key: cord- -qbgwcbfu authors: ni, bin; xu, bingqing; ni, yicheng title: a newly found handbook for developing vaccines during world war ii in china: the legacy of global responses to crises date: - - journal: nan doi: . / . . sha: doc_id: cord_uid: qbgwcbfu nan the august this year marks the th anniversary of the ending of world war ii (wwii), which is the largest and most destructive war in modern world history, with an estimated million people or about % of the world population died. however, epidemiologically the wwii also played a key role in spurring the vaccine innovation [ ] . in the past, wars often caused the spread of infectious diseases like new waves of emerging infections, but only worse than the outbreaks of ebola and the more recent covid- in modern time because multiple pathogens could be involved during the wartime. the us military recognized during the wwii that infectious diseases are not less threatening than enemies in the battlefield, and forged with industry and academia to develop vaccines for the soldiers. the efforts also led to formal wide use of vaccines to global general populations after the war. almost completely unknown to the world scientific community, microbiologists in china had very formidable efforts in the development of vaccine and bioproducts in the early s during the wwii. a recent discovery of a completely handwritten and high quality -page handbook of vaccine manual from two former researchers, late professors bin ni and bingqing xu, brought back the direct evidence and the scope of vaccine work exactly years ago in china during the wwii (figure ). profs ni and xu, both born in and later as a married couple, were junior faculty members of the early days of nanjing medical university (nmu). like many universities in china at that time, nmu (under a different name at the time) moved to the western inland of country to escape from the japanese invasion and occupation. despite woeful shortage of resources, nmu established a new chinese institute of preventive medicine. under the leadership of the late prof. meixian wang [ ] , nmu scientists worked hard to develop a wide variety of much needed vaccines ( table ) . as stated by an additional single page recalling note written in by prof. bin ni, this compiled manual of bio-products was rediscovered as a historical research document, and now it has been evaluated for its academic and scientific values by a group of international experts of epidemiology and immunology. the list of bioproducts included in the manual is quite impressive and comprehensive, including active vaccines for typhoid fever, rabies, smallpox and cholera, and passive antisera like tetanus antitoxin and diphtheria antitoxin (table ) . detailed step-by-step protocols are documented in this neatly written manual (figure ), including the type and amount of reagents needed and the instructions on how to prepare such biological products. the in vivo procedures are also well described with exquisite diagrams as part of the guidance. this handbook was produced during - , clearly serving as a source of lab instructions and guidelines for the work conducted in nmu's chinese institute of preventive medicine. there was no confirmation on whether any vaccine or antiserum products were actually used in humans or animals to prevent infections as implied from the recalling note. nor is known from where the original scientific contents were received. the vaccine manual is now donated to the nmu history museum, nanjing, china, by profs ni and xu's surviving children including the corresponding author of this paper. it provides great value to have a close look at the actual work of developing vaccines during the wwii time. such information is scarce even in the scientific literature in the us and other western countries. as highlighted by a recent new england journal of medicine commentary [ ] , the urgency, aura of crisis, national attention, and material resources needed during a wartime have catalyzed developments in medicine which should also include vaccines. we can only hope the covid- pandemic, no less damaging than a world war to some degree, will also stimulate the development of better vaccines to control the current and future emerging infections, just like what were accomplished after the wwii. vaccine innovation: lessons from world war ii hemorrhagic fever with renal syndrome: relationship between pathogenesis and cellular immunity a national medical response to crisis -the legacy of world war ii the experts including dr. dong-xiang xia and prof. zu-hu huang are acknowledged for their evaluation of the old handbook and recommendation to the nmu museum for donation of this historical document. no potential conflict of interest was reported by the author(s). an electronic copy of scanned full handbook can be available by contacting corresponding author. yicheng ni http://orcid.org/ - - - key: cord- - p ug authors: mcgeer, allison title: let him who desires peace prepare for war: united states hospitals and severe acute respiratory syndrome preparedness date: - - journal: clin infect dis doi: . / sha: doc_id: cord_uid: p ug nan on march , the world health organization (who) first posted a worldwide alert concerning an outbreak of severe acute respiratory syndrome in vietnam, hong kong, and guandong province, china [ ] . in june , the centers for disease control and prevention (cdc) surveyed members of the infectious disease society of america emerging infections network (ein) about sars preparedness in their hospitals. it is a measure of the rapid globalization of both the outbreak and the outbreak response that, ! months after the outbreak was recognized, % of responding members of the ein reported that their hospital had cared for a patient meeting the case definition of sars and that % had plans in place to address sars [ ] . the major characteristics of the plans were remarkably uniform, given the very short time for their development and the rapidly changing data. it is a credit to who, cdc, and the outbreak management teams in each country that as much information flowed as rapidly as it did. the variability in the plans illustrates both the uncertainties inherent in the data available at the time of the survey and the significant challenges in sars preparedness. the most important and most difficult component of sars preparedness programs is the identification of infected patients. sars is a febrile respiratory illness that is often clinically indistinguishable from other causes of fever and pulmonary infiltrates [ ] [ ] [ ] . identification of cases depends on prompt recognition of epidemiological risk and clustered infections. of the ein members responding to the survey in this issue of clinical infectious diseases [ ] , ( %) reported that patients with respiratory symptoms in their emergency department (ed) would be screened for a travel history. routine screening in the ed is a substantial investment for most hospitals and one that some may judge to be of dubious benefit, given that only laboratory-confirmed cases of sars were diagnosed in the united states [ ] . on the other hand, the hospitals of % of respondents that have not implemented screening are dependent on their admitting physicians to consider sars in the differential diagnosis and to order appropriate precautions. this latter system has been shown to repeatedly fail to identify tuberculosis, another cause of acute respiratory disease [ , ] . sars is much more likely than tuberculosis to be transmitted and to result in disease. in the event of another outbreak of sars, systematic screening of ed patients, at least those who are to be admitted to the hospital, should be part of every plan. some aspects of the plans from june will likely now have changed. for instance, the relatively low percentage of plans ( %) that incorporated follow-up of exposed patients and visitors reflected the focus on health care worker infections early in the outbreak. documentation indicating that exposed visitors and patients who became ill were the major source of transmission should result in the incorporation of prompt patient and visitor follow-up into all plans [ , ] . similarly, at the height of the outbreak, uncertainties about transmission led many institutions to impose quarantine on returning travelers (and led some travelers to self-impose quarantine). however, transmission of sars was almost invariably linked to households and hospitals and did not occur before the onset of symptoms [ ] [ ] [ ] . thus, quarantine of travelers is not a necessary measure. recognizing the power of denial, however, some hospitals may continue to require daily checks of returning workers until the full incubation period has passed. as noted by srinivasan et al. [ ] , the survey also highlights more-general issues in infection control in hospitals. it may still be possible to manage sars safely in the significant minority of hospitals ( %) and eds ( %) that lack airborne isolation rooms. however, it is not possible to manage chickenpox, measles, or tuberculosis without appropriate airborne isolation precautions. because % of the responding hospitals admitted a traveler from an area of sars endemicity despite travel restrictions, it seems unlikely that they can avoid caring for all diseases spread by the airborne route. the issue of whether protection from sars requires airborne precautions will continue to generate controversy. a careful assessment of exposures in sars outbreaks, particularly those due to superspreading events and transmission despite compliance with isolation precautions, is needed to determine whether airborne spread occurs [ , [ ] [ ] [ ] . in addition, continued work on the science of health care worker respiratory protection is clearly needed. national standards vary widely in the developed world. in the united states, the standards of the occupational safety and health association recommend annual fit testing for n respirators [ ] . the results of this survey suggest that compliance with this recommendation is the exception rather than the rule. in canada, the canadian standards association, in the absence of data, has made no recommendation for protection against infectious agents [ ] . in some countries of the european union, fit testing is required before use but is not required annually; in others, fit testing of individuals is not currently recommended [ ] . the issue of how best to assure protection for each ward nurse in the middle of a weekend night is real. so is the fear that the logistical problems associated with always having a supply of fit-tested masks for all health care workers will push in-vestigators to downplay the risk of airborne spread. at least issues of importance in hospital preparedness for sars were not touched on in the survey reported by srinivasan et al. [ ] . disaster preparedness plans allow most facilities to contact all staff rapidly at the beginning of an emergency. outbreaks of disease, however, require plans for regular (sometimes twice daily) information updates for hospital staff, patients, visitors, and related medical service professionals. preparedness for sars also requires clear delineation of the roles and responsibilities of hospitals and government agencies in many areas of outbreak management. for instance, it is essential before outbreaks to determine who will set hospital policy (e.g., restrictions on hospital admissions, requirements for managing infected patients, and decisions as to which hospitals will admit patients with sars), who will establish work restriction policies for exposed health care workers, and who is responsible for follow-up of exposed patients, staff, and visitors. a number of ein members surveyed expressed concerns about health care worker compliance with precautions. at least analyses of risks associated with health care worker infection despite the use of precautions now identify that h of infection-control training and confidence that precautions would be protective are associated with substantial reductions in the risk of infection (toronto sars hospital investigation, unpublished data; lau et al. [ ] ). management personnel at all hospitals should now be asking themselves how confident they are that clinical staff clearly understand infectioncontrol precautions and how they can be sure that, if sars should reemerge, all health care workers have the training necessary to comply with precautions. one challenge for hospitals is to maintain the impetus to integrate the rapidly expanding new knowledge about sars into the best prevention programs. a second is to reassess the management of ex-posure to droplet-spread pathogens in hospitals. the cdc is currently recommending that all hospitals consider offering masks to all coughing patients and using droplet precautions (placing patients for whom such precautions are required in a private room, if possible; masking health care workers within m of such patients or upon room entry; and limiting the movement of such patients outside of their room), in addition to standard precautions, for all patients with symptoms of respiratory infections [ ] . although, as srinivasan et al. [ ] suggest, these isolation precautions may have benefits that extend to situations beyond sars outbreaks, it is also true that isolation may have risks, as recently demonstrated by redelmeier et al. [ ] . as life returns to a "new normal" after sars, we urgently need a better understanding of how to minimize the risk of transmission of viral respiratory diseases without creating adverse events associated with additional infection-control precautions. world health organization. cases of severe respiratory illness may spread to hospital staff. released hospital preparedness for severe acute respiratory syndrome in the united states: views from a national survey of infectious diseases consultants discriminative ability of laboratory parameters in severe acute respiratory syndrome (sars) analysis of deaths during the severe acute respiratory syndrome (sars) epidemic in singapore: challenges in determining a sars diagnosis council of state and territorial epidemiologists. sars investigative team, cdc. revised u.s. surveillance case definition for severe acute respiratory syndrome (sars) and update on sars cases-united states and worldwide environmental infection control of tuberculosis nosocomial transmission of multidrug-resistant mycobacterium tuberculosis sars transmission and hospital containment investigation of a nosocomial outbreak of severe acute respiratory syndrome (sars) in toronto, canada. hospital outbreak investigation team epidemiological determinants of spread of causal agent of severe acute respiratory syndrome in hong kong clinical features and short-term outcomes of patients with sars in the greater toronto area possible sars coronavirus transmission during cardiopulmonary resuscitation superspreading sars events cluster of sars in medical students exposed to a single patient institute for occupational safety and health. tb respiratory protection program in health care facilities: administrator's guide. september selection, use and care of respirators. document severe acute respiratory syndrome (sars) sars transmission among hospital workers in hong kong public health guidance for community-level preparedness and response to severe acute respiratory syndrome (sars) safety of patients isolated for infection control key: cord- - mspnc q authors: kassem, issmat i. title: refugees besieged: the lurking threat of covid- in syrian war refugee camps date: - - journal: travel med infect dis doi: . /j.tmaid. . sha: doc_id: cord_uid: mspnc q nan travel medicine and infectious disease requires that all authors sign a declaration of conflicting interests. if you have nothing to declare in any of these categories then this should be stated. a conflicting interest exists when professional judgement concerning a primary interest (such as patient's welfare or the validity of research) may be influenced by a secondary interest (such as financial gain or personal rivalry). it may arise for the authors when they have financial interest that may influence their interpretation of their results or those of others. examples of potential conflicts of interest include employment, consultancies, stock ownership, honoraria, paid expert testimony, patent applications/registrations, and grants or other funding. all sources of funding should also be acknowledged and you should declare any involvement of study sponsors in the study design; collection, analysis and interpretation of data; the writing of the manuscript; the decision to submit the manuscript for publication. if the study sponsors had no such involvement, this should be stated. no funding sources. deaths, respectively, as of april th [ ] . this perhaps casts shadows of doubt on the absence of outbreaks or cases in the camps. indeed, there are suggestions that the refugees might not be reporting infections due to ) lack of knowledge in regards to infection and symptoms, ) lack of access to tests, which are already limited and insufficient for the needs of the hosting communities, and ) fear of stigma which might lead to increasing restrictions and crackdown on the refugees. covid- has ignited fears in many communities and reactions to patients or potential carriers of the virus are not always charitable. furthermore, it is well known that certain hosting countries established curfews and implanted deportations of unregistered refugees even before the onset of the pandemic. therefore, tackling the spread of covid- in the refugee camps appears to be complicated and fraught with many complications. a quick assessment of the nature of the disease can reveal the potential scope of threat to the refugees. it is known that covid- is mainly transmitted via the respiratory route (spreads by close proximity), and that patients with comorbidities and those that are prone to recalcitrant and antibiotic-resistant secondary infections do not fair comparatively well. additionally, the major current approaches to control the spread of covid- in communities, include ) social distancing, ) close adherence to hygienic approaches (washing and disinfection), and ) protective gear (such as masks and gloves), ) frequent testing and quarantines, and ) maintaining a good health. these measures in any community have proven difficult, but they might be even more challenging in syrian refugee camps. indeed, it is widely known that many refugee populations that witnessed catastrophic events might be immunosuppressed and can carry multidrug resistant pathogens [ ] , while the camps also host elderly refugees, which are particularly susceptible to covid- . furthermore, populations of refugees live under crowded conditions in makeshift tents that provide little protection, while camps may share common services, which render distancing very difficult. furthermore, the quality and availability of water (drinking and domestic) in many camps are insufficient; with intermittent access, shortages and documented contamination with bacterial indicators of fecal pollution and multidrug resistant pathogens [ , ] . this obviously decreases the efficacy of hygienic practices that rely mainly on sufficient access to clean water and is more problematic in scenarios that also include shared latrines and vulnerable camp water cisterns. additionally, shortages in-and monopolization and soaring prices of protective gear, disinfectants, virus tests and nutritious food mean that these items will be even more scarcely available for the refugees, which will adversely impact the maintenance a good health. the situation is layered further with more complications and challenges. for example, lebanon, a country that hosts an estimated . million syrian refugees (distributed in makeshift camps and other dwellings) is currently facing a very severe economic crisis, civil unrest (decreased after the pandemic), and a covid- outbreak. lebanon is currently under a curfew in order to control the disease, and prices of food and medicine are soaring in a country that relies heavily on imports to meet its needs. the latter is becoming more difficult under restrictions imposed by the economic crisis as well as the spread of the disease. consequently, allocating resources and much needed help to the refugees might be unavailable or scarce at best. while the un refugee agency (unhcr) and other ngos are attempting to provide support and awareness to the refugees, the realty is that significant funding is required, given the various needs and the high number of refugees. in that regard, the unchr has appealed for urgent funding to combat covid- in refugee camps, but the results of this initiative remain to be seen [ ] . in contrast, there are anecdotal reports of fears that foreign aid might withdraw from the camps due to the pandemic. the latter would have severe consequences, especially in case of an outbreak, which will leave the refugees besieged in their camps and facing a dire threat. during these challenging times, we call for global and urgent support for these disenfranchised populations. the health of refugees is intimately linked to that of their hosting communities and beyond, which is more reason to protect the camps from covid- . consequently, an uncontrolled outbreak would result in significant morbidity and mortality that might not be confined to the camps. therefore, transparent and thorough investigations along with preemptive and inclusive control measures are urgently required to prevent and/ or control the dissemination of covid- in syrian and other refugee camps worldwide. the authors declare no competing interests. ethical approval: none was required. coronavirus covid- global cases by the center for systems science and engineering infectious disease profiles of syrian and eritrean migrants presenting in europe: a systematic review first report of the plasmid-borne colistin resistance gene (mcr- ) in proteus mirabilis isolated from domestic and sewer waters in syrian refugee camps first report on the detection of the plasmid-borne colistin resistance gene mcr- in multi-drug resistant e. coli isolated from domestic and sewer waters in syrian refugee camps in lebanon coronavirus emergency appeal unhcr's preparedness and response plan key: cord- -nzc ir n authors: guo, sun-wei title: china’s “gene war of the century” and its aftermath: the contest goes on date: - - journal: minerva doi: . /s - - - sha: doc_id: cord_uid: nzc ir n following the successful cloning of genes for mostly rare genetic diseases in the early s, there was a nearly universal enthusiasm that similar approaches could be employed to hunt down genes predisposing people to complex diseases. around , several well-funded international gene-hunting teams, enticed by the low cost of collecting biological samples and china’s enormous population, and ushered in by some well-connected chinese intermediaries, came to china to hunt down disease susceptibility genes. this alarmed and, in some cases, enraged many poorly funded chinese scientists, who perceived them as formidable competitors. some depicted foreign gene-hunters as greedy pilferers of the vast chinese genetic gold mine, comparing it to the plundering of national treasures from china by invaders in the past, and called upon the government and their fellow countrymen to rise up and protect china’s genetic gold mine. media uproar ensued, proclaiming the imminent “gene war of the century.” this article chronicles the key events surrounding this “war” and its aftermath, exposes some inherent complexities in identifying susceptibility genes for complex diseases, highlights some issues obscured or completely overlooked in the passionate and patriotic rhetoric, and debunks some misconceptions embedded in this conflict. in addition, it argues that during the entire course of this “war,” the public’s interest went conspicuously unmentioned. finally, it articulates several lessons that can be learned from this conflict, and outlines challenges facing human genetics researchers. around , and amid the talks of hong kong's upcoming return to china and later the asian financial crisis, a recurring topic in the chinese media was the so-called ''gene war of the century'': the lopsided condemnation of foreign scientists coming purportedly to pilfer china's vast genetic resources for a profit. some scientists wrote articles and gave lectures, calling for heightened vigilance for the pilfering act, and proposed that the country protect its precious genetic resources by conducting genetic research on its own. while the public might have been completely flummoxed by some esoteric and arcane jargons, the message was nonetheless loud and clear: the western capitalists were trying to profit from china's unique genetic heritage. in a country with a past history of repeated foreign invasion, defeat, and humiliation, this message struck a tender emotional chord and caused an eruption of national furor. the person who likely triggered, perhaps unintentionally, the first spark of this ''war'' is xiping xu, a chinese expatriate at harvard at the time. despite his repeated proclamation as a staunch and unwavering patriot loyal to his beloved motherland and dedicated to the advancement of china's science and technology, he nonetheless later became embroiled in an avalanche of controversies surrounding the ''gene war.'' he effectively became a lightning rod for all the controversy on genetic resources, intellectual rights, informed consent, and the protection of human research subjects. well over a decade has since passed. what was at stake? did these precious genetic resources actually exist? who was the most likely beneficiary of the gene-hunting endeavor? how did this ''war'' end? who were the winners and losers, if there were any in the first place? what happened after the conflict? as war is invariably a continuation of politics by other means, what was the politics behind it? what happened to the people who were embroiled in the ''war''? the answers to all these questions can be addressed, at least in part, now with the benefit of a / hindsight. war breaks out simply because of irreconcilable conflicts in interest. the ''gene war,'' whether it was real or fictitious, was no exception. this article chronicles the key events surrounding the ''war'' and its aftermath, exposes some inherent complexities in identifying susceptibility genes for complex diseases, highlights some issues obscured or completely overlooked in the passionate and patriotic rhetoric, and debunks some misconceptions embedded in the lopsided condemnations. in addition, it describes how, during the entire course of the ''war'' of intense and often politically charged uproars, the patients' interest was conspicuously unmentioned and likely overlooked. examining the larger issues regarding science and politics, it also argues that the ''war'' and its surrounding events can be best understood through the lens of credibility contest vying for resources. finally, it lists several lessons that can be learned from this conflict, and outlines challenges facing current researchers in human genetics. ''gene war of the century'': the genesis in , the human genome project (hgp) was launched. with a price tag of billion us dollars and a -year timeline, this ambitious megaproject aimed to sequence the entire human genome, with the ultimate goal of ''understand[ing] the human genome'' and ''knowledge of the human as necessary to the continuing progress of medicine and other health sciences as knowledge of human anatomy has been for the present state of medicine.'' supported by the us department of energy (doe) and the us national institute of health (nih), the hgp was the culmination of several years of research building on a series of breathtaking breakthroughs in molecular genetics. considered the ''genetic blueprint for human beings'' and hailed as the ''book of life'' or simply the holy grail, the human genome, when completely sequenced, would purportedly unlock the secrets underlying a plethora of human traits as mundane as facial resemblance between parents and offspring and as complex as human behavior. against this foreground, human genetics research entered a golden age. in , scientists identified (called ''cloned'') the genetic mutation responsible for a rare genetic disease called cystic fibrosis, that is, the gene responsible for the disease was identified with known location and size. in the inaugural year of the hgp, a gene responsible for breast cancer was localized, or ''mapped,'' to chromosome . in the following few years, the genes responsible for huntington's disease, breast cancer ( - % of the cases), alzheimer's disease and other rare genetic diseases often with a tongue-twisting name would be cloned (see table for the timeline of research milestones and events surrounding the ''gene war''). following on the heels of successful cloning of genes for these mostly rare mendelian diseases in the early s, there emerged a nearly universal enthusiasm, hope or even conviction that similar gene-mapping approach could be employed to hunt down susceptibility genes predisposing people to various complex diseases -primarily common chronic diseases such as asthma, diabetes, and cancer that invariably have an elusive pathogenesis and collectively contribute to the major health burdens (lander and schork ; risch and merikangas ) . it was hoped that once genes were identified, the characterization of their functions would not only help better understand genotype-phenotype relationships, but also facilitate the development of specific therapies and preventative measures and the identification of people at increased risk of developing the disease (collins and mckusick ) . it was also hoped that once the risk of particular combinations of genotype and environmental exposure is known, medical interventions, such as lifestyle changes, could then be institutionalized to target high-risk groups or individuals (collins and mckusick ) . some biotech companies quickly saw the potential of enormous business opportunities and joined the fray. human genome sciences, founded in by william a. haseltine, a noted harvard professor and aids researcher, partnered with some genomics companies and soon filed patents on , genes and, in , quadrupled its stock price (zimmer ). other genomics companies followed suit. yet this practice had one problem: most, if not all, patented ''genes,'' in fact, rna transcripts, were merely pieces of cdna without any known functions at the time of filing. to understand what a gene does and how it does, and to establish the causal relationship between a gene and a human disease, let alone treatment, is by no means an easy task, even with modern technology. very often, it is a slow, arduous, painstaking, and imprecise process full of dead-ends and false leads. many other biotech companies and academic scientists took a different approach called ''positional cloning.'' this approach eliminates the need to understand the molecular genetic mechanisms underlying the disease of interest. instead, through the collection of pedigrees enriched with patients having the disease, the existing genetic sign posts (called dna markers, which are scattered around the human genome with known locations and content) would be used to localize the responsible gene in a particular region. this would allow researchers to zero in the gene, identify it, and ultimately figure out its function and its relationship with the disease through extensive lab work. thus, by ''positioning'' the gene, the gene could be cloned and its functions and roles in disease pathogenesis elucidated without any prior knowledge of the possible pathogenesis of the disease. this conceptual simplicity and beauty, coupled with increasingly fast and affordable methods of making genetic signposts (called ''genotyping'') attracted many biomedical scientists and even converted many of them this discovery was later found to hold universally true in all organisms, including humans, and became a corner stone and a principle in genetics. basically, if a trait is determined by a gene, then the gene will tend to go hand in hand with its neighboring signposts when transmitted from parents to offspring-thus the term ''linkage.'' if many relatives in a pedigree having the same trait all carry the same signposts, then there is a chance that the gene responsible for the trait is near to the signposts. although different cross-breeding cannot be made in humans for obvious reasons, this difficulty can be offset by statistical computations. the advent of personal computers in the s coincided with the booming of human genetics and proved to be indispensable in this endeavor. the discovery of various classes of dna markers also facilitated the gene hunting. the approach based on pedigree data is called ''linkage analysis.'' since , scientists found that for common diseases, another approach, called ''association studies,'' can be more powerful in gene hunting. association studies identify disease genes by finding the significant gene frequency differentials between a group of unrelated healthy individuals and another group of unrelated people with the disease of interest. ''gene war of the century'' and its aftermath to human genetics, who were frustrated by the slow, arduous and often fruitless process of finding the cause(s) for disease. thus, in the s hardly a week went by without a news report or announcement of the discovery of genes for some disease, at least in the us. one high-profile study, published in in a prestigious journal, science, reported the localization of a gene in chromosome x q that is responsible for male sexual orientation. this approach has one catch, however. one critical prerequisite for position cloning is the availability of a sufficient number of pedigrees saturated with people having the same disease, along with correct diagnoses or precise measurements of the disease (called ''phenotyping''). once such pedigrees are collected, phenotyping and genotyping can proceed and the positional cloning endeavor can start. since genotyping and phenotyping a large number of people can be costly, there are strong incentives to cut the cost of either process. everything else equal, locations with low costs of acquiring blood samples (for genotyping purposes) and labor (for phenotyping purposes) would be extremely attractive. in , sequana therapeutics, a start-up biotech company located in la jolla, california, announced that it had achieved two significant research milestones related to its asthma gene discovery program. it analyzed dna collected from about people on tristan da cunha, an island in the south atlantic, about , miles from south africa. approximately % of the island residents had asthma, presumably passed on from an original settler generations ago. the announcement prompted cash payments of $ million from boehringer ingelheim, ingelheim, germany, based on a prior agreement. boehringer later paid sequana an additional $ million for its exclusive right to market the drug derived from the putative asthma gene, while sequana retained the exclusive right for developing gene-based diagnostics. sequana announced in late may that it had identified a mutated gene that predisposes people to asthma, a feat hailed by one clinical investigator as ''perhaps this century's most important finding in the etiology of asthma'' (asthma gene discovered. ). early in the same year, sequana announced that it had signed a letter of intent with pe applied biosystems to form a broad-based dna sequencing joint venture in shanghai, china. circa , several well-funded international gene-hunting teams, lured apparently by the low cost of collecting biological samples and the sheer population size and also ushered in by some well-connected chinese scientists working in north america, arrived in china to hunt down susceptibility genes for various complex diseases (shou ) . one biotech company from california announced that it had discovered a large pedigree of hundreds of people enriched with asthma patients in a small village in zhejiang province, china. perhaps the most notable team was one led by dr. xiping xu, who was at that time working at harvard and was well-connected in anhui, china. an anhui native, xu spent the mid- s after high-school as a ''barefoot doctor'' in anhui, providing basic medical care for peasants after a small amount of training at a time when access to medical care in rural china was a luxury. he received his medical degree from anhui medical college (now anhui medical university) in the early s, and was admitted to beijing medical college (now peking university school of medicine) for a student exchange program, a prep program for oversea studies. he went on to get his ph.d. degree in epidemiology in japan, went to harvard to receive his post-doctoral training in epidemiology in respiratory diseases, and received his master's degree in biostatistics from harvard university school of public health (hsph). he stayed on at hsph as a faculty member. even at harvard, xu apparently kept close ties with the anhui medical college, and was involved in several epidemiological studies in the anhui province. when his post-doc supervisor, dr. scott weiss, a harvard university respiratory epidemiologist, told geoffrey duyk, a geneticist who had left harvard to join a biotechnology start-up called millennium pharmaceuticals, that one of his postdoctoral fellows came from the anhui province and had access to a large number of dna samples, they instantly saw the potential and quickly formed a collaborative relationship to discover susceptible genes in complex diseases in anhui (keim ) . a formal partnership between harvard and millennium was established, where xu would direct the collection of a large number of dna samples in anhui, for which millennium would pay the university $ million (keim ) . with tens of thousands of blood samples provided by anhui's villagers, the partnership hoped to identify the susceptibility genes predisposing people to asthma, obesity, miscarriages, schizophrenia and other illnesses. contingent upon its access to the anhui population's dna, millennium also secured sizable capital shortly afterwards from the swedish pharmaceutical company astra ab and from another pharmaceutical giant, hoffmann-la roche. the company's access to dna from the ''large, homogeneous population'' of anhui province was also featured prominently when millennium went public in , raising $ million in its initial public offering (keim ) . leveraging the existing and some preliminary data collected from anhui, xu went on to apply for more funding support from the nih. a search of crisp, a searchable database of nih-funded biomedical research projects (crisp ) using ''xiping xu'' as the principal investigator (pi)'s name reveals that xu received grant on genetics of airway responsiveness and lung function in besides two other nih non-genetics grants, and in he received nih grants on genetics of osteoporosis, airway responsiveness and lung function, nicotine addiction vulnerability, hypertension, and asthma on top of other nih grants (table ) . being a pi almost concurrently on nih grants is remarkable, especially for a junior faculty without much track record, but having nih grant support in diverse research areas ranging from osteoporosis, hypertension, nicotine addiction, and asthma to human reproductive effects due to endocrine disruption or rotating shift work is extraordinary and certainly breathtaking. in all, he received well over million usd in grant support from the nih, the pharmaceuticals industry, the march of dimes, and other funding agencies to investigate genetics of various complex diseases (yang ; keim ) . recognizing his scholarly potential and the growth area he was in, hsph promoted xu to associate professor in and made him the director of the newly established program in population genetics (now disbanded) in hsph. the solid financial backing and extensive connections allowed xu to enlist the enthusiastic support of the local government officials and his alma mater, who helped xu collect thousands of blood samples from rural villagers. a nearly palpable aura of harvard university which xu embodied and was (and still is) revered by many in china as the premium research institution and the most prestigious institution of higher learning also helped. many villagers were illiterate, had no idea what would be done with their samples, and were given merely empty promises of free medical care in exchange for their blood samples. these lapses of oversight, deliberate or otherwise, would return later to haunt xu and his team. the increasing number of scientists like xu with huge financial backing arriving in china to conduct genetic research alarmed many poorly funded chinese scientists, who perceived the situation as a major threat to their profession and a danger of eclipsing their own work. in november , about leading chinese biomedical and genetic researchers gathered in xiang shan, beijing, and held a conference on ''the human genome project and the development strategy for the st -century medicine'' to evaluate and discuss the situation. one incident further fueled the concern shared by all participants. a translated version of a science article was presented at the conference, which stated that xu sought to gain ''access to million chinese through collaboration with six chinese medical centers.'' but in the chinese version, the program became one that would ''take blood samples from million chinese'' (hui and jue ) . this seemingly astronomical figure incensed all conference participants, who were at that time cash-strapped and still playing catch-up with the west. they quickly reached a consensus and soon made it public: ( ) china's genetic resources should not be pilfered by foreigners; ( ) chinese scientists should immediately grasp the opportunity to find disease genes and patent them; ( ) we should educate the people, and raise the awareness and importance of protection of our genetic resources; ( ) we welcome all international collaborations based on fairness and mutual benefits; ( ) through various avenues, the chinese scientists should be vocal about certain views deemed to be harmful to china's genetic research (xiao et al. ) . soon after the xiang shan conference, some scientists published articles depicting foreign gene-hunters as greedy pilferers of the vast chinese genetic gold mine and comparing them to past foreign invaders plundering china's national treasures. they called upon the government and their fellow countrymen to rise up and protect the putative genetic gold mine of the chinese gene pool (fang a, b; lv ) . shortly after, financial details about the millennium-harvard deal based on anhui samples were leaked to the chinese press and caused a media blitz of condemnations. the media called it an imminent ''gene war of the century'' (shou ) . in fact, the notion of foreign capitalists profiting from china's precious genetic resources sparked such a fury that several other genetic research projects unrelated to xu were stalled for a year (hui and jue ) . around the same time, it was rumored that one prominent geneticist, who received his ph.d. from cal-tech in the s for his work on ladybug genetics, yet had no training in either medical genetics or genetic epidemiology, had written a letter to president jiang zemin urging the government to take the matter seriously and to protect china's precious genetic resources. this, along with the media furor, duly alarmed the central government. in , the office for management of china's human genetic resources was quickly established under the auspice of the ministry of science and technology, and charged with overseeing the handling and export of all biological specimens potentially containing genetic materials. soon a de facto law, the interim measures for the administration of human genetic resources, promulgated by the general office of the state council (ministry of science and technology & the ministry of public health, ), was enacted in june . it mandated that genetic resources were not allowed to be taken abroad without explicit permission and observance of due procedures as defined in the interim measures. funding for domestic human genetic research subsequently poured in (swinbanks ), which spurred human genetics research in china (du et al. ) . two genome research centers, one located in beijing and the other in shanghai, were established. while the phrase, ''china's genetic resources,'' has been used widely and extensively, surprisingly no definition has ever been officially provided. some scientists likened china's genetic resources to natural resources, claiming that, as the most populous nation in the world, china has the largest number of ethnic groups and also has the widest and the most complex disease spectrum (xiao et al. ). in addition, with a long documented history and many isolated populations, there were many genetic isolates and thus china has the purest genetic heritage in the world. therefore, china is a ''gene giant'' and ''the new world of genes,'' making many technologically advanced nations envy and salivate (xiao et al. ) . however, the analogy between ''genetic resources'' and natural resources has several problems. granted, the vast population facilitates the recruitment of patients with rare diseases for medical research and the low cost of collecting specimens is conducive to large-scale biomedical research. however, china did not and still does not necessarily have more types of diseases, and even if it did, few people outside china would be interested in finding the genetic causes for diseases that are unique to the chinese population. in fact, for many rare genetic diseases (called ''orphan diseases'') for which susceptibility genes have been cloned, many pharmaceutical companies are often reluctant to invest in drug research and development (r&d) for these diseases due to concerns of profitability. the values of natural resources are determined by their amount, their extractability, and market demand. there are two forms, renewable (such as wind power) and non-renewable (such as fossil fuels). a commodity is considered a natural resource when the primary human activities associated with it are extraction and purification, as opposed to creation. thus, mining, petroleum extraction, fishing etc. are natural resource industry, but agriculture is not. since gene identification requires much more than collecting blood samples and are both labor and knowledge intensive, genetic resources are, by definition, not natural resources. in addition, unlike fossil fuels, genetic resources are not entirely non-renewable, if the disease spectrum remains the same. with dramatic economic and social changes, the living standard in china has risen remarkably in the last years. following these changes, diet and lifestyles also have changed quite dramatically. as a result, the disease spectrum in the chinese has shifted, especially in coastal regions. the incidences of breast cancer, colon cancer, prostate cancer, hypertension, and type diabetes all have risen sharply in the last decade (xiang et al. ) . in large cities such as beijing, childhood obesity is used to be very rare but now it is reported to be in the range of % (and another % of children are overweight). in contrast, incidence of stomach cancer has decreased, especially in those highincidence areas where living standards have been improved. ''gene war of the century'' and its aftermath the rapidly changing disease spectrum means that, firstly, the genetic resources would be forever lost if not used in a timely fashion for gene-hunting purposes. secondly, hunting disease susceptibility genes for a disease that obviously has a strong environmental component was an uncharted territory -no one at the time was absolutely certain how it would turn out. over ten years would elapse before people realized that heritability would vanish even for human traits that are known to be mostly hereditary (maher ) . lastly, the notion of china's genetic resources touched upon some thorny issues. unlike other natural resources, genetic materials, as in blood samples, exist only in the human body, which is technically owned by their hosts, not by the state. if a person strikes a deal with a drug company, or acts simply out of genuine altruism, and is willing to give away his blood sample, does the state have the right to intervene? if so, would such intervention infringe on the donor's human rights? giving away or even selling one's blood sample is certainly different from prostitution or selling one's own body parts. if the state does have the right to intervene, where can we draw the line? unfortunately, such questions were never raised and discussed. for biomedical research, there surely is such thing as a genetic resource. but what is it? what constitutes a genetic resource? contrary to the popular belief, population size and diversity of diseases, in and by themselves, actually do not make china ''an ideal place for gene hunters'' (guo et al. ) . few among the common diseases in china are known to have a hereditary component or to be amenable for positional cloning. in fact, while a small portion of breast cancer cases, for example, may be attributed to gene mutations, the large proportion of common and complex diseases is unlikely due to a few gene mutations or polymorphisms (see below). as demonstrated by an interventional study conducted in finland, by reducing body weight, eating healthy and regularly engaging in physical exercise, the risk for developing type diabetes can be reduced by nearly % (tuomilehto et al. ). the dramatic changes in incidence of various diseases in china clearly show that many complex diseases have a very strong environmental component. indeed, a -year interventional study conducted in da qing, china, shows that, after merely years of lifestyle intervention after recruitment, those in the intervention groups had a % lower incidence over the year period as compared with control participants (li et al. ) , very similar to the finnish results. what constitutes a genetic resource, then? an ideal population for positional cloning and association studies should have a well-enumerated genetic disease positional cloning is a method of gene identification in which a gene for a specific disease is identified. a scientist can know nothing about the disease etiology. but just by collecting family data, dna, and some sleuthing, s/he could roughly localize the putative gene in a chromosomal region (i.e. positioning). then, with other molecular genetic tools, the scientist can then identify the gene from the region-thus the phrase, positional cloning. heritage, such as that of the finns (norio et al. ) , and a relatively welldelineated population genetic structure, such as in finland, where extensive church records often exist that document pedigree information for many populations. the catalogue of the genetic disease heritage would allow for correct specification of genetic models and facilitate gene identification. a well-delineated genetic structure of the population should facilitate fine-mapping (i.e. zero-in) and genetic association studies. in contrast, when the ''gene war'' broke out, the documentation of chinese disease heritage was scant at best, and its research in population genetics and genetic epidemiology lagged far behind that of other developing countries. since genetic epidemiology is itself a new branch of epidemiology, and since the design, execution and analysis of genetic epidemiologic studies require not only the expert knowledge of disease epidemiology but also a good command of statistical genetics, genetic epidemiology in china was in its infancy at the time. consequently, there was little, if any, genetic epidemiologic research in china. as a result, little was known of the mode of inheritance, penetrance, and gene frequency for major complex diseases. even credible estimates of disease incidence/prevalence were hard to find. therefore, the notion that china is ''an ideal place for gene hunters'' is questionable and somewhat dubious. the fact that after well over a decade no genes for any common, chronic disease have been identified in china is a testament to this. while calling for protection of china's genetic resources and equating large number of dna samples to huge commercial profits, virtually no one at the time was even remotely aware that there are actually numerous obstacles to this gene prospecting. first, there were huge financial barriers. hunting susceptibility genes for complex diseases usually requires a large number of blood samples, along with accurate phenotypic data in the first place. while genotyping costs have been reduced substantially, they were still expensive in the late s, especially when the whole genome would be scanned. these procedures alone would require a significant upfront capital investment. and like any other scientific endeavor, the gene hunting expedition would carry inherent risk of failure, lacking any guarantee that the investment would bear any financial rewards. the demand for huge resources, coupled with the uncertainty of yield from the investment, raises the question as to whether these endeavors were actually good investments, especially in a developing nation like china where there were and still are problems in providing affordable and equitable medical care for all its citizens (hsiao ). indeed, lifting living standard for all, improving child and maternal health, and better health education on healthy lifestyles (smoke-cessation, healthy a well-enumerated genetic disease heritage can provide the scientists with basic information about the disease of interest, such as mode of transmission and disease frequency. a well-delineated population genetic structure would come in handy when trying to narrow down the gene in a chromosomal region. penetrance refers to the probability that a person with a certain genotype (a genetic makeup) will develop the disease. ''gene war of the century'' and its aftermath diet, physical exercises etc.) can have a proven improvement of health of the general population. secondly, there were numerous scientific hurdles, some seemingly insurmountable. hunting for complex disease genes was an uncharted territory in , and no one could be reasonably sure as to whether there were susceptibility genes, and, if so, whether they could be identified, especially with reasonable time and resource constraints. even if they could be identified, whether they could fulfill the promises of better diagnosis and treatment is also completely uncertain. the genetic mechanism for sickle cell anemia has been known for well over half a century, for example, but so far no gene-derived therapeutics is available. lastly, there were technical hurdles. to genotype large number of samples with high accuracy and reasonable cost was still a challenge around . methodologically, how to analyze the data for diseases which apparently are also influenced by environmental factors and aging process was, and still is, a serious challenge. in addition, how to handle gene-gene interaction, gene-environment interaction, and variable age of onset posed formidable analytical challenges (di and guo ) . these hurdles were further compounded by the lack of a systematic catalogue and documentation of hereditary diseases in china in terms of disease frequency, mode of transmission and penetrance, the lack of documentation of population genetic structures in china, and the scarcity of well-trained genetic epidemiologists. even though the per-sample cost of sample collection was relatively low, this only advantage rarely offset the other, more fundamental deficiencies, and boded ill for many gene-hunting endeavors. viewing the xiping xu case as the nexus of international, transnational, national, and local interests, sleeboom eloquently provides ten different perspectives representing the views and ideals of different interest groups on xu's genetics research program in china (sleeboom ) . indeed, it is often stated that there are several stakeholders in the putative ''gene war'': chinese scientists, foreign gene hunters, and the chinese government. all of them apparently had a vested interest, mostly financial, in china's genetic resources. however, one critically important stakeholder and a potential beneficiary of this gene prospecting, obscured by the media blitz, were actually the patients of various complex diseases in china and the rest of the world. somehow, their voices were muffled and not heard. indeed, from a patient's perspective, it really does not matter which country finds the genes first and comes up with an efficacious therapeutics as long as s/he can access it at a reasonable cost and within a reasonable timeframe. in the s, china's drug r&d lagged significantly behind the west. most, if not all, drugs and diagnostic kits with proven efficacy used in china today have sickle cell anemia is a life-long blood disorder, characterized by abnormal, sickle-shaped red blood cells that do not have usual elasticity as normal red blood cells do. the disorder is caused by a single mutation in a gene called hemoglobin and manifests excruciating pain and shortened lifespan. it has been known to be an abnormality in the hemoglobin molecule since . been first discovered and developed outside china. in fact, all major pharmaceutical companies have now set up manufacturing facilities in china, and almost all drug companies market their products in china once approved by the state food and drug administration of china, a counterpart of the fda of the us. in fact, anecdotal evidence suggests that, when money is not an issue, many patients in china, especially those with potentially fatal diseases, usually prefer imported drugs or drugs made by foreign companies even though cheaper, domestically made drugs of purportedly equal efficacy are available. thus, one simple fact was overlooked in the entire media blitz: an intellectual right on genes can be profitable only when it has a market. china's market is too big to ignore for any rational pharmaceutical company. and when a drug company sells its gene-derived products to china using materials collected from chinese, some patients may still reap the fruits of gene prospecting. this seemingly obvious fact was completely overlooked at the height of the ''gene war.'' the attention that xu's projects drew was certainly unexpected and was likely distracting to xu's projects. xu vehemently denied that he was exploiting poor villagers in anhui for personal gains. he lamented that ''i came from china, and i love the country. but i have been treated like a traitor'' (hui and jue ) . fearing that the media furor and the lopsided condemnation from scientists in china would torpedo his projects in anhui, xu quickly moved to act. when a letter to the editor appeared in science questioning the validity of the ''gene war'' (guo et al. ) , xu quickly translated it into chinese and circulated it among chinese officials. xu also enlisted the support of several established chinese scholars in the us. he appealed to peng peiyun, who was then the director of the state family planning commission, soliciting support for his projects. he adamantly maintained that he was patriotic, and his projects in anhui and elsewhere in china had already trained chinese scientists and elevated their research capabilities. xu apparently had mastered the finesse of keeping a good relationship with the government officials and adroitly played the card of a patriotic oversea chinese scholar. the official people's daily reported in that ''in the last few years, the chinese biomedical researchers collaborated with the world-famous harvard university on various projects, and achieved exciting results in the pathogenesis of complex chronic diseases…. in particular, the research in genetic epidemiology of asthma and hypertension is now at the forefront in the world'' ([benefiting thousands and thousands of families.] ). in another report, it said that ''harvard's project has so far produced postdocs, doctoral students, visiting scholars, and senior investigators'' ([east and west collaborate for the health of humankind.] ). in xu's hometown, the provincial newspaper reported, after enumerating various human genetics research projects with harvard, that ''these collaborative projects not only injected new vitality to anhui's science and technology but also helped attract investment in the amount of about million ''gene war of the century'' and its aftermath rbm yuan'' ([anhui-native scientist climb peak of human genetics.] ). it remarked that ''these projects helped establish tens of laboratories with advanced instruments, …, and laid the foundation for our nation to catch up and surpass the west in human complex diseases research in the st century'' ([anhui-native scientist climb peak of human genetics.] ). xu's preference for dealing with the high-rank officials, however, went overboard and nearly caused his undoing (see below). as xu's various gene-hunting projects in anhui took off, some disturbing incidents involved in these projects gradually surfaced and leaked to the press. participants were initially promised by the research team that they would get free or reduced-cost medical care, but these promises were never honored. informed consent supposed to be obtained from potential participants actually was not-a flagrant violation of nih regulations. rumors circulated regarding coercion by local officials to participate in the projects, sample mishandling and mix-ups in the lab. prompted by these allegations, a fact-finding team of six people from harvard, including xu and his mentor, scott weiss, arrived in anhui in march to investigate the ethical and scientific integrity of xu's projects, but found no irregularities. five months later, the department of health and human services (dhhs) launched its own investigation of harvard's genetic research in china, based on the complaint of a whistle-blower from hsph alleging violations of us human subject protection regulations (pomfret and nelson ) . in late , the washington post ran a lengthy report detailing the allegations that chinese villagers had not been given low-cost medical care as they were promised in exchange for providing blood samples for xu's us-funded genetic research. the report also included allegations of xu's lapses in informed consent (pomfret and nelson ) . partly because of the controversy surrounding this case and others like it in china, the us embassy in beijing issued an advisory recommending that american scientists stop conducting medical research in extremely poor areas of china like anhui. in march , an investigative report by two xinhua news agency reporters was published in outlook, a major chinese magazine. the report reiterated some of the allegations made in an earlier report published in the washington post and supplemented them with interviews with chinese farmers in an isolated region of the anhui province and their various predicaments. the controversies surrounding xu's anhui projects reached a new crescendo at the symposium on bioethics, biotechnology and biosecurity held in early april , which was sponsored by the united nations educational, scientific, and cultural organization (unesco) and organized by the hangzhou municipal government. xiong lei, the lead reporter of the outlook report, presented her investigation and findings with their interview with chinese rural villagers in anhui. her presentation elaborated various irregularities in xu's projects, including the lack of informed consent, broken promises of providing medical care for those who participated in xu's projects, and xu's taking more blood samples than officially approved. an intense debate ensued, starting with xu's anhui collaborators, who maintained that the rate of getting informed consent was close to %, and that the chinese side did reap benefits from the collaboration with the harvard team. but their presentation was confronted by incensed chinese scientists, who questioned their numbers and practice. xu's legal counsel also made some comments, but the comments were challenged and ridiculed. some scientists expressed grave concerns about the loss of chinese genetic materials to the west, in fear of jeopardizing china's own genetic research. prompted by the outlook report, china's office for management of human genetic resources also launched its own investigation. it soon concluded, in june , that xu's projects did not violate any chinese regulations, and told the us embassy so (pomfret a) . but the controversy took another turn in late june . in a letter to xu dated june , , the dean of the hsph reprimanded him, strongly criticizing him for writing two letters to senior chinese government officials, in which xu urged the government to silence the voice from his detractors and to take actions against a major figure who had criticized his work. defending himself as a patriot, xu's letter suggested that the outlook report had released state secrets to ''foreigners'' (pomfret b) . the dean condemned xu's actions, and warned him that he would ''not receive the continued support of the school for you or your research if you persist in exercising independent action.'' if he continued his campaign against journalists and others who questioned his research, the letter said, xu would face ''appropriate sanction'' (pomfret b ). yet xu's woes, unfortunately, showed no sign of abating. on march , , the federal office for human research protections (ohrp) of the dhhs issued a scathing indictment of the hsph research. the ohrp found that projects in china that hsph was involved, including projects on which xu served as the pi, failed to be approved by institutional review boards (irb); where approval had been granted, significant and unannounced changes were often made. it found that many of the informed consent documents approved by the hsph irb included complex language that would not be comprehensible to all subjects, particularly for rural chinese subjects. hsph was charged with failing to minimize risks to their vulnerable subjects, such as economically or educationally disadvantaged persons. in the end, subjects never even received the free medical care as promised. as a result of the indictment, xu was ordered to suspend all human subject interventions in his active studies pending the outcome of an internal audit. this new development was soon reported dutifully in china's press (xiong and wang ) . on may , , lawrence summers, then the president of harvard university, gave a speech at peking university. when responding to a question from a student in the audience regarding harvard's projects in anhui, summers admitted that some irregularities in the projects were ''wrong.'' xu eventually breathed a sigh of relief when ohrp sent a letter to hsph in early may , stating that all issues raised in the hsph-involved china studies have been either resolved or dissolved because of unsubstantiated allegations (as in alleged forged informed consent documents). consequently, ''there should be no need for further involvement of ohrp'' in these matters. notably, the letter acknowledged that xu had decided not to continue the hypertension study due to ohrp's concern that some of the interventions in the protocol exceeded the level of minimal risk. shortly afterwards, hsph held a press release announcing the ''[c]onclusion of u.s. government's inquiry into hsph genetic research in china. '' soon after the hsph news release, one internet article, by xiong lei, alleged complacency and a likely cover-up on the part of the chinese government. it raised several issues (xiong ) . first, among the harvard projects in china that the ohrp found to have problems, projects were headed by xu. yet officially, only of xu's projects had ever been approved by the government. hence there was a glaring discrepancy. second, the official from the office for management of human genetic resources, who was in charge of the investigation of the allegation of irregularities in xu's projects, told xiong privately that it was not an official investigation. however, the same official then turned around and told the american embassy that no violation was found. it was rather strange that the results of this unofficial investigation, which was shielded from the media and the public, would then be used by the americans to prove that there are no irregularities in these projects. lastly, one peasant in anhui whose ordeal led to the exposure of apparent lapses in informed consent later recanted his story after talking with officials from anhui and the central government. presumably, he changed his story because of pressure he experienced. this changed story explained why the ohrp eventually found no wrong-doings in xu's projects (xiong ) . since xiong's article appeared in a website that is officially blocked in china, it did not cause any stir. in china's news media, the criticism of xu's anhui projects also subsided consequently. xu's woes finally ended. more than a decade has passed since the purported ''gene war.'' despite well over a decade of hard work and well over million us dollars in grant support of various forms, xu's team has so far not cloned a single gene for any complex disease or disorder. in fact, they are not even close. other teams were no luckier. in fact, besides numerous reports of association of diabetes, asthma, and other complex diseases with certain genetic polymorphisms, so far not a single gene has been proven to be chiefly responsible for any of these diseases. most genetic loci identified to be associated with the disease risk confer only miniscule relative risks, ranging from . to . (kraft and hunter ) . even when genetic polymorphisms that are associated with a modest increase in risk are combined, they generally have a low discriminatory and predictive ability (janssens and van duijn ) . a more recent study reports that after examination of genetic variants reportedly linked to heart disease, the variants turned out to have no value in predicting disease among , women who had been followed for over years and that family history had better predictive value (paynter et al. ). for human height, a trait that is known to be mostly hereditary, it is calculated that approximately , single nucleotide polymorphisms that are required to explain % of the population variation (goldstein ). this nearly astronomical number certainly inspires no enthusiasm for conducting large-scale gene hunting projects, and questions their value in genetic screening, genetic testing, and the possibility of developing gene-derived therapy (wade ). the idea that disease genes can be quickly identified, patented, and then quick profits can be made now seems to be too naïve. indeed, years after the first draft of the human genome was completed, medicine has yet to see any large part of the promised benefits (wade ) . even gene patenting, the very topic that made the ''gene war'' so contentious, has begun to encounter resistance (kintisch ). there is indication that, at least in the united states, the status of gene patenting is changing (kintisch ). in fact, the us government recently decided that human and other genes should not be eligible for patents because they are part of nature (pollack ) . this move, viewed as ''a bit of a landmark, kind of a line in the sand,'' followed a surprising ruling made in march , by judge robert w. sweet of the united states district court in manhattan, which ruled the patents held by myriad pharmaceuticals and the university of utah on two genes that predispose women to breast and ovarian cancer invalid (pollack ). on june , , the u.s. supreme court ruled in association for molecular pathology vs. myriad genetics that ''naturally occurring'' dna sequences, but not lab-created synthetic cdnas, are off-limits for patent protection. millennium pharmaceuticals, the initial financial backer of xu's projects, pulled out of anhui early in , with no significant medical or business discoveries to show for its $ . million investment (pomfret and nelson ) . it since has moved into a field of drug r&d that seeks to customize medical treatments for individual patients. it has grown into a successful, billion-dollar enterprise. yet no doubt xu's anhui projects played a crucial role early in its success by securing a much needed infusion of funds (pomfret and nelson ) . for sequana therapeutics, despite its public announcement of the discovery of the asthma gene in , so far there have been no publications from the company regarding the gene. the claim has never been independently verified. the prospect of making diagnostics or therapeutics derived from the putative gene never materialized. it was acquired by arris pharmaceuticals, forming axys pharmaceuticals which later on formed axys advanced technologies, later bought by chemrx. the remains of axys were bought by celera. what used to be sequana therapeutics no longer exists. human genome sciences' stock price reached its peak at $ on january , and went through two splits in . its president and founder haseltine said that his work ''speeds up biological discovery a hundredfold, easily.'' he talked of finding ''the fountain of youth'' in genes in the form of ''cellular replacement'' therapies. the company raised more than $ billion in investments by . in september , the company reported that it had found a way to treat large, painful sores that often plague elderly patients, using a protein spray called repifermin, made by a human gene called keratinocyte growth factor- . in february , however, the company said that it was ending the development of repifermin because it showed no more benefit than a placebo in clinical trials. another initial drug also failed in clinical trials. in late , the company announced haseltine's retirement and named h. thomas watkins the new president and ceo. in , the first draft version of the human genome was published, thanks to collaborative work among geneticists from china, france, germany, japan, united kingdom and united states. in , the completed version of the human genome was published, marking the completion of the hgp. from the first draft of the human genome, it was quickly learned that there are about , genes, less than one quarter of , ''genes'' patented by the human genome sciences. along with this shrinkage in the number of genes, the company stock price also shrank dramatically: the closing price on july , , was $ . , a reduction of . % from its historical high. other genomics companies have not fared much better. iceland-based decode genetics, for example, was founded in to identify human genes associated with common diseases using population studies. its stock price reached $ . on september , , but plummeted to $ . on july , , a reduction of . % in value. its stock was removed from the nasdaq biotechnology index in november . the company's annual report reveals that its net losses were in excess of million us dollars, and that they have never turned a profit. its annual report says that ''decode has recorded substantial operating and net losses over the past years'' and the company filed for chapter bankruptcy in the same year (http://www.decode. com/investors/dcgn-sec-filings.php). it was acquired by amgen at the end of for million usd. on the chinese side, human genetics research moved on with the infusion of research funding from the government. most scientists who participated in the xiang shan symposium established themselves in genetics research. several of them were later elected to the chinese academy of sciences, the most prestigious honor that can be bestowed on to a scientist in china. besides all the trappings and perks, being an academy member also carries far more influence and political clout than its us counterpart. huangmin yang, the most vocal in criticizing xu's projects, went on to establish china's premier genome research center, and his career culminated recently in the completion of the diploid genome of the first asian individual (wang ) , rumored to be the dna extracted from yang himself. the purported ''gene war'' has a profound resonance. even today, over a decade after, the reverberations of the media blitz and the fallout are still palpable: a google search of ''gene war'' or ''genetic resource'' turns up numerous websites still talking about the ''gene war'' or even the purported attempt by the us to wage war against china using ''gene weapons'' (tong ) . the ''war'' also spurred a flurry of research papers in chinese scholarly journals, universally calling for the protection of china's genetic resources and profit-sharing arising from gene research (jia and wang ; jiang and wei ) . xu left harvard in and joined the school of public health, university of illinois in chicago, as a non-tenure track research professor of epidemiology (http:// www.cade.uic.edu/sphapps/faculty_profile/facultyprofile.asp?i=xipingxu), apparently failing to secure a tenured position at harvard. the negative publicity surrounding xu likely made him seem more a liability than an asset to hsph, especially when he and his group had made no important discoveries. in , the epidemiologist-turned genetic epidemiologist went through another metamorphosis and became an entrepreneur. he was the chief technology officer and, as of writing, is now the president of ausa pharmed company in shenzhen, china. in a glowing profile of xu and his company by people's daily, xu is quoted as saying, ''i used to write prescriptions for people in a small village, and now i am writing a big prescription for people all over the world'' (wang ) , apparently referring to the company's blockbuster-to-be drug for stroke prevention, yiye (''yi'' is the pronunciation of the first syllable of enalapril in chinese and ''ye'' is that of folic acid). according to the company's website, the drug, a polypill consisting of a combination of enalapril (an angiotension converting enzyme inhibitor, or acei, used as an anti-hypertensive drug, on which merck had a patent, now expired) and folic acid (a member of the vitamin b family, used to prevent neural tube defects for pregnant women, and, as an auxiliary, to treat hyperhomocysteine and other conditions), is the fruit of extensive research by ausa scientists, ''the only class i cardiovascular drug approved by the state food and drug administration (the us fda counterpart in china) in the last three years with all china-owned intellectual rights, and is the first novel drug in the world that can simultaneously control two risk factors for stroke, hypertension and hyperhomocysteine.'' in , xu was among the first that were granted the ''thousand scholars'' support, a program designed to attract full-professor-level senior professionals from overseas to work in china. this is a title with enormous privileges and perks given to a select group of best scholars recruited from overseas by beijing. on december , , xu was featured in the oriental satellite tv's special program, people in years, a program that profiled prominent people and their achievements in the years of economical reform in china. in the program, xu talked about his early life as a ''barefoot doctor,'' his admission to peking university and then to harvard, and his dream, as a youth, of ''writing big prescriptions for people all over the world.'' he talked about his work in epidemiologic studies of air pollution and health and his new venture in developing drugs for chinese people. he made no mention, however, about his genetics studies and their associated controversies, and showed no trace of bitterness. curiously, the ausa-sponsored clinical trial on the evaluation of yiye in prevention of stroke was registered at the clinical trial registry, www. clinicaltrials.gov, on november , , which coincided with the official approval from the sfda of yiye. the registered trial, china stroke primary prevention trial (csppt), is a phase iv trial (nct ), which compares the efficacy of enalapril and folic acid combination vs. enalapril alone in preventing strokes. as of writing, its status is listed as ''on-going, but is not recruiting participants.'' its estimated completion date is august, . in modern society, science has become a firmly institutionalized social activity, attracting people through offering generally prized opportunities of engaging in socially approved patterns of association with one's fellow and the consequent creation of cultural products esteemed by the group, in addition to economic benefits that science may offer (merton [ ). as merton eloquently put it, ''such group-sanctioned conduct tends to continue unchallenged, with little questioning of its reason for being. institutionalized values are conceived as selfevident and require no vindication'' (merton [ ). in modern science, especially in biomedical research, scientific enquiries often require large amount of resources-expensive instruments and reagents, lab space, and talented and hardworking students. hence the pressure for getting resources is enormous. anything that promises to help ease the pressure is welcome. scholars of sociology of science often view science as agonistic, made up of rival individuals or groups vying to have their scientific ideas or views recognized and/or accepted as valid (greenhalgh ) . science, as a space of maps of culture, is drawn by scientists hoping to have their research accepted as valid and recognized, their practices esteemed and patronized, and their culture sustained as home of objectivity, reason, truth or utility. the maps are then used by all who are unsure about the reality (gieryn ). yet maps of science change over time, as competing cartographers are constantly drawing, erasing, and redrawing the boundaries of science. by doing this, the scientist cartographers claim authority over a particular issue by taking it within their science or turf. thus, vying for acceptance or the valid ''truth'' among scientists is essentially a credibility contest, with winners viewed as the epistemic authority (gieryn ) . the one with the epistemic authority obviously would be the most influential, and their views and voices would be the most visible and vocal when it comes to policy issues (greenhalgh ). gieryn's credibility contest metaphor aptly depicts the quest for epistemic authority in science, it also is applicable, rather fittingly, to the situation when scientists vie for resources from funding agencies. in fact, when the process of deciding who would get resources lacks procedural justice, and when there is a lack of tradition for open and rational debate and of a checks-and-balances system, the credibility contest becomes literally a ''beauty'' contest-the most glamorous, in terms of rank, status, or simply seniority in the administrative ladder, but not necessarily the vision, merit, or talent, would get the resources. in a country where political loyalty and connections are valued far more than scientific merit and talent, the credibility contest further becomes a contest of political correctness or patriotism. coupled with the lack of a clean and efficient government and of transparency and also with the pervasiveness of guanxi or personal connections, this contest might create winners who are not necessarily the scientifically most visionary. as human beings, scientists are also susceptible to all human frailties. aside from questing for epistemic authority, they also compete for resources and influence, and often vie for political clout, credit, fame, and even glamour, especially when such activities help their quest for epistemic authority or increase their professional and personal gains. if there are no set rules of the game with certain procedural justice or a checks-and-balances system in place that can curtail the tendency and channel it into the maximization of the common good, the human frailties, coupled with the lack of proper avenues for open debate, the contest would be an invitation for inefficiency, waste, corruption, and even disaster. winners might take all, but in the long run the bad money drives out the good. the spectacular fiasco in containing the sars epidemic and in sequencing the coronavirus that causes sars are a prime example (enserink ; cao ) . lured mostly by the low cost of collecting large dna samples and the perceived genetic homogeneity, many gene hunters from the west came to china in the hope to identify genes responsible for complex diseases, and some of them may have hoped to get rich in the process. this was mostly accomplished through some wellconnected chinese intermediaries ''as experienced guide,'' as washington post reporter john pomfret put it (pomfret and nelson ) . letting the intermediary do the leg work did spare them from doing the dirty field work but also insulated them from the sentiment from villagers and the scientific establishment in china and prevented from establishing a rapport with these people. from a scientific standpoint, many gene-hunting projects were launched without much understanding of the population genetic structure of the chinese population or foundational genetic epidemiologic data, let alone the appreciation of the inherent risk in this scientific endeavor. there was no plan b that one could have something to fall back on in case what was planned did not pan out. the execution also was fraught with various deficiencies. with little or no oversight, the daily work was left to the hands of not-so-well trained people. and when rumors of irregularities surfaced, inspection was largely perfunctory, nothing more than sugar-coating or bandaging. it would have been a miracle if such projects were ever productive. faced with numerous well-endowed gene hunting teams coming to china, the cash-strapped chinese genetics scientists had every reason to be worried. the taking of large number of dna samples and, worse yet, the tracking down of some large pedigrees with rare genetic diseases would effectively deprive their chance of finding disease genes, outshining them in the genetic research of chinese populations and threatening their careers. providing dna materials without any reasonable share of possible future financial payoff for the people who donated their blood could also be a concern, but it is not clear which was the primary concern. by calling the attention of the central government through evoking nationalism via calling the protection of china's genetic resources, they got the resources and also claimed a territory that would be off-limit to ''foreign devils.'' yet by doing so, no one apparently was aware then of numerous and enormous hurdles to gene prospecting and vastly underestimated its complexity and challenge. by evoking the urgency to protect china's genetic resources, some scientists played the card of nationalism, wining the contest in getting resources through nudging the unsuspecting government to cough up some much needed funds to thwart ''foreign devils''' pilfering act. through the drafting and implementation of the interim measures for the administration of human genetic resources, the domestic scientists effectively enacted an embargo of the transfer of all dna-containing materials from china to the outside by drawing a clearly demarcated boundary. this may explain why dr. xiping xu repeatedly proclaimed, in many public occasions during the entire course of the ''war,'' that he is a patriot. well-connected and clearly a master of nuances of guanxi, he certainly knew the psyche of many chinese and government officials. lapses and missteps aside, he was no match to domestic scientists united in the name of patriotism. yet his biggest deficiency in the credibility contest was attributable to his betting on a wrong horse: many, if not all, of his well-funded projects did not pan out in the end, producing no headline scientific discovery and failing to establish an epistemic authority. while credibility contest to quest for epistemic authority depicts science and its working, the contest for credibility, glamour or patriotism in getting resources as we see in the ''gene war'' may be ultimately detrimental to china's science and technology. today, china's r&d investment, in terms of dollar amount, has increased dramatically as compared with the era of ''gene war.'' it reached a historical high of . billion yuan, or about . billion us dollars, in , amounting to . % of china's gdp. as a result, china's scientific output, measured by the number of papers published in international journals, also has increased remarkably and is reportedly ranked as the second in the world, just behind the us. yet in terms of average number of citations-a rough measure of impact or research quality, china was ranked a distant th . a more disconcerting observation is that the fruit of biomedical research seldom translates into better patient care, better therapeutics, better prognostics, or better prevention. in other words, the vast majority of tax-payers have not received any tangible benefit from the supposedly noble and grandiose scientific endeavor. this situation, if left unchanged, is not going to justify for heavy investment in biomedical research and to win the continued support from tax-payers in the long-run. ultimately, it would raise the issue of sustainability of biomedical research in china. this problem will become all the more acute as china enters into an aging society in which health care cost will surely skyrocket. it should be noted that, at the height of the ''gene war,'' similar concerns were also raised in finland and india. however, few seemed to have framed their concerns at the level of nationalism, and even fewer have gone overboard and demonized, often in passionate and patriotic rhetoric, all foreign-supported gene hunting projects. the near paranoid that instigated towards all foreign-backed gene-hunting project did help to cough up some much needed research funding from the government, but also fermented xenophobia and some utterly unfounded yet sensational non-sense such as ''gene weapons'' (tong ) and tarnished genetic research in china. remarkably, when a book was published in , sensationally claiming that the sars virus was deliberately manufactured by the west based on dna materials smuggled out of china (tong ) , no one stood out and debunked such scientific rubbish. the chinese also carry a burden of humiliation and painful memories of the past as a result of repeated ravages by foreign aggression and exploitation in the last two centuries. consequently, issues that may be remotely related to national sovereignty or foreign exploitation are hot-button ones. minor incidents can be easily escalated into a major event, as evidenced by the calls for boycotts of french carrefour and other foreign retailers in china in response to the disruptions of the olympic torch relay in paris in , and, more recently, by the vandalization of japanese-made cars in many chinese cities at the height of anti-japanese sentiment rekindled by the territorial dispute between china and japan. china's current funding system and the science policy-making also are vulnerable to subterfuge of various kinds, behind which personal gains are often masquerading as patriotism or national interest. as ambrose bierce once defined, patriotism is a ''combustible rubbish ready to the torch of any one ambitious to illuminate his name.'' it is a challenge to weed out charlatans impersonating as patriots, but the best bet would be a transparent system that values merit, talent and vision above cheap patriotic or nationalistic rhetoric. as china is aspiring to be a leader in science and technology, this ''gene war of the century'' and its aftermath, as narrated here, serve as a cautionary tale. it reminds us, first and foremost, how important it is to be clear-headed and not to follow blindly whatever in vogue. very often, what we see is the conspicuous ''me-too'' science, following whatever fashionable. yet the most important ball that all eyes should lay on, i.e. better health for all, is seemingly lost. in the absence of procedural justice in the process of deciding who would get resources, and when there is a lack of tradition for open and rational debate and of a checks-and-balances system, the credibility contest for resources would easily become a ''beauty'' contest. in a country where political loyalty and nationalism are valued more than scientific merit and talent, the credibility contest would further become a contest of political loyalty, political correctness, or patriotism. the news of pilfering of china's genetic resources by foreign companies could easily strike a chord of painful memories of foreign aggression and exploitation in the last two centuries. the isolation from the world community for nearly three decades since one key finding of the hgp is that all human races are . % identical-dna sequence-wise. therefore, racial differences are genetically insignificant. for many genes, it has been established that genetic variations within the same racial group are larger than those among racial groups. thus, scientifically, it is impossible to devise a ''gene weapon'' to target a specific racial or ethnic group. ''gene war of the century'' and its aftermath the founding of the people's republic purportedly due to the prejudice, discrimination, and containment of the western imperialists and capitalists-or so it was told by the state media-also helped foster or reinforce a nearly xenophobia attitude towards anything perceived to be dangerous if coming from outside of china, especially it touches on ideology. thus, a spark of minor incident could easily kindle the fire of tumultuous nationalistic uproar. hence, the ''gene war'' holds a lesson that being seemingly the most patriotic is not an assurance for good science. the mere possession of resources does not guarantee scientific productivity, either. vision and brain are more important when it comes to scientific innovation and discovery. the over-politicizing science will ultimately prove to be detrimental to china's science and technology. we have seen it during china's great cultural revolution, in which nearly everything in science and technology was politicized. but science and technology then were essentially decimated, and the characteristic hallmark was jia, da, kong or falsehood, grandeur, and emptiness. in addition, when political loyalty prevails over talent and vision, some unscrupulous scientists can hijack the value system to their own advantage. and when there is also a lack of avenue for open debate, then one project purported of to be of national importance could be usurped by another with purportedly greater importance. the conflict also reminds us that scientists are no more than human beings and have all the human frailties. personal gains or some ulterior motives can be camouflaged as patriotism or public interest, as shown in the politics of paleoanthropological nationalism in china (sautman ) . as merton succinctly put it, ''any extrinsic reward-fame, money, position-is morally ambiguous and potentially subversive of culturally esteemed values. for as rewards are meted out, they can displace the original motive: concern with recognition can displace concern with advancing knowledge. an excess of incentives can produce distracting conflict'' (merton [ ). without any measures or system to guard against this, the interest of the nation and of the public will suffer. in human genetics, china's premier challenge now remains to be, as was a decade ago, ''to build up a critical mass of highly competent and visionary scientists who will be able to bring chinese genetics into the world community'' (guo et al. ) . the ultimate goal of biomedical research in general and human genetics in particular is to bring tangible benefits and better health to the general public, not merely some ranking of scientific output, for it is the source of gaining sustainable support from the general public and of economic prosperity. science thrives on openness, reason, and the competition of ideas, and it suffers when subjected to political agenda, faux patriotism or nationalism. anhui-native scientist climb peak of human genetics noncoding rna transcription beyond annotated genes implications of the human genome project for medical science the search for genetic variants predisposing women to endometriosis confirmation of susceptibility gene loci on chromosome in northern china han families with type diabetes china's missed chance shiji zhi zhang: jiyin qian duo zhan [war of the century: the war to seize the genes shiji zhi zhang: jiyin qian duo zhan [war of the century: the war to seize the genes asthma gene discovered cultural boundaries of science: credibility on the line common genetic variation and human traits just one child: science and policy in deng's china gene war of the century? a linkage between dna markers on the x chromosome and male sexual orientation backlash disrupts china exchanges genome-based prediction of common diseases: advances and prospects protection of genetic patent-a discussion of gene providers' sharing the benefits accruing from the use of genetic patent the thought on dispute of cooperative gene research between china and america out of sight, out of mind: how harvard university exploited rural chinese villagers for their dna appellate court weighs 'obvious' patents genetic risk prediction-are we there yet? genetic dissection of complex traits the long-term effect of lifestyle interventions to prevent diabetes in the china da qing diabetes prevention study: a -year follow-up study jiyin da zhan'' [the escalating ''gene war personal genomes: the case of the missing heritability the puritan spur to science behavior patterns of scientists hereditary diseases in finland; rare flora in rare soul association between a literature-based genetic risk score and cardiovascular events in women people's daily. . benefiting thousands and thousands of families u.s. says genes should not be eligible for patents china probe clears harvard's genetic research an isolated region's genetic mother lode harvard-led study mined dna riches; some donors say promises were broken male homosexuality: absence of linkage to microsatellite markers at xq the future of genetic studies of complex human diseases peking man and the politics of paleoanthropological nationalism in china beijing youth daily the harvard case of xu xiping: exploitation of the people, scientific advance, or genetic theft? genome research set to take off in china the last defence: the agony of the loss of chinese genes prevention of type diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance genes show limited value in predicting diseases a decade later, genetic map yields few new cures new drug research in china lift heavy siege. people's daily methods for time trend analysis of cancer incidence rates experimental studies on somatic gene therapy for diabetes i. structuring of recombinant from human insulin gene and mammalian expression vector prc/cmv scramble for chinese genes not ended harvard's genetic research projects in china a ''violation advances in science and progress of humanity: a global perspective on dna the gene puzzle acknowledgments the author would like to thank drs. cong cao, partha majumder, margaret sleeboom-faulkner for their constructive comments on an earlier version of this manuscript. he also thanks dr. yang huanmin for the reading of an earlier draft, two anonymous reviewers and the editors for their helpful comments. thanks also goes to charles guo for his critical reading of and helpful comments on the manuscript. key: cord- -i x z s authors: lemmens, pieter title: love and realism date: - - journal: found sci doi: . /s - - - sha: doc_id: cord_uid: i x z s in this reply i try to show that, contrary to milberry’s apparent assertion, the general intellect of the multitude does not have the explanatory robustness she accredits to it (following both virno and the hardt and negri of the empire trilogy). digital network technologies are currently overwhelmingly effective in proletarianizing and disempowering the cognitariat and only an active technopolitics of deproletarianization could reverse this hegemonic situation. in my response to verbeek, i attempt to correct his misinterpretation (shared by milberry) of the stieglerian approach as being dialectical in nature and show that, far from reinstating the humanist dichotomy between human beings and technologies, my analysis assumes their original, albeit fundamentally ambiguous and even ‘uncanny’ [unheimlich] interconnection. i conclude with pointing out some implications of this view for a ‘really realistic’ political theory of technology. however, i feel compelled to correct two apparent misunderstandings. first, although i largely approve of feenberg's critical theory of technology, my notions of ambivalence and creative appropriation are adapted from stiegler and not taken from feenberg, and are as such based on the former's pharmacological conception of technology, which certainly has some affinities with feenberg's ambivalence theory but, as i write in the article, is rooted in an elaborate 'onto-anthropological' and 'onto-anthropogenetic' understanding of the human life form as a technical life form, one that is lacking in feenberg and that fully explains why and how technologies are fundamentally and irreducibly ambivalent and in constant need of creative (re)appropriation (or 'adoption' in stiegler's terminology). second, the pharmacological approach to technology and technological change is decidely not dialectical, as milberry repeatedly yet erroneously infers. but i'll come back to this in my reply to verbeek, who shares this misunderstanding. referring to both virno and hardt and negri, milberry argues that the concept of the general intellect, indeed central to my article, may have more explanatory robustness than i acknowledge. presuming this to mean that it crucially explains the growing revolutionary potential of the multitude under current circumstances of immaterial labor, i must reiterate that i find this unconvincing, both empirically and conceptually, at least when this is taken in the sense that it 'automatically', as it were, grants labor more autonomy and thus yields it more powerful and assertive vis-à-vis capital. the proletarianizing efficacy of the digital network technologies (dnts) underpinning the 'communism of capital' currently far outweighs their empowering functionality, as a vast and growing body of empirically based literature attests (to mention just a few: carr carr , crary ; keen ; mcchesney ; pariser ; rouvroy and berns ) and only a (bottom-up) technopolitics of deproletarianization oriented towards a positive pharmacology-which entails more than simply 'commonization'-could bring about a turn in this hegemonic tendency. of course, this is not the whole story and in particular berardi's diagnosis is fairly reductionist, i readily admit, yet it adequately describes certain dominant trends in the working conditions of today's cognitariat, resonating for instance with jonathan crary's descriptions of / capitalism (crary ) and the analyses of communicative capitalism's proletarianizing capture of the libidinal energies of workers and consumers via the digital networks by jodi dean, who emphasizes the depoliticizing character of those networks, as they systematically distract subjects from engagement in real political action by soliciting them continuously to online pseudo-activity (dean ) . as a matter of fact, for dean, as an active participant in it, occupy's success (like that of the other revolts of ) should not so much be explained from the political blessings of new social media, but from 'the physical amassing of people outside' (dean , ) . even hardt and negri most recently have recognized the largely disempowering effects of digital media on the thoroughly 'mediated subjects' of contemporary capitalism, constantly absorbed as they are in attentional cycles fragmenting their psyches and eroding their (in particular political) affects. echoing dean, they write: 'facebook, twitter, the internet and other kinds of communications mechanisms are useful, but nothing can replace the being together of bodies and the corporeal communication that is the basis of collective political intelligence and action' (hardt and negri , ) . as for the call for democratic control of technology, which milberry proposes as a student of feenberg: as i've tried to show in a recent article co-written with mithun bantwal-rao, joost jongerden and guido ruivenkamp, under capitalist conditions, the call for democratization of technological innovation seems idle since it 'remains severely limited for the simple reason that there is no incentive for industry to engage in any significant democratization for any reason beyond that of the market […] or public institutional force' (bantwal-rao et al. ) . such a call only makes sense if combined with a radical critique of the capitalist order, something that is conspicuously absent in feenberg's later, watered-down (from too much wrong-headed concessions to sts, that is) version of critical theory. milberry concludes her response with a remarkably idealist critique of my proposal for a pharmacological (re)appropriation and redesign of our digital milieu, arguing that this should be preceded by a change in our 'social values and mores' towards more 'love', thereby apparently disregarding the ruining effects on self-love and the affective capacities of individuals in general of the omnipresent apparatuses of libidinal capture and exploitation that hegemonically constitute the current 'sociotechnical foundation of contemporary life' under capitalist conditions (stiegler ; berardi ). i very much agree that love, also in its social form of philia (aristotle), is key to a better society, but before preaching love, we should-as good marxists-first consider its current means and conditions of production (or better: destruction) and then think of strategies to transform these. i will now turn to verbeek's response, that is more critical about my general approach, which is implicitly accused of being unrealistic (i.e., in its plea for a 'realistic political theory of technology') for basically two reasons: ( ) it is, apparently, not empirically informed in that it disregards 'actual technologies' and only applies 'pre-given philosophical frameworks' 'from outside' (that are even suggested to be obsolete) to a technological domain of 'things themselves' that are left uninvestigated (just like the traditional, transcendentalist philosophers of technology did); and ( ) it remains caught in a dialectic of domination and liberation that is apparently also obsolete and unproductive and should be replaced, or at least complemented, with a hermeneutic approach, present in the allegedly dialectical approach of stiegler (and obviously also feenberg) but lacking in my analysis. the 'realistic' alternative proposed is a more hermeneutic approach oriented towards 'the things themselves', here understood not 'in the phenomenological sense' (as verbeek nonetheless claims) but empirically, in the way sts approaches technologysurely neither husserl nor heidegger ever thought of 'die sachen selbst' as concrete objects; these were precisely 'bracketed' in order to attain the proper phenomenological sach-dimension: the acts of transcendental consciousness (like intentionality) for husserl, modes of being for heidegger. before responding to these critiques, i again feel the need to first correct verbeek's (as well as milberry's) misinterpretation of stiegler's (and my own) approach as being 'dialectical'. to state it directly: stiegler's approach to technology is not dialectical. as organological, it understands the human-technology-society relation with simondon as transductive (and thus not dialectic) in nature and with nietzsche as traversed by composing, rather than op-posing antagonistic tendencies; and in this sense stiegler's view is close to that of post-autonomist marxism (bantwal-rao et al. ) . as pharmacological, it simply cannot be dialectical because the pharmakon's 'negativity' (its toxicity) can never be 'sublated' (aufgehoben) as it persists as technical heteronomy and thus calls for an on-going therapy (stiegler , ) . explaining this first requires some comments on the notion of the dialectic. it is my impression that, for verbeek, this notion only refers to the marxist struggle of oppression and resistance between labor and capital (as derived from hegel's master-slave dialectic). at its origins in hegel and marx, however, the dialectic first of all describes the historical process of human culture as a process of exteriorization, idealistically understood in hegel as the self-externalization and subsequent internalization of the spirit, materialistically in marx as the self-production of the human species through its externalized means of production, i.e., technologies or technical organs. like marx, stiegler also thinks of human evolution and history as based in a process of technical exteriorization (and interiorization). in contrast to marx, however, who remains an instrumentalist in apprehending technologies as means sovereignly determined by the human subject, stiegler conceives of technologies as constituting and conditioning the human 'subject'. moreover, since technologies-as pharmaka compensating for man's 'original lack'-are not only curative but simultaneously and irreducibly toxic as well, i.e., heteronomizing, proletarianizing or disindividuating, no dialectial sublation and thus no perfect interiorization is possible. what is more, the autonomy of 'the interior' ('the subject', 'the self') remains forever dependent on exterior technical heteronomy: yes it is constituted by it, but only after its adoption as the formation of individual or social practices. for stiegler, the 'subjugating' or 'enslaving' character of technology cannot be explained solely (and instrumentally) on the basis of the class struggle, i.e., from the social relations of production, as in marxism. as a pharmakon, technology is originally proletarianizing, but for the very same reason it is also the (only) route towards deproletarianization. in this regard, verbeek is very right to point out that stiegler provides 'a fascinating new turn' to the marxist dialectic (although it is not a dialectic anymore as should be clear by now), in showing that 'the struggle between humanity and technology is constitutive for the human being', although the term 'struggle' does not seem to be very appropriate for what stiegler theorizes as the human's pharmacological relation with technology, in which the latter both con-stitutes and de-stitutes the former. i do not believe i'm regressing towards a traditional marxist position in calling for the (re)appropriation of the digital pharmaka to reconquer our collective autonomy vis-à-vis capital, since this is not 'a call to take up arms against the technologies of capitalism' but a call to fight capitalism with the technologies 'of capitalism', but this attribution precisely becomes problematic of course from a pharmacological perspective. far from reinstating a separation of human beings and technologies, as verbeek claims oddly enough, it is exactly a recognition of the need, the necessity, to reforge the pharmakon-which is always and by its very 'nature' a weapon, as stiegler rightly insists time and again with reference to deleuze-to regain social autonomy on the basis of the new technical heteronomy that the digital pharmaka, which are indeed not 'mere vehicles of capitalism', represent. true enough, whereas stiegler only calls for a struggle against today's capitalism's proletarianizing and heteronomizing tendencies, i firmly side with the post-autonomists in calling for a technical fight against capitalism as such. in that sense, i advocate the challenge of 'pre-given frameworks' on the basis of 'concrete technologies' ('from within' if you like), as verbeek suggests i should do, fully convinced that it is precisely technology in its very concreteness that represents the domain of the (empiricalaccidental) transcendental because it is technologies, first of all mnemotechnologies like writing, printing and digital computing of course, that constitute and condition the possibilities of human thought, knowledge and critique in general, but to explain this would take too much space here (as would the plea for the necessity of a 'transcendental (re)turn' in philosophy of technology to make it properly philosophical again and rescue it from its myopic fascination with empirically describing the effects of the most recent technocommodities on a consumber-subject that is not in any way problematized, and neither is their nature as productive of that subject). that digital technologies 'can also be the source of new forms of social agency and selfawareness' is thus exactly what i claim, and also that 'technologies are not opposed to politics', precisely because 'they are its very media' (although i would prefer to say that they completely re-constitute and re-condition political action and even the political as such in our epoch): what could be more proof of 'a realistic recognition of the technological condition of human existence' than emphasizing that these technologies constitute a new political organology that has yet to be appropriated politically? it is precisely this new (digital) organological configuration that forms 'the ecostructure in which we inevitably live our lives', but as a fundamentally pharmacological milieu it is a battlefield as well as an arsenal that allows for a struggle-that is what politics is-against a destructive and utterly nihilistic capitalism that has for too long now claimed that it is 'inevitable' and without alternative (and about which postphenomenology remains totally silent). it is true that there are no 'close analyses of the technological things themselves' in my article, but i do provide a description of the general characteristics of dnts that make them ideally suited for the invention of an alternative, post-capitalist economy. of course, empirical analysis always remains important in philosophy of technology, but analyzing technologies in complete abstraction from the politico-economic conjuncture in which they appear and operate, as postphenomenology usually does, is also pretty unrealistic in my view. apart from that, and notwithstanding some notable exceptions (e.g. van den eede ), one does not find that much analysis of (new) media, and neither a dialogue with media theory, in postphenomenology, which is strange for a philosophy that explicitly theorizes technological mediation. also, a philosophy of technology that has no eye for the libidinal aspects of technology (and technical artifactuality is precisely that which 'mediates' human affectivity and renders it different from the instinctual behavior of animals), and even questions the usefulness of the libidinal perspective, as verbeeks seems to do, may lose sight of a significant 'reality'-dimension of technology: that of the affective-phantasmatic. and a fortiori a 'political theory of technology' should take account of this, if it is true that political action and communication is about directing collective investment of desire. both postphenomenology and critical theory of technology could profit in that regard from an engagement with psychoanalysis, of course based on an awareness of the thoroughly technologically conditioned 'nature' of the human psyche, its affects and its capacities. open access this article is distributed under the terms of the creative commons attribution . international license (http://creativecommons.org/licenses/by/ . /), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the creative commons license, and indicate if changes were made. technological mediation and power: postphenomenology, critical theory, and autonomist marxism the soul at work. from alienation to autonomy the shallows. how the internet is changing the way we think, read and remember the glass cage: where automation is taking us / . late capitalism and the ends of sleep blog theory. feedback and capture in the circuits of desire declaration. new york: argo navis authors services how capitalism is turning the internet against democracy the filter bubble: what the internet is hiding from you gouvernementalité algorithmique et perspectives d'É manicaption. le disparate comme condition d'individuation par la relation? acting out states of shock stupidity and knowledge in the st century he wrote his philosophy dissertation on the intimate relationship between the human and technology-entitled driven by technology: the human condition and the biotechnology revolution-and received his phd in from the radboud university in nijmegen, the netherlands. he currently teaches philosophy and ethics at the department of philosophy and science studies, part of the institute for science, innovation and society (isis) at the radboud university. he has published on themes in the philosophy of technology and innovation key: cord- - xxpe m authors: din, m.; asghar, m.; ali, m. title: delays in polio vaccination programs due to covid- in pakistan: a major threat to pakistan's long war against polio virus date: - - journal: public health doi: . /j.puhe. . . sha: doc_id: cord_uid: xxpe m nan letter to the editor delays in polio vaccination programs due to covid- in pakistan: a major threat to pakistan's long war against polio virus the disruptions caused by the covid- pandemic have devastating impact over vaccination programs around the globe especially in underdeveloped countries. the delays in immunization campaigns could increase infectious diseases such as polio, measles, and human papillomavirus. the pandemic is overstretching the health-care sectors and countries with limited capacity to deal major outbreaks are at breaking point. in accordance with world health organization (who), more than million infants were vaccinated in , and still more than million children miss vaccination around the world and that the number could have been increased due to covid- . during the ongoing covid- pandemic, pakistan has had to delay vaccination for another life-threatening contagion, poliovirus. since april, around million children missed the polio vaccination due to the cancellation of vaccination campaign nationwide. pakistan stopped the mass vaccination on the th of march under the commands of global polio eradication initiative (gpei). millions of the children are at risk of missing lifesaving vaccines due to rising urge of social distancing, vaccine supply disturbance, blocked borders, and elevated shipment costs which led to the deferment of polio campaigns. although majority of the countries have already removed all the three types of polioviruses, pakistan, alongside afghanistan, is one of the two countries in the whole world where polio is still endemic. it was nearly close to become polio free with only reported cases in but unfortunately, the number of cases rose to in . , in the same year, pakistan was accused of facing the emergence of the p virus strain with reported cases. this strain was thought to have been removed in . the year was thought to be the year for the transformation in polio campaigns to halt transmission in but the country is now facing covid- operations. therefore, any disruption due to covid- in the polio program plans would have significant and drastic impact on this objective. it could be concluded that diverting public health funds to fight against other outbreaks disrupted polio eradication plans, which could lead to the spread the of poliovirus in areas of low immunization coverage and immunity. pakistan could face setbacks due to suspension in the polio vaccination due to covid- . on july of , there have been reported cases of polio in pakistan. the immunization campaigns have been paused or delayed in various countries as the local health-care authorities are putting all their efforts to control coronavirus. therefore, the planned vaccination in many countries may now not take place. this will cause a serious threat to the recently born infants who might now miss out their routine vaccination services. moreover, those children who have not yet received the significant amount of polio vaccine are also at high risk. the who is ready to resume the vaccination plans but as pakistan is witnessing an increase in the number of covid- cases, with the next few weeks crucial, the resumption of polio vaccination campaigns might be delayed. meanwhile, if the polio outbreak gets out of hand, it would pressurize the already overstretched health-care sectors across the countries. at worst, it could even lead to the next global health emergency. the health-care experts in pakistan, agree to resume the polio vaccination campaigns, otherwise the covid- would destroy all the progress being carried out in the last thirty years against the polio virus. the consequences of gaps in vaccination programs could have long lasting drastic effects. the gpei has recommended the countries to postpone the vaccination programmed until the second half of the , taking the decision in deep regret by knowing that as a result of delaying immunization plans, more of the children may get paralyzed by polio. postponing or pausing the routine vaccination campaigns for now seems to be the correct decision, given the urge to avoid further transmission of covid- . however, the fear is that having won the fight against the novel threat basically exhausted and overburdened the health-care sector which could be inundated with other infections especially polio cases. in accordance with who, past outbreaks have clearly showed that when the health-care sectors are overwhelmed, mortality from vaccine preventable and other treatable diseases also increase drastically. in fact, during the e ebola outbreak, majority of the deaths caused by malaria, measles, aids, tb and polio, and these deaths exceeded from the deaths due to ebola. given the complexity of the issue, the health-care authorities do need to prioritize the fight against covid- , they must try to mitigate the effect of older diseases reappearing. there is an urge to resume the polio vaccination campaign to aid protecting children's lives in outbreak. similar to the climate crises, the covid- pandemic could be regarded as a child-rights crisis because it will have life-threatening impact over all the children, who need immunization, now and in long-term. therefore, the health-care authorities must intensify the efforts to track the unvaccinated children so that most susceptible populations such as pakistan, can be supplied with the polio vaccines as soon as possible. otherwise, the impact could span the generations and even borders. public health j o u r n a l h o me p a g e : w w w . e l s e v i e r . c o m/ l o ca t e / p u h e polio cases in provinces efforts to eradicate polio virus in pakistan and afghanistan ebola virus disease outbreak in west africa key: cord- - uzk pi authors: soriano, joan b. title: humanistic epidemiology: love in the time of cholera, covid- and other outbreaks date: - - journal: eur j epidemiol doi: . /s - - -y sha: doc_id: cord_uid: uzk pi nan colombian nobel prize awardee author gabriel garcía márquez, suffered cholera and many bouts of malaria during his life. in love in the time of cholera, one of many masterpieces by him, he wrote that persistence (and handwashing!) were rewarded with love after a life of living with countless cholera outbreaks. i am a respiratory epidemiologist; and literally, at the peak of the covid- pandemic, we are now being bombarded with descriptive epidemiology statistics and standard, cold figures: "as of today the death toll of covid- worldwide is , "; "the peak resource use of respirators and icu rooms in the usa is expected on april , …", and counting. in the distant past, there have been devastating epidemics of infectious disease, such as cholera, the flu (wrongly called spanish), the plague's black death,… other more recent outbreaks like sars, mers or ebola were considered exotic, faraway occurrences. yet we were not ready for this one. and at the least for the last four generations, we are now living unprecedented times. no one, even in the wildest nightmares of any hollywood-based science fiction screenwriter, would have anticipated that would have started with such drama and suffering. when we were raising our glasses and toasting on new year's eve for a happy , few were aware of a safety alert reported that morning in wuhan, hubei province, china due to a cluster of pneumonia cases of unknown etiology [ ] . it took only days, on january , , for china's cdc to report that a novel coronavirus was the causative agent of that local outbreak. as for good and for bad, all is globally interconnected, that minute incident in china is the reason why we live in lockdown, basic civil liberties are limited, many deaths and suffering, and locally my hospital being near collapse. hospital de la princesa, an old -bed, tertiary hospital in downtown madrid, spain, had its d day on march , , when a total covid- patients were admitted, and + more patients were in the emergency room, impatiently waiting to be admitted [ ] . many twopatient rooms already had three, even four occupants. our petite, modern icu room with beds had to be stretched to beds, by invading two surgical theatres turned to critical care, as well as the entire psychiatric ward. mirroring ancient times, all mentally ill patients, including those with active, severe paranoid schizophrenia or major depression, were sent home with their relatives to make room for others requiring invasive mechanical ventilations, mostly with improvised ventilators, or by reusing disposable ones, or duplicating machines with home-made technology. even friends who have been veteran volunteers with médecins sans frontières in syria's civil war, or at sierra leone's ebola zone, were not ready. using military terminology, la princesa was a war-time hospital in the front line; my respiratory department with thirteen staff plus eight residents, suffered eleven "casualties", counting quarantines plus infections plus one admission with severe, bilateral pneumonia. but other madrid hospitals were hit even harder; colleagues at hospital la paz or gregorio marañón, were suffering an even worse avalanche of patients to care for. all like a modern hecatombe, literally from the ancient greek ἑκατόν, hekatón, "one hundred" and βοῦς, boũs, "ox", a religious sacrifice of a hundred oxen to indicate a great catastrophe with great mortality, or the end of the world. we are still facing a cruel disease and global epidemic, both of biblical proportions [ ] . it is still severely and seriously affecting our old ones and others with heart, lung and other chronic diseases. but not only them. several colleagues of mine, young, completely healthy, even athletic, have been admitted into the same ward where the previous day they we still don't know whether an immunological, genetic factor, a combination of risk factors, or serendipity make this little rna virus collapse your bronchi and lungs with a thick "snail snot or slime" and accompanied with an inflammatory outburst killing some perfectly healthy lungs. as dr landete was explaining to junior residents in the morning clinical round: "-this is the first time that i have seen the occurrence of acute sudden respiratory distress syndrome (ards) in front of my eyes. in the emergency room i was examining a walk-in yr-old, female patient with temperature, malaise and a dry cough, and within min, i had to call an ent colleague to intubate this patient, as she had developed the fastest, quickest ards i've ever seen". even after all their greatest efforts and in the best hands, they could not save her. it is indeed a nasty little bug [ ] . however, there is always hope, and as seen in great literature, times of crisis bring out the best in us. to date, i have seen residents choosing to stay longer after finishing a -h duty to try and save one more critically ill patient; auxiliary nurses improvising aprons and boots with trash bags, who, on finally receiving their space suits, posed for posterity like a football team, always with a ready smile (fig. ) ; residents in neurology, immunology or pathology becoming chest medicine residents; medical students volunteering to learn the practicalities of lung mechanics and gas exchange; a department head creating a blog aimed at praising individuals for outstanding bravery and commitment; or i have been privileged to lead a small think tank including nurses, doctors, physicists, engineers and other friends who from saturday march have met on a daily basis to brainstorm initiatives by videoconference at am, just before seeing patients or awakening their families. many of the above have been living for weeks in hotels next to our hospital, extremely and severely sleep deprived for a month already (fig. ) . our hospital administrators recommended all staff not to take weekends off until further notice. no one disagreed, trade unions included, out of a + headcount. and this has been going on for nearly a month. again, all always with a ready smile. this is the so-called, espíritu de la princesa. myself, a humble respiratory epidemiologist that has dedicated his professional life to research on copd, asthma and tobacco had to go back to the textbooks and online resources for a fast-track, hands-on crash course on outbreaks research, counting the number of deaths, infected cases, r infectivity, and the like [ ] . that was the easy part. realizing that behind every case there was a personal tragedy, a family loss, slowly broke my heart and my lungs. so many people dying alone in elderly homes and residences, without medical care, without any care. i imagine not even anyone holding their hands. calling for the sake of hygiene and competing priority, no one available to say a prayer while they were buried or cremated, alone. it will take time to accept this sad passing away, a cruel ending for many. we must live in this planet, there is no other earth or planet/plan b. and we have observed that air pollution and planetary health can be improved within weeks, with concerted individual and societal efforts [ ] . children confined at home for weeks already, have appreciated playing with their brothers and sisters, or talking with neighbors across the balconies; even remotely with their school friends and teachers. they should be the first to end confinement. and we need to learn the lessons from history. this is not our first epidemic. it is the toll we have to pay for living in society and in cities. if we were still collectors and hunters in the wild, no such thing would have happened. yet humans are emotional, social animals and beyond our species homo sapiens, scholars say we are of emotionalis subspecies. as human animals we are not meant to live alone, or die alone, or in solitude. i have no doubt that when this crisis is over, and i am positive it will be over soon, music, theatre, movies, literature and the arts in general, will help to restore balance, and make us all wiser, better persons. the so-called move from omics to humanomics [ ] . beyond modern, ever more technical and robotized medicine, medical humanism in the twenty-first century is to be more important than ever [ ] . as pangloss, candide's optimistic teacher in voltaire's masterpiece, said: "everything happens for a reason". pangloss chants over and over: "… all is for the best in the best of all possible worlds" while candide leads an outrageous life illustrating that it is patently false. but we have no room for pessimism. i remember reading essay on blindness by the portuguese author josé saramago; happily, the panic and selfishness in his outbreak of sudden blindness only occurred in his literature. let's only imagine if gabo's inspiration were by nowadays covid- pandemic, and his love in the time of cholera, were rewritten. or la peste by french novelist albert camus who, at the premature age of died in a car accident near sens. camus, not wearing a safety belt in the passenger seat, died instantly. but, what a life! la peste tells the story of a plague sweeping the french algerian city of oran. nevertheless. it is not a medical book, but about human passions during and after an outbreak. can't wait to re-read it. in all of these books, and other, health personnel have been rightfully characterized and praised as heroes and martyrs. yet, last but certainly not least, i wish to make a call to remember the crucial role played by our nonhealth related hospital staff. thoroughly well-deservedly nurses and doctors are credited since they must frequently and harshly endure the pains of covid- . however, their work would all be a lost effort without the cleaning personnel, wardens, cooks and cafeteria caterers, administrative workers, security forces, lab technicians, and other hospital-based job groups. they suffer this modern plague equally, often without protection, mostly without recognition, but always proudly; working / , weekends included, and again always with a ready smile. these critical workers should be praised and acknowledged equally since, with no cleaners and cooks, our hospitals would instantly collapse. as this is neither the last outbreak, and with all likelihood nor "the" last big one, we need to learn one more lesson from the past. in the future, let's never again take for granted those simple things that during confinement we have suddenly seen as precious: a bear hug, a slap on the back and, of course, a ready smile without a face mask. i have no doubt that medical humanism and the arts are already helping; and they will help us to learn to take better care of our patients, our loved ones, and ourselves. jb soriano, md. madrid, april , . emergencies preparedness, response. pneumonia of unknown cause-china situación de covid- en españa offline: covid- -what countries must do now a novel coronavirus from patients with pneumonia in china in snow's footsteps: commentary on shoe-leather and applied epidemiology the report of the lancet countdown on health and climate change: ensuring that the health of a child the need for humanomics in the era of genomics and the challenge of chronic disease management opening editorial-the importance of the humanities in medical education conflict of interest there are no conflicts of interest or competing interests to report. key: cord- - mlbup i authors: lakhdar, fayçal; benzagmout, mohammed title: letter: neurosurgery at war with the covid- pandemic: patient’s management from an african neurosurgical center date: - - journal: acta neurochir (wien) doi: . /s - - - sha: doc_id: cord_uid: mlbup i nan dear editor, we read with interest the lombardy's experience published by zoia et al. [ ] , describing the taken procedures in neurosurgery department and their main recommendations. coronavirus disease (covid- ) is an extremely infectious and life-threatening viral illness that gave rise to the current pandemic; an overwhelming healthcare crisis putting the healthcare system under huge strain. covid- outbreak has also brought along disastrous socio-economic effects and heavily impacted healthcare activities including our neurosurgical field [ ] [ ] [ ] [ ] . the whole world is facing this challenge which necessitates the engagement of all physicians, including neurosurgeons, to deal with covid- outcomes [ , ] . in morocco, the first case of covid- was reported on march , ; since then, the virus has spread exponentially. despite the lack of resources and the incapacity of our healthcare system to contain the influx of patients, we managed to implement certain strategies enabling us to optimize healthcare provided to our neurosurgical patients and to minimize the risks health care providers are exposed to. the goals were to educate patients and caregivers about covid- and to ensure safety of the neurosurgery staff. for such and based on our experience, we suggest certain measures concerning surgical scheduling, neurosurgical activity, and residents' education to be adopted as institutional policy which may vary between institutions and regions. in order to limit the spread of the virus, hospitals restricted access to entrance, reduced visitors' numbers, and limited all unnecessary human interactions. social distancing for all group-based activities was required and videoconferencing platforms were used for clinical and administrative meetings [ ] . besides, a local monitoring committee was formed and has been in direct daily contact with the central committee responsible for the national management of covid- pandemic at the ministry of health. seeing the rapid worsening of the situation, hospitals' health care administrators had to profoundly reorganize the whole hospital and convert many wards, including the neurosurgery to covid- care units. special circuits were created for covid- patients and many medical specialties and staff were transformed into covid teams after a rapid training. hospitalized patients with stable condition waiting for scheduled surgeries were gradually discharged and all hospitalizations for elective surgical procedures were suspended. consequently, % of the neurosurgical staff had been assigned to the covid- units by march , . altogether, the number of neurosurgical departments in the whole country was reduced and their activity was restricted to emergencies and critically ill patients. academic neurosurgery departments have to manage, in addition to urgent and emergent neurosurgical cases, public health concerns regarding disease transmission, and the safety of department staff. for emergent and urgent cases, a covid- swab was routinely carried out, and surgical operations were performed under strict precautions to minimize exposure to the virus. the neurosurgical covid team (a professor and residents) reviews patient's history, shares radiological findings via mails or telecommunication, and mostly makes decisions for urgent surgical cases. in the operation room, all staff members were required to protect themselves with double surgical gloves and gowns, to decrease the speed of drilling (when needed) to reduce skull bone aerosols, to use dissolvable sutures to minimize patient's return to hospital, and to shorten the operation duration. endonasal skull base procedures were postponed whenever possible given the high viral load in the nose and nasopharynx. furthermore, all postoperative patients were discharged earlier by the first postoperative day, and quarantined in hotels for at least weeks. we have also deferred or virtualized all unnecessary outpatient visits. in this period, we have noticed a drastic reduction in the neurosurgical emergencies compared with what we usually have. routinely, we have an average of three patients to operate in emergency every day. however, only six urgent operations (two chronic subdural hematomas, two decompressive craniotomies, one ventriculoperitoneal shunt, and one posttraumatic spinal fracture) were performed during the last weeks ( march to april ). this decreased activity could be explained by the public "lockdown" and the reduction of road traffic accidents inducing cranial/spinal trauma. however, the fear of contamination might explain the decrease of other emergencies, particularly tumors and vascular diseases. we believe that the current covid- health crisis will have collateral damages related to the delay of consultation, the inability to early diagnose some malignant diseases, and the possible outbreak after return of people to normal activity. this war against covid- has allowed us to identify many gaps and malfunctioning structures in our health care system, and oriented our thinking towards new ways of directing human resources and a new model of health development where technology, efficiency, and safety prevail. nevertheless, some questions remain suspended. how can the neurosurgical community be better prepared for a possible second pandemic? how to smoothly integrate neurosurgeon's work into other specialties work? and if the new generation of communication technology proves their safety and efficiency, why not make it part of routine work? to conclude, all neurosurgical patients presenting respiratory signs and/or neurological manifestations suspicious of covid- should be screened for coronavirus. besides, additional precautions should be taken henceforth in endoscopic endonasal surgeries. conflict of interest the authors declare that they have no conflict of interest. letter: the coronavirus disease global pandemic: a neurosurgical treatment algorithm editorial. neurosurgery in the storm of covid- : suggestions from the lombardy region, italy (ex malobonum) letter to the editor by dobran mauro, paracino riccardo, and iacoangeli maurizio regarding neurosurgery during the covid- pandemic: update from lombardy, northern italy the impact of covid- on neurosurgeons and the strategy for triaging non-emergent operations: a global neurosurgery study introduction. on pandemics: the impact of covid- on the practice of neurosurgery letter: neurosurgery and coronavirus (covid- ) epidemic: doing our part response to covid- in chinese neurosurgery and beyond neurosurgery during the covid- pandemic: update from lombardy, northern italy publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord- - wnvuk n authors: wichlas, f.; hofmann, v.; strada, g.; deininger, c. title: war surgery in afghanistan: a model for mass causalities in terror attacks? date: - - journal: int orthop doi: . /s - - - sha: doc_id: cord_uid: wnvuk n purpose: the aim of the study was to identify solution strategies from a non-governmental (ngo) hospital in a war region for violence-related injuries and to show how high-income countries (hic) might benefit from this expertise. methods: ngo trauma hospital in lashkar gah, afghanistan. four hundred eighty-four war victims admitted in a three month period (february –may ) were included. patients´ characteristics were analyzed. results: the mean age was . years. four hundred thirty-four ( . %) were male, and ( . %) were female. the most common cause of injury was bullet injuries, shell injuries, and mine injuries. the most common injured body region was the lower extremity, upper extremity, and the chest or the face. apart from surgical wound care and debridements, which were performed on every wound in the operation theatre, laparotomy was the most common surgical procedure, followed by installation of a chest drainage and amputation. conclusion: the surgical expertise and clear pathways outweigh modern infrastructure. in case of a mass casualty incident, fast decision-making with basic diagnostic means in order to take rapid measurements for life-saving therapies could make the difference. electronic supplementary material: the online version of this article ( . /s - - - ) contains supplementary material, which is available to authorized users. medical care in low-income countries (lic) differs a from western medical standards [ ] . compared with civilian trauma in lic, which is mainly caused by road traffic accidents, the injuries in war zones present different patterns with numerous wounds caused by bullets, mines, and bombs [ , ] . in high-income countries (hic), the surgical training focuses early on a specialty. this leads to high knowledge in a very narrow surgical field but a lack of broad general surgical experience [ ] [ ] [ ] . the lack of surgical experience might not be relevant as long as a hospital provides a specialist for every probable pathology, but in cases of a sudden high volume of causalities like in a terror attack or train accident, adequate treatment of the injured could get difficult [ , ] . in this setting, a specialist for every injured region in one patient would deplete human resources. besides fast surgery in mass casualties, patients' flow needs to be efficient, both in speed and direction. the in-hospital pathways must be clear for the personnel from the moment the patient enters the hospital to the final destination [ ] . as much as medical standards in lic and war zones lag behind, there might be a potential knowledge of primary injury treatment and basic surgical techniques, expectable injury patterns, and experience in dealing with mass causalities by fast decision-making. a hospital in a war region has limited resources and needs to cope with a high constant and sudden patient inflow. the surgeons in these hospitals would have an incomparable amount of experience in treating war injuries. the question is, if this knowledge can be helpful when an unexpected incident like a terror attack happens in a "developed hic" country. the aim of the study was to identify possible solution strategies from a non-governmental (ngo) hospital in a war region, in lashkar gah, afghanistan. for this purpose, we analyzed the hospital resources, its management strategies, and the epidemiology of war injuries and their treatments. useful pathways and surgical skills for hic should be determined to help cope with mass casualties and terror injuries. the hypothesis was that, when a hospital with limited resources could treat a high amount of war injuries, the important factors must lie somewhere else than on the resources. a solution strategy for hic might be to develop a guideline for fast decision-making with the simplest diagnostic means in order to treat first what kills first with the quickest and safest treatment option available. the ngo hospital is equipped with beds, six intensive care unit (icu) beds without ventilator, two operation theatres (ot), and one outpatient department (opd). besides the six wards, there was a room for physiotherapy and casting. the ot have swing doors and are placed near the opd (short ways). although the ot is clean, the hygienic level is very basic compared with western standards. intra-operative x-ray control is difficult but feasible. the hospitals x-ray machine is analogue and no ct is available. in total, four junior and four trauma senior surgeons were in charge; during on calls one junior and one senior surgeon were present. besides the surgeons, the medical staff had a questionable education concerning medical health college or even school. they are mainly directly instructed at the hospital and have very specifically defined duties. anaesthesia is performed by "anesthiologic technicians" trained by international aestheticians, they are not anaesthetists. the international team was a general surgeon, an orthopaedic/trauma surgeon (the author), and an anesthesiologist. logistics and teaching nurses were provided by the ngo. among admitted patients were war victims, civilian trauma victims younger than years old, and patients in lifethreatening condition of any sort. patients with chronic posttraumatic deformities were not admitted [ ]. the triage and management of injured patients were done by opd nurses. the standardized procedure consisted of the measurement of heart rate, blood pressure, oxygen saturation, and the clinical examination after undressing and cleaning the patient. two intravenous lines were inserted, and blood samples for laboratory analysis were taken. fluid resuscitation was usually done with l ringer's lactate. packed red blood cells were available. the national surgeon completed diagnostics by clinical examination, auscultation of chest and abdomen, and seldom ordering an x-ray. subsequently the patients went for operation without any delay. in the ot, the patient was draped and intubated for surgery by the local staff before the surgeon could even scrub entirely. the patients flow was clearly defined from opd to ot and then to the ward or icu for minor and life-threatening injuries. it was performed very fast by the local staff for both. surgery and treatment of war wounded was performed according war surgery guidelines [ ] . data for evaluation was collected from . . to . . . in this days period, patients were admitted to the hospital, ( . %) war victims, ( . %) children that had sustained falls or road traffic accidents, and ( . %) patients of miscellaneous, life-threatening injuries. patients mean age was . years, most of them were male (table ) . for this study, only war victims were evaluated (n = ). the mean age of war casualties was . years; ( . %) were male, and ( . %) were female. the injuries were analyzed for the cause of injury, the region injured, for the surgical procedures performed, and the death rate. of all patients, were readmitted for planned surgery, and four were readmitted twice. planned suregry was mostly delayed primary closures. all regions of the body were affected: skull, face, eye, neck, chest, abdomen, back, flank, buttock, pelvis, genitourinary, spine, upper extremities (ue), and lower extremities (le). the most common cause of injuries were bullet injuries (bi) n = ( . %) followed by shell injuries (si) n = ( . %), mine injuries (mi) n = ( . %), and stab wounds (sw) n = ( . %). the most common injured body region was the le followed by the ue and the chest or the face. an overview dealing with the cause and the affected body region can be seen in fig. and table . a surgical wound debridement was performed on every patient that got operated upon. all war wounds were left open at the primary operation and planned for delayed primary closure five days later [ ] . no wound dressing was made before that fifth day in the operation room, except there was a high suspicion for infection. if the health condition allowed, the patient was discharged and readmitted for delayed primary closure. in case of clean stab wounds, they were closed primarily after debridement. the second most common specific surgical procedure performed was the laparotomy n = ( . %) (additional revision operations) followed by installation of a chest drainage n = ( . %) and amputation n = ( . %). two hundred fifteen war injuries underwent further surgical procedures. in average . operations were performed and . war injured were admitted per day. taking into account the fact that all wounds have been debrided in the operation theatre, the average number of surgical procedures increases to . per day. broken down into injured body regions: after bi the most common operation was the laparotomy n = ( . %) followed by installation of a chest drainage n = ( . %) and vascular reconstruction/craniotomy n = ( . %). after si the most common operation was the laparotomy n = ( . %) followed by installation of a chest drainage n = ( . %) and vascular reconstruction n = ( . %). after mi the most common operation was the amputation n = ( . %) followed by installation of a chest drainage n = ( . %) and laparotomy n = ( . %). after sw the most common operation was the laparotomy n = ( . %) followed by chest drainage/amputation/vascular reconstruction n = ( . %). an overview over the cause of injury and the surgical procedures performed can be seen in fig. and table . in cases ( . %), the injuries were located on both sides of the body. the percentage was maximal for mi ( . %), followed by si ( . %) and bi ( . %). analyzing the primary laparotomies, the most often injured intra-abdominal organ found was the bowel ( . %) followed by the liver ( . %) and the diaphragm ( . %). a laparotomy was performed on all perforating abdominal injuries. seven of these diagnostic laparotomies were negative. in bi and si, the bowel was injured the most, followed by the diaphragm. third most common injured organs were the liver and kidney for bi and liver and spleen for si. concerning the abdomen, mines injured the bowel only. accordingly, the most frequently performed procedures were bowel-related (direct repairs . %, anastomosis in total, n = ( . %) patients died in the hospital; these were out of bi patients ( . %), one out of si patients ( . %), one out of mi patients ( . %), and one out of sw patients ( . %). trauma surgery in a war zone such as lashkar gah differs from trauma surgery in a hic. thus, there is a lot of knowledge to benefit from, especially when dealing with uncommon injuries and mass causalities [ ] . in this -beds-hospital, this amount equals . % of the overall capacity. this becomes even more impressive, regarding the fact that with exception of the surgeons, the medical personnel was trained in the hospital only, with no pre-existing medical education. it seems that standardized pathways can compensate the lack of medical education and are crucial in the treatment of high patient's inflow. according to lesaffre et al., who analyzed the terror attacks in paris , a "…simpler and more robust organization…" is one of the most significant factors to deal with a mass casualty incident [ ] . during the paris terror in , wounded and dead victims were counted. one hundred twenty-four before reaching a hospital. this day, about firefighters trained in first aid were on call. many of the parisian firefighters are accommodated in fire stations and thus quickly accessible. in case of a terror attack, the severely injured patient may not reach a level trauma centre, but a primary health care institution. this was the case in % of the absolute emergencies in paris . this fact underlines the need of a profound training in life-saving skills of every doctor in charge [ ] . in those cases, necessary diagnostic procedures should be kept simple and focused on life-threatening injuries to assure a quick life-saving treatment. they include a fast but thorough clinical examination of the undressed patient, measurement of heart rate, blood pressure, and oxygen saturation, insertion of two large bore intravenous lines, taking blood samples, and radiography only if necessary. all these steps stick to a well-defined simple pathway. after diagnosing, a fast treatment without delay is essential. besides fast and thorough wound debridement, this means mostly performing laparotomies, inserting chest tubes and amputations. these skills are crucial to save the patient's life [ , ] . they are also providing the basis for western surgeons dealing with an enormous number of casualties by a terror attack or a mass catastrophe [ , ] . the speed factor is essential, not only for the patient treated momentarily, but for the next severely injured patients waiting for treatment. surgical skills needed include vessel repairs, craniotomies, and thoracotomies. the war surgeon needs to combine techniques from different surgical fields such as maxilla-facial, plastic, abdominal, orthopedic, and neurosurgery [ , ] . in lashkar gah, specialist surgical care was needed for eye related procedures. these patients were sent to kabul. although war surgery's spectrum is broad, surgeons have to deal with two main trauma mechanisms. most of the injuries are caused by penetrating high velocity projectiles of any sort (bi and si) or by blasts and burns from explosives like bombs or mines (si and mi) [ ] . even though resources in western countries might be superior to ngo hospitals in lic, critical incidents like terror attacks will overwhelm local resources [ ] . as a solution, mass casualty protocols have been created to assure a proper medical health care even in situations with more than severely injured [ , ] . besides these in-hospital pathways, surgical skills need to be trained as well. teaching of life-saving procedures, compulsory for every surgeon in training might be helpful [ , ] , table but they hardly match the surgeons expertise gained through high patient turnover. but not every patient is "in extremis." wound debridements, simple laparotomies, insertion of chest tubes, and vessel repairs are probably the majority of cases and need to be achieved as fast as possible. treatment pathways and surgical skills are the main characteristics of the lashkar gah hospital for civilian war victims. although medical education was not available for most of the personnel and the hospital is very basic, it could cope with a high number of patients. training, surgical skills, and clear pathways did lead to reliable, appropriate, and rapid treatment of the seriously injured, even with a large proportion of staff who have not received any official medical training. the mission period was restricted to three months, and the data collected only reflect this period. due to the limited documentation in a war zone, a further evaluation of long-term follow-up was not possible. however, the necessity to prepare for an extremely seldom incident, such as a terror attack, can be discussed. although medial impact is increasing, death due to terrorism has decreased over the last years [ ] . further, the data published from these incidents showed good coping strategies of the treating hospitals, even without specific preparation [ ] . nevertheless, the determined characteristics could be useful for polytraumatized patients. in these cases, fast treating algorithms and surgical manoeuvres are essential [ ] . summarizing, the knowledge of any anatomic region and the ability to perform fast surgery make the war surgeon unique. speed is essential in surgery and treatment pathways. those special abilities can provide a basis for surgeons working in hic who are confronted with a mass casualty incident like a terror attack. the lesson learned from lashkar gah for terror surgery in europe: & surgeons must be trained in war surgery performing thorough debridements, laparotomies, chest tube insertions, vessel repair, and craniotomies. & treatment pathways must be trained by the hospitals' staff. & the hospitals´resources are of minor importance. authors' contributions all authors have contributed substantially and sufficiently in the conception, design, acquisition, analysis, and interpretation of the data. funding open access funding provided by paracelsus medical university. conflict of interest nothing to declare. ethics approval due to the study setting in a war zone, no ethics approval was obtained because of a lack of ethical committee in afghanistan. availability of data and material all data gathered including x-rays can be requested from the authors. open access this article is licensed under a creative commons attribution . international license, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the creative commons licence, and indicate if changes were made. the images or other third party material in this article are included in the article's creative commons licence, unless indicated otherwise in a credit line to the material. if material is not included in the article's creative commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. to view a copy of this licence, visit http://creativecommons.org/licenses/by/ . /. impact of surgical lighting on intraoperative safety in low-resource settings: a cross-sectional survey of surgical providers characteristics of the injuries of syrian refugees sustained during the civil war pedestrian injuries in the most densely populated city in nigeria-an epidemic calling for control are american surgical residents prepared for humanitarian deployment?: a comparative analysis of resident and humanitarian case logs general surgery education across three continents preparing japanese surgeons for potential mass casualty situations will require innovative and systematic programs disaster planning. in: statpearls humanitarian missions and surgical training remote damage control during the attacks on paris: lessons learned by the paris fire brigade and evolutions in the rescue system war surgery: working with limited resources in armed conflict and other situations of violence, by christos giannou and marco baldan the role of humanitarian missions in modern surgical training abdominal trauma surgery during recent u.s. combat operations from - saving life and limb: limb salvage using external fixation, a multi-centre review of orthopaedic surgical activities in medecins sans frontieres approach to liver, spleen and pancreatic injuries including damage control surgery of terrorist attacks outcome of craniocerebral penetrating injuries: experience from the syrian war a terrible future: episodic future thinking and the perceived risk of terrorism back to basics: mass casualty incidents preclinical and intrahospital management of mass casualties and terrorist incidents terrorist stabbings-distinctive characteristics and how to prepare for them global terrorism index publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations key: cord- -xpa sxt authors: mcfee, robin b. title: gulf war servicemen and servicewomen: the long road home and the role of health care professionals to enhance the troops' health and healing date: - - journal: disease-a-month doi: . /j.disamonth. . . sha: doc_id: cord_uid: xpa sxt nan become more familiar with these illnesses such as malaria, leishmaniasis, brucellosis, and others given the likelihood our returning troops may be so infected and requiring timely diagnosis and appropriate treatment. , , , , , , , the roles of women in the military have changed. , , , unlike in prior wars, there are significant numbers of women in all military branches of service deployed overseas and in combat theaters, performing a wide array of operating specialties beyond medical and communications. although women have typically been assigned to activities that were not considered direct combat roles during times of war, albeit females have done dangerous jobs including being pilots during world war ii to the present, in the current war in the persian gulf, the distinction between combat and noncombat roles have become almost meaningless given adversaries do not wear uniforms, and confrontation has become urban warfare using guerilla tactics against any us troop, convoy, or post regardless of military designation. as such, women, thought to be in "safer" roles such as convoy drivers, find themselves in the "front lines" facing ied and other weapons just like their male counterparts. in addition to combat-related injuries and the stressors of war, women face discrimination and many are at risk for sexual abuse, victimization, and assault, often from servicemen. , , , of note, male servicemen have reported sexual abuse. nevertheless, women in the persian gulf face a complex array of biopsychosocial stressors not necessarily faced by their male counterparts. these new threats can pose significant challenges to female military, warranting the attention of civilian and military medical professionals. from substance abuse, combat, infections, sexual abuse, and mental illness, troops about to be deployed to or returning from the persian gulf, as well as their families, face potentially significant medical, psychological and financial challenges. , [ ] [ ] [ ] , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] in an era of limited surge capacity, the complex needs of our returning troops will require civilian health care professionals (hcp) to provide much of the care and fill looming voids. physicians and other clinical hcp have long been taught that one of the keys to evaluating and effectively treating a patient is having an appropriate framework or pathway for diagnosing, and treating, which includes referral to specialist care, and follow-up. context is critical and no less so for our patients who are about to leave for or return from the persian gulf war. these patients face enormous threats and are at risk for a complex array of biomedical and psychosocial morbidities, some of which may go undiagnosed and impair the patient's return to normal social function. beyond devastating wounds, the sometimes more subtle injury-tbi, which is becoming a significant and important pattern of injury in the current pgw, tbi can negatively impact social and work functions. , , , , , [ ] [ ] [ ] posttraumatic stress disorder (ptsd), tbi, and other biopsychosocial injuries may be contributing to the worrisome rate of homelessness that is afflicting returning pgw ii troops. , , given our goal as hcp should be to facilitate the returning servicemember's ability to reenter society and to function in daily life, learning about the threats they faced, the medical issues requiring care, and the resources they will need is essential. taking the time to obtain a thorough history is critical to assessing the symptoms and ultimately making the correct diagnosis. a comprehensive physical examination can help the hcp, given many biomedical exposures or injuries, such as tbi, present with symptoms similar to psychiatric illnesses like ptsd. patients may have both-yet each require highly specialized care and long-term follow-up. civilian medical resources are often untrained in the nuances of military care. the following monograph describes and discusses many of the challenges our persian gulf troops will face in the hope it will better prepare civilian health care professionals provide appropriate services, address gaps in resources, promote collaboration between biomedical and psychosocial professional disciplines, and ultimately assist our patients to successfully reenter society. war, adolescents, and the middle east (figs and ) "never in the field of human conflict was so much owed by so many to so few."-winston churchill these words were uttered by prime minister churchill at parliament in tribute to the pilots of the royal air force (raf); an iconic speech in its historical significance and, perhaps cautionary or prescient in wisdom. many of those raf pilots were adolescents, frighteningly outnumbered by the luftwaffe, but were nonetheless, able to protect great britain and defeat the nazis. the fate of the world often rests on the shoulders of our youth. the cause of freedom often depends upon our younger generations. indeed, throughout history, awesome responsibilities have been placed on adolescents. many of the servicemen and servicewomen participating in operation iraqi freedom (oif) and operation enduring freedom (oef) are between the ages of and ; adolescents by medical definition. , such incredible responsibilities undertaken far from home, while experiencing new and vastly different cultures, and being subjected to dangers and violence on a scale beyond comprehension, are the reality of these warrior-adolescents. no one could debate the horrors these young people see on a daily basis, nor the impact-physical, psychological, and social-that they face on their tours of duty and will continue to cope with upon their safe return, god willing, to the united states, great britain, or other coalition nation. they age from adolescent to adult in the first battle. yet they are still adolescents. when they return, we must adapt the health care we deliver to address this hybrid of battle-tested adolescent-adult, addressing the full realm of needs and helping this individual to be able to return to some developmentally appropriate normalcy. [ ] [ ] [ ] the major spheres of influence of an adolescent must be addressed and restored-family, friends, career, close relationships, personal development, health behaviors. [ ] [ ] [ ] however, adolescents are not the only ones who fight wars. adultssingle, married, parents, male, and female. most of us imagine the return home to be joyous and fulfilling, will it be if someone has been wounded? , , , , , , [ ] [ ] [ ] or if someone has lost their job? or has lost the loved one who was supposed to be waiting at home? or meeting children who in return are facing a stranger because they were babies when dad (or mom) deployed? what readjustments will those returning face that we can assist as their health care provider? , while ptsd is expected, so should substance abuse. tobacco use among troops is highly prevalent. often they smoke non-u.s. cigarettes; what health risks beyond the norm would be expected from smoking local tobacco products? do our communities have the resources for returning troops? the veterans administration (va) cannot and will not take care of all the returning troops. what can we do as physicians to fill the voids? the role of the physician has and should always be, in its noblest form, both healer and patient advocate. in our daily practices delivering high-quality health care can be a challenge in the midst of a seemingly dizzying array of insurance plans, financial and time constraints, and a host of other competing issues that impact upon access, cost, and quality. the most dedicated clinicians often aide their patients in fighting for coverage, care approvals, or access to medications even when "the system" seems stacked against the patient. now imagine an adolescent who has returned from battle, having seen the horrors of war, only to find his or her job has not been preserved, or medical care-physical or psychological-is beyond reach because of either cost, access, or quality? it is challenging enough for adults with good jobs and years of life experience to often obtain appropriate care; think about the returning soldier, sailor, or marine returning from a war zone! we often consider medical care of the military to be the responsibility of military facilities like the va hospitals, base infirmaries, and the department of defense (dod) manage care support contract (tricare). yet over one-third or our military in the persian gulf are reservists, not full-time active duty military. these are our neighbors, coworkers, and fellow citizens who thus obtain their health care from the nonmilitary medical worldprobably us! as such, they are likely to return to our practices when they come home from war. how many of us in health care have been in the military or in a war zone? yet we will be called upon to help our patients come to grips with such experiences. moreover, how familiar are we with the many challenges these people will face-interacting in a "peaceful" society, returning to work "business as usual," receiving appropriate psychosocial and medical care attuned to the risks and threats of living in the middle east or other far off lands? as of april there were over . million active duty men and women in the u.s. armed services and over . million reservists. , , almost % are women across the various services, with the highest percentages in the air force, navy, and army. there are over , u.s. troops in the persian gulf-most are in iraq but there are thousands in afghanistan, kuwait, bahrain, turkey, and other countries in the middle east. most of the troops are men. however there are a significant number of women serving in uniform as well. while women are generally not assigned direct combat missions, the nature of the urban or guerilla warfare in iraq, especially, brings the battle to posts and roles not designated as combat operations. nevertheless, the carnage is real; so are the injuries-mental and physical. women serving in the gulf as elsewhere must deal disproportionately with sexual abuse and gender discrimination within the u.s. military and often make accommodations to local cultural customs discriminatory against women that these servicewomen would not face in the u.s. the military operations in afghanistan and iraq represent the largest and most sustained ground combat involving u.s. armed forces since vietnam. unlike world war i and ii, where large forces engaged each other, in uniform and en masse, the modern wars our troops face employ guerrilla warfare tactics using surreptitiously deployed weapons that include the omnipresent roadside ieds and combat against enemies that do not wear a uniform and can be indistinguishable from the majority of the civilian population. in addition, some of the troops have had multiple tours of duty. the likelihood of surviving wounds that in prior wars would have been fatal sets the stage for troops seeing and possibly experiencing horrific wounds, scarring, burns, blindness, or multiple amputations. , , , this type of warfare sets the stage for increased medical and psychological illnesses including ptsd, depression, and substance abuse. unlike previous wars where the number of deaths mirrored closely the number of wounded, improved battlefield medicine has allowed seriously wounded troops to survive, albeit with loss of limbs or multiple limbs. are our practices attuned to the special needs of multiple-prosthetic amputees? how many patients with traumatic amputation have we treated? their needs go beyond stump maintenance-self image, ptsd, retraining for a career, and living with a lifelong disability will be essential components of the long-term care. in addition, there are numerous potential toxic and infectious exposures our troops face that are uncommon in the u.s. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] while the u.s. military may be sensitive to environmental toxicants, the local practices of developing nations may preclude such safety concerns. moreover, abandoned chemicals, the intermingling of pesticides, motor oils, and other potential toxicants can impact patients variably. are there health effects from depleted uranium and, if so, who do we contact? would we be able to identify intermediate syndrome? how would we approach oif/oef patients with diverse symptoms of unrecognized etiologies, and do we have appropriate resources such as a toxicology service? the desert region has numerous endemic illnesses ranging from parasites and bacteria, even unusual outbreaks of potentially deadly viruses. [ ] [ ] [ ] [ ] [ ] , , [ ] [ ] [ ] [ ] [ ] [ ] [ ] how many of us have seen a case of dengue or leishmaniasis except in a textbook or lecture? , , , , , or treated a case of q fever? , would we be able to differentiate the neurobehavioral effects of brucellosis from the symptoms of ptsd in a returning gulf warrior? , , , , [ ] [ ] [ ] [ ] [ ] how long should we be vigilant for signs and symptoms of malaria from a returning soldier who presents with fever? , most of the troops have folks at home who love, depend upon, and worry about them. what is the impact of the gulf war on families? , are we the health care provider to someone who has a son or daughter, husband or wife, brother or sister, close friend in uniform and in a war zone? what special needs do/will they have that we should anticipate and provide? these may include acts of kindness, not just biomedical care. a random call "how are you doing? have you heard from (the person in uniform)? need to talk? got a support network (friends, family, clergy)?" as physicians, we are in a trusted position to ask and a leadership position to try and help. these are times that call upon us to go beyond the mere medical care. yes, we all perform in an era of multiple competing demands. many of our colleagues may even be against the u.s. participation in the gulf. however, we should learn from the lessons of vietnam and separate our feelings about the war from those for the warrior-our patient. in the following sections we will discuss the changing nature of battlefield injuries and the impact on survivors and their families, the endemic illnesses of the persian gulf, approaches to ptsd and other threats to health, psychosocial issues, as well as emerging resources under development and yet to be realized for the care of our returning troops. military personnel receive medical care based upon a variety of factors often associated with their "status"-active or career military, reservist/national guard, retired, or veteran of a war. families are often included. of note, many receive their care from the civilian health care community owing to the fact a significant proportion of troops and their families are not active military but in fact drawn from reserve and national guard units. , [ ] [ ] [ ] [ ] [ ] , , many military families also receive their health care off base. lessons learned from gulf war i raise the question, will the va and domestic military health care facilities have the capacity to treat the complex and often highly specialized needs of all the returning troops? , , , , [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] military health care includes tricare/champus (civilian health and medical program of the uniformed services) and champva (civilian health and medical program of the department of veterans affairs), as well as care provided by the department of veterans affairs. , , tricare/champus. tricare or champus is a military health care program for active duty and retired members of the uniformed services, their families, and survivors and certain former spouses worldwide. as a component of the military health system, tricare brings together the health care resources of the uniformed services and supplements them with networks of civilian health care professionals, institutions, pharmacies, and suppliers to provide access to health care services while maintaining the capability to support military operations. to be eligible for tricare benefits, it is necessary to be registered in the defense enrollment eligibility reporting (deer) system. tricare offers several health plan options. currently there are about . million enrolled beneficiaries. military treatment facilities (mtf) available for tricare beneficiaries include military hospitals, medical clinics, and dental clinics. some civilian medical facilities and health care providers also accept tricare but not universally. in the event a va or mtf is not available to certain returning troops or their families, it is important to work in the community to assist with access to care, especially given the expected biomedical and psychosocial morbidities associated with the current gulf war. champva. champva is a medical program through which the department of veterans affairs helps pay the cost of medical services for eligible veterans, veterans' dependents, and survivors of veterans. veterans administration. the u.s. department of veterans affairs is responsible for providing a wide range of benefits to over million u.s veterans and their families. this includes the almost , u.s. men and women who served in the first gulf war build-up and combat from august to june . currently there are approximately va facilities, although the actual number of hospitals, medical sites, and clinics is much less. according to the va, a "medical facility" includes a va health system facility, va medical center, outpatient clinics, community-based outpatient clinics, and veterans' centers, the latter being a place for "counseling" for servicemember and his/her family. excluding these veterans' centers, there are approximately facilities where medical treatment can be obtained. major benefits provided by the va include health care and disability compensation for illnesses and injuries incurred on military service. the disability compensation includes monthly monetary distributions based upon the degree of disability for service-related injuries or diseases among veterans. a stipulation of benefits is the identification of health risks during military service. the demonstration of such risks can be straightforward such as battlefield wounds or contentious as continues to be seen by the gulf war i health effects controversy which will be discussed in the next section. gulf war syndrome. during the first gulf war of - (pgw i) nearly , u.s. troops were deployed to the persian gulf region. , , [ ] [ ] [ ] , , , , of concern, a significant proportion of these troops began presenting with a wide array of medical complaints in the years following the end of the war and their return to the u.s.-often referred to as gulf war syndrome (gws). gws is sometimes referred to as chronic multisystem illness (cmi). , over in u.s. veterans has sought federal health care and % of united kingdom gulf war veterans describe themselves as suffering from gws. , gw veterans' health problems began to emerge in the early s, often soon after their return to the u.s. [ ] [ ] [ ] [ ] [ ] [ ] [ ] , however the majority of research was not initiated until or later. [ ] [ ] [ ] moreover, many of the veterans' concerns and symptoms were invalidated or attributed to psychiatric illnesses. information about possible exposures to chemicals or other environmental risks was also delayed, including information about the detonation of a chemical weapons facility. these delays may compromise some of the value of research results. therefore one important lesson learned is to value the concerns of returning troops. after numerous studies, including a -year follow-up, cmi continues to be more prevalent among deployed than nondeployed veterans. of concern is cmi, which has yet to be adequately characterized or diagnosed, nor have etiologies been clearly identified; will it become a problem among current or gulf war ii troops? whether called gws or cmi, symptoms usually include but are not limited to fatigue, musculoskeletal pain, sleep disturbances, cognitive dysfunction, moodiness, and other symptoms. these symptoms also had an impact upon veterans being able to sustain employment and impacted activities of daily living. among those with persistent medical complaints, approximately , have been enrolled in a variety of registry and examinations programs. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] similar symptoms have been experi-enced by british, australian, danish, and canadian troops deployed during pgw i. most of these studies and registries report increased numbers and severity of virtually all symptoms when compared with personnel not deployed in the persian gulf region. numerous potential culprit etiologies have been suggested. concerns arose within the veterans administration and department of defense (dod) whether veterans of gulf war i have a medical illness of undetermined etiology? conspiracy theorists opined that dod was withholding information about possible exposures and undisclosed chemical or other weapons of mass destruction (wmd) operations and that the u.s. government had much to lose by admitting an illness since a military-associated medical illness would result in an enormous cost of benefits given the va provides monetary and medical benefits for military-related disability. the government did not divulge the destruction of a nerve agent chemical plant at khamisiyah until a few years after the war. nevertheless, the dod and va expended enormous resources and undertook numerous studies including collaboration with the institute of medicine-a highly regarded scientific organization and other prestigious, independent research organizations such as the national academies of science, the uk royal society and medical research council. , , resulting research suggested that gws was not an easily defined, known disease entity, nor was it, as initially thought, a classic psychiatric disorder. ptsd was present but not in sufficient quantity to account for what was emerging as a significant health problem. what has been observed, and persists, is a large number of symptomatic veterans in ill health. concerns were also raised about undisclosed biological and chemical weapons as well as countermeasures. military planners expected biological and chemical weapons. as a result, the dod authorized a variety of countermeasures be administered to the troops. these included the controversial anthrax vaccine. the british provided their troops with vaccines against anthrax, plague, and pertussis. in some epidemiologic studies, an interaction between unexplained symptoms and receipt of anthrax vaccine, receipt of multiple vaccines and place of vaccination were discovered. , evidence of cellular immune activation in a cohort years after pgw i was also detected. not all ill health were accounted for by these findings. it is well known in health care that no medical intervention-be it antidote or preventive measure, is a free ride; virtually all carry side effects. moreover, while individual countermeasures may have been studied by their manufacturers and other medical researchers and evalu-ated by the food and drug administration, the potential for adverse events by the concomitant administration of multiple countermeasures has not been well tested. troops in the gulf may ostensibly become a vaccine-adverse event research cohort. some coalition forces also received pyridostigmine bromide to counter the threat of nerve agents and pesticides, the latter being used throughout the theater of operations to reduce the enormous threat of insects and the diseases they transmit. the military also provided n,n-diethylm-toluamide (deet) and permethrin insect repellants. a study at duke university conducted animal experiments on the combination of countermeasures and insect repellants-deet and permethrin used by the various militaries. they found that the insect repellants and the nerve agent preventive agent pyridostigmine bromide (bp) were harmless when used alone but could be highly toxic when combined. the researchers suggest that their findings explain the symptoms reported by an estimated , gulf war i veterans. these symptoms include respiratory complaints, digestive and skin disorders, fatigue, and memory loss. some exhibit limb pain or numbness and recurring rashes. the researchers suggest the combination can cause neurological defects. their results are consistent with a study by the university of glasgow that identified in a small group of subjects a pattern of nerve damage. another study demonstrated damage to their immune system in some pgw i troops. scientists agree it is unlikely there is a unique disease to account for gws but more likely several etiologies based upon exposures and other yet to be identified influences. also worth noting is the wide array of insect repellants used by locals in the desert who do not have access to safer, modern alternatives; these older agents can behave like weakened nerve agents. sarin originated as an organophosphate pesticide. those exposed to organophosphates, especially over time, or nerve agent victims, even when treated rapidly and appropriately, may exhibit long-term sequelae that include nightmares and personality changes. some allied troops were potentially exposed to the chemical warfare agents sarin and cyclosarin when the munitions facility was detonated in khamisiyah, iraq. numerous studies have been conducted to evaluate the possible association between proximity to khamisiyah and a wide array of symptoms from troops in that area at the time of detonation. except for a trend towards more diagnosis of any type of cancer, no other long-term health effects were associated with the detonation at khamisiyah. the battlefield by definition is a dangerous place, made so by ubiquitous chemicals, oil well fires, depleted uranium, pesticides, explosion plumes, aerosolized dust and fumes, and other hazards. depleted uranium has been implicated for some of the health effects of gws but it alone cannot account for these given troops in rear areas or sailors-both groups without exposure to depleted uranium experienced similar symptoms to those in proximity to depleted uranium. multiple chemical sensitivity and mycoplasma species have also been suggested. again, studies fail to implicate these in all but a few cases. with the magnitude of troops in pgw i experiencing the variety and severity of symptoms, clearly there is a problem. what the answers are to the gulf war health problem remain elusive. to be sure, the etiology(s) of gws is not a one-size-fits-all answer and the links between cohorts or the ability to assign etiologies to groups has been difficult even after years of research. troops were exposed to chemicals, infections, and combinations thereof, which have not been experienced on such a scale in the past and thus the science must in effect catch up with the symptoms. with the dizzying array of chemicals and potential combinations of environmental contaminants, toxicants compounded by the horrors of war, continued research is necessary. nevertheless, a key lesson learned from pgw i that can be applied to the current persian gulf experiences is to give the returning troops the benefit of the doubt, obtain a thorough medical, exposure, travel, and occupational history. infections, military medical countermeasures, environment or battlefield chemicals, and the experience of war can create a dynamic interplay of multiple morbidities confounding diagnosis. often there is tremendous therapeutic "relief" that results from validating the patients' concerns. the dod and va have developed a variety of resources included web-based risk communication and clinician implementation support (http://www.pdhealth.mil) and complementary tool kits (http://www.pdhealth.mil/clinicians/pdhem/ toolkit/view/ /guideline_ver . .doc) and practice guidelines (http:// www.oqp.med.va.gov/cpg/cpg.htm). returning gulf war ii troops may pose complex diagnostic challenges and require long-term medical and psychosocial support and care but data suggest early treatment offers the greatest promise for enhanced quality of life and likelihood of recovery. biomedical issues. there are over , troops deployed in the persian gulf. according to a cnn review of pentagon figures, u.s. servicemembers have died so far in . the next highest death toll was in , when were killed. combat-related injuries are typically the most severe and dramatic health risks encountered during military conflicts. of note, historically it has been the noncombat injury and illnesses that have had a significant impact on military missions. , in this section we will discuss the combat-related injury, especially tbi and those resulting in amputation, followed by infections that may manifest in illness either in the gulf or when the serviceman or woman returns home. , , [ ] [ ] [ ] [ ] , , , , , large numbers of u.s. troops are returning from southwest asia, an area where numerous endemic infectious illnesses, desert illnesses, and insect-borne diseases are pervasive. our returning troops may present with infections that are not common to the u.s. but may have initial symptoms that could be misattributed to common, relatively harmless domestic illnesses. studies suggest clinicians do a poor job of inquiring about recent travel and diagnosing travel-related illness. in fact, less than % of patients with a confirmed travel-related illness were asked about travel; this resulted in delayed or missed diagnosis. [ ] [ ] [ ] this is a cautionary tale to remind us to inquire about deployment, military experiences-even the monthly and yearly obligatory domestic deployments of reservists, and travel out of the war zone, realizing each country presents an often unique set of risks. as it is likely civilian physicians will provide care for a significant proportion of returning gulf war troops, a familiarity with the medical problems they face-combat and noncombat-is essential to anticipating the needs of the troops and ultimately providing the best biopsychosocial care. combat-related injuries. much of our knowledge concerning combat wounds has been derived from prior gulf war and other military operations. operation iraqi freedom is the first large-scale combat operation since pgw i that involves the u.s. marines. one of their combat surgical companies has provided updated information for consideration; most wounds were the result of high-explosive weapons/munitions such as mines and grenades, with % of the wounds to the extremities. of note, military blast exposure, mostly in the form of roadside ied, continues to be the primary mechanism of injury. , , [ ] [ ] [ ] [ ] in , the u.s. military reported , ied attacks; an average of /day. new combat body armor can protect troops from penetrating ballistic injury such as bullets but does not provide significant protection against ied, especially blast overpressure, which will be discussed in the following section. [ ] [ ] [ ] explosives and blast injury (fig ) . bombings and the use of explosives represent the majority of terrorism-related mass casualty incidentsdomestic and foreign, as well as a significant proportion of injuries in oif and oef. explosives inflict damage by creating a rapid release of energy in the form of gases and heat, depending upon the type of explosive used. [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] from a terrorism perspective, there are four categories of explosives ranging from ( ) projectiles such as missiles; ( ) those set to explode when triggered by a target such as land mines; ( ) passive weapons detonated remotely; and ( ) weapons (usually of category ) designed and placed to produce the greatest degree of physical and psychological damage. the latter two are used most often in modern insurgencies. there is also a phenomenon referred to as "overpressure" with high explosives. , , the flames, "rush of air," and pressure changes all cause injuries. the chain of events beginning with the initial blast determines the general and neurological injuries that the victim sustains. the mechanism of injury resulting from explosives includes (fig ) primary blast injury, secondary, tertiary, and quaternary blast inju- ries. [ ] [ ] [ ] [ ] blunt, penetrating, and thermal injuries are all possible as well as psychological trauma. in addition, patients can experience exacerbation of underlying medical conditions such as asthma and hypertension. primary blast injury. conventional explosives generate a biphasic blast wave (friedlander wave form) that spreads from the primary point source. , the first phase is a high-pressure shock wave of very brief duration. it is followed by the second phase-the blast wind, which is air in motion, and how the phrase "winds of war" emerged during the civil war, when observers found some of the dead on the battlefield did not have visible wounds. injuries from the initial blast are the direct result of blast overpressure on tissue; the outcome differs comparatively concerning hollow or solid organs. [ ] [ ] [ ] [ ] , , among the organs most susceptible from blast overpressure are the ears, the lungs, the gastrointestinal tract, and the brain. these organs are most affected as a result of the interface between a solid or liquid and air. as the pressure wave passes through the tissue, the molecules of the solid or liquid are thrown into the gas media. , , bowel perforation can be acute or delayed as a result of blast injury. the colon is more susceptible than the small bowel, owing to the relative air in the former. of note, the patient who may have lung or brain injury from primary blast injury may not appear to have been injured! stories from ww ii of troops found dead with apparently no injuries, when autopsied, were found to have extensive pulmonary and/or brain primary blast injury. pulmonary barotrauma is the most fatal of the primary blast injuries. , , disruption caused by pressure differentials across the alveolar-capillary interface can lead to hemorrhage, pulmonary contusion, which on chest x-ray results in the classic "butterfly" or bihilar pattern, pneumothorax, pneumomediastinum, and subcutaneous emphysema. these can also lead to air embolism resulting in ischemia and hypoxia. , , disseminated intravascular coagulopathy is possible (dic). the ear is the most vulnerable to blast overpressure. , , , rupture of the tympanic membrane (fig ) is a sentinel finding of blast exposure and can occur at a relatively low pressure differential. recall the "ear pain" during the landing of an airplane. as little as psi above atmospheric pressure can rupture the human eardrum. the injury is dependent on the orientation of the ear to the blast. , , middle ear and inner ear damage can also occur. some key signs that may not have been disclosed in the war zone but may be revealed at home include vertigo, tinnitus, otalgia, hearing loss, and bleeding from the external canal. partial or total hearing loss can complicate triage since the victims will have difficulty following verbal commands and difficulty answering questions. in a recent study of battlefield blast injury victims in iraq, researchers noted a significant association between tympanic membrane perforation and loss of consciousness. , this association between barotraumatic tympanic membrane perforation and concussive brain injury suggest clinicians encountering patients with ear-related complaints should have a high index of suspicion for concomitant neurologic injury including tbi. , , , secondary, tertiary, and quaternary blast injuries. secondary and tertiary blast injuries can result in penetrating wounds. secondary blast injury results from flying debris. , , this also results in blunt injuries; penetrating injuries result from fragmentation. approximately % of blast survivors will have eye injuries. signs and symptoms include pain, irritation, foreign body sensation, hyphema, globe damage, altered vision, and periorbital swelling. in tertiary blast injury the patient becomes a missile and can become impaled or hit a hard surface. , , , this can result in a combination of penetrating and blunt injuries such as fractures, closed and open, brain injuries, etc. quaternary blast injuries are the most random of blast injuries and are caused by circumstances associated with the explosion, such as structural collapse, release of dust, toxins, chemicals, even effects of fire. carbon monoxide and/or cyanide from incomplete combustion of synthetic materials used in new construction is possible. therefore, in addition to the blast effect, thermal injury is possible and can cause first-, second-, and/or third-degree burns in addition to other traumatic injuries. traumatic injuries and traumatic brain/neuro injuries are discussed in the following sections. [ ] [ ] [ ] [ ] , while there are many other mechanisms of injury associated with explosives-ranging from crush injury, traumatic asphyxia, and others, they are beyond the scope of this monograph. , , however, the use of combination weapons that include chemicals has resumed in iraq. in early april , several chlorine gas suicide attacks occurred in iraq, including a truck bomb explosion in ramadi, releasing chlorine and killing at least people. these attacks have resulted in numerous injuries and deaths and raise the specter of greater use of chemical weapons by terrorist groups worldwide. chlorine is the prototypical moderately water-soluble irritant gas. it has been reported that hamas used pesticides, rat poison, cyanide, and even infectious agents as part of their improvised explosive devices. traumatic injury/amputations. injuries resulting from war can produce a myriad of emotions. , [ ] [ ] [ ] [ ] [ ] [ ] , the needs of those who suffer amputations are interrelated but distinct from other injuries. , [ ] [ ] [ ] , , amputations or blindness result not only in the loss of body function, which is significant in itself, but also are dramatic insults to the patient's psychological sense of body integrity, self-image, competence, and worth. in addition to the loss of sight or limb(s), these wounded must often endure other injuries and psychological traumas, which cannot be underestimated or underemphasized. attendant to these wounds are fears of persistent threats, anxiety about military career being curtailed, and response from loved ones. reactions to past experiences in addition to the above set the stage for complex, tumultuous emotional struggles. while any of these challenges can overwhelm a person's psychological equilibrium, taken in totality, all of these set the stage for exceptionally devastating physical, psychosocial hurdles. studies reveal a variety of emotions after the initial trauma and throughout the rehabilitation process in the amputee-depression, anxiety, resentment, anger, fear, helplessness, hopelessness, grief responses, relationship difficulties, and body image problems. , , , , also phantom pain is likely in some. changes in physical appearance may complicate personal relationships. family members may need extensive assistance in adapting. patients have fewer emotional problems and good social support had better outcomes adjusting to prostheses. clearly a biopsychosocial approach to the blinded or amputee is necessary to promote psychological and physical healing and a successful return to family and society even with the new limitations. newer and more advanced prosthetics have been developed which increasingly mimic much of the natural function of native limbs. we are, however, a distance from the "bionics" and superreal prosthetics made famous on a variety of television shows. nevertheless, amputees face better opportunity for increased function than in the past. notwithstanding, the road is long and rehabilitation often painful, discouraging, time consuming, and potentially expensive even with benefits. evidence suggests, after a traumatic lower extremity amputation, admission to a specialized inpatient rehabilitation program significantly improves functional and vocational outcomes, as well as reduces bodily pain. , the u.s. military has two major centers for amputees-walter reed army medical center including their psychiatric consultation liaison service and brook army medical center in texas. reservist/ national guard troops will likely receive their care, at least initially, from the military. however, civilian clinicians may be called upon, as the patient transitions home, as well as caring family members. amputees go through a variety of emotional and physical rehabilitative changes in addition to social ones. amputees often are concerned about if and how relationships with friends and family will change. their anger may manifest in different ways and be targeted to family, friends, even health care professionals. patients must be allowed to find healthy ways to communicate but hcp should be able to tolerate the expression, especially early in the aftermath as a normal response to a horrific, life-changing event. later, amputees may start expressing fears about sexual functioning. , , [ ] [ ] [ ] allowing the patient to address these issues openly, and, facilitating such dialogue among partners, is enormously helpful. amputee patients can more effectively be treated if addressing the needs of the patient's family. loved ones may want to spend time with their injured family member. of concern, they may not, and reasons should be addressed. , these include fear of what to say, guilt, squeamishness looking at the wound, and other issues. children, though often more resilient than given credit for, should nevertheless be assisted in understanding and integrating the experience in a less traumatic fashion before encountering the amputee. , , [ ] [ ] [ ] a variety of resources are being developed to care for the traumatized patient. the va and other military medical facilities are improving their mental health services and emphasizing the need to collocate them with orthopedic and other medical services. different rules may apply to disability benefits concerning active duty compared to reserve or national guard. whether military or civilian, it is important to address patient concerns and their future goals. moreover, it is important to assist them in achieving realistic goals. some do not want to give up their uniformeither out of duty or out of fear of losing career and being unable to support their family. traumatic brain injury (tbi). tbi may become the "signature wound" of the global war on terror and pgw ii given the ubiquitous nature of explosions, especially in iraq. [ ] [ ] [ ] [ ] blast injury is the most common cause of war injuries; different than in prior wars such as vietnam when ballistic projectiles caused a significant proportion of injuries. according to the defense and veterans brain injury center, tbi afflicts between and % of military service members. so far, several thousand have been treated for it, while thousands are believed to be undiagnosed. , primary blast injuries to the brain and spinal cord include blast wave induced concussion as well as barotrauma caused by acute gas embolism, which can produce ischemia and infarction. loss of consciousness and contrecoup/coup injuries are possible. of course, the severity of wounds will differ depending upon proximity to explosion, body armor, and other factors. there are many causes of head trauma. these include blast exposure, gunshot wounds, and motor vehicle injury. according to military data, troops in iraq experience one explosion a month, on average. each blast raises the risk that the next one will do harm. a blast creates a sudden increase in air pressure followed by a rapid decrease in pressure. [ ] [ ] [ ] [ ] , [ ] [ ] [ ] [ ] these pressure shifts can injure the brain directly, producing contusion or concussion. air emboli can also occur, resulting in infarcts. neurological injuries resulting from explosions are the result of a complex cascade of physical and biological events. a pressure wave from the blast courses through the brain, initiating the damage. while severely injured troops are supposed to be screened for head trauma, others who were not obviously injured but were nevertheless rendered unconscious may not present for care nor be considered victims of head injury. however, the group of troops who are rendered unconscious are at risk for tbi and may develop difficulty concentrating, manifest increased irritability or other signs and symptoms but remain undiagnosed. because behavior-related injury such as ptsd has been considered a disorder associated with malingering, the symptoms of unrecognized tbi can as well, further confounding the situation. much of what we know about head injuries are from prior wars, sports concussion patients, and civilian tbi literature. lessons learned from oif and oef will undoubtedly provide additional information. diagnosis. while there are screening/assessment tools available, diagnosing tbi, especially combat-related, is imprecise. the diagnosis remains largely based upon clinical signs and symptoms in addition to a thorough history that includes detailed information about how the patient is adapting to and conducting activities of daily living and, of course, if in proximity to an explosion. different syndromes are identified relative to the effects of the trauma and resulting hemorrhage, barotrauma, edema, and tissue disruption. dyspraxia, dysphasia, executive dysfunctions, paralysis, deficits and dysfunctions of the special senses, and mood disorders can occur and evolve. , , , symptoms include frequent headaches, dizziness, and difficulty with concentrating and sleeping. depression, irritability, and confusion may occur. some patients may be easily provoked or distracted. speech and/or vision may be impaired. many of these symptoms overlap with ptsd. , , - , , - some tbi victims have been misdiagnosed with personality disorders and lost their jobs upon returning to the u.s. because of unrecognized and thus untreated symptoms. fortunately most tbi are mild and most patients recover within a year. however, one of five troops with these "mild" injuries may still have prolonged, even lifelong symptoms requiring continuing medical care, according to military estimates. walter reed army medical center categorizes the severity of tbi according to the duration of loss of consciousness and posttraumatic amnesia as follows: • mild tbi: an injury causing x loss of consciousness for Ͻ hour or x amnesia lasting Ͻ hours x patients usually do not have visible abnormalities on brain imaging • moderate tbi produces x loss of consciousness lasting between and hours or x posttraumatic amnesia for to days • severe tbi causes x loss of consciousness for more than hours or x posttraumatic amnesia for more than week brain imaging studies. of note, patients with moderate or severe tbi may have punctate hemorrhages visible in the corpus callosum and other regions, as well as evidence of bleeding or swelling on brain imaging studies. , , , patients with minor tbi may not have visible abnormalities. nevertheless, such testing should be obtained and consultation with neuroradiologists, neurology, and neuropsychology specialists in brain injury is important and should be done early. it is important to remember that troops are proud and thus may be reluctant to seek help for what is seemingly an innocuous injury on par with "getting your bell rung" in a football game. nevertheless, it is important to ask patients who have been in a war zone, especially oif and oef, about exposures to explosive events and perform a thorough evaluation, documenting the functional status. although not considered combat troops, it is important to screen female troops as well; many have been exposed to ied. if in doubt, consider referral to health care facilities specializing in tbi. treatment. the usual approach to tbi patients is to work on specific symptoms and deficits-headaches, anxiety, vision problems, memory, and attention span. , , , , , to date, there is no "cure" for the injury itself. a multidisciplinary approach is required and clinicians should be knowledgeable about local resources to refer suspected brain-injured patients, neurological and psychological hcp with expertise in the treatment of such patients. it is important to explain to the returning pgw ii patient that you are not sending him/her away, that you are enlisting the services of experts but are going to be engaged in the process and help both the family and the patient through this. [ ] [ ] [ ] [ ] [ ] medications as needed can be utilized to manage epilepsy and headaches; those with fewer cognitive side effects are preferred compared to older ones, which can compound patient challenges. given that the diverse nature of the neuropsychiatric sequelae of tbi and that the trajectory of recovery can continue for several years, medications should be selected that take into consideration adverse effects and impact on daily living. mood disorders, epilepsy, and memory deficits can develop within the first years of injury. psychosis can arise up to years and dementia can occur later during the lifespan of the patient. it is worth recognizing that poverty and disability are interconnected. social, familial, and financial support are important, in addition to appropriate medical and neuropsychiatric care. some states are being very proactive; illinois officials have implemented a plan that would screen members of the state's national guard for tbi and provide a -hour hotline with psychological counseling and other interventions. stories persist of troops who were in close proximity to explosions but were considered "unwounded" because they did not have obvious injuries. these troops are now developing behavioral and memory problems and have clearly been injured by the blast. given there can be a time delay between blast and neuropsychiatric symptoms, the astute clinician will be attuned to this issue when caring for returning troops. in the majority of cases, explaining what is occurring, helping the patient and friends cope with some of the challenges, referring to appropriate care, and conveying "tincture of time"-time to heal, is the normal course of illness can be very reassuring. prevention. can tbi be prevented? newer body armor and kevlar helmets have allowed troops to survive attacks. the current helmets utilized among the four services in oif and oef were designed to protect against ballistic projectiles and shrapnel, not necessarily blast injuries. as a result, open head injuries have been significantly reduced; closed head injuries as discussed above now outnumber penetrating ones, which, for obvious reasons, are easier to diagnose. some of the standard issue padding is either uncomfortable or inadequate in providing appropriate stability, protection, or comfort. as a result, either the troops do not wear the helmets or the equipment may not provide adequate protection during an explosion. upgrades are being developed. a civilian charity-operation helmet-has been providing free of charge advanced padding systems that troops can install in their helmets. research into new helmets designed to better protect against explosions is ongoing. infections. infections remain a leading cause of death worldwide. , , while the u.s. has been able to significantly control many of the infectious diseases and/or vectors that continue to afflict much of the rest of the world, global pathogens remain a threat to the u.s. nevertheless. , , , our troops will face two primary sources of risk for infection-wound-associated and endemic infectious diseases. [ ] [ ] [ ] [ ] [ ] [ ] , , , , what follows is an overview of the most important exposures that may persist in the patient post deployment and thus may be brought back into the u.s. for civilian physicians to diagnose and treat. wound infections/colonization. nosocomial infection with multidrug-resistant acinetobacter baumanii occurs in u.s. hospitals but has emerged as a significant problem among wounded troops and military medical facilities. , a. baumanii can cause wound infections, osteomyelitis, urinary tract infections, and respiratory infections. not surprising, there is a geographic component to infectious threats. multi-drug-resistant a. baumanii infections are described as epidemic among wounded in iraq, compared to afghanistan. of concern, nosocomial transmission of a baumannii within walter reed army medical center resulted in infections and four deaths. as a result, wounded patients are often isolated upon return to the u.s. until they are cleared of a. baumannii. infection control is good medical practice. it is important to address nosocomial infections, especially given the commonplace nature of this problem in u.s. hospitals. while the organism may be different in civilian health care facilities compared to combat hospitals, nevertheless, unnecessary deaths and protracted illness occur because of inattention to infection control measures as basic as handwashing and separating dirty from clean activities. endemic infectious diseases: overview. during u.s. military deployments over the last years, the four most commonly reported diagnosis categories have been non-combat-related orthopedic injuries, respiratory infections, skin diseases, and gastrointestinal infections. clearly infectious illness is a leading cause of morbidity in the gulf. , , , [ ] [ ] [ ] , , , , [ ] [ ] [ ] [ ] [ ] [ ] [ ] given hundreds of thousands of u.s. servicemembers have been deployed to afghanistan and iraq as well as other middle east and southwest asian nations since , it is important to discuss the common and/or chronic infections that may occur or persist upon the return of troops. , , , , of note, there are both similarities and differences in infection risk concerning iraq and afghanistan ; it is worthwhile inquiring as to the countries the returning serviceman or woman has been deployed to as well as countries visited on r and r, which can include qatar, bahrain, and other middle east locations, remembering that the incubation periods of endemic illnesses can be quite long-infection can occur in one region with symptoms evolving elsewhere. infection during deploy-ment may not manifest until return from overseas and the astute clinician will be alert to unusual signs and symptoms. what follows is a discussion of the infectious agents that already have caused illness or pose a significant threat especially if left undiagnosed. infectious diarrhea. during the early stages of oif and oef large outbreaks of norovirus and shigella infections resulted in severe gastroenteritis. , - seventy seven percent of personnel deployed to iraq and % of those deployed in afghanistan reported at least one episode of diarrhea. personnel in iraq tended toward more severe symptoms, longer duration of illness, and greater likelihood of multiple episodes that correlated with local food consumption. in the summer of a surveillance study revealed that % of troops in iraq had multiple episodes of diarrhea. , [ ] [ ] [ ] field tests found enterotoxigenic escherichia coli and enteroaggregative e. coli as the most common pathogens. entamoeba histolytica and other protozoans were found. in another outbreak of diarrhea involving u.s. troops revealed Ͼ % were infected with cryptosporidium species. soldiers who present post deployment with chronic diarrhea should be thoroughly evaluated including consideration of post infection irritable bowel syndrome and for parasites such as giardia, cryptosporidium, and entamoeba. leishmaniasis. , , , , , , , , , in Ͼ cases of cutaneous leishmaniasis (cl), and between and cases of cl and cases of visceral leishmaniasis were diagnosed in u.s. soldiers deployed in iraq, afghanistan, and kuwait. , , from march to june an estimated % of deployed u.s. ground forces were diagnosed with leishmaniasis. leishmaniasis is a sandfly-borne parasitic disease caused by protozoa that live inside mammalian macrophages. this is problematic given u.s. troops suffer intense vector exposures and report receiving numerous insect bites. the high season for insects runs from april to december. as part of a prevention strategy and control research over , sandflies were collected from sites throughout iraq; between . and . % of flies were infected with leishmaniasis. of concern, use of insect repellent seems to be problematic among troops. in one study of troops infected with old world cutaneous leishmaniasis (owcl), % said they used insect repellants but % said that appropriate vector control was unavailable at some point during their deployment. , in another study, . % reported using deet more than occasionally and . % never used it. only . % believed the product was safe. clinicians caring for reserve and national guard members should counsel their patients that deet, especially - %, is a safe and effective measure to reduce the risk of insect-borne illness. owcl is usually associated with the species leishmania major and leishmania tropica. leishmaniasis infection is characterized by diverse clinical manifestations ranging from asymptomatic infection to self-limited cutaneous disease to life-threatening visceral disease. , , there are three major clinical patterns of leishmania disease: ( ) visceral disease, in which the parasite replicates throughout the reticuloendothelial system (res); ( ) cutaneous disease, whereby the parasite replicates in the dermis of the skin; and ( ) mucosal disease, whereby illness involves the naso-oropharyngeal mucosa. cl or owcl is the most common of the three patterns. , , , , , in patients with cl, Ն skin ulcer (fig ) or nodule forms in the absence of fever, anemia, hepatomegaly, or splenomegaly. it may self-heal without medical intervention in to months. however, it can also, albeit uncommonly, disseminate locally with subcutaneous nodules or regional lymphadenopathy. l major and l. tropica can evolve into diffuse cutaneous leishmaniasis. the presentation of cl among u.s. troops is generally chronic, painless skin lesion(s), which are often ulcerative, with a dry, scaling eschar. of note, the appearance of the skin lesion can vary. old world visceral leishmaniasis disease (owvld) usually begins in the absence of recognizable skin lesions or scars. leishmania illness is associated with l. infantum and l. donovani. , these species are also more likely to cause chronic, reactivating illness. owvld can be asymptomatic, subclinical, or symptomatic. symptoms of owvld include irregular or chronic high fever, cough, weight loss, hepatosplenomegaly, lymphadenopathy, and fatigue, with labs consistent with anemia and pancytopenia. in the immunocompromised, those coinfected with immunosuppressing or other pathogens such as human immunodeficiency virus, in the malnourished, or in young children, visceral leishmaniasis can be fatal. among the troops infected with visceral leishmaniasis the incubation period is varied but could be prolonged as much as months after returning from the combat theater. specific parasitological diagnosis requires tissue biopsy specimens from bone marrow, liver, lymph node, or spleen; the latter should be avoided for risk of hemorrhage. treatment with liposomal amphotericin b has been effective. diagnosis depends on parasitological confirmation from skin scraping, slit skin smear, or biopsy. culture and polymerase chain reaction (pcr) permit speciation; species identification may have an impact upon management strategies. treatment for l. major, which is usually self-limited but can persist up to months, includes watchful waiting, cryotherapy, heat therapy, topical paromomycin, azoles such as ketoconazole or fluconazole, and the pentavalent antimonials, which can be administered intralesional and parenterally. , , however, systemic therapies such as the azoles are reserved for larger or multiple lesions as well as cosmetically problematic lesions. the clinician should be especially sensitive to the cosmetic and emotional needs of the returning troop and not assume the lesion is not bothersome visually. perception is reality and the serviceman or woman may assign more value to the lesion as part of an overall post combat emotional response. therefore it is important to take the entire context of their deployment experience-medical and psychological health-into account when providing care. in contrast to l. majo, other species are often treated more aggressively with systemic therapies. however, treatment may not eradicate leishmania infection as this is a persistent intracellular organism. nevertheless, systemic treatment can control clinical disease. leishmania can reactivate in patients who become immunocompromised. patients should be counseled against blood donation; military policy dictates lifelong deferral of blood donation for persons who are diagnosed with leishmaniasis whether treated or not. , , , , given some returning troops may be financially challenged and consider blood donation for funds, it is worth emphasizing that the donor can infect an innocent individual. it is also of value to identify patients who have returned from pgw ii who may be facing financial hardship and guide them to appropriate resources in the community. malaria. malaria is a serious global threat and potentially deadly parasitic illness resulting from the bite of an infected mosquito. , , moreover it remains a significant military challenge in endemic areas. in there were cases acquired in afghanistan and diagnosed among u.s. army soldiers; soldiers presented for care weeks to months after return to the united states. there were , malaria cases in afghanistan reported to the world health organization (who), of which % were plasmodium vivax (fig ) . an outbreak of p. vivax among army rangers was reported after deployment to eastern afghanistan. a case of acute respiratory distress syndrome occurred in a patient who may have developed primaquine-resistant p. vivax. p. falciparum is possible. the observed attack rate was . cases per soldiers with the diagnosis made from to days after return to the u.s. self-reported rates of mefloquine prophylaxis and primiquine prophylaxis were and %, respectively. clearly greater attention, education, and follow-up of prophylaxis are necessary to reduce the risk to our troops. given some troops will be treated by civilian health care professionals, malaria should be considered in patients with fever, chills, sweats, headaches, myalgias, fatigue, nausea, and vomiting. symptoms can occur to days after being bitten but this is variable. moreover, malaria may cause anemia and jaundice. p. falciparum species infection, if not treated, may cause kidney failure, coma, and death. malaria is a risk in all areas of afghanistan below altitudes of m from april to december. chloroquine is not an effective antimalarial drug in afghanistan but, according to centers for disease control and prevention, is recommended in iraq as the preferred antimalarial drug. risks for malaria in iraq are primarily in the nonurban areas such as basrah, dhok, erbil provinces, and areas below m. atovaquone/ proguanil, doxycycline, or mefloquine are recommended for prevention. troops should be counseled against self-medication and the use of locally acquired medications, based upon concerns about safety and effectiveness, especially halofantrine (halfin), which can cause serious heartrelated side effects including death. q fever. , , , , , , , [ ] [ ] [ ] q fever is an emerging infectious disease among u.s. soldiers serving in iraq and a worldwide zoonotic infection caused by the rickettsial pathogen coxiella burnetti. it is usually acquired from inhaling infected particle aerosols often after contact with reservoir hosts, which includes cattle, goats, and sheep, or after exposure to contaminated manure, straw, or dust-the latter being kicked up by vehicles or helicopters. other routes of transmission include ingestion of improperly prepared or raw milk, or tick bites. q fever has been identified as a potential biological weapon. , a report from the defense intelligence agency (dia) in suggested that endemic q fever posed a minor risk to military personnel under normal circumstances but might pose an increased threat to nonconventional forces. , in the dia tested blood samples obtained from iraqi military personnel in the gulf war: of tested positive for previous exposure to c. burnetti-these data suggest that q fever may pose more of a threat to u.s. forces in iraq than previously thought. an epidemic of q fever among coalition allies, czech republic soldiers, occurred in in soldiers stationed in bosnia and herzegovina. in , among cases of pneumonia in u.s. military members in iraq, had serological evidence suggesting c. burnetti as the etiology. the true incidence of infection is unclear and likely underestimated. c. burnetti is highly infectious-a single organism can cause illness. of concern, cases appearing at u.s. health care facilities resulting from infection in the persian gulf were initially misdiagnosed despite the unusual and severe nature of the presenting symptoms in otherwise healthy, strong war-fighters. again, the caveat is that returning troops may be infected with illnesses endemic to the middle east; vigilance is key and patients who have recently returned but have seemingly commonplace symptoms may warrant more aggressive investigation given recent exposures abroad. c. burnetti infection is often subclinical or mild and self-limited. clinically it sometimes resembles a "flu-like illness." common clinical presentations include a nonspecific febrile illness, which can remit and recur, and is consistent with atypical pneumonia and hepatitis. high fever, headache, myalgias, malaise, anorexia, and diarrhea are possible. , , chronic infection can occur and involves the heart, arteries, liver, and bone. laboratory findings include elevated liver enzymes and decreased platelet count. elevated erythrocyte sedimentation rate may occur. abdominal ultrasound may reveal diffuse echogenic portal triads sometimes referred to as "starry sky" appearance of acute hepatitis. chest radiographic findings can include infiltrates but a variety of findings are possible if pulmonary involvement occurs (fig ) . the most characteristic lesion of liver involvement is the fibrin-ring or "doughnut" granuloma-a fat vacuole surrounded by a ring of fibrin, epithelioid cells, giant cells, and neutrophils. differential diagnosis of infectious agents that can cause febrile illness and hepatitis include brucella species (brucellosis), francisella tularensis (tularemia), treponema pallidum, human immunodeficiency virus, cytomegalovirus (cmv), epstein-barr virus (ebv), the hepatitis viruses, histoplasmosis, coccidioides immitis, and toxoplasma gondii. , , serum can be sent for c. burnetti antibodies. the diagnosis of q fever is made primarily by serology; immunofluorescence assay is the preferred method. treatment of q fever can be successfully accomplished with month of doxycycline therapy. the regimen of month of doxycycline in combination with rifampin is also appropriate. , brucellosis. brucellosis is a zoonotic disease endemic in the middle east and caused by several species of brucella organisms that are highly infectious via the aerosol route. , the british referred to it as "undulant fever" in the mid s, and more recently it has been dubbed "flaky fever" because of the altered mental status that sometimes occurs as a result of the direct neurotoxicity. transmission is usually through contact with infected animals or ingesting inadequately prepared food or dairy products from sick animals. brucella can be ingested, inhaled, or percutaneously inoculated. it is estimated that inhalation of only to bacteria is sufficient to cause disease in humans. , the incubation can be as short as days but is variable and can be much longer with some cases developing into an insidious, chronic illness. from to there were three reports of brucellosis among u.s. troops. however, in the u.s., like overseas, brucellosis is often misdiagnosed and the number of cases underreported. worldwide estimates vary; some suggest / , persons. civilian clinicians should emphasize the importance of eating properly prepared foods including dairy products to their patients who are about to be deployed and/or counsel family members in the u.s. to warn loved ones in the middle east. sometimes this can be difficult given our troops are often encouraged to interact with local villagers; cultural norms and polite response to offers of food and hospitality are often challenging. nevertheless, the need to adhere to safe practices is of paramount importance. data suggest that, during world war i, brucellosis-a veterinary pathogen as well as a cause of human illness-was used as a bioweapon to inflict disease upon beasts of burden, in the hope of providing a military advantage in the pre-jeep era when munitions, men, and materials were transported largely with the use of animals. subsequently it was one of the first biologicals weaponized by the u.s. military. symptoms include irregular fever, headache, profound weakness and fatigue, chills, sweating, arthralgias, myalgias, depression, and changes in mental status. patients often complain of a few days of high fever, which subsides with treatment and returns shortly after completion of antibiotics. this is usually the result of incorrect diagnosis, inadequate duration of, and/or inappropriate antimicrobial selection. monotherapy should be avoided. treatments include doxycycline and rifampin for a minimum of weeks, or ofloxacin and rifampin. therapy with rifampin, a tetracycline, and an aminoglycoside is indicated for infections with complications such as endocarditis or meningoencephalitis. , it is worth remembering that certain biological illnesses and bioweapons, including brucellosis, may contain neurotoxins that directly or indirectly affect neurological function and alter behavior, even mimicking some of the early behavioral changes of ptsd. biological illnesses and bioweapons may present with or have deleterious affects on mental status, neurological function, or level of cognitive function, negatively impacting the ability to obtain an accurate history as well as mimicking delirium, dementia, or other age-related cognitive deficits or behaviors including "sundown psychosis." , , viral hemorrhagic fevers, the equine encephalitic agents, and even anthrax are associated with mental status changes. , while rates of ptsd among oif and oef troops are much higher than in prior conflicts, the astute clinician will also be vigilant for other etiologies and possibly comorbidities. , , , , , respiratory illness. in a self-reported survey was collected from Ͼ , homeward-bound members of the u.s. military. sixty-nine percent reported one episode of respiratory illness, while % experienced more than three episodes. , , of interest, almost % reported they smoked more than a half a pack of cigarettes per day, with % being first-time smokers or former smokers who restarted upon deployment. additionally, from march through march , several cases of severe pneumonia were reported with clinical symptoms including rapid onset of cough, shortness of breath with or without fever, and accompanied by leukocytosis. chest radiographs revealed bilateral alveolar infiltrates often requiring mechanical ventilation. of concern, some of these patients had acute eosinophilic pneumonia (aep), which is a rare idiopathic disease usually characterized by pulmonary infiltrates on chest x-ray, eosinophilic infiltration of the lung, and respiratory failure. during this timeframe, cases of aep were identified among the total military deployed in or near iraq, of which died. new-onset smoking was the only reported associated result from an epidemiologic study. there have been some association with smoking non-u.s. tobacco products. there have been additional cases of aep since this study period, one of which presented with symptoms month after returning to the u.s. early diagnosis is essential because prompt medical treatment with corticosteroids can result in favorable outcomes; late diagnosis can be fatal. this again underscores the concern that an illness can be initiated during deployment but manifest upon return to the u.s. the astute clinician must be mindful of travel-related and deploymentrelated illness. other illnesses. there are ongoing studies to assess the rates of other endemic, arboviral infection, including sand fly fever virus, west nile virus, sindbis virus, and rift valley fever virus. so far, seroconversion among troops tested has been Ͻ %. , , , , , , , , nevertheless, if troops return with unusual febrile illness, a thorough examination including consideration of middle east related infections is necessary given the wide range of incubation periods possible. while u.s. troops are vaccinated against typhoid fever, it remains a public health problem in iraq and afghanistan; the vaccine is not % effective and thus, in the proper context, patients with unusual febrile illness, including relative bradycardia, warrant a more in-depth evaluation. of concern, multi-drug-resistant (including ciprofloxacin-resistant) salmonella enterica typhi has been identified in iraq. according to the centers for disease control and prevention, measles continues to be reported in the region. polio has been reported in yemen in and, in - , india, pakistan, and afghanistan. highly pathogenic avian influenza (h n ) has been found in poultry in the middle east. pilgrims to the hajj in saudi arabia have acquired meningococcal infections by serotypes a and w- . other parasitic infections include schistosomiasis and echinococcus, which to date have not been problematic among u.s. troops. , , , cases of ophthalmomyiasis have occurred in iraq. this presents with abrupt onset of conjunctivitis and is caused by motile, mucoid, flatsegmented larvae with a size Ͻ mm and caused by oestrus ovis, the sheep nasal botfly, which can deposit larvae in the eye; it can also involve the globe, resulting in sight-threatening complications. tuberculosis [mycobacterium tuberculosis (tb)] is the second most common cause of death in the world, resulting in million deaths annually and million new cases a year and is endemic in central and southwest asia. , , it is also the most common opportunistic infection associated with human immunodeficiency virus. this is not just a global threat, but a domestic one, with drug, multidrug and extremely drug resistant tuberculosis continuing to be a significant public health concern. who estimates suggest cases per , persons in afghanistan are twice the number of cases per , persons in iraq. the u.s. military uses purified protein derivative of tuberculin to screen troops before and after deployment. the deployment-associated conversion rate is ϳ . %; the number of active cases of tb among u.s. troops serving in the persian gulf has been negligible. nevertheless, it is important to follow-up with troops deployed in endemic regions upon return to the u.s. to ensure that they have been appropriately screened or treated. overview. war-zone exposures may have considerable negative emotional and behavioral consequences. , , , , , , [ ] [ ] [ ] [ ] [ ] men and women evacuated from the war zone with physical injuries are at higher risk for developing ptsd and other trauma-related issues. , , given the mind-body connection often gets severed in current health care and collocation of mental and biomedical services is not often the case, clinical attention should not be solely aimed at the physical wounds of war. , , - some military members will develop chronic, debilitating mental illnesses as a result of traumatic exposures, either directly from patterns of injury known as tbi or psychiatric, as with ptsd, or from depression. [ ] [ ] [ ] , , during and after the persian gulf war in iraq and afghanistan, primary care providers may notice an increased number of veterans or even active duty personnel as well as family members, some of whom may have a loved one who was severely injured or killed. , , , , , , , , while the physical wounds of war are often hard to miss-prosthetics, casts, or bandages, psychological trauma and mental illness, even brain injury, may initially present with subtle clues that, if not early diagnosed, can evolve into significant morbidities. , , among the psychiatric morbidities, ptsd and depression are expected to have high prevalence rates among returning troops. while depression, anxiety, and other psychiatric disorders may occur, this monograph will provide more in-depth information on the neuropsychiatric illnesses like ptsd and tbi, especially given clinicians are likely to be more familiar with the early recognition of depression and anxiety disorders. it bears repeating that multiple psychiatric disorders are possible. patients want their primary care clinicians to acknowledge their traumatic experiences and responses. therefore hcp should be sensitive to the complex needs of service men and women returning from the gulf as well as their families and loved ones. of concern, most medical casualties will not seek mental health care and many veterans can be expected to be reluctant to acknowledge emotional distress as concerns arise about being diagnosed with a mental illness. therefore, clinicians should avoid pathologizing common stress reactions and be sensitive to these concerns, while being vigilant about psychopathology and ensuring proper mental as well as physical care is provided. mental health professionals and primary care clinicians may find themselves collaborating closer in the aftermath of pgw ii than previously with traditional civilian patients as opposed to their reservist or national guard civilian patients. it is worth noting that the mental health and primary care clinicians' task is further complicated by what may emerge as a "signature wound" in the gulf war and war on terror-tbi, which is discussed elsewhere in this monograph. , , the value of faith-based care cannot be underestimated. chaplain services are valuable partners that are considered trustworthy by troops, are often collocated in combat zones and thus considered participants in the stress environment, and are generally a regular presence throughout the military, including health care facilities. the old adage "there are no atheists in foxholes" may or may not hold true. nevertheless, faith-based professionals can be enormously helpful for family members; church members may provide a psychosocial and spiritual support network. inquiring about and arranging faith-based support should be part of the total care plan. studies support the importance of religion and spirituality as resilience and protective factors as well as being therapeutic in the recovery phase. general sherman's famous remark "war is hell" has never been disputed. death and destruction takes its toll on people in a variety of ways but it does ultimately take a toll. ptsd is an anxiety disorder that develops in individuals who have experienced a traumatic event. , , , the term "post traumatic stress disorder" first appeared in to describe a set of symptoms. however, this disease has been well described throughout history, often previously referred to as "shell shock" or "war neurosis." fortunately, greater attention to the actual science of the psychological impact war has on those serving in battle zones has led to a greater understanding of the psychopathology of ptsd and a better method of diagnosing and characterizing this illness. populations at risk. the following is a list of patients/groups at risk for and experiencing symptoms of ptsd: • veterans/active duty military personnel x witnessed frightening aspects of combat x participated in frightening aspects of combat • veterans/active duty military personnel who may have experienced military-related sexual trauma • family members may suffer traumatic stress by x hearing about frightening events that happened to loved ones x loss of loved one (dead, missing in action, prisoner) x fear of loss • non-pgw ii veterans may be reminded of frightening/upsetting experiences from past wars which can exacerbate traumatic stress responses. symptoms. unlike many infections and biomedical processes which may have specific laboratory tests to suggest or confirm the diagnosis, ptsd, as with other psychiatric illnesses, is based upon screening tools, patient history, and the careful evaluation of clinical signs and symptoms. , the clinical history of the patient must be accompanied by the occurrence of a traumatic event. a diagnosis of ptsd cannot be made without a history of a traumatic event. diagnostic criteria for ptsd. according to the american psychiatric association (apa), the following are symptoms and criteria for pstd in its diagnostic and statistic manual of mental disorders (dsm): • the person has been exposed to a traumatic event in which both of the following were present: . the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. . the person's response involved intense fear, helplessness, or horror. (note: children may express disorganized or agitated behavior.) • the traumatic event is persistently re-experienced in the following ways: . recurrent and intrusive distressing recollections of the event, including images, thoughts, or perceptions. (note: in young chil-dren, repetitive play may occur in which themes or aspects of the trauma are expressed.) . recurrent distressing dreams of the event. (note: in children, there may be frightening dreams without recognizable content.) . acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). (note: in young children, traumaspecific reenactment may occur.) . intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. . physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. • persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three (or more) of the following: . efforts to avoid thoughts, feelings, or conversations associated with the trauma. . efforts to avoid activities, places, or people that arouse recollections of the trauma. . inability to recall an important aspect of the trauma. . markedly diminished interest or participation in significant activities. . feeling of detachment or estrangement from others. . restricted range of affect (eg, unable to have loving feelings). . sense of a foreshortened future (eg, does not expect to have a career, marriage, children, or a normal lifespan). • persistent symptoms of increased arousal (not present before the trauma), as indicated by two (or more) of the following: . difficulty falling or staying asleep . irritability or outbursts of anger . difficulty concentrating . hypervigilance . exaggerated startle response • duration of the disturbance (symptoms in criteria b, c, and d) is more than month. • the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. (table ) . as of august more than , iraq and afghanistan veterans have been afflicted with ptsd. , , , [ ] [ ] [ ] [ ] [ ] [ ] according to the national center for post traumatic stress disorder, to % of returning soldiers experience ptsd, compared to % in the general population. it is not difficult to understand why so many returning troops from the gulf wars have ptsd: studies reveal % of soldiers in iraq are the victims of smalls arms fire; % knew someone who was seriously injured or killed; and % had handled or uncovered human remains. these traumatic experiences in addition to long exposures to violence in a foreign, often hostile land, far from home can make service men and women vulnerable. women serving in the military, especially combat zones, are not only subject to the dangers and violence of war but also are at risk of assault from fellow service members or their superiors. a study revealed approximately one in three female veterans who visited a va facility for health care reported being raped or subjected to attempted rape during their military service. sexual assault is well recognized as a risk for ptsd. add this to the psychological trauma of combat and exposure to war-this combination has led to an estimated % of servicewomen who will likely develop ptsd compared to % of male soldiers, who, statistically, are rarely sexually assaulted. it is worth mentioning that reporting sexual assault can have a chilling effect on the servicewoman's military career; often women do not report this to their superiors, again setting the stage for a variety of psychopathologies. servicewomen-reservists, national guard-who return to our practice should be queried about sexual abuse, gender discrimination, and their experience in addition to an overall history of their overseas deployment and travels. ptsd when identified and treated early has very promising outcomes whereby to % are expected to recover, underscoring the need to address the psychosocial issues of service as well as the biomedical. differential diagnosis. other conditions can cause some of the symptoms experienced in ptsd and these conditions must be ruled out. additionally, conditions such as substance abuse and depression may preexist or develop as complications of ptsd. some of the conditions in the differential include adjustment disorder, depression, and panic disorder. moreover, substance abuse must be addressed. the astute clinician will be alert for changes in their patients' behaviors, overall health, and/or concerns expressed by their family. the impact of war not only affects the warrior but the families as well. family members as well as the returning troops (wounded or not) may feel awkward and unsure how to communicate with each other about the events of war or injuries sustained. although generally considered a low percentage of returning pgw i and ii troops, it is worth remembering some may be malingerers. nevertheless, given the atrocities of war, especially on the shoulders of young people, it is better to presume legitimate illness until data prove otherwise. clinical course. the course of ptsd is often determined on the temporal relationship between the trauma and when the individual begins to experience symptoms. immediate onset • better response to treatment • better prognosis (ie, less severe symptoms) • fewer associated symptoms or complications • symptoms may resolve within months delayed onset • associated symptoms and conditions develop • condition more likely to become chronic • possible repressed memories • worse prognosis people who experience trauma sometimes repress their memories of the event to avoid the pain of thinking about it or remembering it. these so-called repressed memories sometimes resurface during therapy or may be triggered by something in everyday experience that reminds the patient of the traumatic event. treatment options. the chronic nature of ptsd mandates early diagnosis, appropriate treatment, and long-term care. a combination of psychotherapy and medication is commonly used to treat ptsd. psychotherapy. psychotherapeutic treatments include debriefing (ie, crisis intervention) and psychotherapy. psychotherapy can help the person address and manage painful memories until they no longer cause disabling symptoms. eye movement desensitization and reprocessing has also been tried. pharmacotherapy. almost all types of psychopharmacological agents have been used to help resolve the symptoms of ptsd. the use of medication in addition to psychotherapy has been shown to be beneficial in the treatment of ptsd. antidepressants. several types of antidepressants are used to treat ptsd , [ ] [ ] [ ] [ ] , : • monoamine oxidase inhibitors • selective serotonin reuptake inhibitors • selective norepinephrine reuptake inhibitors • tricyclic antidepressants each medication class offers a variety of options and side effects. given there is no "one size fits all" approach to the patient with ptsd and/or other psychiatric illnesses, it is suggested the clinician confer with psychiatric and mental health specialists; especially advantageous would be working with colleagues who have expertise in treating returning troops. one of the most important services primary care clinicians can do for returning troops, especially those suffering from ptsd, is to acknowledge the traumatic events and resultant responses. in a military survey, over % of patients indicated the traumatic event they experienced is important and relevant to their care. of note, in a va study, over % of patients in va primary care settings will have experienced at least one traumatic event in their life; most have experienced four or more! given the relationship between exposure to a traumatic event and increased health care, utilization appears to be mediated by the diagnosis of ptsd. health care professionals treating returning troops should be mindful of the essential features of ptsd (table ) . tables - offer some key domains and verbal prompts when interacting with patients who have returned from the gulf war. it is important to acknowledge that the health problems associated with ptsd may represent the dynamic interplay of neurological, psychological, and behavioral factors. ptsd can lead to neurobiological dysregulation, altering catecholamine, hypothalamic-pituitary-adrenocorticoid, endogenous opioid, thyroid, immune, and neurotransmitter systems. patients often take their cue from us as health care professionals. speak calmly, with a matter-of-fact voice in a nonjudgmental demeanor. reassure the patient that you will be there for him or her over the long haul and that treatments are available and will be provided either by you or by arranging appropriate care. remember, if you must refer out, remind the patient that you are still involved in the care and not abandoning him or her. keep a timeline so that as the patient makes progress, you can convey it visibly and encouragingly. if the patient experiences a flashback, remind them that they are in your office and state the date and location. offer water and other comfort measures as needed. battle-injured soldiers present another group of patients. a recent study examined the rates, predictors, and course of probable ptsd and these questions allow the hcp to acknowledge the relevance and importance of the event. • "have you recently returned from the persian gulf?" • "how has your adjustment been back home?" • "do you have family members or friends who are currently in the persian gulf?" • "how are you dealing with their absence?" • "how has the war in iraq or afghanistan (or name) affected your functioning back here?" regardless of their specific duties in or relationship to the war, the hcp should recognize and normalize distress that is associated with the conflict. • "i am so sorry you are struggling with this" • "this has to be a very difficult time for you" • "i have other patients who are struggling with what you are dealing with" use these as opening points to convey concern, validate their struggle. do not patronize. also, if you have not experienced war, do not say that you know what they are going through . . . you do not! another important group of returning troops from the persian gulf are health care providers. a recent study was conducted to determine the level of ptsd and depression among hcp deployed to combat settings. of respondents, % met the criteria for ptsd and % met the criteria for depression. albeit a small study, anonymous surveys revealed deployment exposures and perceived threats during deployment were risk factors for ptsd. of note, it appeared that exposure to wounded or dead patients did not increase risk. our colleagues are not immune to the mental or physical injuries of war; we should be alert to behavioral changes in hcp returning from the persian gulf. there remains a stigma associated with mental health. almost one in four americans will suffer from a mental illness per year, yet only a fraction will receive appropriate care or be effectively treated. stigma, shame, access to experienced mental health care in the community, concerns about abandonment, and cost are some of the issues facing persons with mental illness. as health care professionals, we can do much to help destigmatize their psychiatric disease and assist with proper referral and follow-up. increasingly, civilian hcp may be called upon to provide care to returning veterans. the president's commission on care for america's returning wounded warriors reported a lack of mental health professionals to serve military personnel and their families. as of march only of the va hospitals and clinics contained inpatient ptsd centers. of additional concern, there are only two va facilities that treat women exclusively. , , clearly the demand for mental health care for returning troops can be expected to increase dramatically in the coming months and years. the veterans of operation iraqi freedom and operation enduring freedom who are eligible for years of free military service related health care through the va. however, it is important to recognize the value of civilian health care, especially given the va may not be able to handle the increased demand. according to the office of inspector general of the department of veterans affairs, it appears that the va repeatedly understated wait times for injured veterans seeking medical care and in many serious cases forced them to wait more than days, counter to department policy. of concern, only three in four veterans received timely appointments albeit va reports to congress stated % of veterans received such care. in the immune globulin (ig) expressed concerns that over , veterans were on waiting lists. , , regardless of etiology, returning troops deserve prompt care. the va may not have the surge capacity to provide the access and quality required and thus military, va, and civilian medical communities will need to collaborate more closely over the coming months. with the new roles the military faces, the frequency of deployment into a threat zone or overseas has increased in the past years since the first persian gulf war. such deployments not only pose a threat to the troops but can be a challenge to the military families left behind. medical or emotional/behavioral problems as well as financial problems may preexist and with the resulting loss-temporary or permanent-of a parent or spouse can destabilize an already precarious situation, creating significant problems for the family. because the u.s. military is all volunteer, the heavy responsibilities are carried by two distinct sources of troops-the active military and reserve or national guard, who can and have been activated as well as deployed to combat areas. a significant proportion of those serving in iraq and afghanistan are from reserve or national guard units. do we inquire of our patients if they are active, reserve, or former military or in families of a deployed troop? such information is critical especially to assist us in anticipating challenges our patients and their families may undergo. while the active duty military family lives with deployment as part of their life, and often lives within military communities where a readymade support network of friends with similar issues and government services are nearby, reserve or national guard service members and their families reside in nonmilitary communities and work in civilian jobs generally remote from military resources or support groups. families of reservists can feel isolated and less supported. there are many commu-nities that have few or none being deployed in active duty and thus are neither familiar with nor equipped to provide the support necessary to a civilian family that has instantly become a military family. beyond the normal worries for a loved one in a war zone are the financial concerns, especially if deployment results in loss of income in the transition from a high paying civilian job to a lower paying military one. children can be impacted, especially if the community is demonstrably "antiwar"-adults can often separate the "antiwar" from the "antiwarrior" sentiments; children may not, thus causing a variety of emotional challenges that a savvy clinician should be attuned to and inquire about. [ ] [ ] [ ] [ ] according to the iraq war clinician guide nd edition, there are emotional cycles associated with deployment that have been divided into five stages, each associated with specific emotional issues that should be anticipated and addressed. these include the following: ( ) predeployment; ( ) deployment; ( ) sustainment; ( ) re-deployment; and ( ) post-deployment. pre-deployment. this occurs from the time the family is notified of deployment to when the military member leaves. it often involves psychological denial, intense mental and physical preparation, and anticipation of the departure. deployment. this is the phase from the time the member leaves through the first month of deployment. significant emotional turmoil can occur, especially if the military member is a parent and the family attempts to reach a functional equilibrium. a variety of feelings and emotions occur including numbness, sadness, feelings of isolation, and abandonment. family members may need to incorporate the roles filled by the deployed parent. critical is the communication from the deployed member of the family-providing a realistic appraisal of the new environment, which can be reassuring. from a clinical perspective, it is important for hcp to anticipate such phases and to realize family members will experience these phases differently depending upon their cognitive/developmental stage. sustainment. this is the phase that spans from month post deployment to month before the announced return date. it is usually marked by "settling into the new routine" and going on with life business as usual. if a family cannot return to this business as usual, especially in the absence of one parent, children may have an especially difficult time. moreover conflict between the service member and spouse can result, especially if communications are not widely available and thus preclude resolving disagreements or challenges. re-deployment. this phase occurs from the month before the expected return to the actual physical return of the service member. as one would expect, it is a period of intense anticipation, a variety of emotions, including fear, anxiety as well as excitement. post-deployment. this is the phase beginning with when the service member returns and ending when the family has reestablished equilibrium. this may take several months. although the homecoming can be a time of great happiness, it can also result in frustration and feelings of "let down" from unrealistic expectations about the reunion. the service member may also experience frustration in finding the family has made some changes or had experiences that he or she were not part of. the spouse/parent left behind may have emerged into a new role of leadership or independence that may conflict with the returning member who begins to exercise formerly held authority. marital couples may take time to reestablish physical and emotional intimacy. undiagnosed ptsd, substance abuse, the trauma of war, or other psychological morbidity can impact on the reestablishment of the loving partnership; the astute clinician will anticipate this and work with the family before and during the reunion. overall it is important that the deployed member reassert his or her role within the family to reestablish a healthy family equilibrium. not unexpectedly, children respond to deployment in very individualistic ways depending upon their age and psychosocial and cognitive developmental periods. infants (Յ months of age) tend to respond to changes in their environment, schedule, or presence and availability of their caregivers. worrisome signs include apathy, refusal to eat, even weight loss. toddlers ( - years of age) usually take their cues from their primary caregiver. as such, if the non-deployed parent is coping well and present, the toddler should be expected to cope well. signs of concern include new onset sullenness, temper tantrums, tearfulness, and sleep disturbances. clearly, socializing the child-play dates, support from other parents-is critical both for the toddler and for the remaining parent. preschool children ( to years of age) are more keenly aware of a parent's absence. worrisome signs include regressive behaviors in a variety of domains including toileting, thumb-sucking, separation anxiety/clinginess, and sleep disturbances. irritability, aggression, depression, or somatic complaints may occur. while these can also occur in nonmilitary children, nevertheless, the are worth follow-up. the parent and clinician should be vigilant for children who think their parent left because of something they did. these inaccuracies of thought should be addressed rapidly and in a matter-of-fact manner, discussing the deployment briefly but honestly. this is critical, especially if the military parent gets killed; children should not bear the guilt of their parent's death and thus feelings of responsibility about the deployment should be immedi-ately dispelled. increased attention by the remaining parent, conversations with images of the deployed parent about how much he or she loves the child, and maintaining family routines including physical and emotional warmth are critical. school-aged children ( to years of age) may manifest their emotional issues by "acting out" or exhibiting irritability, aggression, or complains and whining-which may be uncharacteristic of the child prior to the deployment. given children are increasingly being exposed to information through their friends, the internet, and other media, it is important to have regular discussions with the child, to allay their worries as opportunities for information sharing. ideally parents should limit the amount of media exposure children receive during times of war; in the information age, this may be easier said than accomplished. therefore, regular conversations with children are important to address their concerns factually and with love. the age of initiation of alcohol and tobacco occurs from to years of age. [ ] [ ] [ ] [ ] experimentation to chronic use can worsen in the child of a deployed parent. teenagers ( to years of age) may behave similarly to children in terms of irritability, rebelliousness, or other challenging behaviors. , good communications should be encouraged as their concerns about the deployed parent (and the possible impact losing a parent can have on them and the family) may manifest in destructive ways. helping the non-deployed parent to set clear and realistic expectations about behavior, school, and home life can provide supportive structure. the non-deployed parent should be counseled to observe for high-risk behaviors, sexual acting out, or changes in behavior that may result from substance abuse. clinicians can help their patients and families through these challenging times by anticipating these needs prior to deployment and assisting the remaining family members. , , moreover, underscoring the role of the remaining parent in promoting healthy family dynamics that include planning, encouragement, interaction, and education can make the deployment and sustainment phases less harrowing. young children can better visualize the time gap between deployment and return using a chart or timeline, perhaps with stars on the different days representing how helpful the child has been in the parent's absence, which can serve as a gift to the returning parent. other ideas and resources can be found in the references. the clinician should be mindful that the parent will need support and social encouragement as well. working with the family, identifying possible sources of support, and working with the patient as well as the organizations such as churches and other natural networks including the parent-teacher organizations can be highly beneficial. , , , , dostoyevsky once opined that a society can be judged by how it treats its prisoners. as physicians, we could argue as a take off on this concept that a society should also be judged by how it treats its veterans and those charged with protecting our freedoms. if this is the benchmark upon which a society should be judged great or glaringly wanting of moral clarity and direction, what does it say about the u.s. when nearly % of the homeless are veterans and that the rate of convergence for recently returning veterans of iraq and afghanistan, ie, from having a home to becoming homeless, is faster than at any other time in american history?! what does it say when the va office of the inspector general report states that returning veterans are receiving less than optimal care, and must wait an exceedingly long time for such care?! , , homelessness. according to the va, approximately , veterans of all ages were homeless on any given night during . , as if almost , veterans was not troubling enough, the fact that between , and , veterans are chronically homelessness-those who live either on the streets or in shelters for more than a year-is even more troubling. while veterans make up % of the population, they comprise % of the homeless on any given day. so far, more than veterans of the iraq and afghanistan war have turned up homeless in washington, dc. the va and other aid groups say there will be a surge in homeless veterans-returning troops-in the coming years. according to experts who work with war vets, and based upon the vietnam veteran experience, it often takes several years after separating from the military before veterans' problems evolve to a point that drives them into the streets. of concern, some veterans of iraq and afghanistan are already turning up at homeless shelters, and the amount expected could be enormous. as discussed earlier in this monograph, severely wounded troops who would not have survived their battlefield injuries in previous wars are returning home, albeit traumatized and often with chronic illness or disability. these disabilities include tbi, ptsd, prosthesis, hearing deficits, visual loss, or a combination. thus the special trait of this war and resultant "survivors" may contribute to the increased homelessness, especially ptsd and tbi, both of which can cause unstable behavior, and lead to substance abuse. these, plus perhaps the impact of longer tours of duty and recall of troops who should have separated from the military, which leads to protracted absence from families, may make reintegration into home and work more difficult. in oif more women were serving in combat zones and thus experienced ptsd. in addition, a significant number of women troops have experienced sexual abuse, which is also a risk factor for homelessness, as supported by a recent government survey that disclosed almost % of the homeless female veterans of recent wars reported being sexually assaulted by u.s. soldiers while in the military. , more than % of newly homeless veterans are women. of concern is the loss of jobs reservists have experienced upon their return. while by law their job must be preserved and await their return, employers are often ignoring this. as a result, sen. edward kennedy (d-ma) and other legislators are working in congress to enhance the protection for troops and increase the penalties of employers who ignore their responsibilities for profit. we should not tolerate such behavior in our communities. home costs and apartment rents may also contribute to the problem. according to the national alliance to end homelessness in washington report of november , among one million veterans who served after the september attacks, over , are paying greater than % of their incomes for rent, which leaves them highly vulnerable. nevertheless, the primary factors that enhance the risk for homelessness are untreated ptsd, substance abuse, depression, and other psychiatric illness. soldiers have a great deal of pride in what they do and who they are, and rightly so. this may also contribute to delays in seeking help. as discussed earlier, we may be the front line or perhaps the only line of defense for our patient with such mental health needs in our communities. what services-job training, home health, housing, social, and psychological-are available in your community and will they be enough if gulf war veterans start returning home? now is the time to lay the foundations and prepare for the needs of our troops. as physicians, we can and must be the catalyst for change and ensure the support services that enhance our care plans are in place or available whether by collaborating with other communities or reaching out to the va for remote services. some construction companies have dedicated resources to building low-cost homes or pro bono work in concert with volunteers to make a difference in their communities such as "homes for our troops" (see resources section). before , plus troops return to the u.s., we should assess our resources, address our care gaps, and prepare our communities now. a recent study of four returning combat infantry troops-three army units and one marine unit-were surveyed to months after return from iraq or afghanistan combat or security duty, both of which are highly hazardous assignments in those regions. the percentage of study subjects meeting criteria for major depression, generalized anxiety, or ptsd was significantly higher among those serving in iraq than afghanistan. of those who had positive responses consistent with a mental disorder, only to % sought mental health care. respondents indicated there were barriers to receiving mental health-waiting times, but most often the perception of stigma among those most in need of mental health care. given these troops are likely representative of their colleagues who continue to be involved in pgw ii, preparing our practices to address the mental health needs of returning troops is critical. the stigma of mental health is not isolated to military personnel; it remains a persistent challenge. moreover, patients can feel abandoned when referred from our practice to a mental health professional. clearly communicating that they are not being "turfed" but instead are being offered specialist care, similar to being offered cardiology referral if a heart defect was found and reassuring the patient that the mental health professional is one more member of a team that will still center around the patient and primary care provider, can enhance the likelihood of obtaining care. increasingly evidence suggests collocating mental health services as part of the medical practice has improved outcomes. in some rural areas advanced planning will be required to increase opportunities for referral and access to mental health services. clinicians in such areas may want to reach out to the nearest va center and establish a collaborative relationship with ptsd and other services in anticipation of patients returning from the persian gulf. motor vehicle accidents (mva). large-scale studies following male and female gulf war i veterans over several periods of time after return from the middle east demonstrated a significantly higher risk of death from accidents, especially motor vehicle accidents (mva) during the initial years home. [ ] [ ] [ ] , of note, many were not wearing seatbelts. however, by the sixth year post war, the relative risk of mortality due to mva had fallen significantly. these results are consistent with a mortality study of vietnam war veterans. they, too, experienced excess mortality from mva, which was most pronounced in the first years after serving in vietnam. after the fifth year, the mortality rate from mva for vietnam veterans paralleled non-vietnam controls. given mva are a leading cause of death among adolescents and clearly a worrisome cause of death among newly returning war veterans, it is important for clinicians to alert troop patients about this risk and the cofactors that are likely to be at play-alcohol and other substance abuse, exhaustion, work, stress, or coping related, medication effect. it is well described that adolescent males who drive with passengers are more likely to be involved in an mva; returning troops who are adolescents or young adult males are not immune to this reality and should be counseled about the trend in mortality associated with returning war veterans and mva. opening up such dialogue may also make discussing seatbelt use and substance abuse more likely. there has also been an increase in traumatic death among gulf war i veterans. , , , , a population-based survey of , gulf war veterans revealed that, since the war, these veterans have been involved in serious accidents, injuries, and illnesses, more than non-gulf veterans. high-risk activities post war may be part of the etiology. ptsd has also been shown to contribute to excess number of deaths due to trauma. substance abuse. roughly one-third of the u.s. population meets criteria for problem drinking , , , ; it is not unreasonable to expect this proportion to be higher among individuals with varying degrees of behavioral issues or facing horrific challenges as significant life stressors. an example of a population at risk is the young men and women facing impeding deployment to a combat zone or those who are already participating in the war. fortunately, most reactions are generally mild and transient, as healthy coping mechanisms emerge to the stressor. however, in others fear and uncertainty precipitate unhealthy actions. maladaptive behaviors manifest in a variety of actions-substance abuse, abusive behaviors to others-sexual or pugilistic, and a host of psychiatric morbidities. therefore, the hcp who has patients potentially being deployed should anticipate the psychosocial as well as medical needs including a predeployment substance abuse screening. , clearly, in the context of primary care, patients should be screened for risk behaviors regardless of their military or occupational status given the prevalence of substance abuse; nevertheless, those about to enter a war zone present an obvious population in need for guidance. rapid recognition of this potentially life-changing stressor and the need for the hcp to provide resources to develop safer coping mechanisms than alcohol or other drug abuse is essential. screening for substance abuse requires a three-stage strategy that should focus on behavior pre-deployment, during deployment, and return from deployment. , in terms of reservists and national guard troops, there is the potential for "slipping through the cracks" if we as clinicians do not follow the same playbook, given active military may receive their care from military clinical facilities and nonactive duty from civilian health care. nevertheless, each stage warrants brief, focused screening. the goal for returning troops is to ensure they are able to cope with daily life and reconnect with family, friends, work, and society. in addition to ptsd and other mental illnesses, battlefield wounds is the deleterious impact of substance abuse on the critical domains of daily living. there are a variety of screening tools available. , [ ] [ ] [ ] it is important to validate the patient's concerns, that yes, a war zone is a dangerous place, and acknowledge that an impending deployment elicits a wide range of emotions from fear to excitement. asking the patient what best characterizes their reaction is a nonthreatening way to open the dialogue. it can be adapted to the returning troop as well. a statement such as, "how are you (have you) handling your concerns/anxiety/fear?" or "some people find that drinking more alcohol, smoking a few more cigarettes, drinking more coffee, or doing drugs like pot help relieves the stresswhich of these has been your approach?" if such questions have resulted in insights about substance abuse, then a more formal screen with either the quantity-frequency questions (table ) or the traditional cage screening should be administered (table ) . , [ ] [ ] [ ] [ ] of note, combining the quantity-frequency and cage questions with the patient interview can reliably predict to % of individuals with alcohol abuse or dependency. this approach can also be adapted to illicit drug use. the caveat, part i . "on average, how many days a week do you drink alcohol?" . "on a typical day when you drink, how many drinks do you have?" . multiply the days of drinking a week times the number of drinks ϭ score. scoring: any score exceeding for men or for women suggests an at-risk behavior. part ii . "what is the maximum number of drinks you had on any given day since learning about your deployment (or during deployment)?" ϭ score. scoring: any score exceeding for men or for women suggests a potential alcohol problem. c ---"have you ever felt that you should cut down on your drinking?" a ---"have people annoyed you by criticizing your drinking?" g ---"have you ever felt guilty about your drinking?" e ---"have you ever had a drink first thing in the morning (an eye-opener) to steady your nerves or get rid of a hangover?" individuals who answer "yes" to of the cage questions over the past year are likely to be alcohol dependent. individuals who answer "yes" to or of the cage questions may likely have alcohol abuse. however, is that no predetermined cutoff scores have been validated when adapting tables and for the wide range of illicit drugs, including narcotics, marijuana, ecstasy, cocaine, and designer drugs. nevertheless, it is critical and good medical practice to explore these risks with the prethrough post-deployment patient. realize once the patient arrives in the theater of operation, combat stress can amplify preexisting, under-, or untreated substance abuse or mental health issues, underscoring the importance of addressing this with your military (active, reserve, or national guard) patient. there is a sizable "black market" in iraq and the middle eastdiazepam and alcohol, among other substances that are used to selfmedicate-are readily available. herbal products, over-the-counter medications (some of which are controlled substances in the u.s.), even steroids, are available, some of which may not be made according to food and drug administration or good manufacturing standards and thus the military patient should be counseled about the risks of such products. clinicians should be alert to behavioral changes consistent with withdrawal; some of these can be misinterpreted as associated with other morbidities. sleep difficulties, agitation, anxiety, and autonomic hyperactivity can indicate withdrawal, not just combat stress disorder. the correct diagnosis is critical and warrants appropriate, timely evaluation. patients returning to the u.s. after deployment in a combat zone may have significant substance abuse, perhaps even new onset abuse, as well as stress-related behavioral issues, psychiatric illness, and/or traumatic brain injury-all of which share similar signs and symptoms, but presenting widely different diagnostic, therapeutic, and prognostic implications. the fact that ptsd, substance abuse, and combat-related neurological trauma can coexist in a returning pgw ii patient poses a diagnostic challenge and thus hcp should be alert to these issues, providing counsel, reassurance, diagnostic and treatment resources, education, and ongoing follow-up to the servicemember patient. sexual abuse. military sexual trauma (mst) refers to both sexual harassment and sexual assault occurring in military settings. men or women can be victims or perpetrators, although most often women are the victims and men are the perpetrators. va statistics from october through december report females and males seeking medical care stated they were sexually assaulted or harassed. a somewhat unique aspect of mst is that it occurs in a setting where the victim lives and works. civilians do not often live and work in the same environment, unlike the military, which ultimately has its own legal rules (uniform code of military justice) and social norms. as such, the victim often must live and work closely with their perpetrators, which can lead to an ongoing feeling of victimization, feelings of helplessness, and exacerbating the trauma. victims may also rely on their perpetrators, who may be supervisors with enormous influence on careers. an unprecedented number of women are serving in pgw ii compared to prior wars. overall, more than , female servicemembers have been deployed to the middle east, including iraq and afghanistan, compared with who served in vietnam and , in pgw i. although typically limited to combat-support roles, as the battlefield lines are blurred and combat occurs in the streets, roadside bombs, ambushes, guerilla warfare have all virtually eliminated the safety categories and distinction between combat and support roles. ironically driving a truck in iraq is considered combat-support, yet with ied and roadside bombs, this activity is turning out to be one of the most dangerous jobs in pgw ii. camp victory was attacked by mortars, resulting in several deaths including two servicewomen. as such, women are in harm's way with their male counterparts. the impact of combat on women, especially in terms of psychiatric illness such as ptsd, remains to be fully characterized. most data on ptsd and women are derived from civilian research and usually related to sexual trauma, including rape. , a dod report revealed nearly one-third of a nationwide sample of female veterans who sought health care through a va said they experienced rape or attempted rape during their military service. of that group, % reported that they were raped multiple times and % reported being gang-raped. a small va study following pgw i suggested that rates of sexual harassment and assault rise during wartime. from to nearly , women veterans reported being victims of sexual assault or harassment, sometimes from fellow servicemembers. , , compared to the civilian population, men and women in the military have been shown to have higher rates of sexual and physical abuse in their backgrounds than the general population and women entering the military are likely to have more traumas accumulated than their male counterparts. although a small percentage of male veterans revealed being sexually abused/assaulted, the overwhelming majority are women. as such, women experience what has been referred to as a "double whammy" in pgw ii: military sexual trauma and combat exposure. what impact this will have ultimately on the psychiatric health of returning women from the gulf remains to be seen. while sexual trauma presents diagnostic and treatment challenges among civilian patients, the additional impact of military life and the pervasive sense among many military women that reporting a sexual crime is seldom worthwhile can enhance feelings of vulnerability, loss of control, and fear and exacerbate the effect of other traumas. since many of the perpetrators of the sexual abuse are supervisors, reporting such traumas can place the victim in a challenging position-career-wise, among colleagues, and just the normal pain attendant with reliving the event during the vetting process of a formal complaint. also, unlike the typical male bonding that occurs among wartime combatants, small studies suggest this is not the case among female troops during deployment. such isolation can contribute to the deleterious impact of a wartime experience and is worth remembering when treating female military patients-current or retired, as the signs and symptoms of untreated mental illness resulting from such events can persist and go unaddressed or be considered associated with other issues. interestingly, such isolation does not appear to occur among reserve and medical units or when commanders establish a zero tolerance for such sexism. female veterans who use va health care and report a history of mst also report a range of negative outcomes that include poorer health (mental and physical), readjustment problems following discharge (finding work, homelessness, substance abuse), and unresolved mental health issues. studies of sexual assault among civilians identify ptsd as a frequent outcome. interestingly, rates of ptsd associated with mst seem higher than those associated with combat exposure. major depressive disorder is another common reaction following mst. a large-scale study revealed, not surprisingly, that rape survivors compared to nonvictims were times more likely to use major drugs and times more likely to use cocaine. anger, shame, guilt, and self-blame are all associated with mst and sexual trauma in general. moreover, difficulties with trust, social avoidance, and sexual dysfunction may also result-the impact not only seen in the victim but perhaps with loved ones, significant others, life-partners, or spouses. it is important to screen all patients but especially military (active, reserve, national guard, or veteran) for a history of sexual harassment (verbal or physical) and assault. mandated by the va, it is good clinical practice for civilian providers as well. when screening for sexual trauma, avoid terms that may trigger negative responses, are stigmatizing, and may assume an interpretation different from that of the patient. , , these include "rape" and "sexual harassment." instead ask questions in a supportive way and with more open-ended, nonthreatening phrases. examples include "while you were in the military, did you ever experience any unwanted physical or sexual attention, verbal remarks, touching, or pressure for sexual favors?" "did anyone ever use force or the threat of force to have sex or physical contact with you against your will?" remind the patient this conversation is privileged; you care about her/him and are a trusted resource. patients who may have to undergo forensic rape examinations are often less traumatized if education is provided, realizing the examination can present powerful triggers. resnick and schnicke prepared a -minute educational video that has been shown to reduce post exam stress compared to patients who did not view the program. data are scant in terms of validated measures specifically designed to assess mst. most checklist measures currently available include a least a question about sexual assault but do not usually assess sexual harassment. several self-report measures and structured interviews do exist and are designed to assess sexual harassment and sexual assault. one such tool is the sexual experience questionnaire by fitzgerald, the most widely used measure of sexual harassment. interview guidance can be obtained from the national women's study interview developed by resnick and schnicke. clearly the most important issue is to engage in the dialogue and elicit information that can lead to appropriate intervention. while there are treatments available that can reduce the psychological impact of sexual harassment and sexual trauma, improving the victim's quality of life, there are little outcomes-based data on the treatment of mst. nevertheless, given the results of treatment outcomes with civilians, these can be used to guide treatment of veteran populations until such a time that best practices can be identified for military victims of sexual trauma. , , , key interventions start with addressing immediate health and safety concerns, normalizing posttrauma reactions, validating the patient, supporting their existing positive adaptive coping strategies, and helping the patient develop additional coping skills. addressing the cognitive and affective reactions such as fear, self-blame, anger, and other issues is important. referral to appropriate mental health expertise but in the context of a collaborative team approach is essential. it is important to recognize the feelings of vulnerability; thus referral without explanation can lead to feelings of abandonment. reassuring the patient that you are going to be working with her or him even while the trauma specialist is on board underscores you are bringing on an additional member of the health care team, and that the patient is not being sent away. another valuable preparation for community clinicians is to assess and become familiar with the level of local resources available to your patients who may be victims of sexual abuse or mst in advance of returning pgw patients, helping to address gaps in your region, and working with professionals in the field to increase options for care. new threats to our troops have emerged given the evolving nature of battlefield medicine. more severe, even horrific wounds-traumatic amputations, burns, head injuries-are now survivable but at what impact to the survivor and his/her family? , , , , , , , , , , long-term care, the mental and well as physical component of rehabilitation, and readjustment to the u.s. all require hcp to be engaged and aid the civilian troops navigate the often dizzying array of required health care often amid red tape and limited resources. psychological morbidities-ptsd, depression, anxiety, substance abuse, and tbi-are significant problems for troops serving in and returning from pgw as well as for some of those preparing for deployment. , , given many of the troops-male and female-are not full-time active military, it is likely they receive medical care from civilian hcp. reports confirm there is a gap between services needed and available-access, cost, quality, and quantity all need to be addressed from a federal, state and local, military, and civilian perspective. [ ] [ ] [ ] , the role of the civilian hcp cannot be stressed enough! the rates of sexual abuse and mst are on the rise as the number of women in the military, especially in combat zones, increases. female troops are increasingly in harm's way as the distinction between combat and combat support roles blurs amidst a guerilla war. whether mst, tbi, or the fog of war-the complexities of treating female troops represent a unique challenge unseen in prior wars. whether male or female, the need for mental health services in addition to addressing the physical ailments associated with war will likely exceed current capacity. , , primary care clinicians and civilian specialists will be called upon to fill the voids and must be attuned to the special needs of our servicemen and servicewomen. the united states is no longer isolated from a dangerous world or protected by its geography. , - , , , oceans and borders can be readily crossed, making the united states as vulnerable as other nations to acts of terrorism. geoglobal and societal factors have combined to create conditions that facilitate the emergence and spread of previously unknown clinical entities such as severe acute respiratory syndrome (sars), emerging pathogens not common to the united states but endemic to other regions, such as west nile virus, and relatively harmless viruses evolving into highly lethal pathogens such as the hpai h n strain of avian influenza as well as the intentional release of biological weapons. , , , over the last few years we have seen the appearance of monkeypox in the united states as the result of animal importation, and plague patients diagnosed in new york (contracted it in the southwest). war, increased globalization, climate changes, encroachment of previously untouched natural habitats, worldwide food distribution, human population growth, overcrowding, and travel all favor the spread of infectious diseases-especially ones not commonly seen in the u.s. , , , , , tens of thousands of our servicemen and servicewomen will be returning from the persian gulf-many of whom may have been exposed to undetected chemicals or bioweapons, or be infected with diseases endemic to the region. certain "desert illnesses" as well as brucellosis, mosquito-borne diseases, can present with central nervous system, behavioral, and mental status changes. will we diagnose them correctly or will their return be marked by another "persian gulf syndrome?" this syndrome in the early postwar years became synonymous for ptsd. in reality, it represented a variety of etiologies ranging from chemical exposure, desert illnesses, as well as ptsd. therefore the threat of uncommon illness is but the reality of our future practices. the physician should remain alert for such exigencies. if the intentional use of anthrax in taught us anything, it was that an astute physician could save lives. equally, physicians who do not know the common signs of serious, perhaps deadly, emerging illnesses will lose lives. emerging infectious diseases can pose a significant diagnostic challenge and threat to our communities. whether increasing our knowledge and vigilance against emerging threats for our troops or communities, even in a profession fraught with numerous competing demands, the benefit of being able to diagnose rapidly and accurately the index case of an emerging pathogen or helping a servicemember return to health and society is worth the effort. the optimism of the "antibiotic era" and our so-called victory over pathogens should be tempered by the realization that . million annual deaths are the direct result of tb, aids, and malaria, according to the who. this represents approximately one-fourth of the deaths worldwide per year-the result of three infectious diseases. multi-drug-resistant tb and extremely drug-resistant tb are on the increase and pose a significant threat worldwide, including the u.s., where in certain regions and among certain risk groups it remains a significant health problem. , , , , recognition of the potential for troops to import an illness endemic to the middle east and a basic familiarity of the clinical syndromes associated with emerging pathogens-whether those previously unknown, pathogens spread to new areas by global forces, or biological weapons-and subsequently implementing containment and treatment measures will largely rest upon the clinical acumen of the physician. , , , maintaining an index of suspicion for relatively uncommon illnesses-this includes the common presentations of heretofore nonendemic (to the u.s.) infections, staying abreast of trends in travelrelated illness, and emerging patterns of disease, especially in the middle east, using easily obtained sources such as the who internet site may enhance the likelihood of recognizing an uncommon illness. while the incidence of imported infectious disease presenting to hcf is not well defined, , it is well known that significant numbers of patients present to medical facilities upon return from traveling with a variety of complaints, including respiratory infections. studies suggest clinicians do a poor job of obtaining a travel history, including a general lack of awareness by physicians concerning the potential for nonendemic disease in the population that they attend. , in one such study evaluating whether a travel history was recorded in patients, a travel history was recorded in only % of all patients presenting to this emergency department, although among total number of patients presenting to the emergency department, . % actually had the potential for a travel-related illness. , while many of the illnesses that troops are likely to import are not contagious, we should take small comfort in that it only takes one missed case of a contagion to cause an outbreak! physicians and hcp should consider the physical, rehabilitative, and mental health issues within the broader context of a patient who has been in a war zone and now must reenter and adjust to society, job, and family. addressing these domains as part of the overall therapeutic and clinical management plan is critical. moreover, these domains, including financial pressures, will impact recovery, not unlike our civilian patients. however, unlike noncombatant civilians, our civilian troop patients may have faced dramatic, draconian, and devastating experiences unfathomable to their neighbors and thus requiring appropriate medical service. being sensitive to the self-image and pride of these patients, prearranging or collocating psychosocial services, and allowing for seamless care has been shown to improve outcomes. integrating psychiatry and primary care, often referred to as co-location, is effective for improving access to mental health services and for increasing treatment engagement. hcp may be treating the noncombatant family member as well. psychological morbidities can affect loved ones not deployed and, thus, these patients should be screened and counseled. financial worries can cause significant stress and, in a nonthreatening manner, compassionate concern and gentle inquiry should be provided. physicians are often in a position to provide guidance as community leaders and may aid in "networking" on behalf of a financially challenged patient. it is likely some of our patients serving in pgw will experience some form of injury from mst/sexual abuse, ptsd or other psychiatric illness, physical wounds, or a combination thereof. like most patients, they may feel a total lack of control. empowering patients and involving them as active participants in their medical care, education, and choices is an important therapeutic approach. more than , u.s. troops have been deployed to the gulf region. secretary of va principi stated that "we have learned every battlefield poses unique dangers. there are bullet wounds and shrapnel wounds, but there are those things that may not manifest themselves for years. we have to make sure that our system is capable of providing care for them." he is right! it cannot just be the va. it takes a village or a community! as physicians and hcp, we enjoy many privileges in a free nation. we have the benefit of working in far safer conditions than our servicemen and women in iraq, afghanistan, and other dangerous locations worldwide. freedom is not free and we have the opportunity to use our professional skills, community position, and network of colleagues to provide for a special population that placed itself in harm's way for us. deploying to or returning from war presents a spectrum of emotions, risks, injuries, and therapeutic challenges. troops must reenter society after experiencing the horrors of war, the loss of friends, injuries, and deprivation not encountered in the u.s., or they are preparing to enter such a challenging environment, leaving friends, family, safety, and the comforts of home. unlike previous large-scale wars such as wwii or korea, except for families and friends of troops, most u.s. citizens are not engaged in, impacted by, or involved with the war on a daily basis. civilian hcp are in a unique position to help prepare the young men and women who serve as civilian military (reservists/national guard) and active military who may be our patients, for deployment, provide comfort in the knowledge that we will keep a watchful eye on their loved ones-also our patients, in their absence, and be prepared to care for them upon their return to the u.s. builds and remodels homes for severely wounded troops. phone: - - troops. for more information, review their internet site: http://www. homesforourtroops.org/site/pageserver?pagenameϭabouthfot provides helmet upgrade kits to troops in iraq and afghanistan (and about to be deployed); shock-absorbing pads enhance protection against ied and decrease risk of tbi. phone: - - - from to cst or visit their internet site at: http://www.operation-helmet.org/index.html post this information for patients. if a patient is in need of immediate crisis counseling, please contact the va's suicide hotline at - - -talk; counselors are available / to help. an advocacy and humanitarian organization to ensure that our country meets the needs of servicemembers and veterans who have served in oef and oif. veteran's for america focuses on psychological traumas and traumatic brain injuries. resources also for women veterans. internet site: http://www.veteransforamerica.org/military-women/ the central resource for women veterans in the commonwealth of massachusetts. the veterans administration also has resources for women. http://www.mass.gov/?pageidϭveteranstopic&lϭ &sidϭeveterans&l ϭ home&l ϭwomenϩveterans the following may be able to assist veterans and their families: the department of defense (dod) has opened the military severely injured joint support operations (msijso) center ( / ) to help severely injured service members find jobs and answer their or family member questions. toll free - - - . the dod and www.military.com have partnered to create an online career center that can assist severely injured service members with benefits, resources, and employment opportunities. in each of the va medical centers, there is an elk committee at work to help veterans in need, including those who are homeless. bpo elks, usa. n. lakeview avenue, chicago, il . dav develops financial resources for the assistance, care, and support as well as rehabilitation of disabled veterans and their dependents. alexandria pike, cold spring, ky . ph: - - - . a resource and technical assistance center for community-based service providers and agencies that provide emergency and supportive housing, food, health services, job training placement assistance, legal aid, and case management. ph: - - - ( - -vet-help) nahhh is a network of Ͼ organizations throughout the u.s. providing family-centered lodging and support services to families and their loved ones confronted with medical emergencies. ph: - - - . of note, some states (connecticut, for example) establish funds to provide emergency financial assistance. internet site: www.va.gov the intrepid fallen heroes fund provides support toward the severely injured. in january , the fund completed construction of a $ million world-class state-of-the-art physical rehabilitation center at brooke army medical center in san antonio, texas. the "center for the intrepid" serves military personnel who have been catastrophically disabled in operations in iraq and afghanistan, and veterans severely injured in other operations and in the normal performance of their duties. the , square foot center provides ample space and facilities for the rehabilitation needs of the patients and their caregivers. internet site: http://www.fallenheroesfund.org/ in harm's way: infections in deployed american military forces old world leishmaniasis: an emerging infection among deployed us military and civilian workers impact of illness and non-combat injury during operations iraqi freedom and enduring freedom defense intelligence agency, armed forces medical intelligence agency. medical threat assessment-northern iraq q fever and the us military va research and development. united states department of veterans affairs burden of medical illness in women with depression and post-traumatic stress disorder can we prevent a second 'gulf war syndrome'? population-based healthcare for chronic idiopathic pain and fatigue after war combat duty in iraq and afghanistan, mental health problems and barriers to care bringing the war back home casualties of war-military care for the wounded from iraq and afghanistan military sexual trauma: issues in caring for veterans. iraq war clinician guide, dept. of veterans affairs. the national center for ptsd manuals treating the traumatized amputee tympanic membrane perforation as a marker of concussive brain injury in iraq analysis of battlefield head and neck inquires in iraq and afghanistan with 'invisible injuries,' thousands of brain-damaged troops returning home traumatic brain injury in the war zone report faults hospital for marine's death. the tampa tribune, friday rehabilitation and the long-term outcomes of persons with trauma-related amputations does the presence of a specialized rehabilitation unit in a veterans affairs facility impact referral for rehabilitative care after a lower extremity amputation? acute psycho-social intervention strategies with medical and psychiatric evacuees of protecting military convoys in iraq; an examination of battle injuries sustained by a mechanized battalion during operation iraqi freedom ii the experience of the us marine corps' surgical shock trauma platoon with operative combat casualties during a month period of operation iraqi freedom screening for brain injury is set for illinois veterans treatment of medical casualty evacuees caring for the wounded in iraq-a photo essay the san diego union-tribune. / / va preparing for health issues from iraq war vets wait longer for care than va allows combat duty in iraq and afghanistan, mental health problems and barriers to care are veterans seeking veterans affairs' primary care as healthy as those seeking department of defense primary care? a look at gulf war veteran's symptoms and functional status the neurological consequences of explosives casualties treated at the hospital in the madrid experimental pressure induced rupture of the tympanic membrane in man military tbi during the iraq and afghanistan wars operation helmet; data on helmets and brain injury blast injuries toxicology of blast overpressure medical management of explosives explosive and traumatic events q fever meningoencephalitis in a soldier returning from the persian gulf war brucellosis in a soldier who recently returned from iraq cutaneous leishmaniasis in soldiers from fort campbell, kentucky returning from operation iraqi freedom highlights diagnostic and therapeutic options centers for disease control and prevention. two cases of visceral leishmaniasis in u.s. military personnel-afghanistan an outbreak of malaria in us army rangers returning from afghanistan acute eosinophilic pneumonia among us military personnel deployed in or near iraq q fever and the us military acinetobacter baumannii infections among patients at military medical facilities treating injured us service members centers for disease control and prevention. outbreak of acute gastroenteritis associated with norwalk like viruses among british military personnel-afghanistan gastroenteritis outbreak in british troops sequelae of traveler's diarrhea: focus on postinfectious irritable bowel syndrome deployment related conditions of special surveillance interest, us armed forces world health organization (who) institute of medicine committee on the gulf war and health diagnostic and therapeutic pitfalls associated with primaquine tolerant plasmodium vivax persistence of leishmania parasites in scars after clinical cure of american cutaneous leishmaniasis: is there a sterile cure? opthalmomiasis caused by the sheet bot fly oestrus ovis in northern iraq q fever in members of the united states armed forces returning from iraq old world leishmaniasis: an emerging infection among deployed us military and civilian workers defense intelligence agency, armed forces medical intelligence agency. final report: analysis of iraqi military blood samples q fever in oif deployed soldiers: an emerging disease of military importance diagnosis of q fever avian influenza: the next pandemic atypical q fever in us soldiers treatment of cutaneous leishmaniasis by curettage military of the united states www.defenselink.mil surge seen in number of homeless veterans. erik eckholm. the ny times the impact of deployment on the military family post traumatic stress disorder (ptsd) mental health online. www. mentalhealthchannel chapter vii: ptsd in iraq war veterans: implications for primary care topics specific to the psychiatric treatment of military personnel posttraumatic stress disorder and depression in battle injured soldiers iraq war clinician guide, dept. of veterans affairs. the national center for ptsd substance abuse in the deployment environment in: iraq war clinician guide, dept of veterans affairs va intranet) . national institute for mental health information on ptsd increased ptsd risk with combat-related injury: a matched comparison study of injured and uninjured soldiers experiencing the same combat events veterans' mental health in the wake of war adolescent health and risk behaviors: the role of the primary care physician train the trainers guide integrating comprehensive adolescent preventive services into routine medical care; rationale and approaches mental health problems, use of mental health services and attrition from military service after returning from deployment to iraq or afghanistan post traumatic stress disorder and depression in health care providers returning from deployment to iraq and afghanistan gulf war injections are toxic cocktail when combined, researchers say. cnn presidential advisory committee on gulf war veterans' illnesses. presidential advisory committee on gulf war veterans' illnesses: final report national institutes of health technology assessment workshop panel. the persian gulf experience and health national academy of sciences. health consequences of service during the persian gulf war: recommendations for research and information systems the iowa persian gulf study group. self-reported illness and health status among gulf war veterans illness among united states veterans of the gulf war: a population-based survey of , veterans chronic multisymptom illness affecting air force veterans of the gulf war health of uk servicemen who served in persian gulf war the centers for disease control vietnam experience study. post service mortality among vietnam veterans present at the conference on federally sponsored gulf war veterans' illnesses research chronic q fever: ninety-two cases from france including cases without endocarditis endocarditis after acute q fever in patients with previously undiagnosed valvulopathies q fever outbreak during the czech army deployment in bosnia self-reported description of diarrhea among military populations in operations iraqi freedom and enduring freedom update: cutaneous leishmaniasis in us military personnel-southwest/central asia cutaneous leishmaniasis: clinical aspect biological warfare-an emerging threat bioterrorism and weapons of mass destruction : physicians as first responders. the do new and re-emerging infectious diseases: epidemics in waiting coxiella burnetii infection psychiatry and the military: an update veterans affairs. internet site: www.va.gov playing numbers game with our dead posttraumatic stress disorder and the risk of traumatic deaths among vietnam veterans mortality among us veterans of the persian gulf war: year follow-up arm center for substance abuse programs with links to world wide asap locations federal research strategy needs reexamination. united states general accounting office (gao) epilogue: social and historical perspectives on the vietnam veteran avian influenza: critical considerations for the primary care physician epidemiology of travel-related hospitalization knowledge, attitudes and practices in travel-related infectious diseases: the european airport survey update: chlorine use as a weapon- pulmonary agents-(phosgene, chlorine, vinyl chloride, vinylidine chloride) healthcare for the whole person; reconnecting the mind and body study makes case of reintegrating behavioral health, primary care mind and body primary mental healthcare: new model for integrated services building new bridges in primary care new rule will change the psychologist-physician relationship. monitor psychiatry multidrug resistant tuberculosis: a menace that threatens to destabilize tuberculosis control visceral infection caused by leishmania tropica in veterans of operation desert storm diffusely disseminated cutaneous leishmania major infection in a child with acquired immunodeficiency syndrome rapid diagnosis of leishmaniasis by fluorogenic polymerase chain reaction comparative study of the efficacy of combined cryotherapy and intralesional meglumine antimoniate (glucantime) vs. cryotherapy and intralesional meglumine antimoniate alone for the treatment of cutaneous leishmaniasis a randomized controlled trial to test the efficacy of thermotherapy against leishmania tropica in kabul blood donation eligibility guidelines usamriid's medical management of biological casualties handbook preparing for an era of weapons of mass destruction (wmd)-are we there yet? why we should all be concerned women veterans' network of the department of veterans' services the central resource for women veterans in the commonwealth of massachusetts. the veterans administration also has resources for women us low risk drinking guidelines: an examination of four alternatives validation of the screening strategy in the niaaa. physicians' guide to helping patients with alcohol problems cognitive processing therapy for rape victims: a treatment manual treating the trauma of rape: cognitive-behavioral therapy for ptsd america's secret war: victims of sexual assault while serving in the military world health organization (who) the author thanks lt. deena disraelly (usn, ret) for tremendous assistance, both for military service and for the preparation of this manuscript. her insights into the health care issues of returning troops were invaluable. there were several active and retired military who shared their personal experiences but on condition of anonymity; my gratitude for their service and candor. the author also thanks jamie walker, an amazing editor and colleague; her guidance, enthusiasm, and skills shared on this and previous manuscripts are greatly appreciated. thank you to dr. caren teitelbaum, yale university school of medicine, department of psychiatry, for sharing her knowledge and insightful suggestions. key: cord- - g jebq authors: nan title: in the realm of opportunity: the kaiser wilhelm institute for anthropology, human heredity and eugenics during world war ii, / – date: journal: the kaiser wilhelm institute for anthropology, human heredity, and eugenics, - doi: . / - - - - _ sha: doc_id: cord_uid: g jebq on march , , eugen fischer wrote a long, confidential letter to otmar von verschuer, director of the institute for genetic biology and race hygiene at the university of frankfurt at that time. in this letter fischer expressed critique — and certainly also self-critique — about the scientific development of his institute since the mid- s. speakers for public lectures, as representatives of the new germany at international congresses, all of which were performed at the cost of the scientific work. more serious was that the emphases of research had shifted as a consequence of the interconnections with politics -and not necessarily in the direction fischer would have wished. in , under pressure from arthur gütt and with a view to the genetic health policy of the new rulers, fischer had placed the stress on genetic pathology. with verschuer's departure in , fischer had ceased forcing genetic pathology research, although the projects in progress were continued, and the emphasis was shifted to strengthening genetic psychology instead. the dual course shift had the result that the research program was visibly fragmenting into unrelated, individual projects. fischer recognized that the institute was in danger of losing its scientific focus. as he wrote in his letter to verschuer of march : aside from the problem of demarcation from the university clinics and institutes working in the area of genetic pathology, fischer probably foresaw that a clinical orientation of his institute would cause conflicts of competence with two other kaiser wilhelm institutes: the kaiser wilhelm institute for brain research, which, under the direction of hugo spatz since , had turned increasingly to questions of genetic pathology in neurological disorders, mental illnesses and mental disability, and above all with the german research institute for psychiatry in munich under rüdin. in munich the very founding of the department for genetic psychology had been taken as an affront, and the vehement exchange of blows concerning diabetes research in had shown that the two institutes were bound to get in each other's way in the field of genetic pathology. against this background it seemed to fischer, who had never worked purely clinically anyway, that a onesided orientation of research at the kwi-a toward genetic pathology -while neglecting fischer's own original research field, the heredity of "normal" (not pathological) attributes -to be a strategic mistake, although he certainly held genetic pathology to be a constitutive element of his further research strategy. but as fischer established self-critically, his own research in the field of physical anthropology did not have the potential to constitute a new paradigm either: for my own (personal) work, of course, i have plans that include my doctoral students. the one project is, as for many years, the research of the conditions for the shape of the skull; the other the bastardization problem. but these two topics cannot fill an entire institute, and assistants from the field of medicine, who want to pursue practical activity later, cannot, or at least not exclusively, be set to work on such subjects. and since you have been gone i feel both a great void and a sense of being orphaned. the department for human genetics had been dissolved in , as mentioned above. in addition to the department for anthropology led by fischer himself, the only pillar of the institute that remained was the department for race hygiene headed by fritz lenz. however, fischer lamented, it could hardly be expected that new impulses would come from there. for lenz does not take care of any of this. he works without planning, assigns themes to pupils without a plan. these themes are individual questions of a genetic pathology or race hygiene biological nature, which occur to him while editing baur-fischer-lenz or during his critical perusal of the literature. such occasionally arising, isolated themes were to be pursued in the future as well, and the work of the department for genetic psychology under kurt gottschaldt was to be continued according to fischer's wishes. but as to the main point, such an institute needs an ambitious plan. and because i can not receive it from lenz's sphere of interest, let alone through his initiative, i do it alone. but such a plan is conceived for a number of years, and certainly -not only presumablylonger than i will be in office here. because i do not doubt in the least that you will be my successor someday, in truth i would like to begin with a long-term plan only if i have the hope that you like it enough to pursue it further. term for all factors affecting phenogenesis that did not lie directly in the genes. fischer emphasized that the "series of forces" triggered by genome and peristasis do not simply complement each other cumulatively, but are related in a very complex system of interdependence and synergy that is subject to constant change. the task of phenogenetics was thus to disentangle the networks of effects exerted by genes and peristatis for analytical purposes and to pursue their effects and interactions all the way up to the complete phenome. methodologically this task was to be approached through a combination of classical genetics, embryology and developmental mechanics, anthropometry and clinical diagnostics, whereby fischer repeatedly emphasized the utility of combining the animal model with observation of humans. at this juncture it is worth taking another look across the atlantic. since the early s the interest of geneticists there, too, encouraged in part by the rockefeller foundation, shifted increasingly to physiological genetics. in sharp competition with the research group around kühn, the geneticist george beadle and the embryologist boris ephrussi worked in pasadena to bridge the gap between classical genetics and developmental physiology. they may have lost the race to identify kynurenin, but in the early s beadle and edward lawrie tatum succeeded in finding evidence for the "one-gene-one-enzyme" hypothesis they had advanced during experiments on the neurospora mold -a pioneering success, for which they were awarded the nobel prize in . while this had directed attention to the effects of genes, the embryologist, geneticist, and evolutionary biologist conrad h. waddington broadened the horizon in with his concept of "epigenetics," in which he -in nearly the same words as eugen fischer years previously, and also with reference to valentin haecker's phenogenetics -shifted the complex developmental processes from the genotype to the phenotype into the focus of interest: for the purposes of a study of inheritance, the relation between phenotypes and genotypes can be left comparatively uninvestigated; we need merely to assume that changes in the genotype produce correlated changes in the adult phenotype, but the mechanism of this correlation need not concern us. yet this question is, from a wider biological point of view, of crucial importance, since it is the kernel of the whole problem of development. many geneticists have recognized this and attempted to discover the processes involved in the mechanism by which the genes of the genotype bring about phenotypic effects. the first step in such an enterprise is -or rather should be, since it is often omitted by those with an undue respect for the powers of reason -to describe what can be seen of the developmental processes. for inquiries of this kind, the word "phenogenetics" was coined by haecker. the second and more important part of the task is to discover the causal mechanisms at work, and to relate them as far as possible to what experimental embryology has already revealed of the mechanisms of development. we might use the name "epigenetics" for such studies […] . the concept of epigenetics has since undergone a series of transformations, but has managed to persist -off the track of mainstream genetics. indeed, in the most recent bioethical debates many hopes are pinned on the concepts of epigenesis and epigenetics, as they promise to break open the "reductionist approach" of classical genetics. from fischer's perspective, the new paradigm of phenogenetics offered several advantages. first, it permitted a whole series of projects that had been performed at the kwi-a and its periphery in the s, which were rather loosely connected, to be related to each other under a complex of issues that applied to all of them. this was true first of all for a great number of works by wolfgang abel, georg geipel, bernhard duis, and others on the methodology of dermatoglyphics, that is, the genetics of epidermal patterns, on the increased frequency of characteristic epidermal ridge patterns for certain human races, and on the connections between defective epidermal ridge patterns and physical disability or mental diseases. fischer attributed a central position in the field of phenogenetics to the works of his earlier pupil konrad kühne on the genetics of the variations of the spinal column, which had been continued at the kwi-a in maria frede's work on rats. great value was also ascribed by fischer to the embryological studies by rita hauschild on the skulls of negroid and caucasion fetuses and by baeckyang kim about race differences in embryonic pig skulls -even at the time, both studies were understood explicitly as contributions to phenogenetics. according to fischer, various other works originating from the kwi-a on morphology and the genetics of human hair growth, the auricle, on asymmetries in body structure, on the heritability of stature, on miscegenation and on genetic pathology could also be classified under the umbrella of phenogenetics. on the other hand, second, the paradigm of phenogenetics demarcated a broad research area that the existing works had barely begun to cover, and which was underdeveloped in terms of both breadth and depth. at the congress in würzburg, fischer established retrospectively in , it became apparent that the "true course of development" was only really known for coloboma, the congenital gap in the eye area due to the insufficient closure of the fetal eye cleft, on the iris, choroid, lens, or lid. just as we have a history of development of every normal organ, we should have an exact history of development of every hereditary disease. everything has yet to be done here. much is also missing on the heredity of normal things. the paradigm of phenogenetics was thus open enough to provide the foundation for a comprehensive research program with questions covering all of its areas. a further advantage of turning toward phenogenetics was that, third, the research focused on a form of human genetics that was compatible with the orientation of developmental genetics predominant in german animal and plant genetics at the time. in his lecture in würzburg, fischer referred to the work of the developmental physiologist hans spemann , who had performed experiments on amphibian embryos in the s, which proved that some parts of the embryo, such as the primitive roof of the mouth and the eye socket, act as "organizers" to "induce" the formation of other structures in the embryo. spemann had not attempted to explain the inductive effect of the organizers by investigating the genes. alfred kühn made more progress on this with his experiments on the flour moth ephestia kühniella, to which fischer referred several times in his comments. kühn had found a mutant ephestia with red eyes rather than the usual black ones, and his doctoral student ernst wolfgang caspari ( * ) was able to prove that, by injecting tissue from wild moths into the larvae of the red-eyed mutants, the eye color of the mutant could be adapted to that of the wild type. a substance missing in the mutants was apparently added through the injection. genes, it was concluded, obviously work through enzymes. if an enzyme is lost through mutation, this can block the transformation of a certain substance into another. through artificial implementation of the missing enzyme -in the case of the light-eyed ephestia this was the tryptophan derivate kynurenin, as two assistants to adolf butenandt , erich becker and wolfhard weidel, were able to prove -it was possible to generate a "phenocopy" of the wild type, an idea that apparently fascinated eugen fischer. yet, even more often than he referred to kühn, fischer brought up hans nachtsheim's work on the genetic pathology of rabbits. consequently, in march fischer presented to verschuer the idea of bringing nachtsheim to the kwi-a as director of a new department for experimental genetic pathology, in order to supplement his studies on the phenogenesis of genetic illnesses of the rabbit with "parallel studies of a clinical nature on humans" as a way of connecting animal and human genetics. fischer's remark, "i have no idea whether he [nachtsheim] would want to," indicates that fischer had not yet negotiated with nachtsheim at this time. he first wanted to await his designated successor's opinion of this plan, and further of the plan associated with it -quite explosive in terms of institute politics -to "completely dismantle" the department for race hygiene headed by fritz lenz, as "race hygiene could then be taken care of in the university institute." in other words, the kwi-a was supposed to give up race hygiene as a field of research, and fritz lenz gradually be forced to the margins. fischer closed his letter to verschuer with the request that he not answer in writing, for he hoped that there would be opportunity at easter to discuss the complex of topics in person. hence we know nothing about verschuer's immediate reaction. yet the further course of events suggests that verschuer fully agreed with "drosophila genetics has been our pacemaker until now. this appears to be nearly over; it no longer teaches us anything new." (ibid.). this can be interpreted as a renunciation of the drosophila genetics at the genetic department of the kwi for brain research under nikolaj v. and elena a. timoféeff-ressovsky. of course, it must be remembered that the timoféeff-ressovskys, before turning to the genetics of mutations and populations, made significant contributions to developmental genetics. cf. harwood, styles, pp. f. the research plan developed by fischer. the two most important conceptual works by verschuer from the year -his lecture about "the genotype of humans" to the main assembly of the kaiser wilhelm society in breslau on may , and his presentation "on the genetic analysis of humans" for the th international congress for genetics in edinburgh (which he was not able to give himself due to the early departure of the german delegation, but was read to the audience on august , ) -first of all show that verschuer picked up on fischer's impulses immediately, and also illuminate the background against which fischer's and verschuer's new conception must be viewed: over the course of the s, classical mendelian genetics was undergoing a dramatic and extensive process of transformation. the idea generally accepted up to that time, that every attribute was simply transmitted as dominant or recessive, monofactorial genetic information, did not hold up to the results of mutation research, population genetics and developmental physiology. thus mendelian genetics was giving way, in the words of the day, to "higher mendelism, which presumed much more complicated mechanisms of heredity. it became generally accepted that genes could not be observed in isolation from each other, but only in the context of the genotypical setting -the effect of one gene was always influenced by other genes, and even by the genome as a whole. it was acknowledged that the genes on the chromosomes are not just pearls strung on a string in any order, but that the effect of each gene depends on its position in the genome. with increasing clarity it became apparent that these mutual effects within the genome, but also prenatal influences on the intra-uterine environment during maturation of the embryo, and even influences from the external environment, had modifying effects on the way genes were manifested in the process of phenogenesis. the phenomenon of "weak genes" made its first appearance. the team of the kwi for brain research around nikolaj vladimirovich timoféeff-ressovsky and elena aleksandrovna timoféeff-ressovsky had attempted to grasp the phenomenon of the variations in how such genes were manifested in terms of the three concepts "penetrance" (the frequency with which a genetically conditioned attribute develops in the phenotype), "expressivity" (the degree to which it develops) and "specificity" (the nature of its development depending on the part of the body the gene must affect for this development) -a terminology that was picked up everywhere, including by fischer and verschuer. it was acknowledged that in many cases a single gene is involved in the development of several attributes (pleiotropy) and, inversely that the development of a single attribute can be influenced by multiple genes (polygeny). furthermore, the advances in differential diagnostics showed that one and the same clinical picture can be caused by both genetics and environment (heterogeny). finally, the results from radiation and verschuer, erbbild vom menschen; idem., bemerkungen zur genanalyse. cf. roth, schöner neuer mensch, pp. - . the term was coined in , probably by günther just, and picked up on immediately by verschuer. cf. just, probleme des höheren mendelismus; verschuer, genetic pathology, nd edn., p. . cf. weß, humangenetik, pp. - . population genetics suggested that the rates of mutation were higher than originally presumed, but that the heterozygotic mutants did not become visible because the gene did not necessarily develop in their phenotype. verschuer, as his lecture texts indicate, was completely up to date in the contemporary specialized discourse; his institute in frankfurt had even made a significant contribution to theoretical research in human genetics in , when one of verschuer's staff members, bruno rath, on the basis of a family study of a "bleeder clan," succeeded in finding the first proof of a crossing-over (exchange of genes or gene sections through the recombination of chromosome fragments) in humans. against the background of higher mendelism, verschuer was fully aware that the previous conception of human genetics required greater differentiation, an expanded catalog of questions, and a larger arsenal of methods. fischer's suggestions could hardly have come at a better time. in his breslau lecture verschuer first related the success story of human genetics. by that time around , of the estimated , - , genes in humans were known, along with several hundred hereditary diseases, for most of which the heredity had been illuminated. "the human being is an object of the human sciences that has been examined in manifold ways […] ." yet there remained much to be done. genetic analysis could no longer be content with using the methods of family and twin research to reveal the dominant or recessive mode of inheritance of a gene. on the contrary, a whole bundle of new questions had to be posed: in summary it can be stated that the cognitive advances in the field of human genetics in the s practically forced an expansion of classical mendelian genetics. theoretically, expansion was conceivable in various directions -from mutation research, to the "synthetic theory of evolution," all the way to molecular genetics. however, considering its own resources, and also with a view to the orientations of competing research institutions, the paradigm of phenogenetics seemed most promising for the kwi-a. moreover, it was quite advantageous for verschuer, because his personal research interest in clinical genetic pathology dovetailed perfectly with the new paradigm. as such -another point that must not be overlooked -it was practically tailored to verschuer and provided him a weighty advantage over lenz as a potential rival for fischer's succession. at this juncture our discussion turns to the thesis by niels c. lösch, who goes into great detail about the changes that took place under the banner of phenogenetics at the kwi-a in the years - . however, because he is fixed too one-sidedly on personnel-policy strategies, he interprets the development as a kind of "false label" designed to "prepare the ground for verschuer." there is no question that fischer, who celebrated his th birthday on june , , had been building up his pupil and friend verschuer as his successor for a long time already, and that the establishment of the new paradigm of phenogenetics was linked intimately with verschuer's person. it is also indisputable that fischer had long since begun taking precautions to nip in the bud any aspirations fritz lenz might have for the post of the institute director -although, it must be added, there are no indications that lenz pursued ambitions in this direction. in september , when fischer, much to his dismay, learned of the plans to call verschuer to frankfurt, he immediately began considering whether the chair in frankfurt could serve verschuer as a stepping stone on the path to succeeding fischer. in november -that is, while the würzburg lecture was being printed -fischer then set the course for the future development of the institute in a talk with ernst telschow, general secretary of the kaiser wilhelm society: "for the case of his departure upon reaching the age limit in - years, professor fischer nominated professor verschuer of frankfurt as his successor." in march fischer informed verschuer of this conversation, after congratulating him for the most recent evidence of the kaiser wilhelm society's favor -"exchange professor in london! speaker at the general meeting […] some time ago mr. telschow and i had a long talk, during which we also discussed you in great detail. he is informed for now and for the future and was entirely of my opinion." in his exchange of opinions with telschow, fischer had indicated that he rejected the plan to set up a major institute for anthropology at the friedrich wilhelm university in berlin, advising telschow "to pare this institute down considerably and plan it […] merely as an institute for race hygiene. as director prof. lenz would then be suitable on a full-time basis." this is yet another indication of fischer's strategy of strengthening lenz's role at the university and pushing him to the margins of the kwi-a, even though at this point in time he was still advocating lenz's appointment as deputy director of the institute. in july -by this time fischer had coordinated his plans for reorganizing the institute with verschuer -the departing director expressed himself more clearly to telschow: in repetition of earlier conversations, prof. eugen fischer designated prof. von verschuer in frankfurt as a suitable successor. it would then be appropriate to grant prof. lenz the title of "director" because of his age, without entrusting him with the direction of the institute. prof. fischer held it even more appropriate to transfer prof. lenz to the institute for race hygiene at the university of berlin, which -at present consisting of two rooms in the hygiene institute -would have to be expanded. then, in october fischer got down to brass tacks: within his institute prof. fischer wants to have a special institute for race hygiene under prof. lenz, who thus would receive the title of "director," as it were, but without becoming prof. fischer's deputy. on the contrary, prof. fischer wants to prevent this, in consideration of the proposed succession to his position by prof. von verschuer. at the same time fischer conveyed his intention to rename his institute. in the future it was to be called the "kaiser wilhelm institute for genetic and race science" (kaiser-wilhelm-institut für erb-und rassenkunde) and thus in its very name express the demarcation from race hygiene. fischer's attitude toward race hygiene was expressed quite clearly year later, in october , when he argued -much more aggressively than lenz, who lacked the requisite tact -for the expansion of the university's race hygiene institute: […] today race hygiene [has] become a state policy, it no longer requires propaganda. race hygiene is a required lecture and examination subject for medical students. i can no longer recognize race hygiene as such as a research subject; rather, the research subject is its substrata, first of all human genetics and then demographics. […] for these reasons i hold the expansion of a university institute for race hygiene at the greatest german university to be a quite self-evident necessity. […] because of the auspicious historical development in the third reich, at the kaiser wilhelm institute this race hygiene department must be dismantled rather than expanded. race hygiene, as the theory of the practical implementation of the knowledge in human genetics and demography, one could summarize fischer's argument, had a right to exist at the kwi-a during the weimar republic, but in the third reich race hygiene seemed to him unnecessary baggage that distracted the institute from its theoretical research. by no means did fischer want to force lenz out of the institute entirely -as an astute critic he made a major contribution to the conceptual foundations of the research at the kwi-a. the fact that he did not want to see lenz in the director's post concerned not only his lack of qualities as a science manager, and was not founded only in personal animosities between the two scientists -that, too -but above all lenz was far too much a proponent of classical race hygiene, which fischer did not believe had much potential for innovation. the result is indisputable: fischer machinated behind the wings in order to guarantee that verschuer would be appointed director of the kwi-a and to prevent lenz from offering himself as an alternative candidate. in contrast to niels lösch, however, this author advocates the thesis that the paradigm of phenogenetics was also, but by no means only a means to an end in order to prejudice an impending personal-policy decision. the realization of the newly developed research conception presupposed a kind of package solution: the new orientation of research in progress; opening up new areas of work, but also relinquishing areas that could not be fit into the new paradigm in a meaningful way; integrating scientists who fit into the new research profile; changes to the internal structure of the institute; the creation of an infrastructure to implement new methods in practice, and finally the solicitation of the additional financing these tasks would require. in the years - fischer resolutely pushed ahead in all of these directions, but initially he met with considerable resistance. this setback opened up a precarious phase in the reorganization of the institute, for the new department for experimental genetic pathology was to become one of the pillars supporting phenogenetic research, if not the supporting pillar. fischer needed political protection to succeed in implementing his plan by circumventing the general administration -but this strategy was also shaky, as hans nachtsheim was not exactly considered a convinced national socialist. nevertheless: fischer sought and found the necessary patronage of a functionary located high in the machinery of the national socialist regime: leonardo conti. it was convenient that a connection to conti already had been established, as mentioned above, albeit a loose one. in december conti had taken over the duties of the medical councilor of berlin. in this capacity he was entitled to a seat and vote on the boards of the kwi for brain research and the kwi-a. the kwi for brain research must have interested him less -in any case in november he appointed one of his closest staff members, director of the department for the care of genes and race in the main health office of berlin, dr. theodor paulstich ( * ), as his permanent representative on the board of this institute, although he reserved the right to participate in future board meetings himself. at first conti did not have anything to do with the kwi-a, either -in the years from to no board meetings took place. conti had since moved up to the pinnacle of civilian health care: in april hitler had appointed him as director of the main office for national health (hauptamt für volksgesundheit) and "führer of physicians of the reich (reichsärzteführer) and awarded him the title of reichsgesundheitsführer ("reich health leader"). in august conti was also appointed state secretary for health care in the reich ministry of the interior and thus held all of the reins to steer the health matters of the state and the party. when fischer endeavored to call a board meeting in january , he discovered that the previous chairman of the board, the premier of saxony, landeshauptmann richard otto, who had resigned his office as senator of the kaiser wilhelm society in "in quite an abrupt manner," no longer considered himself to be in office. because the general administration -after consulting with ministry director mentzel -did not regard the option of convincing otto to remain on the planck to conti, / / , mpg archive, dept. i, rep. a, no. , p. . max planck solicited conti's interest insistently: "because the next sessions of the two boards will probably not be held until the coming spring, perhaps you might first find an opportunity to tour the two institutes." for a biography: klee, personenlexikon, p. . cf. schmuhl, hirnforschung, p. . kater, conti; labisch/tennstedt, weg, vol. , pp. - . fischer to otto, / / , mpg archive, dept. i, rep. a, no. , pp. - . justifying the long interruption in board meetings, fischer stated that there had "never occurred anything in particular and on the other hand the years were so eventful politically that one wanted to dispose of the time of such very busy men as sparingly as possible." note by telschow institute's board to be opportune, the question of a successor was raised, an issue fischer and telschow discussed in a meeting on march , . apparently telschow's first suggestion here was leonardo conti, followed by walter groß. on the following day fischer expressed his opinion on these suggestions in writing, declaring himself completely agreeable to state secretary dr. conti. i find this proposal of yours especially good. of course, i would have nothing against dr. groß either; on the contrary, i would be pleased. but here my good personal relationship with groß should not be the crucial factor. as a responsible representative of race policy, groß is not as professionally close to the objectives of my institute as conti, the director of the medical and race hygiene department of the reich ministry of the interior. the connection to him would presumably be more important to the institute; in any case, i already have a connection with mr. groß. it would soon become apparent that this was quite a clever move, especially since fischer's strongest ally in the nazi health leadership up to that point, arthur gütt, had been ousted by an intrigue in , clearing the way for conti. but fischer needed strong political protection to realize his ambitious -and exceedingly costly -plans for the reorganization of the institute under the banner of phenogenetics. on october , the general administration of the kaiser wilhelm society officially filed fischer's proposal to offer conti the chairmanship of the board of trustees of the kwi-a. fischer, it was recorded there, wanted "first to personally approach [conti] on this matter." this personal meeting between fischer and conti took place on november , . it can be presumed that fischer took this opportunity to relate his plans for reorganizing the institute to the new strong man in the health policy leadership and acquire his support. in any case conti declared himself willing to accept the chairmanship of the board of trustees and call a board meeting immediately, which was initially scheduled for december , , but then postponed to january , due to conflicts with conti's schedule. telschow to fischer, / / , ibid., p. . fischer to telschow, / / , ibid., p. . the situation was all the more piquant because gütt remained a member of the board. conti proved magnanimous. he informed fischer that he woud find it "especially nice if gütt were retained on the board without further ado." fischer, as he let telschow know, had "the sense that he, too, wanted to avoid the appearance of having forced him [gütt] out." fischer himself spoke for gütt's remaining on the board: "since mr. gütt always had especially friendly interest in the institute and did much for it, i, too, would be very pleased if he remained on the board. of course, this is only possible if, first, the number of members would not be raised to beyond that allowed by any existing regulation, and second, if mr. gütt is not expressly nominated as a representative of his ministry." (fischer to telschow, / / , ibid ., pp. - v.) both were not the case, and consequently gütt remained a member of the board. telschow attending this decisive meeting were -besides fischer and conti -from the side of state and party, walter groß and hans reiter, further the medical councilor of berlin, theobald sütterlin ( * ); and -as representative of the german council of municipalities -from kiel, dr. klose; then the inspector of the army medical corps, general and chief staff physician siegfried handloser; from the side of the kaiser wilhelm society, general secretary ernst telschow and friedrich schmitt-ott; as representatives of science, finally, fritz von wettstein, director of the kwi for biology, otmar von verschuer, and -as a guest -fritz lenz. the new chairman of the board set a political signal right in his welcome message, by pointing out that activity and research of the kaiser wilhelm institute for anthropology, human heredity and eugenics is of particularly great importance for the state and that it would be wrong if -as it sometimes seems -interest in the meaning of issues of the heredity and race of our nation were to decline. the new greater germany needs such knowledge urgently, the next generation of scholars in this area must be provided for. the kwi-a as the "first and most outstanding" in this area must "serve and influence other institutes as a model." for this reason he, conti, had accepted the chairmanship of the board. telschow's comments about the institute's budget plans from to turned out to be considerably more sober. cuts of , rm from the regular budget had been necessary. the reich education ministry was not able to refrain from this cut, "although the other ministries relevant for the kaiser wilhelm institutes had not made such cuts in consideration of the institute's acknowledged status as essential for the war." on this subject, fischer elaborated that the institute had been able to "get over" the reduction due to the decline in the personnel budget, which had been eased as staff members were called up for military service, and thanks to savings in the material budget achieved by the "restriction of experiments" -although, fischer emphasized, at "the detriment to scientific achivement." however, a glance at the revenue and expenditure accounts of the institute and the auditing reports of the kwg for the fiscal years and indicate that telschow and fischer painted an exaggeratedly gloomy picture of the institute's financial situation, which did not correspond to reality -more on this later. the fifth agenda item, the "director's report about the erection of a new department for experimental genetic pathology" was the sensation. in a speech explaining the entire framework of his proposal, fischer submitted to the board his plans to reorganize the institute under the paradigm of phenogenetics. he started by for a biography: klee, personenlexikon, p. . the invitation was declined by arthur gütt providing detailed reasons why, in the middle of the war, he was submitting a research plan that pointed so far into the future. "the impending victorious conclusion of the war and the vast expansion of the greater german reich," fischer claimed, would also pose "great and new challenges" to the research institutes. while until now the institutes directly important for the war had stood at the foreground, like those in the areas of physics, chemistry, and technology, in the "near future" all institutes that dealt with "questions of genetic health, race, human selection, environmental influences" would become more important, as these were "of consequence for leadership." one could never know "how pure scientific research, often of a seemingly completely theoretical nature, will work out in practice in the future." and thus, fischer added somewhat less than humbly, there had been no way of knowing that his bastard studies of "one day could lay a foundation for race legislation." until his institute had transformed "the young field of human genetics into a securely founded, widely developed theory, […] which measured up to all demands of practical application in genetic consulting, genetic legislation, and as a basis of race theory and race legislation." by this time human genetic research was so far, fischer proclaimed boastfully, that the genes for all essential normal and pathological attributes were known "in principle," the external phenotype could be related to these genes and "to some extent […] the approximate scope of the environmental effects" was known. then came the transition to fischer's project of phenogenetics: but one large area here is still quite dark. this is the question of how a given genetic disposition actually develops, how it works, how the gene "does its thing" (metaphorically speaking) to obtain the external appearance it is due. the path from the finished genetic disposition to the completely developed genetic attribute is still unknown. to legitimate the new research program, fischer's argumentation stressed applicability. phenogenetics was not only of "greatest scientific interest;" beyond this it promised "practical medical utility, the direction of which i can only hint at: differentiability of genetic conditions, prophylaxis for the genetically encumbered and corresponding marriage consulting, treatment of symptoms." embedded in this context of justifications, fischer concretized his ideas for reorganizing the institute: first he emphatically championed the hiring of hans nachtsheim. for because "human embryonic material with certain pathologically determined genetic dispositions [could be] received only in very restricted amounts," one had to rely on "model experiments" on animals -and nachtsheim's rabbit breeding was the most suitable model by far. the study of genetic conditions of the rabbit must be linked closely with clinical research. iv. genetic illnesses: fetuses, newborns, and organs from families with certain genetic pathological dispositions (later sorting by illnesses) v. domestic animal races: fetuses and organs vi. animal genetic illnesses: fetuses, newborns, and organs from breeds with certain genetic pathological dispositions lösch advances the thesis that this central collection was "a new label for the institute's already existing, extensive collection of specimens." this is a misinterpretation, however -there had not been an embryologically oriented collection of fetuses, premature births and stillborn children at the institute before this time. back in fischer had placed appeals in the deutsche medizinische wochenschrift and the wiener klinische wochenschrift ("vienna clinical weekly"), asking practical physicians to supply the institute with such material. moreover, verschuer the only problem left was what should become of fritz lenz and his department for race hygiene. this was to "remain linked securely to the whole," but granted autonomy as an "institute for race hygiene" under "director" fritz lenz. to the board of trustees, fischer sang lenz's praises as a race hygiene pioneer. his strength lay in "positive suggestions, consulting with the responsible offices and oral and written instruction for students, physicians and the general public." due to his "unique character," however, he could "not be considered […] for the organization of the institute -a fritz lenz needs and has received unreserved relief and liberation from simple administrative and other institute activities in the interest of his theoretical work." this was an extremely elegant formulation to express that fischer held his department head to be unsuited for the post of director. the fact that lenz attended the meeting and did not contribute to the discussion again confirms the impression that lenz was altogether satisfied with the solution of an "institute in the institute" to which fischer aspired. as the negotiations concerning the extension of the race hygiene institute commencing later that year showed, lenz pinned his hopes on his institute in the institute receiving its own budget and the right to hire its own staff, and, if this would be guaranteed, was even willing to relinquish any claim to a larger institute for race hygiene at the planned university clinic. in closing fischer addressed the delicate issue of financing. he offered to finance the equipment and furnishings of the new department for experimental genetic pathology from institute funds, since the budget offered some latitude as a consequence of the restrictions to its work necessitated by the war. but additional finances were required for future operating costs, of which the personnel costs of , rm comprised the lion's share, as fischer intended to hire not only the department head, but also an assistant with experience in anatomy, pathology, and histology, a technical assistant, and an animal keeper. fischer estimated the additional material costs incurred by keeping animals at , rm, so that the future additional requirements amounted to , rm annually, and fischer wanted this sum in the form of a regular budget increase rather than as a special allocation. finally, new land was also required for the construction of stalls for the rabbits, as no more room was available on the grounds of the institute. lösch presumes that such a comprehensive concept for the reorganization of the institute "was expected by hardly any of those attending," and that it was "new in this dimension" even for telschow. however, this is not the case. in fact, fischer had sent a written draft of his talk to both telschow and conti back on december , . telschow thus would not have felt "affronted," as lösch presumes; rather, his comments about necessary budget cuts simply made clear once and for all whence the funds for the institute's modernization would not come. in so doing he had hit the ball back into the politician's court, where it was readily received. the game was rigged. for back on october , , in the very same conversation between fischer and telschow in which fischer officially made the proposal to give conti the chairmanship of the board of trustees, and offered "to personally approach [the reichgesundheitsführer] on this matter," fischer had laid out to the general secretary of the kwg his plan to equip the department for experimental genetic pathology, applied for a , rm increase in the personnel budget and , rm in the material budget, and for an investment of , rm for the rabbit hutches. fischer even brought with him to this meeting hans nachtsheim, who used the opportunity to negotiate with telschow about his future salary. his appointment was slated for january , . at the same time, according to a file note by telschow, agreement was reached that the additional funds would "of course not be demanded in professor fischer's budget request until after conclusion of the war." since, as we showed above, telschow did not believe that the war would be over within the year , only one conclusion is possible: fischer and telschow had agreed to ask conti for help in procuring the missing money from other sources for the time being. the course of the board meeting makes unmistakably clear that fischer had done precisely this in his meeting with conti on november , , and that conti had pledged his support. under conti's direction, the board thus recorded in the protocol that the discussion had reiterated for the record "the special importance of the new department"; the provision of , rm was also "designated as urgently necessary." as regards the purchase or leasing of property for the rabbit hutches, the reichgesundheitsführer pledged his "active support." conti's confidant sütterlin seconded the motion, signalizing the interest of berlin's city medical administration and promising its support as well. at the same time, sütterlin stated for the record "his satisfaction with the cooperation with the institute achieved in the working group with dr. diehl in sommerfeld." even should the hospital change leadership, sütterlin ensured, diehl's research could be continued without restriction. finally, army medical inspector handloser also wished to have "his special interest in the work on rabbit tuberculosis" written in the protocol. yet again it must be emphasized that fischer's push surprised neither conti and his right hand sütterlin nor telschow, nor verschuer and lenz -in a sense, the roles had already been distributed in the preliminary talks, and the course and result of the consultations set beforehand. the entire meeting was completed in just min, and the society retired to harnack house for a snack. on the very day after the board meeting, conti turned to telschow to coordinate the next steps. the general secretary of the kwg drew up two letters in the name of the reichgesundheitsführer, which he forwarded for conti's signature. one was directed to rudolf mentzel, the president of the german research association. it contained a request to the dfg to approve fischer's application for a research grant of , rm for the / fiscal year to finance the department for experimental genetic pathology -the sum had increased over fischer's original estimate, as fischer now wanted to hire a clinical physician for the department as well. to the kwg fischer justified this decision with the board of trustee's express wish "to bring the experimental […] results in as rapid and lively connection with the humanclinical questions as possible." "from the close cooperation between the zoologist and theoretical genetic researcher nachtsheim and a clinical physician [he hoped for] an acceleration of the results and and adaptation of the formulated questions to the burning questions of medicine." fischer submitted the application heralded by conti to the german research association on march , , and the grant was issued by the reich research council on march without further ado. "the influence of conti," lösch established correctly, "was worth its weight in gold […] ." but conti's patronage did more than make the money sources gush forth: the second letter telschow prepared for conti in january was directed to the responsible district economic office (bezirkswirtschaftsamt) and applied that the kwi-a be recognized as strategically important for the war because of the research to be performed at the new department for experimental genetic pathology in the course of formation. since the beginning of the war it had been a formidable obstacle to the work of the institute that it was the only one of the total of kaiser wilhelm institutes (including the general administration of the kwg) in the region of the mark brandenburg province not to be classified as a "w" concern (for wehrwirtschaft, army economy). here, too, conti sought to remedy the problem, just as he also supported telschow's request for the classifying the pathologist otto baader as "indispensable" with the responsible military district command (wehrkreiskommando) after such an application by fischer had been rejected. conti supported the undertaking as best he could, even after fischer had finally secured the appointment of abel as his successor to the professorship for anthropology, and verschuer as his successor for the directorship of the institute in winter / . verschuer came to berlin on may , and put his ideas and demands on record. in the case of his appointment, he guaranteed, he would continue the research under the banner of phenogenetics according to the wishes of eugen fischer, but in doing so would stick to his own research profile, shifting the emphasis to genetic pathology. further, he and his pupils would continue the twin and family studies already begun. accordingly, a small polyclinical and a small clinical department were to be created at the institute, which was to employ two national social workers (volkspflegerinnen) and two nurses. his own department for human genetics, for which verschuer requested two further assistant positions, would continue to work closely with the department for experimental genetic pathology. "as a central, connecting node between these, a new department for embryology should be set up." the planned changes, so verschuer calculated, necessitated an increase of , rm in the personnel budget and , in the material budget. besides this, verschuer's plan earmarked non-recurring expenditures -for a new stall building for nachtsheim's rabbit breeding, a laboratory for the animal breeding, equipment of the clinical and polyclinical departments, etc.totaling , rm. verschuer also requested, if possible, a full professorship at the medical faculty of the university of berlin. despite the strained financial situation, the kwg accepted verschuer's ambitious plans surprisingly readily -after verschuer had conducted a conversation with the president of the kwg on may , , the fulfillment of his demands was approved, initially orally; and this approval -upon his express wish -was confirmed in writing shortly thereafter. there is no indication that the kwg, and be it "even only pro forma," had been on the lookout for another candidate for the post of director. correctly, lösch assesses: "fischer had been successful with his tactics of making verschuer out to be the only sufficiently qualified candidate." in july fischer received the message that his son hermann had been killed in action on the eastern front -he lost any interest in the work of the institute and moved to freiburg in august. due to an illness he was not able to resume the business of the institute. since verschuer was not able to take over direction of the institute until october , , in september -irony of fate -fritz lenz was appointed interim director. on october , verschuer continued his negotiations with the kwg. during these negotiations he appeared full of self-confidence and demanded that the grants from the reich and the prussian state be increased considerably in the next fiscal year. yet finances were not the decisive problem -although the increase in public grants demanded by verschuer was rejected, he ultimately received the money from the dfg and from the "sponsorship association of german industry" (förderergemeinschaft der deutschen industrie). more difficult to master, as the negotiations on october , evince, were the restrictions on facilities and personnel due to the war. here, too, verschuer pinned his hopes on conti. with the assistance of the reichgesundheitsführer, the new director hoped to win back the lower rooms of the institute, which had been used as sanitary facilities up to that time. further, conti was to procure the construction permit for extending the attic -until then the skull collection had been kept there, which now was to be transferred to the university -into a sickroom and rooms for the nurses. further, verschuer hoped to achieve with conti's help that gottschaldt and his colleague from frankfurt hans grebe ( - ) be classified as "indispensable." originally conti was to be addressed in a board meeting, but since this never took place, walter forstmann ( - ) from the general administration visited conti at his office on november , . the reichgesundheitsführer willingly pledged his support on all points, inquired as to the works in progress and promised to tour the institute over the course of the next months. under these circumstances the genetic research of tuberculosis had to be of immense interest for the reichgesundheitsführer, especially as it can certainly be presumed that fischer played this card in the decisive conversation with conti. back at the beginning of world war ii he had justified his application to the general administration for feed for the rabbits in beetz by claiming that there was "no doubt that these studies from the area of one of the worst national epidemics promise to be of great importance for fighting human tuberculosis" -a justification that was forwarded by the general administration to the responsible food office (ernährungsamt) almost word for word. that conti was familiar with diehl's and verschuer's tuberculosis research can be proved on the basis of an (undated) typed lecture manuscript on the subject of "genes and performance" (erbgut und leistungsfähigkeit): the genetic disposition also plays a role in infectious diseases. the views about heritability have oscillated extremely. first it was observed that tuberculosis occurred in certain families, then the pathogen was discovered and the way it befalls the diseased, namely in earliest childhood; the disease is then carried forth and does not break out until puberty and professional life and even later: at that point no one considered that the disease in question might have been acquired in childhood. it was twin research that illuminated us to the fact that this congenital inferiority is important in tuberculosis. it was possible to establish that identical twins who grew up separately nevertheless got tuberculosis. if a person is resistant he will not become ill if he is only susceptible. it is clear that someone who may be absolutely resistant, but becomes a tuberculosis doctor or nurse, ultimately does take in the bacillum, which then spreads in the body. a doctor who may come from a tuberculous family, but so far has remained entirely healthy, may not become a tuberculosis doctor, for the risk of infection is too great. in other respects the environmental influences are important in fighting tuberculosis; reasonable living conditions must be created. if any further proof is needed that tuberculosis research was irresistible bait for the reichgesundheitsführer, it is provided by a letter which verschuer wrote on january , -that is, just weeks after the decisive board meeting -to his friend karl diehl. the latter had asked for advice about whether he should set about expanding the rabbit hutches in sommerfeld. verschuer's advice ran as follows: i would undertake absolutely everything that is at all possible. so build with all of the money and material you get! since your research activity was acknowledged at the board meeting of the institute in dahlem by the relevant people, above all by the city medical councilor and reichgesundheitsführer, and its continuation declared to be urgently necessary, you need not have any concern about your future. your tendency toward moving forward is thus altogether correct. in the end, verschuer's assessment turned out to be right. diehl's project enjoyed high priority up to the end of the third reich. upon verschuer's application, the reich research council classified diehl's research on tuberculosis as "important for war and state" and issued a corresponding research contract on august , . achim trunk is correct to emphasize that diehl's project was the only one of all of the research projects being conducted at the kwi-a in to be granted the higher priority of "ss." since the costs of the project ultimately consumed a large portion of the institute budget, in february verschuer submitted an application for funding of , rm to the reich research council, which was also approved without a hitch. "it is truly unpleasant for me to be the greatest consumer of the institute's funds," diehl commented about the application. "couldn't money be saved? but where? everything i have is still so meager and yet so much money. it embarrasses me. and if anything is to come of it, this is only the beginning." conti's interest in tuberculosis research is easy to understand. but here the thesis will be advanced that conti was interested by no means only in genetic pathology research, but also in research under the banner of phenogenetics. this thesis is supported by a source from the estate of leonardo conti, which indicates that, at the time when the negotiations about the reorganization of the kwi-a were under way, the reichgesundheitsführer was fervently interested in issues of "ethnic cleansing" in occupied poland, the "germanization" of poland and the resettlement of german nationals. conti was concerned with this complex of subjects because of the danger of epidemics associated with the resettlement of german nationals. at himmler's request, in december the rusha had presented the draft of a "selection system for the settlement of the new reich districts" (ausleseordnung für die besiedlung der neuen reichsgaue), which also entailed the participation of the reichsgesundheitsführer. the reorganization under the banner of phenogenetics had significant consequences for the institute budget. the size of the budget grew continuously in the war years. fiscal year on, the institute lived beyond its means. in order to be able to continue working in the same order of magnitude as it had until then, it was dependent on the constant flow of third-party funds of considerable scope. this, in turn, had effects on the research program and practice. the initial financial situation when fischer set about to reorganize his institute was not as bad as he had portrayed it to the board of trustees. it had been possible to stop the gap left by the cuts at the start of world war ii through the significant surpluses amassed in the years from to . in september the subsidies from the reich and prussia planned for / were cut to , rm, despite fischer's vehement protest -the shortfall of nearly , rm resulting from this cut ate up around half of the credit balance from the previous years. in the / fiscal year the subsidies from the reich and from prussia were cut by another , rm to , rm, but the expenditures dropped so sharply due to the drafting of nearly all scientific staff and "the cessation of research works associated therewith" that a surplus of nearly , rm remained at the close of the fiscal year. this, together with the remaining surpluses from the previous years, yielded a credit balance of almost , rm, which was transferred to the new budget in view of the research projects the institute had been forced to defer because of the war. added to this was a travel fund of , rm, leaving the cf. fischer to generalverwaltung, / / , mpg archive, dept. i, rep. a, no. , pp. - v: "a certain reduction as a result of the war situation is certainly understandable. but the overall situation is not such that the institute will be closed. […] all of our operations, which, of course, were greatly restricted in the past, first weeks of the war, are coming back into gear. it would be entirely wrong to perform exclusively chemical and physical science because these can be put directly in the service of military economy. our studies about hereditary diseases are at least as important for the volk." thus fischer rejected -successfullyhuge cuts to his budget. kwi-a with "secret reserves" of around , rm in april . in other words: the balances could barely conceal that fischer was again hoarding money in his institute for future research projects. in comparison to the balances for the / and / fiscal years, however, it becomes apparent that funds flowed even faster now. the subsidies from the reich and prussia increased by about , rm. they reached the level of , rm and thus more or less that of the late s. despite the dramatically increased personnel costs -a consequence of founding the department for experimental genetic pathology -at the end of the fiscal year a new surplus of over , rm remained, so that the surpluses, including the full-to-bursting travel fund, totaled over , rm -and this although of the , rm earmarked for nachtsheim's department from the german research association, only , rm were called in right away. and because this subsidy could not be spent in any reasonable way, with the consent of the general administration it was used for the purchase of the library and collection of specimens from the private property of the departing director -the money thus flowed into fischer's pockets. the rest could be transferred to the next accounting year. in other words: at the start of the budget year the institute had "silent reserves" of , rm at its disposal, more than a third of the entire kwi-a budget. not until the / fiscal year did the unchecked expansion thrust result in a hefty deficit. the subsidies from the reich and prussia diminished to , rm, and although the oustanding payment of , rm from the dfg balanced this out, the revenues were not sufficient to cover the dramatically increased expenditures. the personnel costs were the largest post -in this fiscal year alone, three new scientific assistants and eight technical and administrative employees were hired. the deficit ultimately amounted to , rm, through which the accumulated reserves dwindled to just under , rm; however, this did not include the travel fund of over , rm, which remained untouched. the new director otmar von verschuer was faced with a weighty problem. the personnel costs had exploded so greatly as a consequence of creating the departments for human genetics and experimental genetic pathology that they far surpassed the level of the usual grants. in the negotiations with the general administration about his appointment on october , verschuer thus submitted a cost estimate of , rm for the / fiscal year. in oral negotiations telschow made clear that, while an increase had been requested from the reich education ministry, it could not be expected in such an order of magnitude. this assessment was to prove correct: the allocations from the reich and the prussian state did increase back to , rm in the / fiscal year, however, under the condition that the remaining funding gap of , rm be covered by another source. in this situation, alfred kühn, deputy director of the kwi for biology, who had followed the reorganization of the kwi-a around phenogenetics since with interest, leapt into the breach. in his capacity as chairman of the biology and medicine section of the academic council of the kwg, he took part in the meeting of the kwi-a board of trustees on may , , which was dominated by the financial crisis. kühn suggested turning to the association of sponsors of german science (stifterverband der deutschen wissenschaft), which had free funds at its disposal at the time. to this effect friedrich schmidt-ott, the chairman of the association of sponsors, was to be addressed, who also belonged to the board of trustees, but had not attended the meeting on may . also missing was reichsgesundheitsführer leonardo conti, who had supported all of the institute's financial requests so effectively before. conti's star was waning by this time, and it is striking that fischer, verschuer, telschow, and kühn, who were alone at the meeting on may , , no longer included conti in their calculations, but rather decided to arouse the interest of conti's former rival, karl brandt , who had since overtaken conti in importance as the "accompanying physician" of the führer, one of the two figures responsible for the "euthanasia" program, and since july also hitler's authorized representative for the medical and health service, in the institute's work. telschow took immediate action. just day after the board meeting, on may , , he addressed schmidt-ott -with express reference to kühn. since the association of sponsors no longer had such a high sum at its disposal, schmidt-ott forwarded the letter from telschow to albert vögler, president of the kwg since , who suggested directing a petition to the "sponsorship association of german industry" (förder[er]gemeinschaft der deutschen industrie), to request a nonrecurring grant of , rm. verschuer kept this possibility under his hat for the moment. for in the meantime, on may , , the german research association -in response to an application by verschuer on march , -had approved , rm for the institute in dahlem, for "studies in the area of comparative genetic pathology." in june verschuer reported that kühn was negotiating with schmidt-ott about the remaining deficit of , rm. these negotiations ultimately resulted in resorting to vögler's offer: on september , the association of sponsors of german industry approved a -year research grant of , rm annually for the kwi-a. the association of sponsors of german industry had been founded officially in november . the motives that led to the founding of this organization were located on two levels: for one, in view of the profit restrictions imposed upon business by the national socialist regime, sponsoring research was simply a possibility for "investing the considerable war profits, when the traditional possibilities for reducing profits, that is, increasing share capital and increasing capacity, no longer appeared interesting." second, leaders in industrial circles were concerned about theoretical research and the sponsorship of young scientists -at a point in time that coincided with the "first disillusionment about germany's chances of military success" and in view of "the future existence of business and research in a postwar period." extremely interesting -and until now disregarded -is that the economic leaders assembled in the association of sponsors accorded such great importance to phenogenetic research in dahlem in this context that they approved quite a considerable amount for the kwi-a. by way of comparison: in spring the association of sponsors had an endowment of million rm, of which a total of around , rm in interest yields were available for distribution. in the / fiscal year, besides the subsidies from the reich and prussia, the kwi-a received third-party funds from the association of sponsors and the dfg amounting to , rm. in the / fiscal year this total even increased, to , rm, as the dfg not only renewed its grant of , rm, but also, as mentioned above, responded to verschuer's petition by providing an additional , rm for diehl's tuberculosis research. in august verschuer was able to state with satisfaction, in a letter to his friend bernhard de rudder: surprisingly, the cutbacks i expected in my institute have not come to pass; on the contrary, great value is placed on continuing the research important to the war. and so the cogs remaining in my institute machine are turning at full speed, as if the entire machine were still running. but i am glad that so much remains in operation, and that thus still quite a bit of productive work can be performed. since the subsidies from the reich and prussia had been fixed at , rm, the ratio of public subsidies to third-party funds was : in the final budget year. in other words: the subsidies from the german research association and the association of sponsors of german industry were of vital importance for the institute from on. the at the congress of the german society for genetics in , which took place at verschuer's institute for genetic biology and race hygiene in frankfurt, nachtsheim introduced his breeding experiments to the genetic community, and also aroused the attention of those geneticists working on the genetic pathology of humans. after the war, fischer admitted that the idea of winning nachtsheim for his institute occurred to him at this congress. when fischer approached nachtsheim in september , the latter did not hesitate. in the very next month he gave notice that he would be leaving his senior assistantship. his professional status was precarious. since , when the institute for genetic research, along with the agricultural academy, had been integrated into the agricultural faculty of the friedrich wilhelm university, his room for maneuver had been severely restricted. although nachtsheim had been appointed associate professor of the university in , there was no prospect of a regular professorship, especially since he was considered suspect in party circles. he never joined the nsdap. in he had been dismissed as chairman of the reich league of german rabbit breeders. for nachtsheim entirely new possibilities for continuing to advance his research on comparative genetic pathology opened up with the switch to the kwi-a, on a secure material foundation, shielded by the kaiser wilhelm society. the new orientation presented no difficulty for him, since his research on the genetic pathology of mammals had been conceived from the outset as a model for human genetics. in nachtsheim then also switched from the agriculture to the mathematical-natural sciences faculty of the university of berlin -he could not bring himself to decide to switch to the medical faculty. as in the cases of kurt gottschaldt and karl diehl, in hans nachtsheim, too, fischer opted for a scientist whose career seemed to have hit a dead end in the third reich -and who was rather distanced from national socialism. this proved to be a skillful move, for nachtsheim, too, justified the trust placed in him and built the new department for experimental genetic pathology into a supporting pillar of the kwi-a in a very short time. in fischer's and verschuer's plans for reorganizing the institute in dahlem, the triangle of clinical genetic pathology of humans, the animal model and embryology was assigned decisive importance in terms of research strategy. the high value placed on embryology in this concept is often overlooked, because the planned department for embryology was never founded due to the war. this was not for verschuer's lack of trying. in june -that is, a full three months before he took over as director of the institute in dahlem -he began asking around in his circle of colleagues in order to find candidates for the position of director of the new "department for embryology or genetic developmental physiology" in planning. since the new department was not only to study animal embryos from nachtsheim's department for experimental genetic pathology, but also "to build the bridge […] to humans" and to work "on human material" as well, verschuer elaborated to inquiries that no zoologist, but only an "embryologist coming from the field of anatomy" came in question. preferably, verschuer was searching for a young scientist who was nevertheless well-versed in embryological methods -postdoctoral qualifications were not required. the survey produced very few indications of any utility. an acute lack of young anatomists was a problem at the time, and most of the few younger scientists in this area had been drafted, so that ultimately only one of the candidate's names seemed at all suitable to verschuer: the university lecturer dietrich starck ( * ), prosector and senior assistant at the anatomical institute of the university of cologne. verschuer entered into detailed negotiations with starck and his superior franz stadtmüller, the director of the anatomical institute. starck indicated that he was interested, but expressed from the very beginning reservations because he was "an anatomist, body and soul," and could find that a move to dahlem could " 'sideline' [his chances as] an anatomist" and end up doing himself out of a chair in anatomy. in early verschuer and starck agreed to put the negotiations about the appointment on ice for the time being. in may , verschuer invited the still hesitant starck to hold a lecture at one of the upcoming "biological evenings" in harnack house. these evenings were presided over by alfred kühn -the invitation to starck underlines an earlier indication by verschuer that "through the close cooperation with the neighboring kaiser wilhelm institutes, above all with von wettstein, kühn and butenandt, quite special working possibilities are presented" for the new department for embryology, especially "in joint colloquia and team projects." as becomes apparent in the correspondence between verschuer and his friend de rudder, in summer semester starck actually did appear "at a dahlem biological evening" and held a talk about "the importance of developmental physiology for comparative anatomy, explained on the example of the head of vertebrates," which, according to verschuer, was "outstanding in form and content." personally, too, starck had "made the best impression." ultimately he rejected the appointment to dahlem, however, because he did not wish to "endanger his anatomical career." "despite the high qualification of mr. starck," verschuer continued, he was "not unhappy about the rejection," as he had since believed to have found "another and […] apparently more suitable candidate for the position of department director." the person in question here was the university lecturer wouter frans hendrik ströer, prosector at the anatomical-embryological institute of the university of groningen, who had worked as a guest scholar at the kwi-a for several months in . "ströer is a dutchman, but entirely on our side." he was "an outstanding researcher personality" and "decidedly the best man i could think of for my institute." nevertheless it was open to question whether his move to dahlem would take place. ströer himself had "doubtlessly the greatest inclination." however, "by order of the reich commissioner for the netherlands," he was supposed "to take over a professorship at the new reich university in groningen." the decision was still open. verschuer had informed the reich education ministry of his intention to appoint ströer to departmental director on july , -mediated by the general administration of the kwg: dr. ströer is a scientist known for his superior research work in the field of developmental history and genetic pathology […] . he has been occupied with phenogenetic studies as a guest assistant at my institute for some time […] . politically i hold him to be altogether reliable and pro-german -he is a storm-trooper of the germanic ss in the netherlands. in the end verschuer was not able to get his way. as late as september he reported to de rudder that ströer was "still being held back by the reich university of groningen (by now one must write 'former'!) for the time being," but his wife and three small children had been "sent here into my protection, as their lives were threatened directly by their fellow countrymen." "emergency quarters" had been set up for them at the institute. in a further letter by verschuer written a short time later, this time to fischer, he stated that ströer was "stationed with the ss in arnheim" and "certainly took part in the heavy fighting there." the total number of "working scholars" remained -on paper -nearly unchanged during world war ii: from ( / ) it fell slightly to ( / ) and finally to ( / ), and then rose again over the course of verschuer's takeover, to ( / ), then ( / ). yet this impression of relative stability is misleading, for the numerous drafts into the wehrmacht thinned out the scientific personnel extremely. as fischer's activity report for the / fiscal year shows, this began as early as spring : the activity of the institute was restricted, for even in the first five months of the year covered by this report, which were before the outbreak of the war, all assistants but one had been drafted for military drills, sometimes alternately, sometimes simultaneously. at the beginning of world war ii, in addition to the department director kurt gottschaldt, all assistants of the kwi-a and the majority of the male doctoral students were drafted. until late three assistant positions remained unfilled, and the remaining assistants -wolfgang abel, otto baader, heinz lemser, and siegfried tschamler -were in the wehrmacht and held contact with the institute only sporadically. thus, the "central block" was lost, so to speak, which not only had the consequence that all of the assistants' research projects lay idle. the supervision of the foreign guest scholars and the remaining doctoral students suffered as well. the fact that the assistants were drafted also meant that eugen fischer and fritz lenz had to take on more duties in academic instruction -in winter semester / , fischer himself had to hold the practical course in anthropology at his university chair, which he had been able to load off to his assistant abel until that time. demands on lenz's time were made by academic instruction duties, but primarily through the supervision of a great number of dissertations. further, due to the loss of their assistants, fischer and lenz had to take on an even higher degree of activities in producing expert opinions and evaluations. the situation remained unchanged in the / fiscal year -despite leonardo conti's intervention there was no success "in freeing up even a single assistant from military service, through which the scientific activity of the institute is greatly limited," fischer lamented. in the first draft of his activity report the final clause read as follows: "[…] since even among the doctoral students only one foreigner and two ladies remained, the scientific activity of the institute, aside from professor lenz, professor gottschaldt and the institute director, was completely extinguished." fischer's final activity report as director of the kwi-a, which referred to the / fiscal year, began with the resigned observation: through the further duration of army service of all assistants, one departmental director [abel] and at times a second [gottschaldt] , through the lack of nearly all male doctoral students, the institute has not been able to carry out scientific activities on a larger scale. not until the change in institute leadership did the personnel situation improve. wolfgang abel, by now director of the department for race science, was finally classified as "indispensable" in october , as was kurt gottschaldt, so that all departmental director positions were filled. in the first round of negotiations with the kwg in may , verschuer had also, as mentioned above, managed to acquire two further assistantships for his own department of human genetics to be reestablished, which he wanted to occupy with his closest colleagues from frankfurt. in july verschuer reported to the race biologist wolfgang lehmann of strasbourg, a member of the "dahlem circle": "i will take almost all of my newly founded institute for genetic biology and race hygiene at the university of rostock. siegfried liebau ( * ) had worked at the rusha and as an adjutant of the ss medical academy of berlin since , from may to september he was a personal consultant in the ss paramedical office in berlin. from december to october he was detached to the kwi "for professional training in the areas of anthropology, human genetics and race hygiene." the posting of liebau, whose wife ingeborg, née von ekesparre, was a close friend of the verschuer family, apparently can be traced back to a request by verschuer on november , . as will be shown below, liebau carried out twin studies in auschwitz during his time at the institute. in the further course of the war he became chief physician for the higher ss and police leadership of the adriatic coastal region and italy. the two assistants grebe and liebau were joined in the / fiscal year by two auxiliary assistants: karl joachim hene, who had entered gottschaldt's department for genetic psychology as an auxiliary assistant in and taken his ph.d. in with a genetic psychology dissertation about twins in early childhood, returned from military service. further, the teacher hans ritter ( * ), who had begun a second university degree in zoology, anthropology and psychology in , but then had been drafted into military service, started work as an auxiliary assistant in abel's department for anthropology, where he dedicated himself to "gypsy twin research." additional reinforcements came in the course of : karin magnussen ( magnussen ( - , working at the kwi-a on a scholarship since , was promoted to an assistantship -during the war period she was the only woman to hold this status. finally, heinrich schade was also hired. schade, member of the nsdap and sa since , had taken part, as already mentioned elsewhere, in the first yearly course held at the kwi-a for physicians from the ss in / . in he collaborated in the sterilization of the "rhineland bastards." in the same year he started at the frankfurt institute as verschuer's assistant and senior physician. in he submitted his postdoctoral dissertation about the genetic biological inventory of the population of the schwalm region, located between treysa and alsfeld in hesse. in december he moved -on paper -to the kwi-a as verschuer's senior physician. however, because he had been drafted into the wehrmacht, he was not able to start his new position right away. not until the turn of the year / did schade come to berlin, in the course of a military command, where at times he was able to continue his work of evaluating the genetic biological inventory of the schwalm region. he must have been detached to the front again later, for he experienced the end of the war as a yugoslavian prisoner of war. of the veteran scientific staff, only georg geipel remained at the institute over the entire period of the war. otherwise german scientists could only be recruited sporadically, like the "lateral hire" karin magnussen, and -as a convalescent -the physician gerhard koch ( koch ( - . the ranks were filled instead with foreign guest scholars from neutral or allied states. piebenga was supposed to become director of an institute "for the execution of certificates of ancestry and race" in . to make inquiries about him, l. ten cate, a consultant for questions (erik hug), spain (jésus cabeza), turkey (senhia tunakan) and hungary (mihali malán, lajos csik, anton steif, ladislaus apor). the number of doctoral students at the kwi-a oscillated between ( / ) and eleven ( / ), whereby the number of those who worked under fritz lenz - in / -is not included. the comparatively high numbers are deceiving in this case, too, however. numerous doctoral students had been called up to the wehrmacht -those who were able to work at the institute with any continuity were generally only the foreign doctoral students and the female doctoral students, whose number oscillated between two and four. finally, a glance at the nonscientific personnel, which also grew considerably in the course of reorganizing and expanding the institute. at the beginning of world war ii four technical assistants, eight secretaries, one nurse, and five "wage earners" (gardener, driver, keeper, cleaning ladies) had worked at the kwi-a; in / there were five technical assistants, secretaries, one photographer, one laboratory technician, one nurse, one auxiliary technical assistant, one caretaker, plus the married couple who worked as caretakers in the external department for tuberculosis research in sommerfeld, as well as four "wage earners" (keepers, cleaning ladies) and several "temps." despite verschuer's fears to the contrary, the institute was able to maintain all of its personnel in the second half of as well, as impending drafts were postponed for the time being: apparently it is primarily thanks to the vigorous action of prof. osenberg [werner osenberg ( - ] of the reich research council that research is so protected at the moment and should be continued to its full extent. thus verschuer still expected that abel and gottschaldt would be called up again, and perhaps nachtsheim as well, who had been ordered for a physical examination. hours of the institute -in keeping with the times -but only to such a degree that overstraining is avoided […] . verschuer's private household had initially employed foreign civilian workers. in the move from frankfurt to berlin in november , the verschuer family had a croatian maid. at the beginning of the family appears to have employed an additional female "eastern worker." in late february, verschuer reported in a letter to bernhard de rudder, that there had been "all kinds of sagas with our russian east worker." "it turns out there had been minor thievery, with which she provided provisions for all kinds of male compatriots […] ." yet she had been "kept again on probation." shortly thereafter verschuer again complained of "troubles at home with our russian (bolshevik!)." besides this, since at the latest, an additional female "eastern worker" was working at the neighboring institute. in august , after the renewed proclamation of "total war," verschuer feared that he would probably "have to give up the two eastern workers from the house and the institute." yet it never came to this. in late september verschuer wrote to fischer in freiburg that the "russian woman" in service in his household had "run away" -as once before in , and this time "the russian woman from the institute […] ran away with her." between september and november most of the scientific work at the kwi-a -aside from the external department for tuberculosis research in sommerfeld and (from ) the department for experimental genetic pathology -came to a standstill due to the fact that so many departmental directors and assistants had been drafted. this was not immediately apparent to the outside world, however. between and the institute still published scientific papers; however, this was the result of a "publication backlog." most of the publications from this period -to the extent that they were not simply overview papers, conceptual or methodological discussion papers -resulted from research projects that had been concluded before the outbreak of the war. only very few papers, such as a paper by karl diehl and eugen fischer about the tuberculosis experiments on rabbits in sommerfeld and the papers by hans nachtsheim about "the state of convulsion readiness and genotype," referred to current projects. the change came with the new director. verschuer was successful in getting the departmental director kurt gottschaldt and wolfgang abel classified as "indispensable," filled the ranks of the assistants with hans grebe, siegfried liebau, hans ritter, and karin magnussen and obtained a larger number of foreign guest scholars. and -not to be forgotten -verschuer achieved a budget hike and solicited considerable third-party funds. thus research resumed on a large scale from december on. of course, this was not immediately reflected in the publication lists. even so, between and the institute in dahlem produced another publications, whereby -in addition to the general intensification of the war situation -it must be taken into consideration that nearly all of the publications that had accumulated in the prewar period were published at this time. the papers published in the last two years of the war were almost without exception minor works presenting intermediate findings from projects in progress, and some of them were based on material that had been collected previously. a number of publications that had been available in manuscript form or were even in print were lost in the chaos of the war's end; others were not completed before the collapse of the third reich. some of these papers were still published after world war ii, for others this did not seem opportune because they were all too closely associated with the state crimes of national socialist germany. in the final years of the war, the shift in emphases between the fields of research of the institute in dahlem, observable since , continued at a faster pace. genetic pathology moved to center stage with publications -and this was, so to speak, only the tip of iceberg, as several large-scale projects in the field of genetic pathology never found their way to publication. this dominance of genetic pathology had various reasons: first, the two departments that had been able to keep up their operations in the first war years, that is, the external department for tuberculosis frankfurt to dahlem, verschuer had an assistant who, because of a project for the collection of stillborn fetuses in progress since the prewar period, and because of his postdoctoral dissertation about chondrodysplasia, had a rich fund of pathological material at his disposal, which could be evaluated without any great cost. fourth, through the activities of preparing assessments and evaluations, individual cases of genetic pathological interest (including all of the important genealogical information required for their genetic pathological evaluation) came to the attention of the researchers in dahlem. fifth and finally, the findings of genetic pathology promised a direct practical utility with regard to the measures of both genetic health policy, as well as eugenic sterilization, marriage bans in accordance with the "marriage health law," the allocation of "matrimony loans" and so on. the kwi-a extolled this practical aspect of genetic pathology research quite audibly, which was evident in the mere fact that the research application which covered the major portion of the work in this area bore the keyword "race hygiene." in total it can be asserted that the research field of genetic pathology increasingly pushed its way into race hygiene over the course of world war ii: there was hardly a genetic pathology study that was not oriented to genetic health policy, and hardly a race hygiene paper without clear references to genetic pathology. the trend toward specialization observed in the final years before world war ii, which inclined to lead race hygiene and genetic pathology (and race biology) away from each other, was reversed at the kwi-a from on. for a concrete example, in the years - there were nine research contracts with the keywords: wehrmacht contract numbers: pp. - ( / ) -iii/ ("genetic pathology research"), ss - ( / ) -iii/ ("tuberculosis"), s - ( / ) -iii/ ("specific proteins"), k ro/rfr- / / -iii/ ("eye color"), k ro/rfr- / / -iii/ ("twin camps"), k ro/rfr- / / -iii/ ("race hygiene"), k ro/rfr- / / -iii/ ("genetic biological inventory"), k ro/rfr- / / -iii/ ("stillborn fetuses") and k ro/rfr- / / -iii/ ("pneumoconiosis"). five of these nine research contracts -"genetic pathology research," "tuberculosis," "race hygiene," "stillborn fetuses" and "pneumoconiosis" -were located directly in the field of genetic pathology, one further -"genetic biological inventory" -had strong bearings on genetic pathology. this illustrates the dominance of genetic pathology even more strongly than the analysis of the publication list. the genetics of normal attributes, even and especially under the aspect of race was relegated down to second place, with two research contracts -"specific proteins" and "eye color" -and a total of publications. weighting the individual research projects according to their financial, political, and research-strategic value, it becomes apparent that from on, four areas were of fundamental importance for the future of the institute: comparative genetic pathology (nachtsheim), research on the heredity of tuberculosis (diehl), the project on the phenogenetics of eye color (magnussen) , and the project to develop a serological race test (verschuer) . their progress determined whether the budget could be fixed at a high level, whether sources of financing outside of the regular budget kept flowing, and whether research operations could be maintained in their entirety. they decided whether the project of phenogenetics, above all its integration into general genetics and biology, would succeed. and they were eminently important for genetic health and race policy. verschuer energetically pushed ahead with the concept of phenogenetics developed by fischer, but placed the emphasis on genetic pathology research, whereby, of course, he consequently conceived of genetic pathology as "medical genetics," thus embedding it in general human genetics. besides, verschuer understood genetic pathology as a principle encompassing and penetrating all subdisciplines of medicine and urged -in keeping with his concept of the "genetic doctor" -that it be indulged generously in both specialized and general medical practice. with his attempts to influence the medical students' conditions of study and examinations, his house journal der erbarzt, and -since -fortschritte auf dem gebiet der erbpathologie, rassenhygiene und ihrer grenzgebiete ("advances in the field of genetic pathology, race hygiene and their boundary areas"), and finally with the remaining areas had nearly no importance at all: in the area of geographic and paleoanthropology six papers appeared (mainly connected with colonial science research on "white africa"); four papers dealt with subjects that were decidedly race hygiene; four works were dedicated to conceptual and methodological issues. no papers appeared on genetic psychology. his leitfaden der rassenhygiene ("manual of race hygiene"), verschuer contributed to the process of making the findings of genetic pathology research flow into practice. the orientation on genetic pathology was also expressed in the erection of a genetic biological examination office in the attic of the kwi-a, which was to be expanded to a "clinical and polyclinical station […] in order to be able to continue the activities of consulting and producing expert opinions and also genetic clinical and genetic pathology research." verschuer had already operated such an office in frankfurt -the model for it had been the "polyclinic for the care of genes and race" in berlin-charlottenburg, which verschuer had run in / . from frankfurt he brought nurse emmi nierhaus ( * ) from the protestant social services association (evangelischer diakonieverein), who not only took over the administration of the institute as his "right hand," but also provided nursing care for the examination office. "for as intensive specialized study of the research material as possible" verschuer further founded a "genetic pathology working group," to which he invited -besides the staff of the institute -prominent representatives of "pathological anatomy, radiology and all clinical specialities." this working group, which convened for the first time in march , was also supposed to "discuss difficult questions in the practical care of genes and race and prepare the basic decisions for the state offices." in his journal erbarzt, too, verschuer emphasized the genetic pathology working group's orientation to practice: over and again he was "enlisted for genetic medical consultations and evaluations, by the health offices as a genetic biology consultant, and by the hereditary health courts and appellate the nd edn. of leitfaden der rassenhygiene appeared in . in verschuer reported that a french edition was in printing, and a portuguese one in preparation. cf emmi nierhaus started at verschuer's institute in frankfurt in september , followed him to dahlem in december and from there to the lay-by in solm. after the war nierhaus continued to work as verschuer's assistant, from july on, officially in the service of protestant social services (evangelisches hilfswerk). after a short interruption in / she joined verschuer at the university of münster. her responsibilities proceed from a letter by verschuer from the year : "i would like to assign nurse emmi the same group of duties she used to perform for me in frankfurt and then in berlin in such an excellent manner: it means a great deal to me that those people who come to use for scientific examination (e.g. twins), for evaluation (e.g. paternity certificates) or for their own consulting and examinations (e.g. marriage counseling), enjoy nursing care. the help of a nurse during the examinations currently in progress at the institute would thus have the highest priority. added to this would be the economic direction and administration of the institute, along with the many individual tasks associated with these duties, in which nurse emmi has proved particularly invaluable in the past." verschuer to oberin sprenger, evangelischer diakonieverein, / / , archiv des evangelischen diakonievereins zehlendorf, w (pre-archive). courts and other offices contracted to carry out race hygiene measures, as a chief evaluator." in frankfurt, whenever a specialized medical examination became necessary, he had turned to his specialist friends and their clinics -the working group in dahlem was supposed to serve an equivalent function. in his report about the / fiscal year verschuer reported that the genetic pathology working group had held "several sessions […] at which not only scientific cases from the field of genetic pathology were presented and discussed, but also practical issues of the care of genes and race debated, in order to provide to the reich ministry of the interior and the hereditary health appellate courts a position on evaluations." the erbarzt published the protocols of two meetings of the working group, those held on march and may . in his memoirs, published in , gerhard koch stated that he attended a further meeting of the genetic pathology working group in july or august , in which the subjects were hip luxation and club foot and whose participants included the internist friedrich wilhelm bremer, the orthopedic surgeon lothar kreuz ( - ), director of oskar helene heim and the orthopedic clinic of the university of berlin, and the pathologist robert roessle ( - ). on this occasion kreuz claimed he advocated the elimination of these two congenital disabilities from the catalog of indications in the gzven; his proposal had been agreed to, even "by the high-ranking medical officers of the army and waffen-ss attending this session, whose names were not known to me." koch presumes that the publication of the protocols of the meeting was "suppressed by the censors." this could in fact be the reason why -in contrast to the original proclamation -after the first two, no further protocols of meetings by the genetic pathology working group were published. however, it must be taken into consideration that koch's account is not confirmed by any other source and that koch has a tendency to exaggerate the frictions between genetic pathology research at the institute in dahlem and ns genetic health policy, not to mention the importance of censorship. a key role in the area of genetic pathology was played by hans grebe, who came to berlin from frankfurt with verschuer. it is essentially due to his influence that a new emphasis on the field of the differential diagnosis of congenital defects developed at the kwi-a from on. in grebe had begun with comprehensive studies on chondrodysplasia (hereditary disproportional dwarfism). he wrote a circular to health offices in southern, western, and northwestern germany, with which the institute in frankfurt had already been in contact regarding further professional training for medical officers. eighty-five health offices responded to this survey and reported a total of people with "dwarfism," nearly all of whom grebe visited personally and subjected to a thorough clinical and radiological examination, together with the members of their families (parents, siblings, children, uncles, aunts, nieces, nephews, and cousins). family tables were produced on the basis of registry office and church records, whereby particular attention was paid to the question of whether the parents were related by blood. for the purpose of comparison, grebe consulted the specimens of miscarried and stillborn chrondodysplastic fetuses that had been dissected at the pathological institute of the university of frankfurt in the years from to . grebe had to discontinue his work after the beginning of the war because he was called up for military service. in summer -as previously mentioned, grebe had been discharged from the wehrmacht because he was seriously wounded -the "main part" of the work performed at the university of frankfurt was submitted as his postdoctoral thesis. the manuscript was sent to thieme-verlag in leipzig for publication, but the proofs were destroyed there by a bombing -not until was the work published in analecta genetica, largely unchanged, by luigi gedda , the founder and director of the mendel institute in rome. grebe had examined a total of families with around , persons, frequently against the bitter opposition of the subjects. one of the probands, who had been sterilized at the age of in , as grebe reports casually in , had reacted to "a clinical and radiological examination and especially the production of photographs […] with the greatest resistance." among these probands, he continued, there was the "highest degree of mental sensitivity, which was also shared by most of the members of the family." of one -year-old subject he writes that she was "very sensitive mentally" and seemed "decidedly depressive. for instance, during the examination, against which she put up vehement resistance, she began to cry. during a later visit, too, her mental behavior seemed melancholy." only in the case of a -year-old girl, who had been sterilized in spite of an appeal to the hereditary health court, did grebe express a degree of sympathy: "the resistance brought against our examination was particularly great under these circumstances." the boundaries between voluntariness and compulsion were blurred to the extent that some health offices used grebe's survey to request an opinion as to whether a marriageability certificate could be issued for certain probands. occasionally a hereditary health grebe, chondrodysplasie, pp. - . ibid., pp. vii-viii. ibid., pp. - . ibid., p. . grebe did not even hesitate to secretly take a picture of a female subject whose behavior was guarded and suspicious. ibid., p. . ibid., p. . ibid., p. . further indications of resistance on, e.g., pp. , , p. , , . cf. e.g. ibid., p. : "with the negative family finding and the particular professional prowess of the proband, who also successfully graduated from a rural vocational school," in this case court requested that the frankfurt institute for genetic biology and race hygiene provide an evaluation in accordance with the gzven -in these cases it was not possible for the subjects to refuse an examination. as grebe adhered strictly to his analysis of the conditions of heredity, he sometimes took a position against sterilization, yet this did not change the fact that in this situation he confronted his subjects in compulsory proceedings as an officially empowered evaluator with comprehensive powers of attorney. this constituted a transgression of the boundaries of scientific ethics of major importance, both potential and in principle. the material grebe had collected in the course of his study of chondrodysplasia constituted the basis for a series of publications in the years - , as he had run across an abundance of additional physical defects, mental disabilities, and mental disorders in his comprehensive genealogical studies. this material increased when, after completing his postdoctoral dissertation, grebe set about recording miscarried and stillborn fetuses on a large scale. by march he had examined nearly families who had produced a stillborn child with a serious defect. verschuer's activity report for the / fiscal year relates: grebe concluded a major family research project using a non-selected series of deformed stillborn fetuses. generally speaking he was able to prove that heritability plays a much greater role in the problem of stillbirths than was previously presumed. for the first time he was able to prove that certain forms of congenital defects are hereditary. thus grebe, proceeding from his collection of stillbirths, described three families in which multiple intestinal deformities had occurred (stenoses, atresias, ventricles, cysts). in he published a paper about the problem of a genetic disposition for hernias (inguinal and umbilical), based on observations of twins and families. grebe attempted to prove that a hereditary factor was involved in the etiology of both cases. in other cases he endeavored to illuminate the hereditary precisely. in , for instance, he published an essay that proceeded from the "stillbirths" project, on the emergence of arhinencephaly (absence of olfactory tract, olfactory bulbs, and frequently the frontal lobe of the brain), whereby he presumed an grebe took a position for issuing a marriageability certificate. a case with similar circumstances is depicted on p. . cf., for instance, ibid., pp. , . perusing the book, indications of more than twenty sterilization trials are found, whereby in one case (p. ) the application was supposed to have been submitted by the subject herself. cf. grebe, fistula; idem., struma; idem., erblichkeit; idem., akrocephalosyndaktylie; idem., lipomatosis. "irregularly dominant genetic disposition." in the same year he published a major paper on acrocephalosyndactylia (a syndrome characterized by skull deformation and webbing of the fingers). with reference to the etiology of this syndrome he rejected all "exogenous attempts at explanation (above all deficient amnion, lues and hypophysis damage)." grebe assumed a specific mutation and concluded that "no race hygiene measures proceed from acrocephalosyndactylia at this time." in all of his research grebe endeavored to make as precise a differential diagnosis as possible. he assumed that one congenital defect could have very different genetic or even exogenous causes (heterogeny). verschuer emphasized the importance of grebe's research in this direction in his activity report for the / fiscal year: in the area of the typical clinical picture [of chondrodysplasia] it was possible to establish several gene types that could be differentiated clinically and genetically. on the margins of the typical complex of symptoms there are many other genetic conditions of the cartilageskeletal system, some of which could be observed and described for the first time. the project thus yielded a very far-reaching heterogeny, which is of fundamental importance. this finding made it seem very important to demarcate the different clinical occurrences as precisely as possible, to explain the genes responsible in each of the hereditary forms, and to reveal genes that were manifested to a hardly perceptible degree or not at all. in the context of his study about chondrodysplasia grebe published a family study in which he pursued the question as to whether the heterozygotic carriers of the recessive gene for chondrodysplasia could be recognized on the basis of minor, nonpathological varieties. in x-rays he established that the heterozygotic family members showed minimal changes in the bone structure of the hands and feet. "but should it not be possible," grebe asked at the close of his article, "to find a way to recognize the heterozygotes in the future, for other recessive genetic conditions as well?" for the "practical care of genes and race" the importance of this question "could not be underestimated." yet another study by grebe of the year must be viewed against the background of his search for stigmata. this particular work dealt with a family with an increased frequency of lipomatosis (painless symmetrical diffuse deposits of fat), but also "mental anomalies (schizophrenia, schizoid psychopathy, feeble-mindedness to greater or lesser degree, suicide, epileptic-type fits, melancholy)" as well as physical deformities (chondrohypoplasy, microcephaly, wryneck, hernias). in this case, however grebe discarded the hypothesis of a genetic connection. rather, he traced the coincidence of the various anomalies back to "sifting by mating." moreover, it was possible "that the effect of one or more pathological genes on the manifestation of other genes resulted from the particular frequency of anomalies in the family described." in a further essay entirely tailored to practical race hygiene, in grebe discussed the question of how high the risk should be estimated that a mother who already had experienced a miscarriage or stillbirth would give birth to yet another child with defects. in the case of very serious defects that made survival impossible, grebe summarized his considerations, "more or less complete destruction" resulted on its own. however, a "complete elimination" of all genes responsible for defects was not possible, "first of all because only some of the carriers of very frequent, irregularly dominant and recessive genes become phenically ill, and further, because constant new generation through mutation is possible." after all in many cases the probability that a further deformed child would be born after the birth of a non-viable, seriously deformed child was so low that there was no need to advise against a new pregnancy. and even for minor changes "that can hardly be addressed as defects" there was no need to take action. "on the other hand, great misgivings about the conception of additional children must be expressed in cases of defects which allow the affected child to survive and reproduce, but reduce to some degree the capability of the adult to work or perform military service." in every consultation, however, "the total value of the given family [must be] considered." methodologically speaking, genetic pathology research at the kwi-a was committed to higher mendelism at the time of the world war ii, and its objectives thus differed from those of practical race hygiene. in terms of contents a clear emphasis on the area of physical defects emerged, due above all to grebe's research interests. in the department for race hygiene the research "about the heritability of deaf-muteness and the race hygiene prospects of its prevention" begun in the prewar period was continued. hereditary blindness, too, remained an object of interest. finally, these were joined by the research on epilepsy in the department for experimental genetic pathology. this constitution of emphases entailed a clear division of labor with the german research institute for psychiatry and the kaiser wilhelm institute for brain research in berlin-buch, both of which, closely connected with the nazi "euthanasia," were concerned with the differential diagnostics of the various forms of mental disability, schizophrenia, and neurodegenerative diseases at this time. this area played no further role at the kwi-a during world war ii. grebe, mißbildung, pp. f. yet the withdrawal from the areas of psychiatry and neurology was only in part the result of a conscious demarcation of the fields of work. it was much more a result of the fact that the large-scale project on the genetic biological inventory of peasant villages in the schwalm region of hesse, which was begun in frankfurt and was supposed to be continued in dahlem, was not making any headway. originally, the project was one of those taken on by walter scheidt as part of the "german race science" campaign. at scheidt's request church records had been catalogued, scholars had begun to compile family tables from the around , excerpts from church records -the declared objective was to establish the genealogy of the peasant population of schwalm from to the present. in scheidt had turned the project over to the frankfurt institute for genetic biology and race hygiene, which used funds from the reich committee for national health service to hire an assistant to complete the family tables. further, verschuer's institute set about recording the living population in these villages, whereby not only the usual anthropometric examinations took place, "but rather beyond these also comprehensive clinical-physiological and pathological findings [were to be] recorded" -this was the reason for handing the project's direction over to the physician heinrich schade. as the counterpart of the long-time resident population of the schwalm region, a parallel genetic biological inventory of the city of frankfurt south of the main was to be carried out using the same methodology. the objective of the genetic biological inventories was to link together the fields of race anthropology, genetic pathology, and race hygiene: schade and his staff had been working in the schwalm region since winter / -with the active support of the district administration, the mayors, the health offices, the schools, and the party offices. in february they had concluded their studies in two villages. in addition they evaluated the patient files of the relevant institutions of the treatment and care, hospitals, welfare offices, and practical physicians. all findings were recorded in the family tables and files, which were made accessible by a personal card index. in late schade -with financial support from the dfg -had over , excerpts from the case histories of the university clinics in marburg and the files of the ziegenhain health office, the state insurance institute in kassel and from army physicals. schade and his colleague günter burkert had personally examined , patients. by march over , excerpts from patient files and health office certificates had been produced. in the framework of the project, schade's interest was directed primarily to the distribution of "feeble-mindedness" in the "inbreeding area" of the schwalm region, with a strong practical orientation to race hygiene. burkert dealt with "acts of selection" through immigration to and emigration from the schwalm region. a study about the "character and aptitude of the schwalm population" apparently was never concluded. the project staff member heinz koslowski performed anthropological studies in one of the region's communities, which had been founded as a hugenot settlement, establishing there "demonstrable differences with regard to the population of purely german descent." schade submitted his postdoctoral thesis about the genetic biological inventory of the schwalm region in -it appeared in print in . at the beginning of the war the evaluation of the daunting mountain of material was far from concluded, however. schade was drafted into military service. in december -on paper -he followed his mentor verschuer to dahlem, but continued to serve as a surgeon major on the front and was not able to work at the institute himself. a new "auxiliary statistical assistant" continued to evaluate the genealogical, anthropological and medical data. not until the turn of the year / could schade, as mentioned above, come to berlin in the course of a military command and resume his work at the institute. in his activity report for the fiscal year / verschuer reported that schade had [t]he essential task of processing the great amount of material on the genetic biological inventory for an old-established peasant population (from the pre-war period) continues to be sponsored. the population movements over years have been established, the average burden with numerous illnesses determined and the question as to the importance of heredity for early invalidity investigated. two publications that had been announced never came to be, however. consequently there was a great deal of material available at the kwi-a that could have been evaluated with regard to aspects of genetic pathology, in particular with regard to mental disabilities, had there not been a dearth of personnel. in other areas, too, such as internal medicine, for practical reasons it was hardly possible to perform genetic pathology research during the war. back in grebe had begun a large-scale study in frankfurt on the question of a "constitutional conditionality" of pneumoconiosis ("black lung" disease) on behalf of the reich labor ministry. through his service at the front this study was interrupted for years and was supposed to be brought to its conclusion in dahlem in . but the air war made it impossible "to perform systematic examinations in the ruhr area at this time, whence the majority of the cases originated," such that completion of the study was delayed even further. by then grebe had recorded over , cases of black lung, which had been treated in social miner's hospitals or discovered during the series of x-ray examinations performed by the ss. the twins had been determined by means of inquiries at the offices of vital statistics. grebe had contacted over twins and requested file data and photographs. the clinical examination of the twins was interrupted by the start of the war, however, and the study had run aground in the second half of the war. in the area of infectious diseases, genetic pathological research in the last years of the war concentrated exclusively on tuberculosis research, after another longterm project had remained without any concrete results. around verschuer, together with the biologist richard prigge ( - ) of the state institute for experimental therapy in frankfurt, had begun a "heredity experiment" on the "natural resistance of the guinea pig to diphteria toxin." in their final report published in , prigge and verschuer reached the conclusion that "the question of hereditary differences in resistance to diptheria toxin in the guinea pig clearly must be answered in the negative." of the guinea pigs tested, only two survived, which had been "taken into breeding." the production of a diptheria-resistant erkrankungsstatistik einer wohnbevölkerung ("illness statistics of a residential population") and bevölkerungsbewegung in drei jahrhunderten in acht dörfern ("population movement over three centuries in eight villages"). cf guinea pig through pure breeding was not successful, however. instead, it seemed that the breeding of a tuberculosis-resistant rabbit was within reach. since tuberculosis research using the twin method had hit a dead end in the s, karl and anne diehl -in close collaboration with verschuer and fischer -had been experimenting with rabbits in the "waldhaus charlottenburg" since . diehl infected his experimental animals with a constant strain of the bovine tuberculosis bacillum by means of intravenous injection, but not until sufficient progeny were available for further breeding. the infected animals were held in a secluded stall and dissected after their death. clear differences, interpreted as conditioned by heredity, became apparent as regarded the time of survival after injection and the infestation of the individual organs. interest was directed primarily to two breeding lines -the one, "central" type developed a serious tuberculosis of the lung, while the other organs were hardly affected at all; in the other, "peripheral" type, by contrast, the sources of infection emerged primarily in the peripheral tissues, like in the kidneys or the nerve tissue. "a heritability of this organ specificity in the reaction to tuberculous infection," fischer announced in his / annual report, was "thus proven experimentally for the first time." in the next annual report fischer added that the results of the rabbit experiments could be "conferred without further ado […] to humans. this also yields important prospects for combatting tuberculosis in humans." according to fischer, at the tuberculosis congress in baden-baden diehl "held a lecture that aroused great attention and was received with much applause." from on fischer and diehl presented the results of the rabbit experiments in sommerfeld to the experts. the two different manifestations of tuberculosis could be bred constantly and in a pure form through eight generations of rabbits. the hereditary character of the clinical picture remained completely preserved, "even when animals were pre-treated with human tuberculosis bacilla, which are avirulent for rabbits." now diehl attempted to get to the bottom of the riddle of organ resistance in animal experiments: it was attempted to modify the type of tuberculosis manifestation by inbreeding specimens. for this ink blocking, re-infections and organ transplants were performed. the persistence of the way in which tuberculosis is manifested appears to be very great in the bred specimens. these experiments will be expanded further, since it is possible that their result can be of fundamental importance for the medical therapy of humans. the endeavors to obtain clarity about the status of individual organs in the process of infection in the bred specimens aimed in the same direction. what was particularly interesting here was the status of the liver. in addition to these experiments, diehl began crossing the two pure breeds with each other. when in the period from april to july he set about infecting the animals proceeding from the crossbreeding experiments with tuberculosis, he believed that his research was entering a decisive phase: crossing the two pure breeds has now yielded a large f . seventeen animals from the pure breeding experiments were taken as the point of departure. the f amounts to around animals. from the f , which we generated from animals born the previous year, we unfortunately lost quite a few because of the wet weather and the consequently wet feed. now we have only about animals. in the coming year the f will then appear in full force. i am glad that these animals were "vaccinated away"without having been able to reproduce. only the desired "immune" animals will reproduce. i believe that if i aim for an f of about animals that should be sufficient. the approach was clear: through crossing the two pure breeds diehl hoped to be able to cultivate "tuberculosis-resistant" rabbits. thus, he continued working as if obsessed, although he felt miserable and exhausted at the time, since the late consequences of a lung tuberculosis contracted in his youth became noticeable. diehl and verschuer were feeling time pressure, too, not least because they had heard about rabbit experiments by the american tuberculosis researcher max bernhard lurie ( * ). in january -the catastrophe of stalingrad was imminent -diehl was still filled with hope by the sight of the dying rabbits: i go into the stalls in sonnenberg often. biological events are taking place there with a cruel consequence. it seems obvious that i hold the key in my hand. the decision will be made this summer! the hope for tuberculosis-resistant rabbits was not fulfilled, however. nevertheless, diehl continued working doggedly on crossing the two pure breeds until the end of the third reich. in october he had dissected nearly rabbits originating from verschuer, tätigkeitsbericht / , mpg archive, dept. i, rep. , no. . in diehl's draft the final point was explained in more detail: "in order to obtain clear results, pieces of the liver were surgically removed from members of the last two inbred generations, these pieces tested in terms of their antibacterial power and the animals, after recovering from surgery, tested as usual. the antibacterial power of the liver proved to be very different among the animals. the lung is currently being examined in the same direction." diehl's draft for the these crosses and performed statistical analyses of the results -but without attaining any final certainty. nonetheless, diehl -and verschuer as well -still believed that this was the way to achieving a breakthrough in tuberculosis research. biochemists were also interested in diehl's experiments. the specifically genetic resistance of the organs had to be effected through the production of a substance in the organism, which prevented or hindered the tuberculosis bacillus from settling in certain organs. thus the search was on for a biochemical compound. if they succeeded in isolating and identifying it, this would yield far-reaching consequences for tuberculosis therapy as well. this is the background of the lateral contacts between the external office of the kwi-a in beetz and the kwi for biochemistry under adolf butenandt. the connections extended all the way back to . to keep from distorting the results of his study, diehl required for his injections an emulsion that was completely dispersed, i.e. the tuberculosis bacilla had to be distributed as regularly as possible without any clumping. to solve this problem, diehl had arranged with gerhard schramm ( * ) of the kwi for biochemistry to use the colloid mill located there, which could liquidify the tissue by rotating it at high speeds, in late august or early september . verschuer made adolf butenandt himself aware of diehl's experiments in july , who proved to be "extraordinarily" interested. "unfortunately," verschuer reported to his friend diehl, "we were interrupted, so that our conversation did not come to a conclusion. thus i cannot give you any result yet today. yet i will come back to the matter upon the next opportunity." in a telephone conversation just a few days later, butenandt expressed his wish to meet diehl personally as soon as possible and learn about his experiments. verschuer asked diehl to bring "some of his family tables, tables, pictures or specimens." the meeting was supposed to take place in july or august, but apparently was delayed until october. this is in keeping with the comment in a report by verschuer to the dfg of september , that contact had been established with butenandt in connection with the tuberculosis project in order to accomplish the biochemical analysis. the collaboration between diehl and butenandt survived the third reich, but diehl's research ultimately fizzled out. through diehl's rabbit experiments, butenandt became aware of the entire range of genetic pathological research performed under the banner of phenogenetics at the kwi-a. on november , verschuer held a lecture to the prussian academy of sciences about "heredity in infectious diseases," in which he attempted to link the results of the phenogenetically oriented research -especially diehl's rabbit experiments -with the work by alfred kühn and adolf butenandt on gene action chains. it was no longer possible to publish the text of the lecture before the imminent collapse of the third reich, but it appeared -unaltered, as far as we can judge -in under the title die wirkung von genen und parasiten im körper des menschen ("the effect of genes and parasites in the human body"). verschuer's argumentation is still entirely fixed upon the problem of the interaction between infection and hereditary disposition, but also picked up on some thoughts of butenandt's to touch on issues that are highly relevant today. for instance, verschuer emphasized the importance of infectious diseases that jump from animals to humans, which is nothing short of prophetic in the age of bse and sars. he further indicated the similarity between viruses and genes -today we know that a significant part of the human genome consists of incorporated viral material. in butenandt verschuer found an attentive listener; the two even had "an especially pleasant (post-)meeting over a cup of tea at home." on january , the department for experimental genetic pathology under the direction of hans nachtsheim began its work. in the meeting of the board of trustees on january , fischer explained -presumably above all for leonardo conti -the key role of the new department. in the science of genetics, fischer claimed, "the animal experiment [had] always been in the lead"; "human genetic research" had "always [received] directions and stimulation from the former." nachtsheim's great service had been "to have recognized the fundamental importance of this wonderful research material and to have set about its evaluation […]. this new ground he has broken must become ours." this ground was not entirely new, as since the institute's founding in fischer had occasionally provided for experiments to be performed on rats, rabbits or guinea pigs in order to get to the bottom of the genetics of normal attributes, especially race attributes, through the study of embryos. but now nachtsheim's preliminary works opened up the possibility of continuing this research on a grand scale and, what was even more important, expanding it to the area of genetic pathology. although nachtsheim's papers since fit into the leading research paradigm of phenogenetics and were not designed for rapid and direct application to race hygiene, fischer never tired of emphasizing the practical importance of experimental genetic pathology before the board and also to the dfg, to whom he applied for , rm in research funds for nachtsheim's department on march , : what is most important is the corresponding examination of those genetic diseases that are important for humans. these are then model experiments for human genetic pathology. they will teach us why the same genetic condition often occurs in such different intensities; it will give us tips as to whether the development can be steered by external influences. at the same time, fischer stressed again that there was no alternative to the animal model: such studies are practically impossible on humans, because it is never possible to know with any certainty what would have become of a dead embryo. as fischer elaborated to the german research association, nachtsheim and his staff were to perform three parallel series of experiments on the diseases and anomalies to be studied: the first were breeding experiments. nachtsheim's group of scientists was to detect rabbits with pathological genes, to propagate these "in pathologically pure culture" to the extent that pregnant females could be killed at all stages of embryonic development, and finally the heredity of the pathological genes be elucidated in crossbreeding experiments. second, the dead embryos -in close collaboration with the department for embryology, still to be founded -were to be examined pathologically and histologically, in order to be able to study the inception of pathological processes during ontogenesis by comparing findings from various embryonic stages. third and finally, it was to be attempted to influence the outbreak of disease by environmental stimuli (poisons, chemicals, feeding), not least in order to be able to differentiate between a "general" and a "genetically increased" susceptibility, which, according to fischer, was "of particular importance in view of the most modern methods of treating diseased humans." at the close of his application fischer stated his conviction "that these theoretical and experimental studies will be of benefit to suffering humanity and serve the preservation of the genetic health of our volk." mentioning discreetly that the reichsgesundheitsführer shared his views, fischer guaranteed that he could "carry the full responsibility" for the importance of nachtsheim's research "even now at a time of war." when nachtsheim started in dahlem, he had at his disposition, as fischer informed the dfg, a series of rabbit strains that exhibited genetic diseases or disabilities: these were "genetic epilepsy […], shaking palsies and other nervous diseases; glaucoma and other eye diseases; deformation of the limbs, the external sex organs (similar to those of humans), harelip and cleft palate and many others." from nachtsheim's report to the german research association of january , -the first he submitted from his new position in dahlem -proceed the work emphases of the group of scientists around nachtsheim in , that is, still at the institute for genetics and breeding research. at the very foreground was epilepsy research. nachtsheim had bred from vienna white rabbits a pure "strain of epileptics" and shown "through crossing with strains free of epilepsy […] that one recessive gene [was] responsible for the increased convulsion-readiness." however, this gene was subject to certain fluctuations in manifestation: "in the pure-bred epileptic strain the condition becomes manifest in about % of individuals." nachtsheim had also made some progress in the search for a genetic marker, although no real breakthrough had been achieved. according to nachtsheim's observations, the gene responsible for the increased convulsion-readiness must also grant leucism (the white color of the coat), although nachtsheim was forced to admit that not every form of leucism could be traced back to this gene. moreover, the influence of other genes, such as those for albinoism or "sooty coloring," could suppress the occurrence of leucism. the breeding experiments were complemented by a largescale series of experiments on nearly rabbits of different races, both from the "epileptic" and the "non-epilectic" lines, in which an injection of cardiazol induced convulsions to test their convulsion readiness. in addition to epilepsy research, pathogenetic research on eye diseases, especially on the progressive heredity of certain forms of cataracts, constituted a second working emphasis, in collaboration with hellmuth gürich of the charité ophthamalogical clinic. a third and final emphasis emerged from the work of the two doctoral students christian schnecke ( * ) and harry suchalla , who concerned themselves with growth anomalies. schnecke's studies on the "lethal dwarfism in rabbits led to the result, also important for the assessment of corresponding conditions in humans, that while the recessive dwarf factor in general may lead to a pathological form only in the homozygotes, but that there are genes that are harmless in and of themselves, which, when linked with the dwarf in his report to the board (mpg archive, dept. i, rep. a, nr. , p. ) fischer further mentioned rabbits "with a kind of st. vitus' dance." "genetic st. vitus' dance," one of the indications in the gzven, was the contemporary term for huntington chorea. it is unclear whether this might have indicated the rabbits with "shaking palsy," which is a general lay term for morbus parkinson. in his activity report for the / fiscal year fischer also mentioned rabbits with "skin diseases" (fischer, tätigkeitsbericht factor in the homozygous form, yield a combination with lethal effects, even if the dwarf factor is only present in a single dose." suchalla crossed giant and dwarf varieties of rabbits. this paper, nachtsheim emphasized, represented "the first attempt to achieve an analysis of skull genetics by performing experiments with modern methods on large amounts of material." here the research projects of the department for experimental genetic pathology overlapped with hans grebe's studies on chondrodysplasia -nachtsheim and grebe did, in fact, work together closely, for instance, on a genetic biology dictionary. in , the first year for the department for experimental genetic pathology, the group around nachtsheim was able to continue its research only on a very restricted scale. because it was increasingly difficult to obtain feed for the experimental animals, it was necessary to reduce their number and restrict the "consumptive research." the apparatus applied for arrived only after major delays -as, for instance, the "convulsator" for the generation of electric spasms -or were not delivered at all, as was the case for a slit lamp, a zeiss microscope and a binocular eyepiece. the greatest problem was that all of the staff was called up for military service, such that the experiments could only be continued by nachtsheim on his own. the fact that epilepsy research remained at the focus, although it had come to a preliminary conclusion in , was grounded first of all in pragmatic reasons: the research on eye diseases could not be continued because hellmuth gürich, the partner in this collaboration at the ophthamalogical clinic, was drafted to the wehrmacht. the same was true for research projects on growth anomalies. by this time christian schnecke and harry suchalla had also been drafted. the planned genetic pathological studies on a syndrome observed in dachhunds (characterized by hypodactyly or hyperdactyly, respectively, and hereditary blindness) never really got in gear. the resumption of research on the "pelger anomaly" (today: pelger-huët nuclear anomaly), an autosomal-dominant hereditary anomaly of the leucocytes that occurs in both humans and rabbits, was just getting started -the first task that kept nachtsheim busy was breeding a "pure pelger-huët strain," on the basis of which the characteristics of the gene it was based on could be studied. when an epidemic broke out among the laboratory rabbits in summer of , which necessitated halting the epilepsy experiments temporarily, the research on the pelger anomaly shifted far into the foreground. moreover, in this area nachtsheim was able to present a sensational finding. while up until that time it had been assumed that "this deviation of the blood count from the normal [was] to be observed in both humans and animals as a harmless variety of blood without any further clinical manifestations," nachtsheim produced evidence that in a rabbit which inherited the pelger gene from the maternal and paternal side, and was thus homozygous with reference to the pelger gene, "most serious impairments" were to be expected. according to nachtsheim's observations, most of the homozygous pelger rabbits died in the womb. the few survivors -the "über-pelger," as nachtsheim called them -showed not only a changed blood count, but also a whole bundle of other clinical symptoms: "meager growth, serious deformation of the limbs, especially the forelegs, with shortening and twisting of the long, hollow bones and synostoses [fusion of bones], rashes of scurf around the muzzle and nose, salivation, anorexia." these findings, nachtsheim explained, were of extraordinary importance for humans. true, no human "homozygous pelgers" had been encountered as yet. yet, trusting in the soundness of the animal model, nachtsheim predicted that in humans, too, the homozygous carriers of the pelger gene, if they were able to survive at all, would "thus certainly be greatly weakened in their vitality and deformed." in any case it is clear that the pelger anomaly did not constitute a "harmless 'play of nature'" in humans either, but was an "erroneous mutation […], whose propagation, in terms of race hygiene, [was] altogether undesirable." here nachtsheim opened up a new race hygiene perspective. the only way to be able to follow this perspective was to link the research on animal models with the genetic pathology of humans. the mission of the research would be, in nachtsheim's words, "to carry out exhaustive surveys about the propagation of the pelger gene in human populations." at the same time it would have to be investigated "whether among the stillbirths or behind an already familiar clinical picture, especially among cases with certain deformations of the limbs, homozygous pelgers are to be found." this suggested building a bridge from experimental genetic pathology to the genetic pathological research by heinrich schade and hans grebe, namely to grebe's series of studies on stillbirths. in his report about the fiscal year nachtsheim remarked that work in this direction had been "initiated," but had "not yet led to positive results." he further announced embryological studies in order to clarify in "which embryonic stage the homozygous pelgers die and what the cause of this death" and "what, on the other hand, [is] the cause of the survival of individual homozygous pelgers of certain parents." the clinical and histopathological diagnostic picture of the homozygous pelgers also demanded closer study. since these formulations were repeated word for word in nachtsheim's final report, which was dated march , , it must be assumed that the studies never picked up speed. in nachtsheim turned his attention to another hereditary blood anomaly of the rabbit, which had its parallel in humans: erythroblastosis, which occurs in rabbits as hereditary, general dropsy (hydrops universalis congenitus). today we know that this form of newborn jaundice in cases of incompatible rhesus factors in the blood of mother and child is caused by the formation of antibodies in the mother and their transition into the circulatory system of the fetus, where they destroy red blood cells. in , however, nachtsheim traced erythroblastosis in rabbits back to a gene that was "inherited recessively." but, nachtsheim continued, this was "not a case of simple heredity" -indeed, it appears "that a wide variety of factorsbesides the remaining genotype, also those of a peristatic nature -had an influence on the manifestation of the condition." in nachtsheim presumed that "several genes" were involved. perhaps there must also be "a certain conditional factor present […] so that the actual dropsy gene [could] become effective." possibly, however -and nachtsheim was on the right track here -"in addition still other factors located in the mother but outside the embryo [played] a role." as far as erythroblastosis in humans was concerned, nachtsheim's judgement in was more cautious, stating that it was "still quite contested," whether a hereditary condition was involved or not -much spoke against, some for heredity. in his penultimate report of march , nachtsheim suggested that "certain observations on humans [made] probable a connection between the fetal blood diseases and certain serum characteristics of the blood." thus it appeared desirable "to test experimentally for existing connections of this kind in animals, too." again, he states that experiments in this direction had been "initiated." by the way, the serological studies on hydrops universalis congenitus in rabbits were conducted in collaboration with the serological department of the reich health office, and the histopathological studies by hans klein while the research on fetal blood diseases of the rabbit was an emphasis of the work in the department for experimental genetic pathology in , in the research on the growth anomalies of the rabbit swung into full gear, when wouter ströer, the designated director of the planned department for embryology, took on the histological study of the rabbits with "lethal dwarfism" during his residency in dahlem. in addition to these working areas, in the final years of the war, epilepsy research moved back up to the top of the agenda of the department for experimental genetic pathology. in further breeding experiments nachtsheim investigated the heredity of genuine epilepsy. here it had become apparent, he reported in , that the "epilepsy gene," although its behavior was "generally recessive," and thus had to be inherited homozygously in order to take effect, was also able "to let the diagnostic picture of epilepsy develop" even in cases of heterozygous heredity, "in combination with certain genes." as such, "the carrier of two albino genes and one epilepsy gene can become an epileptic." the situation was similar for the allele closest to the albino gene, the "black factor." in addition to his breeding experiments, from nachtsheim performed a great number of experiments on producing spasms through oxygen deprivation. since these experiments led him directly into the research accompanying the nazi "euthanasia" program, they are described in detail in another section. this field of research now lagged behind, also and primarily because of problems acquiring material. much of genetic pathology research was based on clinical material, which verschuer and his staff had brought with them from frankfurt, and which could be supplemented continuously through individual cases brought to the institute for evaluation. the genetic pathology research by diehl and nachtsheim also used the animal model -and the rabbit stocks were safeguarded by the elevation of the kwi-a's status into that of a military economic enterprise. general human genetic research, in contrast, was based essentially on the combination of twin and family research. yet these methodological approaches were nearly completely obstructed in the second phase of the war. as fritz lenz lamented in his annual report for the "institute for race hygiene" in / : the work of research has been quite impeded by the circumstances of the war, especially since summer . it is very difficult and frequently impossible to acquire sufficient observation material for certain essential scientific and practical problems. as a consequence of the evacuation of women and children, family research and twin studies are practically impossible. not even surveys can be conducted any more. conventional twin research in this area apparently did not come to complete standstill, but the difficulty in acquiring subjects for both twin research and family research soon became an obstacle that could hardly be surmounted. thus it is no coincidence that the research in the area of the genetics of normal attributes in the year was restricted to two projects -"specific proteins" and "eye color"which made use of the unfettered access to subjects in the auschwitz concentration and extermination camp -more on this later. in the department for genetic psychology, gottschaldt, who was called up to the wehrmacht for a time, and his staff continued even after the start of world war ii with the evaluation of the enormous amount of material they had compiled in the twin camps in / , and working through it "in a new methdological way. removed to stavenhagen castle in mecklenburg in september . these tasks of evaluation were extremely elaborate: in the months from october to march , gottschaldt reported, "around psychological analyses [were dictated], each of which was pages long." by october gottschaldt and his staff had put to paper around psychological analyses, "which cover extraordinarily comprehensive material, prepared for statistical evaluation, of more than , individual findings." and for the coming months gottschaldt requested another , sheets of writing paper. during the war period, gottschaldt could not simply retire to his ivory tower. more and more he worked together with state and party offices, and endeavored to make the methods of genetic psychology useful for genetic health, race and colonial policy -be it voluntarily or under the pressure of the conditions must remain an open question. even today, almost nothing is known about most of these projects. in the / fiscal year, gottschaldt's department, in collaboration with the department for the protection of children and youth (kinderund jugendschutz) of the nsv, began with "catamnestic surveys of children formerly under the care of state welfare." the / business report also stated that the "polyclinic for nervous and difficult children," whose resources "increasingly [were] claimed for the scientific evaluation of the very extensive material on families that accumulates there," and that this would continue. from / gottschaldt held lectures and training courses, connected with the german labor front (deutsche arbeitsfront), the department for professional training and the improvement of efficiency (abteilung für berufsausbildung und leistungsertüchtigung) in the reich chamber of commerce and the colonial policy office of the nsdap. a deeper collaboration arose from the contact with the colonial policy office -more on this later. with the excursion into colonial science, gottschaldt set out on the field of race psychology, which he had only skirted before world war ii. thus it was fitting that he prepared an article about "race psychology" for the fifth edition of "baur-fischer-lenz." also to be viewed in this context are the untersuchungen über den rassenruf mongolider völker im rassenbewußtsein von japanern ("studies about the race reputation of mongoloid nations in the race consciousness of japanese"), which were carried out in the department for genetic psychology in collaboration with the cultural department of the japanese embassy -presumably by the two japanese guest scholars, the doctoral student masataka takagi and professor masaji kamitake. the fact that gottschaldt participated in a "german-japanese science camp" together with the two guest scholars in summer suggests that he, too, was actively involved in these obscure studies. finally, it must be added that a doctoral student of gottschaldt's, inez the parallel progression of political and scientific thought is no coincidence, but an internal necessity. […] we genetic biologists and race hygienists […] remain in the peace of our scientific research activity from the interior conviction that on this field, too, battles of major importance are being fought for the continuity of our volk. however, even as director of the kwi-a he was sometimes subjected to political pressures. with his very first lecture as a newly appointed member of the prussian academy of sciences on november , he offended party circles. under the title erbanlage als schicksal und aufgabe ("genetic disposition as fate and function") verschuer took his audience on a tour d'horizon through the regions of higher mendelism and phenogenetics. certainly: verschuer criticized the naive dogma of heredity predominant in higher mendelism. "for in many cases genotype and race were regarded far too simplistically in terms of materialistic determinism -as the sole source of all life performance, even of intellectual power, especially for culture and history." but at the same time verschuer made it perfectly clear that it was hardly his intention to explode the structure of genetic determinism: after these results of genetic and race research, is it justified to assert that genetic disposition is fate? yes and no! through genetic disposition, certain fateful limits are determined for the development of each individual. a negro cannot produce any white children, the genetically feeble-minded have predominantly feeble-minded children, certain defects are passed down according to familiar rules, etc. these are limits that are becoming ever more clearly and definitely demarcated through our research. they cannot be transcended. what could appear offensive, however, were the social and moral conclusions verschuer drew from the insights of higher mendelism and phenogenetics: in terms of their genetic dispositions, verschuer grouped people into a three-level model, arrayed between the two poles of "fate" and "function." verschuer located the majority of people on the third and highest level: in their genetic dispositions lay "a fateful predetermination only very weakly […] concealed," they had a "great breadth of possibilities for development." the shaping of the phenotype on this third level was the task of the individual and of society. the people on the second, intermediate level may carry the disposition for serious diseases and disabilities with them, but these appear either not at all or only weakly in the phenotype due to the oscillation of manifestation, and in any case can be compensated for by measures of prevention or rehabilitation. on this second level the molding of the phenotype lay between fate and function. as examples verschuer named club foot and congential hip luxation. from his comments clearly proceeded that he believed that all possibilities for orthopedic rehabilitation must be exhausted -he was well advised to factor out the question of race hygiene sterilization at this juncture, since both conditions were officially considered to be indications for sterilization, a position that verschuer and his colleagues, as we will show later, did not share. on the first and lowest level, finally, verschuer placed people with serious genetic defects, whose manifestation was not mediated by other factors -"association with other genes," "course of development," "external influences." on this level the phenotype was "to be accepted as determined by fate." nevertheless, with a view to these humans as well, verschuer argued in terms of the dualism of fate and function. although their genetic dispositions had to be "accepted as given by fate," the affected confronted a double function: first, even with a serious genetic defect, it is possible to give one's own life higher value and deeper meaning. just think of the extraordinary achievements of the blind and deafmute. yes, even a mentally retarded person can still carry out useful work and distinguish himself through loyalty, love and the spirit of sacrifice. second -and this demands a selfless readiness to make sacrifices -for the welfare of the volk, the serious genetic defect must be eliminated by forgoing propogation. this passage could be understood as a criticism of the "euthanasia" under way since , which had already claimed the lives of over , mentally ill and mentally disabled by this time -and it appears that party circles understood it as such. even more important: it was probably so intended. at this juncture verschuer made clear that he would continue to actively support eugenic sterilization that could be legitimated with the moral philosophy and theology of the idea of sacrifice -a position which verschuer had advocated since the final years of the weimar republic -, but rejected for ethical reasons the murder of the mentally ill and mentally disabled. what's more, he openly repudiated the "breeding of the Übermensch" in friedrich nietzsche's terms as the basic motif for race hygiene -he wanted to restrict race hygiene to its function as "custodian of the genotype of the race." as demonstrated, verschuer's lecture included some critical tones that could not have pleased the makers of national socialist genetic health policy. but an entry in the diary of ulrich von hassell ( - ) shows that verschuer's lecture could be interpreted differently as well: for me, a lecture on race policy for the berlin circle of the german academy was indicative of the level of some sectors of german science. the speaker was prof. von verschuer, the man whom e. fischer dared to propose as his successor in the mittwochs-gesellschaft. superficial prattle tailored to the purposes of party politics, truly a disgrace. nevertheless: what appeared as pseudoscientific party propaganda to a member of the resistance provided for unrest in sectors of the party. on april , , ibid., pp. f. ibid., p. (original emphases). ibid., p. . diary entry of / / , hassell-tagebücher, p. . that is, a considerable time after the lecture, verschuer related in a letter to fischer: yesterday afternoon i visited [walter] groß in his new office in babelsberg, a country house in a beautiful setting. we conversed for ½ hours in a very friendly and mutually obliging tone. he confirmed that he found nothing objectionable in the content of my lecture to the academy, and that my depiction and my standpoint were irreproachable. incorrect reporting and the misleading interpretation of individual passages have caused political turbulence. however, i got the impression that he will put an end to the matter. i made an agreement with him to submit to him any publications that encroach upon the area of race policy for fine tuning. so i hope that our friendly terms are restored, and that in future he will not be so easily disquieted by such yapping and put the over-zealous curs back on their chains. the incident is further exemplary evidence of the fact that, within the alliance between science and politics, it was ultimately the political decision makers who made the rules. hans-peter kröner's interpretation must be endorsed, that verschuer's account of his meeting with groß promoted his own self-deception: with the arrogant gesture of the academic, he required every effort to conceal from himself and his mentor that he -the director of a kaiser wilhelm institute -had been "muzzled" by one of the national socialist satraps. after the war, verschuer, together with his "whitewashers," greatly exaggerated the danger that threatened him from this direction. politically, he deviated from the line of state and party only in part. aside from the issue of "euthanasia," broad consensus predominated in genetic health and race policy. as will be shown in the next section, verschuer and his staff legitimated and propagated this policy, tended to the scientific substrate, provided practical support and did not hesitate to use the national socialist politics of genocide in order to acquire scientific "material." until well into the year , the staff of the kwi-a, hardly hampered by the circumstances of the war, undertook lecture trips all over germany and europe. the lectures at universities and to scientific societies were attended by "science camps" thus it is hardly possible to say that verschuer was "invited to report" to groß. according to kröner, von der rassenhygiene zur humangenetik, p. . in addition to their foreign travels, in february fischer and verschuer held lectures at the führerschule der deutschen Ärzteschaft ("leadership school of the german medical fraternity") on the occasion of a "joint camp" for physicians from alsace, luxembourg and the netherlands in alt-rehse. beyond their general foreign policy function, many of the lectures abroad apparently had the additional task of bringing functional elites from the field of medicine in the occupied and allied states "on course" with national socialist genetic health and race policy. thus in a dual sense they were a "service" the institute performed for the political rulers. however, they were also in the institute's own interest, as they can be regarded as part of a strategy to shape a continental european research alliance under german leadership after the collapse of the international scientific community. in this view, utilizing a large number of foreign guest scholars at the kwi-a, too, made a virtue of necessity. beyond this fischer and verschuer endea- contacts to scientists from the "antagonistic foreign countries" were disrupted as a natural course of the war. however, otmar von verschuer regarded science, too, as part of the military campaign. while he was at pains to keep himself up-todate on the scientific production of the "enemy states," he did his best to conceal this from foreigners. this became particularly clear in march , when he rejected fischer's proposal to publish the swiss guest scholar erik hug's summary of the last volumes of the most important anthropological and eugenic journals from the great britain and the usa in one of the journals he edited: , which were loaned out to me for days. the time was just sufficient for me to have the works most important for us photocopied." after all, he was a subscriber to the journal fortschritte der medizin ("progresses in medicine"), which had developed into a "reference work of the foreign medical press." "however, this journal is only dispensed for on may , , fritz lenz addressed an extensive letter to the editorship of das schwarze korps. he took reference to an article of april , entitled eine frau hat das wort ("a woman has her say"). the anonymous author had demanded, in view of the surplus of women after world war i, that the state should create incentives for women of who were still single to become unmarried mothers: such single mothers should receive a higher income than childless married women of the same age; their dual role as mother and career woman should be accommodated by flexible working hours; they should receive a one-off benefit similar to the marriage loan; "for the less well off," further, "current state supports [were] to be guaranteed." prerequisite for this benefit was the "genetic health" of the mother and the father -sperm donations were to come from single young men who had not yet started their own families. finally, the anonymous author, "for the protection of the honor" of the single mothers, had demanded that "anyone who reproached the morals of a single mother" be sentenced to prison on principle. lenz responded to these proposals with sharp critique. higher income for single mothers which, as lenz emphasized, would have to be financed by state subsidies, was not only economically intolerable, especially since, for reasons of equal treatment, the demand would "as a consequence […] would have to amount to ongoing support for all mothers." under aspects of race hygiene, too, it would always make more sense to support married mothers. the particular displeasure of the nestor of the race hygiene movement was evoked by the proposal to guarantee ongoing support for single mothers who were less well off: "a similar demand was raised in the reichstag of the weimar system by the communists." lenz warned that measures of this kind would "encourage the propagation of elements that [could not] demonstrate any sufficient performance as a result of mental or physical weakness and thus also [could not] exhibit any sufficient income." there was the danger of "adverse selection," which, as lenz argued with reference to possible concealed genetic dispositions, could not be avoided by making the "genetic health" of the men and women involved a prerequisite, either: "by no means can the danger of a preferential propagation of inferior race elements be averted in this manner." under quasi educational aspects lenz pointed out that the proposals would make necessary "special legislation" to expressly exempt the fathers of the children from support payments, "while in recent years the tendency has been to increase the responsibility of the father, in economic terms as well." the whole scheme boiled down to "state-approved temporary marriages of uncertain duration, which moreover would even be privileged by the fact that the state would take over the costs of official use and under the obligation that it be kept under lock and key, to certain subscribers who must pledge their confidentiality with a signature on the back cover." at another juncture verschuer reported that he received, "from the exchange service," the eugenics review, of which he had photocopies made. verschuer bringing up the children." this would have to weaken marriage as such. here lenz argumented quite conservatively and fundamentally, but not consistently in terms of race hygiene. he did see the childlessness of many women from the generation of the world war i as a race hygiene problem, but to him illegitimate motherhood did not seem a suitable solution under moral aspects -when, then polygamy instead: "purely objectively" he would hold the "permission of a […] limited number of second wives to be the relatively best solution; but the moral tradition of the german occident appears to virtually exclude such a solution." "breaking the moral tradition of a nation" was, however, "always perilous." lenz did not insist that his reply be printed in das schwarze korps. but he did call upon both the editorship and the author to enter into a critical dialog -to no avail, as the editorial board of das schwarze korps did not react at all. lenz addressed copies of his letter to the rusha, the race policy office and the german family league of the reich (reichsbund deutsche familie). at the close of his letter lenz illustrated his conception of state measures to increase the birthrate among married couples. a "state obligation to bring up children" should be introduced, in keeping with the principle "every member of the nation capable of living has the duty to bring up at least four children." anyone who did not fulfill this obligation should ante up "substitute payments in percentages of his income," which corresponded to "approximately the cost of bringing up children." lenz elaborated on this basic idea in an exposé about "ways to further advance in population policy," which he wrote at the same time as the protest letter to das schwarze korps. the french campaign had not yet entered its decisive phase, but lenz appeared optimistic that the end of the war was immediately imminent and would offer "a unique opportunity for generous population policy." because the birth cohorts since , which were already not terribly strong as a consequence of world war i, had been weakened further by the losses in the war from to , the idea was to induce the birth cohorts before to bring up as many children as possible. "against birth premiums and child subsidies," lenz announced yet again apodictically, there were "serious race hygiene objections." the experiences with marriage loans were, under quantitative aspects alone, "by no means encouraging." each marriage supported by a marriage loan accounted for "slightly less than one child." what is more: "from the perspective of race hygiene there is hardly a reason to regret that only meager funds are available for such benefits at this time." in contrast, lenz expressly advocated burden sharing for families through higher taxes for families with no or only few children. the tax increases dictated by the war seemed to offer a convenient opportunity to engineer such a burden-sharing scheme; the idea was "to make a demographic policy virtue out of the financial necessity of the war." the core of the tax policy concept worked out to the last detail by lenz was the proposal that the war surtax on income be eliminated after the end of the war only for families with four or more children. tax advantages for childless married couples were to be omitted, just as the temporary tax relief for young couples and the enduring tax break for couples with grown children. both parents of illegitimate children were to be allowed to deduct a child from their taxes, but only by half. only families with many children were to enjoy full deductions from property and inheritance taxes. finally, lenz developed a mandatory savings system for peasant families, to finance the compensation paid out to the daughters and sons who did not inherit property -if a peasant family had fewer than four children, part of the money saved would fall to the state. in fact, lenz's proposals -measured against the tax level before the beginning of world war ii -amounted to a constant tax burden for families with many children and enormous tax increases for everyone else. what is interesting is that verschuer, to whom lenz sent both of his documents for his perusal, responded immediately and declared himself in complete agreement with the contents. he expressly subscribed to lenz's thesis that the propaganda for illegitimate children evoked the "race hygiene danger" of "adverse selection." he proposed publishing lenz's tax policy exposé in the erbarzt. yet lenz had misgivings, since his proposals collided with the tax policy of the relevant state secretary in the reich finance ministry, fritz reinhardt ( - ), whom he did not want to provoke by publishing the exposé. however, lenz reported, it had been forwarded to reinhard via the race policy office. in lenz decided to publish his ideas after all, in the archiv für rassen-und gesellschaftsbiologie under the title gedanken zur rassenhygiene (eugenik) ("thoughts on race hygiene (eugenics"). with this he spurred into action the press department of the reich government in the reich ministry for propaganda and enlightenment of the nation, which ordered that the passages about relieving families of the tax burden be struck. new in this version of was that lenz demanded compulsory employment for childless and "child-poor" women. while lenz continued his efforts on the path of scientific policy consulting to secure recognition in population policy for a program of positive eugenics, verschuer and his staff continued to be in demand as experts and evaluators whenever questionable cases arose in the application of the gzven. as has been shown above, after the changing of the guard at the head of the institute, genetic pathology research in dahlem was consistently oriented toward this practical application, in order to "clear the complex jungle of the activity of producing expert opinions." due to the incomplete knowledge about the heredity of the diseases and disabilities listed in the catalog of indications of the gzven, since a jumble of contradictory decisions had resulted, and the initial enthusiasm of the race hygienists had given way to a kind of "hangover." in accordance with the insights of higher mendelism, since verschuer had urged that the hereditary health court proceedings be based not on the clinical diagnosis, but solely on the genetic diagnosis, to be reached through intensive genealogical studies. this had the consequence that in some cases which had fallen under the gzven as a matter of course up to that point, verschuer and his staff advised against sterilization. in one case this consistently pursued line went too far for even verschuer's friend and teacher fischer. when in verschuer's employee heinrich schade advocated the interpretation that certain defects of the limbs were not genetic and thus, must be excepted from sterilization, fischer lodged vehement protest with verschuer: with a degree of shock i read the paper by schade about the defects of the limbs. i do not hold to be correct the conclusions that heredity was not present in general, presented here in apodictic form. here goethe is wrong!! all fun aside. schade is, of course, right, that heredity is not proved in these cases. but for schizophrenia we also do not know what kind of and how many genetic factors are the basis. for the limbs there could hardly be any single, separate gene for each form and each location of defects, but rather different kinds, such as those which govern the development processes chemically. […] there is not only this theoretical side to the matter, however. in terms of praxis, schade arrives at the conclusion that one may not sterilize these cases unless another identical case was found to have occurred in the family. and this is extremely rare for today's small families. then we would have the situation, which seems intolerable to me, that conditions like cleft palate, club foot and hip luxation are sterilized as serious physical defects, but when an entire extremity is missing, or when both hands are completely crippled, sterilization does not take place. the public knows both groups as congenital. now the one defect, in fact the lesser, is regarded as congenitally inherited and thus to be sterilized; the other, more serious one, is regarded as congenital but not inherited, and thus not to be sterilized. the volk does not understand this. and for us, too, it goes against every feeling of justice. perhaps we were really somewhat hasty with the presumption of heredity in the case of defects. if one believes that, then the consequences must also be drawn for luxation, harelip, etc. i do not believe it personally. i am of the opinion that schade went too far and allow only that while we do not know the individual genetic process, genes are the cause. here fischer pursued the dual logic of an applied science, which must always attempt to combine the logic of science with the logic of politics. its recommendations to politics are always the product of several factors: scientific knowledge, the consideration of the practical utility of a measure, the expectation of its political feasability and its cultural acceptance, and finally its ethical admissibility. thus, weß, humangenetik, p. . ibid. cf. e.g. verschuer, unfruchtbarmachung. many scholars of the human sciences in the third reich advocated large-scale eugenic sterilizations, although it was quite clear to them that they were on shaky ground scientifically. the heritability of one or the other clinical picture constituted a plausible assumption, but one that in many cases required further empirical confirmation. that this assumption was sometimes presented to the outside world as a fact -to the public, but also to the state -is by no means unusual, but rather is part of everyday science even today. they believed that the empirical proof for the seemingly evident facts of the case could be presented afterward, sooner, or later. fischer's stated opinion is practically paradigmatic for this position. yet verschuer did not follow his mentor on this path. on the contrary: he countered fischer's argument that if one did not want to sterilize people with deformed limbs, then "cleft palate, club foot and hip luxation" would also have to be deleted from the gzven's catalog of indications, by aspiring to that very end. as regarded cleft lip, cleft jaw, and cleft palate, since the late s verschuer had proceeded from the assumption of a high degree of heterogeny -based on josef mengele's dissertation, by the way. but the consequence of this was that heredity had to be checked for in each individual case. and according to the testimony of gerhard koch mentioned above, in july or august the genetic pathology working group under verschuer's direction argued that club foot and congenital hip luxation should no longer be recognized as "genetic conditions" in the sense of the gzven. in the first, still-documented sessions of the genetic pathology working group, the participating scientists had also been extraordinarily reluctant to recommend sterilization in individual cases -in principle they were in agreement that the heritability of a condition had to be proved with certainty on the basis of family anamnesis in the individual case, whereas the logic of the gzven had saddled the subject to be sterilized with the burden of proof: he or she had to prove that in his or her case the general assumption did not hold that the condition was hereditary. in the judgement of concrete cases, verschuer consistently held fast to the genetic diagnosis. as a rule, he was extremely reluctant to acknowledge nonscientific considerations, even when they spoke for the subject. this became apparent, for instance, in the different judgements of the very first case dealt with in the genetic pathology working group, by verschuer and lenz. it involved a -yearold man, who had gone completely blind at the age of due to hydrophthalmus congenitus (congenital glaucoma), but had nevertheless graduated from secondary school, worked as a music teacher and piano tuner and led the association of the blind of his district, and finally studied law. in he wanted to marry a healthy teacher, but he was denied the marriageability certificate and an exemption from the regulations of the marriage health law. an application for sterilization in accordance with the gzven was rejected, however. the case had been submitted to verschuer for his expert opinion. in the ensuing discussion about the race hygiene consequences, lenz argued that the risk of rare, recessive genetic conditions occuring in the couple's progeny was so low that the couple, which consisted of "personalities of above-average talent and prowess," should not be deprived of the possibility of having children. verschuer argued against sterilization as well, but believed that according to the gzven the man "would have to be sterilized because of genetic blindness, if the hydrophthalmia was definitely genetic in his case, which he [verschuer] personally did not hold to be proved." by contrast, lenz was steadfast in his judgement "that even if the heritability of the condition was presumed, the man was not be sterilized, because there was no high probability that genetically ill individuals were to be expected among the progeny. the probability of this was less than %, and one may not do without healthy children because of one that might be genetically ill." in the end lenz and verschuer came to an agreement, "albeit for slightly different reasons," that in the given case neither sterilization nor a marriage ban was justified. the salient point is that in his argumentation lenz adhered closely to the letter of the law, to his official interpretation, and above all to the jurisdiction of the hereditary health courts, which had long since begun to grant broader latitude to the criterion of "preservation of life" in their judgements. verschuer's standpoint that upon proof of genetic blindness the subject was to be sterilized in any case, regardless of all other aspects, amounted in fact to an intensification of the existing legislation and administration of justice. that he decided against sterilization in this concrete case was due solely to the fact that he did not consider the proof of heritability to have been adduced. here it becomes apparent how misleading it is to use the individual cases in which verschuer and his staff advised against sterilization as an indication for the fact that the scientists of the kwi-a attempted, as a rule, to exert a moderating influence on the praxis of sterilization. they wanted to place the sterilization program on a new scientific basis that did justice to the insights of higher mendelism: some of the subjects to be sterilized, who up until that time had been sterilized without any hesitation, were thus spared from sterilization. in other cases verschuer and his staff judged even more harshly than the hereditary health courts. what is more: as a consequence of verschuer's position, sterilization legislation had to be extended to the heterozygotic bearers of recessive genes, who had no grebe, hydrophthalmus, p. . so koch, humangenetik, p. . in a case of paramyotonia congenita (eulenburg syndrome), a dominant autosomal genetic disorder with occasional muscular rigidity, primarily induced by physical excercise and cold, gerhard koch indicated that sterilization was not appropriate. in his memoirs koch emphasizes that this work "despite my critical opinions on the 'gesetz zur verhütung erbkranken nachwuchses,' [was] released for publication in the erbarzt by the military censors." (ibid., p. ). of course, from the perspective of nazi genetic health policy, there could hardly have been anything objectionable about this article. the passage in question reads: "[heinz] boeters holds an application of the g.z.v.e.n. to be unnecessary due to the rarity of myotonical clinical pictures ( of every , - , affected). in the case before us now, too, sterilization does not appear suitable because of the intellectual abilities of the subject. but since it is not to be expected that the disorder will become extinct through self-selection, as a rule marriage and having children should be urgently advised against. […] patients with myotonic apraxia are, of course, of no use for military service." koch, paramyotonia, p. . clinical symptoms. verschuer -in contrast to lenz -was too cautious to make such a demand publicly, for after all -to the disappointment of many a eugenicist and race hygienist -hitler and the national socialists had excepted the healthy bearers of genetic dispositions in their formulation of the gzven (which the prussian draft of had not, by the way). under conditions of war it was not to be expected that they would consent to such an explosive expansion of the sterilization program, which had been geared down in anyway. nonetheless, verschuer and his staff attempted to lay the scientific foundations for such an expansion, as shown by research like grebe's search for stigmata that would allow healthy bearers of the genes for chondrodysplasia to be identified. in principle and potentially, verschuer's position amounted to a further intensification of the sterilization legislation. while the kwi-a continued to fulfill an important consulting function as regarded the sterilization program, as mentioned above, verschuer distanced himself publicly from the nazi "euthanasia." in contrast, fritz lenz cooperated with the "euthanasia" planning staff to create a legal foundation for the mass murder of the mentally ill and mentally disabled. it has been asserted on several occasions that lenz had changed his opinion on the question of the "annihilation of life unworthy of life" at the beginning of world war ii -but this is only partially true. in the third edition of his work menschliche auslese und rassenhygiene (eugenik) -that is, the second volume of "baur-fischer-lenz," which appeared in -lenz had expressed his views on the issue of "euthanasia" at great length, after having made the impression on the public that he unreservedly advocated "euthanasia." on the contrary, lenz emphasized "that so-called euthanasia [is out of the question] as an essential means of race hygiene." taking reference to intensified postwar discussion about medically assisted suicide, killing on request and the "annihilation of life unworthy of life," lenz pled for the view that "euthanasia" was "preeminently a question of humanity. even the ancient spartan abandonment of deformed children is still incomparably more humane than today's practice of rearing even the most unfortunate creatures in the name of 'compassion' […] ." with reference to race hygiene, however, "euthanasia" had no great importance to the extent that the circle of those affected would hardly have the opportunity to propagate -if this danger existed, then it could be prevented by sterilization. what did speak for the painless killing of disabled children from the standpoint of race hygiene is that it would enable the parents to bring another, healthy child into the world. this would also mean that "the question of the marriageability of encumbered persons [could be] judged much more generously than it is today." for instance, there would be lenz, gedanken zur rassenhygiene, p. . at this juncture lenz also openly demands the inclusion of "asocial" subjects in the sterilization legislation. ibid fewer misgivings about permitting a marriage between partners who were healthy themselves but known to be bearers of a recessive gene for deaf-muteness, because the deaf-mute children from such a marriage could be killed and thus the parents given the opportunity to have as many healthy children as their economic situation allowed. although lenz thus indirectly attributed a eugenic function to "early euthanasia," he persisted in his opinion that "euthanasia" was "hardly […] so effective a means" under race hygiene aspects "that race hygiene must advocate it." decisive for lenz was that through "euthansia" the "respect for individual life, which is an essential foundation of our social order, would experience a critical loss." although more than a few infanticides occurred for the purpose of family planning even in the western cultures, "the moral consciousness in the occident [excluded] a legal license for infanticide." in other words: lenz did hold the killing of disabled newborns to be justifiable in principle as an act of "humanity," but in the early s he still believed that deregulating "early euthanasia" would shock the "moral consciousness" and the "social order." it is presumably not incorrect to presume that lenz feared "early euthanasia" could become the gateway to the deregulation of abortion for social indications. in principle lenz adhered to his position. after including the passage about "euthanasia" unchanged in the fourth edition of his work in , in the preface to the publication by wolfgang stroothenke about erbpflege und christentum ("care of genes and christianity") published in , in which "early euthanasia" was demanded on as a measure of caring for the genetic pool, lenz reaffirmed his standpoint that "euthanasia" was primarily a question of "humanity." what lenz did not write openly, however: apparently he believed the time had come to set about resolving this question. in any case lenz -presumably in his capacity as a member of the expert council for population and race policy -proved ready to participate in a commission, which probably convened in october , to debate and finalize a draft law to legalize the "euthanasia" program under way since the change of years / . a number of the physicians represented in this commission belonged to the medical staff of the "euthanasia" program -among them georg renno, who had passed through the kwi-a's first annual course for ss trainees -as well as several representatives of the medical administrations of the states, and, finally, the chief of the security police and the sd, reinhard heydrich , who was interested in the procedure because at this time he was concerned with the planning for a "community alien law" (gemeinschaftsfremdengesetz). the draft law lenz, auslese, rd edn, p. . cf. the preface in stroothenke, erbpflege. on the previous history: roth/aly, "gesetz über die sterbehilfe"; gruchmann, euthanasie; klee, "euthanasie," pp. f.; schmuhl, rassenhygiene, nationalsozialismus, euthanasie, pp. - . cf. on this: ayaß, "asoziale," pp. - . otmar von verschuer also got involved in this discussion. he approved the establishment of a register of "community aliens" in order to attain a "differentiation between those to be eliminated and those to be supported" (erbarzt , , pp. f.). ultimately worked out by this body then presumably bore the title proposed by fritz lenz, "law about euthanasia for the incurably ill." the final version of the draft was not preserved, but the contents of its six articles can be reconstructed on the basis of some of the surviving commission protocols. apparently the preamble states that people "who because of an incurable disease long for [an end to their suffering]" or "as a consequence of an incurable chronic condition are incapable of productive life," were to be afforded assisted suicide. the first two articles represented slightly modified versions of a draft law debated by the official criminal law commission on august , : § : anyone who suffers from an incurable disease [that presents a great burden to himself or others or is certain to lead to death] can receive euthanasia upon his express request with the approval of a specially authorized physician. § : the life of a patient who otherwise would require lifelong custody as the consequence of incurable mental disease can be ended through medical measures unnoticeable for the patient. the following four articles regulated the process. the patients were to be registered -unless the patient himself submitted the petition -by the public health officers and institutional physicians. thereupon an evaluation was to take place by "expert committees," each of which was to include a "specially authorized" public health officer and two medical assessors (psychiatrists). the committees were to be assembled by a "reich deputy" to be appointed for the execution of the law. this special agent, vested with far-reaching powers, was also to make the final decision about the petitions for "medical assistance" on the basis of the expert opinions submitted by the expert committees, and to appoint the physicians to perform the procedure. if an executing physician stated that he did not agree with the vote of an expert committee, he could submit a detailed written explanation of his reasons and apply for a new expert opinion by another expert committee. what role did lenz play on this commission? according to the protocol he was one of the most eager discussants, and many of the essential formulations of its content were based on his proposals. this began with the title of the draft law. upon lenz's suggestion, the word "deliverance" was struck, "which, originating from the world of christian ideas, would evoke negative feelings against the law." the wording of article also came from lenz. he had rejected the original term of "abnormal disposition" as "too indefinite and vague." in some cases it was "not at all clear whether abnormal genes or external damage was the basis"; "idiotic or seriously deformed children" would thus not be included by the concept of abnormal disposition -for these, moreover, "a special legal determination was required." therefore lenz pled for restricting the law only to the mentally ill for the time being. presumably with a view to heydrich and his interests, lenz added that one would also have to define expressly "that criminal psychopathy is a mental illness in the sense of the law." lenz did not want to make exceptions, but he held the inclusion of "senility of the mind" to be unsuitable. all in all the impression arises that lenz was one of the driving forces in the discussion and that he left his mark on the draft law. repeatedly he pushed for precise specifications -in the interest of legal certainty. it was also due to this interest that lenz wanted to make sure that the law would be applied initially only to cases of serious mental disease, whereby he urged a regulation of "early euthanasia" at a later point in time. that it was by no means his concern to check the "euthanasia" program in progress is apparent in the fact that he was ready to include the "criminal psychopaths" in the sense of the "community alien law" planned by heydrich. in the end the draft law discussed remained nothing more than paper. hitler rejected a legal enclosure for the "annihilation of life unworthy of life." "euthanasia" continued to proceed in the unlawful cavity of the national socialist "prerogative state," flanked by an ambitious program of genetic psychiatry and genetic pathology research. in one case the kwi-a, too, profited from the unfettered access to human subjects in sanatoriums and hospitals. back in hans nachtsheim, as mentioned above, had performed a large-scale series of experiments on almost rabbits of different races, both from the "epilectic" and the "non-epileptic" breeds, in which convulsions were induced through cardiazol injection to check their compulsion-readiness. as explained, the point was first to theoretically illuminate "the connections between convulsion-readiness and genotype." the series of experiments also pursued a second, entirely practical purpose, however: they were supposed "to provide a contribution to the question so debated in psychiatry, as to whether a genuine epileptic responds to a lower dose of cardiazol with convulsions than does a symptomatic epileptic or a non-epileptic, and thus whether inducing convulsions by cardiazol is of value for differential diagnostics." in this respect the experiments ended in failure. it became apparent that the convulsion-readiness of the rabbits was dependent on their age: young rabbits convulsed at a lower dose of cardiazol than older animals; convulsion-readiness in response to cardiazol thus, appeared to diminish with increasing age. this alone would not have debased cardiazol convulsions as a differential diagnostic instrument, as the rabbits of the purely bred "epilectic strain" reacted more sensitively to cardiozol at all ages than did other rabbits. however, at the same time it turned out that the convulsion-readiness of the "epileptic" rabbits was subject to frequently occurring, strong individual oscillations, so that the animals sometimes did not respond to a high dosage -at which even a high percentage of "non-epileptic" animals convulsed, and at other times convulsed even at low doses that would never have triggered convulsions in "non-epileptic animals." in view of these findings nachtsheim had to admit that cardiazol convulsions possessed "only limited differential diagnostic value." although the hope for a direct practical use of the convulsion experiments had not been fulfilled, nachtsheim continued to grant high priority to his research on the "epileptic" vienna whites even after starting at the kwi-a on january , . from this point on the research projects on epilepsy pursued modified research questions: the direct perspective on differential diagnostics was abandoned, and epilepsy research oriented instead entirely toward the paradigm of phenogenetics. what appeared as a mere disruptive factor in the experimental arrangement under the aspect of differential diagnostics -the modifying influence of age, time of year and season on the convulsion-readiness of the rabbits-, became the actual object of research when embedded in the paradigm of phenogenetics, for apparently the convulsion-readiness of the experimental animals was the result of an interplay among genetic and peristatic factors, which intertwined to cause, enable and induce. if research succeeded in exposing the complex reciprocal actions of genetic disposition, maturation, and environment, science would be much closer to illuminating the process of the pathogenesis of epilepsy. in his activity report about the / fiscal year, eugen fischer quite skillfully referred to nachtsheim's "investigations about the epilepsy of rabbits, which corresponds completely to that of humans." the experiments "to use cardiazol to induce epileptic convulsions like those in humans" were "in full swing," and promised "a more precise analysis of the genetic and non-genetic conditions of the convulsion-readiness of vessels in the brain." here fischer did imply that the studies in progress could contribute to the demarcation between genuine and symptomatic epilepsy, yet he painstakingly avoided the term "differential diagnostics," selecting a more open formulation. on the other hand, he left no doubt as to the applicability of the animal model. however, nachtsheim had to struggle with some exceptions voiced from the ranks of his critics on precisely this point. concerns, such as the fact that the structures of the human and rabbit nervous systems were too different for the findings obtained with rabbits to be applied to humans without further ado, were forestalled by nachtsheim himself, who raised the conjecture that the pathological processes which also occurred in humans might possibly be better studied on rabbits, because in the rabbit the convulsion takes place in a much more primitive form, "without all of the accessory parts that have accrued in humans," -an argument based on an abridged mechanistic concept of the organism, which was not terribly solid. after brashly asserting the applicability of the animal model at the outset, over the course of time he sought refuge in more careful formulations: in this we are certainly aware that a result in an animal experiment can be translated to humans only with caution, especially when the substrates in question are as different as the rabbit brain and the human brain. however, a result for rabbits can be regarded as at least pointing the way to the conditions in humans. nachtsheim also had to struggle with the clinicians' critical pointer to the polymorphy of the various clinical pictures subsumed under the concept of epilepsy. he thus toned down his pretense of using the animal model to explain the epilepsy of humans and hence aspired only to relate "rabbit epilepsy to a certain 'variety' of human epilepsy." the most serious was the objection of leading psychiatrists that cardiazol convulsions in rabbits were not comparable to spontaneous convulsions in humansthis critique was aimed straight at the experimental arrangement, which made the animal model organism available for human genetic research. nachtsheim and his staff therefore, also tested other possibilities such as insulin and acetylcholine shock as well as electric spasms. in the course of these tests they concluded that the convulsions in vienna white rabbits artificially triggered by cardiazol most closely approximated the spontaneous convulsions of the human epilepsy victim. according to the concept of convulsion-readiness, every human could suffer convulsions -in the case of epilepsy nachtsheim imagined the boundaries between health and illness to be fluid. epileptics were different from other humans, he presumed, in that their convulsion threshold was significantly lower. now, under the banner of higher mendelism, this was no longer simply regarded as genetic, but rather -in terms of phenogenetics -as the result of a causal chain, the first cause of which is to be sought in the genotype, but which was also influenced by factors in the internal and external milieu. when an organism in a condition of heightened convulsion-readiness was subjected to an adequate environmental stimulus, this would trigger a convulsion -the epilepsy became manifested clinically. his rabbits by changing the intervening peristatic variables that modified the effect of the gene. the comparison of young and mature animals was an obvious choice for the first series of tests, as nachtsheim believed he had determined in his cardiazol experiments, performed to resolve the differential diagnostic problem, that the convulsion-readiness was dependent on age. therefore, in a paper for the zeitschrift für altersforschung in nachtsheim reevaluated his previous experimental results under this aspect, and in so doing also introduced them into the still young discipline of geriatrics. in the field of psychiatric research it was controversial at what point in time and in what form the various types of epilepsies became manifest, whether the clinical picture changed over the course of life, and whether such age differences occurred only in symptomatic epilepsy or in genuine epilepsy as well. nachtsheim wanted to attempt to pursue these questions using a comparative experimental system on the animal model. in summer an epidemic raged among nachtsheim's experimental animals and forced him to temporarily suspend the experiments on epilepsy, because the stocks had to recover before this form of "consumptive research" could be continued -in the artificially provoked convulsions, especially when cardiazol was used, it was not seldom for the experimental animals to suffer broken bones or collapse. when nachtsheim resumed the experiments in early , he changed the method. he no longer resorted to cardiazol, which had the disadvantage in nachtsheim's view that its toxic effect was superposed upon the convulsion events and made their observation more difficult. therefore, it must have been easy for him to give up this method, especially since cardiazol was difficult to obtain during the war as it was urgently needed for therapeutic purposes. the electric spasm attempts conceived as an alternative to the cardiazol experiments in had "not proceeded beyond certain preliminary tests," not least because the "convulsator" by the siemens-reiniger plant procured in proved unsuitable for animal testing. a change in the experimental arrangement was thus essential, and this led nachtsheim to high altitude medicine. crucial for the further development was the incipient collaboration between hans nachtsheim and gerhard ruhenstroth-bauer . after completing his studies of physics, in september ruhenstroth-bauer had come to adolf butenandt at the kwi for biochemistry to write a dissertation in the area of hormone chemistry. when this dissertation project hit a snag due to the war, ruhenstroth-bauer turned to research on the regeneration of red blood cells (hemopoiesis). he had been forced to interrupt this research when he was drafted into the luftwaffe as a military physician and sent to the eastern front. butenandt lobbied erich hippke ( - ), head of the luftwaffe medical corps, to have ruhenstroth-bauer reassigned to berlin, and hippke -it is not clear whether upon butenandt's urging or on his own initiative -ordered the young military physician to berlin in june , in order to perform special research on hemopoiesis. ruhenstroth-bauer was searching for a substance that was capable of effecting a prolonged propagation of the red blood cells (erythrocytes) -he assumed that it would be a hormone, which he intended to name hemopoietin. the potential military importance of the project for air warfare was obvious: pilots who were injected with the blood-enriching substance before takeoff would be able to fly at higher altitudes in air with less oxygen, without any decrease in performance. in a series of preliminary tests, ruhenstroth-bauer endeavored to research the process of generating blood cells in various experimental animals in different test arrangements, and in so doing also experimented with oxygen deficiencies and low air pressure. at this point the research interests of ruhenstroth-bauer and nachtsheim overlapped. convulsions are a characteristic symptom of altitude sickness -ruhenstroth-bauer's research practice was oriented around raising the threshold for altitude convulsions by increasing the number of red blood cells. for its part, epilepsy research was close to altitude research because oxygen deprivation had long been discussed as a possible trigger for epileptic convulsions. the possibilities of high altitude medicine to generate oxygen deprivation experimentally in vacuum chambers thus also opened up new ways for nachtsheim to move his experiments with the "epilectic" vienna whites forward. nachtsheim was interested in collaborating with ruhenstroth-bauer because the latter experimented with rabbits deprived of oxygen, was well familiar with the physiology of blood and respiration and brought along biochemical expertise. for ruhenstroth-bauer's part, nachtsheim's research on the phenogenetics of convulsion-readiness must have been of fundamental importance -and added to this was the fact that nachtsheim developed an interest in blood and hemopoiesis starting around mid- . the initiative for collaboration probably came from hans nachtsheim, although it can be presumed that the two men were already acquainted due to the tight net of reichsluftfahrtministeriums) , for assistance in conducting the low-pressure experiments involved in his hemopoietis project. nachtsheim, too, through his former doctoral student harry suchalla, who had found a position on the "top floor" of the institute, had contacts to strughold, whose institute, which was housed in the military physicians' academy (militärärztliche akademie) along the bank of the spandauer schiffahrtskanal on scharnhorststrasse in berlin, had several vacuum chambers at its disposal. around june nachtsheim and ruhenstroth-bauer began with their rabbit experiments in the vaccum chamber of the research institute for aeronautical medicine. yet these low-pressure experiments constituted only a small portion of the around experiments that nachtsheim and ruhenstroth-bauer performed in , with support from the reich research council and the third-highest priority rating of "s," for the purpose of depriving their test subjects of oxygen in various ways. the two scientists advanced a concise justification for their experimental program: the results of the cardiazol experiments on epileptic and non-epileptic rabbits in previous years made it seem desirable to investigate the importance of oxygen deprivation for the inducement of the epileptic attack in special experiments on young and mature animals. through the experiments in the vacuum chamber nachtsheim saw his view confirmed that convulsion-readiness depended on age. "normal mature animals" subjected to oxygen deprivation in the vacuum chamber, which corresponded to a height of , - , m, showed no reaction at all, and this was also the case for "normal young animals" and "mature epileptic animals." in contrast, "young epileptic animals aged - months" nearly always suffered at least a rudimentary epileptic attack under these conditions, and in cases of a "generalized attack with all phases of spontaneous convulsions" the frequent result was "the sudden death of the animals." further series of tests "proved" to nachtsheim that it was the oxygen deprivation ensuing from the low pressure that induced the convulsions: for one, the same result could also be attained when the test subjects were subjected not to low pressure, but to a mixed nitrogen-oxygen atmosphere that corresponded to a height of around , m. second, it turned out that an epileptic attack could also be induced in the rabbits by interrupting the flow of blood to the brain, again, particularly "promptly and impressively" in the "young epileptic animals." for a more precise analysis of the effect of oxygen deprivation, in further tests the rabbits were "set in part into a proconvulsant, in part into an anticonvulsant condition." so some animals were tested in the condition of alkalosis or acidosis (shift in the acid-base balance in the blood toward the alkaloid or acidic side, respectively). others were placed in a mixture of air and carbonic acid, or treated with bromural, luminal, or caffeine before the oxygen deprivation test. it proceeded from all tests, nachtsheim proclaimed, "that in the epileptic rabbit oxygen deprivation is the root cause for the inducement of the epileptic attack." the term "myoclonic threshold" is largely identical to the term "sensitivity to oxygen deprivation of the brain cells inducing the attack." this very assertion was disputed from an influential quarter. a group of scientists around alois kornmüller , director of the department for the experimental physiology of the brain at the kwi for brain research, had been studying epilepsy for a long time -also in collaboration with strughold -and was already looking into the connections between epilepsy and altitude sickness. the junior physician j. gremmler, who belonged to the "brain research office of the air force" (gehirnforschungsstelle der luftwaffe) under hugo spatz, performed a series of experiments in which (adult) epileptic patients from sanatoriums and hospitals were experimentally put into a condition of hypoxemia and then their brain waves measured. this experiment brought gremmler to the conclusion that oxygen deprivation must be excluded as the trigger for epileptiform convulsion fits. this result constituted a double challenge to nachtsheim: not only were gremmler's findings on the importance of oxygen deprivation diametrically opposed to his own, but gremmler also cast doubt as to whether the convulsions in altitude sickness could be equated with the epileptic attack at all. in so doing, he also questioned the very foundations of the animal model developed by nachtsheim and ruhenstroth-bauer, for if the convulsions generated in rabbits by low pressure were not epileptiform, then the results on varying convulsion thresholds in young and mature animals could not be translated to human epileptics. unless nachtsheim and ruhenstroth-bauer wanted to call gremmler's findings into question in principleand they did not, because they saw nothing objectionable in the experiments -there was only one way for them "to salvage" their own research findings: elsewhere it has been proved for humans that adult epileptics do not respond to oxygen deprivation with an attack. since a significant difference in the behavior of mature and young epileptics was yielded in our animal experiments, we tested epileptic children at low pressure in a similar manner. if they were successful in inducing epileptic attacks in epileptic children through low pressure, gremmler's negative findings would be relativized -in gremmler's experimental arrangement, it could be argued, the oxygen deprivation was simply not great enough to induce a convulsive attack in the adult test subjects -and the hypothesis of oxygen deprivation as the trigger of the epileptic attack would be saved. beyond this, if the epileptic children reacted to low pressure in the same way as the young epileptic rabbits, this would furnish impressive evidence of the animal model's applicability. paradoxically, in this case the human experiment was to function as the confirmation for the animal experiment, which was originally conceived of as a substitute for human experiments. there are only two written sources on the further course of events, both of them quite meager -a report by nachtsheim to the reich research council of september , or march , , respectively, and a short letter from nachtsheim to gerhard koch of september , -as well as several testimonials put down in writing by gerhard ruhenstroth-bauer at great intervals of time. these sources document without a doubt that at least one such human experiment took place. however, we know hardly anything about how this experiment came about and how it proceeded in detail. for the present we also remain in the dark about what happened to the human "guinea pigs" later and whether further experiments of this kind followed. apparently nachtsheim, in his search for epileptic children for the planned tests, turned to gerhard koch, who was convalescing in berlin from june to august and worked as a guest scholar at the kwi-a during this period. at the time koch's research included work on "residual epilepsy." as he wrote in his memoirs, he and nachtsheim "repeatedly [conducted] instructive and useful conversations about the etiology and heritability of the various epileptic convulsive conditions in humans and animals and about the convulsion-readiness behind these conditions which is so different for each individual." it was presumably koch who drew nachtsheim's attention to the berlin-wuhlgarten sanatorium and hospital (heilund pflegeanstalt berlin-wuhlgarten), in which a large number of epileptics were housed. koch had worked there from to on "family studies" in the context of his dissertation about sturge-weber disease (today: sturge-weber-krabbe syndrome). he had maintained contact afterward -as late as julius hallervorden sent koch the pathological report of a test subject who died after the family study was concluded. while still working in dahlem in summer , koch, assisted by hans grebe and and mature epileptic animals in response to oxygen deprivation made it appear desirable to investigate on humans a comparison of young and adult epileptics. gremmler investigated only adults, and was not successful in inducing an epileptic attack in them through hypoxemia. after conclusion of our own studies of young epileptics, which are also interesting to the clinic, we intend to report about the detailed results." -on the human experiment described in the followiing, cf. chamber. yet the tests came out just as negative as those gremmler performed on adult epileptics. but at the moment it is not possible to say that rabbits and humans respond differently to low pressure, for the children we tested were aged - , which corresponds to a rabbit aged - months. however, epileptic rabbits of - months do not show the reaction-readiness of - -month-old animals, which nearly always had attacks. we would have to be able to test epileptic children of - years of age, but this is not possible at the moment because this age group is not present at görden. so from wuhlgarten, ruhenstroth-bauer and nachtsheim had been referred to the state institute in brandenburg-görden directed by hans heinze, which played an important role in the nazi "euthanasia" program. it remains unclear who ultimately established contact with görden. in the s ruhenstroth-bauer claimed that nachtsheim had enjoyed good contacts to görden and was involved in the treatment of epileptic children there, so that he addressed the children by their first names and elucidated their anamneses, while he -ruhenstroth-bauer -met the children for the first time in the vacuum chamber on september , , had never seen them before and did not even know where they came from. considering the letter from nachtsheim to koch, there is certainly reason to regard this testimony as an attempt at self-justification, but it is indeed conceivable that nachtsheim had been in contact with görden for some time previously. this could have come about via the kwi for brain research, which was, for its part, linked closely with görden through julius hallervorden, who was both director of the department for histopathology at the kwi for brain research and prosector of the brandenburg state psychiatric institutes from onward -in fact the department of pathology located in görden from had been officially transferred to the kwi for brain research in berlin-buch, and the laboratory in görden was run as an outpost of the kwi. through the department of pathology in görden and other channels, over brains of "euthanasia" victims made their way to the kwi for brain research, where they were subjected to pathological examination by julius hallervorden and hugo spatz. nachtsheim had good contacts to the kwi for brain research -for years he had sent his rabbits from the epilepsy experiments to gerd peters ( - ) for postmortem examination. as mentioned above, nachtsheim also had close contact with the pathologist hans klein, who performed postmortem examinations on rabbits with dropsy for him starting in , but also participated in the autopsies of the victims of the "special children's department" at wiesengrund. what should not be forgotten is that fritz lenz was familiar with a number of physicians from the staff of the "euthanasia" program from his consulting activities on the draft law for euthanasia, including hans heinze. pointing out these entanglements is important to the extent that it can be presumed with a high degree of security that nachtsheim was aware of the "euthanasia" program still in progress. as the available sources testify unanimously, the experiment did not produce any tangible result -it did not succeed in inducing an epileptic fit in the children through low pressure. consequently it did not cause them any suffering -but ruhenstroth-bauer and nachtsheim could not have foreseen this. according to nachtsheim's account, the children were subjected to a low-pressure situation that corresponded to an altitude of , m (not to mention the mental strain of being locked into the vacuum chamber). according to the knowledge available to altitude medicine at the time, at this altitude the onset of threatening conditions had to be expected even for adults -all the more so for children. moreover, there was no possibility of resorting to any previous experience with epileptic humans in lowpressure situations. furthermore, ruhenstroth-bauer and nachtsheim knew from the animal experiments that young epileptic rabbits reacted to low pressure with violent, often fatal convulsions -and they expected (and hoped!) that the children would react like the rabbits. in other words: the scientists knowingly accepted the risk that the children could be placed in fatal danger. ruhenstroth-bauer's reassuring statement that he himself, nachtsheim and an additional physician of the luftwaffe had been in the vacuum chamber with the children and had been able to abort the experiment at any time -as could the children themselves -thus fails to get at the root of the matter. there is no doubt that ruhenstroth-bauer and nachtsheim planned further tests with younger children after the failed first experiment. whether these came about cannot be determined with any certainty. however, it is probable that it was no longer possible to realize these tests. of the six children in the first experiment, there is proof for only one having survived the third reich; the fate of the other children must remain an open question. perhaps they fell into the gears of the "euthanasia" program -in contrast to the clinical examinations and tests in the two "research departments" of the "euthanasia" apparatus in brandenburg-görden and wiesloch/heidelberg, however, it went against the logic of the experiment to kill the children and examine them pathologically as long as they had not suffered an epileptic attack. nonetheless: the low-pressure experiments by nachtsheim and ruhenstroth-bauer ignored the reich health council's regulations on human experiments from the year as a matter of course. for the most part, these regulations, as adduced elsewhere, had already been ignored by research back in the s. yet this experiment marked a further boundary crossing, as the experimenters unscrupulously subjected the children to an incalculable health risk, even accepting a potentially fatal outcome of the test -and all of this needlessly, for the utilization of the vacuum chamber was by no means imperative. oxygen deprivation could have been effected in other ways, especially as gremmler, upon whose work the experiment was based, had not worked with low pressure. apparently the standards of scientific ethics had shifted further. a comment with which nachtsheim and ruhenstroth-bauer preceded their short report about the low-pressure experiments on rabbits implied as much: for the clinician working on patients experimentally, the possibilities are always restricted, for he has to take the welfare of his patients into consideration. only in exceptional cases will a researcher dare to perform an experiment on a patient in the interest of future patients, the outcome of which cannot be predicted with any certainty. here a method assists the field of medicine, which allows these difficulties to be circumvented at least for a few genetic illnesses, the model experiment on animals. alexander von schwerin is correct to emphasize that this opens up a new moral dimension. while up to this point nachtsheim had designated the human experiment as morally inadmissable without restriction, and recommended the animal experiment as a morally unobjectionable alternative, he now no longer categorically excluded the possibility of research on humans for the benefit of others, even if the outcome was uncertain. in this case human and animal experiments no longer appear as mutually exclusive alternatives; on the contrary, it suggests a complementary relationship. schwerin lists a number of factors that contributed to the erosion of the ethical standards of science: the objectifying linguistic usage, which not only blurred the boundaries between humans and animals (nachtsheim, for instance, referred to both as simply "epileptics") and transformed both into "material," but also elevated the "genotype epilepsy," detached from the human patient, to the actual scientific object; and also the "militarization" of altitude research. two other aspects deserve special emphasis: first it must be kept in mind that the newly developed coma and shock therapies (insulin coma treatment, cardiazol convulsion treatment, and electric shock therapy in the first years of world war ii) had been widely adopted in german institutional psychiatry since the mid- s, although these "heroic therapies" put the patients in horrible states of anxiety, often inflicted serious injury to their health, and in some cases even resulted in their deaths. therapeutic ambition was willing to accept high risks -thus, it is no wonder that artificially inducing convulsive fits in epilepsy research was not questioned. second it must be considered that by , somewhere around , mentally ill, epileptic, or mentally disabled patients from the sanatoriums and hospitals of the german reich already had been murdered in the course of "euthanasia" -and thousands of infants, children, and teenagers had also been killed in the course of the children's "euthanasia," the "aktion t " and "decentral euthanasia" ruhenstroth-bauer/nachtsheim, bedeutung des sauerstoffmangels, p. (original emphasis). schwerin, experimentalisierung, pp. f., f. cf. kersting/schmuhl, einleitung, pp. f. since august . this undermined the moral status of the children from görden. now they were little more than readily available, not terribly valuable "material" for "consumptive research." with the entry of the german reich into the circle of colonial powers, german anthropology and ethnology -like the other sciences -felt challenged to make their knowledge useful for the justification and legitimation, execution, and consolidation of colonial rule. a relationship of mutual engagement emerged: the sciences aligned themelves with colonial interests in their selection of subjects and objects, their theoretical and methodological approaches, and made the knowledge thus obtained available to the colonial administration. in return, the colonial state furnished the colonially oriented scientific disciplines and subdisciplines with financial resources, granted them privileged status in the institutional structures and raised their value in the public. colonial interest groups mediated between state and science. "in this system of mutual obligations between state, political parties, interest associations, and sciences after , a spectrum of new areas of knowledge developed in the german science landscape, which was known as the 'colonial sciences' in the contemporary diction […] ." fischer's study on the "bastards of rehoboth" of the year was conceived and intended as a contribution to colonial science, apparent in the fact that the author drew practical consequences for colonial policy from his research findings in its concluding chapter, die politische bedeutung der bastards ("the political importance of the bastards"). despite his heterosis thesis, according to which a "population of bastards" is located between the "source races" as regarded their physical, mental, and intellectual characteristics, he took a clear position on the ban on mixed marriages in the colonies so hotly debated at the time: every european nation without exception […] that has assimilated the blood of inferior races -and that negroes, hottentots and many others are inferior can be denied only by dreamers -has paid for this assimilation of inferior elements with intellectual, cultural decline. at the end of his colonial policy conclusions, fischer designed a system of apartheid for german southwest africa, long before such a system was introduced in south africa: the ovambo and herero were to be deployed as agricultural laborers, the hottentots as herders. the "bastards of rehoboth," in contrast, were assigned an important function as a privileged intermediate class, "as native craftsmen and manual laborers […], as policemen, i.e. minor officers, foremen, and leaders of the entire supply lines and vehicle pool of the government, troops and private persons, in part as small farmers in their bastard country, to which everyone returns after serving their time." despite his paternalistic attitude toward the "little nation of bastards," fischer regarded the rehoboths from the perspective of the colonial masters: so they will be granted just that degree of protection which they need as a race inferior to us, in order to endure, no more and only as long as they are useful to us -otherwise free competition, i.e. in my opinion, here downfall! this last comment by fischer reads like a retrospective justification of the war of extermination the german colonial troops had led against the rebellious herero and nama from to . fischer had profited from this genocide directly, for he apparently brought skulls and skeletons of "hottentots" with him from southwest africa, which may have come from the internment camps on shark island, where people died like flies. the skeleton of the nama leader cornelius frederiks ( † ) also supposedly came into fischer's collection in this way. as mentioned above, fischer continued his studies of the "bastards of rehoboth" until . yet the "bastard studies" by fischer and his pupils were no longer embedded in a colonial science and colonial policy context, but rather in the concept of anthropobiology: with its particular methodology, which combined anthropometry, genealogy, genetics, and ethnology, they were supposed to bring together anthropology and human genetics. however, "bastard research" had not lost its practical application, as the role of the institute in dahlem in the sterilization of the "rhineland bastards" quite impressively evinced. after world war i the colonial sciences became part of the "colonialism without colonies," which blossomed so lushly in germany between and . colonial research did not simply cease after the loss of the colonies. on the contrary, in view of a future german colonial empire, it was even intensified. until the german defeat in stalingrad, when colonial planning was officially discontinued, a perfect colonial empire had been designed on the drawing board. "one can only ask with astonishment," in the words of wolfe w. schmokel, "whether at any point in history a non-existent empire had ever been so well administered […] ." increasingly, colonial planning was based on a scientific foundation. tropical medicine, tropical technology, geography, regional development, demography, anthropology, social hygiene, and eugenics dealt intensively with colonial policy issues. at this time there is no indication that the kwi-a was included in colonial policy planning in the late s -be it by the race policy office of the nsdap, which was closely linked with the institute in dahlem through its director walter groß, and which had presented the main features of a future national socialist race policy in the colonies in with a tract entitled kolonialfrage und rassegedanke ("the colonial question and race theory"): the plan was for strict race segregation, a ban on mixed marriages, the restriction of contact between blacks and whites to a minimum, and so on. in an article for the periodical rassenpolitische auslandskorrespondenz (race policy foreign correspondence), eugen fischer legitimated such forms of apartheid with reference to "indisputable and provable facts, to the fact that mental attributes are based on genetic dispositions, that race differences are genetic differences, that mental attributes are different for each races, and that there are thus mental differences between races." fischer's admonition to investigate such "mental race differences" scientifically and to lay a scientific foundation for race policy fell on deaf ears, however. that the "law for the protection of colonial blood" drafted by the colonial policy office in equated the "half-breeds with an admixture of native blood" with the population of color as regarded the ban on mixed marriages was certainly in accordance with fischer's wishes, but the notion upon which this passage was based, that the "halfbreed" was under both "source races" in terms of his or her mental and psychic attributes, stood in blatant opposition to fischer's theory of heterosis. in the course of world war ii, however, as mentioned above, collaboration developed between the colonial policy office and gottschaldt's department for genetic psychology. in september gottschaldt took on the article about "psychological problems and methods in colonial science" for the afrika handbuch der angewandten (kolonialen) völkerkunde ("africa manual of applied (colonial) ethnology") contracted by the colonial policy office of hugo adolf bernatzik ( - ). the manuscripts were ready for printing in fall , but were destroyed as a result of a bombing, so that the handbuch der angewandten völkerkunde could not be published until -including the article by gottschaldt along with a "questionnaire for the psychological evaluation of native workers" he had developed. hecht, kolonialfrage. fischer, geistige rassenunterschiede, p. . in fischer felt compelled to protest vehemently in volk und rasse, the organ of the national committee for the national health service, against an article by the catholic theologian theodor gentrup (berlin), who had advocated "racially mixed marriage" in the colonies on the authority of fischer's work on the "bastards of rehoboth." fischer, frage "rassenmischehe." another, entirely unexpected possibility to reestablish himself in the field of colonial science emerged from one of fischer's other research interests: his search for the "cro-magnon race," whose traces he believed to have discovered back in upon his return journey from southwest africa, and then on a further research trip in in the population of the canary islands, and finally also in the contemporary european "phalian type." on a research journey to spanish morocco, planned for the / fiscal year, fischer apparently had intended to track down the cro-magnon type in northern africa as well, yet this research plan was delayed indefinitely because of fischer's heavy workload at the rectorate. with the formation of the german africa corps in january and the conquest of cyrenaica in march/april , when the plans for founding a german colonial empire in northern africa took on more concrete shape, cro-magnon research, little more than a hobbyhorse of fischer's for so many years, quite surprisingly took on political importance. the virtuosic research strategist eugen fischer immediately recognized the emerging possibilities. on may , he lectured to the prussian academy of sciences about "the problems of white africa." proceeding from the term "white africa," coined by dominik josef wölfel ( - ), fischer claimed that the part of africa located north of the sahara, in terms of climate, geology, zoology, and botany, but above all "according to human races and cultures, clearly and fundamentally departs and stands out from the remainder of africa, from the africa of the negroes, from black africa." fischer presumed that the entire mediterranean region was settled by a "mediterranean race," in which shares of other races had been incorporated in the historical era -arab, nordic, alpine, negroid. fischer saw one of the roots of the "mediterranean race" in the prehistoric cro-magnon race, which was characterized by "blondness and blue eyes." the line of attack is clear: through the anthropological-ethnological differentiation between black and white africa, fischer supplied the scientific basis to legitimate pushing forward the borders of the emerging greater european empire under the hegemony of national socialist germany to the northern edge of the sahara, without any race policy scruples. it can come as no surprise that fischer, in return, demanded funds to accelerate the advancement of the scientific exploration of northern africa. following his lecture, fischer -along with the africanist dietrich westermann ( - ) and the egyptologist hermann grapow ( - ) -thus proposed to the prussian academy of sciences the establishment of an interdisciplinary research commission on white africa. in their proposal the three scholars urged for haste, for "after the war the development of the sahara areas with automotive and aeronautic routes, and through the construction that has just commenced of a […] trans-saharan railway, will certainly restart in full strength, and thus an increasing cf. also ritter, cro-magnon-merkmale. quoted in lösch, rasse, p. . reworked version of the lecture: fischer, weißafrika. ibid., p. . destruction of the remaining witnesses of the white african past set in." the academy approved the proposal immediately. in / fischer held "soliciting lectures" on the topics surrounding white africa. the commission instigated by fischer had no opportunity to develop any activities of note -germany's colonial dreams were over too soon. when the commission's three subject groups convened for the first time at the invitation of the colonial science department of the reich research council and the german research association on january , -a few days before the defeat in stalingrad -for a -day conference about "colonial ethnology, colonial linguistic research and colonial race research" in leipzig, all of the colonial science plans were already scrap. the speakers in the "colonial race research" section -besides otto reche, director of the institute for race science and ethnology at the university of leipzig, and egon von eickstedt ( - ), director of the institute for anthropology at the university of breslau -were eugen fischer and wolfgang abel. based on a reworked version of his lecture for the academy, fischer outlined the anthropological concept of white africa once again. abel dealt with "race problems in sudan and its borderlands." this harmless title concealed extremely explosive subject matter. abel presented numerous photographs of anthropological types from the sahel zone, most of which depicted french prisoners of war. as abel mentioned in passing, he had been detailed to the "inspection of the personnel controlling of the army (army psychology)" (inspektion des personalprüfwesens des heeres (heerespsychologie), to perform series of anthropological examinations of french colonial soldiers in a number of war prison camps. "hereby the residents of different areas or different tribes of sudan were put together in large groups and the number of the persons best rendering the type were always photographed." thus, "good illustrative material" was created, comprising the photographs of around persons. according to statements made in the s, in the context of this activity abel was also at a "leper station in bordeaux" -what was probably meant was the special military hospital for colonial medicine in st. médard near bordeaux -in order to examine the changes in the pattern of fingerprints caused by the disease. the footprints of "guinea negroes" from the special military hospital for colonial medicine in georg geipel's estate were quite probably taken by abel. abel was not alone: otto baader, too, combed through the war prison camps in france in his search for cro-magnon types. both scientists presented their findings to the berlin anthropological society. those involved apparently had no grasp of the fact that such examinations in prison war camps signified a subtle, but nevertheless fundamental boundary crossing -for the first time, scientists of the kwi-a researched on people who were capable of giving consent, but whose possibilities for refusing the examination were at least restricted because they were imprisoned. even though the examinations as such were harmless, and the probands had to suffer neither pain and fear nor abasement and were not subjected to any health risks, abandoning the principle of informed consent signified a deep rupture. the war prison camps of the french campaign amounted to a sort of laboratory for race anthropology research. the special conditions of such research resulted in a process of radicalization, which is to be illustrated with a further example: robert stigler ( - ), director of the institute for the anatomy and physiology of domestic mammals at the university of vienna, and his five assistants, performed a series of race anatomy and race physiology tests in a war prison camp near vienna in july . in the camp, besides around , white french, alsatians, flemish and walloons there were also around , moroccans, tunesians and algerians, tonkinese, annamese, negroes, among them from west africa, from tropical america, and european jews, among them several diamond merchants from antwerp. as in the examinations by abel and baader, here to the question as to the consent of the probands was not posed at all. even so: our examinations met with no resistance at all from the prisoners. the colored were intially very shy, but soon began to trust us and many cheerful scenes ensued. i had the negroes perform their dances and sing their songs for us. the moroccans, tunisians and algerians were much more negative, the little yellow tonkinese were the shyest of all […] . recorded in the examinations was the clotting time of the blood, the sinking speed of the blood, the viscosity of the blood, blood pressure, pulse rate, respiration, the upper hearing limit, the threshold of the sense of touch, reaction speed, right-handedness and left-handedness, hair growth on the genitals, and sexual characteristics -the last of these substantiated by numerous photographs. in comparison to the examinations by abel and baader, further boundary trangressions can be determined: not only would the measurements of the naked body and the photographing of the genitals have been perceived by the probands as humiliating and a violation of modesty. in taking blood samples the scientists had gone a step further -this was a first, albeit minimal, invasive approach. the examinations of the group of researchers around stigler were thus positioned between those of abel and baader and the examinations and experiments of karl horneck, which will be depicted at a later juncture. even after the start of world war ii, eugen fischer and otmar von verschuer brought their national and international reputations to bear in order to provide a scientific foundation to legitimate the "total solution to the jewish question" tackled by the national socialists, which by late early had taken on the character of the "final solution" once and for all. for fischer and verschuer there could hardly have been a doubt as to what the measures aimed to achieve. they were guests of honor to a working congress at the inauguration of the "frankfurt institute for the investigation of the jewish question" (frankfurter institut zur erforschung der judenfrage) on march / , . the aspired goal of the "total solution" to the "jewish question," as was bluntly stated here, was the volkstod ("death of the nation"). the economist peter-heinz seraphim pointed out for consideration that the deportation for forced labor in camps in poland or an overseas colony could also have the consequence of "social pauperization and upheaval," but "by no means the physical self-disintegration of jewry, for the death of a nation is never a fast death." the logical conclusion from these comments was, as benno müller-hill emphasizes correctly, that the "physical self-disintegration" would require some assistance. when the deportation of the german jews began in october , nobody who had participated in the congress in march could have been in doubt as to what was in store for the jews deported to the east. this did not prevent fischer from making an appearance in late /early as part of a lecture series organized by the german institute in paris. in his lecture about "race and german legislation," fischer certified that the "bolshevist jews" were of "monstrous mentality" and assigned them to a "different species." fischer himself emphasized in a report about his trip to paris that he had found much acknowledgement among the attendant french scientists for his discussion held of the "negro problem" and the "jewish problem" in a "very candid, but in purely scientific form" -and this right before the deportation of , jews from france was discussed at the wannsee conference. as mentioned previously, in fischer and the theologian gerhard kittel published a book about the "world jewry of antiquity," essentially a selection compiled by kittel of ancient sources with a decidedly anti-semitic perspective. kittel supplemented the written sources with illustrations of egyptian mummy tablets, which supposedly constituted further evidence for the worldwide propagation of jewry. at kittel's request, fischer undertook to determine the "race type" of the persons illustrated. this was not the first time fischer had done something like this (for instance, he had studied the illustrations on etruscan tombs and the masks found during excavations in mycenae), yet in this publication it was practically tangible that fischer's interpretations of the pictures completely abandoned the basis of precise anthropometry and relied only on intuition -and that his intuition was distorted by anti-semitism: granted, the expert sees for all races, and also for the basic races of the jews, a number of physiognomic details which we cannot name and fit into the usual model: shape of nose, shape of face, shape of skull, etc. often a jew is recognized as a jew with complete certainty even though he does not have […] a so-called "jewish nose." there is something […] in the jewish physiognomy that cannot be measured, and can hardly be described in detail such that the reader or listener can visualize it clearly. but no one will doubt that very many jews can be picked out from groups of non-jews with complete certainty. […] it is not permissible to disqualify as unscientific the statement of a general "impression" of "jewish" in the evaluation of the pictures. the attempt by niels c. lösch to play down fischer's participation in this anti-semitic pamphlet as an expression of senility deserves vehement contradiction -fischer, years old at the time, was of remarkably fresh intellect, and his scientific publishing activities extended well into the s. it must also be kept in mind that fischer's studies on "jewish physiognomy" were by no means the concern of an individual scholar in retirement, but rather were based on preliminary work performed at the kwi-a at the beginning of world war ii. in late /early -probably in the first months of -one assistant and three students made several trips to Łódž ("litzmannstadt") on fischer's behalf, where the group -in a cauldron of executions, pogroms, and synagogue cf. also heiber, walter frank, p. . upon fischer's request, verschuer had copies of the "jew pictures of egypt" slides made for the collection of the kwi-a. cf fischer explained the costs, stating that "all four gentlemen occasionally traveled and worked independently, so that i was not able to give the entire sum of the expenses to the assistant, so that he could pay out the individual amounts, but occasionally had to pay all gentlemen individually. […] and in so doing the account between their own funds and those of the institute occasionally were somewhat mixed up." fischer to generalverwaltung, / / , desecrations, while at the same time ten thousands of jews were deported from the city and carried off to concentration camps -performed series of anthropological examinations on more than jews. among the students were also harry suchalla and christian schnecke, who were still working as doctoral students of nachtsheim's at the institute for genetic and breeding research and were "loaned out" by fischer, presumably for want of manpower of his own. this circumstance indicates that the opportunity was favorable and time was pressing. it can be presumed that herbert grohmann, a graduate of the first annual ss course at the kwi-a and an assistant to fischer in the years / , made the "field research" in Łódž possible, having held the position of senior medical councilor at the newly founded health office of "litzmannstadt" since september . in not only photographs taken by suchalla and his comrades on their trips to Łódž were included in fischer's and kittel's book about "ancient world jewry." after the war the fingerprints and handprints from the Łódž ghetto were recovered in hans nachtsheim's institute for comparative genetic biology and genetic pathology of the german research academy in dahlem, where they were discovered by georg geipel, who, as elaborated elsewhere, had worked at the kwi-a as an expert for dermatoglyphics (and who had introduced suchalla to the technique of dactyloscopy in ). as late as the end of , the publication of this material was discussed in all earnestness in the context of dermatoglyphic race research, but was stopped, presumably upon fischer's advice. the fingerprints and handprints themselves are untraceable today. however, the anonymized fingerprint formulas of "litzmannstadt jews" are included in geipel's scientific estate. the incident shows that fischer was willing to use the "total solution of the jewish question" at short notice in order to obtain research material, and in return ibid., pp. a- a v, quote: p. a. -the trips must have taken place between september , , the day on which Łódž was occupied by the wehrmacht, and the close of accounts on march , . in retrospect, harry suchalla dated his stay in Łódž to the year . the incident shows that a close connection between fischer and nachtsheim must have existed before october . to place the results of his research, as dubious as they might have been, unquestioningly at the service of "jewish policy." that fischer regarded his anthropological studies as a contribution to the "total solution of the jewish question" was demonstrated quite clearly in june , when alfred rosenberg ( - ), minister for the occupied eastern territories, invited fischer to act as one of the presidents of an international "anti-jewish congress" to be convened in kraków. fischer accepted the invitation, explaining: i hold […] your intention to found a scientific front to defend against the influence of jewry on european culture and to call together the scientists of all of the nations in conflict with jewry to be very good and altogether necessary. yes, it is high time for such an action, for jewry has been battling us for decades not only politically, but quite certainly in terms of pure intellectural history as well. the congress never took place. nevertheless the incident shows how loyally fischer supported the "final solution" even at a point in time when the collapse of the national socialist state was already clearly imminent. this was also true for his successor, friend and pupil otmar von verschuer. in late /early -the deportation of german jews had begun a few months previously -he wrote in the erbarzt: never before in history has the political importance of the jewish question emerged so clearly as today: the whole of europe in alliance with japan-led east asia is battling against the english-american-russian world power jointly led by jewry. the nations unified with us recognize more and more that the jewish question is a question of race, and that they therefore must find a solution like the one we initially introduced for germany. this was open approval for the deportation of jews from the third reich, and pled for its expansion to german-dominated europe. in evaluating this statement it must be kept in mind that the mass murder of mentally ill and mentally disabled people in the gas chambers of the "aktion t " in / was known to large sectors of the german population, and that information had leaked quickly about the massacres committed by the task groups of the security police and the sd in the occupied territories of poland and the soviet union. when the systematic deportation of german jews began in october , a significant degree of self-deception was needed to accept the official version of "resettlement" and "work assignment in the east." as late as verschuer, as mentioned above, demanded a "new total solution of the jewish problem," now that the "historical attempts at solution" -"absorption of the jews," "seclusion of the jews through the ghetto" and "the emancipation of jewry" -had failed. as to what the "total solution" looked like in the ghettos and extermination camps, there was hardly a scientist in the german reich who had such profound information as otmar von verschuer. yet, with his research on the development of a serological race test all the way into the final months of the war he made his contribution to this "total solution." fischer to rosenberg, / / , quoted in müller-hill, tödliche wissenschaft, p. . at fischer's suggestion lothar loeffler also took part in the organization of the congress. verschuer, erbarzt an der jahreswende, p. . verschuer, leitfaden, nd edn., pp. f., . in addition, under verschuer's directorship the kwi-a continued, albeit to a diminished degree, to contribute practical legwork on "jewish policy" in the form of certificates of race and descent. in / , for instance, verschuer and his staff members schade, grebe, mengele, fromme, baader, and liebau produced evaluations bringing in a total of , rm. "as a special war service" the institute also provided "certificates of wehrmacht members (racial descent, marriage permits)." that verschuer used his activities as an evaluator to help those suffering racial persecution methodically and systematically, as a war legend claimed, must be challenged on the basis of today's state of knowledge. it is indisputable that he delivered a judgement advantageous for the individual involved in individual cases. it is also obvious that the test subjects enjoyed his sympathy in these cases. yet for the assertion that one of his closest friends, the frankfurt pastor otto fricke, made in his denazification testimony of october , that verschuer had gone "to the limit of scientific credibility […] in order to prevent people from fall victim to the methods of the national socialist state," there is no believable source evidence. important in this context is a letter by verschuer to karl diehl of february , . the subject was the case of the "half-jewish" physician werner wund , to whom approbation was denied in national socialist germany and who had found employment in may as an intern in the remote eckardtsheim branch institute, one of the von bodelschwingh bethel institutes. his situation had become precarious in september , when the reich ministry of the interior had rescinded the employment permit it had initially granted for wund. thereupon bethel endeavored to procure a certificate of exemption from the reich chamber of physicians. in this context a file on the "wund case" must have made its way via the channels of the deaconry to the practicing catholic karl diehl. diehl had submitted the case to his friend verschuer, requesting his assistance. however, in a letter of february , verschuer expressed his regret that he could not undertake anything, "as the question of the racial descent is undisputed." "for such applications a race biology certification plays no role. for it is of no consequence whether or not the individual involved looks jewish." verschuer recommended a "clemency plea to the reich chancellory," whereby he was skeptical about the success of such a petition from the outset. interesting in this context is a passage of his letter in which verschuer went into his role as an assessor: only in those cases in which doubts exist as to the correctness of the blood descent am i consulted as an expert, and in many such cases i have been able to help the people involved decisively. just recently, for instance, a physician from stuttgart came to me, whose wife was hitherto supposed to be a full-blooded jew. from her appearance alone doubts as to this descent were justified. the couple also had four children, who now were supposed to be taken out of school and who would be banned from all higher professions as " st degree mixed-race." in this case i could supply evidence that the woman was not descended from her jewish father, but had a german physician, since deceased, as her biological father. this just as an example of the cases in which my involvement can be successful. here verschuer was probably alluding to the case of the professor's wife luise s., in which he had been consulted as an assessor. verschuer's expert opinion had in fact been successful in declaring mrs. s., who had been considered a "full jew" until that time, to be a "half-jew," by abnegating the biological paternity of her legal father. by no means did this close the case, however, for the husband of mrs. s. fought for the recognition of his wife as "german-blooded" by questioning the biological maternity of her legal mother as well. the race policy office, to which he addressed his petition, called in the race biologist wolfgang lehman from strasbourg, who, as already mentioned, was a member of the "dahlem circle." lehman was to examine photographs to ascertain whether they yielded "indications for a jewish descent" of mrs. s. since he gathered from the files that verschuer had already submitted an expert opinion, lehmann turned to verschuer first before delivering an opinion himself. the characteristic style of lehmann's letter to his former colleague makes apparent that he was disposed to agree with the standpoint of professor s., and that he proceeded from the assumption that verschuer would agree as well. the response was different than expected, however. while verschuer allowed that mrs. s. belonged to the cases "in which nobody would suspect a jewish influence. as such one can concede to her husband that she appears to be a 'pure german woman' […] ." but in his expert opinion at the time he had not been able to "lend support for the assumption that she was not the child of her mother. she received notification from the reich heritage office that she was […] degree mixed race, and i believe," verschuer added with slight irritation, "professor s. professor for race biology and the race policy office of the nsdap -to relieve mrs. s. of the stigma of being a "half-jew," and her children "quarter-jews" -had he only been willing, despite his scientific conviction, to depart from the result of his first expert opinion in the interest of this human being. this case confirms the judgement hans-peter kröner made about verschuer as an evaluator on the basis of a case of "race treason" from : verschuer was neither one of those scientists who provided incorrect opinions knowingly and deliberately in order to save people, nor one of those who interpreted the race laws extensively to the disadvantage of their subjects. verschuer was the type of the "correct, law-abiding but merciless evaluators." of course, verschuer abetted the emergence of his legend by portraying to his friend diehl his first expert opinion as emergency assistance for a subject suffering racial persecution, although he did not claim at this juncture to have falsified the findings of the paternity examination. through this it was possible for the impression to emerge in verschuer's circle of friends -and also among the affected -that he used his position as an evaluator to help the persecuted. however, all cases documented by sources prove that verschuer followed the exact letter of the law and that "scientificity" was the only criterion for his expert opinions. with his appointment to "reich commissioner for the fortification of german volkstum" himmler was entrusted with the "ethnic cleansing" of the occupied eastern territories. consequently he set a mighty population transfer in motion, whereby the settlement of german nationals in the conquered areas and the deportation of poles and jews from these spaces drove each other like cogs in a powerful machine. yet the forced migration, which was effected starting in winter / , constituted only a fraction of the planned resettlement program, which was worked out by himmler's accomplices between and and entitled the generalplan ost ("general plan for the east"). the original generalplan ost, which was reworked several times, has not survived. but through two written position papers from the pen of the head of the race division in alfred rosenberg's reich ministry for the occupied eastern territories, erhard wetzel , we know its contents down to the details. within years at least million germans were to be resettled in the east. the territories slated for settlement were the occupied areas of poland, the baltic countries, belarus, parts of russia, ukraine and crimea. the population in these areas was estimated at about million, including - million jews, whose extermination wetzel presupposed as a matter of course in his position paper of april , . in total, of the million people who lived in the territory destined for german settlement were categorized as "racially undesirable." they were to starve or be expelled to siberia. according to generalplan ost, - % of the population of poland, % of the population of western ukraine and % of the population of belarus was to disappear. the remainder was to be "germanized" or to serve the german "master race" as "helot folk." as such, generalplan ost was the blueprint of a gigantic program of extermination, expulsion and enslavement. three scientists from the kwi-a were involved directly or indirectly in elaborating the plan. eugen fischer took part in a meeting in the ministry of the east protocolled by wetzel on february , "about the questions of germanization, especially in the baltic countries," in which a draft of generalplan ost, presumably worked out by group iii b of the rusha in late was discussed -by the way, side by side with his old nemesis bruno k. schultz, by now head of the race office in the rusha. according to the protocol, in this meeting fischer gave one of the introductory position papers and spoke once during the discussion, when wetzel asked the group to consider "whether through the industrialization of the baltic region it might not be possible to scrap the racially undesirable sectors of the population," rather than forcibly deporting them to siberia. with the formulation "scrapping through industrialization" wetzel did not mean "extermination through labor." by way of explanation he added, namely: "if they [the 'racially undesirable' sectors of the population] were given suitable pay, in particular, if their cultural condition were to be raised, a drop in the birthrate would be expected." wetzel thus set his hopes in the regularly observed drop in birthrates in the industrialized states as a means of making the sectors of the baltic population that were not to be "germanized" vanish in subsequent generations. in opposition fischer expressed misgivings: the "better standard of living" could, contrary to wetzel's expectation, "easily lead to a rise in birth rates." wetzel admitted that fischer's view was "correct to the extent that […] those concerned are unmistakably anti-social." in short the brief exchange between fischer and wetzel amounted to the scholar coming out against the representatives of the ministry of the east and with the representatives of the ss for large-scale deportations from the baltics to siberia, and thus giving preference to a more radical variant of "ethnic cleansing." in spite of this, fischer's consulting activity continued to enjoy high estimation in the ministry for the east. he played a key role in rosenberg's plans for the founding of a "reich headquarters for research on the east." in a file note for hitler of march , rosenberg informed the führer that he had "thought of" fischer to fill the position at the reich headquarters, "as a representative personality for biological research and a leading member of the kaiser wilhelm society." quoted in heiber, generalplan ost, p. . quoted in müller-hill, tödliche wissenschaft, p. . in a detailed position paper on generalplan ost of april , , wetzel took reference to fritz lenz and eugen fischer in the section about "german settlement issues." this section concerned the question as to whether southern ukraine and crimea would come into question for german settlement because of the climate there. lenz, as wetzel reported, had "taken the standpoint that the climatic conditions in these regions were detrimental for the settlement of the nordic-phalian appointed race." in this wetzel must have referred to lenz's exposé submitted to the rusha in january , bemerkungen zur umsiedlung unter dem gesichtspunkt der rassenpflege ("remarks on resettlement under the aspect of the care for the race"). lenz continued to concern himself intensively with the issues involved in "east settlement," and advised the ss physician hellmuth thieme ( * ), who had been involved with the processing of marriage applications at the rusha since , on his dissertation on the topic of "the selection of new peasants and their importance for a race hygenic population policy." in december , eugen fischer, too, expressed his opinion on the question of german settlements in southern ukraine and on the crimean peninsula. wetzel cited him with the words "that a settlement of german people in these regions could only be considered if there was a conscious effort to create rich wooded regions all over and thus bring about a change in climate." in his exposé of april , wetzel finally cited a third scholar from the institute in dahlem: wolfgang abel. after being called up for military service, abel had first seen action in the luftwaffe, but after he was wounded he was transferred to the department for army personnel controlling as a consulting anthropologist. as mentioned above, in this capacity he had examined colonial soldiers held in war prison camps in occupied france in . in winter / , accompanied by two army psychologists, he then visited various war prison camps in which soldiers of the red army were crowded together in close quarters. on behalf of the superior command of the wehrmacht, he subjected the russian prisoners of war to crude anthropological evaluation. his findings, which he presented to a larger public in a lecture at the "east conference of german science" (osttagung der deutschen wissenschaft) flowed directly into wetzel's exposé. according to wetzel, abel had reached the conclusion: [t]hat in the russians much stronger nordic race elements are present than had been presumed up to this time. in addition to these truly nordic race elements, the great mass of which probably have been located in this region for some time now, especially in the northwestern areas of russia, and which cannot be traced back solely to germanic, especially varangian immigrants, there are a predominant number of light-skinned, primitive caucasian, more or less long-headed race types, who by no means fall under the races of günther's system, and cannot be explained as caucasian-mongoloid hybrid forms either, but rather constitute the undoubtedly ancient caucasian race forms that have yet to be described in detail. also present among the russians, primarily in the western regions, are eastern baltic influences. however, these eastern baltic race characteristics are by no means as strong as was previously presumed. at the congress, wetzel continued to relate, abel had proposed two different "solutions" to this delicate race question, which showed how abel's advantageous judgement about the racial composition of the russian nation ultimately cut both ways: the "very serious comments by abel," according to wetzel, deserve "the very greatest attention." the "path of liquidating russian volkstum" suggested by abel, however, aside from the fact that its "execution [was] hardly possible," was "out of the question for political and economic reasons." however, the strategy that wetzel himself developed in the following -fragmentation of the russian population, "racial lixiviation of russian volkstum," the "singling out the nordic clans present in the russian nation and gradual germanization," sinking of the russian birthrates -was largely oriented to abel's biologistic perspective. what is more: because abel in all seriousness posited the idea of physically exterminating many millions of people, he set a negative precedent against which all other proposed solutions, no matter how radical they were, seemed moderate. abel continued his anthropological examinations of russian prisoners of war, intensifying his connection to the ss ahnenerbe ("ancestral heritage society") at the beginning of -presumably not least with a view to his own uncertain future prospects, as the call to fischer's vacated professorial chair met with hans f. k. günther differentiated between the nordic, phalian, mediterranean, dinaric, alpine and eastern baltic races. wetzel, stellungnahme und gedanken zum generalplan ost des reichsführers ss, / / , reprinted in: heiber, generalplan ost, pp. - , quotes: p. . ibid., p. . unexpected resistance. abel sought cover with the ornithologist and ss sturmbahnführer (major) ernst schäfer . after three expeditions to tibet -he had just returned from the last in august , schäfer had taken over the "department for the central asian research and expeditions" of the ahnenerbe society in , which developed to become a "reich institute" of its own under his direction. the "sven hedin institute for central asia and expeditions," soon the largest department of the ahnenerbe, with its own domicile in the medieval castle of mittersill in pinzgau, had been opened on january , on the occasion of the th anniversary of the university of munich and the awarding of the honorary doctorate to sven hedin ( - ) . one week later, on february , , abel, who had performed anthropological examinations of around , soviet prisoners of war by this time, turned to schäfer with a request for support -a clever move, as schäfer had since encroached on the entire area of the natural sciences within the ahnenerbe organization. abel's concrete request was that the anthropologist and ss hauptsturmführer (captain) bruno beger ( * ) be assigned to him. beger had originally belonged to the rusha, then was transferred to himmler's personal staff, took part in schäfer's expedition to tibet in / as an anthropology student, entered schäfer's department for central asian research and expeditions in the ahnenerbe in , and took his doctorate in anthropology with ludwig ferdinand clauss. on march , schäfer forwarded abel's remarks to himmler's personal assistant rudolf brandt , with the request that he report them to the reichsführer ss. after intial skepticism, himmler's staff received abel's research plans quite positively. not wanting to make a decision without consulting the directors of ahnenerbe, however, the managing director of this organization, wolfram sievers ( sievers ( - was called in. sievers first consulted with a number of staff members at the "institute for military science application research" (institut für wehrwissenschaftliche zweckforschung) under his direction, which, founded in , functioned like a "state within the state of the 'ahnenerbe'," which also approved abel's research plans. on may , he wrote to brandt that he held lösch, rasse, pp. f. even though abel had been drafted into military service, he was still a departmental director at the kwi-a and maintained constant contact with the institute. as such, his examinations of soviet prisoners of war and the demands and recommendations derived from these studies cannot be factored out of the kwi-a's responsibility, especially since abel's anthropological studies in war prison camps were a direct continuation of his prewar work in the context of the institute. for a biography: kater, "ahnenerbe," pp. f., - available until the analysis has been completed. if the reichsführer-ss approves the application, however, then we must come to a precise agreement with prof. abel as to how long the designated anthropologists will have to be available for the evaluation. what was the "caucaus project" mentioned here? on august , , days after the wehrmacht had captured the oil fields of the caucasus, heinrich himmler ordered the "ahnenerbe" to prepare a scientific expedition led by schäfer in order to explore the caucasus under the aspects of botany, zoology, entomology, geophysics, and also anthropology. the planning for this unternehmen k as michael h. kater establishes, "exceeded in scale everything that came before it." with the defeat of stalingrad the plan for an ss expedition to the caucasus may have lost any basis in reality, but unternehmen k was not abandoned for good until january . thus it was from the pool of scientists involved in this planned caucasus expedition that three anthropologists were detached temporarily for abel's project of an anthropological study of russian prisoners of war. in a further letter to brandt of may , sievers stated more precisely that the evaluation of the material from the study was "extraordinarily important, because labor is to be assigned, and also for demographic, economic and cultural reasons. […] however, prof. dr. abel should be disposed to concentrate his work above all on the question of the individual groups' treatment and utilizability for labor in the war and to orient his work toward the solution of these questions." as such, abel's examinations were embedded in a new context. after the defeat at stalingrad, the labor administration under the direction of the "general deputy for the employment of labor," fritz sauckel ( - ), made every effort to effect the deployment of foreign forced laborers under the banner of "european workers against bolshevism." anthropological expertise was welcome in the attempt to differentiate from the giant army of "eastern workers" individual "racially more valuable" groups, who were supposed to be spurred on to higher performance by offering them better living and working conditions, or so the apparent calculation of the ahnenerbe. by way of precaution, sievers had rübel, endres, and fleischhacker exempted from the staff of unternehmen k on the very same day. sievers further proposed in his letter to brandt of may , that the three anthropologists to be detached to abel could take care of an additional mission on this opportunity: once access to the auschwitz camp is possible again, these anthropologists could also perform the examination there for that collection of persons of which you are familiar. since at this time, as ss obersturmbannführer ( st lieutenant) [adolf] eichmann informed me, there is especially suitable material available, the time would be particularly opportune for this examination. in this abel's project was linked with another one that had been pursued for quite some time by the ahnenerbe: the erection of a "jewish skeleton collection." the first impetus for this project proceeded from bruno beger in december . on the search for a scientist who was to take control over the setting up of the collection, the organization quickly hit on august hirt ( - ), who held the chair for anatomy at the newly founded "reich university" in strasbourg. from late /early he was courted by sievers, brandt, and himmler, so that he took over a primary role in the framework of the natural science research empire that was to emerge under the protectorate of the ss. on december , brandt passed on to sievers a generally formulated directive of himmler's that hirt should be "given the possibility to engage in experiments of every kind that could support his research work, using prisoners, professional criminals who will never be released anyway, and persons awaiting execution." initially the jewish skeleton collection was an issue. rather, the hope was to win over hirt for the directorship of a planned institute for entomology. the anatomist had made a name for himself with his work in the fields of the sympathetic nervous system and intravital microscopy, and especially this latter area was to be used in the research of new possibilities for pest control. in the end, hirt's criminal experiments with poison gas (mustard gas) on prisoners at the natzweiler concentration camp emerged from these plans. yet back in january there was also talk of "anthropological studies" hirt was supposed to perform. probably the jewish skull collection was meant with this. in any case, a report by hirt about his research fields, which sievers forwarded to the reichsführer ss on february , , was appended by an exposé in which the plan for establishing the jewish skull collection was explained in greater detail: comprehensive skull collections exist for nearly all races and nations. only of the jews are there so few skulls available to science that their processing does not permit any certain results. the war in the east now offers us the opportunity to remedy this lack. in the jewish-bolshevist commissars, who embody a disgusting, but characteristic class of sub-humans, we have the possibility to acquire a concrete scientific document by securing their skulls. the plan was frustrated by the reality of the war. hirt, sievers, and beger thus agreed to procure the material not from the front, but from a concentration campand then not just skulls, but entire skeletons. on november , , in a secret letter to brandt, sievers wrote, "for certain anthropological examinations […] skeletons of prisoners (jews) [were] required, which are supposed to be provided from the auschwitz concentration camp." the head office for reich security was instructed to issue a corresponding directive. brandt forwarded this request to the ss obersturmbannführer adolf eichmann , head of the department for jews (judenreferat) iv b in the head office for reich security. as the letter from sievers to brandt of may , indicates, eichmann had just sent word that "at present especially suitable material" was available in auschwitz for the jewish skeleton collection. on june , bruno beger arrived in auschwitz, surveying technician willi gabel having been sent ahead. on june fleischhacker followed, temporarily detached from the rusha to the ahnenerbe. by june beger had selected and, assisted by fleischhacker, gabel, and several prisoners, measured the victims. in total beger had selected, as sievers wrote eichmann on june , " persons, of which were jewish men, polish men, central asian men, and jewish women." the unfortunate were deported to the natzweiler concentration camp in august and murdered there in a specially furnished gas chamber under hirt's direction, and some parts of their bodies conserved, others preserved. so how was abel's project of anthropological examinations of soviet prisoners interlocked with this complex of crimes? and how did it continue? at present these questions can be answered only in part due to the fragmentary sources available. what is clear is that abel, armed with a research contract from the reich research council, continued working on his "race biological studies of eastern nations." in september , with sievers' help, he managed to extend his "indispensable" quoted in mitscherlich/mielke (eds.), medizin, p. . quoted in kater, "ahnenerbe," p. . quoted in mitscherlich/mielke (eds.), medizin, p. . beger's own interest focused on the four "central asian" prisoners. "two usbeks, usbekian-tadjik mixed-race and chuvash from the kasan region [were] measured and cast," beger reported to his superior schäfer on june , . "in addition, just for our institute" (quoted in kater, "ahnenerbe," p. ). status. this was justified with the fact that it was absolutely necessary that the examinations of war prisoners be concluded, "since it is imperative that the racebiological selection and evaluation of the great russians be clarified for later deployment, for up to this point we knew almost nothing about them and were misguided by incorrect conceptions." sievers' intercession can be interpreted as an indication that abel's research on russian prisoners of war continued to be performed in cooperation with the ahnenerbe. this fits in with the fact that in october , beger suggested continuing the anthropological studies begun in auschwitz on the "mongoloid" types among the soviet prisoners of war "by taking advantage of the material handed to us by this war in the form of prisoners." with the help of schäfer and sievers, in spring beger succeeded in deploying the wounded anthropologist rudolf trojan ( * ) to various camps in order to measure "central asian" prisoners of war. another question is whether and to what extent the ss was involved directly in abel's anthropological examinations. in response to his letter of may , , in which he suggested providing abel with three assistants, the anthropologists rübel, endres, and fleischhacker, sievers received an answer on june , . brandt had presented the plan to himmler and now imparted the decision of the reichführer ss: one of the anthropologists can be detached for the short term, for , or weeks, while instead of the other two suitable inmates of the sachsenhausen concentration camp should assist. for this it would be necessary that prof. dr. abel and one of the three ss führer move out to sachsenhausen for this period to take care of their work there […]. whether fleischhacker -for only he came in question under the circumstances, as endres and rübel were no longer available -was actually dispatched to abel's project after his assignment in auschwitz, and whether abel actually set up a base in the sachsenhausen concentration camp, must remain an open question at the current state of knowledge. the assumption that abel's examinations of soviet prisoners of war took place in the sachsenhausen camp is highly plausible. for one, sachsenhausen was very conveniently located, not only near berlin, but more importantly, not far from the kwi-a's external department for tuberculosis research in sommerfeld/beetz. secondly, a large number of soviet prisoners of war were held in sachsenhausen, such that this would open up a further field of activity for abel's ambitions. since abel had pursued the idea "of an instructive collection for the race history of europe and the world, the development of race, population movements domestic and international, etc." should this idea have taken on shape over the course of the war, a portion of the material could have come from sachsenhausen. from the testimony of witnesses we know that skulls, skeletons, and other body parts were sent from the sachsenhausen concentration camp to universities and other anatomical institutes. but specimens could also have come from auschwitz -at least the former prison physician miklos nyiszli ( nyiszli ( - ) mentions in his memoirs that jewish skeletons were sent from auschwitz to berlin for a "race exhibition." in the first years of the third reich, "gypsy policy" for the most part remained in the trails blazed for it in the weimar republic. the outlines of a new "gypsy policy" began to emerge as individual sinti and roma were subjected to compulsory sterilization in accordance with the gzven. from fall on they also fell under the "blood protection" law, which enacted bans on marriage between "germans" and "members of alien races" -besides jews, as the commentators of the nuremberg race laws emphasized expressly, this meant above all the sinti and roma -and also under the "marriage health law," which prohibited marriage for the "inferior," regardless of their ethnic heritage. this complex of laws signaled a shift in "gypsy policy." had the "gypsy question" been conceived as a problem of regulatory policy up to that time, now it was reinterpreted, like the "jewish question," as a "race problem." as such the sinti and roma found themselves doubly suppressed: like the jews they were stigmatized as an "alien race" in terms of race anthropology; as mentally ill and mentally disabled they were also considered to be "genetically inferior aliens to the community" in terms of race hygiene. the supposed "anti-sociality" of the sinti and roma was interpreted to be the consequence of a genetic defect, which, in term, was traced back to the interbreeding of the "genuine gypsy lineage" with the "german-blooded" lower classes. the racist conception of national socialist "gypsy policy" necessitated the collaboration of scientific functionary elites. the scientific center to "combat the gypsy nuisance" was the "race hygiene and population biology research office," which was founded in spring at the reich health office in berlin-dahlem. it was headed by robert ritter ( - ) , who was chief physician in the youth department of the tübingen university psychiatric clinic before turning to the research of "vagabond stock" and "gypsy half-breeds" full time in / . from spring on, the research office dispatched "mobile working groups," which sought out sinti and roma at gathering places, in camps, prisons, and institutions, subjected them to anthropometric examination and interrogated them -even under the application of threats and violence -to ascertain their family backgrounds. this information was supplemented by genealogical material from church and civic registries, private and state archives, as well as communications from the police, the courts, community authorities, welfare institutions, prisons, and penitentiaries. the information was compiled into family tables at the "gypsy clan archive" of the research office, which, in turn, served as the data source for the expert opinions produced by the research office. by march the research office produced almost , such expert opinions, in which the subjects were classified according to a sophisticated system as "gypsies" or "gypsy half-breeds" of various degrees. the staff of the research office was aware of the deportation of the german sinti and roma to the auschwitz concentration and extermination camp in march . in spite of this they continued to write their certified expert opinions, which constituted a decisive foundation for internment in auschwitz. the research office also took on consulting duties. it advised the offices of the criminal police on the application of the "gypsy legislation," the wehrmacht and the reich labor service on physical inspections, the groupings of the nsdap on the admission and expulsion of members, the school boards on school admissions, factory managers on hiring and labor offices on the provision of labor, rural authorities on the issuing of peddling licenses, mayors, national socialist welfare offices in welfare questions, and tax offices regarding the granting of child subsidies. above all, however, ritter and his staff instructed medical officers and registry officials about how to behave when sinti and roma applied for banns and marriage loans. by the second half of the war, the research office also delivered recommendations for sterilizations and abortions among sinti and roma. finally, by at the latest, ritter intervened in the discussion about a "reich gypsy law," but this legislation was never introduced. shortly after the founding of the race hygiene and population biology research office, close connections developed with the nearby kwi-a. wolfgang abel, who, as mentioned above, had undertaken a "study trip" to romania in / in order to examine the roma living there with regard to "the question crossbreeding," established contact with ritter in march in order to draw his attention to the supposed importance of fingerprints in differentiating between "purebred gypsies" and "gypsy mixed-breeds". at abel's instigation, from this time forth the anthropological files of the sinti and roma collected by the "mobile working groups" of the research office also included fingerprints, which were registered by the police as a matter of routine. at the beginning of world war ii, two doctoral students and scientific staff members of the kwi-a moved to ritter's research office: adolf würth, as mentioned above, had earned his doctorate under eugen fischer in with a dissertation on the emergence of flexion creases on the human palm. immediately thereafter, würth, who had also been interested in the "gypsy ques , ritter's "right hand," obtain her ph.d. in . after training as a nurse, justin had begun work as an intern in ritter's genetic biology laboratory at the university of tübingen clinic in . in the race hygiene and population biology research office she effectively acted as ritter's deputy. in she registered as a student at the university of berlin, where she supposedly studied anthropology, genetic psychology, race hygiene, criminal biology, and ethnology -although she could not provide evidence of a methodical program of study when she registered for her doctorate in . she had accepted a dissertation topic proposed by kurt gottschaldt, but then changed it without consulting gottschaldt, and then on her own, so to speak, written her dissertation about "the fates of gypsy children raised as aliens and their progeny." upon fischer's recommendation, on the basis of this dissertation she was permitted to register for the doctorate with a major in anthropology and minors in ethnology and criminal biology. fischer, ritter, and the ethnologist richard thurnwald ( - ) passed the dissertation, which quite obviously did not meet basic scientific standards. the oral examination by fischer, abel, thurnwald and ritter took place on march , in ritter's private residence. why fischer, abel, and thurnwald were willing to issue positive evaluations as an obvious favor to ritter becomes clearer upon perusal of justin's references: the documents include letters of recommendation from hans reiter, president of the reich health office; herbert linden, hitler's reich deputy for sanatoriums and hospitals, one of the key figures in the ns "euthanasia" program; as well as the ministry official paul werner , deputy director of the reich criminal police department, responsible for "preventative crime-fighting," "gypsies," "juvenile delinquency" as well as concentration camps for juveniles, and who had assisted the "euthanasia" planning staff by procuring medications for the murder of patients. justin's dissertation picked up directly on the debates about the "limits of educability" underway since the s in the area of corrective training. she subjected sinti children, who were accommodated in the catholic st. josefspflege home in mulfingen/württemberg, because their parents were interned (most of them in the concentration camps at buchenwald and ravensbrück), to "psychological" tests. on may , , months after justin's dissertation appeard in print, the children were deported to auschwitz-birkenau -only four survived. also in , georg wagner ( * ) submitted his dissertation about "race biology observations on gypsies and gypsy twins." the trained farmer had spent the years from to abroad, where he apparently worked as a correspondent for german newspapers and as a "nationalist political writer." in he began studying natural sciences at the university of berlin. he must have joined up with ritter's research office shortly thereafter, for the material upon which wagner's dissertation was based had been collected in the framework of the total inventory of the sinti and roma in germany and the occupied territories initiated by ritter. as such, wagner -like eva justin -was at the same time an employee of ritter's research office and a doctoral student at the kwi-a. his doctoral research was advised by verschuer, although verschuer requested that fischer step in as the official doctoral advisor for wagner, whom he described as "a somewhat peculiar fellow." in the introduction to his dissertation wagner proudly remarked "that for the examinations of the probands around , km had to be traveled, and over locations of the old reich and the protectorate had to be visited." he had examined persons and categorized them according to ritter's classification system. he characterized the "pure gypsies" as the descendants of the aryans. thus, wagner was the right man for the ss ahnenerbe, which was searching for a scientist to "research the gypsy attributes derived from aryans" in november . on behalf of the ahnenerbe and with the consent of arthur nebe ( - ), head of the reich criminal police department until , wagner settled in königsberg, intending to survey the "gypsies" in latvia, estonia, lithuania, and finnland first, and to visit the "gypsy settlements" in the białystock district. hence, wagner, despite an unmistakable fondness for the "pure gypsies," was party to creating the scientific foundations for the extermination of the sinti and roma. wagner was still working on his research project in march/april . on this joachim s. hohmann fittingly remarks, "apparently wagner was to merely record the evidence of life of an ethnic minority sentenced to extinction, before its genocide was completed. that he obstinately continued working on this just days before the end of the war is presumably one of the many paradoxes of the racist 'third reich'." wagner drew the attention of twin researchers to the sinti and roma, as he had examined "gypsy twins" himself as part of his dissertation, and had reached the conclusion that twin births occur nearly twice as often among sinti and roma than in the remaining population. wagner reported to his colleague karin magnussen about "gypsy twins" among whom he had noticed certain eye anomalies -wagner's scientific curiosity brought these people directly to their death. dahlem and auschwitz josef mengele, with a dissertation about "family examinations in cases of cleft lip, cleft jaw, and cleft palate." mengele proceeded from a group of children with cleft lip, cleft jaw and cleft palate, who had undergone surgery at the surgical clinic of the university of frankfurt/main between and . for these children mengele produced "family tables" covering a total of , "clan members," of whom mengele visited personally. he had the remainder examined by their local health offices. the genetic evaluation of the genealogical material, as mengele summarized his results, made it possible "to recognize an irregular, singly dominant heredity of the disposition, whereby the manifestation depends on other developmental disorders" -among others, mengele mentioned serious defects of the limbs, the lack of a closed spine and closed cranial bones, "as well as feeble-mindedness and mental disorders." in addition, mengele established the frequent occurrence in the families he examined of rudimentary forms of clefts in the area of the lips, the jaw and the palate, which suggested strong variations in the manifestation of the gene. mengele's work made an important contribution to the elucidation of the disputed question as to the heredity of cleft lip, cleft jaw, and cleft palate, whereby the evidence of variations in manifestation fit in well with the recent findings of higher mendelism. moreover, the work was located in the area of arrested development malformations, in which a certain embryonic state of development remains intact, even when development ceases prematurely. such arrested development malformations were of central interest under the aspect of phenogenetics, however -mengele's later attachment to the kwi-a was due not only to his personal relationship with verschuer, but also predisposed by his research emphasis. the "cum laude" dissertation met the scientific standards of the time and was published in in the renowned zeitschrift für menschliche vererbungs-und konstitutionslehre. it immediately attracted considerable attention, not only on the national, but also on the international level, after verschuer referred to mengele's findings in his paper at the international congress for genetic science in edinburgh. well into the s mengele's dissertation was well-received internationally and considered to be the standard work on its topic. until mengele published several short articles and reviews in verschuer's journal der erbarzt. interesting to note is that he worked not only in the field of hereditary defects, but also undertook an excursion into neurology: after the death of the assistant ottwil reichert in , mengele completed reichert's genealogical study "on the heritability of thrombangitis obliterans"(today: thrombangiitis obliterans, winiwarter-buerger disease), which was oriented toward the question of the heritability of rheumatism. mengele also produced expert opinions in frankfurt. verschuer even entrusted him with the scientific evaluation of the comprehensive material that accrued in the "certificates of race and descent." in one case this yielded a short genealogical study on the heredity of fistula auris congenita (branchiogenic syrinx, a special form of the cervical syrinx). whether mengele was actually verschuer's "pet pupil," as hans grebe asserted in the s, remains to be seen. certainly verschuer saw in mengele great promise for the future. it was verschuer's suggestion that mengele attend the international congress for anthropology and ethnology in copenhagen in , and the international congress for genetics in edinburgh in -and that in both cases mengele was not able to participate was due to foreign exchange difficulties, but changed nothing about verschuer's special esteem, which left no doubt that the young scientists included in his list of proposals were the only ones who came into question for him as future university instructors. the judgement of benoît massin, that mengele, had there been no war or had germany not lost the war, in all probability would have made the leap to a professorial chair -like his associates in frankfurt, ferdinand claußen, heinrich schade, and hans grebe -must be confirmed wholeheartedly. it was probably mengele's tremendous ambition that led him into the temptation to take a shortcut against the background of world war ii to drive his career forward more quickly and further than his associates, by unscrupulously taking advantage of the unfettered access opened up to him by the world of the national socialist camps. his close connections to the ss constituted free admission to this world. from to mengele was a member of the stahlhelm; after this organization was subsumed by the sa he remained a member until october . in he joined the nsdap, in , the ss. called up to the wehrmacht in , mengele volunteered for the waffen-ss, where he was assigned to the medical corps inspection office. in november he was transferred to the rusha, where he worked in department ii of the family office, responsible for "care of genetic health" and "genetic health tests." what his job was and where he was deployed has yet to be clarified conclusively. presumably, for a time at least, he wrote expert opinions about the "germanizationability" of "german national" resettlers at an office of the reich commissioner for the fortification of german volkstum in posen. in late /early mengele was sent to the eastern front with the ss division "viking," after he had been promoted from ss-untersturmführer (lieutenant) to obersturmführer ( st lieutenant). during his military deployment he received the iron cross, nd and st class, the eastern campaign / medal and the kriegsverwundetenkreuz (germany's purple heart), nd class with swords. in july -probably due to a wound -mengele was transferred to the office of the "reich physician ss and police" ernst grawitz in berlin, i.e. to the office responsible for oversight of the concentration camps and the human experiments performed there. it is questionable whether he actually reported for service there, however, for he apparently remained with the "viking" division -perhaps he was posted to the "viking" division by the reich physician ss and police. in any case he was still on the rolls of this unit as physician for the troops in october and recommended for a further promotion. he also participated in the battle of stalingrad. as proceeds from a letter by verschuer to fischer of january , , mengele did not return to berlin until early : a few days ago my assistant mengele flew days long from salsk [a city east of rostow on the don] to germany. he took part in all of the battles with the ss division viking, was decorated with the iron cross and has been transferred to an office here in berlin for the time being, so that he can also be active at the institute in addition to his duties there. in february mengele was assigned to the ss infantry substitute batallion "east," which was stationed in berlin. he used his time in berlin -from late january to late may -to consolidate his relationship with his doctoral advisor verschuer. as mentioned above, verschuer already had the intention of bringing mengele to dahlem once he had established himself there. at the institute mengele was apparently regarded as a guest scholar, although he did not sign a regular employment contract with the kwg. his name appeared on an internal list of birthdays, apparently as a matter of course. as also mentioned above, verschuer again entrusted him with expert opinions. however, the official version was that mengele was on combat leave from the university of frankfurt/main until the end of the war -the position as a regular assistant under verschuer's successor heinrich personnel command of / / (signed by siegfried liebau), ibid., p. . recommendation for promotion of / / by battallion commander schäfer of ss pioneer dept. , a sub-division of the ss division "viking," ibid., p. . mengele was not deployed in stalingrad (as stated in kröner, von der rassenhygiene zur humangenetik, p. ), but took part in the battles around stalingrad. wilhelm kranz was reserved for him. nevertheless one may presume that mengele saw his future in berlin. verschuer certainly regarded him as a candidate for professorship, and it probably can be assumed that the two discussed possible topics for his postdoctoral dissertation during mengele's stay in berlin. on may , mengele, who had been promoted to captain of the reserves of the waffen-ss shortly before, was transferred effective may , to the ss main economic and administration office, group d iii (medical care and camp hygiene for concentration camps) and sent to the auschwitz concentration and extermination camp, where he worked as executive camp physician in the "gypsy camp" (section b ii e auschwitz-birkenau). whether mengele was assigned to auschwitz through no fault of his own, or, as verschuer claimed after the war, against his will, or whether, on the contrary, he took steps himself to effect a transfer to auschwitz, and whether verschuer pulled some strings -these questions cannot be answered conclusively based on today's state of knowledge. ulrich völklein argues that mengele ended up in auschwitz more or less by coincidence: the ss physician initially assigned to the "gypsy camp" at auschwitz-birkenau, benno adolph , had fallen ill with scarlet fever in april and was unable to work until november -thus a short-term replacement was sought, and mengele was available at the time. völklein can support his argumentation with the fact that mengele's transfer orders expressly noted "reference: none." this can be assessed as a certain indication that no written transactions existed. in other words: a voluntary enlistment by mengele in written form was in all probability not submitted. but this was not absolutely necessary. it cannot be excluded that mengele -possibly with verschuer's support -contrived behind the scenes for a transfer to auschwitz. this is the gist of benoît massin's argument, whereby he assigns a key role to siegfried liebau and even alleges that there was an "alliance between verschuer and the ss" arranged by liebau. it is documented that liebau, in his capacity as head of the personnel division in the office of the waffen-ss medical corps, signed the order of july , which provided for mengele's transfer from the "viking" division to the "reich physician ss and police." also documented is the fact that liebau, at verschuer's request, was detached to the kwi-a for specialized training from december to october and thus present there in the period when mengele was a regular guest at the institute. finally, it is also documented that liebau spent the first half of there before mengele's transfer to auschwitz -and brought with him photographs of a "gypsy clan" with heterochromous eyes for karin magnussen. massin finds support for his theory in a statement by hans münch ( - ) , who was the director of the ss hygiene institute in auschwitz from to and worked closely with mengele in this capacity. münch, as he stressed later in an interview with robert jay lifton, had the impression that mengele had "requested his transfer to auschwitz, apparently because of the great research possibilities." münch further testified that mengele had worked on a postdoctoral project in auschwitz -and this claim, regardless of how mengele ended up at auschwitz, can arrogate a high degree of probability. in retrospect münch described mengele's mentality with the words, "it would be a sin, it would be crime … that it was irresponsible not to take advantage of the opportunity presented by twin research in auschwitz. if they were going to be gased anyway … this comes around only once, this chance." regardless of whether mengele caught wind of this chance on the basis of information from the office of the "reich physician ss and police" and thus actively instigated his transfer to auschwitz, or whether he did not recognize this chance until he reported for duty -it is clear that mengele unscrupulously exploited the opportunities presented to him there. before long he built up his own research empire. from among the prisoners, he recruited a group of medical specialists for pathology, pediatrics, gynecology, ophthamology, ear, nose and throat medicine, and dentistry, along with technical assistants, nurses, kindergarden and nursery-school teachers, and secretaries. mengele's laboratory barracks in the "gypsy camp" -after its liquidation the laboratory was moved to block in section b ii f of the camp -was directed by the internationally respected pediatrician berthold epstein ( - ) from the university of prague, supported by charles sigismund bendel from the university of paris. for the analysis of blood, urine, feces, saliva and tissue, mengele had the ss hygiene institute in rajsko at his disposal. but above all, the selection of new arrivals on the platform gave him unlimited possibilities to access humans completely devoid of rights and protection. from the endless stream of deportation trains he could single out any human "guinea pigs" he pleased -jews, "gypsies" and other "alien nationals," people with so lifton paraphrased münch's testimony. lifton, Ärzte, p. . quoted in ibid., p. (original omissions). this also explains mengele's obsession, who -in contrast to his colleagues -often came to the platform even when he was not on duty. ibid., pp. - . cf. kieta, hygiene-institut. physical anomalies, entire families and, best of all, twins. mengele created a "twin camp" in auschwitz, the sheer population of which exploded all dimensions previously known. the exact number of twin pairs that fell into his hands in auschwitz is unknown -massin estimates that at least children went through mengele's "twin camp." moreover, twin research under the conditions of the auschwitz concentration and extermination camp presented the unique opportunity to supplement the clinical and anthropological examination of twins with the pathological examination of their corpses, as mengele could murder, or have murdered, both twins at any time. miklós nyiszli already pointed out this circumstance: an event never before experienced in the history of medicine worldwide is realized here: twins die at the same time, and there is the possibility of subjecting their corpses to an autopsy. where in normal life is there the case, bordering on a miracle, that twins die at the same place at the same time? […] a comparative autopsy is thus absolutely impossible under normal conditions. but in the auschwitz camp there are several hundred pairs of twins, and their deaths, in turn, present several hundred opportunities! massin characterizes mengele's research empire at auschwitz as the "auschwitz branch office" of the kwi-a. i find this analysis problematic for two reasons. first, it suggests a formal institutional connection, which certainly did not exist in this form -mengele's position in auschwitz did not at all correspond to diehl's position in sommerfeld. secondly, massin's interpretation constructs all too great a dependence of mengele's on verschuer. certainly: mengele's interests in twin research, in chondrodysplasia, in physical defects and in eye anomalies were oriented toward the model of the frankfurt institute for genetic biology and race hygiene, according to which the institute in dahlem was also reorganized from on. even his interest in noma facies (gangrenous stomatitis, water cancer), a rare deficiency disease caused by extreme hunger, which raged among the children in the "gypsy camp," presumably had a genetic pathology background. in this case mengele probably continued with his mentor verschuer's research strategy of scrutinizing all kinds of forms of disorders -from cancer to tuberculosis, to diabetes, to diptheria, and pneumoconiosis -to see if they were hereditary. this orientation is ultimately not surprising. mengele shaped his own research empire in accordance with the institutes at which he had worked before, but in auschwitz he was his own master. on the other hand it is indisputable that mengele, at his outpost in the no-man's-land of the world of national socialist camps, was interested in being integrated into the scientific community and sought contact and collaboration with other scientists and research institutions -consider, for instance, his pharmacological investigations for massin, mengele, p. , points out that auschwitz, in contrast to all other concentration camps, had sections of the camp in which entire families were imprisoned together: the "gypsy camp" (from february until late july ) with around , inmates and the "family camp" for the jews from the theresienstadt ghetto (from september to july ) with more than , inmates. this was an essential aspect for a scientist interested in "family research." ibid., pp. f. i.g. farben. his most important cooperation partners by far, however, were and remained verschuer and his group of researchers in dahlem (all the more so if the assumption is correct that mengele intended to write his postdoctorate dissertation under verschuer). in any case mengele upheld contact with verschuer from auschwitz, and paid at least one visit to the institute in dahlem during this time -in his memoirs based on his diary of the time, gerhard koch reports meeting mengele sometime around july in the kwi-a library. in at least two cases this contact resulted in concrete collaboration: in the first case, in / , mengele delivered the heterochromous pairs of eyes belonging to several members of a sinti family to karin magnussen, on the other, between october and märz , he joined in verschuer's "specific proteins" project, providing his mentor with around blood samples from persons of various races. as the prisoners' physician miklós nyiszli reported, mengele was also interested in inmates with growth anomalies ("dwarfism" or "gigantism") or physical defects. according to nyiszli, mengele picked out such persons during the selections on the platform, and then had his assistants examine, kill and dissect them. mengele ordered that some of the specimens obtained from these autopsies be sent to dahlem: the scientifically interesting parts of the corpse are preserved, so that dr. mengele can take a look at them. i have to keep anything that could be of interest to the institute in dahlem. these specimens then come into a package for the journey, and a special stamp sees to it that it is dispatched more quickly: 'urgent, contents of strategic importance for the war.' during my stay at the crematorium i expedited countless packets of this kind to berlin-dahlem, in response to which extensive replies with scientific opinions or instructions came in. i put together a special dossier for the purpose of storing this correspondence. for the rare materials we sent, the institute almost always expressed its deepest thanks to dr. mengele. elsewhere nyiszli depicts the case of two jews, father and son, who were deported to auschwitz on a train from the Łódž ghetto and had piqued mengele's scientific interest. the father suffered from scoliosis as a long-term consequence of rachitis, the son from hypomelia (a disorder that affects the development of the limbs). after a clinical examination, mengele had them murdered and commanded that "the skeletons [must be] dissected and sent to the anthropological museum in berlin'." on the basis of this testimony, the authenticity of which is estimated to be very high, there is the suspicion that mengele's deliveries to dahlem took place on a large scale, and that not only eyes and blood, but also internal organs and skeletons found their way to the kwi-a. the most likely recipients are hans grebe and wolfgang abel: grebe as a specialist for chondrodysplasia and physical defects, abel with his plan for an "instructive collection for the race history of europe." in addition to mengele, two other scientists connected with verschuer's institute worked at auschwitz. one of them was siegfried liebau, who performed research on "gypsy" twins in auschwitz during the period when he was detached to dahlem for further training -as mentioned above, he may have been the one who initiated the contact to auschwitz and arranged for mengele's transfer there. the other was the ss-obersturmführer and physician at the ss military hospital in berlin-lichterfelde, erwin von helmersen , who took his doctorate with fritz lenz in august , with a dissertation on "the descendants of an armenian family in a village of the bukovina settled by germans." helmersen had been listed as a doctoral student since , and thus was connected with the kwi-a at the same time mengele was spending time as guest scholar there. after receiving his ph.d., followed by a short assignment in the oranienburg concentration camp, helmersen went to auschwitz, where he worked as camp physician in the "gypsy camp" in section b ii e and in the prisoners' hospital b ii f. helmersen, who was also involved in medical experiments at auschwitz, was thus one of mengele's subordinates for a time. consequently, a network of lines emerge connecting dahlem and auschwitz, which cannot yet be tracked down into its finest nooks and crannies on the basis of the contemporary state of research. clear is that magnussen received from mengele a series of pairs of eyes for her "eye color" project, and verschuer around blood samples for his "specific proteins" project. it is also clear that the two "not only knew of the provenance of these specimens, but that, in this knowledge, they used their contact to mengele in order to obtain these specimens." what is not clear, however, is the question as to whether they knew under what circumstances and in what manner the specimens were extracted in auschwitz. during interrogation by the american military authorities on may , , verschuer denied that he had known about the events in auschwitz, but did admit to having heard the rumors abounding at the time. during a visit by mengele, verschuer testified further, he had asked mengele "just to explain if there was actually anything true about these rumors." in response mengele had reported "about factories located there, his camp hospital, the excellent harmony that existed between him and his patients." "he knew absolutely nothing about inhuman treatment or any other kinds of atrocities." whether mengele completely denied the industrially mass murder perpetrated in auschwitz, or simply let the matter rest with these sinister intimidations, it is highly improbable that he confronted his collaborative partners at the kwi-a with the whole truth. however, it can also be assumed that they did not harry him to do so. they certainly knew enough to not want to know more. in general it can be said -with all due reservations -that only a few germans knew everything about the "final solution," but likewise, only very few knew nothing at all. those working at the kwi-a certainly did not know everything, but quite a bit indeed: "in hardly any other scientific institution in germany," in the judgement of carola sachse and benoît massin fittingly, "could access to knowledge about the crimes in auschwitz have been so easy […] ." as discussed extensively elsewhere, the genocidal character of the "total solution of the jewish question" must have been altogether clear to fischer and verschuer. further, fischer was familiar with the details of the generalplan ost, for which the extermination of the eastern european jews was a prerequisite. beyond this, the kwi-a enjoyed excellent connections to the rusha through herbert grohmann, günther brandt and helmut thieme. at least two scientists who worked at the kwi-a, harry suchalla and christian schnecke, knew about the crimes against jews in occupied Łódz´ . siegfried liebau, josef mengele, and erich von helmersen amounted to three scientists with contact to the kwi-a who actually worked at auschwitz. wolfgang abel, too, had indirect contacts at auschwitz, and perhaps at the sachsenhausen concentration camp as well, but in any case he had insight into the stalags for soviet prisoners of war. karin magnussen was born in bremen in . her mother was a sculptor, her father a teacher at the bremen school for applied arts. after graduating from secondary school, in she began studying biology, chemistry, geology, and physics -still quite unusual for a woman at the time -at the university of göttingen. in she spent two semesters at the university of freiburg, where she was influenced above all by the lectures of the developmental physiologist hans spemann. in , back in göttingen, she took her doctoral examinations in the subjects zoology, botany, and geology. her dissertation, entitled untersuchungen zur entwicklungsphysiologie des schmetterlingsflügels ("studies on the developmental physiology of the butterfly wing") was advised by alfred kühn and published in . this work concerned artificially induced defects in the rudimentary origins of the organs in caterpillars and their effects on the patterns and pigmentation of the fully developed butterfly wing -the influence of spemann and kühn is obvious. göttingen had been a stronghold of national socialism of the first hour, and the student body in göttingen was particularly involved in the earliest successes of the nsdap in the university town. walter groß, who had been involved in the very sachse/massin, forschung, p. . for the basics on the following: hesse, augen, pp. - ; klee, medizin, pp. - . magnussen, untersuchungen zur entwicklungsphysiologie. tollmien, nationalsozialismus in göttingen; dahms, universität göttingen, p. . founding of the göttingen branch of the nsdap back in , one of the first in northern germany, established a university group of the national socialist league of german students (nationalsozialistischer deutscher studentenbund) in göttingen in / . the students in göttingen who were active in the party included rudolf mentzel -as district leader of the nsdap -, who became president of the german research association in ; and achim gercke, the organizer of the "archive for race science statistics on professions" (archiv für rassenkundliche berufsstatistik) who later became "race science expert" (sachverständiger für rasseforschung) to the reich minister of the interior before advancing to the top of the reich genealogical office. magnussen found admittance to this network during her days as a student in göttingen. in she became a member of the nsdap -this, too, highly unusal for a woman, as only very few women joined the party at this time -and was active in the national socialist league of german students. her associates later remember that magnussen had attracted notice in göttingen as a "fanatic national socialist." after the nazis took power she resolutely pursued her party career. in she became a member of the bdm, for which she held training lectures about race and demographic issues in the district of bremen. from on she was also an employee of the race policy office of the nsdap in the district of hanover. magnussen apparently also had contact with the bremen branch of the german society for race hygiene under its chairman, the lecturer hans duncker ( - ) since the weimar republic. in this framework, magnussen may even have experienced the greats of weimar eugenics first hand -fritz lenz, hermann muckermann, eugen fischer, and otmar von verschuer -all of whom held lectures to the bremen branch. there is no doubt that karin magnussen was a fervent national socialist, race hygienist and anti-semite. in -barely years of age -she published her -page book rassen-und bevölkerungspolitisches rüstzeug ("the munition of race policy and population policy"). the third edition appeared in , now swollen to pages. the tract, which propagated "population statistical and race statistical material" and discussed relevant "legislative measures," was conceived -as stated in the preface to the first edition -as an overview for "biology teachers and trainers for instruction in the graduating classes and for race biology training." in the author designated the solution of the "jewish question" as the "core racial problem in europe": emigrants merely breed unrest and incite the völker ("nations") against each other. […] the race policy goal of this struggle of nations thus must be: the spatial separation of the european races and nations from all aliens (jews, gypsies, negroes) […] . with her book magnussen supplied an apparent basis of scientific legitimation to the national socialists' gigantic deportation program, which reckoned with the decimation of the deported from the very outset. in december magnussen passed the state examinations for secondaryschool education in the subjects biology, chemistry, and geology and began teaching. her last position -from to -was as a secondary school teacher in hanover, in line for a civil service post. on september , she began her work at the department for experimental genetic pathology at the kwi-a -initially as a scholarship student. none of the details of the circumstances of her hiring are known. hans hesse conjectures that she was hired "because of her old connections and early party membership." walter groß, whom she knew well from her days in göttingen, had played an important role on the board of trustees of the kwi-a since , as discussed previously. hesse further assumes that the drafting of male employees to the wehrmacht had created gaps in the scientific staff that were difficult to close, so that eugen fischer had been forced to appoint a "woman and not particularly established scientist." this thesis can be concurred with only in part. that political protection played a role in magnussen's appointment may well be true. that a woman was hired and entrusted with a research project central to the conception of the institute, however, was not as rare an exception as hesse apparently assumes, even before -remember rita hauschild. what is least true of all is the assumption that karin magnussen was not sufficiently qualified for her post at the kwi-a. true: she had worked years as a teacher, far removed from research. but for eugen fischer she was nevertheless a very interesting candidateespecially against the background of the paradigm shift to phenogenetics: the complex interplay of genes and environmental factors in the pigmentation of the iris constituted one of the central research fields in fischer's conception of phenogenetics, and he oriented his focus above all on alfred kühn's and adolf butenandt's research on the flour moth ephestia. a pupil of kühn, magnussen had worked on the influence of genes and pharmacologically effective agents on eye color, and after earning her ph.d. in july with butenandt as her advisor, worked on pituitary hormones. according to later testimony by magnussen, back in she was already researching the pigmentation of the eyes, and the phenomenon of heterochromia (the occurrence of two irises with different colors) in particular. in other words: magnussen was well-versed in a research field that was of the greatest interest to fischer in the course of restructuring his institute, and she had collaborated with the researchers to whom he had sought closer contact since . magnussen, rüstzeug, rd edn., pp. f. hesse, augen, p. . moreover, as a student in freiburg she had also learned from hans spemann the techniques of producing, dyeing and embedding microtome cuts. the new institute director otmar von verschuer also thought the world of magnussen, and gave her an assistantship in november , when she was unable to extend her leave from the school system. from that point on, magnussen was listed in nachtsheim's official reports as a staff member of his department for experimental genetic pathology, but nachtsheim neither went into her research in his annual report of / , nor did he include her works in the list of publications from his department -verschuer did this instead in his own report. it seems that nachtsheim and magnussen followed different paths in their research, although magnussen took up work in one of nachtsheim's main areas of research -in fact, she started at the kwi-a shortly after nachtsheim's eye research had begun stagnating as a consequence of his collaboration partner hellmuth gürich's being drafted. there are also numerous potential points of contact: both used rabbits as their animal model, both were interested in the pigmentation of the rabbit eye (nachtsheim's "epileptic" vienna whites had blue eyes as a consequence of a pigment deficiency), both directed their attention to the effects of the aging process on genetic attributes. yet their research projects, as far as we can tell, proceeded in parallel and without any connection: nachtsheim worked on genetic pathology in the strictest sense, while magnussen understood her work as a contribution to the phenogenetics of normal attributes. nachtsheim stated after the war that he had not wanted to work with magnussen because of her political views. he also claimed to know about her connections to auschwitz, which was the "greatest shock" he experienced during the third reich. in three of magnussen's progress reports of september , march and october , the contours of the research project "on the investigation of the heritability of the development of eye color as the basis for examinations of race and descent" became clear, which covered six different, clearly demarcated subareas: first, in preparation for all other subareas, as it were, magnussen dealt with methodological questions on the determination of the structure, color, and pigment distribution of the human iris. she published the results of this work in in der erbarzt. this clarification of preliminary methodological questions pertained directly to application: "in the paternity expert opinions, new experiences are being collected constantly and already obtained experience evaluated." in the very heading of her first research report magnussen had emphasized that her research, as applied genetics, was of importance for the praxis of national socialist race policy. it can be presumed that in magnussen's case this was more than the rhetoric necessary to get a research application approved, and that she placed her research at the service of national socialist race policy out of true conviction. but this was only one side of the coin: her research on eye pigmentation was also, and above all, conceived of as theoretical research, as an important building block of phenogenetics. second, magnussen bred strains of rabbits with certain eye colors "for the purpose of determining the influence of certain hereditary dispositions on eye pigmentation." the animals were under constant observation so that the development of pigmentation could be followed over time. from the report of october it is clear that magnussen was also busy with "breeding for the investigation of heterochromia." third, magnussen performed experiments on rabbits "to physiologically influence pigment development." this project was initially delayed by the war. "the series of experiments planned," magnussen reported in september , "could not be performed, since the compound required, which is manufactured in hamburg, was lost in the terrible attack […] ." in october magnussen was able to report on the first results of these experiments: during the main breeding period in the summer months, several series of examinations on the physiology of pigment development were performed, in which the action of several hormones and pharmacologically effective substances on the development of pigment in the eyes of different races was studied. here certain races whose pigment development showed certain similarities with that of humans, the influence of such substances was determined and thus the foundation laid for larger series of experiments in the coming year. it is no longer possible to reconstruct which substances were used in these series of experiments -possibly a conversation which magnussen conducted with adolf butenandt on december , concerned the question as to which hormones should be applied in the animal experiments. it proceeds from an essay fragment -which presumably originated in -that magnussen dropped adrenaline into the eyes of several chinchilla rabbits in experiments performed privately from to , as well as the extraneous substances physostigmine, atropine, and doryl. magnussen, bericht über die durchführung der arbeiten zur erforschung der erbbedingtheit der entwicklung der augenfarbe als grundlage für rassen-und abstammungsgutachten, / / , ibid., p. . magnussen, bericht über die durchführung der arbeiten zur erforschung der erbbedingtheit der entwicklung der augenfarbe als grundlage für rassen-und abstammungsgutachten, / / , ibid., p. . magnussen, bericht über die durchführung der arbeiten zur erforschung der erbbedingtheit der entwicklung der augenfarbe als grundlage für rassen-und abstammungsgutachten, / / , ibid., p. . in summer the studies about the pigment development in childhood and the required genetic inquiry among the families could be performed only on a smaller scale than previously, due to the drafting of fathers for military service and the evacuation of children. yet the observations are still in progress and, as soon as the situation in the air permits, will be continued on a larger scale. […] as the start of a larger series of observation series, serial examinations about iris structure and eye pigmentation were performed on over , children in holstein. half a year later she sounded less optimistic: "the remaining observations of humans had to be discontinued for a time for reasons concerned with the war, but are to be resumed in summer, to the extent possible." in addition to the serial examinations in holstein (eutin), two further were performed in baden (wolfach) and upper bavaria (mittenwald), and moreover "in eutin and mittenwald family studies to investigate the heredity of certain structural attributes […] (especially important for opinions on descent)." further studies of schoolchildren planned "in several cities of the reich" had to be discontinued in september , since they were not categorized as of strategic importance, and because "by no means [were] they to interfere with lessons." magnussen's research report of october shows that, once the serial examinations of the german population had been disrupted, magnussen intended to start a parallel study in the world of the national socialist camps: "the first series of observations of alien nations in a prisoner of war camp, planned as a comparison with the german population, was prevented by enemy operations. further series of magnussen, bericht über die durchführung der arbeiten zur erforschung der erbbedingtheit der entwicklung der augenfarbe als grundlage für rassen-und abstammungsgutachten, / / , barch. koblenz, r / . , p. . magnussen, bericht über die durchführung der arbeiten zur erforschung der erbbedingtheit der entwicklung der augenfarbe als grundlage für rassen-und abstammungsgutachten, / / , ibid., p. . magnussen, bericht über die durchführung der arbeiten zur erforschung der erbbedingtheit der entwicklung der augenfarbe als grundlage für rassen-und abstammungsgutachten, / / , ibid., p. . on this also, verschuer to fischer, / / , mpg archive, dept. iii, rep. a (münster), no. : "miss magnussen was just here. she performed iris examinations of schoolchildren in eutin (schleswig-holstein) and collected very interesting findings. it is necessary for her to examine populations in germany of different racial composition in the same manner. presumably she will best find the alpine groups in the black forest. i am writing to my sister in wolfach, which seems to me a suitable location. studies of this kind are planned for the coming months." at the current state of knowledge we have no more details about this first serial study in a war prison camp, for which there were already concrete plans, but which never took placewhich camp was involved, who the prisoners were whose eyes were to be measured, in what manner and with whose help magnussen intended to gain access to the camp. neither do we know whether such studies ultimately did take place in other camps and, if so, what happened. the fifth subarea of magnussen's project was histological, in which she dissected the eyes of rabbits, and of humans as well, in series of microtome cuts. as proceeded from the progress report of september , this area had high priority: at the moment, primarily the histological works are being performed, so that the irreplaceable material is processed and thus not subjected to the risk of loss due to long storage. from this emerged a paper "about the relationships between iris color, histological pigment distribution and the pigmentation of the bulbus in the human eye," which was completed in , but not published until . for this study magnussen used the eyes of " subjects from central europe" and compared them with "specimens from the institute's collection, of the dissected eyes of colored races and of a papuan eye." magnussen failed to make any mention of who those people from central europe were. hans hesse suspects that they could also have been concentration camp inmates. in procuring her material, magnussen had few scruples: according to benoît massin's account, magnussen also worked on the eyes of people who were murdered by the gestapo and made available to the anatomist hermann stieve ( - ) in berlin. by the way, it is equally unclear where the dissected specimens of "races of color" contained in the institute's collections came from, which magnussen studied comparatively. sixth and finally, magnussen was interested in anomalies of the eye, such as corneal conjunctivalization, but above all heterochromia. in october she magnussen, bericht über die durchführung der arbeiten zur erforschung der erbbedingtheit der entwicklung der augenfarbe als grundlage für rassen-und abstammungsgutachten, / / , ibid., p. . magnussen, bericht über die durchführung der arbeiten zur erforschung der erbbedingtheit der entwicklung der augenfarbe als grundlage für rassen-und abstammungsgutachten, ibid., p. . magnussen, beziehungen. cf. also idem., beitrag. magnussen, beziehung, p. . massin, mengele, p. . the "papua eye" had been provided to magnussen by eugen fischer. magnussen had established corneal conjunctivization in several animals of one strain of rabbits from nachtsheim's breeding experiments. at the same time, georg wagner, in his examinations of "gypsy twins" apparently discovered in east prussia two "clans" of "gypsy half-breeds of predominantly gypsy descent" in which this anomaly occurred with unusual frequency (wagner, partielle irisfärbung, pp. , ). thereupon magnussen systematically investigated a series of human eyes provided by hermann stieve for the occurrence of this anomaly and found several cases. she also found "during the systematic investigation of the eye specimens of colored races at the institute […] a corresponding tissue fold in a negro." she concluded that the conjunctivization "is propagated more widely announced: "a paper about the histology of total heterochromia in humans is about to be concluded." this work had become possible through one of the most monstrous medical crimes by josef mengele in the auschwitz concentration and extermination camp. in "a member of the institute's staff who worked on criminal biology issues" -from another source it is clear that this meant georg wagner -, in one of the "mixed-breed gypsy clans" he had examined, which also included several pairs of twins, established an increased frequency of heterochromia, "in addition to other supplementary findings interesting in terms of genetic biology." it is highly probable, as hans hesse convincingly portrayed, that the family in question was that of the sinto otto mechau of oldenburg. verschuer commissioned magnussen with the task of taking on the "genetic biological analysis" of this case of heterochromia. to the institute director, this sinti clan must have seemed a rare godsend in several respects at once: first, as mentioned above, heterochromia represented an extremely interesting anomaly within the phenogenetic concept, which promised information about the way gene action chains worked in phenogenesis. second, in this case -as a consequence of the complete inventory of sinti and roma aspired to by the "reich central office of gypsies" and the "race hygiene research office" -it was possible to create a complete family table, clarify the genealogical relationships of the "clan" and thus and occurs in various races" (magnussen, hornhautüberwachsung, p. possibly obtain conclusions about the heredity of heterochromia. third, because the sinti and roma were "locked up" in "gypsy collection points," the test subjects were together at close quarters and -even more important -in the completely lawless area in which sinti and roma were now compelled to live, there were practically unlimited possibilities for access. the scientists could thus perform all examinations and collect all data they liked -even against the will of the affected. fourth, the circumstance that this family included several pairs of twins with heterochromous eyes presented a truly unique opportunity to combine family and twin research in order to investigate the developmental physiological events in the emergence of heterochromia. for this, however, an imperative prerequisite was the histological examination of the heterochromous eyes of the twins -and that meant: the death of these children. fifth, it must have seemed an advantage that the affected family was also the object of criminal biology research -as such, supposedly genetic physical stigmata like heterochromia or deaf-muteness potentially could be linked with supposedly genetic social deviance. sixth, the circumstance that the family was classified in the group of "gypsy half-breeds" built a bridge between phenogenetics and race research, and race diagnostics in particular. thus it is no surprise that verschuer strived to obtain additional financing from the german research association for this central research project. clear is that magnussen performed eye examinations of members of the mechau family before their deportation to auschwitz in march . after the war she gave contradictory accounts about the exact course of events. in her interrogation by the bremen denazification commission on may , she testified: "in spring i took my own photographs of the eyes of such twins at the institute in dahlem, before the twins ended up at auschwitz." a short time before, on march , , in contrast, magnussen had written in a letter to viktor schwartz, an associate of alfred kühn's: the only thing i got to see of the entire clan was two young boys without an eye anomaly, for all of the clans were interned around that time, namely in auschwitz. since civilians were not admitted, any inspection of the people was made impossible during the period of their prophylactical internment. i had a "criminal" twin researcher, who was allowed to visit the camp in his capacity as a officer of medical corps, bring me back color photographs of a number of the people at the time, so that i had a small foundation, but it was very imprecise." the officer of the medical corps described here ironically as a " 'criminal' twin researcher" was, as mentioned above, siegfried liebau. at the time i had seen only one pair of twins from this clan, which had come to the institute in dahlem for the doctoral student [wagner] . i was able to photograph the eyes of both children on this occasion. at the time it was said that these twins (like a major portion of this clan already) were supposed to be sent to an internment camp. at the time i was told that antisocial clans were to be interned in this camp for the duration of the war as a preventative measure. thus, it is probable that magnussen herself photographed the (homochromous) eyes of one pair of twins from the mechau family, which georg wagner had brought to the institute in dahlem for examination before their deportation to auschwitz in march , and that she received additional photographs of the (heterochromous) eyes of members of the family in auschwitz from liebau. through had i not heard from prof. von verschuer that a previous associate of his [mengele] had been ordered to the camp as a physician, i would have been able to base the further genetic biology of the attribute only upon police files. through this colleague, who recorded the attributes precisely and compiled the family tables, i learned that a part of the clan was contaminated with pulmonary tuberculosis, above all a family with children. in her written testimony from magnussen went into this point in greater detail: my demand to be able to visit the remaining members of the clan in the camp was rejected as impossible. at that time i was forced to conclude that women were strictly forbidden mengele , who had been his assistant in frankfurt, and who had been ordered to the camp as a physician (officer of the medical corps). i did not know dr. m. at the time; i only knew from the literature that he worked in the field of genetics. during a visit to the institute in dahlem (summer ?) i made his acquaintance and discussed with him the possibility of performing the research task. i asked him first of all to make sure that this clan not be lost track of after the war, so that the research on this very rare mutation could then be continued intensively. the work of the geneticist is entirely dependent on the life of the carriers of the gene, who hand their genes down to the next generation. at the time dr. m. told me that a particularly important family was subject to tuberculous contamination (with children). everyone knew what that meant in those days, when there was still no remedy for pulmonary tuberculosis, especially for young people under years of age. thus i asked dr. m., whenever any of the carriers of heterochromia should die, to send me protocols of the autopsy and the pathological eye material for examination if possible, -just as i would have in any other case. magnussen's account cannot be confirmed, supplemented, or contradicted by other sources. as far as the framework of facts is concerned, it appears to be coherent and fits in logically with the reconstruction of the project on heterochromia: by this account magnussen, when the project slowed down as a consequence of the deportation of the mechau family, was alerted to mengele by verschuer. had mengele made efforts of his own to be ordered to auschwitz, and had verschuer known of these or even actively encouraged mengele's assignment to auschwitz, the tip to magnussen might have been issued before the posting was ordered on may , ; on the other hand, had verschuer been surprised by mengele's transfer he might have informed magnussen immediately after the command was issued. in either case it is conceivable that magnussen, even before menegele's departure from berlin to auschwitz, reached an agreement with him that he would compile the "family table" of the mechau family on location in the "gypsy camp" andpresumably using the eye-color table developed by magnussen -determine the eye color of the family members. otherwise such a deal must have been made during one of mengele's visits to dahlem on leave. at this or a further meeting then, the arrangement must have been made concerning the family members supposedly suffering from pulmonary tuberculosis. with some degree of certainty it can be presumed that magnussen rendered the events by and large correctly in her postwar testimony. her interpretation of what happened, however, can be scrutinized with a critical view to the sources. in her defense after world war ii she made every effort to portray her arrangement with mengele as entirely normal cooperation among colleagues. in , she stated on record to the bremen denazification commission: in her letter to schwartz, magnussen vested this argument in the form of a rhetorical question: in cases of death should i thus dispense with the histological analysis of the unique, abnormal material just because the people happened to die in the camp? otherwise i could have arranged to get the material from the responsible pathological institute. in her statement from she added that in she had also received from the charité hospital the heterochromous eyes of a deceased patient. the linchpin of this argumentation is magnussen's assertion that she did not know that auschwitz was an extermination camp. in her testimony to the denazification commission she claimed to have been unsuspecting: according to the impression i had of the case histories and of the extremely responsible and humanly decent attitude of dr. mengele toward his interned patients and staff (after the war, he hoped to win over for the institute a certain female polish physician interned in auschwitz, as he told me), the idea would never have entered my mind that anything could occur at the auschwitz camp that might violate state, medical or human laws. to schwartz, too, magnussen asserted that "nothing awful [was] known" to her; "on the contrary -from the case histories, the colleague's stories and from his human attitude to the inmates i could only have the impression of proper and decent treatment." nevertheless, it seems more than improbable that karin magnussen, a scientist at an institute whose leading members had been involved in the discussions about the generalplan ost and who made no secret of their attitude toward the "final solution" of the "jewish question" and the "gypsy question," and, moreover, an active national socialist with close contacts to the race policy office of the nsdap, had no knowledge at all of the genocide of jews, sinti and roma and no conception at all of the conditions in a concentration camp; accordingly, this must be dismissed as nothing more than an attempt to rationalize her behavior. rather, it can be assumed that it was altogether clear to magnussen that the sinti and roma had hardly a chance of survival in birkenau, and that this came in handy due to her interest in the eye specimens. mengele's indication that a family was "contaminated" by tuberculosis could even be interpreted as a discreet offer to assist in their demise, and magnussen's request to send her the specimens as consent. at this juncture magnussen also claimed that she did not know that other categories of prisoners besides "gypsies" and "mixed-race gypsies" were held at auschwitz. quoted in klee, medizin, p. . magnussen went so far as to assert that even former prisoners from auschwitz had "nothing awful" to report. the following testimony in her defense from must be relativized in this respect: "my work about the genetic biology of heterochromia was not performed on this clan because it was in a concentration camp, but rather even though it was interned in a camp, which made my work extraordinarily difficult, and almost impossible, had not a scientist coincidentally been assigned as a physican there. of the twelve children from the one family, initially two died in the years and (one of erysipelas and one of a pulmonary tb on both sides). a child from a related family died of pulmonary tb as well. the case histories and autopsy reports i received were painstakingly recorded. at this juncture the testimony of two surviving prison physicians can be drawn upon for further information. in his memoirs, miklós nyiszli reports that on several occasions he was required to dissect the corpses of "gypsy twins." once the corpses were of four pairs of twins, that is, eight children who were under years of age. nyiszli established the cause of death to be injection of chloroform to the heart -therefore the children were murdered systematically. nyizli related the further events as follows: of the four pairs of twins, three have eyes of different colors. one is blue, the other brown […] . i dissect the eyes out and lay them, each separately, in formalin, whereby i note precisely all information about them, so that they cannot be mixed up. […] in two pairs i also find an active pulmonary tuberculosis. […] in the afternoon dr. mengele makes his rounds of the ward. […] he is very interested in the heterochromia of the eyes […]. right away he instructs me to prepare the entire material for dispatch, along with the protocols, but i should also list the causes of death. he leaves it up to me what i write, but the causes of death must be different. almost by way of apology he says that these children, as i could see myself, suffered from syphilis or tuberculosis and would not have been able to survive anyway, so … he does not say anything more. this account is confirmed in its entirety by testimony from the ss commander erich mussfeld. whether the children's corpses autopsied by nyizli were members of the mechau family must remain an open question. the children of the mechau family may also have been autopsied by the jewish romanian prison physician iancu vexler, who worked in the "gypsy family camp" from june , . at least, this is what hermann langbein, himself a prisoner at auschwitz reports: vexler also reports about mengele's laboratory in the sauna block of b ii e, in which anthropological examinations took place, especially on hair and eye color. […] once a gypsy family by the name of mechau with striking heterochromia of the eyes was brought in. mengele drew vexler's attention to the family and ordered him: 'well, good, when it's time -when that happens, understand? -you will carefully take out the eyes and put them in bottles prepared for you. they will go to berlin for the investigation of the iris pigment. you understand, genetic issue, heredity dominant, recessive, etc. highly interesting. the parallel account suggests that several prison physicians were occupied with the autopsies of (twin) children with heterochromous eyes from the "gypsy family camp" at auschwitz-birkenau -and there are additional indications that point in this direction. in any case the reports from the prison physicians confirm the suspicion that mengele killed many more twin children from the "gypsy family camp" because of their eyes, and delivered many more eyes to the kwi-a than magnussen testified in her defense after world war ii -in she spoke of three, in of five pairs of eyes that she received from mengele. nyiszli's report further suggests that several heterochromous pairs of eyes from twins ended up in dahlem simultaneously. by this time at the latest it must have been clear to magnussen that the children had to have died a violent death. benoît massin is justified to establish: morphologie und anthropology, which was then edited by hans weinert -failed due to misgivings about the origin of the material investigated. in auschwitz, mengele also performed experiments "about the possibility of a change in iris color," by dropping substances into the eyes of numerous children. the consequences of these experiments ranged from slight itchiness to swelling, inflammations, and suppurations of the eyes, in some cases the subjects lost their eyesight. mengele even performed such experiments on newborn infants -with fatal results. according to the prison physician ella lingens , in a newborn died after mengele injected a substance into its eye "because he was attempting to induce a change in eye color. little dagmar was to get blue eyes." in irmgard ludwig had her newborn child taken away from her. when she saw it again, the eyes looked "like a crude clump." it is not known what substance mengele dropped into the children's eyes. according to a report by the polish prison physician rudolf diem, mengele claimed that the drops he had administered to persons with heterochromous eyes contained adrenaline: "he believed that the application of these drops would cause the iris color to change." what at first glance seems to be a mad, pseudoscientific experiment to instantly "aryanize" brown-eyed "gypsy children" by injecting substances like methylene blue takes on a new meaning against the background of magnussen's project on heterochromia. these experiments investigated the pigmentation of the human eye under phenogenetic aspects. mengele did not perform these experiments "singlehandedly […], but rather in 'teamwork' with magnussen. mengele was thus more than a passive supplier of dead 'human material,' and by no means did magnussen research on dead objects only; she was actively involved in mengele's human experiments." after the war magnussen confirmed that she had taken part in mengele's eye experiments, whereby she boldly redefined heterochromia as a disease and passed off the human experiments performed by mengele in coordination with her project as an attempt to cure the subjects: the histological investigation succeeded in obtaining an indication of the presumptive cause of the disturbing anomaly. -we decided to apply the results immediately in the interest of the same family as an attempt to cure the anomaly in one of the children. -since animal experiments of this kind had already been performed with success by other scientists, and since we had received previous assurance from the university ophthamological clinic in berlin that no unpleasant side effects of any kind were to be expected from the treatment planned (adding drops of a bodily substance for the purpose of restoring a disturbed function), the treatment was started. -since the child, unfortunately, died after a few months, it was not possible to perform the treatment for a sufficient length of time to yield an externally visible success. -shortly thereafter i received the eyes of this child for histological analysis, along with the eyes of another deceased child from this family contaminated with tb, -(i.e., of children) and performed the histological analysis of these eyes as well, although the histological work on the first three pairs of eyes had been langbein, menschen in auschwitz, p. . quoted in hesse, augen, p. . for instance, lifton, Ärzte, p. . in opposition: massin, mengele, p. . ibid. concluded long ago. -the possibility that an advantageous effect of the treatment is present after two months is given in the histological examination, so that i would advise this treatment even today in a case with similar conditions. also closely linked with the auschwitz concentration and extermination camp was that secretive research project of verschuer's, funded by the dfg and listed in the files of the reich research council as "experimental research on the determination of the heredity of specific proteins as the foundation of genetic and race research." this project was long regarded as a contribution to genetic pathology research under the aspects of race and implicated with diehl's tuberculosis research in the external office of the kwi-a in beetz. one of the connections existed on the organizational level, for verschuer's project used rabbits from diehl's breeding; their sensitivization with human blood sera took place in the kwi-a "reception center" in haus am see in beetz, that is, in the direct vicinity of the external department for tuberculosis research, and technical problems were resolved in part thanks to the know-how of the kwi for biochemistry, which also provided consulting for genetic tuberculosis research. yet there was also a connection on the conceptual level, to the extent that both projects fit in to the paradigm of phenogenetics. there may have been a practical connection beyond this, as it cannot be excluded that blood samples of sick patients were also targeted for use in the "specific proteins" project -more on this later. in this case there would have been the prospect of genetic pathology findings becoming available as a kind of "byproduct" of the "specific proteins" project. however, it must be emphasized that the two projects did not constitute a single unit and that it is by no means correct to conceive of the tuberculosis project as a preliminary phase of the "specific proteins" project. benno müller-hill and many others after him advanced the theory that the "specific proteins" project concerned the investigation of race-specific susceptibility or resistance to tuberculosis, and this, in turn, was connected with the theory that josef mengele had purposely infected inmates of the auschwitz camp with tuberculosis on behalf of the kwi-a. in contrast to this, bernd gausemeier formulated the theory that the project pursued the goal of developing a serological race test. achim trunk recently subjected both positions to meticulous critique, reaching the conclusion that gausemeier's theory can be reconciled with the scant source material available much better than that of müller-hill. i concur with gausemeier's position, whereby i can submit a document not yet taken into consideration that provides magnificent confirmation for trunk's analysis. the "specific proteins" project was presumably launched in spring . it was acknowledged as strategically important and thus received special funding as regarded material procurement, but yet -in contrast to the tuberculosis project -it was rated as the lowest priority s. the first indications as to what the project was about appeared in verschuer's interim report to the dfg of september/october : once all materials for the performance of this research had finally been delivered, the first preliminary examinations were begun and the methods tried out in consultation with privy councilor abderhalden, halle. an interruption in the work occurred when this branch of research was moved to the reception center of the institute in beetz, but by now the laboratory there is completely equipped. work can be continued. two things can be taken from this report: the project had been temporarily moved to haus am see in beetz, and it used a method that was widespread in germany at the time, although controversial, "aberhalden's reaction." this procedure, developed by the swiss biochemist emil abderhalden starting in , proceeded from the basic assumption that an animal organism can recognize and destroy a foreign protein that penetrates it -such as those of bacteria in the case of an infection -by manufacturing enzymes (at that time they were known as "ferments") that catalyze a defensive reaction against the foreign protein. the "protective ferments," the presence of which abderhalden and his pupils believed they could demonstrate in blood, and since in urine, ultimately turned out to be chimerical. the entire edifice of teachings constructed by abderhalden was founded on either fraud and/ or -scholars are still arguing about this -on error and self-deception. in the early s abderhalden had faced increasing criticism, but his method had not yet been clearly disproved. broad hopes were still linked with the method; it was believed that it might open up new possibilities for the diagnosis of infectious diseases, cancer, and even psychoses. what is more: in the second half of the s, abderhalden and his pupils attempted to use protective ferments for the determination of race in sheep and pigs. "this important research," verschuer commented in his review, "finds the greatest interest of the genetic biologist […] ." in abderhalden and verschuer exchanged several letters, in which it was abderhalden's idea to investigate the reactions of protective ferments in twins. verschuer rejected this for the time being, referring to the difficulties of obtaining blood samples. the correspondence between verschuer and abderhalden shows that in the latter was training one of verschuer's medical-technical assistants to use his methods in halle -müller-hill's investigations produced evidence that the assistant in question was irmgard eisenlohr (from : married haase). the second interim report by verschuer to the dfg of march confirms clearly that abderhalden's method was applied in the "specific proteins" project: in the trials of the methods new difficulties have come to light, which were resolved in consultation with privy councilor abderhalden, halle. series of rabbits are being subjected to thorough testing in order to find animals free of spontaneous ferments and thus suitable for the experiments. my assistant dr. med. et dr. phil. mengele has come in as an associate in this branch of research. he is stationed in the auschwitz concentration camp as hauptsturmführer and camp physician. with permission of the reichsführer ss, anthropological examinations are being performed on this camp's many different racial groups and the blood samples sent to my laboratory for analysis. this is the first evidence that the "specific protein" project used blood samples from people of different races, which came from josef mengele. in two letters by verschuer to the pediatrician bernhard de rudder, a close friend of his and diehl's, he goes into greater detail about the blood samples supplied by mengele. in october verschuer wrote: plasma substrates were produced from over people of various races, pairs of twins and a number of families. and a letter of january reads: what these "actual comparative studies" involved and what purpose they pursued is a matter of great controversy in historical research. achim trunk reconstructed the course of events as follows: from the blood samples serum was extracted and sent to berlin. from this, dry preparations were produced in the laboratory, which were then supposed to serve as the "substrate" converted by the protective ferment in the defense reaction. meanwhile, the search was on for suitable test rabbits, i.e. ones that did not already have the capability to decompose the foreign protein before they were inoculated with this protein. this is what verschuer was referring to with his comment that "series of rabbits [had been] subjected to thorough testing in order to find animals free of spontaneous ferments." when suitable rabbits were found, researchers injected them subcutaneously with a portion of the dried substrate and waited until they developed protective ferments against the race-specific human proteins. in the next step the protective ferments supposedly created had to be isolated. to do this, the urine of the rabbits was collected in special apparatus, as it was believed that the protective ferments were excreted with the urine. all substrates were then subjected to cross-reactions by adding the ferment solutions extracted from the rabbit urine in order to determine similarities and differences between the substrates. the final objective was to identify a panoply of protective ferments, each of which reacted with the proteins from the blood of a very specific human race. this would indeed have opened the way for a biochemical race test that would have eclipsed all anthropometric methods of race diagnostics attempted up to that time. a letter from verschuer to karl diehl of july , presents impressive confirmation for trunk's version of events: the experiment about the serum proteins with abderhalden's reaction has proceeded to the point where i have copious material at hand in the form of substrates. a conversation i conducted a few days ago with one of butenandt's assistants gives me occasion to begin now with the actual experiment, i.e. the reaction with the protective ferments generated in the rabbit. to do this, first of all, as last fall, the rabbits must be subjected again to thorough tests for the presence of spontaneous ferments, so that we can finally arrive at an animal that tests negative for ferment. therefore i request of you, just as you did last fall, to allow that a few animals from each of your normal breeds be placed into the special cages so that urine can be collected for the examination. this clearly proves that which trunk held to be very probable: the "specific proteins" project quite clearly did not concern protective ferments against tuberculosis or any other infectious disease in the blood samples taken by mengele in auschwitz. rather, these served without a doubt as substrates, which were to be converted by protective ferments extracted from rabbits. also worthy of emphasis in this letter by verschuer is the term normal breeds. what must be kept in mind here is that diehl held not only rabbits from the two pure breeds in his stalls -the ones he called "lung and belly rabbits" -and from the cross of these two breeding lines, but beyond these also a great number of other rabbits, of which many gave their lives for "preliminary experiments," for instance, by using glycerine to extract from their lungs a culture medium for tuberculosis bacilla. the normal breeds were very valuable for diehl -in december he answered the verschuer family's inquiry as to whether he could spare a rabbit or two for the christmas feast in the negative. presumably with a heavy heart, he declared himself willing to make rabbits from the "normal breeds" available for the "specific proteins" project, in return for verschuer's submitting a dfg application to obtain funding for his "tuberculosis" project. the point here is that the "specific proteins" project had nothing to do with diehl's pure breeds and the crosses between these pure breeds. thus, we can exclude with a high degree of probability that the human tuberculosis bacilla, with which a portion of the pure breeds were pretreated according to verschuer's statement, came from auschwitz. in verschuer's letter to diehl of july , the "specific proteins" project's connection with the kwi for biochemistry becomes clear for the first time. the report by verschuer to the dfg of october provides further explanation: "it is too bad that our shared work plans cannot be continued at the time being, but i hope it will be possible later." from what was said it should have become obvious that while the "tuberculosis" and "specific proteins" projects were closely linked together on the practical level, they pursued different objectives and were located in different fields of research: diehl's tuberculosis research fit into the long series of genetic pathology projects at the kwi-a, while the "specific proteins" project concerned human races. nevertheless verschuer, as proceeds clearly from his letters to de rudder, saw a close connection between the two projects. this is evinced particularly by a letter of october , , in which verschuer named the two projects in one breath with regard to his impending lecture to the academy: diehl obtained new, and as i believe, fundamentally very important research in his tuberculosis research. […] i believe that my research about the question as to the heritability of specific proteins is also connected to the problem as a whole. […] the goal of my different endeavors is now not only to establish that the influence of heredity is important in some infectious diseases, but in what manner it takes action and what kind of processes occur in these cases. at first glance this passage appears to speak for müller-hill's reconstruction of events, according to which the "specific proteins" project did have the object of race-specific dispositions or resistances to tuberculosis. it is clear that verschuer was interested in such issues. in his lecture to the academy on november , he hit on the gradual differences in the susceptibility and frailty of various human races with regard to infectious diseases -here he also mentioned the supposedly greater resistance of jews to tuberculosis -but he added, with reference to a publication by de rudder, that it had yet to be elucidated "whether these differences are truly conditioned by the different genetic disposition of the races and not by other influences." the "specific proteins" project actually promised to contribute to the clarification of this question indirectly, and thus there was an internal connection to tuberculosis research. the conceptual brackets around the two projects were constituted by the paradigm of phenogenetics. while each of the projects had a practical application in mind: diehl's attempt to breed rabbits resistant to tuberculosis was borne by the hope of discovering a biochemical substance that could also give humans protection from tuberculosis -and this without inoculation. at the forefront of verschuer's protein project was the development of a biochemical race test. however, it must not be overlooked that both projects were apparently understood as complementary contributions to theoretical research in the area of phenogenetics, as they both aimed at the level of the proteome, where the gene action chains proceeding from the genome are set into action and shape the phenome, where race attributes are developed and many of the dispositions for diseases were also established. the "specific proteins" project shows -as did karin magnussen's project on heterochromia, by the way -that research guided by the paradigm of phenogenetics, although it left behind the genetic determinism of the old race hygiene and race anthropology, was by no means invulnerable to drifting into the zone of crime. my theory is that one can conclude from this that in the area of the science of humans there can be no security against crossing scientific boundaries inherent in the paradigm guiding research -whatever shape it may take -. every form of research on humans takes place in the tug of war between the researcher's interest in scientific knowledge and the human and civil rights of the person researched, regardless of their idea of man, that is, no matter whether they regard the individual as a pure product of his or her genetic information, as result of the interplay between heredity and environment, or as a tabula rasa that is marked by the environment. drawing science-ethics boundaries takes its basis of legitimation from values held beyond the sphere of science. otmar von verschuer was neither the only one nor the first to work on a serological race test. the anthropologist theodor james mollison had long been concerned with the question as to whether serological race diagnostics was possible. mollison attempted to reach his goal using the "precipitine reaction." this reaction involved the formation of precipitation that occurred when blood serum from another animal, for example, from a chimpanzee, was injected into a rabbit, and the antiserum, which was produced from the blood of a rabbit immunized in this fashion, was mixed with the original serum of the chimpanzee. if the same antiserum was allowed to react with sera of related species -like macaques, gibbons, orangutans, or humans -the precipitin reaction varied in strength. mollison traced this back to proteins in the blood serum specific to each species. what was true for animal species, mollison deduced, must also be applicable to human races. therefore, since the s he had been attempting to develop serological race diagnostics on the basis of the precipitin reaction. other scientists in the third reich picked up on this approach. werner fischer ( - ) from the scientific department of the institute for experimental cancer research in heidelberg under ernst rodenwaldt, who collaborated with benno raquet in to submit a paper "on the question of the proof of a perform studies on the "question of generating mutations in drosophila through x-rays." "in these studies [work was performed] in very close coordination with timoféeff-ressovsky, in order to achieve as great a consistency as possible in work methods and work orientation." in june loeffler was able to report that the studies, which were part of the joint project sponsored by the german research association and the reich health office, already covered , cultures with over , animals. yet loeffler had strong competition in this field he had originated, for instance, from the genetic biology department of the reich health office. thus, it was altogether logical that he assigned his right hand horneck to the explosive problems surrounding a serological race test, which -as loeffler had recognized clearly -touched on not only "important fundamental issues of our science," but also was aimed "at purely practical matters." thus, loeffler could open up a new field of research, which was not only of scientific interest, butmore importantly -also of immense importance for national socialist race policy. in this he attached himself to werner fischer, who had been working on the complex of themes for some time and had both the required know-how and the necessary infrastructure at his disposal. for his part, fischer was happy to accept loeffler's advances, and bound horneck's project to his institute, as in this manner he could take advantage of loeffler's far-reaching political connections in the national socialist state. this was of particular interest to fischer because, at around the time horneck published his first results, he had begun with serological examinations of concentration camp inmates. on this, a report by the reich physician ss ernst grawitz to reichsführer ss heinrich himmler of july , states: wittenau sanatoriums, but perhaps through wolfgang abel, who, we recall, also had spent time at the special colonial medicine military hospital in st. médard, possibly worked in the sachsenhausen concentration camp as well, and could have stumbled over horneck's and fischer's tracks. whatever the sources from which verschuer obtained his knowledge about the competition's project: with the "specific proteins" project he attempted to regain the upper hand in this field of research. second, the experimental design of the "specific proteins" project, as reconstructed by achim trunk, corresponded to fischer's and horneck's approach down to the last detail -only that verschuer pursued his goal using abderhalden's protective ferments rather than the precipitin reaction. verschuer was familiar with mollison's attempts to make the precipitin reaction useful for race diagnostics, just as he was with abderhalden's works, but, as his reviews show, since the late s he granted the better chances to abderhalden's method. since he enjoyed a direct connection to abderhalden, he believed his hand held a decisive trump over fischer and horneck. third it becomes apparent that the competition between the scientists corresponded to the rivalry between the politicians involved -conti and blome. it was all the easier for verschuer to win over conti for his plans because the competing undertaking was located in blome's sphere of influence. fourth and finally, against the background of horneck's project it cannot be excluded that the "specific proteins" project utilized the blood of subjects who were ill, perhaps even that of humans who were made ill. since horneck had researched on blood samples of diseased subjects of various races to investigate whether the serum of sick members of a race behaved differently in the precipitin test than did that of healthy members of the same race. this question was also posed in principle by verschuer in his application of abderhalden's reaction -in competition with horneck and fischer he could not really afford to leave this question unanswered. thus, it is possible that the blood samples mengele sent to dahlem include some originating from diseased inmates. similarly, against the background of horneck's research, the suspicion that mengele purposely could have infected humans with infectious diseases, such as typhus, cannot be dismissed completely in the context of the "specific proteins" project. moreover, verschuer was interested in questions of "race pathology," as his paper from already demonstrated. in this paper he presented "as certain pathological facts" that "numerous genetic disorders like diabetes, deaf-muteness, endogenous psychoses [occurred] in germany more frequently among jews than non-jews and "amaurotic idiocy [had] been observed only in polish jews. as we have seen elsewhere, he was still concerned with "race pathology" in and -to that extent it is quite conceivable that verschuer followed horneck's experimental design and opened up the "specific proteins" project toward a genetic pathology orientation. as heavy air attacks on berlin increased in mid- , verschuer began to look around for possibilities to relocate part of the institute. he managed to rent a house in sommerfeld, on lake beetz, in the direct vicinity of the external office for tuberculosis research in waldhaus charlottenburg, which had been expanded and equipped as an auxiliary hospital, but had never been moved into. from july this haus am see had been used as a "receiving office for the institute" -it was staffed by hans grebe with his secretary, nurse emmi nierhaus, karl diehl's technical assistant charlotte gruetz and the technical assistant irmgard eisenlohr, who was involved with the "specific proteins" project. verschuer had thought about relocating the entire institute to beetz, but for tactical considerations he dispensed with this idea. if the institute were vacated voluntarily, verschuer wrote in a letter to fischer, it might be lost, even if it were not destroyed by air raids. "i could not take responsibility for being at fault myself." in order "to prevent the destruction of our scientific body of thought" he had a wagon load brought to beetz and sommerfeld, and in beetz a hutch for nachtsheim's rabbits was to be built as well. in the dahlem institute, which officially bore the name "eugen fischer institute" since its founding director's th birthday in june , of the valuable goods only the "photograph collection" remained, which was stowed in the air raid shelter. the only staff that continued working in dahlem were the department heads, karin magnussen and a few auxiliary assistants. "this dispersion of items is not ideal," verschuer wrote, "but provides great reassurance." in order to preserve coherence, he set up a standing "courier service" between dahlem and beetz. in february the institute was damaged in a heavy bombing attack. yet verschuer still regarded the situation to be "by no means so grave that a relocation of the complete institute would come into question." in the provisionally repaired building he kept operations afloat for the time being. in september , however, first signs of deterioration became apparent. lenz, as verschuer reported, after having brought his wife and children to relatives in obernfelde near lübbecke in westphalia, fell deeper and deeper into depression and could hardly work any longer -shortly thereafter he took leave for reasons of poor health and followed his family to the west, such that the institute for race hygiene ceased to exist in fact. abel had "left his people more or less to themselves and consumes aerated baths in bad ischl." according to verschuer, abel managed "excellently to put his personal affairs in order as advantageously as possible. now he is shifting ever further away from the institute and has become a rare guest." karl and anne diehl, despite health problems, continued their rabbit research, "albeit often by summoning their last strength;" the same was true of hans nachtsheim, who had been declared fit for combat in his army physical, so that it was only a matter of time before he was called up. gottschaldt was the only one who exhibited "an active demeanor loaded with energy," and pushed ahead "the evaluation of his twin findings with extremely hard work and great energy." however, he was often in rottmannshagen, where he had lodged his wife and children. the situation there, verschuer warned, was "by no means harmless, for in the sparsely settled land the foreign workers constitute a majority, which could easily seize power for themselves if enemy pilots were to furnish them with ringleaders." on february , a directive was issued by the reich minister for armaments and war production, albert speer , to the operations staff of the kwg, instructing that the institutes under its control be relocated from endangered areas. ernst telschow forwarded this directive to the kwi-a, where it arrived on february , delivered by a courier. had it been, up to new year's , verschuer's express goal to hold out in dahlem as long as possible and await the further course of events in order to defend the institute building against competing claims, by february it must have been clear to him that the fall of berlin was merely a matter of time. relocating the institute appeared imperative, and in secret verschuer already had begun the preparations for a move. so speer's directive came at just the right time, although initially appearances suggested that it was already too late, for an execution of the directive appeared "impossible." in addition, between february and , telschow, as he claimed angrily after the fact, informed verschuer orally that speer "in retrospect [had] not desired" the "application of the relocation directive" to the kwi-a. although verschuer later vehemently denied ever having received such a communication, telschow's account is confirmed by other sources. thus, it can be presumed that verschuer was quite aware that he had received a green light to relocate his institute neither from the general administration nor from the armaments ministry. however, when engelhardt bühler, who had been assigned to the institute a short time before, managed to organize a trailer truck around february , -to everyone's surprise, verschuer acted without delay, supported by speer's written command to relocate, abruptly overrode the oral counter-command communicated by telschow and set the relocation in motion. on february , , when part of the material sent to beetz had already been loaded on the truck, he sent a circular to the department heads abel, diehl, gottschaldt, lenz, and nachtsheim, officially informing them that the majority of the institute's inventory was to be relocated to his family estate in solz near bebra. the department for experimental genetic pathology remained in dahlem, since the extensive animal breeds could not be taken with the institute. nachtsheim was appointed verschuer's deputy and entrusted with the oversight of the institute building and the inventory remaining there. the external department for tuberculosis research stayed in sommerfeld, as diehl was indispensable as the senior physician of the waldhaus charlottenburg hospital, and he, too, did not want to leave his animal breeds behind. by contrast, the alternative location rottmannshagen, under gottschaldt's direction, was to be dissolved and also relocated to solz as soon as possible. some of the "followers" were supposed to remain in dahlem, some were to move to solz, and some sent home on leave. on february , the inventory of the dahlem institute was loaded on the trailer truck provided. in a letter of february , verschuer informed the general administration in writing of the relocation already in progress. immediately before his departure, on the afternoon of february , , verschuer must have had another meeting with telschow, in which the general secretary vented his anger, but he was not able to stop the operation in progress. quite obviously, verschuer used the chaos predominant in the final phase of the war, above all "the nearly complete collapse of the standard paths of communication," to remove himself from berlin and in this manner present the general administration of the kwg with a "fait accompli." how hasty verschuer's departure was is apparent in the fact that he did not even find the time to contact günther hillmann to discuss the continuation of the "specific proteins" project. he left the inventory of the laboratory with the "special rabbit cages for the collection of urine" in butenandt's institute in dahlem. "i brought with me only the especially valuable and irreplaceable protein substrates," verschuer reported from solz -thus it is possible that some of the sera that ended up in solz came from the blood samples taken by mengele in auschwitz. on the other hand, the written documentation on the "specific proteins" project may have been left in dahlem. on march , nachtsheim wrote to verschuer: verschuer confirmed that some of the material involved was "secret files, which by no means may fall into enemy hands," asked nachtsheim to attend to the matter and to give the caretaker the order to burn the material "in good time." on february , verschuer laconically informed the general administration that the relocation of the institute to solz had been completed "without significant inconvenience." on march , gottschaldt arrived in solz as well, with the material that had been stored in rottmannshagen. in a letter to his friend karl diehl of march , verschuer appeared optimistic that the institute would be able to continue its scientific work in solz: from here i have good news as far as it goes. it is certainly an enormous luxury not to have any sirens in the village and not to feel like a direct target of enemy pilots. as such i manage more positive work than was possible during the last phase in berlin. the establishment of my small institute here is making progress, although all sorts of difficulties must be overcome. someday i would like to give you a tour of my facilities here, my director's study (also living room and bedroom for erika and me); the library, in which all of the books brought from beetz have been arranged, which is also the study for miss sesselberg (not to mention the group dining room); to the church hall in the manse, which i have furnished as a study for miss lüdicke and nurse emmi, in which thus the twin files are being analyzed and the institute's administration and treasury are located; and, finally, in a restaurant hall where the institute property is stacked (including that which gottschaldt has since brought here from rottmannshagen). shortly before christmas eugen fischer and his wife had fled from freiburg before the approaching allied troops to their daughter gertrud in sontra, near bebra, so that fischer and verschuer found themselves just a few kilometers distance from each other at the end of the war. in berlin nachtsheim had to struggle with increasing signs of dissolution. in fear of the approaching red army, many staff members refused to work. most of nachtsheim's rabbits had to be slaughtered once the plan to bring the animals to switzerland had been discarded. some of the institute's rooms had to be yielded to the reich office for land use planning, the reich ministry for church matters and to a department of the university of posen. finally, on march , the institute building was requisitioned as a reserve military hospital. the general administration of the kwg, angered by verschuer's going it alone, undertook nothing to prevent the requisitioning. the general administration also took a passive stance in the conflict about the haus am see that broke out in march , when the responsible local group leader requisitioned the building to accommodate refugees. in the end, the kwi-a was left with two rooms of the haus am see, in which institute bericht über die im jahre durchgeführten und für das jahr geplanten forschungen cf. koslowski, einfügung. the genetic psychology part of the project was to be carried out by a "miss dorer erbbiologische bestandsaufnahme rep. a (münster), nr. for the continuation of these studies using biochemical methods contact with professor butenandt has been established tuberculosis (bericht für den zeitraum vom . april bis zum r i/ formulation proposal by ernst wentzler, in square brackets: formulation proposal by lenz. wentzler's version read: "who long for deliverance because of an incurable disease formulation proposal by lenz, in square brackets: formulation proposal by kurt pohlisch . formulation proposal by lenz tätigkeitsbericht / , mpg archive eickstedt himself was not present in leipzig, his lecture must have been read by a deputy. cf. verschuer to fischer, / / , mpg archive on hitler's orders, a large portion of the african prisoners of war -around , men -had been deported to southern france (bordeaux) in an interview with benno müller-hill, abel stated that he was "in a leper station in bordeaux visiting dr. weddingen in the tropical medicine military hospital pictures for the work on pygmy soles of the foot the same formulation is included in verschuer's tätigkeitsbericht for / (mpg archive here: p. ; dekan der medizinischen fakultät frankfurt to hessisches staatsministerium für kultus und unterricht kirchliches urteil über die persönlichkeit und die wissenschaftliche arbeit von herrn professor dr on this in detail: schmuhl, Ärzte in der anstalt bethel jüdische mischlinge von der rassenhygiene zur humangenetik denazification certificate general heiber generalplan ost * ) worked at the rusha in and served as an aptitude tester for the germanization of poles, especially in Łódž sievers to brandt, / / , quoted in lösch, rasse falkenburg am krössinsee" addressed the kwi-a in june , requesting that it make available "for preparatory works for deployment in the future reich commissariat in the caucausus […] data and material about population density, races, nations and religions in the caucasian and central russian areas, respectively sievers had expressed himself quite similarly in a letter to richard korherr (* ), the inspector for statistics at the reichsführer-ss office / / , quoted in lösch, rasse on the following ahnenerbe bdc, wi a- . cf. sievers to hirt, / / , barch on the "auschwitz-dahlem connection untersuchungen des vorderen unterkieferabschnittes review: lothar stengel von rutkowski, grundzüge der erbkunde und rassenpflege; idem., review: gerhard venzmer, erbmasse und krankheit; idem., review: gottfried pressler, untersuchungen über den einfluß der großstadt; idem., review: georg von knorre on the discussions about the naming of this disease in the third reich, cf. schmuhl, Ärzte in der westfälischen diakonissenanstalt sarepta verschuer and his staff had produced paternity opinions. verschuer, vaterschaftsgutachten, pp. f. cf. also idem there is no evidence of collaboration between mengele and kranz, however after the re-integration of the auschwitz ii camp into the main camp in november he became executive camp physician in the men's hospital area b ii f. kubica stellungnahme zu den angaben, die sich auf meine person beziehen und in der "neuen zeitung" nr. vom . . unter der rubrik "kunst und kultur in kürze" in der notiz "vertriebene wissenschaft" erschienen sind on this, the letter by wilhelm r. mann, the director of i.g. farben, to verschuer from the european standpoint the jewish question is not solved by the circumstance that jews emigrate from the racially thinking states to the other states only - % of the new members of the nsdap before were women. cf. falter, hitlers wähler so georg melchers ( - ) in an interview with müller-hill, tödliche wissenschaft esp. pp. ff also walter groß and the later "gypsy researcher extensive case histories and dissection protocols were sent to dahlem with the eye specimens for inspection. after processing they had to be returned, as case histories are the property of the hospital or the treating physician as a matter of principle ) gave the "race biology and anthropological institute in berlin-dahlem" as the address for dispatch, this could -if it is not simply a mistaken memory -have been because one of the possible addressees, wolfgang abel, was both director of the department for race science at the kwi-a and, since , director of the institute for race biology at the university of berlin. abel used letterhead with the address kumpania according to ernst klee, the mother of the hungarian composer györgy ligeti also performed such autopsies in that magnussen, in view of possible fluctuations in manifestation verschuer reports to fischer that he now had the technical assistent irmgard eisenlohr and that "with her the research with abderhalden's reaction, now finally picking up steam i have the substrates from the blood sera of over persons of various racial descent and also of pairs of twins and a few families ready, so that it is now possible to start the actual comparative studies müller-hill, tödliche wissenschaft spezifische eiweißkörper to perform abderhalden's protective ferment reaction in order to study the individual specificity of the serum proteins, i received blood samples sent from several hospitals, like those taken for most clinical investigations (wassermann's reaction, the erythrocyte sedimentation rate [esr]), around - ccm, without harming the health of the patient in any way. among these were also blood samples from the sick bay where that assistant from frankfurt worked in auschwitz / / , ibid. at this point in time diehl had around live rabbits at his disposal, although around young animals had died in the previous weeks spezifische eiweißkörper adolf butenandt. on the friendship between verschuer and butenandt cf. also sachse, adolf butenandt from mollison's work: mollison, serodiagnostik; idem., verwandtschaftsforschung; idem he believed that he had established quantitative differences in the abilities of "white serum" and "negro serum" to react with a certain "white serum-antiserum," which could be demonstrated using precipitation. fischer qualified his conclusion, however, adding that "before the potential perspective of a serological race diagnosis using such antisera can be considered at the same time he was also active in the "protection of the steyr homeland" (steirischer heimatschutz) and joined the austrian national socialists. in he found a position at the medical clinic of the university of graz, from early , however, only as an unpaid assistant. in he applied for a position as railway physician, but his application was denied due to his membership in the nsdap. his application as a panel doctor was not processed for the same reason personnel questionnaire on the request for a research stipend microscopic studies about the structure of the capillaries using infrared photography bericht über die von mir im januar begonnenen untersuchungen über die serologische verschiedenheit der menschlichen rassen loeffler to dfg, / / / , ibid. with von wettstein, butenandt, heisenberg silicate research] (i name only those with whom i actually spoke) we are in agreement that we must defend our institutes here gottschaldt, as mentioned above, sent the materials from the "twin camps" from dahlem to rottmannshagen castle near stavenhagen in mecklenburg, at the same time further research materials were sent to haus am see in beetz verschuer to fischer, / / , mpg archive on this celebration in detail: lösch, rasse rep. a (münster) the broken window panes could not be replaced by september ; the empty window frames were sealed with cardboard. verschuer to fischer, / / , ibid von der rassenhygiene zur humangenetik, p. , is presumably correct in viewing lenz's " 'vacation' " as a "move to withdraw from berlin rep. b rep. a (münster / / , mpg archive, dept. i, rep. a, ni. von der rassenhygiene zur humangenetik in bühler had submitted a postdoctoral thesis, but this had been rejected by the anatomist hermann stieve after fritz lenz had refused to head the examination committee. verschuer endeavored in vain to obtain a professorial qualification for bühler on the basis of the works he had published so far rep. b one of the institute's secretaries] i learned that many files remained here, which should, or must, be destroyed before falling into enemy hands. while i have not yet taken a look to see what and how much is concerned, i presume that miss jarofki knows this exactly. you did not speak about this with me, otherwise i would have advised that the things be taken to solz. in any case we may not choose too late a point in time for their destruction von der rassenhygiene zur humangenetik v. on verschuer's news that a trailer truck had been "made available" to the institute, a marginal comment reads v. here verschuer also claimed that he had been in contact von der rassenhygiene zur humangenetik no. . nachtsheim to verschuer, / / , quoted in kröner, von der rassenhygiene zur humangenetik / / , mpg archive, dept. i, rep. a, no. von der rassenhygiene zur humangenetik rep. a (münster von der rassenhygiene zur humangenetik at the end of the war abel withdrew to his estate at mondsee and dropped out of sight. heinrich schade was still a prisoner of war in yugoslavia. lenz initially remained in eastern westphalia, and -as the first of the "dahlem circle" -was appointed associate professor for human genetic theory at the university of göttingen in october . with this it appeared that the institute's "political baggage" had been swept under the carpet. verschuer indulged himself in the hope that he would be able to reestablish the kaiser wilhelm institute for anthropology, human heredity and eugenics, whereby of the former department chiefs he wanted to reappoint only his friend verschuer to an bürgermeister der gemeinde beetz, / / , mpg archive, dept. i, rep v. cf. also verschuer to generalverwaltung in the course of the change in leadership at the institute, michaelsen had been displaced from her position as executive secretary by nurse emmi nierhaus, had taken a long leave of absence for health reasons, and had found herself in fierce conflict with verschuer in december , who charged her publicly with kleptomania and forced her to resign from the institute (cf. michaelsen to generalverwaltung, / / , mpg archive, dept. i, rep. a, ). magnussen had sided with her friend (verschuer to fischer, / / ; fischer to verschuer that verschuer, and later, fischer as well, broke off contact with magnussen was clearly because of this "micha case" (cf., for instance, an undated postcard by fischer to verschuer until late magnussen was officially listed as an assistant at the institute (cf. notetat für das kwi-a für das rechnungsjahr / , mpg archive returned from captivity," was supposed to take magnussen's place from rep. a (münster), no. . extensively on this: kröner, von der rassenhygiene zur humangenetik his past caught up with him when the physicist robert havemann ( - ), who had spent the final years of the third reich as a political prisoner in the brandenburg penitentiary and been appointed by the city council of east berlin (magistrat) as the provisional director of the kaiser wilhem institutes remaining in berlin in , exposed verschuer's connections to national socialism and his state crimes in . although at times he was in danger of criminal prosecution and temporarily banned from professional activity kaiser wilhelm institute for applied anthropology" in dahlem in / . muckermann's application for admission to the max planck society was dragged out by the general administration. while the "research office for applied anthropoligy" received financial support from the max planck society, it did not receive the title of a max planck institute. the "institute for natural science and humanities anthropology" (institut für natur-und geisteswissenschaftliche anthropologie), as it was known from on, never developed noteworthy activities; it was dissolved without further ado in . in the end verschuer was appointed to the newly created chair for human genetics at the university of münster in , which long remained the only one of its kind. even though the dahlem institute fell apart after the end of the war: the "dahlem circle" of verschuer the case of the three heterochromous pairs of eyes from twins, which died more or less on the same day, must have been conspicuous and surprising. the very case that two twin siblings die "a natural death" on the same day and in the same place is a statistical rarity. moreover, twins with heterochromous eyes are extremely seldom. but the death of six twin children with heterochromous eyes on the very same day or in the very same week is well outside the bounds of statistical probability and clearly points to a crime. the above-mentioned publication of her research results about the "heredity and histology of a total heterochromia of the iris in humans" failed in late /early , because from the article it was clear -at least, according to testimony by georg melcher ( - ) of the kwi for biology and coeditor of the zeitschrift für induktive abstammungs-und vererbungslehre at the time, in an interview with benno müller-hill in the early s -that all subjects died at the same time and thus it stood to reason to suspect that they had fallen victim to a crime. in karin magnussen herself claimed that her essay did not appear because the printing plates, ready to go to press at the time, were destroyed in an air raid -this was probably much closer to the truth. then, after world war ii, magnussen's persistent attempts to place the manuscript after all -perhaps in the zeitschrift für the research has continued to enjoy intensive support. blood samples of over persons of various racial descent were processed and substrates of the blood plasma produced. the further research will be continued in collaboration with dr. hillmann [günther hillmann ( - ], a staff member of the kaiser wilhelm institute for biochemistry. dr. hillmann is a biochemical specialist for protein research. with his help abderhalden's original method has been perfected, so that now the actual experiments on the rabbits finally can be started. official visits" with werner fischer, by this time director of the serological department of the robert koch institute for infectious diseases in berlin, he had arranged to participate, under fischer's "guidance," in the control experiments fischer had declared necessary in his essay of . possibilities for this of which he never could have dreamed presented themselves in occupied france. horneck took blood samples from two "moroccans," one "annamese" and one "senegalese negro" from the ranks of the colonial troops held in war prison camps, and conducted serological investigations on these and other blood samples while on leave, assisted by a french laboratory technician in the serological-bacteriological laboratory of the hospice générale du havre. from the blood samples taken in the war prison camp, horneck produced "moroccan, annamese and negro sera." these he compared to various "european sera." over a period of two months, horneck injected five to seven intravenous injections of these sera in five rabbits, in order to immunize each of them against a specific serum. then he killed the animals, let them bleed to death and in this manner obtained a "precipitating antiserum" for each serum injected. a precipitin reaction was induced for each antiserum by combining them with all sera -i.e. with "white, annamese, senegalese negro, and moroccan serum." horneck arrived at the conclusion that the "white serum" reacted more weakly in the two cases portrayed in detail -both in the precipitation with "moroccan serum-antiserum" and with "white serum-antiserum" -and thus possessed less "precipitating antigens" than the other sera. this, horneck stated, could mean "that the differences present were not actually of race, i.e. based on the circumstance that whites, besides the antigen for the human species, also possess a white antigen, while the moroccan, negro, annamese also possess a moroccan, negro, or annamese antigen in addition to the antigen for the human species; rather, there may merely exist certain differences between whites and the other races in the amount of precipitatable antigens." the "determination of the protein content" and the determination of the composition of the protein were thus an imperative prerequisite "for a serological race diagnosis." at werner fischer's urging, for this research in horneck also began "to attempt the immunization of human to human in different races." in a later research report horneck mentions incidentally that these first immunization horneck, nachweis, p. . ibid., p. f. two rabbits who were treated with "senegalese negro serum" perished of peritoneal tuberculoses during this procedure. since there was not sufficent "senegal negro serum" available, horneck dispensed with immunizing the third animal, so that no antiserum was available for this serum. ibid., p. . ibid., pp. f. (original emphasis). it could be that other races possessed more easily precipitatable (lyophobic) serum protein (euglobulins), while europeans had more strongly lyophilic serum protein (pseudoglobulins, albumins). ibid., p. . ibid., p. . attempts, which had not produced any "usable results," were performed on himself. however, this account must be cast in doubt -horneck, who had worked as a general physician for years, after all, must have been aware of the great risks involved with such immunization experiments. it is highly improbable that he bore this risk himself."as a consequence of his […] deployment on the eastern front," in horneck was forced to discontinue his experiments for the time being. he published his results in a paper, which he submitted to the editorial board of the zeitschrift für menschliche vererbungs-und konstitutionslehre on april , , and was published in october of that year.even before this paper appeared in print, lothar loeffler submitted an application for research funding to the german research association, in order to allow horneck to continue his project. the objectives of future investigations were, according to loeffler, "absolute exclusion of individual differences, especially diseases, within one and the same race," as well as "determination of the protein factions of the antigens." independent of this, the "experiments about immunization from human to human" were to be continued. research on "negroes" was to be continued, "as initially only significantly different races come into question." the medical faculty of the university of königsberg, he stated further, soon will apply for a military exemption or "working leave" for horneck, which had good prospects for success. since the institute in königsberg was not equipped for such extensive examinations, and the required apparatus could not be procured during the war either, and because the race biology institute being set up in vienna (loeffler was just about to move from königsberg to vienna at the time) did not yet have a serological workplace, werner fischer expressed himself willing to grant horneck a temporary workplace at the robert koch institute.since , loeffler had first propelled ahead with his research in the field of radiation genetics. called upon by alfred kühn to take part in a joint project for the investigation of genetic damage through x-rays, in december he had requested a considerable sum from the emergency committee of german science for radiation genetics experiments on mice, which loeffler wanted to perform in collaboration with paula hertwig ( - ) of the kwi for biology and nikolaj timofféeff-ressovsky of the kwi for brain research. the emergency committee actually approved a credit of up to , rm for this project. de crinis ( - ) , a national socialist emigrated from austria whose curriculum vitae exhibited many a parallel to horneck's, and who had succeeded karl bonhoeffer as full professor for psychiatry and neurology at the charité hospital in berlin. loeffler bestowed particular urgency upon his application by following it with a letter to kurt blome ( - ), deputy director of the main office for national health at the nsdap, a liaison of the german research association for the subject area "population policy, care of genes and race," who was certain to be one of the people evaluating horneck's research plan. loeffler supplied a short synopsis of horneck's biography, summarizing that he had "proved his worth both politically and in the war." according to report, loeffler continued, horneck had been listed in third place for two pending appointments, and it was to be expected that he would move up to positions with more prospects in later appointments, so that, also in view of the "lack of truly good new blood," it was important to give horneck the opportunity to perform scientific work in the future. moreover, horneck was "almost the only race biologist performing serological work at this time." blome actually did send loeffler's letter immediately to the reich research council with a request for review. one month later -in november -the reich research council approved the application for a grant of , rm. in january horneck, who was working in the special colonial medicine military hospital in st. médard near bordeaux at this time, resumed his research. in his first preliminary report, horneck once again described the point of departure of his study: the purpose was to establish whether the varying intensity of precipitin reactions to human sera was influenced by individual factors, especially by diseases, in such a way that the race differences were blurred. therefore sera of both healthy and sick "negroes" as well as of whites -for the purpose of comparisonwere tested using the precipitin method (optimal precipitation), whereby the same blood groups were used in each test. "with the enormous material" horneck had "at his disposal an abundance of the most varied diseases, some of which hardly occur at all in our country (like leprosy the blood group to which each of the rabbits belonged was also taken into consideration. there were "as we know, rabbits -known as 'a rabbits,' who possess an anti-a factor. upon pretreatment with a serum, these rabbits give a much more strongly precipitating antiserum, and that is why this fact must be taken into consideration." karl horneck, bericht über die von mir im januar begonnenen untersuchungen über die serologische verschiedenheit der menschlichen rassen, n.d. (april ) , ibid. tuberculosis, typhus abdominalis and the worm infection filaria bancrofti. horneck summarized his preliminary results as follows:to the extent that anything at all can be said about them, these studies showed that individual differences do exist, but that they are expressed only in the time and intensity of flocculation. thus in such a manner that the serum of a certain subject, e.g., a typhus patient, flocculates earlier and more intensively than the serum of a healthy subject of the same race. however, in all experiments it could be confirmed that with regard to the concentration at which the best (optimal) flocculation occurs, fundamental differences exist between white serum and negro serum. in a later, brief interim report horneck portrayed this preliminary result as already proven and declared categorically: "differences in the optimal stage of flocculation may thus be based only on race differences." the studies to "determine the protein factions" had not been tackled yet in the first quarter of . on the other hand, horneck had resumed his experiments on immunization from human to human:this time i began the immunization experiments on several negroes with various blood groups. before the first injection, about - ccm blood was taken from each of the negroes, in order to obtain a serum of the species before treatment. then the negroes received a total of - cmm white serum in four intravenous injections. twenty-four hours after the final injection and one week after the last [sic, presumably must mean: first] injection, another - ccm blood was taken from the negroes. the sera of the pre-treated and those of the non-pre-treated were evaluated for their optimal precipitation and interesting differences were established in this anaylsis. a portion of these sera was filled into sterile test tubes and sent by courier to fischer in berlin, where control tests were to be undertaken. ernst rodenwaldt showed animated interest in the immunization experiments in particular. he visited horneck on location in the special colonial medicine military hospital -as mentioned, werner fischer had worked as rodenwaldt's assistant at the institute for experimental cancer research in heidelberg from to . in his later report horneck noted with disappointment that "extensive attempts at a direct immunization from human to human [proceeded] completely in vain." "the proof of an immunization can only be furnished indirectly via rabbits […] ." with the immunization experiments on war prisoners of color, horneck clearly transgressed the boundary to criminal human experiments, for hereby he not only disregarded his proband's right to self-determination -as in taking blood samples for the precipitin reaction, but he also subjected them to serious health risks. for with the injection of the foreign serum horneck assented to hazard the potential occurrence of allergic ibid. karl horneck, bericht über die arbeit "serologische differenzierung der menschlichen rassen," n.d., ibid. ibid. karl horneck, bericht über die arbeit "serologische differenzierung der menschlichen rassen," n.d., ibid.shock, of hemolysis (dissolution of the red blood cells), of intravascular clotting events and thromboembolism with consequent circulatory failure and death.apparently horneck's research came to a standstill when he was transferred from france to italy in . in november loeffler reported to the reich research council that horneck "has received a command from the wehrmacht, which now puts him in the position to continue his scientific work despite his continued military service status." horneck intended to travel to france in the near future to resume the interrupted research, loeffler continued. in february horneck applied for a further grant of , rm, which was approved in march. in october he informed the reich research council that he had completed a paper "about the possibility of a serological race differentiation" and sent it to fischer for appraisal -"with consideration of the fact that this paper contains many new aspects," fischer expressed the wish to talk through it with horneck personally before it went to print, a plan that was frustrated for the time being by the fact that horneck was denied special leave. the account ends abruptly at this point; the project must have run aground.horneck's and fischer's project is of fundamental importance with respect to verschuer's project for several reasons:first, it temporally preceded the "specific proteins" project. verschuer had dealt with the proteins of human serum back in his dissertation in and showed his lively interest in the possibilities of serological race diagnostics in the late weimar republic. in a short paper about "physiology and pathology in anthropology" of , verschuer had regretted that there was still no success in using the precipitin reaction to "establish with certainty protein differences between the human races." one must presume that he observed the developments in this field of research attentively. when he succeeded eugen fischer in , the race to develop a race test on a serological basis was in full swing -and the institute in dahlem had not left the starting blocks. engelhardt bühler's project begun in , on the heritability of the isoagglutinin content of human blood serum, which -as eugen fischer had implied to the german research association -also was to open up possibilities for a serological race test, had come to a complete standstill when bühler was called up to the wehrmacht at the beginning of world war ii. certainly it can be assumed that verschuer had taken notice of fischer's and horneck's work, and it can also be assumed that he knew about the series of experiments in progress at the sachsenhausen camp and in the special colonial medicine military hospital, perhaps from lothar loeffler, who was, after all, a member of the "dahlem circle," and -as portrayed elsewhere -probably remained in constant contact with the kwi-a because of the fingerprints and handprints from the