NEW YORK — The hallway of Eva Deutsch Costabel’s small Manhattan apartment is lined with her lively, colorful paintings. Just past the impromptu corridor gallery is her small, cluttered kitchen.

“My friends always tease me because my refrigerator is always full. They say, ‘You could feed ten people.’ I think this is definitely from starving for many years,” Costabel said.

The 91-year-old artist survived two concentration camps and spent 18 months in the Yugoslav resistance. And like many of the roughly 60,000 survivors in the New York Metropolitan Area, Costabel still suffers from the war, partly due to the effects of malnutrition.

The repercussions of wartime starvation are an overlooked and poorly understood factor in survivors’ lives today. While some survivors tend to hoard food, or eat spoiled food rather than throw it away, they also have higher rates of osteoporosis, cancer and other medical conditions, likely related to starvation during the war. Added to the mix is the shockingly widespread poverty among survivors today, making it difficult for many to eat healthy — even in a city of plenty like New York.

Wartime famine for Europe’s Jews was extreme. The Nazis fed inmates in camps a meager diet of thin soup and bread, and in some camps, prisoners’ life expectancy was only three months. In the Warsaw Ghetto, some 15 to 18% of the population died of starvation within 18 months of the ghetto’s establishment. One survey of survivors noted they lost on average an estimated 60 pounds in the camps.

After surviving those horrors, “They have higher nutritional needs today than the general elderly population and meeting those needs is costly,” said Masha Pearl, the executive director of the Blue Card, an organization helping support survivors in New York. “This is really the start and end to many different things in their lives.”

Starving prisoners of the Ebensee concentration camp in Austria, a subcamp of the Mauthausen concentration camp, photographed by an American soldier at liberation on May 6, 1945 (National Archives and Records Administration)

Starving prisoners of the Ebensee concentration camp in Austria, a subcamp of the Mauthausen concentration camp, photographed by an American soldier at liberation on May 6, 1945 (National Archives and Records Administration)

An American soldier, quoted as “Colonel Edmund M.” in the book “Witness: Voices from the Holocaust,” described the condition of the inmates in the Mauthausen-Gusen concentration camp in Austria when his unit discovered the complex. “Some of them actually looked almost like living skeletons. I took a look at some, and I would estimate the average weight probably might have been eighty, ninety pounds or so,” he said.

Artist Costabel survived two concentration camps in Italian territory on the Adriatic Coast. While the conditions were relatively better than in the Nazi death camps and the Italians did not kill captive Jews, Costabel said, the conditions were still extreme and they were still starving.

“I went to a psychiatrist for years, many years. I had post-traumatic stress, this was in New York. It’s a horrible disease,” she said.

A poorly understood problem

Researchers have studied the long-lasting psychological effects of the Holocaust. Dr. Janina Galler of Harvard Medical School, however, studies the long-term effects of malnutrition.

Galler is not aware of any longitudinal studies looking at the damage done specifically by starvation during the Holocaust, she said. However, she added, researchers have documented the lasting effects of famine in China, the Netherlands, Leningrad, Latin America and elsewhere.

Galler, herself the daughter of Holocaust survivors, said there are well-documented mental health effects among survivors, and starvation likely played a part in these problems.

“The major studies of the Holocaust have looked at the impact of trauma and I don’t think people have really focused on the nutritional aspect, but it is very parallel to these other situations, but even more extreme because it also involved murdering six million people and more,” Galler said. “It’s hard to understand why people haven’t quite followed it up in the same way.”

A survivor of the Bergen-Belsen concentration camp eats soon after the camp's liberation by British forces in April 1945 (Imperial War Museum)

A survivor of the Bergen-Belsen concentration camp eats soon after the camp’s liberation by British forces in April 1945 (Imperial War Museum)

Galler says malnutrition is difficult to research, partly because it is hard to isolate it as a variable for study.

“It’s hard to tease it out from stress and other traumatic exposures that these people went through,” she said.

Survivors are now geographically dispersed, she said, making it hard to study a group who had similar experiences during the war.

The long-lasting health effects

Survivors suffer from increased rates of cancer and other diseases, likely related to both trauma and malnutrition. A 2007 study found that female survivors were more than twice as likely to suffer from osteoporosis than the general female population. Researchers at the University of Haifa in 2009 found that survivors in Israel were significantly more likely to get cancer, especially those who were younger during the Holocaust. Diabetes and dental issues are also significant problems, said Pearl of the Blue Card.

Galler said her research indicates that children of young mothers born soon after liberation would also be vulnerable to the lasting effects of starvation.

“The major effect that my work and the work of others have pointed to, the major effects are in utero, in pregnancy and also going into pregnancy,” Galler said. “Not to put a burden on these people, but women who got pregnant within the first year or two may have experienced some degree of compromise during pregnancy.”

A British social worker treats survivors of the Bergen-Belsen concentration camp soon after liberation (Imperial War Museum)

A British social worker treats survivors of the Bergen-Belsen concentration camp soon after liberation (Imperial War Museum)

The damage caused by malnutrition could potentially last even longer. Researchers studying survivors of famine in the Netherlands in World War II found that the grandchildren of women who were malnourished when pregnant had poorer health.

Additionally, researchers led by Rachel Yehuda of Mount Sinai Hospital in New York found evidence that Holocaust survivors can pass the effects of trauma onto their children in their genes, a phenomenon called epigenetic inheritance. An Israeli study published in 2007 found some correlation between the severity of Holocaust survivors’ experiences and disordered eating in their children and grandchildren, although the authors of the study noted the need for further research.

Disordered eating

A 2004 study of survivors in South Florida found five major effects on survivors’ long-term attitudes toward food:

“(1) Difficulty throwing food away, even when spoiled; (2) storing excess food; (3) craving certain food(s); (4) difficulty standing in line for food; and (5) experiencing anxiety when food is not readily available.”

In an Italian study published in 2000, 33% of the survivors surveyed reported binge eating behavior sometime in their lives.

But not all research agrees. A 2005 study from the Hebrew University in Jerusalem on 55 survivors in Israel did not find evidence of eating disorders. The authors acknowledged contradicting previous research, and said they did not have an explanation for the discrepancy, although survivors in Israel may be different in some ways than survivors elsewhere, they said.

Eva Deutsch Costabel in her apartment in Manhattan (Luke Tress/Times of Israel)

Eva Deutsch Costabel in her apartment in Manhattan (Luke Tress/Times of Israel)

Pearl says she has seen some of these problems firsthand through her work with survivors in New York.

Some of the women the Blue Card works with recreate recipes from their childhoods. Many don’t have photos of their family members and the smell of the food reminds them of relatives they lost in the war. The practice is so widespread among female survivors that there is a collection of recipes and stories in print called “The Holocaust Survivor Cookbook.”

The foods are often unhealthy and high in fat and sodium though, Pearl said.

Hoarding food is another issue.

“They will finish what they have or make it last as long as possible,” Pearl said.

Treating the damage today

Treating the health effects of survivors requires special dietary considerations. The Blue Card runs a Nutritional Guidance Program, a Vitamins Program, and a Dental Program for its clients, among other services.

The Blue Card, which was established by Jews in Germany in 1934 to help the community deal with Nazi oppression, works with the Academy of Nutrition and Dietetics to help educate survivors on better nutrition, especially those with illnesses. They distribute a tip sheet on eating a healthy kosher diet while receiving cancer treatment, for example, and provide individual dietary advice to those who need it.

The Academy of Nutrition and Dietetics, a Cleveland-based organization of nutrition professionals, had several special interest groups but was lacking information for the Jewish population, said Dr. Sari Edelstein.

A nutrition guide for survivors with cancer published and distributed by the Blue Card and the Academy of Nutrition and Dietetics (Courtesy)

A nutrition guide for survivors with cancer published and distributed by the Blue Card and the Academy of Nutrition and Dietetics (Courtesy)

“When I looked I didn’t see one for Jewish members. I knew that there were lots of patients and the public who had a need for kosher diets and they didn’t have a group catering to their needs,” Edelstein said. “There was an overwhelming support for how many dieticians thought this would be a win-win.”

Edelstein developed nutritional education guides for survivors based in research on geriatric nutrition, but with Jewish cultural and kosher considerations. Meal plans had to be both economical and appealing. They distributed the guides by mail because many survivors have limited mobility and do not like to attend meetings. The program started in 2012, Edelstein said.

“We heard many don’t like to go out or are afraid, some are hoarding, some are frugal and don’t want to spend,” Edelstein said. “We wanted to make them aware of a lot of the foods that were nutritious that they would have an easier time with.”

Fortified beverages from Ensure, which Edelstein describes as “a meal in a can,” are an essential part of the academy’s program. They are the best way to keep someone nourished, Edelstein said, and many elderly people have difficulty preparing or chewing some foods.

“None of this is the answer but it all helps a lot,” Edelstein said.

Costabel receives the drinks through the Blue Card.

“I cannot swallow vitamins very well, so this liquid, it’s a lifesaver,” she said.

The Italian flag hangs over the Rab concentration camp, where Costabel was held. The island of Rab in the Adriatic sea was occupied by Italy and is now a part of Croatia (Public domain via Wikimedia Commons)

The Italian flag hangs over the Rab concentration camp, where Costabel was held. The island of Rab in the Adriatic sea was occupied by Italy and is now a part of Croatia (Public domain via Wikimedia Commons)

The problem of poverty

The Academy of Nutrition and Dietetics and the Blue Card get some of their supply through donations because many elderly survivors would not be able to pay for the drinks, Edelstein said.

In addition to the drinks and other support from the Blue Card, Costabel receives food assistance from New York City’s Supplemental Nutrition Assistance Program (SNAP).

Masha Pearl of the Blue Card (Courtesy)

Masha Pearl of the Blue Card (Courtesy)

“I get two hundred dollars worth of food each month, which is extremely helpful, because food is very expensive, and I don’t eat so much, you know, when you’re old you don’t,” she said. “If I have a little dish this is enough food for me.”

Kosher foods can cost up to $400 a month, which is hard for many survivors to afford, said the Blue Card’s Masha Pearl.

About one half of survivors in New York live near or below the poverty line, while about 20% of New York City’s seniors live in poverty. A 2013 report by Selfhelp, a nonprofit that works with survivors, estimated that by 2020, there will be more than 38,000 survivors in the New York City Metropolitan Area, and 35 percent of them will be dealing with serious or chronic illnesses. “Fifty-two percent will be ‘poor’ under Federal guidelines,” the report said.

Pearl’s grandparents on both sides of her family were Holocaust survivors, and she became involved in advocacy work after seeing other survivors living in poverty in New York.

‘Not every survivor came here and made it and was a wonderful success story’

“Not every survivor came here and made it and was a wonderful success story,” she said.

Some stock up on cheap but unhealthy canned and processed foods, and those with limited mobility have a hard time getting fresh produce, Pearl said. Some were unwilling or unable to have children, or married another survivor who has since passed away, so they lack family support.

“We see many cases where there was a two person household and one passes away,” Pearl said. “Moving is very difficult, and paying rent becomes very difficult and landlords tend to take advantage of that.”

Costabel is grateful for the help she receives from friends, but is proud of the fact that she has always supported herself, even though she arrived in New York alone.

“I never owed a cent to anybody, all the 65 years I’m here. I never owed money, I never bought anything I couldn’t afford. This is my rule. Everything you see, my furniture I bought used, used stores and whatever,” she said.

‘What I did is I put all my emotion, all my frustration in my paintings’

She struggled with the effects of the Holocaust for years, she said, but her art allowed her to cope with her experiences.

“This is something you cannot deal with if you don’t get it out of your system, and of course what helps me tremendously is that I’m an artist,” Costabel said. “What I did is I put all my emotion, all my frustration in my paintings.”

She still paints regularly, and teaches a workshop on abstract art for people with chronic diseases.

Many victims of the Holocaust need more support than Costabel does, and the window to help them is closing fast, Pearl said. Auschwitz was liberated 71 years ago. In 2020, all survivors will be at least 75 years old.

“It’s a time-limited issue. We need to know we’ve done all we could,” Pearl said.

Costabel's Manhattan apartment is full of her lively, brightly colored paintings (Luke Tress/Times of Israel)

Costabel’s Manhattan apartment is full of her lively, brightly colored paintings (Luke Tress/Times of Israel)