Health of Holocaust Survivors as Reflected in Cause of Death Data

Background: Holocaust survivors (HS) underwent extreme trauma and stress during WWII including physical and emotional violence, food deprivation, loss of family, friends, home and property. They require multi-disciplinary care, particularly at older ages.

Aim: To compare overall and cause specific mortality rates of Holocaust survivors with comparisons of similar ethnic origin.

Methods: Survivors of severe Nazi persecution (HS, n= 64,836), of pre-Holocaust persecution (early HS, n= 5,980) and a comparison group who immigrated before the war or from countries not subject to Nazi occupation (n= 19,553), were defined from 1972 Israeli National Census data, and followed up till 2014 for causes of death as coded by the Israeli Central Bureau of Statistics (CBS). Standardized mortality ratios were calculated (SMR), comparing survivors to comparisons using the total age specific person years of each group for denominator. Cox regression models were run for leading causes of death to check for significant differences between HS and comparisons controlling for sex, baseline age and education.

Results: European HS and early HS had lower total mortality than comparisons, SMR = 0.93 (95% CI 0.92-0.94) and 0.87 (95% CI 0.84-0.89) respectively, as well as significantly lower mortality from heart and cerebrovascular disease. However, significantly high SMR`s were found for liver disease and diabetes mortality for HS, 1.50 (95% CI 1.35-1.67) and 1.28 (95% CI 1.22-1.34), respectively, and suicide for early-HS only, SMR = 1.56 (95% CI 1.15-2.07). Total cancer mortality SMR was not significantly higher in HS but was higher from respiratory and liver/gall/pancreas cancers. The results were maintained in Cox regression models, except for diabetes.

Conclusions: Although overall mortality and lower suicide rates may reflect higher resilience among HS and possibly good healthcare, their elevated mortality from diabetes and liver diseases may reflect prolonged exposure to dietary deprivations and toxic conditions, not shared by early HS.