The startling truth is that a Nazi physician was the first to systematically study and uncover the link between smoking and lung cancer. The discovery led to a "war on cancer" in Germany that sought to eradicate not only lung cancer, but all varieties of the disease. In 1941—some thirty years before substantive American regulations were placed on cigarette ads—firm restrictions were placed on tobacco advertising in Germany, and a national campaign was launched to inform citizens of the dangers of smoking. But the ugly truth is that the Nazi "war on cancer" was not as altruistic as it might seem at first glance. It was supported and encouraged by the same yearning for "purity" that led to so much hateful and deadly behavior, a philosophy that the great Sherwin Nuland explains and wrestles with below.
To mark its 100th anniversary, The New Republic is republishing a collection of its most memorable articles. This week's theme: History lessons.
This piece originally appeared at The New Republic on June 14, 1999.
The news of last month's reopening of the Reichstag building, sixty-six years after its ruination by fire, sent a small chill up more than a few aging spines. The stable parliamentary democracy that is today's Germany can hardly be faulted for acceding to its own understandable yearning for symbolic continuity with eight centuries of a representative legislature—the imperial Diet goes back to 1100—or its nostalgia for an edifice erected during a period of unbridled cultural energy. Still, many of us cannot but be assailed by the obvious memories associated with that historic place and the events surrounding its near-destruction: the birth-pangs of fascism, the first reports of terror in the streets, and finally the incendiary pretext that ushered in the long night of the most destructive dictatorship the world has ever known.
And then there are the words. Germany is alone among nations in preserving the language of empire for the name of its legislative body. Chancellor Schroeder asserted in his opening address that there is no equation between the retained use of "Reich" and current or future reality, but some of us are not completely reassured by his facile certitude. The word reverberates. Perhaps our unease would be less were we not confronted with another verbal reminder of horror that his government has chosen to keep in place. Emblazoned on the facade over the tall pillars fronting the refurbished building is the old proclamation that in a bygone time stirred so many nationalistic hearts: Dem Deutschen Volke, "To the German People."
In restoring a building, anguished emotions have also been restored. To men and women of a certain age throughout the world, the sight or the sound of the word "Volk" brings back an entire panoply of painful recollections. Who, growing up in the 1930s or the early 1940s, can forget the horrifying uses to which the ancient Germanic concept of Volk was put, in the name of racial purity, ethnic hatred, persecution, and murder? To Hitler's votaries and their generations of like-minded predecessors, the German Volk was more than a people. It was an imperious familial community of tribal origin, held indissolubly together by ties of unblemished blood and an attachment to the sanctity of the Vaterland. Its basis was the myth of a lustrous history and the glorification of the imagined heroic sagas of the Mittelalter, the near-primitive and therefore noble early Middle Ages of Wagnerian confabulation.
The notion of Volk was, in Hitler's words, "a blood-conditioned entity" and "the sacred collective egoism which is the nation." Addressing the members of the displaced Reichstag on January 30, 1937, Hitler proclaimed his plan: "The main plank in the National Socialist program is to abolish the liberalistic concept of the individual and the Marxist concept of humanity and to substitute for them the Volk community, rooted in the soil and bound together by the bond of its common blood." The German Volk was the Master Race, disdainful of lesser tribes and murderously contemptuous of the impurities of surrounding cultures. Its assumed existence was the arrogant justification for some of the most repulsive crimes ever perpetrated in the name of ideology. Lofty oratory did not disguise its inherent rot.
One need not be a Freudian to intuit that an obsessional insistence on purity is a reaction to a deep sense of uncleanness. One need not even subscribe to the theory of unconscious motivation to perceive a national phenomenon in Nazism that figuratively reeked of the fear of contamination. To understand the details of Robert Proctor's illuminating analysis of the interaction between science and national neurosis, it is only necessary to recall that cancer, in the 1930s, was seen by the laity and by many doctors as a disease likened to degeneration and defilement, a disease that approached by stealth and killed by treachery, a disease tinged with shame, a disease not to be disclosed.
The Nazi aim was to detoxify the Volk—to free it of pollutants from without and within, and to create what Proctor calls "an exclusionist sanitary utopia." Ridding the country of cancer and carcinogens was likened to ridding the country of Jews and other undesirables: "People saw the [Nazi] movement as a source of rejuvenation—in public health and in other spheres as well. People looked to Nazism as a great and radical surgery or cleansing." Der Mann in the street shared this attitude with his doctor. Like their leader, "Germany's physician-führers were less concerned about the health of individuals than about the vigor of the 'race,' the so-called folk community (Volksgemeinschaft)." This is National Socialism, in other words, as a great obsessive-compulsive disorder, the Third Reich with OCD.
But there was a lot more than national neurosis at work in the Nazi war on cancer, and surprisingly much of it was valid. In the general condemnation of the uses to which science and particularly medicine were put during the Hitlerian period, there is a tendency to overlook the great heritage of the German-speaking researchers not only in the Fatherland, but in Austria, Czechoslovakia, and Switzerland. Despite being substantially weakened by World War I and its aftermath, the German scientific establishment had long maintained a very high level of productivity. Although it is difficult to agree with Proctor's uncharacteristic exaggeration that during the Weimar period "German medicine and science were the envy of the world," there is no doubt that he is correct when he states that "Nazism took root in the world's most powerful scientific culture."
The nation and its Germanophone outposts in nearby countries were steeped in the atmosphere of scientific investigation. When the study of human biology reached a point in the mid-nineteenth century where the necessity for detailed observation, measurement, and painstaking record-keeping became paramount, meticulous German minds were perfectly prepared for the challenge. Not only that, but liberalizing trends in the universities as a consequence of the revolutions of 1848 resulted in a system in which free and wide-open competition meant that faculty posts were occupied by only the most highly qualified professors. This could be said of no other country. The goodly number of well-supported state schools assured ample numbers of talented graduates, who then went on to be creative in the laboratory and popular in the classroom. Considering the devastation that would be wrought by the Nazification of the universities in the 1930s, it is ironic that the term "academic freedom" made its first appearance in the German motto of Lehrfreiheit und Lernfreiheit, freedom of teaching and freedom of learning, which originated in the post-1848 period.
Research thrived after that time, as investigative opportunities multiplied and each new discovery opened up more avenues in the universities and the clinics. A veritable golden age of medical progress followed, lasting until the Great War slowed it but hardly stopped it. Until then and even after, young physicians all over the world studied German and flocked to the many great centers where the grand Geheimraten had established a system of education and research without peer in the long history of Western medicine. It was a heady time, and its heritage was still very much in evidence on that cold February night in 1933 when the Reichstag fire gave the new Chancellor precisely the excuse he needed to assume the emergency powers that suspended constitutional rights and launched his dictatorship. From then on, it would be as Hans Frank, Germany's leading lawyer, wrote in theVolkischer Beobachter in 1936: "Our Constitution is the will of the Führer."
By then, half of the world's Nobel prizes had been won by Germans; almost all of the great pharmaceutical houses were German or German-Swiss; and, most telling, no physician or researcher could be fully conversant with contemporary medical practice or theory without a reading knowledge of German or at least access to good translations. By 1933 it was no longer as powerful as it had been, but still the German influence over medicine was very much in evidence.
No wonder, then, that the association between cigarettes and lung cancer should have been discovered not by English-speaking researchers in the 1950s, as has been believed by most medical historians, but by Germans in the late 1920s and 1930s. And no wonder that Germans were the first or among the first to recognize so many of the diseases of workplace exposure, and to legislate protective measures against them. That the industrial dangers of asbestos, chromium, arsenic, silicon, aniline dyes, and radioactivity were first perceived and documented was largely to the credit of German physicians and epidemiologists.
Authorities on the subject of tobacco-induced lung cancer invariably point to a series of seminal papers published in American and British journals in 1950 and several years thereafter, in which the cause-and-effect relationship was identified by epidemiological and experimental studies. The names of Ernest Wynder, Evarts Graham, E. Cuyler Hammond, Richard Doll, and A. Bradford Hill are a virtual Who's Who of the acclaimed discoverers. It is one of Robert Proctor's contributions to medical history that he has documented the priority of the Germans, first in a scholarly review in the Bulletin of the History of Medicine in 1997 and now in The Nazi War on Cancer. "The startling truth," he writes,
is that it was actually in Nazi Germany that the link was originally established. German tobacco epidemiology was, in fact, for a time, the most advanced in the world, as were many other aspects of the anti-tobacco effort. Support for tobacco hazards research was strong among the Nazi medical elite; indeed it was in Germany in the late 1930s that we first find a broad medical recognition of both the addictive nature of tobacco and the lung cancer hazard of smoking.
Without taking any of the well-deserved credit from Wynder and the others, whose studies were much larger and in the long run proved to be the definitive ones, Proctor provides ample documentation of his claim. As early as 1929, Fritz Lickint, a physician in Chelmnitz, published statistical evidence of the association of the malignancy with cigarettes, and colleagues followed this with one paper after another in various German medical journals. Lickint went on to become the most vocal of the country's opponents of smoking, culminating in his publication of the 1,100-page Tabak und Organismus (Tobacco and the Organism) in 1939.
It was a monumental work, produced in partnership with two government-sponsored groups, the Reich Committee for the Struggle Against Addictive Drugs and the German Antitobacco League. Astonishing to today's reader is the accuracy of the long list of problems attributed to tobacco, some of which have needed to be rediscovered in recent years. As Proctor recounts:
Surveying eight thousand publications worldwide, the author blamed tobacco for cancers all along the Rauchstrasse ("smoke alley")—lips, tongue, lining of the mouth, jaw, esophagus, windpipe, and lungs. Tobacco was an instigator not just of cancer but of arteriosclerosis, infant mortality, ulcers, halitosis, and dozens of other maladies. Tobacco was a powerful drug: tobacco addiction he characterized as Nikotinismus (or, more properly, Tabakismus), and the people so afflicted as Nikotinisten (or Tabakisten). He also compared tobacco addicts to morphine addicts and made a convincing argument that "passive smoking" (Passivrauchen—he seems to have coined the term) posed a serious threat to nonsmokers.
Not a single one of those claims has proved to be erroneous. One can almost visualize Lickint at work, his precise Teutonic mind poring over the data as he extracted it bit by bit from the exacting analysis of the eight thousand publications. All the evidence was there, but only a German working in Hitler's Third Reich took the pains to unearth it. It would be decades before the medical world accepted or acted on some of the information that became available in Lickint's masterful opus. Proctor attributes this long period of inertia to "both the conservatism built into postwar epidemiology and the postwar political disregard for all things German, the stigma of Nazism." The lesson in this is hardly hidden.
In the powerful hands of the State, the documentation provided by Lickint and the many other medical scientists delving into cancer etiologies could be used to mount an intense campaign, primarily against tobacco. The kampf's first-line assault weapon was a storm of propaganda, by means of public lectures, congresses, books, magazine articles, and compulsory anti-tobacco reading in all elementary schools. Beginning in 1938, the government did not hesitate to issue ordinances much like those to which we have in recent years become accustomed in our own country. It was forbidden to smoke, for example, on the grounds of the post office, many workplaces, hospitals, government offices, and certain other public spaces. SS Reichsführer Himmler forbade police officers in his own organization from smoking on duty. Tobacco was banned on all civic transport in 1944, expanding the jurisdiction of similar decrees that had previously existed in sixty of Germany's cities.
Beginning in 1941, restrictions on tobacco advertising were increased. Smoking was not to be portrayed as healthful or even harmless, nor were advertisements for tobacco to be directed at sportsmen, automobile drivers, or women. Athletes, pilots, and similar masculine types upon whom young men might model themselves were not to be shown smoking, nor were women. Tobacco advertising was not to appear on billboards, in sports facilities, or on public transportation, nor was it to be sent by mail or accepted for publication in the text sections of newspapers or magazines.
In that same year, the government provided 100,000 Reichsmarks to build the Institute for Tobacco Hazards Research at the University of Jena. Karl Astel, one of the many physician members of the SS, was chosen as its director. Astel was a fanatic known for declaring opposition to tobacco a "National Socialist duty." His assertion was consistent with the words of the original proposal for the Institute's founding, which stated that abstinence was "as important as Aryan ancestry." The author of that proposal, the Thuringian Gauleiter Fritz Sauckel, would be executed after the war, following conviction by the Nuremberg Tribunal for his role as the Plenipotentiary for the Mobilization of Labor, a lofty title for the fiendish role he played in the forced conscription of millions of German and foreign workers.
At the two-day conference celebrating the opening of the Institute, Johann von Leers, editor of the rabidly anti-Semitic journal Nordische Welt, accused "Jewish capitalism" of being a major factor in the spread of smoking throughout Europe. And Hitler himself was also heard from. The Führer greeted the many assembled dignitaries via telegram, wishing them "good luck in your work to free humanity from one of its most dangerous poisons." A reformed heavy smoker himself, Hitler was known for his personal aversion to tobacco. He, too, had become a zealot in the matter, to the point of awarding a gold watch to any of his close associates who gave up the foul habit.
Although not as extensive as the war on tobacco, the Nazi effort against other industrial carcinogens and chemical hazards was no less resolute. Occupational safety regulations to guard the health of German workers against radiation and such dangerous substances as asbestos, chromates, nitro-compounds, lacquers, varnishes, and other chemicals began to be promulgated in 1936, and multiplied in number throughout the period. The ever-widening use of diagnostic X-rays weighed particularly heavily on the Nazi mind, for fear of possible effects on the national heredity from its tendency to cause genetic mutations. As early as 1935, the racial monthly Volk und Rasse (Folk and Race) issued a warning to physicians that even tiny levels of exposure might result in damage to the precious Aryan germplasm. All in all, the Third Reich's war on cancer was another Nazi war fiercely fought.
When we contemplate the story of medicine under the Nazis, thoughts naturally turn to the 350,000 Germans sterilized in the name of racial purity, the 200,000 mentally or physically handicapped put to death, and the more than a thousand concentration camp inmates who died during the course of the notorious experiments renowned for their cruelty and their violation of even the most fundamental principles of medical ethics. We remember how Nazi doctors eagerly participated in the Holocaust. Proctor has written extensively about the participation of physicians in the development of racial science and National Socialist policy in Racial Hygiene: Medicine Under the Nazis, which appeared in 1988. These are not matters easily ignored, nor should we try to ignore them. They should be kept in the forefront of our minds. Yet it behooves us also to remember that, regardless of its employment for the purposes of evil, normative and even valuable medical science did not go out of existence in Hitler's Reich. We have discounted it to our disadvantage. Studies untinged by moral depravity, by the savagery of human experimentation, did proceed during those dreadful years, and there is value in knowing about them.
In the extraordinarily high quality of Fritz Lickint's work can be found this most important lesson of The Nazi War on Cancer. The condemnation of the German medical profession under the Nazis is thoroughly deserved, but it should nevertheless be known that a great tradition of medical progress did not suddenly evaporate because it came under the vicious influence of fascist ideology. Useful and even inspired work continued to be done, even if much of it was instigated or distorted in the name of the state's political priorities.
Two juxtaposed facts here present themselves: large numbers of German physicians voluntarily joined the Nazi party, and the Nazi war on cancer was unparalleled among nations for its vigor and determination. The second fact emerges, of course, from the first. As Proctor appropriately observes, "The Nazi war on tobacco shows that what most people would concede to be 'good' science can be pursued in the name of antidemocratic ideals. It is therefore not enough to speak only of the suppression or even survival of science; we have to see how dictatorial ideals worked to inspire and guide the science and policies of the time." Proctor rightly emphasizes that the identification of carcinogens was fostered "by a national political climate stressing the virtues of racial hygiene and bodily purity."
And here we return to the concept of cleansing the Volk of contaminants. It is in this connection that the term Gleichschaltung appears, and must be properly understood. Although its technical meaning is "political coordination," Proctor, to help the reader more thoroughly understand its implications under Hitler, defines it as "unification and purification," and elsewhere more directly as what it meant in actual practice, which was "Nazification." In his view, Nazism can be seen as a vast hygienic experiment, detoxifying the body politic as though in paranoid fear of destructive pollutants and parasites that have invaded its Aryan sanctity.
These were not only Jews, Gypsies, homosexuals, the retarded, the mentally ill, and the genetically inferior, but also communists, liberals, and all manner of political and intellectual opponents. Radiation, occupational carcinogens, drugs, alcohol, perceived nutritional hazards, artificial colorings and flavorings: all of these were contaminants to enervate theVolk. This officially sanctioned paranoia went beyond mere striving for health; it had to do with the temple that was the uniquely German body, the temple that must be protected against the insidious creepings of the silent crab that is cancer. "Dein Körper gehört dem Führer," "Your body belongs to the Fuhrer," proclaimed the propaganda posters, and the Führer knows what is best for it. Hitler famously neither drank nor smoked, and he ate meat—which he called "the flesh of dead animals" and "cadavers" (meat broth was "corpse tea")—only on rare occasions.
The theme of contamination by undesirable elements, human or otherwise, permeated much of the medical thinking and the public education of the Nazi era, and was considered useful as a means of illustrating disease and urging prevention while making a political statement. Propagandists associated smoking with Jews, blacks, Gypsies, loose women, jazz, and degenerates of all sorts. Proctor describes a radiotherapy lecture in Frankfurt in 1936, conducted by the X-ray specialist and SS officer Dr. Hans Holfelder, in which cancer cells were depicted as Jews, while the healing rays were stormtroopers.
In a well-known lithograph by Ivo Saliger, which I have examined in the Yale collection, the invading cancer in a beautifully formed and all but naked young woman's breast is being destroyed by the powerful X-ray beam, as the black-hooded skeleton of death cringes in fear. The radiologist supervising the process of purification bears an uncanny resemblance to a pudgy Heinrich Himmler. Saliger's painting is an unabashed portrayal of the Third Reich rescuing virtuous and lovely Aryan womanhood from the depravedAuslander—the malignant outsider so despised in Hitlerian theology, who would enter her body, like a cancer, to violate its racial purity.
Proctor has produced a much-needed corrective to our understanding of the Third Reich's medical culture, which we have become accustomed to castigating as though it were a monolith, and a sudden departure from an illustrious scientific past. It was neither. For historians, for ethicists, for physicians, and for thoughtful people in general, it can be instructive to ponder this most extreme instance ever witnessed of "how the routine practice of science can so easily coexist with the routine exercise of cruelty." Between the lines of Proctor's book is the unstated message that—like so many excesses of the Nazi regime—there is in this one a hint of ourselves. When we consider the many examples of heedless neglect of the rights of experimental subjects that have come to light in our own country, we would do well to remember the German doctors.
Neither in quantity nor in quality have our society's violations of human decency so much as approached the scale on which they were perpetrated under Hitler; and yet we are not without blemish. The worst of the German medical transgressors rationalized their sadistic experiments by believing that they were designed for the greater good, and were in any event being conducted on people lower on the scale of human worth than those they were meant to benefit. As the defense at the Doctors' Trial at Nuremburg in 1947 was quick to point out, however, members of the Allied nations—the United States, France, and Britain among them—had also been guilty of performing dangerous experiments on prisoners without their consent.
Since then, other such and similar instances have been revealed. Even today, there remain questions about the degree to which experimental volunteers are informed before signing on to adventures in biomedical research. These problems did not originate with the Nazis. In condemning them, we would do well to remember our obligations to one another. Those of us who are physicians would do well to remember the full range of our obligations to the sick who come to us to be healed. This is a kind of purification from which our society would surely benefit.
Yet the overt and intended theme of Proctor's book is something else entirely. Throughout the book, the series of events being described can be seen to build up a massive case for the inevitable conclusion to which Proctor steadily leads his reader by the judicious insertion of carefully constructed commentary. Whether in the interest of racial purity or the purity of science, physicians and medical researchers during the Nazi period made discoveries and instituted reforms that continued in the great tradition of healing established by the Hippocratics in ancient Greece and brought to a peak of accomplishment in their own country during the late nineteenth century. That many of the self-same physicians brought their contributions into the public arena with a political and even racist agenda in mind; that many of them were either Nazis or subscribed to the cruelties of the Nazi regime; that they willingly and even enthusiastically allowed their innovations to be used for purposes of persecution and even murder—all of these seemingly complicating factors only add up to the author's straightforward and basically elementary summing-up, a conclusion with which there can be no disagreement given the massive weight of the evidence that he provides: "the Nazification of German science and medicine was more complex than is commonly imagined."
This brief and seemingly simplistic statement is a clear demonstration of the most valuable purpose to be found in the never-ending return to sources and the constant rewriting of history. The discovery of hitherto unknown findings and the repeated analysis of the old may bring us no closer to truth. Nor may it even help to elucidate what Leopold von Ranke, the greatest of the nineteenth-century German historians, called wie es eigentlich gewesen ist—how it really was. But there is one thing that the critical study of historical sources is guaranteed to accomplish: subjecting the same ground to one after another evaluation will acquaint posterity with the difficulty of making unalloyed judgments about the past or its participants. The profusion of large and small events and the never-ending interplay of influences create a complexity that defies later reconstruction or a closure of the book on a period understood. All that we of later generations can do is to keep trying, and recognize the incompleteness of the lessons that we learn from the study of the past. And that is the lasting message of the historian.