Caring for Holocaust Survivors
Rabbi Barry M. Kinzbrunner, MD
Chief Medical Officer
Vitas Innovative Hospice Care
Who is a Holocaust Survivor?
“A holocaust survivor will be defined as any Jew
who has lived in a country at the time when it
was:
• under Nazi regime
• under Nazi occupation
• under the regime of Nazi collaborators
as well as any Jew who fled due to the above
regime or occupation.”
Holo-Stats: Number of Living Holocaust Survivors; Israeli Prime Minister’s Office
Translated from Hebrew (transmitted by AMCHA on
[H-HOLOCAUST@h-net.msu.edu], 13 Aug, 1997) National Journal:
http://globalfire.tv/nj/03en/history/holostats.htm
Concentration Camp: Photo by Arthur Kaye, US Army Air Corps, 1945
Concentration Camp Barracks: Photo by Arthur Kaye, US Army Air Corps,1945
Concentration Camp Survivors: Photo by Arthur Kaye, US Army Air Corps, 1945
Concentration Camp Survivors Showing Numbers
Photo by Arthur Kaye, US Army Air Corps, 1945
Estimates of Holocaust Survivors
Country
Israel
Former Soviet Union
USA
Western Europe
Eastern Europe
Other Countries
Total
Holocaust Survivors
1997
2011 (estimate)
360,000-380,000
208,000
184,000-220,000
113,000
140,000-160,000
84,000
80,000-100,000
51,000
50,000-80,000
37,000
20,000
11,000
834,00-960,000
504,000
Holo-Stats: Number of Living Holocaust Survivors; Israeli Prime Minister’s Office
Translated from Hebrew (transmitted by AMCHA on
[H-HOLOCAUST@h-net.msu.edu], 13 Aug, 1997) National Journal:
http://globalfire.tv/nj/03en/history/holostats.htm
Generation of Holcaust Survivors Disappearing. Accessed 2/2/12 at http://matzav.com/generationof-holocaust-survivors-disappearing
Holocaust Survivors Living in USA: 1997
140,000-160,000 living holocaust survivors
• 33,000 refugees arrive in US: 1933-1937
• 124,000 refugees arrive in US: 1938-1941
• 119,373 refugees arrive in US: immediately after the
war.
• 24,090 arrive in US during 1950’s and 1960’s
• 49,416 arrive in US from FSU during recent wave of
immigration
Mortality rate based on average white American life span
Allen Gliksman: Polisher Research Institute
Holo-Stats: Number of Living Holocaust Survivors; Israeli Prime Minister’s Office
Translated from Hebrew (transmitted by AMCHA on
[H-HOLOCAUST@h-net.msu.edu], 13 Aug, 1997) National Journal:
http://globalfire.tv/nj/03en/history/holostats.htm
Holocaust Survivors Living in USA: 2003
• United Jewish Communties Report
• From National Jewish Population Survey of
2000-01
• Published in December 2003
• Estimated 122,000 “Nazi victims” in US
– More economically and socially vulnerable than
non-victims
– Poorer health, more disabilities, and greater social
service needs than non-victims
Nazi Victims Now Residing in the United States. Findings from the National Jewish
Population Survey 2000-01
United Jewish Communities Report, December, 2003
Holocaust Survivors Living in USA: 2003
Demographic Data
Country of Origin
Pre-1965
• Germany: 41%
• Poland: 21%
• Austria: 11%
• Czech:
6%
• Hungary: 6%
Post-1965
• FSU:
– Ukraine:
– Belarus:
– Russia:
• Poland:
• Romania:
93%
66%
11%
10%
3%
3%
Nazi Victims Now Residing in the United States. Findings from the National Jewish
Population Survey 2000-01
United Jewish Communities Report, December, 2003
Holocaust Survivors Living in USA: 2003
Demographic Data
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•
•
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•
•
Age:
Gender:
Region:
Marital Status:
Education:
Employment:
71 (mean) (+ 7 years to 2008)
62% female
53% NE; 26% W; 13% S; 8% MW
70% Mar; 7% Div; 17% Wid
52% College degree or more
59% Ret; 14% employed
23% Disabled and unable to work
Nazi Victims Now Residing in the United States. Findings from the National
Jewish Population Survey 2000-01
United Jewish Communities Report, December, 2003
Holocaust Survivors Living in USA: 2003
Financial Data
• Financial State
– Comfortable; very comfortable; wealthy:
– Just managing; Can’t make ends meet:
• Income
– < $35,000: 44%
– $ 35,000-$75,000:
– > $75,000: 9%
– Unreported:
• Below US Federal Poverty Line:
– 99% are post-1965 immigrants from FSU
• Social Security at 1/3 of household income:
63%
37%
13%
33%
25%
42%
Nazi Victims Now Residing in the United States. Findings from the National
Jewish Population Survey 2000-01
United Jewish Communities Report, December, 2003
Holocaust Survivors Living in USA: 2003
Health Data
• Social Isolation; Living alone:
• Health Assessment
– Poor: 26%
– Good:
– Fair:
34%
– Excellent:
• Health conditions
– Limited activities:
– Assistance or supervision:
daily or several times a week
25%
30%
10%
34%
24%
Nazi Victims Now Residing in the United States. Findings from the National
Jewish Population Survey 2000-01
United Jewish Communities Report, December, 2003
Holocaust Survivors Living in USA: 2003
Health Data
• Cost of health assistance program
– Paid by government program:
29%
– Paid by personal savings:
8%
• Social Service Needs
– Home health care:
16%
– Home nursing care:
5%
– Live in retirement home or ALF:
10%
• English as a second language: 6% (all post-1965)
Nazi Victims Now Residing in the United States. Findings from the National Jewish
Population Survey 2000-01
United Jewish Communities Report, December, 2003
Holocaust Survivors and Cancer Risk
• Compared:
– 1.8 million Israelis born 1920-1945-to Israel after WW II
– 464,000 Israelis born 1920-1939-to Israel before 1939.
• Overall survivors 2.4 times the risk of cancer
– Colorectal ca: 9 X the risk in male survivors, 2.25 X in females
– Breast ca: 1.5 X the risk in femal survivors
– Breast ca risk also double for women who were under 10
during the holocaust
• Believed to be related to exposure to starvation during childhood
and adolescence when the body is in a period of accelerated
growth
• 5 year ca survival rates 5-13% lower among survivors
Sinai R. Study: Cancer risk over twice as great for holocaust survivors. Ha-aretz,
4/14/07. Accessed on 1/14/10 at
http://www.haaretz.com/hasen/spages/848529.html
Holocaust Survivors and PTSD
Post-Traumatic Stress Disorder (PTSD)
• PTSD is an anxiety disorder that can
develop after exposure to a terrifying event
or ordeal in which grave physical harm
occurred or was threatened.
NIMH: Post-Traumatic Stress Disorder (PTSD). Accessed on 2/4/10
at http://www.nimh.nih.gov/health/publications/post-traumatic-stressdisorder-ptsd/index.shtml
Holocaust Survivors and PTSD
Symptoms of PTSD
• Re-experiencing
– Flashbacks
– Bad dreams
– Frightening thoughts
• Hyperarousal
–
–
–
–
Being easily startled
Feeling tense or “on edge”
Having difficulty sleeping
Having angry outbursts
NIMH: What are the symptoms of PTSD. Accessed on 2/4/10 at
http://www.nimh.nih.gov/health/publications/post-traumatic-stressdisorder-ptsd/what-are-the-symptoms-of-ptsd.shtml
Holocaust Survivors and PTSD
Symptoms of PTSD
• Avoidance
– Staying away from places, events, or objects that
are reminders of the experience
– Feeling emotional numbness
– Feeling strong guilt, depression, or worry.
– Losing interest in activities that were enjoyable in
the past.
– Having trouble remembering the events that
triggered the PTSD
NIMH: What are the symptoms of PTSD. Accessed on 2/4/10 at
http://www.nimh.nih.gov/health/publications/post-traumatic-stressdisorder-ptsd/what-are-the-symptoms-of-ptsd.shtml
Holocaust Survivor Syndrome
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•
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Exaggerated reactions to chronic pain
Depressive Reactions
Anxiety states
Somatic complaints
Intellectual impairment
Contact abnormalities
Sleep disturbances
Chronic functional gastrointestinal symptoms
Barile A: Geriatric study of survivors. International Society for Yad Vashem,
Martyrdom and Resistance. March-April, 2000, p. 14.
Holocaust Survivors and Pain
Goals of the study
• To define chronic pain characteristics of
Holocaust survivors 50 years after WW II
• To compare survivors with controls who did
not experience WW II atrocities
• To investigate the connection between past
trauma and chronic pain
Yaair A, Eisenberg E, Adler R, Birkhan J. Chronic pain in holocaust
survivors. J Pain Symptom Manage 17:181-187, 1999.
Holocaust Survivors and Pain
33 Holocaust survivors and 33 control patients
Yaair A, Eisenberg E, Adler R, Birkhan J. Chronic pain in holocaust
survivors. J Pain Symptom Manage 17:181-187, 1999.
Holocaust Survivors and Pain
Yaair A, Eisenberg E, Adler R, Birkhan J. Chronic pain in holocaust
survivors. J Pain Symptom Manage 17:181-187, 1999.
Holocaust Survivors and Pain
Yaair A, Eisenberg E, Adler R, Birkhan J. Chronic pain in holocaust
survivors. J Pain Symptom Manage 17:181-187, 1999.
Holocaust Survivors and Pain
Conclusions
• Holocaust patients had:
– High pain intensity
– Moderate to severe depression
– High activity levels
• By remaining active, Holocaust survivors fight back
their pain, distress, and depression.
• Holocaust atrocities affects survivors’ chronic pain
even years later.
Yaair A, Eisenberg E, Adler R, Birkhan J. Chronic pain in holocaust
survivors. J Pain Symptom Manage 17:181-187, 1999.
Holocaust Survivor Health Issues
Aging
• Retirement: after working hard to build new lives:
– free time may be daunting and/or threatening.
– free time may reduce defenses and allow room for intrusive
thoughts and other symptoms of post-traumatic stress
disorder
– needed relocation to a facility may raise memories of prior
loss of home and freedom
• Increased need for health care and exposure to
hospitals, nursing homes, and ALF’s
– Raise memories of Nazi medical experimentation
Pelly, S. “Aging Holocaust Survivors”, in Caring for Aging Holocaust Survivors, A
Practice Manual. Baycrest Centre for Geriatric Care, Toronto, Canada, 2003.
Holocaust Survivor Health Issues
Challenges that May Elicit Difficult Memories
• Exaggerated grief reactions:
– Vulnerability to loss, separation, illness, and
institutionalization
• Need to Bear Witness:
– telling their story or refusing to tell their story
• Absence of Kin:
– contemporaries are aging and dying, bringing
back memories of prior losses.
Pelly, S. “Challenges that May Elicit Difficult Memories”, in Caring for Aging
Holocaust Survivors, A Practice Manual. Baycrest Centre for Geriatric Care,
Toronto, Canada, 2003.
Holocaust Survivor Health Issues
Dementia and Cognitive Loss
• Blurs and confuses events of the past in time and
place
• Increasing dependence
– Invasion of privacy
– Increased exposure of vulnerabilities
– Institutionalization: authority and regimentation
• Behaviors associated with such as hoarding or
preoccupation with food
Goodman, R. “Aging Survivors with Cognitive Loss”, in Caring for Aging Holocaust
Survivors, A Practice Manual. Baycrest Centre for Geriatric Care, Toronto,
Canada, 2003.
Holocaust Survivor Health Issues
Complicated grief and bereavement issues
• Multiple layers of profound loss
– Premature loss of family
– Loss of homes, communities, lifestyles, years, and sense of
security
• No one to share grief with
• Recent losses compound losses during holocaust
• Death of spouse:
– loss of dependence
– need to be placed in a facility
Grief CJ. “Grief and Bereavement” and David P. “Grief and the Holocaust
Survivor” in Caring for Aging Holocaust Survivors, A Practice Manual. Baycrest
Centre for Geriatric Care, Toronto, Canada, 2003.
Holocaust Survivors Coping with Aging & Cancer
2000 Israeli study published in 2007
• 150 Holocaust survivors with cancer vs. 50 controls
• Typology of survivors (Danieli)
– Victims: keep to themselves, trust only those who are very
close, avoid contact with non-survivors, believe it could happen
again (17.3%)
– Numb: emotionally numb, constrained, socially isolated, lack in
vitality (0%)
– Fighters: sense of strength, deny weakness and depression,
most active socially and politically (39.3%)
– Those who “made it”: tend to deny the impact of the holocaust
on their lives, distance themselves from other survivors, and
are drive to succeed to indicate a “victory” over the Nazis
(43.4%)
Hantman S, Solomon Z. Recurrent trauma: Holocaust survivors cope with aging
and cancer. Soc Psychiatry Psychiatr Epidemiol 42:396-402, 2007.
Holocaust Survivors Coping with Aging & Cancer
Hantman S, Solomon Z. Recurrent trauma: Holocaust survivors cope with aging
and cancer. Soc Psychiatry Psychiatr Epidemiol 42:396-402, 2007.
Holocaust Survivors Coping with Aging & Cancer
Adjustment to aging
• Percentage of patients who reported the Holocaust
made it more difficult to cope with old age
– Victims:
76%
– Fighters:
41.8%
– “Made it”:
37.9%
(p < 0.001)
Stage of Cancer
• No significant association between stage of cancer and
PTSD symptoms, psychiatric symptoms, or
psychosocial adjustment to symptoms was found in any
of the groups.
Hantman S, Solomon Z. Recurrent trauma: Holocaust survivors cope with aging
and cancer. Soc Psychiatry Psychiatr Epidemiol 42:396-402, 2007.
Triggers that affect Holocaust Survivors
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White coats or uniforms
Commanding voices
Foreign accents
Handling individuals roughly or with force
Darkness and night hours
Fire alarms, strobe lights, sirens, whistles
Dogs
Bier D, Supporting Resilience in Aging Populations, The Impact of Earlier Trauma.
Learning from work with survivors of the Holocaust and elderly survivors of other
trauma. Holocaust Community Services, Jewish Child and Family Services, Skokie,
Ill. January, 2008.
Triggers that affect Holocaust Survivors
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•
•
•
Waiting in line, crowded conditions
Being counted off or directed
Food: Hiding or hoarding; eating too fast
Separation
– Into new environment: i.e. from home to ALF
or NH
– from family after visits
• Distressing sounds, cries, screams
Bier D, Supporting Resilience in Aging Populations, The Impact of Earlier Trauma.
Learning from work with survivors of the Holocaust and elderly survivors of other
trauma. Holocaust Community Services, Jewish Child and Family Services,
Skokie, Ill. January, 2008.
Triggers that affect Holocaust Survivors
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•
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•
Use of the shower or bath
Upsetting smells, or being unclean
Staff changes and new routines
Limits on freedom
Seasonal or religious holidays
Current events and/or political turmoil
Bier D, Supporting Resilience in Aging Populations, The Impact of Earlier Trauma.
Learning from work with survivors of the Holocaust and elderly survivors of other
trauma. Holocaust Community Services, Jewish Child and Family Services,
Skokie, Ill. January, 2008.
Triggers that affect Holocaust Survivors
Illness, Hospital Care, Medical/Dental procedures
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Giving blood or urine
• Injections
Wristbands
• Being shaved
Anesthesia
• Restraints
Undressing and being given hospital gown
Weight loss and change in body image
Lack of disease modifying therapies for illness
“Experimental” therapies
Advance care planning or terminal prognosis
Bier D, Supporting Resilience in Aging Populations, The Impact of Earlier Trauma.
Learning from work with survivors of the Holocaust and elderly survivors of other
trauma. Holocaust Community Services, Jewish Child and Family Services, Skokie,
Ill. January, 2008.
Advance Care Planning
• Holocaust survivors may refuse to discuss advance
care planning issues or be willing to execute an
advance directive
• Survivors have been so intent on survival that they
cannot accept the idea that they may die and so
discussing these concepts may be too painful for
them.
• Recommendations
– Be particularly sensitive when discussing these issues
– Involve children and other family members
David P. “Environment factors and potential triggers” in Caring for Aging Holocaust
Survivors, A Practice Manual. Baycrest Centre for Geriatric Care, Toronto, Canada,
2003.
Advance Care Planning
• Religious belief and practice may affect end of life
decision-making
• Holocaust survivors have a wide variety of beliefs
and practices that cover the entire spectrum of
Jewish practice in the US
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–
–
–
–
Orthodox
Conservative
Reform
Reconstructionist
Unaffiliated
Advance Care Planning
• Qualitative analysis by interview of 15 Israeli
Holocaust survivors
• Question of whether Nazi policies are similar to or
different from modern concepts of euthanasia
– Withholding food and fluid may be unacceptable because
Nazi’s often starved people to death
• Part of a larger study looking at attitudes of elderly
toward life-sustaining therapies
– No distinction perceived between active and passive or
voluntary and involuntary euthanasia
– Previous life experiences were important to individual
meanings and attitudes toward euthanasia
Leichtentritt RD, Rettig KD, Miles SH. Holocaust survivors’s perspectives
on the euthanasia debate. Soc Sci & Med 48:185-196, 1999.
Advance Care Planning
Results
• Participants were not familiar with the idea of
choosing one’s own death
• 9 pro euthanasia; 6 con euthanasia
• All participants concluded that profound differences
exist between Nazi Germany and socially assisted
dying regardless of their attitudes
• Themes of similarities
– Confined to the idea that the final outcome was—
Death
Leichtentritt RD, Rettig KD, Miles SH. Holocaust survivors’s perspectives
on the euthanasia debate. Soc Sci & Med 48:185-196, 1999.
Advance Care Planning
Results
Themes of differences
• Physicians as actors
– Authority taken vs. authority requested
– Intervention to kill vs. intervention to assist
• Participants as actors
– Wish to live vs. the wish to die
– Motivation to survive: continuity of the Jewish
people vs. the survival of the individual
– Decision of self vs. the decision of others
Leichtentritt RD, Rettig KD, Miles SH. Holocaust survivors’s perspectives
on the euthanasia debate. Soc Sci & Med 48:185-196, 1999.
Advance Care Planning
Results
Themes of differences
• Physician-participant relationships
– Power differentiation vs. Power equality
– Abusive vs. respecting relationships
• Social context
– Social ideology vs. individual needs and
preferences
– Decision by dictator vs. democratic procedures
– Injustice vs. justice and fairness
Leichtentritt RD, Rettig KD, Miles SH. Holocaust survivors’s perspectives
on the euthanasia debate. Soc Sci & Med 48:185-196, 1999.
Advance Care Planning
Results
• Survivors cautioned philosophers about comparisons
between the holocaust and other human behaviors
• They perceived that such a comparison has negative
consequences for:
– Their own well being
– The dignity of their family members
– The next generation
– Israeli society
Leichtentritt RD, Rettig KD, Miles SH. Holocaust survivors’s perspectives
on the euthanasia debate. Soc Sci & Med 48:185-196, 1999.
Children of Holocaust Survivors
Relationship with parents
• Closer
• Have more difficulty separating from them
• Protective and act in a protective manner at an
earlier age than American Jewish peers
• Call or visit parents more significantly than controls
• Closeness with parents may interfere with their
ability to establish close relationships outside the
family
• If asked “Have you ever found yourself acting like
your parents?” they knew what was meant; controls
did not
Gorko S. Myths and realities about offspring of holocaust survivors: An
overview of research findings. Accessed on 8/28/08 at
Children of Holocaust Survivors
• There is an increased vulnerability to PTSD and
other psychiatric disorders among offspring of
Holocaust survivors
– Yehuda et al, Am J Psych 155:1163, 1998
• Dreams, fantasies, and associations that have
holocaust content
– Believing they are riding on a cattle care rather
than the subway
– Epstein, “Children of the Holocaust,” Putnam, 1979.
Gorko S. Myths and realities about offspring of holocaust survivors: An
overview of research findings. Accessed on 8/28/08 at
Children of Holocaust Survivors
Fogelman & Savran, Am J Ortho-Psych 50:96-108, 1980
7 Psychosocial effects in children of survivors
• Need to identify with parents’ suffering to understand
them better and to feel more intimate with them
• Difficulty communicating with parents about holocaust
for fear of causing themselves or parents pain, or of
discovering what their parents had to do to survive
• Conflict between the need to express themselves
openly and the attempt to protect their parents from
further suffering by remaining silent about their own
pain and anger
Gorko S. Myths and realities about offspring of holocaust survivors: An
overview of research findings. Accessed on 8/28/08 at
Children of Holocaust Survivors
Fogelman & Savran, Am J Ortho-Psych 50:96-108, 1980
7 Psychosocial effects in children of survivors
• Struggle with the fantasy of compensating their
parents for the loss of family, friends, and entire
communities
• Problems in coping with their own rage, shame,
mistrust, guilt, fears, or scarred feelings because of
what happened to their parents
• Inability to mourn people they never knew
• Searching for a personal way to express their thoughts
and feelings about the holocaust and develop
continuity with the family’s past
Gorko S. Myths and realities about offspring of holocaust survivors: An
overview of research findings. Accessed on 8/28/08 at