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People with mental illness commonly experience discrimination, exclusion and neglect in various different ways. They have increased rates of homelessness and imprisonment; they often experience social isolation and poor access to healthcare; and they have sharply diminished life expectancy for a variety of reasons.
But in addition to neglect and exclusion, the mentally ill have also experienced active abuse and persecution over the course of history. Perhaps the most egregious example of this took place in Europe during World War II, between 1939 and 1941.
World War II was the worst conflict in the history of humanity, involving 50 to 85 million fatalities and inestimable suffering among many millions more. Certain groups suffered more than others, including the six million European Jews who were murdered in the Holocaust.
Other groups were also targeted, however, and increased attention is now being paid to the fate of the mentally ill and intellectually disabled in Nazi-controlled territories before and during the war.
Based on the doctrine of racial hygiene, people with disabilities and mental illness were exposed to discrimination and persecution from an early stage. From January 1934 onwards, many were subjected to compulsory sterilisation under the ‘Law for the Prevention of Genetically Diseased Offspring’. Approximately 400,000 people were sterilised as part of this programme and upwards of 5,000 died from complications of the operation.
The situation worsened in 1939 when Adolf Hitler authorised a programme of systematic killing of people ‘deemed incurably sick, after most critical medical examination’. At least 70,273 people were then killed at extermination centres located at psychiatric hospitals in Germany, Austria and occupied Poland. The programme ran from September 1939 to August 1941 and was known as ‘Aktion T4’, after Tiergartenstraße 4, the street address of the department set up in Berlin to administer the programme in 1940. Aktion T4 was possibly the most extreme persecution ever experienced by the mentally ill in recorded history.
One of the most notorious killing centres was located in a psychiatric hospital in Hadamar, a small town between Cologne and Frankfurt am Main in Germany. Between January and August 1941, approximately 10,000 patients were killed in the gas chamber in Hadamar. After a one-year break, Hadamar then became involved in the second phase of the programme, chiefly involving overdosing with drugs and targeted malnutrition. From August 1942 until the end of the war, approximately 4,500 people died in Hadamar.
The complicity of doctors and other clinical staff in these actions is deeply troubling. After the war, American forces tried seven staff members from Hadamar: Three were executed and the other four given lengthy prison sentences. In 1946, German courts tried other members of the Hadamar staff for the murders of nearly 15,000 Germans and Adolf Wahlmann and Irmgard Huber, the chief physician and the head nurse, were convicted.
But trials only bring justice to a certain point. Real, lasting justice is harder to achieve and, for the mentally ill, explicit protections of their rights were slow to evolve, even after the atrocities of the war. Today, the UN’s ‘Principles for the Protection of Persons with Mental Illness and for the Improvement of Mental Health Care’ seek to protect the rights of the mentally ill.
The lessons to be learned from Nazi Germany are stark: Aktion T4 could easily happen again, if political and social circumstances move in that direction. Such a development is by no means impossible, so it is important to remain consistently focused on human rights and provision of care, and to remember the horrors of Aktion T4.
Today, the killing centre at Hadamar has become a memorial, a place of remembrance, historical learning and political education aimed at children, young people and adults. Its mission it to convey historical information and to improve political education so that similar events do not happen again.
In Berlin, too, Aktion T4 is remembered. There is an especially striking memorial at Tiergartenstraße 4, where the programme was based. Visiting this memorial was easily the most poignant moment of a visit to Berlin this summer. The street where the memorial stands is a busy, bustling one with plenty of traffic, pedestrians and modern new buildings. But the stark memorial to the deliberate, cold-blooded deaths of so many mentally ill and intellectually disabled people is a point of great stillness and solemnity in the midst of the traffic and noise. It is both understated and overwhelming.
But, most of all, the Berlin memorial to Aktion T4 is humbling. It should never have happened, even once. But it did. As healthcare professionals, it is our job to help ensure it never happens again. Such an eventuality might seem very distant from our lives today, but politics and society can shift in subtle, powerful ways, so we are never too far away from another Aktion T4.
Deeply and desperately, we need to remember this.