus, not only to broaden his general education, but also to assist [the physician] in gaining an understanding of the psychology of the people with whom he will have to deal in his later practice, and to attempt to bridge the existing gulf between the classes and between town and country.” In addition, Davis and Kroeger mentioned the German Civil Service Act of April 7, 1933, without addressing its implications. They explained without comment: “The applicant must be a German citizen, must be in the possession of full civil rights, and must not be of Jewish descent or married to a person of such descent.” Apparently, they considered the discrimination against Jews irrelevant to what they saw as reasonable and progressive change. Moreover, since membership was compulsory for every physician engaged in the health insurance program, the 1933 decree excluded a substantial portion of the medical profession. Nonetheless, Davis and Kroeger lauded this decree as comprehensive in its coverage and ethos.

Davis and Kroeger’s article did not go unchallenged. In a letter to the editor published 2 weeks later, Joseph Muller, a dermatologist and an active member of the Massachusetts Medical Society (which owned and still owns the Journal), complained about the Journal using Davis and Kroeger’s article “as a propaganda organ for half cooked world improvers.” The article, he claimed, was “neither medical nor scientific, but contains plenty of propaganda and is therefore unworthy to appear in our periodical. It is remarkable by omission of facts rather than by its statements.” Moreover, he wrote, the omission “that more than three thousand medical men were deprived of their means of supporting themselves should open the eyes of the American medical profession to one great danger of State Medicine.” Though Muller showed sympathy for the Jewish doctors, however, the real crux of his critique was not Nazi genocidal atrocities but — remarkably — the danger that socialized medicine could hold sway over the profession, a long-held concern among American physicians about “state medicine.”

Davis’s brief response to Muller’s attack is important in that it reveals what have come to be understood as critical elements of structural racism: unconscious bias, denial, and compartmentalization. In his rejoinder, Davis tried to bring some clarification to his omission by denying the relevance to his argument of discrimination against and persecution of Jews. He wrote: “The deplorable repressive policy of the Hitler government in respect to Jewish physicians had no bearing on the main point which the article was intended to bring out, namely, that the organized medical profession of Germany has, by the actions described in the article, been placed in a more responsible position than ever before with respect to the medical services under German health insurance. This concerns not so much the addition of a physician to the Council of each local health insurance unit, but the new and much more important position accorded the national representatives of the medical organizations in Germany.” For Davis, the expansion of medical power was thus more important than the fact that this gain in power came at the expense of thousands of Jewish physicians. Moreover, it did not matter to Davis that the doctor whom he described as the “guardian of the health interest” of the German people had to be “Aryan” to be able to practice.1 As we now know, however, this reliance on the benevolent and altruistic physician to act in accordance with the Hippocratic Oath was insufficient to prevent the atrocities committed by physicians in the Nazi death camps.

How could Davis claim that the fate of thousands of Jewish physicians was irrelevant for his assessment when these reforms were central to the Nazi agenda? The sickness insurance reform in particular led to more dismissals of “undesirable” individuals (e.g., Jews, communists, social democrats, unionists, and people with disabilities) than any other new policy. Furthermore, Davis and Kroeger’s praise of the centralization of decision making in the hands of “leaders,” which displaced more democratic governance of the insurance fund by elected councils, was deeply misguided. Far from merely being illiberal, as Muller noted, this centralization effort effectively implemented the “Führer principle” that endorsed a more authoritarian, albeit more efficient, managerial structure; advisory councils were dismissed, and physicians who were Jewish or deemed “subversive” were purged from the administration and replaced by regime sympathizers or party members. As medical historian George Rosen remarked, the head of this new “hierarchical pyramid,” who now held absolute power, was appointed by Hitler himself. Furthermore, after 1933, “every phase of a physician’s professional activity was minutely regulated, and it was expected that the physician would accept and further the principles of National Socialism.” This “great reorganization” that appealed to Davis and Kroeger was hence part of the Nazi regime’s consolidation of power. The persecution, discrimination, and purge of “undesirables” all went hand in hand.

If we leave aside Kroeger, who later research would reveal was a Nazi sympathizer, it remains perplexing how Davis, who by 1935 was a preeminent figure in the field of American health policy, was reluctant to engage with the supremacist ideology of Nazism and its implications for medical practice, ethics, and education. His stance is especially surprising in light of his Jewish ancestry. Moreover, as the director of the Boston Dispensary between 1910 and 1920, he had worked diligently for the provision of health services and social welfare for recent American immigrants. How, then, could he have uncritically embraced Hitler’s medical reform program? How could he have found the reorganization of health insurance worth emulating despite its explicit antisemitism and racism? How did he manage to ignore the treatment of Jewish physicians? And beyond Davis, how do we account for the virtual silence of the Journal about these issues over the ensuing decade? Part of the answer lies in denial, compartmentalization, and rationalization, all of which depend on structural and institutional racism — deep historical, often unrecognized, bias and discrimination that serve the status quo. Davis’s admiration for German state authority, efficiency, and control appears to have blinded him to the full implications of his sympathies. He was apparently unwilling to entertain the idea that the reforms he praised as “revolutionary” were not merely technical but fundamentally ideological and inhumane. This moral blindness resulted from an idealized, indeed romanticized, or compartmentalized worldview that could not be reconciled with what Germany had become — namely, a persecutory totalitarian regime and, as of 1938, a mass-murder machine.

Conclusion

The Journal paid only superficial and idiosyncratic attention to the rise of the Nazi state until the liberation of the camps in 1944–1945. Perhaps it was this complacency or lack of careful attention to the pernicious nature of Nazi rule that allowed Davis and Kroeger’s article to be published in the first place. As we explore historical injustices in the Journal and beyond, we must consider not only expressions of explicit and implicit bias, discrimination, racism, and oppression, but also how rationalization and denial may lead to silence, omission, and acquiescence — considerations that are critical to understanding systematic historical injustices and their powerful, tragic legacies.

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