Diabetes Prevention, Care and Research in the German Democratic Republic (GDR), C.1949 – 1990

‘Conditionally Healthy and Able to Work’: Diabetes Prevention, Care and Research in the German Democratic Republic (GDR), c.1949 – 1990

A thesis submitted to the University of Manchester for the degree of Doctor of Philosophy in the Faculty of Biology, Medicine and Health

2019

Kathrin A. Hiepko Centre for the History of Science, Technology and Medicine

CONTENTS

I: List of Abbreviations 4 II: List of Figures 6 III: Abstract 7 IV: Declaration and Copyright 8 V: Acknowledgements 9

Introduction 11 0.1 A dictatorship of sorts: political and economic interpretations of the GDR 14 0.2 Debates on East German medical thinking and prevention practices 21 0.3 Historical (im)balance: studies on the East German healthcare system and its medical professionals 26 0.4 New directions: using diseases as case studies for the analysis of the GDR 35 0.5 Outline of the thesis and sources 39

Chapter 1: A System of Chronic Disease Management for a ‘New Society’: The Introduction of Diabetes Care in the GDR (c. 1949-1961) 44 1.1 The epidemiological strategy of social hygiene and its emphasis on prevention in early East German diabetes management 44 1.2 The development of outpatient care for diabetics: the polyclinic model and the Dispensaire System 51 1.3 Defining the role of the new state socialist doctor and diabetes specialist 56 1.4 Economic and material challenges in evolving state socialism and their impact on the treatment methods for diabetics 63 1.5 The introduction of specialist institutions for diabetics 70 1.6 Conclusion 80

Chapter 2: ‘Aktion Störfreimachung’ and the Shadow of the Berlin Wall (1961-1966) 82 2.1 Import-Insulin and the policy of Störfreimachung 87 2.2 The site of consumption: diabetes advice centres during the ‘Störfreimachung period’ 98 2.3 Finding new consumers: the expansion of regional screening programmes for diabetes 105 2.4 Responding to consumption: the evaluation of the structures of diabetes care 111

2.5 Conclusion 120

Chapter 3: Keeping Up, Moving Ahead and Falling Behind: the GDR’s Drive for International Recognition (1966-1973) 123 3.1 From Institut to Zentralinstitut: the position and leadership of the GDR’s foremost institution for diabetes 125 3.2 The ‘Research Project “Diabetes Mellitus”’ and ambitions for ‘world-leading’ research 133 3.3 Painting a positive picture of East German diabetology: trips abroad and visits made by international specialists 140 3.4 Already ahead of the rest? Changing perceptions of prevention and organisation in ambulatory and stationary care 148 3.5 Conclusion 157

Chapter 4: The Height of the so-called ‘Normalisation’ Period (1973-1980) 158 4.1 The ‘Research Project “Diabetes Mellitus”’ in the early Honecker years 161 4.2 Clinics I, II, III: the ‘normalisation’ of the Central Institute for Diabetes 165 4.3 ‘A highly qualified, highly specialised, high achieving, highly complicated and highly organised system of care’: the Dispensaire System’s capacity to deliver ‘real-existing socialism’ to diabetics 171 4.4 The pharmacy of the Eastern Bloc? Insulins, oral anti-diabetic tablets and the continued dilemma of imports 179 4.5 Conclusion 190

Chapter 5: The Final Curtain for Diabetes Care and Research ‘East German-Style’ (1980-1990) 192 5.1. Importablösung: a return to the 1960s? 196 5.2 The patients’ view: everyday life of diabetics in the final decade as portrayed by the Patientenaktiv and in Eingaben 207 5.3 The diabetologists’ view part I: struggles at home 216 5.4. The diabetologists’ view part II: international recognition at last? 221 5.5 Conclusion 230

Conclusion 232 Bibliography 241 Appendix 273 *Word count: 99,999 (incl. footnotes), 80,878 (excl. footnotes)

List of Abbreviations

Alt-Insulin Fast-acting pig and bovine insulin by VEB Berlin-Chemie

AWD Arzneimittelwerk Dresden

BArch Bundesarchiv/ Federal Archive (Berlin Lichterfelde)

Berlinsulin Depot bovine insulin by VEB Berlin-Chemie

B-Insulin Depot pig and bovine insulin by VEB Berlin-Chemie

BStu Der Bundesbeauftragte für die Unterlagen des Staatssicherheitsdienstes der ehemaligen Deutschen Demokratischen Republik/ Federal Commissioner for the Records of the State Security Service of the former German Democratic Republic

COMECON Council for Mutual Economic Assistance

DAFNE Dose Adjustment For Normal Eating

EASD European Association for the Study of Diabetes

EDESG European Diabetes Epidemiology Study Group

EDV Elektronische Datenverarbeitung/ Electronic Data Processing

FRG Federal Republic of Germany (West Germany)

FDJ Freie Deutsche Jugend/ Free German Youth

GDR German Democratic Republic (Deutsche Demokratische Republik, ‘DDR’)

GERMED Pharmaceutical combine created in 1979

Humaninsulin Recombinant/ ‘human’ insulin

IBM International Business Machines Corporation

IDF International Diabetes Federation

IFAR Institut für Arzneimittelwesen/ Institute for Drugs

IM Inoffizieller Mitarbeiter/ Stasi informant

Kombinat Industrial Combine

L-SNC Depot neutral pig insulin MC Mono-component insulin

NATO North Atlantic Treaty Organisation

NÖS Neues Ökonomisches System der Planung und Leitung/ New Economic System of Planning and Management

NPH Neutral Protamine Hagedorn/ isophane insulin

Polfa Polska farmacja

PZ Protamine Zinc insulin

SAPMO Stiftung Parteien und Massenorganisationen der ehemaligen DDR/ Foundation Archive of the Parties and Mass Organisations of the GDR in the Federal Archives

SED Sozialistische Einheitspartei Deutschlands/ Socialist Unity Party of Germany

SMAD Soviet Military Administration

SNC Fast-acting neutral pig insulin

SPOFA Spojené farmaceutické závody

Stasi Staatssicherheitsdienst der DDR/ State Security Service of the GDR

TB Tuberculosis

UN United Nations

VEB Volkseigener Betrieb/ Publicly Owned Enterprise

WHO World Health Organisation

ZGA Zentraler Gutachterausschuss für Arzneimittelverkehr/ Central Review Committee for Drug Traffic at the Ministry of Health

ZID Zentralinstitut (Central Institute) für Diabetes ‘Gerhardt Katsch’

List of Figures Figure 1: An example of a polyclinic in East Berlin, August 1976 53 Figure 2: Prof. Dr. Gerhardt Katsch (1887-1961), inventor of the notion that diabetics were ‘conditionally healthy and able to work’ 58 Figure 3: Formerly ‘Schloss Karlsburg’, now the ‘Institut für Diabetes’ 71 Figure 4: The Boarding School for Diabetics, Island of Rügen, September 1964 78 Figure 5: Repairing a filling machine at the insulin department of VEB Berlin-Chemie, April 1971 88 Figure 6: Typical example of a test set containing urine test strips from Feinchemie KG, Sebnitz 103 Figure 7: The 1965 article ‘Every Tenth is a Diabetic’, promoting the importance and merits of large-scale screening 110 Figure 8: Sanatorium Rheinsberg, September 1964 113 Figure 9: The Zentralstelle für Diabetes und Stoffwechselkrankheiten, East Berlin, May 1971 116 Figure 10: Placard highlighting obesity as a risk factorfor cardiovascular disease and diabetes, 1970 153 Figure 11: Taking blood samples from patients at the Central Institute for Diabetes (Klinik I), October 1978 167 Figure 12: Diabetes nurse dealing with a patient admission at the Central Institute for Diabetes, 1978 176 Figure 13: Glass syringe produced in the 1970s and 1980s by VEB Injecta Steinach 206 Figure 14: A specialist shop selling the East German brand of diet foods, ‘Sucrosin’, October 1973 211

* Translation note I, the author, have translated all original quotations, phrases and medical terminology from German into English

Abstract

Abstract submitted to the University of Manchester in February 2019 for a Doctor of Philosophy thesis by Kathrin Hiepko entitled: ‘Conditionally Healthy and Able to Work’: Diabetes Prevention, Care and Research in the German Democratic Republic (GDR), c. 1949- 1990

This thesis seeks to chart the development of a comprehensive system of diabetes care in a socialist state, the German Democratic Republic (GDR). There have been few seminal studies to date on chronic diseases using state socialism, and in particular the GDR, as a contextual base. The thesis serves to highlight the fact that chronic diseases were acknowledged, treated and rationalised behind the Iron Curtain. It uses diabetes as a case study to shed light on what exactly the state socialist response was to a rising, and potentially debilitating, disease. It is therefore primarily concerned with what makes diabetes management in the GDR, first, distinctly state socialist, and, second, unmistakably East German.

Following the Second World War, a radically different approach to health developed out of the rubble in the Soviet Zone and later GDR. The principle of social hygiene, firmly within the realm of epidemiology, focused on the economic and social causes of disease. It allowed for the previously marginal diabetes to become a focus of attention when East German diabetologists discovered an unexpectedly higher incidence of the disease than previously assumed. Aware that diabetes could lead to complications, the addition of a Marxist-Leninist productionist critique meant that the prevention of invalidity and keeping people in work were of paramount concern, leading to the development of an elaborate screening programme and a prevailing attitude of ‘prevention first’. When the diabetologist responsible for the creation of the GDR’s showcase ‘(Central)Institute for Diabetes’, Gerhardt Katsch, proclaimed that diabetics were ‘conditionally healthy and able to work’, it chimed with the expectations of a regime of which he and his ideas were now a part.

Surveying the entirety of the GDR’s lifetime, this thesis begins by looking at the introduction of new institutions catering to the needs of diabetics, from outpatient specialist polyclinics to a boarding school for diabetic children, and examines the influences underpinning them. The thesis is structured chronologically with embedded themes in a deliberate attempt to reveal how broader events, including autarkic economic policies, diplomatic relations and political upheaval came to shape the novel, East German approach to diabetes.

DECLARATION

I declare that no portion of the work referred to in the thesis has been submitted in support of an application for another degree or qualification of this or any other university or other institute of learning.

i. The author of this thesis (including any appendices and/or schedules to this thesis) owns certain copyright or related rights in it (the “Copyright”) and s/he has given The University of Manchester certain rights to use such Copyright, including for administrative purposes. ii. ii. Copies of this thesis, either in full or in extracts and whether in hard or electronic copy, may be made only in accordance with the Copyright, Designs and Patents Act 1988 (as amended) and regulations issued under it or, where appropriate, in accordance with licensing agreements which the University has from time to time. This page must form part of any such copies made. iii. The ownership of certain Copyright, patents, designs, trademarks and other intellectual property (the “Intellectual Property”) and any reproductions of copyright works in the thesis, for example graphs and tables (“Reproductions”), which may be described in this thesis, may not be owned by the author and may be owned by third parties. Such Intellectual Property and Reproductions cannot and must not be made available for use without the prior written permission of the owner(s) of the relevant Intellectual Property and/or Reproductions. iv. Further information on the conditions under which disclosure, publication and commercialisation of this thesis, the Copyright and any Intellectual Property and/or Reproductions described in it may take place is available in the University IP Policy (see http://documents.manchester.ac.uk/DocuInfo.aspx?DocID=2442 0), in any relevant Thesis restriction declarations deposited in the University Library, The University Library’s regulations (see http://www.library.manchester.ac.uk/about/regulations/) and in The University’s policy on Presentation of Theses.

Acknowledgements

I would first like to start by thanking the AHRC’s North West Consortium Doctoral Training Partnership for providing me with generous funding during my doctoral studies. The writing of this thesis would certainly not have been possible without this. I am extremely grateful to my two supervisors, Dr. Carsten Timmermann and Professor Stephen Parker, for their excellent advice and guidance throughout the writing and research process. I have benefited a great deal from being based at the Centre for the History of Science, Technology and Medicine (CHSTM) at the University of Manchester. I have found the department to be warm and friendly, and I wish to extend my gratitude to all members of staff there for making it the environment that it is. I am also heavily indebted to my fellow PhD students in the CHSTM Postgraduate Office for their constant friendship, support, the coffee ‘on tap’ (a necessity for a coffee-lover like me!) and all-round good humour.

During the research for this thesis, I consulted many documents at the Federal Archive in Berlin. The staff were fantastic and were only too willing to help me order files and photos. In addition to archival work, I have interviewed several diabetes patients who gave up their time to tell me in earnest their experiences of the care they had received in the former GDR. I really value their input and courage in recounting these details, and I thank them profusely. I have also talked to many specialists from across eastern Germany. I have been overwhelmed by their generosity and kindness, not only sharing their life’s work with me, but also keeping me supplied with ‘Kaffee und Kuchen’ (coffee and cake) and making me feel welcome when I asked them questions about what diabetes care in the GDR was like, their day-to-day activities in healthcare facilities, the types of research they undertook, and so much more. I would therefore like to thank, in turn, Dr. Anders, Dr. Austenat (who was also very helpful in arranging a meeting with Dr. Schliack), Professor Hanefeld, Professor Lürmann, Dr. Schliack (and his wife, Dr. Bärbel Schliack), Dr. Singer, Dr. Verlohren, Dr. Wegner and Dr. Ziegelasch (who I would like to thank for the lovely day I spent in the equally lovely city of Schwerin).

There are two doctors, Professor Bruns and Dr. H. Schneider, who I have interviewed several times over the course of the PhD, to whom I must give special thanks. From the beginning, they have been very generous in sending me copies of their many published journal articles and books, giving me access to photographs, and providing me with a vivid picture of what life was like for doctors and patients in the GDR. Dr. Schneider has been crucial in helping me find

9 and liaise with patients; it is no coincidence at all that, when interviewed, those who have been treated by him have recalled him fondly. I have spent many hours interviewing Dr. Schneider, and particular mention should be made of his wife Thea, too, who kept us all going with the very best coffee and cake!

Finally, I want to thank my family for their unending support and belief in me.

Introduction

Since the fall of the Berlin Wall in 1989, the history of the German Democratic Republic (GDR) has become a topic of great interest, both in German as well as international historiography. Much of what had been written about the East German state prior to that time, due to the unavailability of source material, had been either conjecture or heavily influenced by the GDR’s firmly controlled and censored media output. The full availability of archival material following reunification meant that much deeper and more reliable research became possible. Whilst a large amount of the early literature produced after reunification focused on the main institutions of the state, such as the Staatssicherheitsdienst (Stasi), and was often informed by the fact that the GDR had collapsed and therefore appeared as an utterly failed state, a more differentiated approach has been adopted in recent years. This has also encompassed efforts to establish the extent to which state socialism affected the lives of individual citizens living in the GDR.

Many of the attempts to assess what life was really like for those inhabiting the GDR have so far concentrated on defining the nature of the East German dictatorship. Increasingly, though, there has been a realisation that a clear understanding of the quality of the lives led by East German citizens can only be achieved by a deeper analysis of individual aspects of everyday existence. One such aspect is the way in which the GDR’s healthcare system was constituted, and how this system affected those who received treatment within it. This thesis intends to add to this strand of literature by offering a detailed study of the care for diabetics, an area which has hitherto not been analysed in any depth. The study will initially set out the framework for diabetes care established immediately after the creation of the GDR state in 1949 but will then have a particular focus on the time between the building of the Berlin Wall in August 1961 and reunification in 1990. By focusing on this time frame, it will be possible to get a glimpse of life in East Germany during the time when the GDR state was at its most stable, not least because this was the period when there was, quite literally, no escape from it for the vast majority of the population, but it will also allow for an assessment of the effects of the decline experienced during the later years of the regime. The choice of diabetes as the topic for the thesis is hoped to assist in the attempt to provide a deeper analysis of life under state socialism than has been undertaken so far, as, for patients, the chronicity of the condition inevitably involves long-term exposure to the systems employed by the state to deal with the

11 disease and its consequences within socialist society in general and the world of work in particular.

What follows is intended to give an overview of existing literature which will be useful to inform the research undertaken for this topic. As this thesis is primarily engaged with the GDR as a contextual backdrop, much of the historiographical and theoretical framework concerns the nature of the GDR and its healthcare system. To highlight why the GDR is such an interesting context in which to place the subject of diabetes, one need only look at what is absent from current studies on diabetes and chronic diseases. It has been acknowledged that the historiography of infectious diseases is relatively extensive, but for chronic diseases, there is much that has yet to be done.1 This is certainly true in that not many studies to date have really shifted attention away from the predictable territory of twentieth-century capitalism. Some assumptions about chronic diseases, like their necessary association with modernity, have been disproved, as Jason Szabo and Carsten Timmermann have pointed out in their respective studies.2 The understanding of what ‘chronic disease’ has come to mean, and why diabetes is considered a typical example of one, has also been helped by the introduction of important characteristics like ‘incurability’, ‘manageability’, ‘insidious onset’ (for type 2 diabetes) and risk factors for other diseases.3 The work of George Weisz should be mentioned in this regard; his notion of the term ‘chronic disease’ as a ‘meta-concept’ which covers ‘different diseases and conditions depending on the time, place and goals of those utilising it’ is a useful starting point, but also confirms the potential of an alternative state socialist context.4

It is only very recently that historians are reminding us that chronic diseases existed in the post-war state socialist world, that they were prevalent, rationalised and treated by health and political authorities in those states. If the term ‘chronic disease’ is so malleable, as Weisz states, it would be all the more interesting to see how those diseases categorised as such were

1 See: Carsten Timmermann, ‘Chronic Illness and Disease History’, in The Oxford Handbook of the History of Medicine, ed. by Mark Jackson (Oxford: Oxford University Press, 2011), pp. 393-410 (p.406). 2 Jason Szabo, Incurable and Intolerable: Chronic Disease and Slow Death in Nineteenth-Century France (New Brunswick, NJ.: Rutgers University Press, 2009), p. 60; Timmermann, ‘Chronic Illness’, p.395. 3 ‘Incurability’ in: George Weisz, Chronic Disease in the Twentieth Century: A History (Baltimore: Johns Hopkins University Press, 2014) p. 1; Chronic diseases as ‘manageable’ in: Timmermann, ‘Chronic Illness’, p. 399; British medical professionals used the term ‘insidious onset’ to describe the lack of symptoms in type 2 diabetes and many other chronic diseases: Martin D. Moore, ‘A Question of Control? Managing Diabetes and its professionals in Britain, 1910-1994’ (unpublished PhD thesis, University of Warwick, 2014), p. 29; ‘Risk factors’ for other diseases in: Chris Feudtner, ‘A disease in motion: diabetes history and the new paradigm of transmuted disease’, Perspectives in biology and medicine, 39:2 (1996), 158-170 (pp.160-2). 4 Weisz, p. 2. For more detail on how chronic diseases were viewed in the GDR, see Chapter 1.

12 shaped by a highly politicised, one-party state like the GDR. Extensive ‘disease biographies’ about diabetes from Chris Feudtner and Robert Tattersall explore the clinical responses to diabetes, especially following the discovery of insulin, but, valuable as these studies are in providing a ‘historical journey’ and ‘patient-oriented approach’, the politics is often left out.5

This is beginning to be rectified somewhat by studies that look more carefully at how health policy and the politics of a given country have come to shape institutions, specialists and treatment methods. Martin Moore’s study of diabetes in Britain asserts that diabetes management ‘cannot be divorced from major political and social changes of twentieth-century Britain’.6 These social changes, including the post-war ‘consumer revolution’, were by no means exclusive to the western world, and, as this thesis will illustrate, the GDR experienced many of them, too, but sometimes handled them differently. The fact that Moore’s study focuses on what is now termed broadly ‘type 2’ diabetes, which, due to links to age, obesity and heredity as well as numerical prevalence, has garnered public and medical attention, also hints at a hole that a state socialist context could fill. Following the discovery of insulin, ‘type 1’ diabetes gradually became a ‘chronic’ rather than ‘acute’ disease, although complications could render a case temporarily ‘acute’.7 Juvenile onset type 1 diabetes was emphasised strongly in the GDR since it was a society that accentuated young over old, and it aroused political and medical responses every bit as much as type 2. Specialist institutions and programmes like a boarding school, holiday camps, a large children’s hospital and clinical department at the showcase ‘(Central)Institute for Diabetes’, the GDR’s lead establishment for the disease, serve to suggest that specific political and social circumstances were highly influential in shaping responses to a disease as multi-faceted as diabetes from the immediate post-war period onward. The forthcoming discussion therefore seeks to evaluate the peculiarities of the GDR, the origins and development of its ideas on healthcare and disease,

5 Chris Feudtner, Bittersweet: Insulin, and the Transformation of Illness (Chapel Hill, NC.: University of North Carolina, 2003), Preface p. xvii; Robert Tattersall, Diabetes: A Biography (Oxford: Oxford University Press, 2009), pp. 10-32. 6 Moore, ‘A Question of Control?’ p. 15. For other studies embedded in state politics, see: Aaron Mauck, ‘Managing Care: The History of Diabetes Management in Twentieth Century America’ (unpublished PhD thesis, Harvard University, 2010). 7 Type 1 diabetes before the discovery of insulin could be categorised as acute, but Michael Bliss warns that the discovery of insulin did not make it immediately ‘chronic’ in nature: Michael Bliss, The Discovery of Insulin: 25th Anniversary Edition (Chicago: University of Chicago Press, 2007), p. 245. To explore diabetes as an ‘acute’ condition, see: Elizabeth Lane Furdell, Fatal Thirst:Diabetes in Britain until Insulin (Leiden and Boston: Brill, 2009).

13 and where this thesis fits in the new and emerging field concerned with analysing disease management ‘East German-style’.

A dictatorship of sorts: political and economic interpretations of the GDR

Having broadly discussed the works on the history of diabetes and chronic diseases, and the absence of a state socialist context within most of those histories, it is the purpose here to justify why, according to the scholarship which has been done on the GDR, it is an alternative background in which to place the study of diabetes. Historians rarely dispute the fact that the GDR should be classed as a dictatorship of sorts. The setting up of the Marxist-Leninist Socialist Unity Party of Germany (SED) in 1946, and the ‘leading role’ it was to play after the GDR was founded in October 1949, made it fundamentally clear that the GDR would be to all intents and purposes a one-party state. Along with associations with the word ‘dictatorship’, the GDR has also been described in one way or another as ‘totalitarian’.8 In recent years, historians have begun to treat this term with caution, not least because it was often used in knee-jerk reactions to new archival material and the falling of the Berlin Wall, articulating East Germany’s physical dilapidation and Orwellian culture from shocked Western perspectives. Peter Grieder has stated that in spite of the reductionist ‘totalitarian thesis’ of the 1990s and the near-obsessive interest in the infamous Stasi, the GDR does fit the criteria of a ‘totalitarian state’.9 It had an ‘all-encompassing ideology’, ‘a monopolistic political party’, a monopolised mass media, a ‘centrally-directed economy’ and a high level of participation from top to bottom.10 At the same time, though, Grieder warns that the GDR is evidently not like the Third Reich in character. This makes it important to treat totalitarianism not only as a ‘concept’, but also as a ‘theory’ in order to explain as well as describe how the GDR functioned.11

The relationship between totalitarianism and communism (as opposed to fascism) is a necessary factor in determining the totalitarian flavour of the GDR. Tony Judt, for example, has concluded that ‘communism depended upon control – indeed, communism was control: control of the economy, control of knowledge, control of movement and opinion and people’.12 The GDR had consistently grappled with questions over its legitimacy and was culturally and linguistically linked to its Western neighbour. This served to heighten control, and it was

8 Peter Grieder, The German Democratic Republic: Studies in European History (Basingstoke: Palgrave Macmillan, 2012), pp. 1-2. 9 Grieder, The German Democratic Republic, p. 2. 10 Grieder, The German Democratic Republic, p. 2. 11 Grieder, The German Democratic Republic, p. 2. 12 Tony Judt, Postwar: A History of Europe since 1945 (London: Pimlico, 2007), p. 257.

14 through welfare measures in particular that the GDR tried to legitimise its existence to an initially sceptical population. The use of health as a political tool in attempts to appease the population has been detected by Young-Sun Hong in her study of the GDR and Third World Humanitarianism. She observes that the GDR was ‘a state in search of a society’ and that ‘as part of this search, the government sought to make the ideal of healthy, productive living into a source of popular legitimacy and national identity’.13 Health topics are thus a vital reflection of the challenges facing the GDR and the way in which the state sought to exert its control as a response.

The constant search to establish how best to characterise the GDR has formed the basis of many important studies in recent years. Andrew Port has stated that ‘no single concept captures the complexity of the GDR’.14 By choosing different topics to study, and approaching the GDR from cultural, economic, political, medical and social perspectives, each time a new and different light has been shed on the GDR and the way it interacted with its citizens. This is not necessarily problematic but one has to be careful, as Grieder has reminded us with regard to the word ‘totalitarian’, that the appropriate theory or theories (if complementary to one another) should be chosen as an explanatory tool for a subject of study and a helpful point of reference for the reader. Port also points out that establishing the appropriate terms to capture the GDR’s character should be the start and not the end of the discussion.15

Mary Fulbrook mentions in her brief section on health in The People’s State that despite ‘making many strides, particularly in amending the structure of provision…its health service – and the health of the people it was supposed to serve – has been the subject of considerable criticism and controversy’.16 The range of opinions on the healthcare system will be discussed in the following section, but, interestingly for this thesis, several of the theories about the GDR that have been posited are based on welfare, and these will inevitably encompass healthcare provision and disease management. In fact, the theme of welfare is one of the most revealing categories in showing how the SED sought to control the population at large. The offering of ‘cradle-to-grave’ care, a phrase that was used frequently by the SED and health officials to

13 Young-Sun Hong, Cold War Germany, the Third World and the Global Humanitarian Regime (Cambridge: Cambridge University Press, 2015), p. 179. 14 Andrew I. Port, ‘Introduction: The Banality of East German Historiography’, in Becoming East German: Socialist Structures and Sensibilities after Hitler, ed. by Andrew I Port and Mary Fulbrook (Oxford and New York: Berghahn, 2013), pp. 1-32 (p.9). 15 Port, ‘Introduction’, p. 10. 16 Mary Fulbrook, The People’s State: East German Society from Hitler to Honecker (New Haven and London: Yale University Press, 2008), p. 90.

15 describe the all-encompassing nature of provision, was a convenient way of controlling the population; health benefits prompted implicit ideological support for the GDR from a large mass of the population.17 A prominent and increasingly applied concept that was created either to characterise or at least contextualise the GDR has been that of a totalitarian welfare state, for which Konrad Jarausch in his socio-cultural history of the GDR has used the term ‘Welfare Dictatorship.18 This interprets the state as a curious and paradoxical mixture of care and coercion. The Welfare Dictatorship captures the overbearing, paternalistic spirit in which affairs were conducted. Jarausch also spells out clearly the compulsion in healthcare, the idea that people, whether they wanted to or not, were given treatment or screened for a disease to maintain the health of as much of the population as possible so that society as a whole could progress.

However, the major issue presented by concepts such as the Welfare Dictatorship is the way in which the GDR is approached; it is automatically seen from the point of view of those at the top of the political hierarchy, with their policies filtering down to the population at large. The need to look more carefully at the outcomes of these policies, which involves analysis ‘from below’, was recognised by Mary Fulbrook, whose book, The People’s State, and later, the edited volume, Power and Society in the GDR, are all about how ordinary East German citizens lived and made sense of their state.19 Fulbrook advises that, unlike other ‘social history’ studies, where the ‘politics is left out’, for the GDR, this is impossible.20 She also states that there needs to be serious reconsideration of the demarcation between ‘ordinary people’ and ‘high politics’, and statements of resistance to ‘top-down’ policies.21 As a dictatorial state, the GDR blurred some of these boundaries and did not always cause the population to resist measures imposed by the SED or pit themselves against them.

Fulbrook, one of the most well-known and prolific English-speaking authors on the topic to date, has made two important changes to GDR historiography in her work. She has shifted attention away from high politics to ordinary citizens and their experiences, and focused

17 Grieder, p. 5; Beatrix Bouvier, Die DDR–ein Sozialstaat? Sozialpolitik in der Ära Honecker (Bonn: Verlag J.H.W. Dietz Nachf., 2002), p. 355; Alexander Burdumy, ‘Reconsidering the Role of the Welfare State Within the German Democratic Republic’s Political System’, Journal of Contemporary History, 48:4 (2013), 872-889 (p.873). 18 Konrad Jarausch, ‘Care and Coercion: The GDR as Welfare Dictatorship’, in Dictatorship as Experience: Toward a Socio-cultural History of the GDR, ed. by Konrad Jarausch, trans. by Eve Duffy (Oxford and New York: Berghahn, 1999), pp. 47-72 (p.60). 19 Mary Fulbrook (ed.), Power and Society in the German Democratic Republic 1961-1979: The ‘Normalisation of Rule?’ (Oxford and New York: Berghahn, 2009). 20 Fulbrook, The People’s State, p. 10. 21 Fulbrook, The People’s State, p. 14.

16 on what had been the neglected area of the ‘middle period’ in GDR history, the transition of power from Walter Ulbricht to Erich Honecker in the 1970s.22 She has coined the term ‘Participatory Dictatorship’ to sum up the relationship between ordinary people and their state. This implies a level of broad participation by the people, which developed over time and was particularly apparent in the Honecker era, where materially, people were much better off than before. It refutes the commonly held assumptions of people living under dictatorial regimes as being outright ‘victims’ with very little agency (Eigensinn) whatsoever.23 Participatory Dictatorship is, to a large degree, an extension of the Eigensinn concept, which has been used to positive effect by Corey Ross to make the point that dictatorial societies need not be manipulated from above.24 Unlike the Nischengesellschaft, which assumes that condemned institutions and behaviours, such as the church and private medical practices, developed their own ‘niches’ as almost a survival mechanism,25 the Participatory Dictatorship and Eigensinn are built on the premise of opting in rather than out. Even if certain agendas of ordinary East Germans clashed with policy and the SED’s ambitions, on both sides a culture of frustrated compromise developed into what Fulbrook terms an ‘out-and-out “grumble society”’ which inexorably led to the GDR’s own downfall.26 This sort of culture will be interesting to assess within the area of health, which, as is evident in the Welfare Dictatorship concept, was of huge significance to the SED.

The Normalisation of Rule thesis, which has primarily informed the chapters of Power and Society, adds another dimension to Fulbrook’s Participatory Dictatorship. From initial thoughts on the term, it appears rather futile to assess whether any nation is ‘normal’, and the GDR, with its omnipresent surveillance system and wealthier Western neighbour on the other side of a Wall, is not a likely candidate to be considered as such. However, the Normalisation Thesis serves as an analytical tool and accesses something more deep-rooted about everyday life in the GDR. It does not simply define the GDR as developing into a nation that was considered from an outsider’s or insider’s perspective as being normal, nor does it connote a ‘return to normal’ as was frequently referred to in West Germany.27 Instead, it characterises

22 Mary Fulbrook, ‘The Concept of Normalisation and the GDR in comparative perspective’, in Power and Society in the German Democratic Republic: The ‘Normalisation of Rule?’ ed. by Mary Fulbrook (Oxford and New York: Berghahn, 2009), pp. 1-32 (p.12). 23 Fulbrook, The People’s State, pp. 14-15. 24 Corey Ross, Constructing Socialism at the Grassroots: The Transformation of East Germany, 1945-65 (Basingstoke: Palgrave Macmillan, 2000), pp. 64-5. 25 Esther von Richthofen, Bringing Culture to the Masses: Control, Compromise and Participation in the GDR (Oxford and New York, 2009), p. 14. 26 Fulbrook, The People’s State, p. 14. 27 Fulbrook, ‘The Concept’, p. 17.

17 the way in which East Germans had begun to accept their lives within this artificially constructed polity. The building of the Berlin Wall massively reduced the number of skilled individuals fleeing to the West, a fact that can be seen in the medical profession (diabetology specifically). Dietrich Staritz has called the building of the Berlin Wall ‘der heimliche Gründungstag’ (the secret day of the GDR’s foundation), 28 since it did consolidate and solidify, albeit forcibly, the GDR’s permanence, and allowed Ulbricht greater freedom to enact more state socialist policies without provoking a reaction (mass emigration).29 By the time Honecker took over in 1971, there was a new post-war generation of East Germans who had direct experience of no other society than the one in which they were currently living. As Fulbrook makes clear when introducing her theory, ‘there is a history to be told, which varied according to area in rhythm, pace and trajectory, of the degrees of stabilisation of structures and routinisation of practices, which had been more or less rapidly introduced in the post-war decade and a half or so of radical transformation and Aufbau’.30 Whether they believed in the goals of the SED or not, a large number of East Germans consciously or unconsciously sustained the dictatorship in their daily lives.

Healthcare, and hence diabetes management, was dependent to a large extent not only on the political and social fabric of East German society but also on the way in which the economy functioned. This is an area of East German historiography that has experienced some scathing criticism. Timmermann warns that ‘scholarship in science studies in the last few decades has taught us to be careful about equating a lost argument with qualitative inferiority’.31 Indeed, Hartmut Berghoff and Uta Andrea Balbier believe that ‘the time is ripe to set aside the simplistic narrative that regards the GDR economy primarily as a failure and as nothing but an example of the inherent deficiencies of central planning, especially when contrasted with…the Federal Republic.’32 Nevertheless, the effects of the East German economy were highly pervasive and, whether positive or negative, must not be overlooked in

28 Dietrich Staritz cited in Philipp Heldmann, Herrschaft, Wirtschaft, Anoraks: Konsumpolitik in der DDR der Sechzigerjahre (Göttingen: Vandenhoeck and Ruprecht, 2004), p.11. 29 Staritz, p. 196. 30 Fulbrook, ‘The Concept’, p. 29. 31 Carsten Timmermann, ‘Americans and Pavlovians: The Central Institute for Cardiovascular Research at the East German Academy of Sciences and its precursor institutions as a case study of biomedical research in a country of the Soviet Bloc’, in Medicine, the Market and the Mass Media: Producing Health in the Twentieth Century, ed. Virginia Berridge and Kelly Loughlin (Abingdon: Routledge, 2005), pp. 244-265 (p.260). 32 Hartmut Berghoff and Uta Andrea Balbier, ‘From Centrally-Planned Economy to Capitalism Avant-Garde? The Creation, Collapse, and Transformation of a Socialist Economy’, in The East German Economy, 1945- 2010: Falling Behind or Catching Up?, ed. by Hartmut Berghoff and Uta Andrea Balbier (Cambridge: Cambridge University Press, 2013), pp. 3-16 (p.6).

18 any topic of discussion. Berghoff and Balbier argue that the GDR economy was very complex due to its fragmentary nature, combination of ‘continuity and upheaval’ and ‘persistence of regional disparities’;33 it is the regional differences in particular that clearly had an impact on the variability of diabetes care, as mentioned by doctors in the reports of the Diabetikerberatungsstellen (diabetes advice centres).34 An understanding of the East German economy is also an understanding of the context of a particular leadership; as part of the Marxist-Leninist tradition, both Ulbricht and Honecker privileged the economy and wanted to manipulate the development of East Germany by introducing a number of flagship economic policies.

André Steiner views Ulbricht’s new economic strategy of 1963, the New Economic System of Planning and Management (NӦS), as the first turning point.35 As the Berlin Wall marked the beginning of the stabilisation alluded to in the Normalisation thesis, this new policy was, albeit only to a limited extent, a move away from detailed centralised planning towards pseudo competition and individuals taking more responsibility for the minutiae of their companies’ production.36 The wider implication of all this was a strong emphasis on quality rather than quantity of products. For diabetes, that therefore entailed, for example, an attempt at producing better injection needles, albeit with limited success. This was not, as Sontheimer and Bleek remind us, an attempt at liberalising the economy, and planning remained at the heart of the system.37 They add that Ulbricht also insisted on modernising the economy, with considerable investment in technical innovation.38 Sontheimer and Bleek remark that the East German economy made good progress under NӦS but the ultimate goal to match the FRG’s performance was not met.39

Ulrich Mählert suggests that Ulbricht’s ambitious programme of investment had adverse effects on living standards; this was of paramount concern to Honecker when he took

33 Berghoff and Balbier, ‘From Centrally-Planned Economy’, p. 6. 34 See in particular the following Ministry of Health documents from the Bundesarchiv: SAPMO-BArch DQ1/4445 – Diabetiker-Fürsorge-bzw. Beratungsstellen: Statistische Berichte, Berichtsjahre 1951 und 1953; SAPMO-BArch DQ 1/20569 – Diabetiker-Fürsorge-bzw. Beratungsstellen: Statistische Berichte, Berichtsjahre 1957 und 1958; SAPMO-BArch DQ 1/20570 – Diabetiker-Fürsorge-bzw. Beratungsstellen: Statistische Berichte, Berichtsjahr 1958, Berichtsjahr 1961. 35 André Steiner, Von Plan zu Plan, Eine Wirtschaftsgeschichte der DDR (Munich: Deutsche Verlags-Anstalt, 2007), p. 147. 36 Steiner, p. 147. 37 Kurt Sontheimer and Wilhelm Bleek, Die DDR: Politik, Gesellschaft, Wirtschaft (Hamburg: Hoffmann und Campe, 1972), p. 198. 38 Steiner, p. 161-162. 39 Sontheimer and Bleek, p. 199.

19 over in 1971.40 According to Mählert, he focused less on the grand industrial projects of his predecessor and more on consumption goods, and other everyday staples.41 His Unity of Social and Economic Policy implied a strong connection between social concerns and economic delivery. Honecker’s idea was essentially to appease the population by keeping rents and prices of basic items artificially low.42 Where Ulbricht stressed quality, Honecker encouraged quantity. Part of the plan to increase productivity was to make sure that people had good accommodation and were able to buy whatever they needed.43 This led to a situation whereby demand overtook supply, due to the fact that money was not spent on industry as it had been before. Other than the level of debt that most scholars argue was at least a contributing factor to the GDR’s downfall,44 from the perspective of health, the most problematic and indefensible consequence of Honecker’s economic policy was the substandard quality of goods. Frequently in literature on health, there is an overriding sense of what the East German healthcare system might have been had the economy provided the right conditions for its development; the economic problems overshadowed the medical expertise and positive aspects of care given in the centralised model of the healthcare system.45

As far as diabetes is concerned, Steiner points out that the high subsidies for everyday goods prompted an unhealthy consumption of meat, fat and sugar,46 which will have had an effect on the numbers of type 2 diabetics and the possibility of mismanagement on the part of individual diabetics. This in itself implies the very close links between the economy and health, warranting a much closer analysis than has been undertaken hitherto. The economic deficiencies have been a major theme of the article written for the German Diabetes Society by former East German diabetologists Waldemar Bruns, Konrad Seige, Ruth Menzel, Günther Panzram and others.47 Even though they write with the benefit of hindsight and are liable to have altered their perception of the economic realities somewhat, this is, however, largely what they perceive as the negative side of their work amongst more positive comments. The

40 Ulrich Mählert, Kleine Geschichte der DDR (Munich: C.H. Beck, 2004), pp. 117-118. 41 Mählert, pp. 118-119. 42 Steiner, p. 195. 43 Steiner, p. 194. 44 Steiner, p. 257. 45 See: Manfred Schmidt and Gerhard Ritter, The Rise and Fall of a Socialist Welfare State: The German Democratic Republic, 1949-1990 and German Unification 1989-1994, trans by David Antal and Ben Veghte (Berlin and Heidelberg: Springer-Verlag, 2013), p. 202; Paul Weifens, Economic Aspects of German Unification: National and International Perspectives (Berlin and Heidelberg: Springer-Verlag, 2013), p. 172. 46 Steiner, p. 247. 47 Waldemar Bruns, Konrad Seige, Horst Bibergeil, Ruth Menzel and Günther Panzram, Die Entwicklung der Diabetologie im Osten Deutschlands von 1945 bis zur Wiedervereinigung, ed. by Die Deutsche Diabetes Gesellschaft (Hildesheim: Wecom, 2004), pp.25-26 and p.39.

20 implications of a lack of investment in industry led to the poor quality of insulin produced by VEB Berlin-Chemie, the main production company. They cite cases of East German diabetics being forced to get up at three o’clock in the morning to inject because the depot insulin would not last them through the night. Waldemar Bruns also outlines the poor technical equipment and the gap between the advancing medical knowledge of diabetologists and an economy that was unable to deliver what they needed.48

Debates on East German medical thinking and prevention practices

After the Second World War, German doctors of the Central Administration for Health in the Soviet Zone, many of whom were of a communist, socialist or social-democratic political persuasion, sought to adopt the principle of social hygiene to curb the ephemeral growth of epidemic diseases (e.g. Typhus) and the more incremental and permanent growth of chronic diseases. As part of the wider aim of strengthening public health, social hygiene was a preventive strategy that involved surveying the social, living and economic conditions of population groups deemed to be at risk of developing particular diseases. One would proceed from there to alter those conditions in order to limit the spread of diseases.49 The idea was originally introduced during the years of the Weimar Republic in the spirit of the progressive, public health reforms that were being planned. Firmly rooted in a social-democratic background, one of the founding fathers of social hygiene, Alfred Grotjahn, raised the issue of social inequality and its effects on medical matters.50 This overriding message of social hygiene made it attractive to Soviet health theorists in the nineteen twenties, most notably Anton Semashko, who famously stated in 1925 that the Germans were the creators of social hygiene but the Soviets were the best pupils in the world when it came to putting it into practice.51

There are several reasons why social hygiene was adopted after the Second World War and remained an important concept in medical vocabulary (although not necessarily in practice

48 Waldemar Bruns, ‘Die Geschichte der Diabetologie in der DDR’, in Festschrift 50 Jahre Deutsche Diabetes Gesellschaft, ed. by Erhard Siegel and Dietrich Garlichs (Berlin: Die Deutsche Diabetes Gesellschaft, 2014), pp. 68-79 (p.77). 49 Sabine Schleiermacher, ‘Contested Spaces: Models of Public Health in Occupied Germany’, in Shifting Boundaries of Public Health: Europe in the Twentieth Century, ed. by Susan Gross Solomon, Lion Murard and Patrick Zylberman (Rochester, NY.: University of Rochester Press, 2013), pp. 175-204 (pp.180-1). 50 Jeannette Madarasz-Lebenhagen, ‘Perceptions of Health after World War II: Heart Disease and Risk Factors in East and West Germany, 1945-75’, in Becoming East German: Socialist Structures and Sensibilities after Hitler, ed. by Mary Fulbrook and Andrew I Port (Oxford and New York: Berghahn, 2013), pp. 121-140 (p.124). 51 Udo Schagen, ‘Die Gesundheitspolitik in der Sowjetischen Besatzungszone’, in “Gesundheitsschutz für alle” und die Ausgrenzung von Minderheiten: historische Beiträge zur Aushöhlung eines gesundheitspolitischen Anspruchs, ed. by Udo Schagen and Sabine Schleiermacher (Berlin: Inst. für Geschichte der Medizin, ZHGB, 2006), pp.62-81 (p.65).

21 for the long term) in the GDR. Due to the fact that social hygiene was embraced by the Soviets, they had the chance to put it into practice in a centralised and nationalised healthcare system, a setting that was considered ideal by East German social hygienists who came to the fore during the early post-war years. Key figures included Kurt Winter, Hermann Redetzky and Alfred Beyer, all of whom had written extensively on the form and direction social hygiene was going to take in the GDR. Jeannette Madarasz-Lebenhagen and Sabine Schleiermacher have both pointed out that, whilst based on the Weimar German equivalent, East German social hygiene was married with the state socialist visions of egalitarianism and collective responsibility,52 and, if anything, became more of a socialized medicine (seen, for example, in Winter’s Soziologie für Mediziner53 and diabetologist, Gerhard Mohnike’s article on Sozialmedizinische Diabetesfragen54) as opposed to medicalized social policy. Where social hygiene in the Weimar Republic was marginal, it became central to epidemiology in the GDR. According to Gabriele Moser, Grotjahn’s social hygiene contained a number of reprehensible elements with regard to eugenics and the position of women.55 These were removed by the Soviets and did not feature either in the East German variant. The Soviet input, along with the fact that social hygiene was still associated with progressive Weimar politics, made it a ‘strong political statement’, a justification, according to Madarasz-Lebenhagen, for its adoption in East and not West Germany.56

Using the case study of infectious diseases, there have been recent challenges to the assumption that East German social hygiene was, from the start, ‘social’ in outlook. Moser in the concluding thoughts of her book on social hygiene suggests that in the case of East Germany, the term ‘medicalized social hygiene’ would be more appropriate, largely in reference to her examination of contagious diseases.57 She believes that a social analysis of disease was minimal at the beginning, where efforts to manage diseases drew largely on medical expertise. Evidently, she concludes that the pre-1933 social hygiene, characterised so much by the emphasis it placed on social conditions, was different. Moser still suggests that there was a subordination of the individual to the good of the collective and a strong focus on

52 Madarasz-Lebenhagen, p. 124 and p. 127; Schleiermacher, ‘Contested Spaces’, pp.194-5. 53 Kurt Winter, Soziologie für Mediziner (East Berlin: VEB Verlag Volk und Gesundheit, 1973). 54 Gerhard Mohnike, ‘Sozialmedizinische Diabetesfragen’, Das deutsche Gesundheitswesen, 7:9 (1954), 286- 292. 55 Gabriele Moser, Im Interesse der Volksgesundheit: Sozialhygiene und öffentliches Gesundheitswesen in der Weimarer Republik und der frühen SBZ/DDR ; ein Beitrag zur Sozialgeschichte des deutschen Gesundheitswesens im 20. Jahrhundert (Bad Homburg: VAS Verlag, 2002), pp. 46-8. 56 Madarasz-Lebenhagen, p. 124. 57 Moser, p. 207.

22 prevention that communist social hygienists had encouraged to remain, but social factors did not predominate in the management of diseases.58 In contrast, Jens-Uwe Niehoff believes that medicalising and individualising developments only took place in the 1960s, and before then, it was a socialised, ‘classical’ social hygiene driving the East German healthcare system forward.59 Donna Harsch’s study of Tuberculosis in the immediate post-war GDR is largely in line with Moser, but she does agree with Niehoff that there were individualising trends in the 1960s. Harsch states that ‘given the almost non-existent research on how physicians and health officials actually combated disease in the German Democratic Republic (GDR), both hypotheses [those of Moser and Niehoff] lack empirical support’.60 What Harsch is essentially hinting at in her article, which is not clear to the reader through her use of medicalized social hygiene as an analytical framework, is that in addition to what some consider (e.g. Madarasz- Lebenhagen) as a break with the immediate past through the use of progressive public health reforms of the Weimar era, there was also an element of continuity with the previous system (Third Reich).

Using diabetes as a case study to add to what Harsch rightly acknowledges is a dearth of studies on disease management in the GDR could add an alternative view to that which she proposes. Harsch suggests that Tuberculosis policy was tackled using the epidemiological method of ‘medicalized social hygiene’ only. The problem that diabetes poses to her conclusion is that there are simultaneously, on the one hand, elements of strictly medical expertise informing decisions and on the other, social/socio-economic factors that are taken into consideration by diabetologists which should not be underestimated. Would diabetes management be classed as ‘medicalised social hygiene’ in approach therefore? The interest in not simply collecting statistics but also in conducting demographic studies of diabetes, as well as the decisions made to remove diabetic children from socially compromised environments before placing them in a special boarding school in Putbus (Rügen) reveal evidence of supposedly ‘classical’ social hygienic measures.61 Moreover, these measures did not change over time. Another problem lies in the definition itself; social hygiene was founded by medics (Grotjahn), theorised by medics (epidemiologists, such as Winter and Redetzky) and carried

58 Moser, p. 207. 59 Jens-Uwe Niehoff cited in Donna Harsch, ‘Medicalized Social Hygiene? Tuberculosis Policy in the German Democratic Republic’, Bulletin of the History of Medicine, 86:3, 393-423 (p.394). 60 Harsch, ‘Medicalized Social Hygiene?’ p. 395. 61 See, for example, Volker Schliack, Statistisch-klinische Diabetesfragen (Leipzig: Geest und Portig, 1953); Otfried Günther, ‘Warum ein Schulheim für zuckerkranke Kinder?’, Das deutsche Gesundheitswesen, 7 (1952), 988-990.

23 out by medics (diabetologists such as Professor Katsch). Social hygiene is immersed in the field of medicine and has always been firmly in the grasp of medical expertise. This raises questions about the meaning of the term ‘medicalized social hygiene’ and whether it is really adding to the scholarship on disease management in the GDR or confusing it entirely.

Social hygiene continued to be a topic for discussion in the GDR in the 1960s and 1970s, even when, in hindsight, medical historians such as Timmermann and Madarasz- Lebenhagen have discovered that a competing strand of thought became popular in the GDR for the management of chronic diseases: the American risk factor approach.62 The individualising trends that Harsch and Niehoff mention are likely to be alluding to the introduction of the risk factor approach in the GDR. Whilst not altogether uncomplementary to social hygiene, which might explain why social hygienists were still prominent in epidemiological discussions, the risk factor approach focused on individual risks rather than broad social concerns to combat the increase in chronic diseases.63 It was based on studies of heart disease in the USA, making it a contentious policy for the GDR to adopt.64 This could explain why it took until the mid-1960s for it to feature properly in East German health policy. It was nonetheless a concerted attempt by the GDR to compete internationally within the arenas of health and medicine, which, in the 1960s was also seen in specialist circles including diabetology/endocrinology, where the staging of international conferences at the (Central)Institute for Diabetes at Karlsburg to showcase research ushered in a new era of Cold War competition.65

Robert Aronowitz has argued that the advantage of the risk factor approach was that it was set up to be ambiguous, allowing for it to feature in strategies of chronic disease management in both East and West Germany with relative ease.66 There was naturally some opposition from Kurt Winter and later, Jens-Uwe Niehoff, about its pitfalls in establishing the aetiology of certain diseases. There was additionally a sense that the ‘socially superior’ aspects of social hygiene would be subverted on account of the fact that so many of the risk

62 Robert A. Aronowitz, Making Sense of Illness: Science, Society and Disease (Cambridge: Cambridge University Press, 1998), p. 115 and p. 131. 63 Carsten Timmermann, ‘Appropriating Risk Factors: The Reception of an American Approach to Chronic Disease in the Two German States, c. 1950-1990’, Social History of Medicine, 25:1 (2012), 157-74 (p.160); Madarasz-Lebenhagen, p. 128. 64 Timmermann, ‘Appropriating Risk Factors’, p. 160-1. 65 Egon Brauns and Peter Wulfert, „Glückliche Kombination: Klinik und Forschung unter einem Dach“–ein erstarkendes Institut‘ in Karlsburg: Ein Dorf und Sein Institut, ed. by Peter Wulfert (Karlsburg: Institut für Diabetes, Karlsburg. 1989), pp. 59-66 (p.60). 66 Aronowitz, p. 144.

24 factorproponents in the GDR and elsewhere were, according to Timmermann, clinicians and not epidemiologists.67 On a general note, those who have praised the healthcare system in the Soviet Union and Eastern Bloc countries, such as Henry E. Sigerist, have argued that whilst healthcare in the USA was technically advanced, it was socially backward.68 This is, of course, controversial, but it does highlight the perceived differences in emphasis of the risk factor approach, an American ‘individualist’ construct, and social hygiene.

Risks were identified for particular individuals, and Timmermann suggests that the approach ‘gave patients the feeling that to some degree they controlled their exposure to’ a chronic disease, referring in this case to heart disease.69 The flexibility of the risk factor approach makes it difficult to assess if or when there was a gradual shift away from social hygiene, and that is particularly so for diabetes. Madarasz-Lebenhagen believes that there was a realisation that statistics of population groups and other demographic studies failed to reveal individual risk and that the adoption of the risk factor approach was a logical response to the weakness spotted in social hygiene.70 She also points to an era of political discontent in the GDR towards the end of the Ulbricht era (the late 1960s) and a backlash against collectivist strategies.71 However, the risk factor approach introduced a clearer emphasis on the individual taking responsibility, which, although symbolic of individualism, could conveniently serve the wider socialist aim of keeping society as a whole healthy. Where diabetes is more problematic than heart disease is perhaps in its aetiology. Like heart disease, it can be dependent on lifestyle choices, which social hygiene did emphasise to some extent. The medical interest in the influence of the genetic predisposition to both type 1 and type 2 meant that there may have been a stronger focus on individual cases (e.g. family history of diabetes) in the 1950s (at the peak of social hygiene).72 There was also a strong emphasis on lifestyle choices from diabetologists almost immediately after the formation of the GDR through manuals/guides.73 As type 1 is an autoimmune disease, it is not strictly comparable to heart disease or type 2 diabetes where risk factors can be easily identified, and lifestyle measures are adopted to ease

67 Timmermann, ‘Appropriating Risk Factors’, p. 170. 68 Henry E. Sigerist cited in Timmermann, ‘Americans and Pavlovians’, pp. 244-5 and 260. 69 Timmermann, ‘Appropriating Risk Factors’, p. 160. 70 Madarasz-Lebenhagen, p. 128. 71 Madarasz-Lebenhagen, p. 128. 72 See G. Schernthaner, ‘Ӓtiologie und Pathologie des Diabetes mellitus’, in Diabetes mellitus: Ein Nachschlagewerk für die diabetologische Praxis, Mit Beiträgen von 25 Fachwissenschaftlern ed. by Horst Bibergeil (Jena: VEB Gustav Fischer Verlag, 1989), pp. 118-144 (p.125). 73 See, for example, the handbook designed for patients: Gerhardt Katsch, Gerhard Mohnike and H.J. John, Aceton bis Zucker: Nachschlagebuch für Zuckerkranke, Zweite Auflage (Leipzig: VEB Georg Thieme Verlag, 1957).

25 or even reverse the condition. This is why in the case of diabetes it is more challenging to assess the impact of the introduction of the risk factor approach.

Historical (im)balance: studies on the East German healthcare system and its medical professionals

Analyses of the East German healthcare system that have been completed before and after the reunification of Germany are plentiful, but they tend to focus on the ‘macroperspective’, as Alexander Burdumy has explained in a revisionist account of the GDR’s ‘welfare state’.74 At the centre of discussion are the institutions that were created, the changes that were made after 1945 (referring to the previous system(s) of the Third Reich or earlier and comparing with West German healthcare) as well as the influences of those changes on the provision of diagnosis, care and rehabilitation. Social hygiene is a way of thinking about disease management, as has been pointed out, but it also came to shape in part the structural outcomes of the healthcare system and functional aspects within each institution. It formed, in effect, the overall ethos of the healthcare system, especially with regard to its emphasis on prevention and egalitarianism. Whether in the field of ‘welfare’, ‘healthcare’, Sozialpolitik or Sozialstaatlichkeit, the way in which the East German healthcare system has been rationalised is largely based on its structural and political components. There are discernible debates that have taken place on the nature and origins of the various parts of the system, leading to an assessment of how ‘Sovietised’ it was and how politically determinist it came to be. In reference to chronic diseases more specifically, some have emphasised the Dispensaire System in studies of GDR healthcare;75 this was the section of the healthcare system devoted to the early detection and treatment of chronic diseases. The Dispensaire is also a strong element in the ‘Sovietisation’ debate as a result of its presence in the Soviet health system prior to 1945, even though its exact origins could well be in the progressive Weimar health reforms, as Melanie Arndt has suggested. 76

It is difficult to divide literature on healthcare into themes (other than Sovietisation) since the purpose of general works on health provision in the GDR is to provide the reader with an extensive narrative of the East German healthcare system, and not a lot more. By splitting the literature chronologically, namely before and after reunification, there are a number of key

74 For this argument, see: Burdumy, p. 876. 75 Examples of clear emphasis on the Dispensaire to promote the merits of the healthcare system include: Jürgen-Peter Stössel, Staatseigentum Gesundheit: Medizinische Versorgung in der DDR (Munich: Piper Verlag, 1978); Maria-Elisabeth Ruban, Gesundheitswesen in der DDR: System und Basis, Gesundheitserziehung, Gesundheitsverhalten, Leistungen, Ökonomie des Gesundheitswesens (Munich: Holzapfel Verlag, 1981). 76 Melanie Arndt, Gesundheitspolitik im geteilten Berlin 1948 bis 1961 (Cologne, Weimar and Vienna: Böhlau Verlag, 2009), pp. 26 and 45.

26 differences in the way that the East German healthcare system was viewed. In terms of pre- reunification literature, there are, on the one hand, studies by some West German authors, notably the economist, Maria Elisabeth Ruban, and the medical journalist, Jürgen-Peter Stössel, which offer substantial praise of the system. Ruban’s praise is subtler than that given by Stössel. She is concerned by the maldistribution of physicians in West Germany, particularly specialists, and believes that the East German system was much better at overcoming that problem.77 Ruban stresses the fact that there were at least five specialist areas served within East German polyclinics, and three within smaller Ambulatorien, which eased access to specialist care, and showed recognition of the ‘specialized nature of modern medicine’. 78 She is positive about the links between stationary and ambulatory care, which, she implies, were separated markedly in the West.79 Both authors give special attention to the merits of the Dispensaire System, something which Stössel states is no longer a Fremdwort in the GDR due to its well-established and efficiently functioning status.80

One of Stössel’s chapter headings immediately showers compliments on GDR health: ‘Heart attack: help on all sides’.81 He lists a number of lessons that West Germany can learn from the East German approach, including the testing of what appeared to be healthy people who may unknowingly be suffering from a chronic disease, and the recording of case details in a national database.82 His overriding message to West Germans is, however, that prevention and prophylaxis must be prioritised, and a situation should no longer arise whereby the doctor must wait for the patient to come to them if they feel unwell; the doctor must seek out patients with known risks.83 He believes that this was more feasible in the GDR on account of polyclinics being at or near workplaces and residential areas, as well as the interventionist strategies of the Dispensaire System like Reihenuntersuchung (screening).84 This opinion was expressed by Kurt Winter and Alexander Mette in Der Arzt in der sozialistischen Gesellschaft, and was phrased very similarly.85

77 Ruban, Gesundheitswesen, p. 40. 78 Peter Rosenberg and Maria Elisabeth Ruban, ‘Social Security and Health-Care Systems’ in Political Values and Health Care: The German Experience, ed. by Donald W. Light and Andreas Schuller (Cambridge, MA: MIT Press, 1986), pp. 257-289 (p.257). 79 Ruban, Gesundheitswesen, p. 33-4. 80 Ruban, Gesundheitswesen, p. 49; Stössel, p. 55. 81 Stössel, p. 29. 82 Stössel, pp. 56-9. 83 Stössel, p. 61. 84 Stössel, p. 61. 85 Kurt Winter, Alexander Mette and Gerhard Misgeld (eds.) Der Arzt in der sozialistischen Gesellschaft (East Berlin: Akademie-Verlag, 1958).

Reading Western literature from this particular standpoint is almost akin to reading Kurt Winter or any other publication from VEB Verlag Volk und Gesundheit. Certain ‘showcase’ elements of the GDR healthcare system, for example its preventive outlook, are strongly encouraged in both. Where Winter would talk about the evils of a capitalist society and the health problems brought about by the poverty it allegedly caused,86 Stössel talks about the ‘health crisis’ in West Germany as a result of too much privatisation, and the need therefore for a more state socialist approach to prevent people from being left behind.87 Stössel had spoken to some East German doctors and quotes them at length, with little commentary of his own, seemingly taking their word for it. He does not appear to recognise that the East German doctors who were interviewed, including the director of the (Central)Institute for Diabetes at Karlsburg, Horst Bibergeil, are highly likely to have been selective in the information they gave to present the healthcare system in the best light possible.88 Had Bibergeil given an entirely unvarnished picture, the reality was that he may have lost his job as a high-ranking diabetologist. There is clearly a critical eye toward West German healthcare, and Stössel was quick to point out whatever faults it may (or may not) have had, finding solutions in the East German approach. Prevention being the Schwerpunkt of the healthcare system in the GDR was not actually incorrect and there is potential to praise preventive efforts, but the agenda here to pit one healthcare system against the other illustrates the lack of balance in some West German opinion. 89

At the same time, there exists literature from West German authors which offers different interpretations of the East German healthcare system, some overtly critical and others expressing ambivalent feelings. Wilhelm Weiβ wrote one of the earliest books on East German healthcare in 1952, condemning it as ‘a deliberate imitation of Soviet structures’; he was clearly not giving it much time to develop into anything credible.90 Although his study will contribute to the issue of Sovietisation that will be discussed later in this section, it displays the anti- Communism that pervaded the early post-war and Cold War period, painting a very reductionist picture of health and welfare in the GDR. In the 1986 edited volume, Political Values and Health Care: The German Experience, the collaborative efforts of American and

86 Kurt Winter and Alfred Beyer, ‘Geschichtliche Entwicklung, Inhalt und Definition der Sozialhygiene’, in Lehrbuch der Sozialhygiene, ed. by Kurt Winter and Alfred Beyer (East Berlin: VEB Verlag Volk und Gesundheit, 1953), pp. 3-22 (p.11). 87 Stössel, p. 7-11. 88 Stössel, p. 56. 89 Stössel, p. 60. 90 Wilhelm Weiβ cited by Jessica Reinisch, The Perils of Peace: The Public Health Crisis in Occupied Germany (Oxford: Oxford University Press, 2013), p.11.

‘a score of West German social scientists’ have led to very mixed views on East German healthcare.91 The editor also mentions that it took ‘almost three years…attempting to recruit authors from East Germany’, and eventually ‘no essays were sent’.92 Renate Baum (Free University of Berlin) mounts fairly critical arguments about the political aspects of ‘the socialistic healthcare system,’ in particular the issue of socialist rhetoric versus reality in terms of what the healthcare system had achieved.93 The availability of healthcare and the ‘free at the point of delivery’ message espoused by the SED meant very little, according to Baum, when so many East Germans had to sacrifice a portion of their income in payments to the state-run health insurance to appreciate these privileges.

Unlike the positive depictions of the Dispensaire System by Ruban and Stössel, Baum warns that in practice, there were not enough financial resources and manpower to satisfy ambitions. She also criticises the heightened responsibility of individuals to society for the preservation of their health, and the relationship between health and economic productivity, making the case that in East Germany there were ‘more far-reaching means of forcing a person to submit to treatment’ than in West Germany on account of a citizen being ‘held legally responsible for the maintenance, restoration, and betterment of his health’. Helmuth Jung (also from the Free University of Berlin) clarifies this by discussing the ‘economic laws’ that were ‘consciously employed in the interests of human health’.94 Paul Ridder (University of Constance) agrees with both comments by Baum and Jung, adding that the introduction of Marxism ‘was quick to divest medical care of its philanthropic pretences’ and the primary aim of medical care was ‘to serve the socialist revolution’.95

Jung, however, concludes that, whilst politically and structurally different, East and West German healthcare systems led to similar results. Jung is a strong proponent of American conservative economics, viewing both German healthcare systems, therefore, as far from optimal and lacking in ‘market forces’. Nevertheless, his remark about outcomes being

91 Donald W. Light, ‘Introduction: State, Profession, and Political Values’, in Political Values and Health Care: The German Experience, ed. by Donald W. Light and Alexander Schuller (Cambridge, MA: MIT Press, 1986), pp. 1-23 (p.2). 92 Light, p. 2. 93 Renate Baum, ‘Out of the Rubble: Political Values and Reconstruction’, in Political Values and Health Care: The German Experience, ed. by Donald W. Light and Alexander Schuller (Cambridge, MA: MIT Press, 1986), pp. 239-256 (p.243). 94 Helmuth Jung, ‘Political Values and the Regulation of Hospital Care’, in Political Values and Health Care: The German Experience, ed. by Donald W. Light and Alexander Schuller (Cambridge, MA: MIT Press, 1986), pp. 289-324 (p.292). 95 Paul Ridder, ‘Ideological Influences on the Organization of Ambulatory and Hospital Care’, in Political Values and Health Care, ed. by Donald W. Light and Alexander Schuller (Cambridge, MA: MIT Press, 1986), pp. 325-354 (p.327).

29 comparable in diagnosis, therapy and even prevention in the two German states, despite political differences, is an interesting one. 96 The West German DDR-Handbuch, written on behalf of the Bundesministerium für innerdeutsche Beziehungen (Ministry for German-German relations), makes a similar point to Jung. It is not entirely negative about East German healthcare, highlighting that chronic disease prevention and diagnostic practices in the East led to results that were analogous to the West.97 The publication included studies on the East German healthcare system suggesting that there were a number of aspects that were better in the GDR; the Bundesministerium claimed that the GDR had a higher life expectancy than the West, and due to the more paternalistic nature of the healthcare system, specifically so within the area of neonatal care.98 Aside from praise, there were points of criticism. The Bundesministerium thought that the German tradition of having a free choice of physician, which was supposed to have been preserved in the GDR, did not always materialise in practice in a centralised system governed by a high authority (the Politburo).99 The impression was that a number of East German patients were aggrieved by this. The study also accused the GDR of adopting not simply a caring attitude to workers (the early detection or prevention of chronic diseases), but that the measures employed were bordering on the surveillance (Überwachung) of the working population.100 Whether from a left-wing, centrist or right-wing standpoint, several West German authors have questioned the level of equality generated in the healthcare system in the GDR. The Bundesministerium implies that there were profound regional differences in the quality of care given, and that there were certain geographical areas that attracted doctors more than others, with a pronounced split between urban and rural, the latter bearing the brunt of poorly equipped hospitals and inadequate staffing.101

The theme uniting this pre-unification literature with post-reunification literature is that of the supposed ‘Sovietisation’ of the East German healthcare system. It reveals that, in some ways, the literature written after the eagerly anticipated opening of GDR state archives had not moved forward completely from the polemic of East versus West and capitalism versus communism, and still has some way to go. Where West German literature (that was not explicitly left-wing), such as that of the Bundesministerium, in the 1970s kept a fairly open

96 Jung, p. 290. 97 Peter Christian Ludz and Johannes Kuppe,‘Gesundheitswesen’, in DDR Handbuch, ed. by Bundesministerium für innerdeutsche Beziehungen (Cologne: Verlag Wissenschaft und Politik, 1975), pp. 375-383 (p.375). 98 Ibid., p. 383. 99 Ibid., p. 376. 100 Ibid., p. 383. 101 Ibid., p. 382.

30 mind about GDR health, the problem in the early 1990s was that the analysis had begun to be teleological, the end point of the GDR overshadowing reasoned explanations of its lifetime as a whole (the ‘totalitarian thesis’ being a good example). It had reverted to the reductionism of Wilhelm Weiβ. Yet, the ‘Sovietisation’ debate is not entirely futile in that it at least allows scholars to get to the bottom of what shaped East German health, and, more importantly, attitudes toward chronic diseases. The Soviets no doubt had a part to play, and there are varying assessments of how big that part was. Since the origins of social hygiene lay in traditional (Weimar) German socialism and ideas on public health, this has primarily instigated the wider debate about the external influences on the East German health care system, and, in essence, what type of state socialism was going to impact on health matters. 102 Hence, there have been a number of attempts in studies on health, particularly for the early years of the GDR, to make a conscious assessment of how Sovietised the health care system became.

Jessica Reinisch has proposed that, due to the ‘bad press’ that the Soviet Zone was getting, those who were quick to judge the ‘Gesundheitswesen in der Sowjetischen Besatzungszone’, such as Wilhelm Weiβ, claimed that it was an exact replica of the Soviet model.103 It soon became apparent after the formation of the SED in 1946 (which was answerable to Moscow) that East German health care would be heavily exposed to its ideological dictates.104 It is, however, very difficult to decide whether aspects such as prevention, and the primacy of it in the system, can be interpreted as part of German or Soviet traditions, since historians have now discovered that it featured in both.105 Gabriele Moser has argued that what was assumed to be Soviet, even by some historians, was invariably Weimar German originally, a clear example being the Dispensaire System,106 presumed by historians even now to have originated from the Soviet health system. To understand how this happened, Winfried Süβ has framed his discussion of the role of the Soviets in shaping health care on the idea that there was merely a Reimport of Weimar socialist principles.107 Gerhard Naser has added that the Germans putting themselves forward to work for the Soviets, which, as Reinisch

102 Schleiermacher, ‘Contested Spaces’, pp.193-4. 103 Wilhelm Weiβ cited in Reinisch, p.11. 104 Schmidt and Ritter, p. 36. 105 Susan Gross Solomon, ‘Introduction: Germany, Russia, and the Medical Cooperation between the Wars’, in Doing Medicine Together: Germany and Russia Between the Wars, ed. by Susan Gross Solomon (Toronto: University of Toronto Press, 2006), pp. 3-31 (pp.7-8). 106 Moser, pp. 180-1. 107 Winfried Süβ, ‘Gesundheitspolitik’, in Drei Wege deutscher Sozialstaatlichkeit: NS-Diktatur, Bundesrepublik und DDR im Vergleich, ed. by Hans Günter Hockerts (Munich: Oldenbourg, 1998), pp. 55-100 (p.64).

31 and Anna-Sabine Ernst have analysed,108 were often communist and socialist doctors returning from exile, worked and thought in a similar fashion to the Soviets and were a ‘self-selected’ group.109 For this reason, Melanie Arndt has stated that the Soviets restrained their influence to such an extent that it is wrong to talk about the Sovietisation of health,110 and Jan Foitzik claims that the Soviet Military Administration was so chaotic that the Germans had no choice but to take the lead in shaping policy, including that of health.111

Annette Timm is wary of dismissing the involvement of the Soviets simply because their ideas differed little from their German communist and socialist counterparts. She explains that the Soviets brought with them the ‘lessons of Soviet communism’, and as Ridder has also suggested, helped to amplify the ‘dictatorship of the proletariat’ as part of the future commitment of the GDR to Marxism-Leninism.112 The adherence to this particular brand of Marxism, which presupposes strong leadership and certain coercive measures, did not, as Jung points out, evade the realms of health. According to Jung, the level of state involvement, bolstered by the belief in social hygiene, as well as the Marxist emphasis on production and economic determinism (getting people back to work), were reawakened by the Soviets who used the Weimar Republic as an example of the failings of a disparate political system. Jung adds that centralisation and nationalisation, combining to form ‘the institution of democratic centralism’, were already in full force in the Soviet system, benefitting from the experience of putting into practice what remained only novel ideas in the Weimar Republic.113

The debate on Sovietisation has provided a strong focus for scholars of East German health. However, these sorts of debates, as well as the pre-reunification interpretations of health, tend to be ‘top-down’, intellectual, clinical and lacking a social dimension. Reinisch’s comprehensive study of the occupation period in Germany has been one of the first to bridge the gap between political personnel and leading medical professionals, and those on the receiving end of treatment. Her study is rich in official documentary evidence as well as testimonies from various groups of people, and the variety of primary source material has

108 Ernst cited in Reinisch, p.118. 109 Gerhard Naser, Hausärzte in der DDR: Relikte des Kapitalismus oder Konkurrenz für die Polikliniken? (Bergatreute: Eppe, 2000), p. 58. 110 Arndt, p. 47. 111 Jan Foitzik, ‘Funktionale Aspekte der Organisation und der Tätigkeit der SMAD’, in SMAD-Handbuch, Die Sowjetische Militäradministration in Deutschland 1945-1945, ed. by Wladimir P. Koslow, Horst Möller, Sergei W. Mironienko, Alexandr O. Tschubarjan and Hartmut Weber (Munich: Oldenbourg, 2009), pp. 36-51 (pp.36- 41). 112 Annette F. Timm, The Politics of Fertility in Twentieth-Century Berlin (Cambridge: Cambridge University Press, 2010), p. 264; Ridder, p. 331. 113 Jung, p. 292.

32 brought with it greater balance in opinion and judgment.114 Besides the dearth of social analyses of East German healthcare, there have been other reminders of developments and changes which need to take place. Whilst the East/West divide in the discussion of East German healthcare is largely unavoidable, it does not have to be the only contextual framework that can inform on health matters. In Drei Wege deutscher Sozialstaatlichkeit, it is refreshing that Süβ has compared and contrasted features of the GDR healthcare system with both previous and parallel German healthcare systems.115 In fact, in terms of seeking out the origins of the healthcare system and establishing the true nature of East German healthcare, this study avoids the narrow-mindedness of ‘Sovietisation’, which can only lead to a simple conclusion, that is, whether the system was Sovietised or not. Even if, on the face of it, East Germany’s interventionist welfare state could have been influenced by its Marxist-Leninist political roots, brought by the Soviets and their German socialist and communist counterparts, Süβ argues convincingly that this trait could also have been distinctly Prussian in character.116 The GDR could at times adopt socially conservative attitudes, anchoring itself in certain German traditions. Aspects of the wider cultural history of the GDR, such as the attitude towards what was regarded as rebellious behaviour as well as the use of the term ‘asozial’ in TB policy, as Donna Harsch has discovered, reveal that the GDR was more firmly rooted in long-standing German traditions than the anti-fascist and anti-capitalist rhetoric seemed to imply.117

Whatever sort of ‘dictatorship’ the GDR was, there is as much utility in comparing it to another dictatorship as there is with the liberal democracy of West Germany. Contrasting the GDR with the Third Reich is extremely helpful for understanding the character of the East German state and its overriding sense of keeping the collective (society) healthy. Süβ makes the point that there were incidences where the dictatorship of Nazi Germany manifested itself in the destruction of life, whilst the East German dictatorship was absolutely intent on preserving life by whatever means necessary. This sums up in a nutshell the importance of health in the GDR, including the relevance of studying health topics, due to its influence on shaping and furthering the dictatorial forces brought to bear on patients within the GDR society.

114 See interviews in the ‘German Medical and Political Traditions in Post-war Berlin’ section of Reinisch, p. 130. 115 Süβ, p. 55. 116 Süβ, p. 57. 117 Harsch, ‘Medicalized Social Hygiene?’ p. 394.

Ernst’s study on medical professionals working in the healthcare system and medical higher education has been a welcome addition to the scholarship on East German healthcare.118 Her work serves to highlight the importance of examining not only the structural framework but also the historical actors involved in the processes of structural change. When basing one’s study on the introduction of new institutions (for example, polyclinics), the likes of which had not been seen in Germany (in practice), changes in East Germany in the area of health appear quite radical. If one focuses on memoirs of certain prominent doctors, such as Ingeborg Rapoport, a strong proponent of the regime, this will also prompt conclusions on its radicalism.119 However, Ernst shows that the process of transformation towards a socialist system was slower in the medical profession than elsewhere.120 She goes on to state that there was continuity in terms of medical personnel and their political background, citing important statistics collected in 1957 on the numbers of doctors who had been trained before 1945 (57 percent).121

Ernst and Schleiermacher discuss what measures were put in place to change the way that doctors conducted their work and how they were supposed to be perceived within this ‘new society’. They both agree that these measures were not altogether successful. They explain how the efforts to change the medical profession irrevocably, by fixing salaries so that doctors were ‘state employees’ (as opposed to ‘entrepreneurs’), and by attempting to change the social background of medical students, partly backfired.122 The aim to encourage working-class students to become doctors was a difficult one; there were contradictions inherent in the SED’s policy, associating the medical profession with the ‘intelligentsia’ and, at the same time, holding the medical profession in high regard. Ernst clarifies that the insistence on preferring working-class students to those from other social strata, and especially from medical backgrounds (Selbstrekrutierung), led to a backlash from existing doctors and university lecturers, who argued that students should be admitted on merit alone.123 Ernst believes that the obstacle facing the SED in trying to increase working-class intake was the fact that students

118Anna-Sabine Ernst, ‘Die beste Prophylaxe ist der Sozialismus: Ärzte und medizinische Hochschullehrer in der SBZ/DDR 1945-1961 (Münster: Waxmann, 1997). 119 Ingeborg Rapoport, Meine ersten drei Leben: Erinnerungen (Berlin: Nora Verlag, 2002). 120 Ernst, p. 105. 121 Ernst, p. 99. 122 Udo Schagen and Sabine Schleiermacher, ‘Drittes Kapitel, Sozialpolitische Entwicklungen, Thema 6, Gesundheitsschutz und Sicherung bei Krankheit–Ergebnisse: Politische und rechtliche Entwicklungen‘, in Geschichte der Sozialpolitik in Deutschland, Band 8: 1949-61, Die Deutsche Demokratische Republik im Zeichen des Aufbaus des Sozialismus, ed. by Dierk Hoffmann and Michael Schwarz (Baden-Baden: Nomos, 2004), pp. 408-430 (p.424); Ernst, pp. 107-8. 123 Ernst, p. 108.

34 from such backgrounds were often simply not attracted to the medical profession, instead wanting to study law or economics.124 Schleiermacher also notes that the SED’s plan to assimilate doctors into the ‘Staatliche Charakter’ of the healthcare system was a double-edged sword. Many doctors were keen to preserve their economic and professional independence, and this appeared increasingly difficult when private practices became no more than a tolerated model and the centre of day-to-day health provision shifted to polyclinics and Ambulatorien.125 This fuelled considerable discontent amongst the medical profession, which in turn led to mass emigration to the West, which was only stopped effectively by the building of the Berlin Wall.126

Despite Ernst, Schleiermacher and other historians focusing on medical professionals in the early years of the GDR, their work is still relevant for the middle and later period of the state. Many doctors who had reacted sceptically during the period of transition to state socialism were, if they had not emigrated, still active until the 1980s (and possibly after reunification). Gerhardt Katsch, the foremost diabetologist of the 1950s in the GDR, and also in the Third Reich, had younger colleagues who had been influenced by traditional, bourgeois Weimar doctors, a group to which Katsch arguably belonged.127 A prominent example is Gerhard Mohnike, Katsch’s closest colleague and director of the (Central)Institute for Diabetes at Karlsburg until his death in 1966, who was known to have a sceptical attitude towards the SED in particular and the GDR in general. Clearly, what is covered by Ernst et al is relevant in that it had lasting effects, even during the era of supposed ‘normalisation’.

New directions: using diseases as case studies for the analysis of the GDR

There have been very recent attempts to address the deficiency in studies on health and disease management that use the GDR as a background. As has been mentioned earlier, Harsch has bemoaned the lack of studies on disease management in the GDR, and there is indeed a lot that can be done in terms of analysing the GDR from a social history of medicine point of view. There have been two fairly substantial studies on disease management in the GDR by Madarasz-Lebenhagen and Harsch on heart disease and tuberculosis respectively. Neither of these works covers the entire period of the GDR’s existence, with Madarasz-Lebenhagen focusing on the time from 1945-1975, and Donna Harsch’s study on tuberculosis unavoidably

124 Ernst, pp. 106-7. 125 Schagen and Schleiermacher, ‘Gesundheitsschutz und Sicherung’, p. 424. 126 Schagen and Schleiermacher, ‘Gesundheitsschutz und Sicherung’, pp. 426-7. 127 See Gerhardt Katsch diaries, for example, Mathias Niendorf (ed.), Gerhardt Katsch: Greifswalder Tagebuch 1945-6 (Kiel: Ludwig, 2015).

35 linked to the early years of the GDR. The omission of the 1980s, especially for Madarasz- Lebenhagen’s analysis of a chronic disease, should not be neglected. In fact, inclusion of the 1980s would have added to her analysis of preventive health programmes for heart disease, in particular in view of her emphasis on Peter Baldwin’s finding that political concepts and cultural settings shape prevention practices.128 The impact of the economic and political situation of the 1980s in the run-up to the ‘gentle revolution’ would have been interesting to assess with regard to preventive strategies. Madarasz-Lebenhagen’s aim to look at how the political and social context of the GDR influenced prevention strategies shows that she envisages discovering changes from the previous regime and that it would be different too from West Germany.129 Since she compares the GDR with West Germany, where social hygiene and collectivism were not adopted, she is able to conclude that ‘East Germany’s centralized structures made the healthcare system more susceptible to the political desires of the SED’ and that ‘political ideology clearly moulded perceptions of health and prevention practices’. 130

What is noticeable in Madarasz-Lebenhagen’s analysis of heart disease (chronic) is that she emphasises change rather more than continuity in practices employed. The same cannot be said for Donna Harsch’s studies (article and chapter in Becoming East German). She concludes that ‘“preventive” East German TB policy…overlapped with similar trends in the GDR’s rival state, the Federal Republic’, such was ‘the all-German politics’ surrounding TB and the shared ‘cultural and historical circumstances’.131 In her article, the summary reveals that ‘methods of both treatment and prevention were characterized less by radical change and innovation than by tradition and pragmatism’. This shows that choosing an infectious disease with a long history of care and a strong existing institutional set-up (sanatoria, for example) meant that there was far greater potential for elements of continuity (and less political influence beyond the Cold War rivalry in which Harsch situates her study).132 Heart disease too had some pre- war disease management history, as did diabetes, but the duration of that history was shorter (especially for diabetes) due to the limited prior knowledge and acknowledgement of chronic diseases and their effects on the health of society. There was thus scope to establish new institutions or embed disease management within a new institutional structure. This is

128 Madarasz-Lebenhagen, p. 121. 129 Madarasz-Lebenhagen, p. 122. 130 Madarasz-Lebenhagen, p. 133. 131 Donna Harsch, ‘Socialism Fights the Proletarian Disease: East German Efforts to Overcome Tuberculosis in a Cold-War Context’, in Becoming East German: Socialist Structures and Sensibilities after Hitler, ed. by Andrew I Port and Mary Fulbrook (Oxford and New York: Berghahn, 2013), pp. 141-157 (pp.150-1). 132 Harsch, ‘Socialism Fights the Proletarian Disease’, p. 141.

36 something which is also apparent in treatment strategies for diabetes e.g. in the fact that the (Central)Institute for Diabetes in Karlsburg was established and that Diabetikerberatungsstellen (diabetes advice centres) featured within the newly constructed polyclinics and Ambulatorien.

Using the example of diabetes and comparing it to Harsch’s conclusions on TB, there is some overlap in the message that there was ‘a dynamic interplay of change and continuity’.133 Social hygienists in the 1953 Lehrbuch der Sozialhygiene comment on the fact that the sanatoria used to isolate TB patients were also used in diabetes care (and heart disease).134 However, judging by the overall tone, Madarasz-Lebenhagen has underscored the political influences and cultural changes that seem to feature in heart disease and are therefore also likely to be present in diabetes, another chronic disease, thereby marking out a slight dichotomy between infectious and chronic diseases. Madarasz-Lebenhagen also mentions the East German Ministry of Health appealing for collective efforts to organise nationwide heart disease prevention in 1954;135 in the same year, they appealed for similar collective prevention for diabetes. This implies, therefore, that heart disease and diabetes were developing at a similar rate in terms of preventive action in the GDR.

The other element that both diabetes and heart disease have in common is their link to lifestyle and food. This is also a sign of a significant overlap between the social history of medicine and cultural history. Neula Kerr-Boyle has completed a PhD thesis on anorexia in the GDR, as well as a chapter in Becoming East German about the culture of dieting. She has encouraged the GDR to be ‘understood as a complex, modern industrial society, facing similar problems to contemporaneous non-communist societies’, and that goes for ‘food, health and the body’.136 She raises the issue of change and continuity that has already been discussed, expressing similar views on there being a mixture of the two; opinions on anorexia were ‘shaped by traditions and mentalities of the pre-1945 era, as well as by socialist ideals and values’.137 Kerr-Boyle raises an interesting question relating to the level of individualism that developed in the GDR in maintaining and changing the size and shape of the body, talking of a ‘locus of individual identity’ and a ‘pursuit of private goals for personal happiness’ in the

133 Harsch, ‘Socialism Fights the Proletarian Disease’ p.152. 134 Kurt Winter,‘Bedeutung und Organisation stationärer Einrichtungen’, in Lehrbuch der Sozialhygiene, ed. by Kurt Winter and Alfred Beyer (East Berlin: VEB Verlag Volk und Gesundheit, 1953), pp. 153-159 (p.155). 135 Madarasz-Lebenhagen, p. 124. 136 Neula Kerr-Boyle, Orders of eating and eating disorders: food, bodies and anorexia nervosa in the German Democratic Republic, 1949-1990 (unpublished PhD thesis, University College London, 2012), p. 26. 137 Kerr-Boyle, p. 26.

1970s/1980s.138 This could be applicable to the personal responsibility taken to manage a particular disease, and the measures needed to lose weight for sufferers of type 2 diabetes. Although there will have been pressure from the SED and strict plans imposed on patients by medical professionals, the individual did have some control, which, according to Kerr-Boyle, increased over time as new ideas about the body began to emerge. Unlike Donna Harsch, who declares her work to be ‘an archive-based study’,139 Kerr-Boyle draws upon interviews with patients.140 Health topics need not always be ‘clinical’ and distant in character and can be extremely intimate. The introduction of people and their stories adds a human dimension to Kerr-Boyle’s thesis and chapter on dieting that is missing from the other disease management studies.

Ulrike Thoms’ study on obesity in the two Germanies uncovers differences between East and West with regard to food consumption. Her chapter is very useful for this thesis in that it partly makes reference to diabetes (type 2) in her discussion of the sense of alarm in both states at the increasing numbers of overweight people, even though most of the information on diabetes is not drawn from archival material. She believes that ‘due to the complex mix of economic and political factors, the different histories of the two German states were accompanied by differences in food consumption’.141 According to Thoms, East Germans ‘consumed more fat, sugar, grain, potatoes and vegetables, but less fruit, cheese, cocoa and coffee’ than West Germany. 142 Thoms’ statistics suggest that both states encountered similar problems with obesity and overweight people; the GDR recorded slightly higher numbers of underweight people in the 18-24 age category and higher numbers of overweight people in the 55-64 category. In spite of the lengthy scientific cooperation between East and West until 1961, Thoms stresses that health policy was very different.143 This does not mean that the outcome of the differing health policies diverged; in fact, she concludes that it did not. Yet, she talks about the GDR’s message to ‘the active socialist’ to take responsibility for his/her health ‘as the wellbeing of society depended on his work’, and the preventive outlook of testing early for diabetes as aspects that could be learned from what she has termed ‘health policy eastern

138 Kerr-Boyle, p. 29. 139 Harsch, ‘Medicalized Social Hygiene?’ p. 394. 140 Kerr-Boyle, pp. 222-244. 141 Ulrike Thoms, ‘Separated, But Sharing a Health Problem: Obesity in East and West Germany, 1945-1989’, in The Rise of Obesity in Europe: A Twentieth Century Food History, ed. by Derek J Oddy, Peter J. Aitkens and Viriginie Amilien (Farnham: Ashgate, 2009), pp. 207-22. 142 Thoms, p. 216. 143 Thoms, p. 210.

38 style’.144 She concludes that in terms of reducing the incidence of obesity, both German states were ineffective, but ‘it seems worthwhile to reconsider the East German centralized system, leaving behind all ideological objections, as it was much cheaper than the highly individualised West German model’.145

Even if historians have suggested that the GDR’s major downfall was the fact that it went bankrupt, the healthcare system and those working within it were committed to saving and not spending money. They spent far less on health than West Germany did, which, for a state socialist nation with a very large emphasis on a welfare state, is difficult at first to reconcile but true nonetheless. She mentions in passing that the preventive outlook of the East German healthcare system and the national diabetes register were both set up to lessen certain diabetics’ (again, type 2) reliance on insulin, which was imported throughout the history of the state. They were able to deliver treatment to patients on a tight budget, and part of the reason for that, she believes, was the ease with which a centrally organised system could organise patient information and allow for cooperation between medical specialists.146 Her study, and her mention of diabetes, is very broad, but this link to the health economy is an important area for this thesis to probe.

Outline of the thesis and sources

A study of diabetes in the GDR clearly raises many interesting questions within various strands of secondary literature that this thesis intends to confront. It is ideally placed to add to studies that shed light on the life of ordinary East Germans, as well as those concerned with the way in which the East German healthcare system functioned. It will also provide valuable additions to literature which has examined the perception and management of chronic diseases (and diabetes) in different (political) contexts. The use of state socialism as a political background is a departure from the current trend to examine western, liberal democracies. In contrast to the few emerging studies of specific diseases using the GDR as a contextual base, this thesis will demonstrate that the use of diabetes as a case study is ideal and an even better vehicle to show the nature of healthcare within state socialism than the diseases studied thus far. The fact that the life expectancy of diabetics, certainly in what can be described as mature state socialism, was not that much lower than that of a healthy person, makes it possible to obtain a long-term view of the experiences of both patients and the doctors treating them. In this sense, the

144 Thoms, p. 210. 145 Thoms, p. 218. 146 Thoms, p. 218.

39 longevity of diabetes enhances its usefulness as a tool to discover more about the effects of state socialism than would be the case with transient infectious diseases, whose symptoms may cease or may not be continually in need of treatment, such as TB. The other added advantage which diabetes has as a case study is that it is a disease of two overarching types. Whereas type 2 is more like cardiovascular disease in that it tends to affect people in later life and has identifiable risk factors, type 1, a leading autoimmune disease, brings to the fore different issues to which the new political system needed to respond. The idea that both types of diabetics, however, could be made fit for work through certain treatment measures and that the state had a distinct interest in ensuring that patients participated actively in the world of work means that a close analysis of diabetes is likely to provide the opportunity to draw conclusions about the interactions between a state socialist system, the GDR’s healthcare system (including those working within it) and the individual sufferer.

The source material used in this thesis can be grouped into three broad categories. The first consists of archival material from the Foundation Archives of Parties and Mass Organisations of the GDR, currently housed in the Bundesarchiv Berlin Lichterfelde branch. The majority of useful documents were written to and by members of the East German Ministry of Health, which can be found under the code ‘DQ1’. There are also other relevant documents, particularly from the mid-1960s onward, relating to economic and technological matters. The documents for diabetes have only recently been catalogued in 2014 and will therefore produce some highly original discoveries. As time progresses, these documents become more concerned with the detail of the treatment administered to diabetics, especially on the topics of insulin and oral antidiabetic tablets, and are also extremely valuable in getting to know the type of research which was being conducted. The correspondence between diabetologists at the two focal institutions for diabetes, the (Central)Institute for Diabetes in Karlsburg near Greifswald and the Zentralstelle für Diabetes und Stoffwechselkrankheiten in Berlin, as well diabetologists from across the regions of the GDR, reveal a large amount about the (political) relationship between colleagues on a number of different levels. It is also possible to ascertain whether this relationship ever had an impact on decisions being made. An awareness of the general chronological trajectory of the GDR more broadly is very important when approaching these documents. It is relevant to keep in mind the political backdrop to developments within diabetes care. These include the repercussion of such events as the building of the Berlin Wall in 1961, the invasion of Prague in 1968, the change of power from Ulbricht to Honecker (1971), and the GDR’s accession to and membership of both the UN and the World Health Organisation

(WHO) from 1973 onwards. The impact of the GDR’s increasing economic decay in the 1980s will also have to be assessed.

The second category of source material comprises the medical journals published during the years of the GDR by the nationalised publisher, VEB Verlag Volk und Gesundheit. There are journals written for a more specialist audience, in particular, Das Deutsche Gesundheitwesen, Zeitschrift für die gesamte Innere Medizin and Medicamentum, and those for a non-specialist audience, the most popular being Deine Gesundheit (‘Your Health’). Deine Gesundheit was introduced in 1956 and widely sold in newsagents to the general public. Contributors to Deine Gesundheit often featured in the specialist journals, too, and the journal contained, in the early years especially, articles with a medicalised content. Deine Gesundheit, as a result of its purpose being to reach out to a wide readership, contained articles which were politically quite overt. However, it must be noted that the specialist journals were also influenced by the political and medico-political developments of the day. It is very easy to find articles in the 1950s using the official epidemiological strategy of social hygiene, for example. Authors and indeed editors of both specialist and non-specialist journals were the ‘official’ health theorists (and therefore, by extension, social hygienists). The GDR did not have a free press, and it was thus unavoidable to encounter political indoctrination in every aspect of the media.

The third category covers memoirs and diaries of East German diabetologists, which are slowly being published and are a growing but small body of primary literature. Although oral history is not intended to be at the centre of this project, written accounts will be occasionally interspersed with reflections of surviving diabetologists and patients during interviews, which, rather than taken for their own sake, have been very useful in adding to existing material and leading to new directions in research that may otherwise not have been thought about. The diaries of the GDR’s leading diabetologist, Gerhardt Katsch, will be of particular use to the early years of diabetes care and the introduction of new institutions in the immediate post-war period. Other surviving diabetologists, including Dr. Heinz Schneider and Professor Waldemar Bruns, have written memoirs about their medical careers in the GDR. Both cover the whole lifetime of the GDR, including their time as medical students in the 1950s; they provide very useful insights into developments, changes and continuities in policy. Since neither were members of the SED, they were keenly aware of the political circumstances and whether these shaped their work. The memoirs, whilst personal, add to the secondary literature on medical professionals, such as that by Anna-Sabine Ernst and Gero Bühler.

Schneider and Bruns, as well as a host of other colleagues, many of whom are now sadly deceased, have contributed to a collection of work on the history of diabetology in the GDR, which has been written for, and on behalf of, the German Diabetes Society. Nuggets of valuable information can help build a picture of how diabetologists and their patients experienced not only the impact of the ideological foundations of the GDR, but also, crucially, its economy (economic policy) and the politics of state socialism.

The overall aim of this thesis is to assess the nature and depth of the influence state socialism exerted on all aspects of diabetes care and research in the GDR. What exactly was this impact, and did it vary depending on institution, area, type of diabetes and period of time? Did its impact act as a help or a hindrance to those delivering diabetes care or conducting related research? Did the system of care it created for diabetes work effectively for patients treated within it? In order to answer these questions, the approach that will be taken in terms of structure is a chronological one. It is necessary to consider that the GDR, despite its mere forty-year existence, changed considerably over time due to several watershed moments. Within the healthcare system and diabetology specifically, there were also events which altered the course of care and research, alongside broader developments that had a clear impact. The deaths of two key diabetological figures, Gerhardt Katsch in 1961, and Gerhard Mohnike in 1966, both of whom led the focal point of diabetes care, the (Central)Institute for Diabetes, were pivotal moments. The successor to Mohnike, Horst Bibergeil, was the first leader of the Institute to be a member of the SED and wanted to bring the Institute more into line politically than Mohnike, a vocal opponent from the start.

This thesis will therefore follow key developments within diabetes care, which are also largely analogous to the wider political context. The first chapter will examine the immediate post-war years, from around 1949 to 1961, the period when Gerhardt Katsch was still a prominent voice in East German diabetology and during which the basis of diabetes care in the GDR was established. The second chapter will analyse events during the tenure of his successor at the (Central)Institute for Diabetes, Gerhard Mohnike, and will include an assessment of the impact the building of the Berlin Wall had within diabetes care. Following the premature death of Mohnike, chapter three will trace developments between 1966 and 1973, the time when the GDR acceded to the UN and the WHO, and when a thirst for international success appeared to surface more prominently than ever before. The fourth chapter will then evaluate how Honecker’s arrival at the helm and newfound international recognition led to the ‘normalisation’ of diabetes care, testing and proving Fulbrook’s theory. This perception of

42 stability will be contrasted with the content of the final chapter, where progress was hampered from at least 1980 by underlying economic difficulties. The GDR’s failure to keep up with medical-technical and pharmaceutical developments was exacerbated by a substantial shift in political mood in the Soviet Union, causing irrevocable damage to the already shaky foundations on which the GDR was built. It is anticipated that the conclusion synthesises the answers to the research questions posed above, highlighting the important moments and turning points for diabetes care and research across the four decades of the state’s lifetime.

Chapter 1: A System of Chronic Disease Management for a ‘New Society’: The Introduction of Diabetes Care in the GDR (c. 1949-1961)

Introduction

Whilst the foundation of the German Democratic Republic (GDR) on 7 October 1949 should not be viewed as a completely blank page on which a new history was written, the almost total destruction of Germany after the Second World War presented an opportunity for a fresh start in all aspects of public life. This was particularly true in the part of occupied Germany ruled by the Soviets, which would later become the GDR. The Soviets brought with them an approach to health and the economy which differed markedly from the other Allies and indeed what had been put into practice in Germany before 1945. This chapter will assess to what extent this paradigm shift manifested itself in the strategies employed to deal with the chronic disease diabetes during the early years of the GDR’s existence until the building of the Berlin Wall in 1961. It will explore what developments took place, as well as their origins; these were not simply in the Soviet Union, but also in Weimar German left-wing political thinking from which the Soviet Union drew much of its inspiration. There will also be reference made to the system of healthcare and approaches to diabetes specifically which pre-dated the GDR, and how far the notions of the duties of medical professionals, especially within chronic disease management, were transformed incrementally in the 1950s.

The epidemiological strategy of social hygiene and its emphasis on prevention in early East German diabetes management

During the years of Soviet occupation, many of the left-wing German health theorists, who formed a substantial portion of the Central Administration for Health and the health department of the Soviet Military Administration (SMAD), brought strikingly similar ideas to the negotiating table. When it came to the ‘guiding light’ of health policy, both parties agreed that the way forward was the original Weimar German principle of social hygiene, a concept which has already been discussed in detail earlier.147 The version of social hygiene ‘reimported’ into the fledgling post-war East German healthcare system was to have a strong emphasis on ‘prevention first’.148 It is logical that social hygiene, strictly within the realm of epidemiology,

147 Dorothy Porter, Health, Civilization and the State: A history of public health from ancient to modern times (London and New York: Routledge, 1999), p. 192. For prior discussion of social hygiene, see the literature review of this thesis. 148 Donna Harsch, ‘Socialism Fights the Proletarian Disease: East German Efforts to Overcome Tuberculosis in a Cold War Context’, in Becoming East German: Socialist Structures and Sensibilities after Hitler (Oxford and New York: Berghahn, 2013), p. 142.

44 was, as Carsten Timmermann rightly points out, ‘in the early years of the GDR… the dominant science when it came to questions of health policy and preventive medicine’. 149 One of the major advantages in establishing consensus within health policy in the Soviet Zone (for the future GDR), was that the Soviet Health Department was staffed by well-qualified health professionals capable of understanding what social hygiene was all about as well as the aetiology of diseases, allying with ‘trusted Germans’, 150 for example Kurt Winter, Hermann Redetzky and Alfred Beyer, singing from the same hymn sheet. 151 Whilst East German social hygienists gravitated toward Grotjahn’s belief in the individual’s social conditions influencing the diseases that he/she acquired, along with the close link between prevention, medical care and rehabilitation, there was much more to it than that. East Germans were keen to follow the approach of Semashko, which was to take Grotjahn’s ideas and adapt them to fit a distinctly socialist state, or as it would later be termed in the GDR, a situation of ‘real-existing socialism’.152 They thus needed to start by defining social hygiene as not simply intending to cure disease, but also, as Semashko stated, to abolish ‘its causes by studying the working and living conditions of every patient’ through a ‘whole system of socialist construction’.153 This system, according to another Russian medical thinker and deputy to Semashko, Zinovij Solov’ev, should be the direct opposite to the disparate, capitalist structures of the ill-fated Weimar Republic, which were open to class discrimination.154

Consequently, in Article 16 of the GDR’s constitution of 1949 the relationship between health and working life (and the working class) was made explicit, a nod to the overarching

149 Carsten Timmermann, ‘Appropriating Risk Factors: The Reception of an American Approach to Chronic Disease in the two German States, c. 1950-1990’, Social History of Medicine, 25:1 (2012), 157-174 (p.158). 150 This idea of ‘trusted Germans’ has been expressed by Reinisch: Jessica Reinisch, The Perils of Peace: The Public Health Crisis in Occupied Germany (Oxford: Oxford University Press, 2013), p. 94. 151 The body of work written by these individuals symbolises their importance as key social hygienists. This includes: Kurt Winter and Alfred Beyer (eds.), Lehrbuch der Sozialhygiene (East Berlin: VEB Verlag Volk und Gesundheit, 1953) and Kurt Winter, Alexander Mette und Gerhard Misgeld, Der Arzt in der sozialistischen Gesellschaft (East Berlin: Akademie-Verlag, 1958). Hermann Redetzky, as the first director of the Institute for Social Hygiene in Berlin, has been viewed as a prolific social hygienist in historical scholarship, such as by: Jeannette Madarasz-Lebenhagen, ‘Perceptions of Health after World War II: Heart Disease and Risk Factors in East and West Germany, 1945-1975’, in Becoming East German: Socialist Structures and Sensibilities after Hitler (Oxford and New York: Berghahn, 2013), pp. 121-140 (p.125). 152 Eli Rubin, Amnesiopolis: Modernity, Space and Memory in East Germany (Oxford: Oxford University Press, 2016), p. 28 153 Anton Semashko, Health Protection in the USSR: The New Soviet Library II (London: Victor Gollancz, 1934), pp. 23-4. 154 Zinovij Petrovic Solov’ev, ‘Thesen zu dem Vortrag: “Die prophylaktischen Aufgaben der therapeutischen Betreuung”, in Fragen der Sozialhygiene und des Gesundheitswesen (Ausgewählte Werke) ed. by Kurt Winter, (East Berlin: VEB Verlag Volk und Gesundheit, 1975), pp. 118-123 (p.118).

Marxist-Leninist ideology.155 The Article states that ‘a comprehensive social security system would serve to preserve the health and ability to work of the working population’.156 This was an important motivator for the Socialist Unity Party to push for prevention-orientated healthcare, which social hygiene sought to deliver through the analysis of social and economic factors. Winter, Beyer and Redetzky all highlighted the issues of productivity, equality and collective thinking in terms of the approach to prevention in social hygiene. It was the duty of the state to enhance the health of all its citizens, especially through improving and maintaining their physical and intellectual capabilities, to ensure the progress of society as a whole.157 These goals could only be achieved if there was sufficient evidence collected relating to the causes of major diseases, namely those categorised as Volkskrankheiten (people’s diseases), which had been identified largely by social hygienists themselves. These included, in the early years, a range of infectious diseases, the most notable being Tuberculosis and STDs, and chronic diseases, including heart disease and diabetes (pronounced a Volkskrankheit by Hermann Redetzky in 1952).158 This evidence was provided in the form of statistics, particularly numerical data of mortality and morbidity rates, from which conclusions could be drawn on how societal factors contributed to a disease and the probable impact that a disease had on society. Udo Schagen and Sabine Schleiermacher have argued that the results of statistical analyses, which could lead to, for example, a conclusion of social inequality and/or that the diseases were affecting working classes, would be the first issue to tackle.159 Gradually, statistical data became a very important part of the healthcare system and was integrated fully

155 Sabine Schleiermacher, ‘Contested Spaces: Models of Public Health in Occupied Germany’, in Shifting Boundaries of Public Health: Europe in the Twentieth Century, ed. by Susan Gross-Solomon, Lion Murard and Patrick Zylberman (Rochester, N.Y.: University of Rochester Press, 2008), pp. 175-204 (p.194). 156 ‘Die Verfassung der Deutschen Demokratischen Republik vom 7. Oktober 1949, Artikel 16’, http://www.documentarchiv.de/ddr/verfddr1949.html [accessed 12/05/19]. 157 Kurt Winter and Alfred Beyer, ‘I. Teil: Einführung, Geschichtliche Entwicklung, Inhalt und Definition der Sozialhygiene’, in Lehrbuch der Sozialhygiene, ed. by Kurt Winter and Alfred Beyer (East Berlin: VEB Verlag Volk und Gesundheit, 1953), pp. 1-22 (p.18 and p.22); Alfred Beyer, ‘V.Teil: Arbeit und Arbeitsproduktivität’, in Lehrbuch der Sozialhygiene, ed. by Kurt Winter and Alfred Beyer (East Berlin: VEB Verlag Volk und Gesundheit, 1953), pp. 273-326 (pp.273-326); Hermann Redetzky, ‘Aufgaben und Ziele der Sozialhygiene innerhalb der medizinischen Wissenschaft’, Zeitschrift für die gesamte innere Medizin, 2 (1947), 1141-1143 (p.1141). 158 For a list of ‘Volkskrankheiten’, see Friedrich Müller, ‘Die sozialhygienische Bedeutung des Diabetes mellitus’, in Lehrbuch der Sozialhygiene, ed. by Kurt Winter and Alfred Beyer (East Berlin: VEB Verlag Volk und Gesundheit, 1953), pp. 493-501; For Redetzky’s proclamation, see: Hermann Redetzky, ‘Die soziale Bedeutung des Diabetes mellitus und seine Berücksichtigung in sozialmedizinischer Hinsicht, Das deutsche Gesundheitswesen, 7 (1952), 152-7 (pp.152-3). 159 Udo Schagen and Sabine Schleiermacher, ‘Drittes Kapitel, Sozialpolitische Entwicklungen, Thema 6, Gesundheitsschutz und Sicherung bei Krankheit: Handlungsrahmen und zentrale Debatten’, in Geschichte der Sozialpolitik in Deutschland seit 1945, Band 8: 1949-61, Die Deutsche Demokratische Republik im Zeichen des Aufbaus des Sozialismus, ed. by Dierk Hoffmann and Michael Schwarz (Baden-Baden: Nomos, 2004), pp. 393- 407 (p.405).

46 into it. The development of national registries for major diseases in the mid-to-late 1950s (the National Register for diabetes was introduced in 1958) allowed for this data to be centralised and systematic.

With large quantities of data at their disposal, the thirst of social hygienists for preventing diseases was clearly visible in their targeting of those categorised as ‘chronic’. Indeed, the writing of social hygienists suggested that chronic diseases were vitally important and the main target. Immediately after the end of World War Two, infectious diseases were rampant, but still, social hygienists were concerned about what they called the diseases of an industrialised society.160 They were keen followers of the notion of the ‘epidemiological transition’ from infectious to chronic diseases as the main cause of mortality, and in particular, morbidity.161 It was precisely the morbidity figures which concerned social hygienists as much as mortality rates. This was where chronic diseases exemplified the mission of prevention and the socio-economic rationale of social hygiene in a way that most infectious diseases did not.

It was seen to be important to prevent the diseases themselves, but it was also important to prevent potential complications as a result of suffering from the disease for a prolonged period and/or mismanaging the condition.162 The reason why morbidity was considered so problematic, and by extension a target for prevention, can be linked to the productive aims of social hygiene and the ruling SED’s Marxist-Leninist leadership more broadly. The very idea of premature retirement (‘Frühinvalidität’) and absence from work or ‘malingering’ (‘Bummelantentum’) troubled the SED.163 As a result, this led to the social hygienist, Redetzky, writing that social hygiene was not simply about keeping people healthy, but enabling them to perform at the highest level possible for the good of the collective.164 There was also a deeply held belief that chronic diseases were costly in financial terms to the healthcare system, and those costs needed to be minimised.165 By looking at the social hygienic response to chronic diseases, it is therefore possible to confirm what Helmuth Jung has stated about health in the

160 Müller, p. 405. He quotes diabetes as one of the foremost modern diseases of the age (‘nachgerade die moderne Zivilationskrankheit’). 161 Carsten Timmermann, ‘Chronic Illness and Disease History’, in The Oxford Handbook of the History of Medicine (Oxford: Oxford University Press, 2011), pp. 393-410 (p.406). 162 Winter, Mette and Misgeld, Der Arzt, p. 21. 163 Erich Apel, ‘Kampf dem Bummelantentum’, Arbeit und Sozialfürsorge, 7 (1952), p. 510. 164 Redetzky, ‘Aufgaben und Ziele’, p. 1141. 165 Redetzky, ‘Aufgaben und Ziele’, p. 1143.

GDR, namely that it came to be viewed as ‘an indispensable precondition for economic growth’.166

In addition, chronic diseases exemplified the social hygienic message of the ‘unity of prevention, medical care and rehabilitation’, with prevention playing a pivotal role at every stage of management.167 The fear of losses in production and the constant desire to diagnose early and to prevent complications provide an intimate glimpse into the way in which prevention would inevitably encourage strong intervention by the state in people’s lives. The theory proposed by Konrad Jarausch of the GDR as a ‘Welfare Dictatorship’ fits rather neatly with reference to the utilitarian aims of social hygiene, namely that there developed, as the forthcoming sections of this chapter will illustrate, an amalgamation of progressive and regressive methods in the quest to prevent chronic diseases like diabetes.168 For those who were branded ‘indifferent’ toward their health (die lässigen und gleichgültigen Menschen), Redetzky stresses the need to be educated into thinking about one’s role as an ideal socialist personality, maintaining one’s health for the good of the state.169

In terms of the direct link between diabetes specifically and social hygiene, social hygienists and diabetologists engaging with the social hygienic consensus viewed diabetes as one of the major chronic diseases of the future and one which was an excellent example of a disease requiring vigorous prevention. In the textbook for medical students and doctors, Lehrbuch der Sozialhygiene, Friedrich Müller believed diabetes to be the foremost disease of modern society (‘nachgerade die moderne Zivilisationskrankheit’), which was starting to influence the social structure of developed societies. He cautioned against underestimating the rates of diabetes and clarified that it was going to be a burning public health problem sooner than anticipated.170 Diabetes specialists were beginning to see the need to follow the social hygienic emphasis on data collection early on in order to assess the prevalence of the disease. The diabetologist, Dr. Volker Schliack, an enthusiastic proponent of establishing epidemiological trends through the use of statistics, first collected data of cases diagnosed during a preliminary screening programme to establish an average rate of the prevalence of the

166 Helmuth Jung, ‘Political Values and the Regulation of Hospital Care’, in Political Values and Health Care: The German Experience, ed. by Donald W. Light and Alexander Schuller (Cambridge MA.: MIT Press, 1986), pp. 289-324 (p.292). 167 Schleiermacher, ‘Contested Spaces’, p. 195. 168 Konrad Jarausch, ‘Care and Coercion: The GDR as a Welfare Dictatorship’, in Dictatorship as Experience: Towards a Socio-cultural History of the GDR, ed. by Konrad Jarausch, trans. by Eve Duffy (Oxford and New York: Berghahn, 1999), pp. 47-72 (pp.59-61). 169 Redetzky, ‘Aufgaben und Ziele’, p. 1142. 170 Müller, p. 493.

48 disease.171 In 1950, when this screening trial was carried out, the assumed percentage of diabetics in the population had been 0.5 percent. However, this trial revealed an alarmingly higher rate of 1.5 percent. 172 This much higher figure may well have exaggerated the scale of the problem at that time (the official nationwide percentage for 1960 was 0.6 percent) but Schliack was right to point out that this was a disease on the rise, and the decades that followed would prove him correct. At the end of the GDR’s lifetime in 1989, its prevalence had increased to 4.1 percent.173

By the early 1950s, perhaps as a direct consequence of Schliack’s findings, social hygienists began to write more prominently about diabetes, especially in the medical journal Das deutsche Gesundheitswesen. In 1952, Redetzky’s article on the ‘social significance of diabetes’ illustrated how social hygienists took the disease seriously and regarded it as an integral part of public health. It is in this article where diabetes was first termed a Volkskrankheit with ‘special socio-economic significance’, sending out a signal that this should not be viewed by social hygienists as marginal.174 Redetzky began by linking diabetes to the economy and the current and future socio-economic situation; diabetes was also, he goes on to state, a good indication of the population’s ‘Lebensbarometer’ and how well or poorly people were living in terms of their diet and housing situation.175 This made it an ideal case study, therefore, for social hygienists to judge the health of the population at large, which was one of their ultimate goals.

The link to the economy was discussed in the context of East Germany’s first Five Year Plan, where prevention and comprehensive healthcare for chronic diseases, including diabetes, were considered to be a precondition to meet the targets set. As with chronic diseases generally, there was a clear message that diabetics were able to work as long as their condition was managed properly; this featured in Redetzky’s article and in the writing of diabetologists in Das deutsche Gesundheitswesen, as well as Müller’s chapter in the Lehrbuch. In a 1954 article, Mohnike expressed his confidence that diabetics were fit ‘for practically all those jobs which

171 See example of his use of statistics in Appendix 3. 172 Volker Schliack, Statistisch-klinische Diabetesfragen (Leipzig: Geest und Portig, 1953). 173 Dietrich Michaelis and Erich Jutzi cited in Christin Heidemann and Christa Scheidt-Nave, ‘Prävalenz, Inzidenz und Mortalität von Diabetes mellitus bei Erwachsenen in Deutschland – Bestandsaufnahme zur Diabetes-Surveillance’, Journal of Health Monitoring, 2:3 (2017), 98-121 (p.108). 174 Hermann Redetzky, ‘Die soziale Bedeutung des Diabetes mellitus und seine Berücksichtigung in sozialmedizinischer Hinsicht’, Das deutsche Gesundheitswesen, 7 (1952), 152-7 (pp.152 and 156). 175 Redetzky, ‘Die soziale Bedeutung’, p.152.

49 their physical and mental abilities allowed them to carry out’.176 The fear that a diabetic might become unable to work, however, is also evident, although he believed that cases of invalidity were likely to be ‘extremely exceptional cases’.177 He even stated that, in the event of complications, such as cataracts, these could be reversed by operation, and that for such patients ‘time-limited invalidity’ was all that was required.178 Redetzky reminded the reader that ‘poorly or insufficiently treated diabetics’ would ‘become unable to work very quickly’.179 Diabetologists drew on a pre-existing belief in the capabilities of diabetics, which fitted rather neatly with the new Marxist-Leninist critique of keeping people in work. Gerhardt Katsch’s suggestion that diabetics should be viewed as ‘conditionally healthy’ (‘bedingt gesund’) and ‘conditionally able to work’ (‘bedingt arbeitsfähig’) epitomises this attitude prevalent amongst the specialists.180 Patients would hence not be lamenting their ‘chronically ill’ status any longer. The terminology adopted by Katsch, who was inspired by Weimar social democratic politics himself, did not need to be modified, and could be easily adapted to the new socialist state.

Regarding the views on the aetiology of diabetes, Redetzky and Mohnike both agreed that it was a combination of genetic and environmental factors, with the latter opening up considerable prophylactic possibilities for both insulin and non-insulin dependent diabetics. Redetzky was convinced that social issues predominated and talked of the ‘psychological- nervous factor’ present in the onset of diabetes. This, he believed, was caused by a number of socio-economic problems, such as financial and employment insecurities and feelings of being suppressed (particularly with reference to the working class).181 The added complexity of diabetes, compared to other chronic diseases, is that it is a disease of two distinct types. The point at which specialists, and later social hygienists, first recognised this is not clear, although a 1953 study by Schliack, on ‘clinical and statistical diabetes issues’ suggested that the insulin and non-insulin dependent types were roughly established by this point. 182

The implications of this discovery meant that there were differences in the way that insulin and non-insulin dependent diabetics were addressed by social hygienic prescriptions. These differences are not always easy to tease out. The language used to describe the two types,

176 Gerhard Mohnike, ‘Sozialmedizinische Diabetesfragen’, Das deutsche Gesundheitswesen, 9 (1954), 286-292 (p.290). 177 Mohnike, ‘Sozialmedizinische Diabetesfragen’, p. 291. 178 Mohnike, ‘Sozialmedizinische Diabetesfragen’, p. 291. 179 Redetzky, ‘Die soziale Bedeutung’, p. 156. 180 Mohnike, ‘Sozialmedizinische Diabetesfragen’, p. 291. 181 Redetzky, ‘Die soziale Bedeutung’, p. 154. 182 Schliack, pp. 36-40.

50 particularly by social hygienists (and less so by diabetologists) was rudimentary, simply referring to ‘child diabetics’, ‘old diabetics’ and ‘pregnant diabetics’, without demarcating types more clearly.183 It does, nonetheless, reveal social hygiene’s propensity to group people socially. The commonality of the length of time needed to manage both types encouraged universal emphasis on productivity, but there were specific aims for each type. For example, the reference made by Mohnike to the importance of prophylaxis in the pre-diabetic phase to prevent complications was in reference to non-insulin dependent diabetics, whose condition, Mohnike warned, could go undetected for years.184 A typical response for insulin-dependent cases was to look more carefully at appropriate working conditions which would not disturb the metabolism, where the effects of the disease would not present a danger to the sufferer or others at the workplace. Production line work, being a driver, chimney sweep, miner or working with chemicals were all discouraged by Redetzky.185 Diabetologists, on account of their more specialist approach compared to social hygienists, brought many specific issues to the fore which happened to work with rather than against social hygienic aspirations. The nature of diabetics being susceptible to infectious diseases, especially TB, amplified the case for preventive health, as well as retaining productive capacities through swift intervention and meticulous monitoring.186 The rising rates of diabetes, constantly monitored by Schliack, were thus met with a degree of urgency, which, due to the evident links which existed to social hygiene, was conducive to the swift construction of an intricate system of outpatient care and occupational health aimed at diabetics.

The development of outpatient care for diabetics: the polyclinic model and the Dispensaire System

One of the most important institutions introduced into the system of outpatient care, which intended to fulfil Winter’s ‘democratisation’ aims, was the new polyclinic model. The introduction of polyclinics was the Soviet Military Administration’s 272nd Order issued during the years of occupation.187 In terms of origins, polyclinics had been, like social hygiene, tried and tested in the Soviet Union, but had also been part of developing ambulatory care and social

183 Müller, pp. 494-499. 184 Mohnike, ‘Sozialmedizinische Diabetesfragen’, p. 288. 185 Redetzky, ‘Die soziale Bedeutung’, p. 156. 186 Mohnike, ‘Sozialmedizinische Diabetesfragen’, p. 291. 187 Michael Geyer, ‘Ostdeutsche Psychotherapiechronik 1945-1949’, in Psychotherapie in Ostdeutschland: Geschichte und Geschichten 1945-1995, ed. by Michael Geyer (Göttingen: Vandenhoeck and Ruprecht, 2011), pp. 29-31 (p.29).

51 hygienic ideas of the Weimar Republic, as Melanie Arndt has suggested.188 They were ‘democratic’ in the sense that they offered, as Annette Timm points out, ‘each citizen access to a phalanx of experts specialised in the various branches of medicine and working together in various preventive, curative, and rehabilitative aspects of medical care’.189 Polyclinics were influential in the treatment of diabetics due to the range of medical specialties they housed (at least four or five broad categories), which, as Winter explained in Lehrbuch der Sozialhygiene in 1953, would increase cooperation between doctors and interdisciplinary medical approaches.190 This was especially important once complications had been recognised in a diabetic patient, inevitably cutting across multiple disciplines in medicine.

Polyclinics were therefore justified to be an essential building block of preventive and comprehensive healthcare. They were also considered to remove geographical and social inequalities on account of the flexibility of their location. Spread across all regions (Bezirke) in the GDR, some functioned as large stand-alone institutions, some were attached to a University or state hospital, and others were attached to places of work (the so-called Betriebspoliklinik), which corresponded to the Marxist and social hygienic emphasis on productivity.191 Before the introduction of polyclinics, diabetics had been treated in private practices by doctors who did not always have the relevant expertise and up-to-date knowledge. The polyclinic heralded a new age of specialist medicine for all, and East German health theorists considered it as appropriate for diabetics to be treated by those best qualified to administer treatment and care. Gradually throughout the 1950s there developed ‘diabetes advice centres’ (Diabetikerberatungsstellen) in polyclinics, which became the central focus for the diabetic patient after he/she had been diagnosed. 192

188 Melanie Arndt, Gesundheitspolitik im geteilten Berlin 1948 bis 1961 (Cologne, Weimar and Vienna: Böhlau Verlag, 2009), p.45. 189 Annette Timm, The Politics of Fertility in Twentieth-Century Berlin (Cambridge: Cambridge University Press, 2010), p. 263. 190 Kurt Winter, ‘Die Organisation der ambulanten Betreuung’, in Lehrbuch der Sozialhygiene, ed. by Kurt Winter and Alfred Beyer (East Berlin: VEB Verlag Volk und Gesundheit, 1953), pp. 166-202 (p.184). 191 Lutz Wienhold, Arbeitsschutz in der DDR: Kommunistische Durchdringung fachlicher Konzepte (Hamburg: disserta Verlag, 2014), p. 612. 192 SAPMO-BArch DQ1/20569 – Diabetiker-Fürsorge-bzw. Beratungsstellen: Statistische Berichte, Berichtsjahre 1957 and 1958; SAPMO-BArch DQ1/20570 – Diabetes-Fürsorge-bzw. Beratungsstellen: Statistische Berichte, Berichtsjahr 1958.

Figure 1: An example of a polyclinic in East Berlin, August 1976193

The polyclinics and the diabetes advice centres within them were part of a diagnosis and referral process which grew into a fluid system known as the Dispensaire System (already alluded to earlier), fully formed by 1954. This, again, was unlike anything that had been put into practice in Germany before.194 It promoted the social hygienic idea of the unity of prevention, treatment and rehabilitation and, whilst strictly within the system of outpatient care, encouraged coordination with inpatient care. Decisions on the next step, that is, a stint in an (inpatient) rehabilitation facility, were made by the specialist at the diabetes advice centre. The focus of the Dispensaire System on early diagnosis and swift treatment was intended to create an efficient way of making sure that fewer cases were left undetected and powerless over their own condition, which would in turn reduce the negative impact on society as a whole.195 It was considered the cornerstone of the Soviet Military Administration’s Order 243, which championed ‘health in the workplace’ (Betriebsgesundheitswesen), so it was ideologically motivated from the beginning.196 It was also firmly committed to the care of chronic diseases in particular, such as diabetes, cardiovascular disease and cancer. By 1953, figures, according to Redetzky, signified that chronic diseases were already raising costs and causing invalidity,

193 Bundesarchiv Bild 183-R0802-0010. 194 Winfried Süβ, ‘Gesundheitspolitik’, in Drei Wege deutscher Sozialstaatlichkeit: NS-Diktatur, Bundesrepublik und DDR im Vergleich, ed. by Hans Günter Hockerts (Munich: Oldenbourg, 1998), pp. 55-100 (p.87). 195 Maria Elisabeth Ruban, Gesundheitswesen in der DDR: System und Basis, Gesundheitserziehung, Gesundheitsverhalten, Leistungen, Ökonomie des Gesundheitswesens (West Berlin: Holzapfel, 1981), p. 46. 196 Kurt Winter, ‘Die Sozialversicherung in der UdSSR’, in Lehrbuch der Sozialhygiene, ed. by Kurt Winter and Alfred Beyer (East Berlin: VEB Verlag Volk und Gesundheit, 1953), pp. 249-256 (p.255).

53 citing that in East Berlin, between twenty and thirty percent of benefit recipients suffered from a chronic disease.197

The Dispensaire System was designed to screen and test people on a large scale and in a variety of locations, such as polyclinics, smaller ambulatory clinics (Ambulatorien) and factories, for undiagnosed chronic diseases. The element of screening and registration of cases was termed Reihenuntersuchung.198 The role played by the Dispensaire System in the workplace increased markedly throughout the 1950s, expanding to shipyards and mining, as well as many other areas of employment. Diabetes, especially the more common non-insulin dependent variant, was considered to be the ideal disease to enhance the importance of the Dispensaire System. Mohnike’s reference to the pre-diabetic phase and the need to screen for the disease due to the absence of noticeable symptoms in its early stages symbolised the extensive and, from some viewpoints, intrusive level of testing. Former doctors involved in the Dispensaire System also mention in their reflections that within the atmosphere of a dictatorship there seemed to be no room for refusing the screening, symptomatic of the heavy state involvement fundamental in Jarausch’s Welfare Dictatorship theory.199

If, following screening, individuals were found to show symptoms of diabetes, namely sugar in the urine, they were advised to consult their nearest diabetes advice centre where they would be assigned a specialist. The Dispensaire System sought to remove the habit of going to the doctor only at the point where a person felt discomfort; for chronic diseases, this was considered simply not good enough, and that it could frequently be the complications of the disease already setting in which caused the pain.200 The idea that the Dispensaire System became so integral to the outpatient care of chronic diseases, and indeed, chronic disease care in general, reflects the notion within diabetological circles of sufferers being ‘conditionally healthy’ and ‘conditionally able to work’ as opposed to ‘chronically ill’.201 Within this system, with its close ties to the workplace, it was possible to justify why it was necessary to see diabetes post the discovery of insulin (1921) as a manageable condition, which could allow a

197 Redetzky, ‘Aufgaben und Ziele’, p. 1143. 198 Jürgen-Peter Stössel, Staatseigentum Gesundheit: medizinische Versorgung in der DDR (Munich: Piper Verlag, 1978), p. 55. 199 Ursula-Renate Renker, ‘Mein Beitrag zur Entwicklung der Arbeitshygiene und der Arbeitsmedizin’, in Im Dienst am Menschen: Erinnerungen an den Aufbau des neuen Gesundheitswesens, Bd. 2, ed. by Karl Seidel, Christa Köhler and Bernhard Meyer (East Berlin: Dietz Verlag, 1989), pp. 248-281 (p.253). Opinions are shared among diabetologists including Dr. Heinz Schneider (6 April 2016) and Professor Waldemar Bruns (7 April 2016). 200 Redetzky, ‘Aufgaben und Ziele’, p. 1143. 201 Winter, Mette and Misgeld, Der Arzt, p. 21.

54 purposeful life. To ensure that most people diagnosed were at a stage where their status was that of a ‘conditionally healthy’ person rather than a ‘chronically ill’ patient suffering from serious and debilitating complications, the importance placed on statistical evidence (present in social hygiene) could be witnessed in the Dispensaire System for diabetics. The ambition to achieve total coverage, namely to have an overview of almost all the diabetic population in a given area, meant that the diabetes advice centres employed a statistician to compile statistical reports on diabetes prevalence. The documents for each diabetes advice centre written by the statistician, in addition to the qualitative report written by a diabetes specialist, were detailed and thorough from as early as 1953 onward.202 Each statistical report contained the total number of diabetics treated at the advice centre, who were then grouped according to age and gender. Mortality rates were also recorded and different reasons for mortality, including deaths resulting from diabetes-related complications, were listed.

For the examination of the prevalence of diabetes, the most crucial statistic was the number of newly diagnosed diabetics, which indicated, if this number was high and increasing annually, that the programme of screening was beginning to work. The more undiagnosed cases discovered, the better it was to deploy preventative healthcare measures. The ability to determine that the prevalence of diabetes was, firstly, underestimated (testing of 35 companies between December 1955 and January 1956 confirmed Schliack’s 1950 estimate of 1.5 percent) and, secondly, that the rate of those discovered was increasing exponentially, signified the need to plan ahead for the problems diabetes was likely to cause to public health in the future.203 The increasing rates made the case for diabetes to be seen in the 1950s as something that should be confronted now even if it was not yet as big a problem as other chronic diseases, such as cardiovascular disease and cancer at that stage. The diabetologists in the diabetes advice centres referred to the successes of screening repeatedly and, by 1957, there was frequent mention of the increasing numbers of people attending the diabetes advice centres, almost, in some instances, too many to cope with.204

202 Reports featured in the following Bundesarchiv files: SAPMO-BArch DQ1/20569 – Diabetiker-Fürsorge- bzw. Beratungsstellen: Statistische Berichte, Berichtsjahre 1957 and 1958; SAPMO-BArch DQ1/20570 – Diabetes-Fürsorge-bzw. Beratungsstellen: Statistische Berichte, Berichtsjahr 1958. See Appendix 4 for an example report. 203 SAPMO-BArch DQ1/21426 – Bericht über Forschungsauftrag Diabetes Nr. 24 24 02 05 h 5-06, 31 December 1955 by Dr. Moldenschardt, Einheit Krankenhaus-Poliklinik, Wernigerode (Harz), I. Innere Abt. 204 For example, in: SAPMO-BArch DQ1/20570 – Analyse zum Bericht der Diabetikerberatung für das Jahr, Poliklinik Riesa, 1958, p. 2; Diabetiker-Jahresbericht 1958 des Bezirkes Rostock, 18 March 1959 by Dr. Kaeding; Bericht der Diabetikerbetreuung für das Jahr 1958, Diabetikerberatungsstellen…des Bez. Neubrandenburg, Analyse, by Dr. Ackermann and Dr. Jung.

Keeping records of individual cases and attracting people to attend the diabetes advice centre was as important as illustrating the successes of screening (in a statistical sense). It was considered necessary to reveal how many new cases were diagnosed, but these new cases should not get lost in the system, and there had to be ways in which a diabetic was encouraged to attend the advice centre regularly for check-ups. Since rationing in the GDR continued until 1958, an efficient method of encouraging diabetics to attend an advice centre was to offer all those who were treated there a generous ration card (Diabetikerumtauschkarte), which was replaced after 1958 with an equally generous 13 Mark payment.205 Whilst this was a somewhat contradictory idea in the sense that extra money could encourage greater food intake which might have contributed to aggravating a patient’s condition, the aim was to justify the extra support by giving diabetics access to the right kinds of food in short supply like fresh fruit and vegetables.206 According to doctors’ reports, the ration card and later extra payment proved hugely successful in achieving the goal of attracting patients to the advice centres and centrally organising cases across each region. Some were newly diagnosed, but others had been treated by a local GP or specialist in a private practice and had previously been unknown to the system.207 This, again, brings to the fore the issues of the care and coercion argument of the Welfare Dictatorship concept. Giving diabetics a form of benefit revealed the caring side of the regime but this has to be juxtaposed with the idea that, in order to receive those benefits, it required attendance at a local diabetes advice centre, possibly overriding, too, the sacred German tradition of the free choice of physician.208

Defining the role of the new state socialist doctor and diabetes specialist

The historian Winfried Süβ has stated that there were three key aspects to the development of the early East German doctor and his/her working environment. He/she was typically a ‘state- paid physician of a factory polyclinic’, who was a ‘representative of a work-oriented, paternalistic health regime’, which intended to link ‘comprehensive state care to rigid

205 Appears in almost all reports from: SAPMO-BArch DQ1/ 20570 – Diabetes-Fürsorge-bzw. Beratungsstellen: Statistische Berichte, Berichtsjahr 1958. 206 The so-called ‘Lebensmittelkarte’ was explained in: SAPMO-BArch DQ1/20569 – Anlage zum Bericht der Diabetikerberatung für das Jahr 1958 Kreiszusammenstellung (Zwickau), Analyse, 3.2.1959. 207 Ibid.; Bruns, Seige, Menzel and Panzram, Die Entwicklung der Diabetologie, p. 17. 208 The idea of attracting new patients was mentioned in: SAPMO-BArch DQ1/20569 – Betr.: Analyse zum Jahresbericht der Diabetikerberatungsstellen des Bezirkes Neubrandenburg für das Jahr 1957, p.2; interviews with former diabetologists, Dr. Wegner and Dr. Schneider (August 2016) confirm that diabetics were always referred to a specialist (not personally chosen).

56 behavioural expectations’.209 It appears that, in the 1950s, when significant changes to the medical profession were attempted (but not always achieved), there was an element of truth to this statement, certainly in principle but more so in practice. Due to the structural changes to the healthcare system, particularly through the lens of chronic diseases and diabetes, it follows that the medical profession was forced to adapt to a substantially different environment and ethos. The Nazi ideal of the ‘Hausarzt’ in a bürgerlich private practice was the antithesis of the state socialist ambition of creating an image of the doctor working alongside many other colleagues in a large facility with a fixed salary. Where there should be a degree of caution when judging the extent to which the new political system impacted on medical care, including diabetes management, in the early years is in viewing the structural set up of the healthcare system and those working within it as one entity. The limits of the new East German state to influence its medical personnel were quite telling in their immediate response to the political measures imposed on them.

Unlike the working relationship between the health officials of the Soviet Military Administration and the German Central Administration for Health prior to the GDR’s founding in 1949, the gulf between the average doctor on the ground and the SED, politically, was large. Membership of the Nazi Party among medical professionals was notoriously high (around 45 percent) and was much higher than their membership of the SED (only ten percent by 1960).210 The stance taken by the Soviets with regard to denazification was arguably tougher than that adopted by the other allies, but it soon became apparent that an extensive purge of the medical profession would prove catastrophic for diseases like diabetes which required specialist attention and intense management, taking into account the adverse conditions immediately after 1945.211 This created a situation where, of all the medical profession, according to Timothy Vogt in his study on denazification, doctors were afforded ‘an extraordinary degree of leniency’ from the regime, with ‘practical considerations of public wellbeing far outweighing the mandate to denazify’.212 Keeping the medical profession onside so that doctors would be able to manage the East German population and persuading as many medics as

209 Süβ [p.97] cited in Manfred G. Schmidt and Gerhard A. Ritter, The Rise and Fall of a Welfare State: The German Democratic Republic (1949-1989) and German Unification (1989-1994), trans. by David R. Antal and Ben Veghte (Berlin and Heidelberg: Springer Verlag, 2013), p. 87. 210 Anna-Sabine Ernst, ‘Die beste Prophylaxe ist der Sozialismus’: Ärzte und medizinische Hochschullehrer in der SBZ/DDR 1945-1961 (Münster: Waxmann, 1998), p. 145. 211 Schleiermacher, ‘Contested Spaces’, p. 191. 212 Timothy R. Vogt, Denazification in Soviet-occupied Germany: Brandenburg, 1945-1948, Volume 64 (Cambridge, Massachusetts: Harvard University Press, 2000), p. 158.

57 possible to remain in the GDR was a top priority. Introducing ‘anti-fascist’ policies would have to wait until a later stage.

The example of the diabetologist, Professor Dr. Gerhardt Katsch, illustrates how the regime approached coveted doctors with a dubious past and the medical profession in general. Katsch, inventor of the notion of diabetes being ‘conditionally healthy and able to work’ mentioned in the previous sections, was one of the most celebrated German diabetologists of his generation. Having spent a good portion of his career at the University of Greifswald and lived on the North East coast, he opened the first diabetes home in Germany on the island of Rügen in 1930, and his second in Karlsburg during the turbulent years of the SMAD in 1947. His papers, kept at the University of Greifswald archive, as well as his diaries, give an extraordinary glimpse into his political life (and dexterity) in addition to his medical career. Katsch confirmed the stereotypical portrait of the doctor from the point of view of the SED; he was distinctly ‘bourgeois’ and upper-middle-class in background, with a temperament which his neighbour, the author, Victor Klemperer, described as a quiet air of authoritative restraint, coupled with a propensity for cultured behaviour.213

Figure 2: Prof. Dr. Gerhardt Katsch (1887-1961), inventor of the notion that diabetics were ‘conditionally healthy and able to work’ 214

213 Irmfried Garbe, ‘Der Mensch’, in Gerhardt Katsch, Greifswalder Tagebuch 1946-47, ed. by Dirk Alvermann and Irmfried Garbe (Kiel: Ludwig Verlag, 2008), pp. 31-52 (pp.34-5); Mathias Niendorf, ‘Behandeln und Verhandeln: Zu Gerhardt Katschs Greifswalder Tagebuch 1945-1946’, in Gerhardt Katsch – Greifswalder Tagebuch 1945-1946, ed. by Mathias Niendorf (Kiel: Ludwig Verlag, 2015), pp. XI-XXXIV (p.XVIII). [Archivists at the University of Greifswald]. 214 Wikimedia Commons: picture donated by the University of Greifswald Archive, https://commons.wikimedia.org/wiki/File:Gerhardt_Katsch.jpg [accessed 13/02/19].

Nevertheless, Katsch was the recipient of the ‘extraordinary degree of leniency’ to which Vogt refers. During the years of the Third Reich, he had been associated with a variety of Nazi organisations, including the SA and the SS, 215 which led to a diabetologist at the University of Düsseldorf in 2002 refusing the ‘Gerhardt Katsch Medal’, an important award given by the German Diabetes Society (DDG).216 A historical commission was set up by the society to establish Katsch’s relationship with the Nazi Party, concluding that whilst outwardly, Katsch had used distinctly Nazi terminology in that period, his main aim had been pragmatic; had he opposed the Nazis, he would not have been able to help diabetics. The archivists and those looking at his personal papers at the University of Greifswald have also discovered that he had a Jewish grandfather and had attempted to shield his Jewish assistant in the mid nineteen thirties by offering implicit support to the Nazis.217

It appeared, therefore, that Katsch used the politics of the day to achieve his own goals in diabetes management. Dagmar Schüβler, in her doctoral dissertation on Katsch, which, incidentally, was supervised by the doctor who refused the medal, comes rather inadvertently to a similar conclusion to the DDG historical commission.218 She claims that his success in dissuading the Nazis from extending their legislation regarding enforced sterilisation of those suffering from hereditary diseases to diabetics illustrates that no matter what, the cause of diabetes was at the forefront of his thinking. However, as Schüβler also points out, he remained quiet when asked to defend other diseases like epilepsy, a cause which did not concern him as much.219 With a change in regime, from Nazi to Communist, came the same political dexterity; since he handed over the town of Greifswald to the Soviet Red Army and was actually treating Soviet officers suffering from diabetes, this made him far less suspicious.220 Michael Dittrich, in his doctoral dissertation on Katsch, which, written in 1984 in the GDR, seems entirely uncritical of Katsch, stated that it was due to his internationally renowned status and his (supposedly) social hygienic solutions to diabetes that every effort was made to encourage him

215 Günter Ewert, Ralf Ewert and Jürgen Boettiger, Der jüdische Familienhintergrund des Greifswalder Internisten Prof. Dr. Gerhardt Katsch und das Naziregime (Berlin: Pro BUSINESS, 2014), p. 43. 216 Waldemar Bruns, Heinz Schneider and Dietrich Michaelis, ‘Die Namensgebung der “Gerhardt-Katsch- Medaille” und Zwangssterilisation von Diabetikern’, in Bericht der Historischen Kommission der Deutschen Diabetes Gesellschaft zur ‘Gerhardt-Katsch-Medaille’, chaired and edited by Peter Hürter (Berlin: Die Deutsche Diabetes Gesellschaft, 2004), pp. 1-16 (p.1 and p.14). 217 G. Ewert, R. Ewert and Boettinger, Der jüdische Familienhintergrund, p. 56. 218 Dagmar Schüβler, ‘Die Bedeutung von Gerhardt Katsch für die Entwicklung der Diabetologie und Diabetikerfürsorge in Deutschland’ (unpublished doctoral thesis, University of Düsseldorf, 1992), pp. 51-2. 219 Schüβler, p. 52. 220 Niendorf, p. XV and p. XXVI.

59 to remain in the GDR.221 There is no doubt that Katsch was considered a huge asset to a state constantly seeking international recognition throughout the 1950s. Hence, he was given privileges through a special contract (Einzelvertrag) such as the right to travel freely and the ability to earn as much as he liked, all of which was unavailable and unimaginable to the ordinary East German citizen.222

The polyclinic model and the Dispensaire System show how the role of the doctor came to be shaped within diabetes care. Social hygienists maintained that doctors needed to learn that they were employees paid by the state.223 The polyclinic in particular, which saw for the first time specialists working together under one roof, was considered to solve the problem of doctors working for themselves (which had so often been the case regarding diabetologists before 1945 in private practices). Instead a collective effort was expected of them in this new institution. Doctors in the GDR were given the label Volksärzte (people’s doctors), who, aside from conventional treatment, were supposed to adopt new habits and responsibilities.224 As early as 1946, the social hygienist, Alfred Beyer, proclaimed that the fight against disease would be moving from doctors’ surgeries to patients’ living rooms.225 This was relevant for chronic diseases in particular. It was no longer the duty of the doctor to wait for patients to come to their surgeries; they were expected to go out and find patients (for example, diagnosing people early through screening programmes and swift intervention for the newly diagnosed), as well as identifying those who might not have symptoms of a disease, yet needed to be treated.

The role of the ‘people’s doctor’ in diabetes management was discharged most easily in polyclinics (as opposed to private practice), which gave doctors the opportunity to cooperate, pool ideas and provide good-quality care for complex interdisciplinary cases.226 This fact has been remembered fondly by a number of polyclinic doctors, such as Dr. Horst Harych, who believed that it gave them the opportunity to learn more about specific diseases.227 It was

221 Michael Dittrich, ‘Die Rolle der wissenschaftlichen Schule von Gerhardt Katsch (1887-1961) für die Entwicklung der Diabetesforschung: Ein Beitrag zur Geschichte der Diabetologie’ (unpublished doctoral thesis, Ernst-Moritz-Arndt University of Greifswald, 1981), p. 118. 222 Garbe, pp. 46-7. 223 E. Fischer, L. Rohland und D. Tutzke, Für das Wohl des Menschen, Band II: Dokumente zur Gesundheitspolitik der Sozialistischen Einheitspartei Deutschlands (East Berlin, VEB Verlag Volk und Gesundheit, 1979), pp. 47-50. 224 Ernst, p. 38. 225 Alfred Beyer cited in Ernst, p. 38. 226 Kurt Winter, ‘Die Bedeutung der öffentlichen ambulanten Betreuung’, Das deutsche Gesundheitswesen, 7 (1952), 1621-1623 (pp.1622-1623). 227 Horst Harych, ‘Zur Zukunft der Polikliniken und der ambulanten Versorgung in der DDR’, in Das Gesundheitswesen der DDR: Aufbruch oder Einbruch? Denkanstöβe für eine Neuordnung des

60 not only working with many other doctors which was considered to shape the role of the ‘people’s doctor’; it was also the number of patients that were seen on a daily, weekly, monthly and annual basis, giving doctors ample statistical data from which distinctly regional patterns could be ascertained on morbidity, thus improving prophylactic measures.

The reaction by the medical profession to the changes in what was studied and taught at University, and what was expected of them in their work, was troubling as far as the SED was concerned. Many resisted the move towards polyclinics; they would have preferred to work in private practice where they might have had an opportunity to maximise their profits, rather than working as an employee of the state on a fixed salary. Large numbers decided that, if the regime was not willing to compromise and meet their demands, the solution was to go to the West, where such opportunities existed.228 To judge the scale of this exodus (Republikflucht), Schagen and Schleiermacher’s analysis concludes that there were 10,267 doctors who had fled from the GDR working in West Germany by 1961, a staggering figure considering that the total number of doctors at that time in East Germany altogether was a mere 14,592.229 This underlines the fact that, despite the ease with which the SED could manipulate the population through the paradoxical mixture of care and coercion in structural reforms of the healthcare system, the boundaries of its influence (therefore the limits of the Welfare Dictatorship theory), were revealed by those working within or indeed abandoning those structures.

The emigration of doctors was not limited to specific sections of the healthcare system, and it certainly afflicted diabetes care and research. It seriously undermined efforts to improve the health of diabetics and to carry out the all-important prevention initiatives, simply due to lack of personnel. This was even the case in the highest and most important institution for diabetes, namely the Institute for Diabetes in Karlsburg, founded in 1947. By the late 1950s, the Institute had developed into a hugely influential force within diabetes management but was hit by the loss of specialists and extremely well qualified staff. Gerhardt Katsch wrote a letter to the Ministry of Health in 1959, complaining about shortages of personnel as a result of

Gesundheitswesens in einem deutschen Staat, ed. by Wilhelm Thiele (St. Augustin: Asgard-Verlag, 1990), pp.99-104 (p.101). 228 Udo Schagen and Sabine Schleiermacher, ‘Drittes Kapitel, Sozialpolitische Entwicklungen, Thema 6, Gesundheitsschutz und Sicherung bei Krankheit: Ergebnisse: Politische und rechtliche Entwicklungen’, in Geschichte der Sozialpolitik in Deutschland seit 1945, Band 8: 1949-61, Die Deutsche Demokratische Republik im Zeichen des Aufbaus des Sozialismus, ed. by Dierk Hoffmann and Michael Schwartz (Baden-Baden: Nomos, 2004), pp. 408-430 (p.424). 229 Schagen and Schleiermacher, ‘Ergebnisse’, pp. 424-6.

61 employees leaving. The matter was also raised during a visit to the Ministry by two doctors from the Institute, Dr. Heik and Dr. Wendler, who talked of an intolerable situation with regard to staff shortages, which had seriously hindered scientific research and the continuity of work in progress at that time.230 The Ministry of Health compiled an internal report on the Institute and the effects of Republikflucht, in which it mentioned that a gynaecologist, two chemists, two dieticians and an employee responsible for budget matters had left the Institute to go to the West in 1959 alone.231

Of those who remained in the GDR in the 1950s and who became key figures within the field of diabetology, some did not do so as a consequence of any tangible affection toward the regime, or so it seemed. Ulrich Mählert has suggested that there was a group of citizens in the 1950s, who, without always believing in the politics and policies of the new socialist state, were nevertheless willing to seize visible opportunities that it could provide them with rather than defecting to the West.232 A good number of important diabetologists belonged to this group, including Gerhardt Katsch. As he appeared to be, from his political history, a pragmatist, he took advantage of the privileges and awards bestowed upon him by the SED and the chance to remain in the North East of Germany, the location in which he had worked since 1928. Similar to his approach during the Nazi era, he decided to commit to some of the new ideological principles enforced by the SED in the arena of health. Diary entries from 1946 and 1947 reveal his contact with one of the principal social hygienists, Hermann Redetzky.233

It can be said that Katsch did not need to be as surreptitious when integrating into the state socialist system as in Nazi Germany. His mantra of ‘conditionally healthy and able to work’ fitted rather neatly with the Marxist emphasis on production and economic determinism present within social hygienic thought, even if it was not intentionally shaped to meet the current political demands. His views on diabetics being fit for work served him well when he needed to apply for funding for his new venture, the Institute for Diabetes in Karlsburg, which was nationalised and brought under the auspices of the Ministry of Health by 1951, providing a secure financial foundation. It can also be questioned as to whether the GDR in this early period was as ideologically pervasive as the Third Reich in that Katsch’s correspondence with

230 SAPMO-BArch DQ1/21526 – File note: ‘Am 28.5.1960 waren beim Staatssekretär der Oberarzt Dr. Wendler aus Karlsburg und der Oberarzt Dr. Heik aus Garz’, by Dr. Rautenberg. 231 SAPMO-BArch DQ1/21526 – File note: ‘Die Kadersituation im Diabetikerinstitut Karlsburg-Garz’, Berlin, den 28.5.1960. 232 Ulrich Mählert, Kleine Geschichte der DDR (München: C. H. Beck, 2004), p. 81. 233 Gerhardt Katsch, ‘6th February 1947 entry’, in Gerhardt Katsch, Greifswalder Tagebuch, 1946-47, ed. by Dirk Alvermann and Irmfried Gabe (Kiel: Ludwig Verlag, 2007) p. 88 [one page only].

62 the Minister of Health, Luitpold Steidle, in the early 1950s was largely, if not entirely, practical, rather than ideological.

The two other notable figures within diabetology, Mohnike (successor to Katsch at the Institute for Diabetes) and Schliack, were much younger than Katsch and did not have the same prior political baggage. Whilst Katsch was the most well-known figure within diabetology, a lot of the work was reportedly done on his behalf in the GDR by Mohnike especially.234 His reservations regarding the political regime have been acknowledged in articles, archival evidence and interviews with former surviving diabetologists who knew him, but he spent a short period at the Akademie für Sozialhygiene in Berlin in the late 1950s, having temporarily left his work with Katsch at the Institute for Diabetes.235 The time spent at the Akademie might explain why Mohnike and Schliack were using more explicit social hygienic jargon in their articles in the likes of Das deutsche Gesundheitswesen, and in their justification of the use of statistics, the Dispensaire System and diabetes advice centres in polyclinics.236 Clearly, they went one step further than Katsch in their attempts to appease the regime outwardly. However, they were likely to be unaware of the impending development that lay ahead, the building of the Berlin Wall in 1961, which sought to stem the flow of (medical) talent leaving, and severely restricted freedom of movement.

Economic and material challenges in evolving state socialism and their impact on the treatment methods for diabetics

A highly persuasive reason why West Germany was a pull factor for medical professionals, other than the fact that it met their political expectations, was its economic situation, with the so-called Wirtschaftswunder marking the start of unprecedented economic prosperity there. Unlike in the other allied zones of occupation which would form West Germany, the Soviets in their zone were intent on exacting harsh reparations on the German population under its occupation. A full recovery was not made throughout the 1950s in the GDR, where there had developed what could be described as a shortage economy. This is especially true of the pharmaceutical industry and medical equipment, which therefore had a direct impact upon the treatment options available to diabetics. The Soviets’ dismantling programme of 1945 and

234 Interview with Dr. Heinz Schneider, 6 April 2016 and Professor Waldemar Bruns, 7 April 2016; Interview with Dr Bernd Wegner, 15 August 2016; SAPMO-BArch DQ1/21526 – File note: ‘Am 28.5.1960 waren beim Staatssekretär der Oberarzt Dr. Wendler aus Karlsburg und der Oberarzt Dr. Heik aus Garz’, by Dr. Rautenberg. 235 Heinz Scheider, ‘Ein deutscher Diabetologe mit Weltgeltung: Professor Dr. Gerhard Mohnike (1918-1966) aus Karlsburg in Vorpommern’, Ärzteblatt Mecklenburg-Vorpommern, 3 (2010), p. 93. 236 Mohnike offers substantial praise of the Dispensaire System in Mohnike, ‘Sozialmedizinische Diabetesfragen’, pp. 286-292; Schliack, pp. 5-6.

63 beyond seriously affected the domestic production of important and life-saving medication, from penicillin to insulin.237 The resistance from medical professionals and the emigration of doctors on a large scale hampered change in the healthcare system. However, perhaps surprisingly, the severe shortages of insulin, injection needles and urine test strips did not undermine the ideological developments in diabetes care as much as they might have done. In fact, there were instances where shortages actually encouraged social hygienic solutions and gave the call of ‘prevention first’ greater impetus. In his 1934 book, Henry J Sigerist claims that one of the strengths of a Soviet-style healthcare system over a capitalist one was its ability to conserve and work with limited resources. In the GDR, the healthcare system was certainly facing this problem in diabetes care in the 1950s. It may be, as Sigerist suggested albeit simplistically, that this was almost a precondition in a Soviet-style or Soviet-influenced healthcare system and that the centralised structures were set up to respond to economic adversity (which had continually been present in the Soviet Union).238

The Schering AG pharmaceutical company was one of the main producers of insulin in Germany before 1945, and one of their branches in Berlin happened to come under the area of Soviet occupation. By 23 May 1945, Soviets had begun removing production facilities from the factory, and dismantled most of the insulin production department.239 Fortunately for the diabetics, the Soviet commander, General N. E. Bersarin, in early June 1945 intervened in the removal process, ordering that a reserve insulin production segment of the factory must be kept.240 He was posthumously awarded an honorary citizenship by the Senate of Berlin in 2002 for his efforts to save diabetics. Unfortunately for the diabetic population, much damage had already been done by this point; no insulin was produced until the beginning of 1946, and even after that production quantities were extremely small. Throughout the 1950s, the GDR was reliant on imports from the Danish pharmaceutical company, Novo, and the West German company, Hoechst.241 At times, lack of hard currency led to delays and shortages in the provision of such very expensive imports, and patients normally reliant on them had to be

237 Rainer Karlsch, Allein Bezahlt?: Die Reparationsleistungen der SBZ/DDR 1945-53 (Berlin: Links, 1993), p. 225. 238 Henry Sigerist cited in Carsten Timmermann, ‘Americans and Pavlovians: The Central Institute for Cardiovascular Research at the East German Academy of Sciences and its precursor institutions as a case study of biomedical research in a country of the Soviet Bloc, (c. 1950-80)’, in Medicine, the Market and the Mass Media: Producing health in the twentieth century, ed. by Virginia Berridge and Kelly Loughlin (Abingdon: Routledge, 2005), pp. 244-265 (p.244). 239 Karlsch, Allein Bezahlt? pp. 226-7. 240 Bruns, Bibergeil, Seige, Menzel and Panzam, Die Entwicklung der Diabetologie, p. 7. 241 Schneider, ‘Die Diabetikerbetreuung’, p. 48. Information corroborated by Bundesarchiv files: SAPMO- BArch DQ1/20569 – Report from Dr. Auerswald, leader of the Diabetiker-Beratungsstelle, Kreis Aue, 1958.

64 hospitalised and to miss work, thus causing damage to the economy, as pointed out by diabetologists in their annual reports to the Ministry of Health.242 The detachment of the East Berlin branch of Schering from the rest of the company in West Germany and its subsequent nationalisation in 1949 did not have a positive impact on production in terms of quantity. The political decision to nationalise the industry therefore influenced the treatment situation for diabetics in a way that could not be described as positive in the short term.243

The quantity of insulin produced was not the only problem facing diabetologists and indeed the Ministry of Health in the 1950s. There was mounting criticism over the quality of what was produced domestically. The quality of imported insulin was good, but there was not enough of it, and there was pressure applied by the SED for the GDR to be more self-sufficient in its insulin production.244 Its reliance on imports from Denmark and West Germany, capitalist countries, will not have been looked upon favourably. Yet, complaints from a number of diabetes advice centres were aimed not only at the shortages of insulin, but, more specifically, at the shortages of ‘higher quality’ import insulin. In Schwerin in 1957, the report by the local diabetologist highlighted the fact that he had to put diabetics on ‘lower quality’ insulin produced in the GDR, which, he went on to state, was having a detrimental impact on the patients’ ability to work.245 Supply problems and adverse reactions to the domestically produced insulin were also reported in Halle in 1958, with complaints made poignant by the fact that the consequences mentioned in the reports were always linked to work and production (or lack thereof).246 This therefore created a political conundrum for the SED leadership, who demanded that diabetics needed to be fit for work, whilst at the same time attempting to reduce the reliance on insulin from countries which were not politically like-minded and ‘enemies’ in a diplomatic sense. This meant that the SED was forced to undertake a political balancing act; on the one hand, they accepted that importing insulin still had to continue, but, on the other, they strongly encouraged diabetologists to conduct research in order to improve the apparent poor quality of East German insulin.

242 Statistics on the cost of medication, including import insulin, are featured in, for example: SAPMO-BArch DQ1/20569 – Analyse zur Bezirksstatistik der Diabetikerberatung Halle/S. für das Jahr 1957, Dr. Hempel, 17.3.58. 243 Karlsch, Allein Bezahlt? p. 241 and p. 247. 244 Interview with Professor Markolf Hanefeld (10 August 2016). 245 SAPMO-BArch DQ1/20569 – Analyse zur Diabetikerberichtserstattung, Dr. Hartwig, 12.5.1958, p.1. 246 SAPMO-BArch DQ1/20569 – Analyse zur Bezirksstatistik der Diabetikerberatung Halle/S. für das Jahr 1957, 7/3/1958, p.1.

The social hygienic call for prevention gained importance and relevance when a response to the insulin shortages was required, especially in respect of complications in diabetics resulting from insufficient insulin intake. In this way, attention was paid to the age and type of diabetic, namely those who were insulin-dependent (and often by definition younger), and those who were non-insulin-dependent. Volker Schliack’s work on statistics placed emphasis on categorising diabetics into distinct types for the immediate purpose of revealing patterns so that prevention could be much more targeted. In his work on ‘statistical and clinical diabetes issues’, his discovery of the effect of the Second World War on the diabetic population, namely a reduction in the incidence of type 2 diabetes during a time when rich and fatty foods were largely unavailable, and that the conclusion was, furthermore, that diabetes was not a monolithic disease, helped greatly in efforts to understand that through radical changes in diet, non-insulin dependent Altersdiabetiker would not need to be reliant on any medication.247 The shift in focus to ‘diet-only’ methods of treatment was telling in the latter half of the 1950s. Reports from the diabetes advice centres across the country suggested that they were beginning to calculate the percentage of their diabetic patients who were given ‘diet only’ treatment. In the 1958 report from Staβfurt, the local statistician estimated that fifty percent of all patients were treated by such means.248 Similarly, in Halle in the same year, the figure was just over thirty percent.249 In 1953, Katsch, Mohnike and their colleague, H.J John, wrote the important patient handbook, Aceton bis Zucker, which discussed the best foods to eat for people with diabetes, and this was published by the widely circulated, nationalised Georg Thieme Verlag. In it, they refer to diet as the basis of all diabetic treatment (‘die Grundlage der Behandlung’).250

However, despite the fact that treatment through diet sought to alleviate the strain on medication and to conserve it for those who needed it most, other material shortages, such as the type of food on offer, often undermined the strategy.251 Again, evidence for this can be found in the regional diabetes advice centre reports. Even with the existence of a diabetes ration card, there were complaints in 1957 from Rostock that there were serious shortages of fresh

247 Schliack, pp. 21-22. 248 SAPMO-BArch DQ1/20570 – Rat des Kreises Staßfurt, Abt. Gesundheitswesen, Grenzstr.9, Analyse, p.1. 249 SAPMO-BArch DQ1/20570 – Analyse zur Bezirksstatistik, Halle Sa, 10/2/59, pp.1-2. 250 Gerhardt Katsch, Gerhard Mohnike and H. J. John, Aceton bis Zucker: Nachschlagebuch für Zuckerkranke, (Leipzig: Georg Thieme Verlag, 1957), p. 50. 251 SAPMO-BArch DQ1/20570 – Analyse der Bezirkszusammenstellung der Berichte der Diabetikerberatungsstellen im Bezirk Leipzig vom Jahr 1958 by Dr. Seige, 7.7.1959.

66 fruit and vegetables, especially amongst pensioners.252 Colleagues from Güstrow were informing the Ministry of Health of the same problems; acute shortages of fresh vegetables were experienced in the spring of 1957, and even canned vegetables were unaffordable for people of pension age.253 The Güstrow report suggests that such problems were particularly acute in rural areas (the overall rate of diabetes was nonetheless lower in those parts of the GDR).254 One of the primary purposes of social hygiene was to assess geographical disparities in health. The distinct bias against rural areas which was identified and referred to in the report as Streuungsfehler (failure in distribution) might have engendered various different responses among social hygienists.255 Distribution problems occurring at that time, eight years into the GDR’s existence, may have represented shortcomings of social hygienic attempts to address the regional inequalities in the health of diabetics. Conversely, they may also have indicated the scale of the work that had yet to be done and that the cause of social hygiene was obvious and identifiable, and therefore worth the fight.

For those diabetics where dietary measures alone simply were not enough to manage their diabetes properly, the economic situation in the 1950s severely stifled production quantity and quality of certain types of insulin. Since the nineteen thirties, two different types of insulin had been used on patients: the short-acting, original insulin, referred to in the GDR as Altinsulin, and the longer lasting Depotinsulin. Depot insulin had become the insulin of choice in the run up to the Second World War, largely due to the reduction in the number of times a patient needed to inject.256 In West Germany, a depot form of insulin was reintroduced relatively quickly in the 1950s. In the GDR, depot insulin seemed to be in short supply, and the home-grown version did not have the desired long-lasting effect owing to its poor quality.257 The main goal of diabetologists was as much motivated by ideological concerns as it was by material shortages, and, actually, the two became intrinsically linked as the 1950s progressed. Ultimately, diabetics needed to be able to function, and so long as a treatment regime was established to deliver this aim, then keeping up with the progress of western countries in the development of depot insulin could be put on hold. Hence, diabetologists turned to the older

252 SAPMO-BArch DQ1/20569 – Analyse Diabetiker-Jahresbericht 1957 des Bezirkes Rostock, Dr. Kaeding, 11.2.1958. 253 SAPMO-BArch DQ1/20569 – Analyse zur Diabetikerberichterstattung 1957 (Schwerin) by Dr. Hartwig, 12/5/58, p.2; SAPMO-BArch DQ1/20569 – Diabetiker-Jahresbericht 1957 des Bezirkes Rostock. 254 Ibid., p.1. 255 Ibid., p.2. 256 Waldemar Bruns, Dietrich Michaelis and Heinz Schneider, ‘Insulinbehandlung’, in Bericht der Historischen Kommission der Deutschen Diabetes Gesellschaft zur ‘Gerhardt-Katsch-Medaille’, ed. by Peter Hürter (Berlin: Deutsche Diabetes Gesellschaft, 2004), pp. 17-19 (p.17). 257 Bruns, Seige, Bibergeil, Menzel and Panzram, Die Entwicklung der Diabetologie, pp. 25-6.

67 insulin, which, in their view, did what they knew it was supposed to do and was far less volatile; as a consequence, it made it much more practical for the workplace.258

Following the announcement that diabetes was a Volkskrankheit, the steady rise of those identified as type 2 diabetics, usually referred to as Altersdiabetiker, who were experiencing the effects of not having access to the right kinds of food, required new treatment solutions. The number of such diabetics had dramatically reduced during and after the war as a result of malnutrition. However, specialists and social hygienists warned that this should not lead to complacency and that this masked a potential problem. In a 1953 article in Das deutsche Gesundheitswesen, Dr. Porstmann of the University Hospital in Leipzig mentioned that, following the first few years after the war, there had been a rapid rise after the transient decline of type 2 diabetes cases.259 Neither diet-only treatment nor insulin were considered appropriate for some of these cases, especially the latter, which was being kept for those diagnosed as type 1 insulin dependent. This stimulated research on tablet treatment, which had begun before the war. It culminated in the production of an oral anti-diabetic tablet called Oranil in the early 1950s. The insistence on retaining and reinvigorating a diabetic’s productive capacities was no more apparent than in the speed of development of Oranil, which in the GDR was prescribed two years earlier than in West Germany. It was only because of the fact that the GDR specialist who had developed the drug escaped to the West that it appeared on the market there so soon after its introduction in the East.260

The pressure to produce Oranil was so high that there was not much time given to trial the medication first. The sooner it could be given to diabetics who needed it, the better it was deemed for East German productivity. There were, however, a few potentially debilitating complications which were recorded at diabetes advice centres after only a year of use. The Polyclinic Grimma informed the Ministry that Oranil did not work after a year, and that for younger and more severe cases of diabetes, it was ineffective.261 The diabetologist from

258 Waldemar Bruns, Dietrich Michaelis and Heinz Schneider, ‘Arbeitstherapie’ in Bericht der Historischen Kommission der Deutschen Diabetes Gesellschaft zur ‘Gerhardt-Katsch-Medaille’, ed. by Peter Hürter, pp. 19- 20 (p.19). 259 W. Porstmann, ‘Die Kriegsaglykosurie der Diabetiker’, Das deutsche Gesundheitswesen, 8 (1953), 1003-8 (p.1004). 260 The issue of the new oral antidiabetic tablet being taken from East to West is discussed in the following literature: Jeremy A. Greene, Prescribing by Numbers: Drugs and the Definition of Disease (Baltimore: Johns Hopkins University Press, 2007), p. 89.; H. Schwadewaldt, ‘Die Geschichte des Diabetes mellitus: Die oralen Antidiabetika’, in Diabetes Mellitus A, Handbuch der inneren Medizin, Siebter Band: Stoffwechselkrankheiten, Teil 2A, ed. by H. Schweigk (West Berlin and Heidelberg: Springer Verlag, 1975), pp. 34-39 (p.38); Bruns, Seige, Bibergeil, Menzel and Panzram, Die Entwicklung der Diabetologie, p. 10. 261 SAPMO-BArch DQ1/20569 – Diabetiker – Fürsorge – bzw. Beratungsstellen: Statistische Berichte, Berichtsjahre 1957 und 1958.

Rostock reported that patients put on Oranil had a reduced white blood cell count and were more susceptible to infectious diseases as a result. Nevertheless, as the 1950s progressed, the use of oral anti-diabetic tablets began to become more widespread, and further research led to the introduction of the second product, Orabet, which was hoped to exhibit fewer side- effects.262 At Polyclinic Nord in Halle figures suggested that twenty-seven percent received anti-diabetic tablet treatment by 1958.263 Political and material considerations together formed an integral part in the rolling out of anti-diabetic tablets in the GDR at such an early stage.

Getting as many diabetics as possible back to work through a particular treatment regime (diet-only, a combination of insulin and diet, the use of oral anti-diabetic tablets) was integral in a shortage economy where a lot of young, physically and mentally strong people were leaving for the West. However, medicinal treatment was not the only way diabetics were motivated to be productive citizens in the early years of the GDR. Often in conjunction with a treatment regime, diabetics were to undergo what was termed Arbeitstherapie (work therapy).264 When diabetics were newly diagnosed and had spent a possibly long period of time in a hospital, the temptation, from Katsch’s point of view, was to see them as ‘chronically ill’ rather than ‘conditionally healthy’. Once Katsch had opened his first home on the island of Rügen in the nineteen thirties, he began to realise that there was no reason why newly diagnosed diabetics needed to be inactive when doctors tried to stabilise their metabolism. Instead, patients should undertake a number of tasks similar to those they might experience in the workplace. Katsch maintained that physical activity was a natural way of lowering blood sugar so it was therefore very useful in developing a treatment regime.265 During the time when Arbeitstherapie was carried out, doctors measured the dose of insulin to determine the correct regime for a typical working lifestyle.

By providing treatment plans both for times of work and times of relaxation, patients’ metabolism would be much more stable when they returned home where they would be monitored by their diabetes advice centre. Prior to 1945, in an ordinary hospital which did not specialise in diabetes care, Katsch believed that this would not have happened. The Arbeitstherapie was yet another example of how an existing idea from Katsch was both workable and attractive under state socialism; it also echoed comments from social hygienists,

262 Bruns, Seige, Bibergeil, Menzel and Panzram, Die Entwicklung der Diabetologie, p. 41. 263 SAPMO-BArch DQ1/20569 – Diabetiker-Fürsorge-bzw. Beratungsstellen: Statistische Berichte, Berichtsjahre 1957 und 1958. 264 Gerhardt Katsch cited in Schüβler, pp. 76-80. 265 Schüßler, p. 80.

69 particularly Hermann Redetzky, on viewing diabetics as potentially good workers.266 The reason it is possible to tell that Arbeitstherapie was received well was how soon it was taken up in the relevant facilities. After the establishment of the Institute for Diabetes in Karlsburg in 1947 and the sanatorium for diabetics in Rheinsberg (1953), both offered several working opportunities for diabetics staying there, including gardening and manual work.267 The close relationship between these inpatient institutions offering diabetics work therapy and outpatient services (diabetes advice centres) was a sign of the all-encompassing nature of the mission to (re)integrate diabetics in the world of work, which may well have been bolstered by the need to drive an otherwise ailing economy forward into the future.

The introduction of specialist institutions for diabetics

Immediately after the Second World War, the main institution which existed for diabetics in the Soviet Zone was Katsch’s first diabetes home in Garz on the island of Rügen. The home suffered severe shortages of insulin, not only as a result of production ceasing, but also as a consequence of the destruction of countless bridges in Germany, and in particular, the one connecting the island of Rügen to the mainland.268 The home in Garz was considered at the time of its foundation to be an important place for the provision of specialist diabetes care and research. Katsch split his time between Garz, where assistants like Mohnike were on hand to help, and teaching at the University of Greifswald. It soon became apparent that a diabetes home on the island of Rügen would not be the ideal place for an institution central to diabetes care in the Soviet Zone and later nationwide in the GDR.269 It was decided that a location on the mainland very close to Greifswald, the small town of Karlsburg, would be much more convenient.

What is revealing from the outset is how far Katsch’s plans for this new institution for diabetes were dictated by the changing political circumstances in the immediate post-war years, with concerted attempts to alter the social and economic foundations of the Soviet Zone/GDR. During the search for a place to develop the new Institute for Diabetes, there were coincidental land reforms in the Soviet Zone (Bodenreform), where large farms were broken up to give

266 Redetzky, ‘Die soziale Bedeutung des Diabetes mellitus’, p. 156. 267 Egon Brauns and Peter Wulfert, “Malen Sie es notfalls weiβ an”–Sorgen der neuen Schloβherren’, in Karlsburg: Ein Dorf und sein Institut, ed. by the Institut für Diabetes ‘Gerhardt Katsch’ and Peter Wulfert (Karlsburg: Institut für Diabetes, 1990), pp. 49-54 (p.52). 268 Egon Brauns and Peter Wulfert, ‘Erstes Deutsches Diabetikerheim–Ein mühseliger Beginn’, in Karlsburg: Ein Dorf und sein Institut, ed. by the Institut für Diabetes ‘Gerhardt Katsch’ and Peter Wulfert (Karlsburg: Institut für Diabetes, 1990), pp. 40-43 (p.43). 269 Brauns and Wulfert, “Malen Sie es notfalls weiβ an”, p. 49.

70 those who had never owned land the opportunity to do so.270 At the Schloss Karlsburg, there was an especially large piece of land attached to it, which was a prime candidate for the reforms taking place. Katsch took advantage of the radical changes made to the socio-economic composition of agricultural society through Bodenreform by managing to secure, in autumn 1945, the castle and the surrounding land at Karlsburg, which had once belonged to a wealthy duchess.271 This was following negotiations with the newly developed government of Mecklenburg-Vorpommern, the region in which Karlsburg and Greifswald were located.272 It is clear, therefore, that from the very start, major institutions for diabetes care would be shaped by this emerging political environment. Equally, they were highly likely to be set up to respond to the imposition of state socialism since the new administration was effectively responsible for the successful acquisition of the castle and land at Karlsburg which would be vital to the diabetologists and the cause of diabetes in the future.

Figure 3: Formerly ‘Schloss Karlsburg’, now the ‘Institut für Diabetes’ 273

The importance attached to health, and indeed diabetes, can be seen in the way that the castle and its land were acquired. Early reports to the German Central Administration for

270 Jens Schöne, Das sozialistische Dorf: Bodenreform und Kollektivierung in der Sowjetzone und DDR (Leipzig: Evangelische Verlagsanstalt, 2008), p. 18. 271 Brauns and Wulfert, “Malen Sie es notfalls weiβ an”, p. 49. 272 SAPMO-BArch DQ1/960 – Bericht über die Dienstreise nach Karlsburg und Garz am 11. und 12. August d.J., 27.8.48, by Dr. Stoletzky. 273 SLUB Dresden, Deutsche Fotothek, Josef Adamiak (DS 20263646).

Health showed that when Katsch first discovered the castle, he found that there were 130 refugees from former German territories in the east living there, complicating matters significantly. Local SED groups rallied to support the refugees, arguing that if they were moved to nearby, worm and rat-infested shacks, it would turn them against the socialist government.274 This argument was a powerful one, with solid political grounds. However, the author Peter Wulfert, who was writing at the time of reunification in 1989/1990, argues that when the dispute was taken to Berlin, Katsch’s plan to develop a ‘centre of excellence’ for diabetes found considerable resonance with the upper echelons of the SED.

The Institute for Diabetes took priority over the refugees. Wulfert stated that, whilst this was not necessarily the socialist response, it did reveal Katsch’s qualities of diplomacy and tenacity.275 However, there were clear reasons why the reaction at the top favoured Katsch, even from a state socialist viewpoint. As has been mentioned already, medical professionals needed to be kept onside, and the health of the population and international recognition were of principal importance. The future problems faced in the productive sphere as a result of diabetes were there for all to see and were sold very effectively to the political hierarchy by Katsch himself. It is necessary to recognise, too, that it was not just the SED who was extremely interested in Katsch and diabetes. Since the process of founding the Institute for Diabetes occurred during the years of occupation, the Soviets, independent of the German authorities, expressed their own interest by requesting that a reparations document on the running of Katsch’s first home be written.276 Evidence that this document existed was found in the Greifswald University archive; it was composed by a junior doctor, Wulf Lübken, in 1947 and outlined treatment methods and research undertaken at Garz. This was to be sent to the Soviet Union as a guide for diabetes treatments there.277 Politically, the occupation years were indispensable in establishing the need to develop specialist and ambitious projects for diabetes, and this might explain why there was so much development in the earliest years for a disease which, whilst likely to be overshadowed at that moment by contagious diseases, had the

274 This argument was documented in detail in the Ministry of Health files, where conflicts between the SED on a national and local level were laid out: SAPMO-BArch DQ1/3151 – Stellungnahme der SED-Ortsgruppe Karlsburg im Kreis Greifswald zur beabsichtigten Räumung von Umsiedlerwohnungen im Zuge der Erweiterung des Diabetikerheims, Karlsburg. See also: Brauns and Wulfert, “Malen Sie es notfalls weiβ an”, p. 50. 275 Brauns and Wulfert, “Malen Sie es notfalls weiβ an”, p. 50. 276 Reinisch, p. 232. 277 Wulf Lübken, ‘Originalbericht von Wulf Lübken’, in Gerhardt Katsch, Begründer des ersten deutschen Diabetikerheims und der Diabetikerfürsorge: Bericht von Wulf Lübken als Wissenschaftliche Reparationsleistung an die Sowjetische Militäradministration Deutschland (SMAD), ed. by Günther and Ralf Ewert (Berlin: Pro BUSINESS, 2008), pp. 25-186 (p.25).

72 potential, as predicted by social hygienists, to be an epidemic of the future. One cannot underestimate the qualities of Katsch as an individual negotiator in the run-up to, and in the early years of, the GDR, which in turn gave the cause of diabetes greater appeal in a state socialist climate than it might otherwise have had. Again, Katsch revealed his ability to work with the new political circumstances in which he and his cause now found themselves.

The combination of material shortages and political change evident in the search for treatment solutions in diabetes care was also a feature in the establishment of institutions. Although Katsch and his assistants had a castle and land at their disposal for the new Institute for Diabetes, only a few rooms of the castle could be used. The facilities were rudimentary to say the least; there was no running water, there were problems with vermin, and medical examinations were done by candlelight.278 Katsch had sought help from the Vice President of the Central Administration for Health, Maxim Zetkin, and a Soviet officer, Major Jessin, to arrange a meeting with the SMAD. Katsch was acutely aware of the centralised structure of the developing economic system, and thought that, if the Institute for Diabetes was put under the control of the Central Administration for Health (and later the Ministry of Health), it would have access to regular funding.279 Once again, political adroitness prevailed. Two Soviet delegates were sent by the Vice President of the Health Department of the SMAD, who were appalled at the terrible conditions in which very notable scientific work was being undertaken.280 Through the shock at the conditions and the surprise at the efforts and ability of the diabetologists, the Institute became Volkseigentum, alongside vast swathes of the East German economy, nationalised and under central control, but financially secure. By October 1950, it had gained the title ‘Institute for Diabetes – Research and Treatment’, and was recognised in the GDR’s five-year economic plan, an integral part of the socialist transition.281 Money was going to be spent on expanding the Institute to include a hospital and a block for research. Positive cooperation between Katsch and the Minister of Health, Luitpold Steidle, ensured further progress was made at the Institute. In 1952, it could already boast two new buildings. The first contained an x-ray department, examination rooms, laboratories, patient

278 Bruns, Bibergeil, Seige, Menzel and Panzram, Die Entwicklung der Diabetologie, p. 22; Brauns and Wulfert, “Malen Sie es notfalls weiβ an”, p. 50 279 SAPMO-BArch DQ1/960 – Bericht über die Dienstreise nach Karlsburg und Garz am 11. Und 12. August d.J. 27.8.48, Dr. Stoletzky. 280 Ibid. 281 SAPMO-BArch DQ1/4216 – Protokoll dated 10/09/50, pp.1-2.

73 records and a library, and the second was intended to house animal and chemical research facilities.282

By the Institute coming under the control of the Ministry of Health and participating in the centralising tendencies of state socialism, it followed that it became an exemplary institution for diabetes which many of those who had anything to do with the disease would look up to. Both outpatient and inpatient diabetes care, from the diabetes advice centres in polyclinics to the university hospitals, were under state control, meaning that the Institute would be at the pinnacle of a state-run network. Gerhard Mohnike in a report to the Ministry of Health explained the pivotal role that the Institute was supposed to play. In his view, the Institute should conduct new research into diabetes, provide advice to the Ministry of Health on matters relating to diabetes care, assist pharmaceutical industry in efforts to produce insulin and other medication, and organise training courses for all staff working in diabetes advice centres.283 By the 1950s, only a decade or so after Katsch had acquired the dilapidated castle, the Institute was viewed as a (even the) centrepiece of diabetes care and research. Reports from diabetes advice centres to the Ministry of Health make several references to the Institute and its value; it was noted that staff who had received training at the Institute returned with their skills and knowledge vastly improved. One report even mentions an ‘efficient’ laboratory assistant, who, when conducting her work with proficiency, subsequently stated, ‘that is how Karlsburg does it’.284

The regular funding given to the Institute for Diabetes was valued very highly by Katsch, and in return he seemed prepared to be politically obedient, a fact which is obvious with regard to the code of conduct and rules for employees at the Institute. When the ‘Dienstordnung’ for the Institute was published in 1951, the wording and expectations, which were written by Katsch, could well have been formulated by an ardent member of the SED.285 There is no evidence that Katsch ever offered vocal support for the regime in the public arena. Yet, amidst all the conventional regulations on patients’ safety and the general upkeep of

282 Egon Brauns and Peter Wulfert, ‘Der Start für das groβe Institut–Die Fundamente werden errichtet’, in Karlsburg: Ein Dorf und sein Institut, ed. by the Institut für Diabetes ‘Gerhardt Katsch’ and Peter Wulfert (Karlsburg: Institut für Diabetes, 1990), pp. 54-8 (p.54). 283 SAPMO-BArch DQ1/21426 – Kurzbericht über das Forschungsthema (Fortsetzungsthema) ‘Diabetesgrundlagenforschung’ im Jahre 1957, 27/1/58, by Prof. Dr. Mohnike, pp.1-2. 284 SAPMO-BArch DQ1/6111 – Betr.: Analyse zum Jahresbericht der Diabetikerberatungsstellen des Bezirkes Neubrandenburg für das Jahr 1957, p.1; SAPMO-BArch DQ1/20570 – Kreis-Krankenhaus Altentreptow, October 1957, p.2. 285 SAPMO-BArch DQ1/2777 – Dienstordnung für ‘Diabetikerheim Garz und Karlsburg, Anstalt zur Erforschung und Behandlung der Zuckerkrankheit, pp.1-6.

74 medical reputation, the language used for the expectations of employees was politically inspired. The ‘correct’ political attitude was considered as important as moral and professional suitability, with employees expected to have ‘a close attachment to the working population’ (‘enge Verbundenheit mit den Werktätigen’). They were also required to consolidate their Staatsbewusstsein, that is, to develop an awareness of and pride in the political system, and the economic and cultural life of the GDR. 286 There was a real attempt by Katsch to integrate the Institute firmly into the new socialist system insofar as his choice of words is concerned. The Dienstordnung is the first time where he used politically specific jargon beyond his pre-existing notion of diabetics being ‘conditionally healthy and able to work’.

There were not only rules for employees; an Anstaltsordnung also existed, outlining rules for the patients staying at the Institute, embodying in its tone those recurring elements of care and coercion.287 The goal of his patients’ stay was to ensure that they would become able members of the GDR’s workforce, as part of the wider mission to create a productive socialist society. Katsch’s approach to insulin therapy, which put the doctor rather than the patient firmly in the driving seat, was also reflected in the rules for patients’ period of rehabilitation and treatment at the Institute. A patient was not given room for any individual decision-making, which could be seen in the fact that they were not allowed to deviate from the diet prescribed for them, they had to participate in all work therapy as well as obligatory daily sports, and they could not determine the length of their stay.288 The sporting activities can be assessed in hindsight as especially controversial in making diabetics fit for work. If they were not used to such physical activity and/or were untrained in the sport they were undertaking, damage and injury were likely outcomes, and that was indeed the case in reality. The Ministry of Health actually had to apply to the Ministry of Finance for extra insurance cover for the Institute on account of the reported accidents occurring during the compulsory sport; several reports to the Ministry of Finance laid the details bare, with one diabetic breaking a shin, another accidentally ‘damaging property’ and several breaking their spectacles.289

The Institute’s structural components were an additional indication that it was going to align itself to the political system. There were several departments which were devised to achieve social hygienic aims, in particular, the creation of a department for statistics with a

286 Ibid., pp.1-2. 287 Ibid. [Abschnitt III, Organisation des inneren Dienstes der Anstalt, Anstaltsordnung], pp. 5-10. 288 Ibid., pp.5-10. 289 SAPMO-BArch DQ1/3151 – Betr.: Unfall – Versicherungsschutz, 21 July 1955, Diabetikerheim Garz und Putbus.

75 full-time statistician. Mohnike remarked that this new department would help diabetologists in their quest to establish patterns and prevalence of diabetes, which might lead to relatively simple but vital conclusions, like, for example, diabetes rates rising in urban areas.290 This would heighten awareness from a socialist perspective about the need to monitor those areas more closely due to the effects diabetes might be having on the working-class communities in industrial cities, such as Leipzig and Karl-Marx-Stadt (now Chemnitz). The Institute for Diabetes engaged in Reihenuntersuchung screening programmes as did many outpatient facilities (polyclinics) across the GDR and attempted to be an exemplary microcosm of diabetes care, following the preventative measures and specialist expertise instructed by social hygienists. 291

Katsch once described his view of the socio-medical care for diabetics as a provision that occurred ‘from cradle to grave’ (‘von der Wiege bis zum Grabe’), a phrase the relevance of which has already been hinted at earlier.292 Katsch’s use of the phrase is a reference to the fact that in the early years of the Institute perhaps there was, in some respects, a disproportionately large focus on pregnant diabetics, with the purpose of ensuring that the lives of their offspring could be preserved.293 As well as keeping people fit for work, there was also emphasis in the new political climate on a high birth rate, this being a direct consequence of what Ulrich Mählert called the Massenflucht (mass exodus to the West).294 The care for pregnant diabetics may well fit into this mind-set. A special maternity ward was created at the Institute in 1952, co-ordinated by Mohnike and a gynaecologist, Dr Martin Worm.295

Several influential changes were made here to the success rate of infant survival. First of all, they believed that more births had to be carried out by caesarean section, and second, the mother was given a higher dose of insulin than had previously been the case even until the early 1950s.296 The latter was particularly important because it prevented babies being disproportionately large or suffering a serious hypoglycaemic shock at the point of birth.297 The extent of the emphasis placed on the youngest members of society can be seen in the results

290 Mohnike, ‘Sozialmedizinische Diabetesfragen’, p. 287. 291 SAPMO-BArch DQ1/21526 – Die Situation der Diabetesbekämpfung in der DDR by Dr. Rautenberg, 8/3/1960, pp.3-4. 292 SAPMO-BArch DQ1/2777 – Letter from Katsch to the Minister of Health, Steidle, outlining the development of the Institute for Diabetes, 20 March 1951, p.1. 293 Ibid., p.1. 294 Mählert, Kleine Geschichte der DDR, p. 95. 295 SAPMO-BArch DQ1/4216 – Letter from Katsch to the section of internal medicine at the Academy of Sciences, 8/8/1953, p.1. 296 Interview with Dr. Knut Lürrmann, 15 August 2016. 297 Schüβler, p. 117.

76 that the GDR obtained in the rate of infant mortality of babies born to diabetic mothers. In the minutes of the 1958 International Diabetes Federation Congress, there was a special mention of the GDR’s ten percent perinatal mortality of such babies, a figure which was recognised as among the lowest in the world (the recorded average was fifty percent).298 Even Schüβler, in her relatively critical dissertation on Katsch, remarks that this was one of the biggest opportunities for the GDR to develop the international reputation it craved.299

Focusing specialist attention on the youngest members of the population did not stop there. In the political rhetoric of the GDR from the early years, older members of society i.e. pensioners were perceived as a drain on the economy, whereas younger people were viewed as the drivers of economic progress, and therefore maintaining their health was fundamental.300 Despite the comparatively smaller incidence of insulin-dependent diabetics, the attention which diabetic children received was, as with pregnant diabetics, larger than one might expect. It was acknowledged that diabetes tended to be more severe and required intense monitoring in younger people; should their condition be neglected, it could have a catastrophic impact on a child or young adult’s ability to contribute to society. Diabetic children, especially from the point of view of diabetologists, were considered to have huge potential for the state socialist society (für die Gesellschaft leistungsfähig machen),301 with some studies revealing an ‘above average’ intellect and a good school performance.302 Whether this was an effort to sell the cause to the political regime or not, it provided the necessary persuasion to do more for child diabetics so that they could overcome the perceived problems of living with the disease. The fundamental word in reference to children with diabetes was potential; it was the way they were treated, the astute management strategies and the right social environment, which Katsch believed was crucial for child diabetics and would ensure that they would be able to fulfil their potential.303

The Institute for Diabetes at Karlsburg was largely replacing Katsch’s first home in Garz as the focal point of diabetes care, but the first home did develop by the mid-1950s into

298 Waldemar Bruns, ‘Die Geschichte der Diabetologie in der DDR’, Festschrift 50 Jahre Deutsche Diabetes Gesellschaft, ed. by Die Deutsche Diabetes Gesellschaft, Erhard Siegel and Dietrich Garlichs (Stuttgart: Die Deutsche Diabetes Gesellschaft, 2014), pp. 68-79 (p.75). 299 Schüβler, p. 121. 300 Generous child benefit schemes and low pensions are a sign in the economic system that this was the case and has been talked about in detail in: André Steiner, The Plans That Failed: An Economic History of the GDR, trans. by Ewald Osers (Oxford and New York: Berghahn, 2010), p. 185. 301 SAPMO-BArch DQ1/4215 – Notwendigkeit und Eigenart einer Sonderschule für diabetische Kinder by Prof. P. Hoffmann, Anlage 2 [of the Protokoll der Sitzung des Verwaltungsrats der Anstalt öffentl. Rechts, 29/8/52], p.2. 302 Mohnike, ‘Sozialmedizinische Diabetesfragen’, p. 288. 303 SAPMO-BArch DQ1/4216 – Memorandum für die Akademie der Wissenschaften, Abteilung Medizin, 10/03/1952, p.3.

77 the primary venue for (newly diagnosed) child diabetics.304 Drawing on prior knowledge and experience from the thirties and forties, Katsch thought that those child diabetics who were coming from disadvantaged social environments and had to spend an extended period of time in Garz needed to be provided with a good education whilst they were there.305 This gave rise to a boarding school for diabetic children receiving care on a long-term basis on the island. Katsch sought the guidance of the pedagogical expert, Dr. Hoffmann, from Greifswald University. The case was mounted and, after lengthy correspondence with the Ministry of Health, the boarding school was opened in November 1955 in Putbus nearby.306 The primary mission was to educate diabetic children well and to help them understand that their illness would not hold them back in the wider world, which was extremely important for the political regime to hear.

Figure 4: The Boarding School for Diabetics, Island of Rügen, September 1964 307

The children studying at the boarding school were chosen primarily on account of their circumstances. According to Günther’s article, the children that would benefit from the boarding school were those who were described as ‘milieugefährdet’ (coming from difficult social backgrounds). Judging whether children were milieugefährdet involved a level of

304 Egon Brauns and Peter Wulfert, “Bisher ein äuβert trauriges Kapitel”: diabetische Kinder–die Herausforderung wird angenommen’, in Karlsburg: Ein Dorf und sein Institut, ed. by the Institut für Diabetes ‘Gerhardt Katsch’ and Peter Wulfert (Karlsburg: Institut für Diabetes, 1990), pp. 44-48 (pp.46-7). 305 SAPMO-BArch DQ1/4216 – Memorandum für die Akademie der Wissenschaften, Abteilung Medizin, 10/03/1952, p.3. 306 Ibid. 307 Bundesarchiv Bild 183-C0929-0001-006.

78 intrusion that has punctuated studies on the GDR which have revealed a blurring of the boundaries between what is public and private. A good comparison to cite here is the ‘re- education’ programme set up in the GDR for delinquent youths, and removing children from their homes reiterated the coercive side of the care given.308 The criteria for admission to the boarding school left ordinary families wide open should they be marked out by a local diabetes advice centre or specialist as a cause for concern. Parents were the immediate target, and, as Günther explains in his article, they could be judged to be ‘incompetent’ or ‘irresponsible’ in the management of their child’s diabetes.309

These sorts of categories seemed rather vague and arbitrary, with little explanation as to what constituted either judgement. Günther describes parents, particularly mothers, who were branded as ‘unintelligent’, and makes specific reference to single mothers who may not be able to cope.310 Mohnike also warns of the over-indulgent parental type who give ‘excessive’ compassion, which manifested itself in allowing their child to have large amounts of sweets. It was believed, certainly by Katsch and his close colleagues like Mohnike and Günther, as well as the educationalists to whom he turned for support, that intervention was key in order to stop productive lives being wasted. Hoffmann, the most prominent educationalist supporting the introduction of the boarding school, referred to the (minimum) figure of 1093 diabetics in the GDR under the age of 18 between 1951 and 1952, whose role in the workforce could be significantly reduced if direct action was not taken.311 That the solution to the problems caused by diabetes in children was a socio-economic one, and a completely different location (not local to the child) was chosen, appears to be one of the clearest examples of where social hygienic thinking was put firmly into practice. The boarding school was, significantly too, an institution which had not existed before, and therefore a likely product of its new political environment.

For diabetic inpatients who required a lengthy episode of stationary care and rehabilitation, a sanatorium was developed, which was a further response to the calls to reintegrate diabetics into society. The sanatorium was created in the small, salubrious town of Rheinsberg in the region of Brandenburg. It was first mentioned officially in Ministry of Health

308 Verena Zimmermann, “Den neuen Menschen schaffen”: die Umerziehung von schwererziehbaren und straffälligen Jugendlichen in der DDR (1945-1990) (Cologne, Weimar and Vienna: Böhlau Verlag, 2004), p. 417. 309 Otfried Günther, ‘Warum Schulheim für zuckerkranke Kinder?’ Das deutsche Gesundheitswesen, 7 (1952), 988-990 (p.988). 310 Günther, pp. 988-9. 311 Professor Hoffmann cited in Günther, p. 990.

79 files in March 1953.312 The model of the sanatorium pre-dated the GDR, and was a feature in all-German healthcare, most notably in tuberculosis rehabilitation.313 The sanatorium, unlike the boarding school, was therefore not a distinct break from the past, but was an institutional model that was malleable and did not cause political friction. Katsch ordered that it should work closely with Karlsburg so that those working there maintained up-to-date scientific knowledge, and it very quickly became popular in the rehabilitation of diabetics. The requirement of physical activity in a typical pre-war sanatorium, doing, for example, gardening work to help recuperate from a condition did not conflict with the aims of the new political system, and, if anything, complemented them. The reports from diabetes advice centres were testimony to the way in which the sanatorium was being viewed as effective in making diabetics fit again. Particular reports from the regions of Rostock and Neubrandenburg in 1957 complain about the lack of places available, illustrating the increasing demand for strictly rehabilitative measures for diabetics.314 Unfortunately, the reaction by the Ministry of Health was not immediate, but by 1960, plans were put in place for a second sanatorium largely due to the apparent successes of the current one in Rheinsberg.315

Conclusion

The 1950s were instrumental years in the setting up of a network of outpatient and inpatient facilities for diabetes, which were specialist-oriented, with a number of talented personnel who decided to remain in the GDR to carry out the tasks at hand. It is clear that the new state socialist regime, and the ideological developments which ensued, had a decisive impact on the shaping of diabetes management from the very early years. Donna Harsch, in her conclusions of Tuberculosis treatment in the GDR in the 1950s, remarks that it was ‘characterised less by radical change and innovation than by tradition and pragmatism, at least until the mid- 1950s’.316 Whilst it has been evident that the key diabetologist of the GDR in the 1950s, Katsch, used political pragmatism in increasing the status of diabetes and acquiring the necessary buildings for the new Institute for Diabetes in Karlsburg, as well as using preconceived ideas on treatment methods/outcomes, there was much to identify as distinctly ‘radical’ or at the very

312 SAPMO-BArch DQ1/4216 – Diabetiker-Sanatorium Rheinsberg, 13/03/53, by Dr. Erler. 313 Donna Harsch, ‘Medicalized Social Hygiene?: Tuberculosis Policy in the German Democratic Republic’, Bulletin of the History of Medicine, 86.3 (2012), p. 394. 314 SAPMO-BArch DQ1/20569 – Analyse Diabetiker-Jahresbericht 1957 des Bezirkes Rostock and Abschrift, 11/2/58 by Dr. Kaeding; Betr.: Analyse zum Jahresbericht der Diabetikerberatungsstellen des Bezirkes Neubrandenburg für das Jahr 1957, p.2. 315 SAPMO-BArch DQ1/21526 – Die Situation der Diabetesbekämpfung in der DDR by Dr. Rautenberg, 8/3/60, p.2; Bruns, Bibergeil, Seige, Menzel and Panzram, Die Entwicklung der Diabetologie, p. 33. 316 Harsch, ‘Medicalized Social Hygiene?’ p. 394. [Also see literature review].

80 least a ‘change’ from preceding approaches. These changes were not at odds with state socialism and were actually the product of them. The Dispensaire System for diabetics, the introduction of polyclinics and the diabetes advice centres within them were not only new additions but also very different from the disparate, private practice model that seemed to continue in West Germany, where money could be earned depending on how many patients a doctor would treat. This explains why so many doctors emigrated there in the first place and led to staff shortages and a loss of talent in the late 1950s, not only in the medical sphere, that culminated in the building of the Berlin Wall.

Social hygienists had developed a growing interest in chronic diseases, and it has been evident in this chapter that diabetes, with statistical evidence showing rising rates annually, merited greater attention than ever before. It therefore provided a fitting climate for diabetes care to develop at the rate that it did, despite ongoing material shortages. In terms of the lack of medication, especially insulin, this confirmed rather than undermined the influence of state socialism on diabetes management and was also strongly connected to the drive to restore diabetics’ abilities to work. The fact that insulin had only been discovered in 1921 meant that for long periods in all-German healthcare, diabetes remained an enigma as opposed to the long- identified Tuberculosis. In some ways, it made diabetes, and other chronic diseases like cardiovascular disease, more open to new political direction. In addition, the GDR’s growing interest in its status and the prolonged search for legitimacy meant that it consciously followed international trends in health, and with the growth in important clinical and epidemiological studies on chronic diseases, especially in the United States, the GDR could not afford to be left behind. At the beginning of the 1960s, the foundations of a wide-ranging and all-encompassing system of care for diabetics in the developing socialist state had undoubtedly been put in place on which could be built over the years that followed. However, the death of Katsch and the building of the Berlin Wall, both in 1961, presented different challenges, but also new opportunities, and led to fresh developments in the inter-relationship between the socialist system and diabetes care in the GDR.

Chapter 2: ‘Aktion Störfreimachung’ and the Shadow of the Berlin Wall

Introduction

The death of the GDR’s most well-known and influential figure in the field of diabetology, Gerhardt Katsch, in March 1961, marked the end of one era and the potential beginning of another.317 Were the death of Katsch to be seen in isolation, it is likely that it could be considered momentous enough to impact on the course of diabetes care and research in the GDR thereafter. However, coincidentally, the year in which this chapter begins, 1961, was the time of another landmark event that penetrated all aspects of life and society in the GDR: the building of the Berlin Wall on 13 August. It is thus apparent in this chapter that the inner chronology of diabetes care and research in the GDR and the outer chronology of domestic and international affairs concerning the GDR as a whole progress in tandem. In the late 1950s up until the building of the Wall, the emigration of labour and talent, witnessed also in the arena of diabetology, had to be curtailed, and this issue was addressed by severely limiting the freedom of movement of aspirational East Germans otherwise drawn to the economic prosperity of West Germany. Solving this problem gave rise to what several historians have called a ‘liberalisation’ period in both political and economic terms to encourage popular support for the SED.318 This does not, however, characterise the immediate consequences of the Berlin Wall as well as it should, certainly as far as diabetes is concerned. In this chapter, it will be argued that the building of the Wall firstly ushered in a sense of permanence, that the GDR was here to stay and that ordinary citizens had to resign themselves to that fact. Even more importantly and secondly, though, instead of ‘liberalisation’, it marked the start of a growing sense of introspection, with an increased tendency of self-examination and even self- scrutiny of the GDR and its place in the world.

The relationship that developed with West Germany in particular manifested itself through an economic policy known as Störfreimachung (‘making free from disturbance’),

317 Anonymous, ‘Prof. Dr. Katsch gestorben’, Neues Deutschland, 9th March 1961, Jahrgang 16, Ausgabe 68, p. 4. 318 Stefan Berger and Norman Laporte, Friendly Enemies: Britain and the GDR, 1949-1990 (Oxford and New York: Berghahn, 2010), p. 94; Peter Grieder, The German Democratic Republic: Studies in European History (Basingstoke: Palgrave Macmillan, 2012), p. 57; Jörg Roesler makes the point that ‘a thaw began much earlier in politics than in economics’, with Störfreimachung being an economic and also hard-line policy: Jörg Roesler, ‘The economy as a pushing or retarding force in the development of the German question during the second half of the twentieth century’, in Economic Change and the National Question in Twentieth-century Europe, ed. by Alice Teichova, Herbert Matis and Jaroslav Pátek (Cambridge: Cambridge University Press, 2000), pp. 48-71 (p.56).

82 which Patrick Major believes was an addition of ‘another self-imposed burden’ by the SED.319 During a speech made by the East German head of state, Walter Ulbricht, on 4 October 1960, the Störfreimachung policy was announced to the general public.320 It officially marked the start of the ‘Störfreimachung period’, as Rainer Karlsch puts it, or what Jörg Roesler calls ‘the GDR’s campaign for total economic separation’, occurring with most vigour between 1961 and 1964, after which time the policy was all but abandoned when losses amounted ‘to the tune of one billion marks’, according to economic historian, André Steiner.321 The word ‘Störfreimachung’ is not easy to translate literally into English, and it is likely to be closely related to the word ‘autarky’, although this lacks the specific political (Cold War) connotations. Despite the SED espousing anti-fascism continually, they were following in the footsteps of the many autarkic projects undertaken during the years of the Third Reich.322 The growing political tensions between West and East Germany culminated in West Germany’s cancellation of the Intra-German trade agreement (the so-called Berlin Agreement) at the end of 1960, and the strained relations between the two states led to paranoia on the part of the GDR that the West would at any moment establish a trade embargo.323 As a result, the SED leadership believed that the GDR needed to lessen its reliance on West German goods and pursue an anti- import production agenda (including the reduction of imports from other NATO countries) in order to avoid catastrophic shortages in the future.324 This did not only mean producing substantial quantities of their own goods (although this was largely what was happening). It also implied by extension a look eastward to the other COMECON (Council for Mutual

319 Patrick Major, ‘Going west: the open border and the problem of Republikflucht’, in The Workers’ and Peasants’ State: Communism and Society in East Germany under Ulbricht 1945-71, ed. by Patrick Major and Jonathan Osmond (Manchester: Manchester University Press, 2002), pp. 190-209 (p.200). 320 Ernst Richert, Die SED als bestimmende Kraft im Staatsapparat (Wiesbaden: Springer Fachmedien, 1963), p. 62. 321 Rainer Karlsch, ‘National Socialist Autarky Projects and the Postwar Industrial Landscape’, in The East German Economy, 1945- 2010: Falling Behind Or Catching Up? ed. by Hartmut Berghoff and Uta Balbier (Cambridge: Cambridge University Press, 2013), pp. 77-9 (pp.85-6); Roesler, p.54; André Steiner, The Plans That Failed: An Economic History of the GDR, trans. by Ewald Osers (Oxford and New York: Berghahn, 2010), p. 107. 322 Eli Rubin, Synthetic Socialism: Plastics and Dictatorship in the German Democratic Republic (Chapel Hill: University of North Carolina, 2008), p. 41; Karlsch, ‘National Socialist Autarky’, pp. 79-81. 323 ‘“Die Welt” muss ihre Lüge widerrufen’, Berliner Zeitung, 11th January 1961, Jahrgang 17, Ausgabe 11, p. 2 and p.5; Roesler, pp. 53-4; André Steiner, ‘From Soviet Occupation Zone to “New Eastern States”: A Survey’, in The East German Economy, 1945- 2010: Falling Behind Or Catching Up? ed. by Hartmut Berghoff and Uta Balbier (Cambridge: Cambridge University Press, 2013), pp. 17-52 (p.27). 324 Karlsch, ‘National Socialist Autarky’, p. 85.

Economic Assistance) countries of the Eastern Bloc, to establish trade links and to export more East German products to those states.325

Two years prior to Ulbricht’s announcement of the policy of Störfreimachung, he also made a speech stating that the GDR would overtake West Germany in per capita consumption of consumer goods by 1961. Hence, consumerism and consumption took centre stage in the ‘Störfreimachung period’, and the policy itself propelled East German consumer habits to the fore. As in the West, the GDR had experienced a ‘consumer revolution’ after the Second World War.326 The state socialist model of consumption was supposed to emphasise the functionality of goods and egalitarian distribution; as Khruschev famously posited, ‘everyone performs according to their abilities, and everyone is provided for according to their needs’.327 The ability of East Germans to see and hear media outlets from a western neighbour who spoke the same language made it much harder for the highest political authorities to define consumerism in socialist terms. As Störfreimachung now shifted the focus to the production and consumption of domestic goods, East Germans were even more keenly aware of what they wanted (and did not want), with Harald Dehne arguing that from the beginning of the GDR’s existence, the West German model of ‘individual consumption’ very much ‘set the standard’.328 An additional dilemma also existed in that a new socialist peculiarity of gesellschaftliche Konsumtionsformen (societal consumption forms) emerged, where people were starting to get used to, and took for granted, collective and free-of-charge services, like healthcare.329

Consumer goods represented ‘a different and affluent world’ to the average East German and they equated quality with what was West and not East German-made.330 In order to stand a chance of manufacturing competitive goods, the planned economy in its current form

325 Michael Lemke, ‘Entwicklungstendenzen der ostdeutsch-sowjetischen Beziehungen von 1955 bis 1961 und der SED-Plan einer bilateralen Wirtschaftsgemeinschaft’, in Vergleich als Herausforderung: Festschrift zum 65. Geburtstag von Günther Heydemann, ed. by Andreas Kötzing et. al (Göttingen: Vandenhoeck and Ruprecht, 2015), pp. 261-276 (pp.268-9). 326 Stephan Merl, ‘Staat und Konsum in der Zentralverwaltungswirtschaft: Rußland und die ostmitteleuropäischen Länder’, in Europäische Konsumgeschichte: Zur Gesellschaft- und Kulturgeschichte des Konsums (18. Bis 20. Jahrhundert), ed. by Hannes Siegrist, Hartmut Kaelble and Jürgen Kocka (Frankfurt am Main and New York: Campus Verlag, 1997), pp. 205-244 (p.205). 327 Hannes Siegrist, ‘Einleitung’, in Europäische Konsumgeschichte: Zur Gesellschaft- und Kulturgeschichte des Konsums (18. Bis 20. Jahrhundert), ed. by Hannes Siegrist, Hartmut Kaelble and Jürgen Kocka (Frankfurt am Main and New York: Campus Verlag, 1997), pp.13-50 (p.32). 328 Harald Dehne, ‘Consumption and Consumerism in the German Democratic Republic’, in Everyday Life in Mass Dictatorship: Collusion and Evasion, ed. by Alf Lüdtke (London: Palgrave Macmillan, 2016), pp. 147- 164 (p.147). 329 Ina Merkel, Utopie und Bedürfnis: Die Geschichte der Konsumkultur in der DDR (Cologne, Weimar and Vienna: Böhlau Verlag, 1999), pp. 312-3. 330 Andreas Staab, ‘Testing the west: Consumerism and national identity in eastern Germany’, German Politics, 6:2 (1997), 139-149 (p.142).

84 could not succeed in improving the qualitative dimension fundamentally lacking in East German production. The New Economic System of Planning and Management (NÖS) of 1963 replaced the overly ambitious Seven Year Plan (intended to run from 1959 to 1965) and was supposed to be the solution to the GDR’s continued struggle to create an ‘economic miracle’ of the kind seen in West Germany.331 Effectively introducing market forces into a planned economic system, the ambivalence of NÖS did little to instil confidence in the GDR’s ability to maintain economic independence from the West. This only clarifies the fact that, as Eli Rubin asserts, the policy of Störfreimachung was ‘an attempt to thread a very difficult needle of competing with West Germany on the one hand, Moscow’s demands on the other, and to improvise ways out of seemingly impossible situations’.332

With the evident link to consumerism, the consequences of the policy of Störfreimachung are more diverse than current scholarship on the GDR has given them credit. This might be the reason why Störfreimachung has been somewhat neglected in general histories of the GDR and has not been explored in much depth by those who have touched upon it. There is no doubt that the GDR was lagging behind its Western neighbour when it came to the consumption of even the most basic goods, and that this was a primary motivation to create more of their own products. The problem in existing historiography is the focus on conventional consumer goods and not on those that affect people’s health, wellbeing and ability to work. Steiner, who offers a fairly detailed explanation of Störfreimachung, talks only about the fact that ‘dependence was especially marked for the metal-processing, chemical and metallurgical industries’, and does not make any reference to pharmaceuticals, medical supplies and equipment for medical research which were all included in the effort to reduce the GDR’s reliance on western imports.333 Using health topics as an example gives Störfreimachung far greater resonance than typically industrial case studies, where the products that were created (for example, the Trabant automobile, which is discussed with Störfreimachung in mind by Eli Rubin) were commodities but not necessities.334 For diabetics depending on insulin or oral anti-diabetic tablets, as well as other ‘accessories’ like urine test strips, quality could not be left to chance. When qualitative shortcomings existed, the productionist principle set down in the previous decade of patients needing to be fit and able

331 Steiner, The Plans, pp. 90-1. 332 Eli Rubin, ‘The Trabant: Consumption, Eigensinn and Movement’, History Workshop Journal, 68:1 (2009), 27-44 (p.34). 333 Steiner, The Plans, p. 106. 334 Rubin, ‘The Trabant’, pp. 33-4.

85 to work would be seriously undermined. This feeds into the idea that consumers, even in the GDR, now desired goods that did not simply achieve survival but a certain lifestyle. Diabetics wishing to honour Katsch’s mantra of ‘conditionally healthy and able to work’ wanted to use products that would best enable them to lead a life expected of the ‘new socialist person’. The association such products as insulin had with lifestyle elevates their status to that of ‘consumer goods’ as opposed to medication per se.335 Based on this tension between East and West around the issue of consumption, diabetics could not accept mere functionality, but only the best on the ‘market’, i.e. goods produced in the West.

This chapter will therefore explore the ‘Störfreimachung period’ and the impact it had on diabetics and the work of those caring for them. It will start by taking the issue of imported depot insulin as a case study through which to view in detail how this new economic situation shaped the lives of those dependent on such medication, both in the giving and receiving of insulin therapy. It will examine in particular the efforts of diabetologists, patients and patients’ relatives to resist the policy either by pressing for a change of course or by improvisation. Their actions, it will be argued, were motivated by consumerist instincts and demonstrated the role of doctors and patients in the GDR as ‘politically regulated consumers’. The chapter will then look more carefully at the gesellschaftliche Konsumtionsformen that were the rapidly expanding ‘diabetes advice centres’ in polyclinics and Ambulatorien. The demand on the centres was meticulously recorded by diabetologists in advice centre reports, along with challenges relating to goods and personnel. These will go some way to examining how far the care delivered was able to meet with expectations of consumption-hungry patients. The issue of demand and the ability to supply the care required to meet it were magnified by the desire of diabetologists to fulfil the obligations of social hygiene to prevent diabetes and its complications through preventative measures. Mass screening for diabetes took off in the early 1960s, as the permanence of the Wall encouraged diabetologists to embrace the new order of healthcare and actually set about moving to the next stage of putting more ideas of the late 1940s and 1950s into practice. The influx of newly detected, largely non-insulin dependent, diabetics via screening initiatives coupled with the acute cases caused by reduced quantities of imported insulin massively increased the number of ‘health consumers’ in the overarching

335 David Bell and Joanne Hollows, ‘Making Sense of Ordinary Lifestyles’, in Ordinary Lifestyles: Popular Media, Consumption and Taste, ed. by David Bell and Joanne Hollows (Maidenhead: Open University Press, 2005), pp. 1-20 (p.4).

Dispensaire System. This will be explored in the chapter by reflecting on the expansion of screening and new institutions catering to the needs of ‘post-acute’ cases.

Import-Insulin and the policy of Störfreimachung In order to look at the policy of Störfreimachung in depth, there is no better case study to use within diabetes management than that of imported insulin. To be specific, the insulin in question here is ‘depot insulin’, which is a long-lasting insulin to ensure fewer injections for diabetics and therefore a more convenient, working life.336 As the previous chapter had illustrated, the GDR was able to produce Altinsulin, a short-lasting insulin quite easily and had attempted to treat the majority of patients with that particular variant. However, the significant developments of depot insulin in the late 1950s and into the early 1960s, as well as the distinct advantages it brought to productivity in the meantime, encouraged the growth in the number of insulin-dependent diabetics who were put, successfully, onto a treatment regime using depot insulin.337 By the time the policy of Störfreimachung had been announced and the Berlin Wall had been built, an opportunity presented itself to focus more carefully not simply on the use of depot insulin, but also on the origins of that insulin. East German pharmaceutical companies, most notably VEB Berlin-Chemie, were not yet producing good enough alternatives to many types of medication, including depot insulin.338 This meant that a significant number of insulin- dependent diabetics were reliant on medication from those countries which were exporting it to the GDR. Several references by diabetologists, particularly Schliack, now advisor to the Ministry of Health on diabetes matters, explained in detail where the insulin was coming from: the United Kingdom (Wellcome); the USA (E. Lilly); Denmark (Novo), and West Germany (Hoechst).339 In 1961, there were estimates by Schliack that 165,000 doses of Hoechst insulin alone were imported, up drastically from the year before (125,000).340 This clearly exposed a distinct reliance on the West, and the policy of Störfreimachung came at just the right time to provide the solution to this ‘problem’.

336 SAPMO-BArch DQ1/4344 – ‘Betrifft: Depot-Insulin Hoechst klar’, 18.1.1965. 337 Ibid. 338 SAPMO-BArch DQ1/6702 – ‘Information über die Insulinversorgung der Zuckerkranken’, 20/12/1960. 339 SAPMO-BArch DQ1/6702 – Letter from Prof. Mohnike to Prof. Dr. Röhrer of the Forschungsinstitut in Greifswald, 10.Sept. 1963. 340 SAPMO-BArch DQ1/6702 – ‘Information über die Insulinversorgung der Zuckerkranken’, 20/12/1960.

Figure 5: Repairing a filling machine at the insulin department of VEB Berlin-Chemie, April 1971341

To add insult to injury, diabetologists were very keen on the insulin that they considered to be the best on the market and catered to German eating habits, that of the GDR’s neighbour and greatest rival.342 Their preferences were entirely natural considering that Katsch, as a member of the pre-war German insulin committee, had been involved in the inception of Hoechst depot insulin in the late nineteen thirties. The ‘all-German’, pre-war background and the fact that this particular pharmaceutical company, Hoechst, was already established in the minds of all diabetologists in East and West Germany as a scientifically trusted firm ensured that its depot insulin reigned supreme. Patients being put onto Hoechst insulin is mentioned frequently in countless documents, from diabetes advice centre reports, in Schliack’s overall reflection of the situation to the Ministry of Health, right through to the Eingaben (petitions to the high political authorities) sent by patients and their relatives. Hoechst insulin was thus the focus of attention when it came to tackling the issue of imports, and was also the particular product on which VEB Berlin-Chemie, and the diabetologists working with them, sought to base the future East German equivalent, to be known as B-Insulin.343

341 Bundesarchiv Bild 183-K0406-0009-001. 342 SAPMO-BArch DQ1/6702 – Letter from Prof. Mohnike to Prof. Dr. Röhrer of the Forschungsinstitut in Greifswald, 10. Sept. 1963; SAPMO-BArch DQ1/6702 – Letter from Dr. Schliack to Dr. Gehring on the situation regarding Störfreimachung in diabetes care, 20.12.62. 343 SAPMO-BArch DQ1/4344 – ‘Verbrauch von Depot-Insulin Hoechst’, 21.1.1966 by Dr. Probst.

Out of desperation, there were additional attempts documented by Schliack to import a new Czech depot insulin following that country’s collaboration with the Danish pharmaceutical company, Novo, but they refused to export it.344 This reveals the severe pressure that Störfreimachung put on diabetologists, firstly to get their patients off Hoechst insulin, and secondly, to put them onto domestic alternatives as quickly as possible.345 The two primitive East German depot insulins which had existed before 1961, PZ Insulin and Globin-Zink Insulin, were used by some diabetologists for patients who did not have adverse reactions to them (according to Schliack, that was approximately thirty percent of cases). However, diabetologists acknowledged that these were not working as well as the foreign insulins that other patients were using, especially Hoechst. The term used by diabetologists when changing diabetics from one insulin to another was Umstellung and, as of 1962, there were substantial Umstellungen from Hoechst insulin to a variety of domestic insulins.346 As a stop-gap, diabetologists worked with VEB Berlin-Chemie to create an insulin that supposedly worked like the American and British depot insulins that had been imported, leading to the production of NPH Insulin, a longer-lasting insulin than both PZ and Globin-Zink insulins.347 The results of the changeover were far from desirable, and both diabetologists and those receiving different insulin therapies or their relatives were extremely concerned.348

Following the building of the Wall, the reports by diabetologists and the Eingaben (petitions) from patients reveal that East Germans believed that there should be more debate about the direction of travel in which the state was heading. This is especially true of the Eingaben, where patients and their relatives claiming to be committed to the socialist state actually wanted to argue against the restriction of imports from an ideologically loyal position, as noticed also by Florian Bruns, author of a study on medical Eingaben in the 1980s.349 What the Eingaben reveal is that the authors (the patients and/or their relatives) act as politically regulated, ‘medical consumers’ here, demonstrating ‘personal responsibility, proactive and

344 SAPMO-BArch DQ1/6702 – Letter from Dr. Schliack to Dr. Gehring on the situation regarding Störfreimachung in diabetes care, 20.12.62, p.5. 345 SAPMO-BArch DQ1/21162 – ‘Vermerk: Eingaben über die Insulinsituation’, 9.7.1962 by Dr. Schliack; SAPMO-BArch DQ1/4344 – ‘Verbrauch von Depot-Insulin Hoechst’, 21.1.1966 by Dr. Probst. 346 SAPMO-BArch DQ1/21162 – ‘Vermerk: Eingaben über die Insulinsituation’, 9.7.1962 by Dr. Schliack [especially pp. 2-3]. 347 Ibid., pp. 2-3. 348 SAPMO-BArch DQ1/4344 – ‘Betrifft: Depot-Insulin Hoechst klar’, 18. 1. 1965. 349 Florian Bruns, ‘Krankheit, Konflikte and Versorgungsmängel: Patienten und ihre Eingaben im letzten Jahrzehnt der DDR’, Medizinhistorisches Journal, 47:4 (2012) 335-367 (p.344).

89 prevention-conscious behaviour, rationality and [a knowledge of] choice’.350 Based on the interpretation of Viola Balz in her work on health consumption in the GDR, patients knew what medication was on offer (there was a choice despite nationalised healthcare and pharmaceutical companies), and they demanded to have a certain type of medication regardless of the doctor’s advice.351 Such knowledge certainly existed for insulins, and this was the stimulus for patients and relatives to use politically weighted arguments as a possible bargaining tool to receive imported Hoechst insulin, the medication patients decided was best for them (this is corroborated by the fact that some patients simply refused to be changed onto domestic alternatives).352

Interest in a specific type of insulin, and the determination displayed to get it, demonstrate that the authors of Eingaben wanted a stake in their own care or that of their relatives.353 A concern, certainly from the SED leadership’s perspective, was that by patients positioning themselves from within the system, the legitimacy of the arguments they put forward with regard to imported insulin could not be denied. Patients were not able to act as ‘market-consumers’ through purchasing power owing to the fact that insulin is a prescribed drug, prescriptions in the GDR were free and rules were very strict when giving insulin to patients; they could only receive it by the diabetologist at the advice centre. In a state ruled by one party, sending an Eingabe was therefore the only real way of getting anywhere on such matters of pressing concern, and, bearing in mind how importantly they were viewed by those at the top of the political hierarchy, such as Ulbricht (who said that they helped assess the general mood of the population) patient complaints were at least listened to in the process.354

The sacrifices required on account of the reduction of imported insulin call into question whether Störfreimachung, in its aim to further one ideological aspect (lessened reliance on the West and an increased concentration on the East) led to the neglect of other ideological aims

350 Gayle A. Sulik and Astrid Eich-Krohm, ‘No Longer A Patient: The Social Construction of the Medical Consumer’, in Patients, Consumers and Civil Society: Advances in Medical Studies Sociology, Vol. 10 (Bingley: Emerald Publishing, 2008), pp. 3-28 (p.22). 351 Viola Balz, ‘“Für einen Aktivisten wie mich muß es in einem sozialistischen Staat doch effektive Medikamente geben”: Psychopharmaka und Konsumenteninteresse in der DDR’, NTM Zeitschrift für Geschichte der Wissenschaften, Technik und Medizin, 21.3 (2013), 245-271 (p.249). 352 SAPMO-BArch DQ1/21525 – Protokoll über die Tagung der Bezirksdiabetesärzte am Freitag, dem 9. November 1962 in der Zentralstelle für Diabetes und Stoffwechselkrankheiten, Berlin C 2, Klosterstr. 71/72. 353 On the notion of patients’ autonomy and self-worth, see: Roy Porter, ‘The Patient’s View: Doing history from below’, Theory and Society, 14:2 (1985), 175-198 (pp.189-90). 354 Ulrike Klöppel and Matthias Hoheisel, ‘“Wunschverordnung” oder objektiver “Bevölkerungsbedarf”?: Zur Wahrnehmung des Tranquilizer-Konsumenten in der DDR (1960-1970)’, NTM Zeitschrift für Geschichte der Wissenschaften, Technik und Medizin, 21:3, 213-244 (p.228).

90 promulgated in particular by social hygiene.355 There are several Eingaben from 1962 that sharply illustrate these inherently political contradictions in the early 1960s. This was the year in which Störfreimachung was at its height and before the GDR’s answer to Hoechst insulin, B-Insulin, was perfected. Patients use very powerful, ideologically-charged arguments in a bid for the highest political authorities to relinquish some control over Störfreimachung demands.

The author of one Eingabe, who had been diagnosed as a diabetic in 1951 following his return from the Soviet Union where he had been held as a prisoner-of-war, states that he had had a severe coma in 1961 when being treated with East German insulin. He had then be changed to Hoechst insulin, which, whilst not guaranteeing a perfect metabolism, had at least ensured his ability to work, a nod to the social hygienic rhetoric encountered in Chapter 1.356 He has now been told that Hoechst insulin cannot be made available to him anymore, and attempts have been made to change him onto the GDR trial version of NPH insulin, but these were unsatisfactory and had to be abandoned. He suggests that this will have the effect of making him unable to carry out his current job.357 Referring as he does to his working lifestyle, and his current problems to achieve it, Hoechst depot insulin has become more than just medication; its position is now that of a ‘consumer good’ in the association the author makes with lifestyle choice. The author remains calm and measured throughout the Eingabe, managing to give the impression that he is a hard-working, socialist citizen. As the GDR advocated ‘rational consumption’, the case made about requiring this insulin to restore productive capacities is an entirely ‘rational’ argument. Under the new terms of Störfreimachung, however, diabetics’ use of imported Hoechst insulin had suddenly become ‘irrational’. Another patient Eingabe takes a similar approach, detailing a recent history of insulin therapy as a way of highlighting the shortcomings of East German insulins and the noticeably better-quality Hoechst insulin. He remarks that he has rejected any further attempts at changing him onto East German insulin variants, having experienced their unwelcome side effects, and requests that he should be put back on Hoechst insulin. He mentions that, although he is a pensioner, he is still working and does not want to run the risk of his health worsening, implying that without western insulin he might become unable to work. 358

355 SAPMO-BArch DQ1/21162 – ‘Vermerk: Eingaben über die Insulinsituation’, 9.7.1962 by Dr. Schliack, p.2. 356 SAPMO-BArch DQ1/6702 – ‘Eingabe an den Staatsrat der DDR zur Frage der weiteren Versorgung mit Hoechst-Insulin’ by P.R, 25.10.1962, p.1. The author writes ‘es gelang jedoch mit Hoechst-Depotinsulin eine zwar nicht ideale Stoffwechselführung zu erreichen, die jedoch die Arbeitsfähigkeit…gewährleistete’. 357 Ibid., p.2. 358 SAPMO-BArch DQ1/6702 – Eingabe by A.T, Betr.: Zuweisung von Insulin Höchst klar Depot für Diabetiker. Arguing against being put onto East German insulin, he writes: ‘Nochmals Versuche mit mir

Eingaben by relatives of diabetics writing on their behalf were also motivated by their role as, essentially, indirect consumers to challenge the policy. Less forgiving than those written by patients, and more willing to challenge the system rather than just the policy and its impact on work and lifestyle, they outline their perspective as witnesses to the destructive nature of Störfreimachung. Dispensing with the sugar coating of a reasonable tone, but still maintaining a loyal and ‘true’ socialist perspective, a daughter of a diabetic taken off a regime using a combination of Danish Novo and Hoechst insulins starts by making it known that she was ‘a party secretary of a nationalised iron and steel works’.359 She then proceeds to denounce the reduction of imports and the response of the regional diabetes head doctor to the case of her mother, claiming that he had said that the state of one person’s health was not as important as the overall policy of the government. She believed that giving a ‘hit to Adenauer, Brandt etc’ was more important to him than fulfilling what ‘a committed member of our [the] Party’ like herself believed was the ultimate goal of socialism, the protection of everyone’s health.360

A final Eingabe, again by a relative, is slightly less strident but one that still appeals to the emotions of the person tasked with reading it. The same lecturing on what the citizen understood to be the true socialist society was made doubly clear by the husband of a ‘seriously ill wife’.361 She had stayed for a prolonged period at the Institute for Diabetes in Karlsburg, following an Umstellung from Hoechst, which had to be reversed at Karlsburg as her condition had become extremely precarious.362 Once again arguing from within the system, the husband accepts the current economic and political situation, but what he cannot understand is why the ‘Workers’ and Peasants’ State’ could endanger people’s lives by not sourcing the optimal insulin for its people. 363 The GDR’s ‘everyday pragmatism’ and focus on what was

vorzunehmen lehnte ich ab, da ich die Folgen genau kenne und meine an sich schon gesundheitliche Lage nicht verschlechtern will, bitte ich Sie daher, mir in meiner Lage zu helfen’. 359 ‘…als Sektretärin in der Parteileitung der VEB Eisen- und Hüttenwerke Thale’, in: SAPMO-BArch DQ1/6702 – Eingabe by M.E from Thale, Harz, 6.11.1962, p.1. 360 Ibid., p.1. She quotes the doctor as saying ‘es kommt nicht darauf an, ob sich der Gesundheitszustand eines Patienten verbessert oder verschlechtert, es geht nicht um ein Menschenleben; die Hauptsache ist, dass wir Adenauer, Brandt usw. einen Schlag versetzen’. She emphatically rejects this view, stating: ‘Diesen Ausspruch…fasse ich als eine direkte Provokation auf, der auch nicht im Sinne unserer Politik sein kann, denn schließlich steht doch bei uns im Arbeiter- und Bauern-Staat die Sorge um den Menschen und seine Gesunderhaltung im Vordergrund’. 361 SAPMO-BArch DQ1/21525, Eingabe from E.S, Reinholdshain, 29.3.1962. 362 Ibid. In the original Eingabe, the author describes the situation in the following terms: ‘Eine Umstellung wurde…versucht und mußte vom behandelnden Arzt rückgängig gemacht werden, da sich ihr Gesundheitszustand rapid verschlechterte und den langsamen, aber sicheren Tod bedeutet hätte’. 363 Ibid. The author is understanding of the economic and political situation but cannot accept why the government is willing to overlook the negative consequences: ‘Bei vollem Verständnis für unsere politische und wirtschaftliche Lage kann ich jedoch nicht annehmen, dass die Regierung unseres Arbeiter- und Bauernstaates über solche Tatsachen einfach hinweggeht’.

‘functional’ is not at the forefront of the mind of this concerned husband; quality is of paramount concern. In keeping with the previous Eingabe, he represents the views of what many thought the socialist state should do to protect the health of its citizens, and argues that healthcare in a socialist society is a basic ‘right’, as stipulated in Article 16 of the GDR’s constitution relating to the ‘preservation of health and ability to work’.364 To some extent, he is reflecting the idea that East Germans, given that their freedom of movement had been curtailed, were now really starting to take advantage of the gesellschaftliche Konsumtionsformen that were offered in the GDR. Since the GDR was one of the few Eastern- Bloc states to be a society of mass consumption at this stage, it delivered similarly motivated healthcare aims to its eastern neighbours, but to a population that demanded it with even greater vigour and could look to a prosperous western neighbour for inspiration on quality and efficacy.

It is difficult to ascertain in the Ministry of Health files how successful patients and relatives were in receiving imports after writing an Eingabe. As the policy of Störfreimachung generally speaking was less stringent after 1964, there is some evidence of patients’ Eingaben being more successful, that is, due to receiving imported Hoechst insulin as a result. This can be seen in the report of a regional diabetes head doctor, who compiled a list of all the diabetics in the region receiving Hoechst insulin (as requested by the Ministry of Health).365 On several occasions, he notes that this was following an Eingabe that a patient had sent.366 However, it is surprising that the number of patients treated with Hoechst insulin increased again in spite of Berlin-Chemie having developed their signature B-Insulin in 1963, which was supposed to be the GDR’s answer to Hoechst. It is necessary to point out that, although at the start of Störfreimachung, there was more pressure applied to diabetologists to take patients off Hoechst insulin, its use was still frowned upon, even when the regime decided the policy should be toned down.367 This was in light of the fact that the production of B-Insulin was supposed to be seen as a positive result of the Störfreimachung policy and should be privileged over imported insulins at all costs. Diabetologists were anxious about where patients were getting their Hoechst insulin, and why in so many Bezirke (regions) patients were using it.368 There were suggestions that patients obtained Hoechst insulin from relatives in the West and that

364 Sabine Schleiermacher, ‘Contested Spaces: Models of Public Health in Occupied Germany’, in Shifting Boundaries of Public Health: Europe in the Twentieth Century, ed. by Susan Gross Solomon, Lion Murard and Patrick Zylberman (Rochester: University of Rochester Press, 2008), pp. 175-204 (p.194). 365 SAPMO-BArch DQ1/4344 – ‘Betrifft: Depot-Insulin Hoechst klar’, 18. 1. 1965, p. 2. 366 Ibid (example on p. 2). 367 SAPMO-BArch DQ1/4344 – ‘Verbrauch von Depot-Insulin Hoechst’, 21.1.1966 by Dr. Probst. 368 Ibid.

93 many injected it from their own secret stash!369 The variability between regions, with some doctors reporting high levels of imported insulin and others low, also reveals a measure of inconsistency with regard to the regional response to Störfreimachung (and possibly the response by different groups/individuals within diabetology).370

Prior to the vigorous application of Störfreimachung after 1961, Schliack writes in July 1960 that there was an acceptance by doctors that people needed to be on imported insulin. Doctors’ opinions on Hoechst insulin were deeply entrenched in the minds of those who were older or students of Katsch, and, although they had more power than patients in dictating insulin therapies, they were also as much, if not more, open to influence due to their position as prescribers. As Jeremy Greene has stated, the ‘peculiar nature of pharmaceutical consumption’ is that it is so multi-layered.371 It is not only patients consuming Hoechst insulin, but also the doctors treating them, acting as consumers on behalf of patients or shaping the consumption of patients. Advertising about prescribed pharmaceuticals, as Julie Donohue explains, was obviously targeting doctors.372 In the case of Hoechst insulin, though, it effectively advertised itself through its historical resonance and the longstanding experience of its use. When diabetologists wrote about East German B-Insulin, they could not help but compare it to the insulin it sought to replace, and it could only be deemed successful if it roughly mimicked its effects. Those allowed to travel to conferences in the capitalist world or who had the opportunity to visit the famous Leipzig Trade Fair saw choice on the international market. Deciding that Hoechst was amongst the best based on this level of exposure would make it very difficult for the Ministry of Health to persuade steadfast diabetologists to change prescription habits.

It is easy to demonstrate that the actions and opinions of certain individuals either reported by or corresponding with the Ministry were in opposition to the policy of Störfreimachung. Crucially, too, they also reveal how they were dealt with by the Ministry, reinforcing the notion that diabetologists were also ‘politically regulated consumers’. Whilst patients sent Eingaben to represent their interests, diabetologists could write reports of their diabetes advice centres in which they detailed the problems caused by limiting the imports of

369 SAPMO-BArch DQ1/6702 – ‘Betrifft: B-Insulin’, 4. 5. 1964 by Dr. Oerter; also in SAPMO-BArch DQ1/4428 – Analyse-Diabetikerberatungsstelle Pasewalk. 370 SAPMO-BArch DQ1/4344 – ‘Verbrauch von Depot-Insulin Hoechst’, 21.1.1966 by Dr. Probst. 371 Jeremy A. Greene, Prescribing by Numbers: drugs and the definition of disease (Baltimore: Johns Hopkins University Press, 2008), p. 139. 372 Julie Donohue, ‘A History of Drug Advertising: The Evolving Roles of Consumers and Consumer Protection’, Milbank Quarterly, 84:4, 659-699 (p.668).

Hoechst insulin. Apart from situations where diabetologists appeared to be on the side of the government, and explicitly advocated the policy of Störfreimachung, like the diabetologist wanting to ‘hit Adenauer, Brandt etc’ in the third Eingabe from 1962, it appears that patients and some diabetologists actually shared similar concerns.373 There is evidence to suggest that diabetologists merely formed their views and acted in response to their patients’ experiences and what they saw in the advice centres. The impact of reduced imports of Hoechst insulin was of such concern to diabetologists across the GDR that in each abstract of the annual analysis of the diabetes advice centres, there is an individual section entitled Import-Insulin.374 The content of those reports dated 1961 and 1962 indicate that it almost completely governed their thinking and manipulated what they could achieve in terms of treatment. Serious misgivings over the efficacy of domestically produced insulins were reported in, for example, Erfurt, Gera and Karl-Marx-Stadt, where only around a third of cases could allegedly use the domestic insulins.375 In the industrial city of Leipzig in 1961, the diabetologist believed that inpatient care displayed the quality of imported insulin, and, if nothing was done to increase imports, the number of diabetes complications in Leipzig would continue to be twice as a high as it was in 1956. 376 The choice of language used by diabetologists is also telling. The repeated appearance of the word Stoffwechselentgleisung which literally translates as a ‘metabolic derailment’ following Umstellungen onto domestic insulins implies that diabetologists tried to stir the Ministry of Health into action.377

One particularly interesting response to the problems caused by reduced imported insulin was from Dr. Hempel of Halle. Echoing the argument made by patients, he states in the annual analysis for 1961 that the desire to reduce reliance on imported insulin stood against the desire to keep people in work. In attempts to privilege the latter, Hempel revealed that this could be achieved but at a price. In the statistics that he had cited on who received imported insulin, 18.6 percent of men (26 percent in the city of Halle itself) and only 9.1 percent of women received imported insulin. In the early 1960s, the workforce was still largely male- dominated even if far more women were entering into employment, meaning that men were to

373 For example, SAPMO-BArch DQ1/4429 – ‘Bericht der Diabetiker-Beratungsstelle für das Jahr 1962, Halle (Nebra)’. 374 SAPMO-BArch DQ1/4345 – Auszug aus den Jahresanalysen der Bezirke 1962. 375 SAPMO-BArch DQ1/4429 – Berichtsjahr 1962-Bd. 1, Enthält: Berlin and Bezirke Dresden, Erfurt, Gera, Halle, Karl-Marx-Stadt, Leipzig, Suhl. 376 SAPMO-BArch DQ1/2908 – Analyse der Bezirkszusammenstellung der Berichte der Diabetikerberatungsstellen: Bezirk Leipzig im Jahre 1961. 377 Ibid.

95 receive preferential treatment.378 Eli Rubin has pointed out that the GDR’s efforts in the early years to build up heavy industry meant ‘controlling the population ideologically by privileging certain groups…while punishing others’, namely those not as involved in heavy labour like women.379 Hempel may well have been instructed by the local SED branch to carry out such measures. Alternatively, he could have made this decision independently to prioritise what he felt was ideologically more important or simply to make a point. A year later, he ironically compliments the government on importing some quantities of insulin due to the faith it showed in specialists, perhaps to provoke the regime further into a change of course.380

Even more importantly, those at the top of East German diabetology did not hold back. The oppositional strategies can be divided into two broad strands: encouraging a change of heart over the new rules on limited imports (as most of the diabetes advice centre reports sought to achieve) and taking matters into one’s own hands (as Hempel did). In terms of the former, Schliack certainly used his influential role within the Ministry to raise awareness of the shortcomings of the Störfreimachung policy both practically and politically. He adopted an approach of brutal honesty when discussing the quality of the insulins produced by Berlin- Chemie, and also explains why Störfreimachung contributed to gross inadequacies in production. In a meeting at Karlsburg with the above mentioned Dr. Hempel, and Secretary Köppen of the Staatsrat (recipient of the Eingaben), Schliack reports that the insulin which had been tested in 1962 was so poor that if used continually, it would cause serious harm to patients.381 He also tapped into the GDR’s insecurities vis-à-vis West Germany by stating that he was forced into using Altinsulin on some patients, a fact which then appeared in the Western press.382

Personal conversations that he had with chemists at Berlin-Chemie revealed that Störfreimachung put pressure on them to produce insulin without the necessary production equipment. Imports of raw materials needed for production were reduced alongside other chemicals. As a consequence, there was not enough home-produced insulin available to give to patients in the first place, and this led to a situation where hundreds of patients were sent to inpatient facilities for Umstellungen, only to find that the insulin supposed to be replacing

378 SAPMO-BArch DQ1/2908 – Analyse zur Bezirkszusammenstellung der Berichte der 22 Diabetikerberatungsstellen der Kreise des Bezirkes Halle/Saale für das Jahr 1961. 379 Rubin, ‘The Trabant’, p. 32. 380 SAPMO-BArch DQ1/4345 – Auszug aus den Jahresanalysen der Bezirke 1962-Halle, p.3. 381 SAPMO-BArch DQ1/21162 - ‘Vermerk: Eingaben über die Insulinsituation’, 9.7.1962 by Dr. Schliack, p.1. 382 SAPMO-BArch DQ1/6702 – Letter from Dr. Schliack to Dr. Gehring on the situation regarding Störfreimachung in diabetes care, 20.12.62, p.6.

Hoechst did not exist in large enough quantities, so they were forced to return for another Umstellung.383 Schliack stated that the financial burden was immense, with people taking time off work and taking up beds in Karlsburg or the Sanatorium Rheinsberg twice over.384 In order to avoid invalidity (social hygienic rhetoric), those who were unsuccessfully put onto NPH Insulin endured what Schliack describes as ‘mental insecurity’ which was bad for the metabolism, and had to be put back onto Hoechst insulin (echoing what the patients and relatives recalled in their Eingaben).385 As the meeting at Karlsburg continued, he responded to ‘the ideological question’ about the lack of a positive attitude by doctors to Störfreimachung by stating that they would be more positive as soon as they were provided with an effective depot insulin to replace Hoechst (making a similar point to the second patient Eingabe).386

When looking at the example of Gerhard Mohnike, leader of Karlsburg, who has been somewhat overshadowed by Schliack’s domineering presence in the Ministry of Health documents, he seemed to belong to the category of those who were taking matters into their own hands. A discussion took place in December 1961 about the provision of insulin for 1962 between Mohnike and another deputy minister for health, Professor Friedeberger.387 Mohnike, less inclined it seems than Schliack to position his arguments from within the system (partly due to his own personal political convictions and reputation as something of a political maverick), expressed his concerns about the Umstellungen.388 He argued that the doctors would not know how to use the new insulins having grown accustomed to imported insulins, and that this would cause debilitating complications in patients unless Hoechst insulin was allowed. Professor Friedeberger replied that Mohnike was taking a ‘dangerous standpoint’, and the dependence of East German diabetics on imported insulin must be stopped, including no new cases using Hoechst insulin.389 The Ministry had already logged that there was a suspiciously high number of patients in comparison to the national average who were put onto Hoechst insulin at Karlsburg. As so many patients had been sent to the Institute following ‘metabolic derailments’ and had returned in a much more stable condition, it appears that there were supplies of Hoechst insulin of which the Ministry were not entirely aware. The actions of the main facility for diabetes and its leader provide a poignant reminder of the willingness to go

383 Ibid., pp. 1-2. 384 Ibid., p. 2. 385 Ibid., p. 2. 386 Ibid., p. 3. 387 SAPMO-BArch DQ1/21162 – ‘Betr. Insulin, 22.12.1961’, p.1. 388 Evidence of being against the state can be found in: SAPMO-BArch DQ1/23140 – Entwurf eines Statuts für das Diabetes-Leitinstitut, (‘Aufgaben’), p. 2. 389 SAPMO-BArch DQ1/21162 – ‘Betr. Insulin, 22.12.1961’, pp.1-2.

97 against Störfreimachung, as consumers and for consumers, regardless of the potential consequences faced.

The site of consumption: diabetes advice centres during the ‘Störfreimachung period’

The policy of Störfreimachung made it abundantly clear to the SED, the Ministry of Health, diabetologists and even patients and their relatives that the GDR was reliant on insulin from the West because it encountered problems producing its own. Störfreimachung belonged to a particular sort of climate that had been developing a few years prior to its official inception. The ill-fated and overly ambitious Seven Year Plan introduced as a tool to overtake West Germany in per capita consumption of consumer goods encapsulated what was known as the ‘Sputnik Myth’. The orbit of the first artificial satellite in space, followed by the successful launch of the first manned spacecraft had created a new sense of optimism across the Eastern Bloc. For the first time, communism exuded a feeling of superiority. Ulbricht believed that this newfound superiority could lead to further scientific progress, economic success, and increased consumption.390 He endeavoured to paint a positive picture to the many East Germans who were undecided as to whether they wanted to remain in the GDR or not.

However, this did not succeed in reducing the number of Republikflüchtige (people who left the GDR) in the area of health and diabetology. 391 The building of the Berlin Wall was to a large degree a response to the GDR’s ‘brain drain’ and the changes in demographics which would come to affect supply within the economy. As the GDR wanted to define itself as a socialist state that also aspired to be a consumer society, the investment in the 1950s in heavy industry was starting to prove costly.392 To ensure that there was a structural shift within the economy, investment needed to focus on what Paul Szobi refers to as ‘consumer-focused operations’.393 Patients and doctors had already demonstrated their ability to act as consumers, thus placing healthcare firmly in Szobi’s category, where significant investment was required to meet consumer demand. Healthcare belonged to the area of ‘social consumption’ and fitted the narrative of creating an alternative, socialist consumer culture.394 Such was the rise in

390 Steiner, The Plans, pp. 90-1; Brian Plane, ‘The “Sputnik Myth” and Dissent Over Scientific Policies Under the New Economic System in East Berlin, 1961-1964’, Minerva, 37.1 (1999), 45-62 (p.45). 391 Patrick Major, Behind the Berlin Wall: East Germany and the Frontiers of Power (Oxford: Oxford University Press, 2010), p. 57. 392 Steiner, The Plans, p. 61. 393 Pavel Szobi, ‘Between ideology and pragmatism: the ČSSR, the GDR and West European companies in the 1970s and 1980s’, European Review of History: Revue européenne d'histoire, 21.2 (2014), 255-269 (p.255). 394 Judd Stitziel, ‘On the Seam between Socialism and Capitalism: East German Fashion Shows’, in Consuming Germany in the Cold War, ed. by David F. Crew (Oxford and New York: Berg Publishers), pp. 51-86 (p.76).

98 demand for healthcare that in one diabetes advice centre in a polyclinic in Leipzig, the ceiling in the room below was reported to be cracking because there were so many patients attending on a daily basis.395

In order to explore what obstacles existed within the realm of everyday outpatient care for diabetics in the quest to become a consumer society, the issue of labour, the supply of foodstuffs, and the supply of various other ‘consumer goods’ for diabetics (such as test strips and syringes) will need to be discussed. To ensure that diabetes advice centres delivered for the growing number of patients coming through their doors, one of the glaring issues emerging from diabetes advice centre reports related to personnel. It is commonly assumed that the building of the Berlin Wall effectively solved the problem of labour shortages, but in the short- term at least, diabetes care was still suffering from the effects of mass emigration. 396 Shortages of personnel, it seems, continued with full force, according to reports from 1961, 1962 and even 1963, and these seriously limited the scope of the work which could be done to treat diabetics. Frequently there was a lack of personnel who were, on the one hand, specialist enough to cope with the rigours of insulin therapies and diabetic complications, and on the other, able to complete more mundane tasks when called upon. This rising crop of established mittlere medizinische Personal (middle-ranking personnel) had the potential to help the diabetes advice centres immensely in a period of rapid growth and consisted of three broad roles: the Diabetikerfürsorgerin (diabetes nurse), the Diätassistentin (diet assistant) and the Laborantin (laboratory assistant).397

The reduced imports of Hoechst insulin and Umstellungen onto GDR alternatives led to complications in diabetics, and therefore increased the demand for hands-on and interdisciplinary care. In the 1950s, a diabetes advice centre was typically manned by a diabetologist, a diabetes nurse, and, if lucky, at least one diet and laboratory assistant. Based on various regional reports from the peak Störfreimachung years, 1961 and 1962, the incidence of diabetic complications was highly problematic. In Leipzig, it was reported to be twice as

395 SAPMO-BArch DQ1/4429 – Analyse Kreiszusammenstellung der Diabetikerberatungsstellen des Stadtkreises Leipzig für 1962. 396 Manfred Wilke, The Path to the Berlin Wall: Critical Stages in the History of Divided Germany, trans. by Sophie Perl (Oxford and New York: Berghahn, 2014), p. 50. 397 All of these terms are mentioned in diabetes reports from the following batches of files: SAPMO-BArch DQ1/2907 – Bd. 1: Enthält Bezirke Cottbus, Frankfurt (Oder), Magdeburg, Neubrandenburg, Potsdam, Rostock, Schwerin, 1961-2; SAPMO-BArch DQ1/2908 – Bd. 2: Enthält Berlin und Bezirke Dresden, Erfurt, Gera, Halle, Karl-Marx-Stadt, Leipzig, Suhl, 1961-2; SAPMO-BArch DQ1/4429 – Bd. 1: Enthält Berlin und Bezirke Dresden, Erfurt, Gera, Halle, Karl-Marx-Stadt, Leipzig, Suhl, 1962-3; SAPMO-BArch DQ1/4428 – Bd. 2: Enthält Bezirke Cottbus, Frankfurt (Oder), Magdeburg, Neubrandenburg, Potsdam, Rostock, Schwerin. 397 SAPMO-BArch DQ1/2908 – Analyse Berlin im Jahre 1961, p.1.

99 high as it was before the policy of Störfreimachung was put into practice, and in Brandenburg, the diabetologist was forced to report an ‘unsatisfactory’ and ‘variable’ situation for the majority of diabetics due to the advice centres in the region not being able to cope with the number of cases and their complications.398 There was little preparation for the mounting eye complications seen in diabetics, and advice centres did not always have easy access to an ophthalmologist for routine eye checks (featured in ten reports to the Ministry of Health).399 Considering the likelihood of advice centres being overrun by the volume of problem cases, intervention and help by the diabetes nurses and diet assistants, and efforts of laboratory assistants behind the scenes testing samples were badly needed.

In spite of the increasing awareness of the importance of the ‘middle-ranking personnel’, their numbers still fell well short of what was required. A diabetologist in Dresden complained that the number of diabetics in the advice centres kept rising but that personnel numbers remained unchanged.400 The situation in other advice centres was even worse, such as in Sömmerda, where they could not even find a permanent diabetologist to man the centre throughout the whole of 1961, let alone recruit diabetes nurses and others.401 Without sufficient numbers of laboratory staff, the analysis of diabetics’ urine in Karl-Marx-Stadt was not regularly possible, making it much harder for diabetologists to prescribe the right doses of medication to maintain a stable metabolism and to diagnose following Reihenuntersuchungen.402 Reports from Potsdam describe the staff as completely overworked and liable to making mistakes.403 In Garz, there were complaints that the pressures applied by staff shortages meant that new recruits did not have enough knowledge about treatment (the GDR having taken pride in the 1950s in the provision of specialist treatment and training for

398 SAPMO-BArch DQ1/2908 – Analyse der Bezirkszusammenstellung der Berichte der Diabetikerberatungsstellen im Bezirk Leipzig im Jahre 1961, p.1; SAPMO-BArch DQ1/4428 – Diabetikerberatung Brandenburg; SAPMO-BArch DQ1/2907 – Analyse zum Bericht der Diabetikerberatungsstellen 1961. 399 Regions featured in SAPMO-BArch DQ1/2908 include: Weimar Analyse by Dr. Nitzsche, 24.2.1962, p.2; Bericht der Diabetiker-Beratungsstelle für das Jahr 1961, Diabetikerberatungsstelle Poliklinik Limbach- Oberfrohna, Karl-Marx-Stadt, p.3; Analyse zum Bericht der Diabetiker-Beratungsstelle des Kreises Rochlitz, 25.1.62. Those in SAPMO-BArch DQ1/4429 include: Bericht der Diabetiker-Beratungsstelle für das Jahr 1962– Öffentl. Poliklinik des Medizinischen Versorgungsbereichs Kreiskrankenhaus Riesa-Analyse p.3; Analyse zum Berichtjahr 1962-Aue, p.1. In SAPMO-BArch DQ1/4428 they include: Analyse–Bad Dobrau 1962, p.1; Analyse-Stralsund 1962, p, 1; Oranienburg-Betr. Analyse 1962, 26.1.63, p.2. Finally, in SAPMO-BArch DQ1/2907: Betr. Analyse zum Bericht der Diabetiker-Beratungsstellen 1961; Analyse-Cottbus (1961). 400 SAPMO-BArch DQ1/4345 – Auszug aus den Jahresanalysen der Bezirke 1962-Dresden. 401 SAPMO-BArch DQ1/2908 – Anhang zum Bericht der Diabetiker-Beratungsstelle-Sömmerda. 402 SAPMO-BArch DQ1/2908 – Bericht der Diabetiker-Beratungsstelle für das Jahr 1961 Diabetikerberatungsstelle Poliklinik Limbach-Oberfrohna. 403 SAPMO-BArch DQ1/2907 – Betr.: Analyse zum Bericht der Diabetiker-Beratungsstellen für das Jahr 1961, 25.5.1962.

100 all).404 The diabetologist in Ludwigslust explained that since there was no nurse to help with medical examinations, the secretary had to assist; she was now ‘at her wits’ end’ as she had no time for her own work.405 In an advice centre in Weimar, staff shortages made it difficult to chase up patients who did not attend, a responsibility which could only realistically be taken up by a Diabetikerfürsorgerin.406 The need for home visits, especially to administer treatment for the elderly (if they took the domestic NPH Insulin, that meant two visits per day rather than one), and a visit to unresponsive, newly diagnosed patients (an issue noted in Gadebusch) also called for the services of more Diabetikerfürsorgerinnen.407

Of all the ‘middling’ roles, the importance of the diet assistant between 1961 and 1963 should not be underestimated. Diet is an incredibly important component to the treatment regime of any diabetic, and the poorer quality insulins some were forced to use only enhanced its importance. In his 1958 speech announcing his ‘main economic task’, Ulbricht made special mention of the need to produce an improved quantity and variety of foodstuffs.408 An almost total collectivisation of agriculture was attempted thereafter, which was disliked intensely by farmers, who gave their verdict by emigrating to the West. There was also a failed harvest in 1960/61, causing issues with the supply of certain foods which were essential to the diabetic population, namely fresh fruit and vegetables.409 Diabetologists across the country continued to contact their local councils for trade and supply (Handel und Versorgung). Rationing in the GDR ended in 1958, but it certainly did not feel like it. Problems of fruit and vegetable shortages, described earlier with reference to the 1950s, recurred and impacted diabetics in a similarly catastrophic way to the Umstellungen onto domestic insulins. Talk of ‘metabolic derailments’ also featured in reference to diabetics’ diet, and it did not matter whether an area was rural or urban. To reach the required calorific content, diabetics ended up eating too many carbohydrates, as reported in the region of Stralsund.410 A diabetologist in Ueckermunde warned that food supply problems gave diabetics an excuse to explain and justify their diet sins.411 Acute cases required inpatient stays, but when they returned from places like the

404 SAPMO-BArch DQ1/2907 – Bericht über die Diabetikerbetreuung im Jahre 1961-Garz (Rügen), 30.1.1962, p.1. 405 SAPMO-BArch DQ1/4428 – Betr. Diabetiker-Beratung für den Kreis Ludwigslust. 406 SAPMO-BArch DQ1/2908 – Analyse zum Bericht der Diabetiker-Beratungsstellen für das Jahr 1961- Dresden, 11.4.62, p. 3 (‘Verschiedenes’). 407 SAPMO-BArch DQ1/4428 – Analyse-Gadebusch. 408 Steiner, The Plans, p. 94. 409 George Last, After the ‘Socialist Spring’: Collectivisation and Economic Transformation in the GDR (Oxford and New York: Berghahn, 2009), p. 60; Steiner, The Plans, pp. 94-5. 410 SAPMO-BArch DQ1/4428 – Analyse-Stralsund, 1962. 411 SAPMO-BArch DQ1/2907 – Diabetikerberatungsstelle Brandenburg, 1961.

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Institute for Diabetes, where they had been placed on a good diet, the regional supply inadequacies worsened their condition again, a matter of concern to a diabetologist in Gera.412 Problems of food supply appeared to be surprisingly long-lasting and continued well into 1963, when it was, in fact, ‘worse than a year before’ in Spremberg.413

Domestically produced medical-technical equipment required either by diabetologists and the mittlere medizinische Personal treating and monitoring diabetics or by the diabetics themselves was also lacking in quantity and quality. Two glaring examples were the urine test strips used in Reihenuntersuchungen and in monitoring a diabetic’s sugar levels, and the syringes used to measure insulin. In order to reap the benefits of Reihenuntersuchungen, one of the key prevention-oriented developments in diabetes care in the 1950s, the medical equipment used to test people, had to be in sufficient supply and of decent reliability. The latter was particularly problematic for test strips. Unlike depot insulin, where the use of imported variants was accepted by doctors and eventually tolerated to some extent by the regime after the softening of the policy of Störfreimachung, the test strips used originated almost entirely from domestic production.414

The inventor of the ‘Biophan’ test strips, Karl-Heinz Kallies, from the company, Feinchemie KG, Sebnitz, was awarded the prize of Verdienter Erfinder (meritorious inventor) in 1961.415 Diabetologists made widespread use of his test strips in the advice centres and stopped importing strips from Britain and the United States.416 However, the test strips did not keep for very long, and there were complaints that they were delivered too early to the advice centre in Rochlitz.417 Others reported that the results of the urine tests were made completely void when the green dye on the strips ran, so that it became impossible to decide if the reading was positive or negative.418 In many instances, the test strips proved to be far too sensitive; for example, in Ludwigslust, they produced a ‘positive’ or ‘doubtful’ result in 1,364 patients, but of these cases, only 48 percent were actually diabetic.419 Complaints about the test strips’

412 SAPMO-BArch DQ1/4429 – Bericht der Diabetikerberatungsstelle für das Jahr 1963-Gera-Poliklinik Ronneburg. 413 SAPMO-BArch DQ1/4428 – Analyse-Spremberg by Dr. Barnasch. 414 SAPMO-BArch DQ1/4345 – Auszug aus den Jahresanalysen der Bezirke 1962 – Erfurt (‘Reihenuntersuchung’); SAPMO-BArch DQ1/6702 – Rat des Bezirkes Schwerin, Betr.: Bevölkerungstestung auf Diabetes mellitus, 13.3.62. 415 SAPMO-BArch DQ1/6702 – Rat des Bezirkes Dresden-Industrie-‘Erfindung des Herrn Karl-Heinz Kallies’. 416 SAPMO-BArch DQ1/6702 – Erfindung des Herrn Karl-Heinz Kallies, 8.3.1961 (written by Schliack to the Ministry of Health’s department of health protection). 417 SAPMO-BArch DQ1/2908 – Analyse zum Bericht der Diabetiker-Beratungsstelle des Kreises Rochlitz 25.1.62. 418 SAPMO-BArch DQ1/6702 – Schwerin-Die Qualität der Biophan-Testpapiere, 14.3.1962. 419 SAPMO-BArch DQ1/4428 – Betr.: Diabetiker- Beratung für den Kreis Ludwigslust-Analyse.

102 sensitivity to glucose were made in Erfurt on the grounds that although one third of those testing positive for diabetes ended up not having the disease, staff still had to carry out a Nachuntersuchung to check all of these cases, leading to mounting financial costs.420

Figure 6: Typical example of a test set containing urine test strips from Feinchemie KG, Sebnitz421

The insulin syringes, a device that one would regard as fairly simple to construct, were not without their rather basic but major faults. The measurement gauge on the syringes was often noted to be incorrect, and this had led to a rising number of hypoglycaemic shocks.422 This may have contributed to the level of difficulty experienced during the Umstellungen onto domestic insulins, what with the move away from an established, regimented treatment plan onto one that was made all the more difficult without the correct measurements. Syringes were

420 SAPMO-BArch DQ1/4345 – Auszug aus den Jahresanalysen der Bezirke 1962-Erfurt. 421 Deutsches Hygiene-Museum, ‘Zucker-Test’, 1998/2059 422 SAPMO-BArch DQ1/2908 – Analyse der Bezirkszusammenstellung der Berichte der Diabetikerberatungsstellen in Bezirk Leipzig im Jahre 1961.

103 the subject of debate during one of the regular meetings attended by all regional diabetes head doctors. This meeting took place in May 1966, almost five years after the building of the Berlin Wall. According to Dr. Thoms of Magdeburg, the measurement scale on the syringes faded, making it almost impossible for diabetics to see the numbers. Furthermore, Dr. Lotz pointed out that one of the biggest faults was the poor quality of the metal ring, which released black particles during use and caused moderate skin reactions in patients.423 The diabetologists witnessing these problems will have regarded them as largely avoidable had it not been for the failings of haphazard production generated in response to the regime’s desire to compete in per capita consumption. The syringes, and the basic problems with them, imply that the targets set by Ulbricht in 1958 appeared to be totally unrealistic and inevitably counterproductive for the GDR in their quest to become a competitive consumer society.

Solving what appear to be deeply systemic problems in production prompted a radical rethink of East German production and the economic goals more broadly. The basic premise of Ulbricht’s flagship policy of 1963, the NÖS was a dramatic change in success criteria. Gone were the planned estimates of quantity, which were to be replaced by a new emphasis on profit- making. The Seven Year Plan, which had preceded the NÖS, had clearly not addressed the desires and needs of consumers within diabetes care. For the first time in the GDR, market forces were introduced albeit into an economic system that was not strictly a market economy.424 This major change was supposed to be combined with decentralised decision- making, but economic specialists involved in devising the new system were not entirely sure how planning and marketization fitted together.425 As Mary Fulbrook points out, there was still an element of long-term planning and forecasting by the state implying that the conditions were far from those of a market economy,426 and Ulbricht did not suddenly become a ‘revisionist’ overnight. 427 He was well aware that East German citizens were not receiving even some of the most basic goods, and knew how conscious East Germans were of West German consumption. The NÖS was therefore supposed to respond to the market on multiple levels.

423 SAPMO-BArch DQ1/4345 – Protokoll-Zusammenfassung der Bezirksdiabetologen-Tagung am Montag, dem 2. Mai 1966 um 10 Uhr, p.2. 424 David F. Crew, ‘Consuming Germany in the Cold War: Consumption and National Identity in East and West Germany, 1949-1989, an Introduction’, in Consuming Germany in the Cold War, ed. by David F. Crew (Oxford and New York: Berg, 2003), pp. 1-20 (p.5); Steiner, ‘From Soviet Occupation Zone’, p. 29. 425 Andreas Malycha and Peter Jochen Winters, Die SED: Geschichte einer deutschen Partei (Munich: CH Beck, 2009), p. 172. 426 Mary Fulbrook, A History of Germany 1918-2014: A Divided Nation (Fourth Edition) (Hoboken, N.J: Wiley Blackwell, 2015), p. 168. 427 Economic reformers in the 1950s were often undermined using the term ‘revisionists’ before the introduction of NÖS, as mentioned in: Fulbrook, A History of Germany, p. 169.

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For diabetics, it was hoped that for the first time their demands for insulin, oral anti-diabetic tablets and necessary medical equipment would be met with the correct supply, as one would expect in a typical supply-and-demand market economy.

In addressing the quality of goods, there was enhanced competition due to the fact that decision-making was mostly conducted at the level of individual companies, institutions and specific sectors of the economy.428 With each economic entity being motivated by profit and their Eigeninteresse (own interests), this was supposed to create a Sozialistische Wettbewerb (socialist competition).429 As a result, the competitive spirit was seen as the answer to improve the quality of goods on offer to consumers, partly through offering increased choice. This might explain why the GDR maintained more than one oral anti-diabetic tablet (Maninil, Oranil and Orabet) and several insulins on the ‘market’. Competition could be seen within polyclinics, hospitals, even amongst diabetes advice centres, with statistical evidence gathered in particular to act as ‘material levers’ in the quest to drive up standards. Where there was certainly promise for diabetes and healthcare more generally in the outcomes of the NÖS was the emphasis on science, and how scientific progress went hand-in-hand with economic progress.430 It gave greater focus to the study of specific diseases and raised their profile in state affairs. However optimistic the vision of the NÖS was, it is largely agreed in historical scholarship that the contradictions in what it aimed to achieve (market economics in a state socialist planned economy) led to ambivalent results. As diabetologists continued to voice complaints about shortages and faulty products well into 1966, it did not lead to many improvements in the issues it was trying to solve. It was nevertheless an ambitious and controversial move forward, and the workings of the NÖS can be witnessed in the major developments of the Dispensaire System and institutions catering to the needs of diabetics addressed in the following two sections of this chapter.

Finding new consumers: the expansion of regional screening programmes for diabetes The policy of Störfreimachung and the continued shortages of personnel and quality goods presented various obstacles in diabetes care. More to the point, they thwarted some opportunities for diabetologists to put into practice the social hygienic ideals called for in the

428 Plane, p. 54. 429 Stefan Wolle, Aufbruch nach Utopia: Alltag und Herrschaft in der DDR 1961-1971 (Berlin: Ch. Links, 2011), p. 146. 430 Steiner, ‘From Soviet Occupation Zone’, p.30; Dieter Hoffman, ‘Robert Havemann: Antifascist, Communist, Dissident,’ in Science under Socialism: East Germany in Comparative Perspective, ed. by Kristie Macrakis and Dieter Hoffman (Cambridge, MA.: Harvard University Press, 1999), pp.269-285 (p.277).

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1950s. In spite of this, the immediate aftermath of the building of the Berlin Wall brought a sense of stability and a belief that the GDR could push on with developments in the healthcare system on a scale that could only have been imagined in the 1950s.431 As Young-sun Hong explains, ‘having just deprived their citizens of…freedom of movement…the East German authorities proceeded with much optimism and seriousness to design a comprehensive public health project’.432 Although it was clear on the ground that the ambitious vision of the healthcare system could not always be translated in practice, there was evidence to suggest that targets had altered. Störfreimachung set a distinct tone, namely that the GDR could stand up for itself and initiate its own successes independent of the West. Far from being regressive in terms of ambition, Störfreimachung was considered by the SED at least to be forward-looking and a potential turning point. Social hygiene, which had always been viewed as superior to Western approaches to healthcare, could be embedded neatly into the rhetoric surrounding Störfreimachung and the sentiment generated by Ulbricht around the issue of consumption.433 As the demands by doctors and patients heightened, with increased levels of diagnosis and more patients coming to the diabetes advice centres, by 1961, Reihenuntersuchungen, statistical evidence and the overarching Dispensaire System entered into a new phase of expansion.

Prevention and prophylaxis were something of a double-edged sword in the early 1960s. Ulbricht’s call to increase per capita consumption conflicted on various levels with the need to minimise costs in healthcare. Issues with personnel, medical-technical equipment, domestically produced insulins and oral anti-diabetic tablets, which could also lead to complications and an increased dependence on imported insulin, meant that advice centres were not coping well with a rising number of patients. Diagnosing early is, of course, extremely important in preventing complications and possibly reversing the disease in some cases, thereby lessening the reliance on the healthcare system. Diabetologists screening for diabetes en masse also cemented their loyalty to the East German healthcare system, and it felt to them as if they could really enact social hygienic principles, like early detection and preventing invalidity. Yet, this was easier said than done when there was a lack of fresh, healthy food that

431 Andrew I. Port, Conflict and Stability in the German Democratic Republic (Cambridge: Cambridge University Press, 2008), p. 97. 432 Young-Sun Hong, ‘Cigarette Butts and the Building of Socialism in East Germany’, Journal of Central European History, 35:3, 327-344 (p.329). 433 On the rhetoric surrounding social hygiene and the West (especially West Germany), see: Jeannette Madarasz-Lebenhagen, ‘Perceptions of Health after World War II: Heart Disease and Risk Factors in East and West Germany, 1945-75’, in Becoming East German: Structures and Sensibilities after Hitler, ed. by Mary Fulbrook and Andrew Port (Oxford and New York: Berghahn, 2013), pp. 121-140 (p.124).

106 would otherwise be used to alter the diets of those diagnosed in screening. Cases could actually get worse and not better, raising the number of health consumers in a healthcare system which was, on current evidence, ill-prepared to manage a possible influx of new cases. When Schliack first screened for diabetes in the early 1950s, he was already alarmed that the rate he found was higher than anticipated. The SED’s continued promises of an improved supply of consumer goods was in danger of leading to ‘excessive consumption’ (and of the wrong kinds of food) rather than the ‘rational consumption’ befitting the ideal of a social personality, a misunderstanding which would come to plague the GDR in future years.434 This, according to Thoms, was precisely why Reihenuntersuchungen really took off, coinciding with the GDR’s status as a society of mass consumption.435

The Eingaben about Import-Insulin, and the cases caught up in Umstellungen, concerned predominantly, but not exclusively, insulin-dependent type 1 diabetics. It was necessary that insulin reserves were kept for those diabetics as opposed to cases of non-insulin dependent type 2 diabetes, which could be treated with diet and/or oral anti-diabetic tablets in the first instance. This raised the stakes for the post-diagnosis treatment of those detected following screening, the vast majority of whom were non-insulin dependent diabetics with no noticeable symptoms. In the long run, these large-scale Reihenuntersuchungen could be massively advantageous to the GDR, and this was perhaps one area of healthcare where they could claim superiority over the West. Thanks to the centralised structure of the healthcare system, the epidemiological data collected by Reihenuntersuchungen could be used to plan for future consumption and satisfy the ‘needs’ of the population.

The quality of the Biophan test strips may have been suspect, but this did not prevent ambitious diabetologists from engaging in mass screening programmes in the regions under their watch. Whilst the idea of more widespread Reihenuntersuchungen was discussed in the 1950s, and doctors independently carried out their own screening initiatives to establish patterns, the effort was neither organised nationally, nor actively sold to the general public. After 1961, this appeared to change in dramatic fashion. Reihenuntersuchung became a topical subject of discussion in diabetes advice centre reports, meetings of regional diabetes head doctors and in medical journals, including those for popular and specialist readerships. In some areas, the approach to Reihenuntersuchungen shared many similar aspects. There are two

434 Ulrike Thoms, ‘Der dicke Körper und sein Konsum im Visier von Wissenschaft und Politik in der DDR und der BRD’, Comparativ: Zeitschrift für Globalgeschichte und vergleichende Gesellschaftsforschung, 21:3 (2011), 97-113 (p.102). 435 Thoms, ‘Der dicke Körper’, p.102.

107 articles from Das deutsche Gesundheitswesen, one written by Dr. Böhme from Nordhausen in 1964 and the other by Dr. H. U. Krüger, also in 1964 but about screening which took place in 1961-2, which record in detail how the procedure worked in many regions.436 The key to the stepping up of Reihenuntersuchung in diabetes care was the link that was made with advanced and existing screening programmes for another disease, tuberculosis. The Röntgenreihenuntersuchungen were regular, obligatory x-ray screenings for tuberculosis and lung disease, which every citizen by law had to attend.437 The diabetologists were ingenious in appropriating this system to fulfil their own social hygienic tasks. Alongside the screening for tuberculosis, they managed to add diabetes testing, knowing full well that people had to turn up as they were legally obliged to do so and that there was no additional loss of working hours.438 This made it possible to increase the numbers of people being tested for diabetes, and allowed diabetologists to get a better impression of true rates of the disease as a result of the sheer volumes of data now at their disposal.

To save time and effort during screening, the Biophan urine test strips were sent out in advance of the screening in envelopes, which contained a leaflet about how to use the test strips. This was considered essential because the patient was only supposed to dip the test strip into the urine for a short space of time. Dr. Böhme reported that overly thorough patients had attached their test strips to a piece of string to ensure it could remain in the urine for several hours, which they believed would lead to a more accurate reading. However, proceeding in this way dissolved the chemicals used and hence, made it impossible to produce a valid result.439 Once the test strips had been used, they were handed in when a person attended the Röntgenreihenuntersuchung.440 If the reports by diabetologists reflect what actually happened, the participation of ordinary citizens in the process of Reihenuntersuchung was quite striking. It follows the trend that people started to view healthcare in the GDR as something that could and should be consumed and reinforces the idea that the maintenance of one’s health for the good of society evidently influenced people’s enthusiasm to participate. Various ‘propaganda measures’ were taken to raise the profile of the disease to ensure that people actively engaged in screening. Diabetologists gave talks about diabetes in companies, larger towns and village

436 H.S.Böhme, ‘Diabetes Suchaktion im Kreis Nordhausen (Bezirk Erfurt)’, Das deutsche Gesundheitswesen, 19 (1964), 188-192; H.U Krüger, ‘Erfahrungen und Ergebnisse der Reihenuntersuchungen auf Diabetes mellitus im Bezirk Schwerin in den Jahren 1961/2’, Das deutsche Gesundheitswesen,19 (1964), 500-506. 437 Böhme, pp. 189-90; Krüger, pp. 500-1; SAPMO-BArch DQ1/4345 – Auszug aus den Jahresanalysen der Bezirke 1962-Rostock (‘Reihenuntersuchung’), p.1. 438 Krüger, ‘Erfahrungen’, p. 500. 439 Böhme, p. 189. 440 Böhme, p. 189.

108 halls, and posters were put up in the street explaining why it was important to screen for the disease.441 The doctors appeared to be very positive about the people’s response; in Nordhausen, some people simply turned up to ask to be screened rather than waiting to be called for screening. Dr. Engelmann of Radeberg noted that people were ‘self-diagnosing’ following talks they had heard about the disease, attending the diabetes advice centre to be checked without having been asked to do so.442 In Schwerin, the willingness of the population to take part in diabetes screening could be seen in the fact that the number of test strips handed in at polyclinics and other ambulatory facilities was higher than the number of people turning up for Röntgenreihenuntersuchung.443 According to the calculations made by diabetologists in Schwerin, there was an average participation rate of 81 percent, with rural areas seeing a higher rate of 87 percent.444 In Oschersleben, Dr. von Knorre cites an average figure of 94.1 percent.445

In order to measure the scale of participation, diabetologists explained that this was heavily dependent on the voluntary help that they received in distributing the test strips to people. Brilliant work was done in both Nordhausen and Schwerin by the patients of mental hospitals, who were given the task of putting the test strips into envelopes. This was symbolic, too, of how far the regime wanted everyone (i.e. even the mentally ill) to be productive in whatever way possible.446 However, the volunteers tasked with delivering the test strips to households did not seem to match the same level of efficiency. The town councils organised the delivery of test strips, but the type of people deployed to help were ill-suited to the task at hand. Some test strips were found in desks in a town council office; they had not been given out at all.447 In Schwerin and Radeberg, test strips were delivered by schoolchildren, who, in an effort to complete the job more quickly, put several envelopes in the same post-box, meaning that not everyone received a test strip (and others received too many).448 Of the 34,000 test strips handed out in Nordhausen, only 22,000 were handed in to be checked, a deficit, therefore, of almost a third.449 Still, the numbers were in the tens of thousands for one single Reihenuntersuchung, which signifies the scale and ambition of early diagnosis for diabetes in

441 Böhme, p. 189; Krüger, ‘Erfahrungen’, p. 501. 442 H. Engelmann, ‘Beitrag zur Praxis der Diabetes-Reihenuntersuchung (Radeberg 1963)’, Das deutsche Gesundheitswesen, 19 (1964), 1319-1323 (pp.1319-20). 443 Krüger, ‘Erfahrungen’, p. 501. 444 Krüger, ‘Erfahrungen’, p. 501. 445 G. von Knorre, ‘Diabetes Reihenuntersuchung im Landkreis Oschersleben, 1961-2’, Das deutsche Gesundheitswesen, 19 (1964), 593-597 (p.593). 446 Böhme, p. 189; Krüger,‘Erfahrungen’, p. 501. 447 Böhme, p. 189. 448 Böhme, p. 190; Engelmann, p. 1320. 449 Böhme, p. 190.

109 the GDR at this stage. In Schwerin, Dr. Krüger tested 386,100 people over the age of 14, and a further 102,000 out of a population of 153,000 children under the age of 14 (sixty percent) in 1962.450 For the early 1960s, so soon after the building of the Wall, these figures were highly ambitious. A double-paged 1965 article entitled ‘Every Tenth is a Diabetic’, published in the popular but short-lived journal, Berliner Medizinische Rundschau, outlines the future ambitions for Reihenuntersuchung.451 By 1970, as part of the ‘perspective plan’, a term that was used in the devolved planning mechanisms of the NÖS, Reihenuntersuchung of the entire population over the age of 14 was expected. This was a particularly specialist area of the healthcare system in which the GDR seemed to be more confident about considering itself as ‘world-leading’, as the article suggested through the abundant praise of Schliack and his chairmanship of the Internationale Suchkomitee. The committee was devoted to early detection with strict diagnostic criteria and included American and Russian scientists. Reihenuntersuchung had evidently started to be politically resonant in its own right by 1965.452

Figure 7: The 1965 article ‘Every Tenth is a Diabetic’, promoting the importance and merits of large-scale screening 453

450 Krüger, ‘Erfahrungen’, p. 502; H. U. Krüger, ‘Reihenuntersuchung auf Diabetes mellitus bei Kindern’, Das deutsche Gesundheitswesen, 20 (1965), 781-2 (p.781). 451 Ursula König, ‘Jeder 10. ist Diabetiker’, Berliner Medizinische Rundschau, 2 (1965), 16-17 (p.16). It must be noted that the assumed rate of diabetes was still 1.5 percent, but the article implies continued screening could help uncover an even higher rate. 452 König, pp. 16-17. 453 König, pp. 16-17.

110

The results of the screenings were analysed extensively by the diabetologists, confirming that, in spite of the problematic test strips and the resultant financial implications, Reihenuntersuchung was worth the effort it took. The lack of quality of the test strips was readily apparent, but in terms of the final goal, to diagnose as many people (latent or otherwise) as possible, they at least encouraged thoroughness. The oversensitivity of the glucose test strips meant that a chemical reaction took place which changed the colour of the test strip, indicating a positive or doubtful result, when only 0.05 percent of glucose existed in the urine.454 Of the 386,100 test strips collected in Schwerin, 14,109 were recorded as positive and doubtful, but following Nachuntersuchung (the further examination) there were only 1,076 cases of diabetes.455 The proportion of new diabetics to those already known was one to four in Nordhausen. The Berliner Medizinische Rundschau article suggests that, nationwide, it appeared that the rate of unknown to known cases was one to two. Even though the projection for 1970 of the total number of diabetics in the population had originally been 250,000, it was recognised that more and regular Reihenuntersuchungen could increase that figure to 350,000 cases.456 The social hygienic criteria set in the 1950s, which included division into demographic area (rural and urban), age and, in particular, gender were also observed with great interest.457 Results gained in this way, it was hoped, would lead to more well-targeted Reihenuntersuchungen, and ‘at-risk’ groups could be tested in regular intervals to leave no stone unturned.458

Responding to consumption: the evaluation of the institutional structures of diabetes care

The reliance on imported insulin of many insulin-dependent diabetics increased the likelihood of the need for inpatient care during the point at which they were put onto domestic alternatives, as instructed by the policy of Störfreimachung. Many of those diagnosed following screening required inpatient and/or outpatient care immediately. Umstellungen and Reihenuntersuchungen both created a new mass of health consumers who were embracing the widening range of services in the Dispensaire System, typical examples of gesellschaftliche Konsumtionsformen that were generated in response to the level and variety of this new demand. The increased volume of inpatient cases highlighted ongoing issues related to the

454 SAPMO-BArch DQ1/6702 – ‘Diabetes Reihenuntersuchungen’ – results from those carrying out extensive Reihenuntersuchungen for diabetes, including Prof. Kaeding of Rostock, Dr. Jung of Neubrandenburg, Dr. v. Knorre of Oschersleben and Frau. Dr. Kirsch of Rheinsberg/Potsdam. 455 Krüger, p. 502. 456 König, p. 16. 457 See especially: Krüger, ‘Erfahrungen’, p. 503. 458 Krüger, ‘Erfahrungen’, p. 506.

111 availability of places in stationary facilities, which in turn seriously impacted on the efficiency of outpatient care (overburdened diabetes advice centres). Inpatient care had been viewed as far too monolithic prior to the building of the Berlin Wall and did not serve the purpose of getting people back to work, reducing invalidity and other social hygienic objectives.

Following Umstellung onto domestic insulins, the condition of diabetics needing inpatient care was acute. However, those who were recovering from an acute state, had been suffering from progressive complications, or were unable to manage their long-term issues themselves required a different sort of care and, by extension, a different institution. This problem, brought rather inadvertently to the fore by the policy of Störfreimachung, opened up heated debate within diabetology about how the institutional organisation of diabetes care could best respond to the growing demand in both outpatient and inpatient care. This prompted the creation of new institutions and a re-evaluation of the hierarchical structure of institutions within diabetes care. Different historical actors alongside familiar faces emerged in decision- making and leadership, attempting to capitalise on this period of expansion and development.

One of the institutions in most demand during and after the period of Störfreimachung was the sanatorium. The opening of a new sanatorium in Saalfeld in 1963 to supplement the work of the existing sanatorium in Rheinsberg was a response to the idea that there was more than one type of inpatient demand.459 A report dated 6 November 1965 stated that the purpose of a sanatorium was to prevent bed-blocking in University hospitals and at the Institute for Diabetes, both of which were to be reserved for acute cases.460 The sanatorium was therefore to be the site for aftercare (post-acute phase) and long-term rehabilitation, forming a fundamental part of the ‘unity of prevention, care and rehabilitation’ called for by social hygienists in the 1950s.461 The unique quality of the sanatoria at Rheinsberg and Saalfeld was that they were dedicated to the care of diabetes only, recruiting staff with a good working knowledge of the disease. Previously, some diabetics had received care in sanatoria which were not specifically set up for their needs and had encountered problems due to the lack of specialist attention.462 A further diabetes sanatorium was established in Bad Berka in January 1964,

459 SAPMO-BArch DQ1/4343 – Beginning of the Sanatorium Saalfeld: meeting with Prof. Mohnike, Dr. Schliack, Herr Hilbert of the Ministry of Health and Dr. Nowak, director of the policlinic of ‘Maxhütte’ and head doctor of the Sanatorium ‘Bergfried’ Saalfeld, 29.1.1963. 460 SAPMO-BArch DQ1/4346 – ‘Bericht über den Besuch im Diabetiker-Sanatorium Saalfeld am 6. Nov. 1965 und den Erfahrungsaustausch mit den drei Diabetiker-Sanatorien Rheinsberg, Bad Berka und Saalfeld’, p.2. 461 Annette F. Timm, The Politics of Fertility in Twentieth-Century Berlin (Cambridge: Cambridge University Press, 2010), p. 261. 462 SAPMO-BArch DQ1/4346 – ‘Bericht über den Besuch im Diabetiker-Sanatorium Saalfeld am 6. Nov. 1965 und den Erfahrungsaustausch mit den drei Diabetiker-Sanatorien Rheinsberg, Bad Berka und Saalfeld’, p.5.

112 continuing this sense of ambition to widen the scope of diabetes care which diabetologists seemed to adopt after the building of the Wall.463

Figure 8: Sanatorium Rheinsberg, September 1964 464

As had been the case with the appointment of regional diabetologists on the ground, the Ministry of Health presided over the ultimate decision of who was appointed the leaders of the new sanatoria in Saalfeld and Bad Berka. The decision had been made to appoint Dr. Schilling to the post of Ärztlicher Direktor or rather Ärztliche Direktorin at the Sanatorium Saalfeld. For Bad Berka, Dr. Keymer took on the same role. Just as the director of Rheinsberg, these two doctors happened to be women.465 Whilst attempting to determine a pattern here and establishing underlying reasons for the appointments of three female doctors may well be far- fetched, it is nonetheless intriguing to have three women leading such important institutions when so few women occupied leadership positions at that time in both the traditional ‘productive’ and ‘non-productive’, consumerist sectors (the medical profession falls into the latter category).466

According to Donna Harsch’s study, women tended to gravitate towards the ‘non- industrial’ or ‘non-productive’ professions which offered better promotion opportunities and

463 Ibid., p.1. 464 Bundesarchiv Bild 183-G0915-0008-001. 465 Ibid., p.1. 466 David Childs, The GDR: Moscow’s German Ally (London: George Allen and Unwin, 1983), p. 253.

113 were less masculinised. By 1966, women were well represented in medicine (47 percent of pharmacists and 34.3 percent of physicians were women), but, as far as leadership positions were concerned, they only made up 7.4 percent of chief physicians, hospital directors and regional head doctors by that time.467 The apparent bias toward men within the economy was illustrated earlier with the clear gender imbalance in patients of working age receiving imported insulin in some regions (far more men than women despite larger numbers of cases of diabetes in females overall). Yet, two of these women were rising in the ranks of diabetology at this stage and were considered to be highly accomplished. Dr. Kirsch was also the regional diabetes head doctor of Potsdam in addition to her role as director of the Sanatorium Rheinsberg.468 Likewise, Dr. Schilling, following Katsch’s death, had temporarily taken over at the Institute for Diabetes until Mohnike took over.469 In terms of the input of the Ministry of Health in making decisions on potential candidates, the leader of the department for specialist health care within the Ministry overseeing many of these matters, Dr. Krüger, was a dominant force and also a woman. Whether this was simply coincidence on account of the loss of personnel to the West or the fact that there were fewer men as a result of the Second World War is a matter for debate. It could, however, reveal that one of the founding principles of the GDR’s 1949 constitution, gender equality, was finally being acted upon within diabetology.

The rehabilitative care administered at the sanatoria relied on good institutional organisation and planning, as well as sufficient quantities of medication and diabetic foods (the ‘Mangelware’ or shortage goods).470 After all, the sanatoria were institutions which were part of the wider ‘Volkswirtschaftsplan’ (national economic plan), whose economic significance was continually emphasised.471 Unfortunately, there were complaints about the lack of money given by the state to provide patients the right foods and, as a result, work was severely limited. The accommodation, especially for staff, was insufficient, which meant that they had to accommodate patients in fewer rooms than was desirable to leave others available for staff living in the sanatoria.472 The report of November 1965 suggested that the three sxanatoria

467 Donna Harsch, Revenge of the Domestic: Women, the Family, and Communism in the German Democratic Republic (Princeton and Oxford: Princeton University Press, 2007), p. 247 and p. 255. 468 SAPMO-BArch DQ1/2907 – Betr.: Analyse zum Bericht der Diabetiker-Beratungsstellen für das Jahr 1961, 25.5.1962 - Potsdam [Dr. Kirsch’s signature on p.3]. 469 Waldemar Bruns, Horst Bibergeil, Ruth Menzel, Konrad Seige, Günther Panzram and Deutsche-Diabetes Gesellschaft, ‘Die Entwicklung der Diabetologie im Osten Deutschlands von 1945 bis zur Wiedervereinigung’, Wecom: Gesellschaft für Kommunikation, (2004), 1-51 (p.23). 470 SAPMO-BArch DQ1/4346 – ‘Bericht über den Besuch im Diabetiker-Sanatorium Saalfeld am 6. Nov. 1965 und den Erfahrungsaustausch mit den drei Diabetiker-Sanatorien Rheinsberg, Bad Berka und Saalfeld’, p.3. 471 Ibid., p.2. 472 Ibid., p.6.

114 were acting too much like clinical facilities due to the lack of beds in hospitals for acute cases, and had not yet adopted the true character of a sanatorium.473

It was suggested, both by Dr. Krüger and Schliack, that the Zentralstelle für Diabetes und Stoffwechselkrankheiten in Berlin was to have responsibility for the setting up of the sanatorium in Saalfeld. 474 Schliack had founded the Zentralstelle in 1959 so that he could pursue his ‘social-medical’ and ‘social-hygienic’ goals. His preoccupation with statistics in the 1950s revealed his interest in the ambulatory aspects of diabetes care in particular. The death of Gerhardt Katsch, a highly influential and dominant figure within diabetology in the GDR, left a potential power vacuum. Coupled with the building of the Berlin Wall, this gave the more ambitious diabetologists a chance to change the course of developments in diabetes care. Up until the death of Katsch, the belief that the Institute for Diabetes in Karlsburg was the central institution in diabetes care was undisputed. However, by 1963, the Institute’s role was up in the air. As this chapter has illustrated, Schliack is a much more regular presence in the Ministry of Health files in comparison to Mohnike, the director of the Institute from the end of 1961. He was the chief advisor to the Ministry of Health on diabetes matters, and this, therefore, put him in a much better position to influence affairs. An evident power struggle between Schliack and key members of the Ministry of Health on the one hand, and Mohnike, colleagues at the Institute and the local SED Party on the other reveals that, even in an environment of consolidation following the building of the Wall, unanimity was not always maintained.

473 Ibid., p.2. 474 SAPMO-BArch DQ1/21526 – Betr.: Leitinstitut für Diabetes by Dr. Schliack; SAPMO-BArch DQ1/23140 – Statut für das Leitinstitut Diabetes, 30.8.65 by Dr. M. Krüger.

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Figure 9: The Zentralstelle für Diabetes und Stoffwechselkrankheiten, East Berlin, May 1971475 From the official archival evidence within the Ministry of Health, it all seemed to begin in early 1963 when Professor Misgeld and Dr. Arnold from the Ministry of Health proposed that the Institute for Diabetes should be the ‘Leitinstitut’ (lead institute) for Diabetes, Endocrinology and Metabolic Diseases in the GDR. Subsequently, questions were asked about what the term ‘lead institute’ actually meant. In conjunction with Mohnike, the local SED Party leadership of Karlsburg wrote to the Ministry of Health in October 1964, calling for the standardisation of modern diabetes therapy and a centrally coordinated system of diabetes care under the leadership of the Institute.476 During their discussions, the local party leaders stated that West Germany was already developing rapidly in diabetes care and research, and that there was a clear danger of the Federal Republic gaining a leading role in diabetology internationally. Tapping into this Cold-War rivalry, the authors mentioned that this was a good enough reason to justify the Institute being the centre of all diabetes care including not only research, but also stationary and ambulatory care.477 They make reference to the fact that the Ministry had requested judicial recognition of the Institute as ‘lead institute’; in a draft ‘perspective plan’ of

475 Bundesarchiv Bild 183-K0521-0010-009. 476 SAPMO-BArch DQ1/23140 – Letter from the ‘Parteileitung des Instituts für Diabetes Karlsburg’ to Professor Misgeld of the Ministry of Health, 15.10.1964. 477 Ibid., p.1.

116 the Institute in April 1965, one of Mohnike’s colleagues, Waldemar Bruns, urged that a statute be drawn up as soon as possible to establish a legal basis for the Institute’s lead role.478

Mohnike duly wrote a draft version of a statute ‘for the diabetes lead institute’, and it was this particular document that opened up a rather sour debate. In the statute, Mohnike stated the Institute’s leadership and control of all ambulatory and stationary diabetes care. He argued that the Institute could set the rules in the area of diagnosis and therapy and could give advice to the Ministry of Health and other institutions.479 He went on to state that, in relation to other institutions, tasks in ambulatory and stationary care could be delegated to others by the Institute.480 Mohnike attached a covering letter dated 22 June 1965 which showed that he had sent this statute to Dr. Krüger and Dr. Oerter, both from the same department within the Ministry.481 In the version of the document received by the Ministry of Health, there is a handwritten comment with the signature of Dr. Krüger of the Ministry of Health below it. The comment reads ‘that is incorrect’, implying that she did not agree with Mohnike’s points.482 As the leader of the department, Krüger sent an official response. This proved to be an inflammatory one, but, more importantly, it is evidence of clear collaboration with Schliack. She remarks that in his statute, Mohnike had failed to mention the Zentralstelle and all the work it had done in leading ambulatory care on the ground. She explained that she wanted a sentence included in the statute along the lines of ‘the institute should work alongside the Zentralstelle in coordinating ambulatory care and Reihenuntersuchung’. She also requested that a sentence be added about the Zentralstelle working alongside the Institute in the training of personnel involved in diabetes care. She accepted that the Institute should have ‘overall’ responsibility, but, due to all the work done at the Zentralstelle in the coordination of ambulatory care, appropriate powers should be given to it in this area.483 Her emphasis on the ‘collective work’, as she put it, between the Institute and the Zentralstelle could have been words used by Schliack himself. Schliack’s role in the Ministry meant that he and Krüger were effectively colleagues, exemplifying the importance of his role as advisor on diabetes.

478 SAPMO-BArch DQ1/23140 – Entwurf zum Perspektivplan zur Weiterentwicklung des Institutes für Diabetes “Gerhardt Katsch” Karlsburg, Krs. Greifswald, bis 1970, 9.4.1965, p.1. 479 SAPMO-BArch DQ1/23140 – Entwurf eines Statuts für das Diabetes – Leitinstitut, (‘Aufgaben’), pp.1-2. 480 Ibid., p. 3. 481 SAPMO-BArch DQ1/23140 – Cover letter by Mohnike about the ‘Statut des Leitinstituts für Endokrinologie und Stoffwechselerkrankungen’, 22.6.1965. 482 SAPMO-BArch DQ1/23140 – Entwurf eines Statuts für das Diabetes – Leitinstitut, (‘Aufgaben’), p.2. 483 SAPMO-BArch DQ1/23140 – Statut für das Leitinstitut Diabetes, 30.8.1965 by Dr. M. Krüger, pp.1-2.

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Krüger clearly had an agenda not to allow Mohnike, his colleagues and the Institute to be in sole charge of East German diabetes care. Mohnike’s known opposition to the regime did not stand in his favour. In an age of competition with the West, Mohnike had already been ticked off by another member of the Ministry about giving away information too freely to Western colleagues. For fear of original work being copied by West Germany on account of Mohnike’s openness, the Ministry had decided that they would reject an application by a Munich-based chemist, Dr. Mittenzwei, to visit the Institute.484 It was on this past evidence of Mohnike’s political frailties that Krüger decided to base her judgements of his leadership. She wrote to Mohnike in August 1965 explaining that during his ‘holiday’, she had visited Karlsburg twice.485 The second time, she had come purely to check whether events were organised in preparation for the upcoming local elections. She remarked that, to her dismay, there had been no evidence of preparations at all. Furthermore, she claimed to have discovered that the mayor of Karlsburg had wanted to stage an event at the Institute where local politicians could explain their activities in the village, but this had not been arranged.486 She ordered Mohnike to improve relations between Karlsburg and the Institute, and that he should attempt to solve the issue of his neglect of his political duties by delivering a ‘humorous speech’ to members of the community, including those of the local Landwirtschaftliche Produktionsgenossenschaft (LPG), which was the collectivised farm at Karlsburg.487

This all sounded rather petty, but it was successful in exposing and confirming Mohnike’s lack of political loyalty to the wider regime. Krüger did not stop with Mohnike, and she targeted other important colleagues at the Institute, including Professor Lippmann, whom she accused of not having voted in the local elections. Lippmann wrote a letter to Mohnike in which he explained his reasons (he went on holiday with his eldest son and tried to arrange to vote, but in the end this was not possible).488 At the bottom of Lippmann’s letter, the now familiar handwriting of Krüger reads ‘these efforts do not seem sufficient’.489 When Mohnike died suddenly in March 1966, many diabetologists supposedly assumed that Lippmann would be his natural successor; Krüger may well have put a stop to that.490

484 SAPMO-BArch DQ109/210 – Aktennotiz über eine Aussprache mit Prof. Mohnike am 17.4.1964 – Betr.: Ablehnung des Einreiseantrages für Dipl.-Chemiker Dr. Mittenzwei aus München. 485 SAPMO-BArch DQ1/23140 – Letter by Dr. M. Krüger to Prof. Mohnike regarding her two visits to Karlsburg in August. 486 Ibid., p. 1. 487 Ibid., p. 2. 488 SAPMO-BArch DQ1/23140 – Letter written by Dr. Lippmann to Prof. Mohnike, 25.10.1965. 489 Ibid [Krüger’s handwriting and signature is at the bottom of p.2]. 490 Interviews with Professor Waldemar Bruns, 7 April 2016 and Dr. Heinz Schneider, 6 April 2016.

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Whilst Schliack appeared only in the background at this point, he soon after gave his own view on the ‘lead institute for diabetes’. Like Krüger, he demanded a more active participation of the Zentralstelle in shaping diabetes care. His solution to the problem of defining the ‘lead institute’ was to create three directors in a tripartite system.491 The Institute for Diabetes in Karlsburg was to be the lead for clinical research and for treatment of the more complicated cases.492 The Zentralstelle was to organise ambulatory care, what with Schliack’s own experience as leader of the Suchkomitee (international early diagnosis committee), his interest in social-medical questions, and the advantageous geographical position of the Zentralstelle in Berlin.493 He suggested that the stationary and sanatorium care could be directed by Dr. Kirsch at the Sanatorium Rheinsberg.494 Deliberate ambiguity was conveyed when discussing the Institute’s potential to be the leader of these three areas. He used the phrase ‘primus inter pares’ (first among equals) to describe the role that the Institute would take using his model.495 Schliack’s thinking outwardly positioned him as a compromiser and a pragmatist, but his ambitions for his own institution were readily apparent, bearing in mind that prior to Katsch’s death the Institute’s role was not even questioned. By 1966, the year of Mohnike’s death, the role of these institutions within diabetes care was still confused. For the fate of the Institute at least, Mohnike’s sudden demise was considered a mixed blessing. Based on the opinions of a range of diabetologists who knew Mohnike, he was a popular and talented figure, looked up to by many at the Institute.496 However, his death opened up an opportunity for the SED to politicise the Institute and simultaneously invest very heavily in it to meet future political ends. The search for a candidate inevitably involved Schliack, but, despite his influence within the Ministry, his great undoing would be his lack of SED membership.497 This eventually dispelled hopes of placing the Zentralstelle at the heart of diabetes care in the GDR.

The confusion over the status of the Institute for Diabetes and the Zentralstelle is likely to have been an indirect consequence of the NÖS. The decentralisation of economic planning, giving more economic autonomy to individual institutions, enhanced the feelings of authority

491 SAPMO-BArch DQ1/21526 – Betr.: Leitinstitut für Diabetes by Dr. Schliack. 492 Ibid., p. 3. 493 Ibid., p. 4. 494 Ibid., p. 3. 495 Ibid., p. 6. 496 His connections with the West may also be confirmed by the touching tribute to him at the Second Annual Conference of the German Diabetes Society in Wiesbaden, West Germany, 21-23rd of April 1966: Die Pathogenese des Diabetes Mellitus: Die Endokrine Regulation des Fettstoffwechsels, ed. by Prof. Dr. Erich Klein, (Berlin, Heidelberg and New York: Springer Verlag, 1967), pp. 2-3. 497 Interview with Dr. Volker Schliack and Dr. Bärbel Schliack, 27 August 2016.

119 at up-and-coming facilities like the Zentralstelle. The economic freedom gave greater scope for new institutions to expand. The ability to control one’s economic Eigeninteresse (own interest) allowed the individual, larger facilities within the system of diabetes care to use the money given to them by the Ministry of Health for more specialised tasks (in the case of the Zentralstelle, ambulatory care).498 However, the NÖS might also have contributed to the long- term post-1966 status of the Institute for Diabetes as the ‘lead institute’ due to the way in which it privileged scientific expertise and progress within the economy to include medicine and health. Therefore, the focus on research at the Institute was conducive to the ‘scientific advancement’ to which Ulbricht had referred at the Sixth Party Conference of 1963 and eventually reinforced its status.499

Nevertheless, the growing importance of the Zentralstelle was evident in the coordination of ambulatory care and Reihenuntersuchungen. Other people beyond Schliack were also convinced of its value, including Dr. Michaelik, leader of the department of rehabilitative care within the Ministry, who even went so far as to say that the Zentralstelle was the ‘de facto’ lead institute.500 The introduction of a ‘night clinic’ for patients, which was a novel and innovative idea, had potential economic benefits in that those visiting it would not be absent from work. Schliack’s international contacts through his leadership of the Suchkomitee allowed him to publicise the work of the Zentralstelle abroad, giving him and his facility even more acclaim. The involvement of the Zentralstelle in standardising ambulatory care in the regions was also a real turning point and was watched with approving interest by the Magistrate of Greater Berlin.501

Conclusion

This chapter has explored the immediate aftermath of the building of the Berlin Wall and the way in which this period shaped treatment options, developments and institutions within diabetes care. It has done so largely through the prism of the policy of Störfreimachung. Although Störfreimachung was phased out in 1964, the fruits of the policy lived on and continued to dictate the course of diabetes care and research. At the beginning of this chapter, it was clear that the policy was influential in establishing boundaries of what diabetologists

498 Wolle, Aufbruch, p. 146. 499 SAPMO-BArch DQ1/3108 – Plan der Einrichtung für das Jahr 1964 des Institutes für Diabetes “Gerhardt Katsch” – Karlsburg, Garz and Putbus. 500 SAPMO-BArch DQ1/4346 – Verbesserung der fachlichen Leitung der Diabetesbekämpfung und Fürsorge, 17.11.1962. 501 SAPMO-BArch DQ1/21525 – Diabetes Betreuung – Magistrat Groβberlin.

120 could administer to their patients and also what patients themselves could receive. The responses to the policy by the various interest groups were, however, as intriguing as the policy itself. Störfreimachung was deeply entrenched in the competitive spirit of the Cold War, but there was a key element which served as a crucial backdrop to this competition, the growth in consumerism and consumer culture. Contrary to the ambitious aims of Ulbricht, the GDR in reality had severe weaknesses in domestic production, and thus limitations were imposed on what its citizens could consume. From incorrect insulin measurement gauges to faulty test strips with a short shelf life, these domestically produced goods seriously hampered progress in pharmaceutical consumption and the social hygienic aims within chronic disease management. As has been seen with the case study of imported insulin, diabetologists did not simply resign themselves to the fact that they could only achieve very little with domestically produced alternatives. Those with ambition and drive instead used the products sometimes to their advantage (the overly sensitive test strips used in Reihenuntersuchung encouraged thorough diagnosis).

Looking beyond the diabetes advice centres to the arena of inpatient care, this too was shaped by the demands imposed by Störfreimachung. The negative reactions following ‘Umstellungen’ onto domestic insulins (NPH, Globin-Zink and even the signature B-Insulin) required both short and long-term inpatient care. Demand for the latter increased considerably to warrant the introduction of two additional diabetes-only sanatoria in 1963 and 1964, the penultimate and final years of Störfreimachung. As these institutions sought to meet the growing demands in diabetes care, the competitive ethos encouraged by Störfreimachung extended to individual personnel and raised potentially transformative questions about the future of the institutional set-up within diabetes care. As Fulbrook has stated about the situation for East Germans after the building of the Wall, ‘it seemed that they would simply have to make the best of a life to which there was no longer an alternative’.502 During the policy of Störfreimachung, when few alternatives existed aside from the domestically produced goods, some diabetologists made clear attempts to make the best of it. In the upper echelons of the medical hierarchy, the likes of Schliack with his growing Zentralstelle also attempted to do the same. Yet, the death of Gerhard Mohnike, the year in which this chapter terminates, in many ways marks an end to the ‘Störfreimachung period’ for diabetes care. It instead marks the start of a further wave of politicisation, where the Institute for Diabetes in Karlsburg was restored to the helm of diabetes care, led by a new leader, Horst Bibergeil. ‘Making the best of a life’

502 Fulbrook, The Divided Nation, p. 168.

121 was, henceforth, not as easy for politically disobedient diabetologists, i.e. those who were not members of the SED, as it had been immediately after the building of the Berlin Wall.

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Chapter 3: Keeping up, Moving Ahead and Falling Behind: the GDR’s Drive for International Recognition, 1966-1973

Introduction

Until April 1966, the Institute for Diabetes had been led by the popular ‘Katsch-Schüler’, Gerhard Mohnike, who continued Katsch’s mission of providing clinical and research success.503 However, crucially, as the previous chapter has illustrated, there were few direct political goals in mind under Mohnike, a known sceptic of the regime. Five years after Katsch’s death, Mohnike died suddenly and unexpectedly at the age of forty-eight. With no figure of comparable clout or stature to succeed him, the Ministry of Health seized their chance to turn the Institute into a distinctly political project. Alongside the politicisation of the Institute, there were a number of diplomatic and domestic events that also proved influential. The 1968 revised version of the East German constitution called for the anchoring of the role of the ruling SED.504 In addition, the GDR’s involvement during the Prague Spring in 1968, the move towards a more conciliatory relationship with West Germany (détente), and the new leadership of Erich Honecker in 1971, all served to epitomise a change in attitude due to the will to achieve political legitimacy.

In the previous chapter, the policy of Störfreimachung implied that the SED attempted to shed the GDR’s reputation as the ‘other Germany’. On a practical, short-term basis, the purpose of the policy was that the GDR could conduct affairs more on its own terms rather than those of West Germany and countries on whose imports they were dependent. In this chapter, despite the abandonment of this policy, the expressed long-term goal broadly speaking, to compete with and surpass the West, was championed even further. The Ministry of Health and diabetologists sized up competition, partly in the East but more substantially in the West and sought to measure the GDR’s standards against those of its Western neighbours more explicitly. New language emerged in communications to and from the Ministry and in medical journals. The repeated use of phrases such as ‘well ahead’, ‘at least five years behind in the area of research’ and ‘keeping up with international developments’, highlighted the acknowledgement of strengths and weaknesses in relation to those of others.505 The amplified

503 For references to ‘Katsch-Schüler’, see: Gustav Erdmann, Die Ernst-Moritz-Arndt Universität Greifswald und ihre Institute (Greifswald: Pressestelle der Universität, 1959), p. 66. 504 Benedikt Hampel, Geist des Konzils oder Geist von 1968?: Katholische Studentengemeinden im geteilten Deutschland der 1960er Jahre, Band 20 (Münster: LIT Verlag, 2017), p. 50. 505 SAPMO-BArch DQ109/94 – Fragespiegel zum Stand der medizinischen Forschung auf dem Gebiet des Diabetes mellitus (D.m) [Bibergeil, p.2, Schliack, p.2 and Lohmann, p.2].

123 status of the Institute as ‘lead institution’, as well as a much stronger Party presence, encouraged large new projects in areas of experimental research, an increased infiltration of global standards, and a keen interest in portraying a controlled view of the ‘excellence’ of East German diabetes care to those from outside.

The GDR was geographically and culturally positioned so that it reflected both the East and the West; this might help to explain why ambitions were not simply for the GDR to be a ‘leader’ of the Eastern Bloc, but also ‘world-leading’ in areas of diabetes care and research. As Nikita Khruschev had allegedly said, the GDR was intended to be the ‘display window’ of socialism to those from the West.506 In this way, a loose analogy to the contemporaneous achievements and efforts in sport (the GDR won 20 gold medals at the Munich Olympics in 1972) can be made here to illustrate the rationale behind this kind of thinking at this specific time. According to Mike Dennis and Jonathan Grix, ‘the raison-d’être for investing increasing resources into sport was to bring international prestige, aid the building of a national identity and engender a “feel good” factor among the population’.507 Whilst diabetes had nowhere near the publicity that sport did, people could still read about it in the popular medical journal, Deine Gesundheit, where coverage was becoming more and more prolific as time progressed.

The argument that Dennis and Grix put forward about sport can be easily applied to many other areas of East German society. Considering the impetus to conduct research, the more powerful political grip on the Institute for Diabetes, and the conscious reflection of status, diabetology appeared to be no exception. Indeed, the overseeing of the GDR becoming ‘world- leading’ within the arena of health was made even more apparent by the commanding presence of Ludwig Mecklinger, the Minister of Health from 1971. He had been leader of the Military Medical Section of the University of Greifswald until 1964, and Deputy Minister of Health from 1964 to 1971, with Mary Fulbrook describing him as ‘having been a thoroughly conscientious and concerned (as well as politically committed) individual’.508 Until his appointment as Minister, to garner the authority that his influence warranted, it was customary

506 Peter Grieder, The German Democratic Republic: Studies in European History (Basingstoke: Palgrave Macmillan, 2012), p. 55; Peter Grieder, The East German Leadership 1946-73: Conflict and Crisis (Manchester and New York: Manchester University Press, 1999), p. 122. 507 Mike Dennis and Jonathan Grix, Sport under Communism: Behind the East German ‘Miracle’ (Basingstoke: Palgrave Macmillan, 2012), p.1. 508 Matthias Willing, “Sozialistische Wohlfahrt”: die Staatliche Sozialfürsorge in der Sowjetischen Besatzungszone und der DDR (1945-1990) (Tübingen: Mohr Siebeck, 2008), p. 280; Mary Fulbrook, The People’s State: East German Society from Hitler to Honecker (New Haven and London: Yale University Press, 2008), p. 109.

124 for the influential Party member to be the deputy, so that political influence in the face of a sceptical medical profession could be kept at a covert level. 509

The increasing political penetration of all aspects of GDR society to generate this ‘feel good factor’ also allowed for the GDR to enter into its ‘middle period’ in a way that many ordinary people could begin to accept or even subscribe to when the mood was high. The extent to which the Party emphasised the image of the GDR as a world beater can be seen to have contributed to the ‘relative stabilisation of domestic political structures and processes, [and] the degrees of routinisation and predictability of everyday practices’.510 This has been termed by historians within the Fulbrookian tradition as the ‘Normalisation of Rule’, and will be discussed in more depth in the next chapter. Visible signs of ‘success’ and national achievement generated a degree of acceptance of a nation very much forced upon its people. It is precisely this thirst for international success or an appearance of it, which achieved, in large part, the stabilisation alluded to above that this chapter will seek to uncover. It will do so by examining first the evident changes made to the Institute (later ‘Central Institute’). It will then look at a wide-ranging research project aimed at addressing areas where the GDR was not the ‘frontrunner’ and bolstering those where it appeared to match international standards. From there, it will analyse the international conferences either hosted by the GDR or visited by an East German delegation, how they were monitored and who was allowed to attend. It will finally chart further developments in care on the ground, an area that the Ministry of Health had always regarded as particularly successful.

From Institut to Zentralinstitut: the position and leadership of the GDR’s foremost institution for diabetes

In order to establish the change in direction at the top of East German diabetes management, it is important to trace how and perhaps why the successor to Mohnike, Horst Bibergeil,

509 It must be noted that the previous Minister of Health, Max Sefrin, was a longstanding member of the East German branch of the Christian Democratic Union (CDU), as was the previous Minister, Luitpold Steidle. The CDU was part of the GDR’s ‘bloc-party system’ which was controlled by the ruling SED. All previous deputies, however, were members of the SED. For more information, see: Peter Joachim Lapp, Der Ministerrat der DDR: Aufgaben, Arbeitsweise und Struktur der anderen deutschen Regierung (Opladen: Westdeutscher Verlag, 1982), pp. 219-220. Indications of Mecklinger’s authority can also be seen in an attachment document about the protocol for the Institute for Diabetes Karlsburg written on the 25th of November 1966, listing those contributing to it, including diabetologists and members of the Ministry of Health. Mecklinger’s name is at the top, listed as ‘Minister’, even though it was officially Max Sefrin at this point. See: SAPMO BArch DQ1/23140 -Anlage zum Protokoll von Karlsburg vom 25.11.66. 510 Mary Fulbrook, ‘The Concept of “Normalisation” and the GDR in Comparative Perspective’ in Power and Society in the GDR, 1961-1979: ‘The Normalisation of Rule?’, ed. by Mary Fulbrook (Oxford and New York: Berghahn, 2013), pp. 1-32 (p.13).

125 eventually became leader of the Institute. It certainly sheds an interesting light on the internal dynamics of East German political instruments of control. From the beginning, as has been mentioned in the previous chapters, there was a clear difference of opinion between some medical professionals (high-ranking East German diabetologists) and those closely connected to the Party (members of the Ministry of Health), with rather shrewd tactics employed by the latter. Following Mohnike’s death, there were ongoing discussions between the Ministry of Health and diabetologists from across the GDR, who formed a Problemkommission, to determine not only the leader, but also the type of leadership. This was due to the fact that, almost immediately, the Ministry raised the possibility of having a Direktorium, where there would be at least three leaders of key sections of diabetes care and research (clinical areas, juvenile diabetes and experimental research).511

The Problemkommission, led by Professor Kaeding, the director of the University of Rostock’s medical clinic, believed that this would not be a good idea because they thought that an ‘important personality’ would provide better leadership and that a Direktorium would do harm to the reputation of the Institute, as well as the people of the GDR.512 The Problemkommission even agreed on the leader they wanted, Professor Lohmann, who was referred to as one of the GDR’s most talented clinicians and researchers. The Ministry thought differently and were insistent on having a Direktorium. To make it appear that they were producing a compromise with the Problemkommission, they were willing to put their proposed leader, Lohmann, in the Direktorium to lead the clinical research section.513 Lohmann’s personal response, however, was telling of the relative tensions and underlying differences between the two parties. Following a conversation that a member of the Ministry had with Lohmann, he was reported to have said that he was not willing to take over the leadership role within the Direktorium, as he believed, firstly, that there should be no separation of clinical aspects and research, and, secondly, that he would want full control if he were leader.514 It is evident, therefore, that the Ministry was faced with resistance. Gerhard Misgeld, head of the

511 SAPMO-BArch DQ1/23140 – Entwurf (draft): ‘Nach dem Tod von Herrn Prof. Mohnike ist die Besetzung des Instituts für Diabetes in Karlsburg erforderlich…’ by Dr. Tischendorf on 15/10/1966. 512 SAPMO-BArch DQ1/23140 – Letter addressed to Ludwig Mecklinger and written by Professor Kaeding of the Medizinische Universitäts-Poliklinik Rostock, leader of the ‘Problemkommission’, whose members have all signed the letter at the end. Their titles also appear alongside signatures: Prof. Kaeding of Rostock, the leader of the commission; Prof. Seige, deputy leader of the commission and leader of the working group of endocrinology and metabolic diseases within the German Society of Clinical Medicine; Prof. Dörner, director of the Institute of Experimental Endocrinology at Humboldt University, and Dr. Lüdtke, secretary of the commission. 513 SAPMO-BArch DQ1/23140 – Aktennotiz über die Aussprache mit Herrn Prof. Lohmann in Leipzig am 14. Januar 1967. 514 Ibid.

126 department of science and education within the Ministry of Health (and editor of Deine Gesundheit), stated that the Ministry would have its way if they produced a united front, demonstrating that he, too, believed that there was resistance, and that it needed to be overcome.515 Curiously, within every proposed Direktorium by members of the Ministry, Bibergeil’s name appeared, and when Ludwig Mecklinger, then Deputy Minister of Health, made the declaration that he was leading the discussions, it was an inevitability that a Direktorium was going to be put in place (and that Bibergeil would be a part of it).

Over the course of 1967, the proposals were even wider, settling eventually on a vague solution, whereby there would be a Direktorium consisting of Bibergeil, Professor Lippmann (influential in experimental research) and Dr. Heik (head of the children’s hospital in Garz), and an extended Direktorium to include the leader of the Zentralstelle, Schliack.516 The way that the Direktorium was supposed to work was that the core three would rotate as leader, each for a five-year period. It was decided that Bibergeil should take over as leader first, becoming the Geschäftsführender Direktor (executive director) in April 1967.517 By January 1970, a slight modification was made. Lippmann was not in the Direktorium, presumably ousted as a result of his lack of political reliability, which was demonstrated in the previous chapter.518 This was also made fairly clear by Mecklinger following the decision to appoint Bibergeil as the first director; he told Lippmann that he had done excellent work in experimental research, but that he was expecting him to put the tenets of the Seventh Party Conference of the SED into practice, thereby clarifying underlying political mistrust.519

He was replaced by Dr. Zühlke, which did not impact on the overall trajectory, as by the following month it was evident that the Institute’s letter head had been changed in two ways. The first change was the name of the Institute, which now had the prefix Zentral attached to it, and the second, was Bibergeil’s title. He was mentioned as the Direktor and had also gone from

515 SAPMO-BArch DQ1/23140 – ‘Leitung des Instituts Karlsburg’ document by Gerhard Misgeld, where the idea of the ‘Direktorium’ was mentioned, 24/10/1966. 516 SAPMO-BArch DQ1/23748 – Entwurf für das Statut [Institut für Diabetes Karlsburg] by Dr. Tischendorf, 9/8/67, p.2. 517 SAPMO-BArch DQ1/23140 – Letter from Mecklinger to Bibergeil explaining his appointment as ‘Geschäftsführender Direktor’. 518 SAPMO-BArch DQ1/10824 – ‘Dispositionsvorschlag für die Ministerratsvorschläge’, 5/1/1970 [generic heading of the paper has been changed, where Lippmann’s name was clearly deleted and replaced by Zühlke, who also had a ‘K’ written after his name which could symbolise ‘Kader’ (political cadre)]. 519 SAPMO-BArch DQ1/23140 – Letter from Mecklinger to Lippmann dated 20/4/1967 [Mecklinger to Lippmann – ‘Der augenblicklich erreichte Stand auf dem Gebiet der Diabetesbekämpfung ist zu einem nicht geringen Teil Ihr Verdienst…Ich verbinde aber damit zugleich die Erwartung, dass die auf dem VII. Parteitag der SED aufgezeigten Grundsätze…in Ihrem Wirkungsbereich zugeführt werden’].

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Dozent (Lecturer or Reader) to Professor.520 Clearly, the Direktorium idea had been abandoned and Bibergeil was now in sole charge. There does not appear to be any particular comment to suggest why this happened, and, therefore, it requires some reading between the lines. Whilst the files cannot tell us anything about this, interviews with surviving diabetologists can clarify the matter somewhat. Although their interpretation cannot be seen as given, bearing in mind that of those interviewed, the majority were not SED members and made that point fairly emphatically, the sheer unanimity on Bibergeil cannot be overlooked. Without necessarily being asked directly, the diabetologists interviewed stated that, despite not being unpleasant or unqualified, he was known as politically obedient and that this, rather than any great scientific prestige, was why he became director. For those who did not work at Karlsburg, such as Dr. Heinz Schneider, who was the regional head diabetologist for Neubrandenburg from 1967, Bibergeil seemed to come from nowhere. It can be speculated, then, that the Direktorium was a ploy by the Ministry to put in the leader they wanted who could fulfil the political demands that were expected of the Institute.521

Along with Bibergeil being put in sole charge, Karlsburg’s status as Leitinstitut (lead institution), with a clearly elevated position in the GDR’s diabetes care was now settled, a move the Ministry had balked at whilst the politically unreliable Mohnike had been at the helm, as was shown in the previous chapter. Internationally speaking, it was called upon to be a shining light in the Eastern Bloc, where doctors from other socialist countries could be invited to work. At a domestic level, its status at the top of East German diabetes care was also assured. Professor Waldemar Bruns, who was an Oberarzt at the Institute in December 1968, explained that in the clinical area, the Institute should be responsible for specific groups of patients. It should maintain its role as carer for the most difficult and interdisciplinary cases, including those with late complications. There was a desire to build a dialysis centre for diabetics with renal failure. The Institute should also be involved in improvements in the care of pregnant diabetics and their offspring. In addition, it should produce guidelines for diagnosis, therapy and metaphylaxis to be used across the whole of the GDR, increase cooperation with pharmaceutical industry, and, lastly, provide training for regional diabetologists and other doctors.522 The final two points mentioned here imply not only the scale of the tasks required

520 SAPMO-BArch DQ109/94 – Fragespiegel zum Stand der medizinischen Forschung auf dem Gebiet des Diabetes mellitus (D.m), 2/2/1970 [see paper heading]. 521 Interview with Dr. Heinz Schneider, 31 May 2017; interview with Prof. Waldemar Bruns, 7 April 2016; interview with Dr. Elke Austenat, 14 February 2017. 522 SAPMO-BArch DQ1/23745 – Betr.: Aufgabenstellung des klinischen Bereichs des Instituts für Diabetes auβerhalb der Forschungsprojekte, 12/12/68 written by Waldemar Bruns.

128 for its leading position, but also whom it might affect. In the previous chapter, there were differences of opinion between those in Berlin at the Zentralstelle, most notably Schliack, and those at the Institute about who was responsible for what. Schliack always maintained that his domain was firmly within the realm of social medicine and practical training, with his work in Berlin giving him a strategic advantage to train doctors and to discuss developments with VEB Berlin-Chemi.e. It is apparent that the Institute, now under tight control of the Party, was encroaching upon his territory, while at the same time giving him the opportunity to be a part of the charade that was the extended Direktorium.

This invasion of Schliack’s area of expertise had already been discussed a couple of months earlier than Professor Bruns’ letter to the Ministry. In July 1968, Bibergeil outlined preparations to take over the functions previously outside of the Institute’s remit.523 Attempts were made to produce a binding contract between the Institute and the Zentralstelle to define each establishment’s responsibilities, but Bibergeil explained in the now Central Institute’s annual report of 1970 that it had proved impossible to ratify the contract. His attempts seemed to have failed, and, he went on to state that, as a result, the research conducted at the Central Institute was not filtering well enough into ambulatory care. This suggests tensions between Karlsburg and the Zentralstelle, signifying, too, that not all resistance could be overcome as easily as in the choice of leadership. Nevertheless, Bibergeil juxtaposed his pointed criticism of the Zentralstelle with what he described as clear progress made in diagnosis, therapy and metaphylaxis, areas which were all within the hands of the Central Institute, to make a point that someone or something was proving a barrier to future good work. 524

One wonders why there was a need for the Central Institute to take such a commanding role, other than the fact that the GDR preferred centrally coordinated healthcare. Having clear expertise in particular places (Berlin being the hub for ambulatory care and pharmaceuticals), as well as other locations completing important work, such as Dresden, Leipzig and Rostock, meant that there was potential for more divisions of power and responsibility. However, there was likely to be an agenda here in the same way that there was a motive behind Bibergeil becoming the director. It was much easier for the Ministry of Health to have influence over the direction of travel of various developments within diabetes care if the overall responsibility was concentrated in one place and put the principle of democratic centralism into practice.

523 SAPMO-BArch DQ1/23745 – Stand der Aufgabenerfüllung in den ersten sechs Monaten 1968, 12/7/68 [written by Bibergeil to Krüger of the Ministry of Health]. 524 SAPMO-BArch DQ1/10824 – Zentralinstitut für Diabetes ‘Gerhardt Katsch’ Karlsburg und Garz, Jahresbericht 1970, p.2.

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Furthermore, there was huge potential for a complex like the Central Institute, with the vision and drive instilled by its founding father, Gerhardt Katsch, to become a ‘showcase’.525 This would allow the GDR to reveal only that which was complimentary to its image and would create an institution which, with money supplied from the Ministry, could be internationally competitive (along with the prestige it brought). As Peter Grieder points out, the GDR was one of many ‘totalitarian polities’ that presented ‘a façade of order and efficiency to the outside world’.526 The regime, and high-ranking members of the SED, were also prone to overlooking the realities and convincing themselves that things were better than they were; those around them did their best to foster such false impressions, with Erich Honecker famously being driven down a beautiful, manicured road in East Berlin that masked the realities existing around it.527

The ‘lead institution’ was considered not only the pinnacle of clinical progress and research within diabetes care, but its status was also measured by political duties and tasks. In no place can this be found more explicitly than in the annual report from 1970 written by Bibergeil, at the time when the idea of the ‘lead institution’ had been officially confirmed in the change of name to ‘Central Institute’. ‘Central Institutes’ became widespread phenomena in the early 1970s, representing the belief of Walter Ulbricht in the mid-to-late 1960s that large-scale research should be conducted to encourage scientific and economic innovation. Andreas Malycha and Peter Jochen Winters argue that the economisation and politicisation of academic research reached a new quality in this period. 528 They also mention that the new Central Institutes were streamlining the research; originally, there were ninety research establishments, and of those, twenty-seven were made into ‘very large’ Central Institutes and a further sixteen into big and medium-sized Institutes.529 Since the Institute for Diabetes became one of the twenty-seven Central Institutes, its extensive research activities, especially within the realm of experimental research, made it a promising political vehicle. Moreover, it might be a

525 The idea of an institution, space or place providing the GDR with a sense of superiority (a ‘showcase’) is outlined in a number of studies. See: Emily Pugh, Architecture, Politics, and Identity in Divided Berlin (Pittsburgh: University of Pittsburgh Press, 2014), p. 161. The famous Leipzig trade fair as a ‘showcase’ is in: Mark Fenemore, Sex, Thugs and Rock ‘n’ Roll: Teenage Rebels in Cold-War East Germany (Oxford and New York: Berghahn, 2007), p. 6. The TV tower at Alexanderplatz is discussed in: Michelle Standley, ‘The Cold War, Mass Tourism and the Drive to Meet World Standards at East Berlin’s T.V Tower Information Center’, in Touring Beyond the Nation: A Transnational Approach to European Tourism History, ed. by Eric G.E. Zuelow (Farnham: Ashgate, 2011), pp. 215-240 (p.223). 526 Grieder, The German Democratic Republic, p. 128. 527 Stefan Wolle, Die heile Welte der Diktatur: Alltag und Herrschaft in der DDR 1971-1989 (Berlin: Ch. Links, 2009), pp. 212-13. 528 Andreas Malycha and Peter Jochen Winters, Die SED: Geschichte einer deutschen Partei (Munich: C.H. Beck, 2009), p. 174. 529 Malycha and Winters, p. 174.

130 contributory factor to why it was considered the ‘lead institution’ for diabetes in relation to the Zentralstelle in Berlin, which was less involved in the research so attractive to the SED and which was called for by Ulbricht. The drive to create a ‘Marxist-Leninist scientific organisation’ through this research also hints at the desire to create a superior, socialist alternative to the research completed in the West, and that the Central Institute for Diabetes was part of that mission.530

The peculiarity of the Central Institute over some others conducting similar research (particularly into chronic diseases) was its lack of affiliation with the East German Academy of Sciences. Until 1969, the Academy was an all-German body, but the East German branch had been gradually filled with ‘progressive’ scientists loyal to the SED and developed into a ‘socialist research academy’.531 It was by far the largest research centre in the GDR, comprising a wide variety of scientific and medical disciplines. Facilities that were affiliated with the Academy became ‘Central Institutes’ in 1972, sometimes having the word Forschung (research) in their title, for example, das Zentralinstitut für Krebsforschung (cancer research).532 However, the Central Institute for Diabetes became a ‘Central Institute’ two years earlier. This could indicate the level of autonomy afforded to (and regard for) the Central Institute for Diabetes on the part of the SED. Thanks largely to Katsch, the development and scope of the Central Institute allowed it to remain relatively independent of a larger body yet fulfil the same political demands as those expected of Central Institutes within the Academy.

The political significance of increased power and authority cannot be overlooked, and Bibergeil’s loyalty to the Party can be witnessed in his assessment of what the Central Institute for Diabetes had achieved. His emergence as leader was part of a broader political trend. Josef Reindl explains that the creation of Central Institutes made it possible for the SED to increase its position in the leadership decisively and was a subtext for amplified political influence. He compares the Institutes of the 1960s belonging to the Academy of Sciences, where only five leaders were members of the SED, to their transformation into Central Institutes, at which point all leaders were members of the SED.533 It is little wonder, therefore, that a large portion of the

530 SAPMO-BArch DQ1/10824 – Zentralinstitut für Diabetes ‘Gerhardt Katsch’ Karlsburg und Garz, Jahresbericht 1970, p.3. 531 Peter Nötzoldt, ‘From German Academy of Sciences to Socialist Research Academy’, in Science under Socialism: East Germany in Comparative Perspective, ed. by Kristie Macrakis and Dieter Hoffmann (Cambridge, MA and London: Harvard University Press, 1999), pp. 140-157 (p.140). 532 Heinz Bielka, Die Medizinisch-Biologischen Institute Berlin-Buch: Beiträge zur Geschichte (Berlin and Heidelberg: Springer Verlag, 1997), p. 85. 533 Josef Reindl, ‘Akademiereform und biomedizinische Forschung in Berlin-Buch’, in Antworten auf die amerikanische Herausforderung: Forschung in der Bundesrepublik und der DDR in den “langen” siebziger

131

1970 report of the Central Institute for Diabetes comprises evidence of a considerably heightened political consciousness. Bibergeil reported that the influence of socialism (Party and trade union activities) and the ideological awareness of the staff had been strengthened. He also discussed an initiative of the local SED leadership of Karlsburg, where a weekend course about ‘Marxist-Leninist scientific organisation’ had been set up for certain staff to attend.534 To keep the appearance of the Central Institute as the ‘showcase’, there were noticeable attempts to reinforce the value placed by state socialism on gender equality, outlining the percentages of women employed in each department. References to the promotion of women, a larger female representation in leadership roles, and determining what needed to be done to ‘qualify them politically’, was a nod to the wider desire to ensure that the whole facility should be in keeping with the concept of ‘display window socialism’.535

Another addition to the report was a curious list of staff who had supposedly had ‘the greatest effect on society’.536 Despite not stating that these people were members of the SED, it can certainly be assumed that if they were deemed to have had an impact on society, i.e. a state socialist society, they were highly likely to have been active in the Party. A fairly long list of names appeared, but there were also notable absences, an indicator that this heading cannot be taken literally. The leader of the children’s hospital and boarding school on the Island of Rügen, Dr. Heik, was not named, an influential enough figure to have appeared in the short- lived Direktorium. In fact, Bibergeil’s report was strikingly negative about the developments at the children’s hospital. The Central Institute had promoted several ‘socialist behavioural norms’, including ‘socialist competition’ (departments competing with one another) and other ‘mass initiatives’ that were brought in under the NÖS but had become a permanent feature of institutions even after the attempts to modernise the economy were abandoned.537 It was justified by Bibergeil as promoting ‘world standard’ and peak achievement in research. The report on participation in the ‘socialist competition’ concluded that for the Central Institute (including the children’s hospital and boarding school), eighty percent of staff took part. For all departments on the Karlsburg site, the figure was ninety-five percent, meaning that the number of those taking part on the Island of Rügen must have been considerably smaller,

Jahren, ed. by Gerhard A. Ritter, Margit Szöllösi –Janze and Helmuth Trischler (Frankfurt and New York: Campus Verlag, 1999), pp. 339-360 (pp.347-8). 534 SAPMO-BArch DQ1/10824 – Zentralinstitut für Diabetes ‘Gerhardt Katsch’ Karlsburg und Garz, Jahresbericht 1970, pp. 2-3. 535 Ibid., pp. 3 and 9. 536 Ibid., p. 4. 537 Ibid., p. 8.

132 although, with something so select as a children’s hospital and boarding school, this is perhaps understandable.538 Yet, Bibergeil highlighted this disparity and argued that more needed to be done to develop such measures as socialist competition in the areas under Heik’s watch. It appeared that Heik was being brought more into line with the rest of the Central Institute through, for example, joint trade union leadership, which would result in ‘unified procedures’ for the ideological work, socialist competition and improvements in working and living conditions.539

Fascination with ideas such as socialist competition emphasised that the Central Institute was being rendered into a kind of microcosm of socialist utopia. The results of the competition (which department had achieved the most in a given period) were to be announced on Lenin’s birthday and the 21st Anniversary of the Republic.540 There was a strong awareness, which had rarely been seen under Mohnike or Katsch, of the political mass organisations working with the Central Institute, frequently the trade unions, but also the Free German Youth (FDJ), whose organisation had been stabilised and expanded, presumably for young patients as well as members of staff.541 Close ties were also maintained and strengthened with the University of Greifswald’s Military Medical Section, where two doctors from (North) Vietnam, with which the GDR had close diplomatic relations, received laboratory training, and a doctor from Syria worked as an assistant.542 Doctors from other socialist countries had also been encouraged to work at Karlsburg. The tone of Bibergeil’s writing differed dramatically from that of Mohnike, where one was hard pressed to discover anything that was overtly political or ideological. Moreover, it revealed that, for the first time, there was more than simply scientific or medical enthusiasm at Karlsburg, and that there was an ambition for something much bigger than even Katsch had envisioned.

‘Research Project “Diabetes Mellitus”’ and ambitions for ‘world-leading’ research

Ever since Ulbricht declared in 1958 that the ‘Primary Economic Task’ was to overtake West Germany in per capita consumption of goods, there was a belief that the main economic driver would be scientific development and expertise.543 The so-called Groβforschung (literally ‘big

538 Ibid., p. 8. 539 Ibid., p. 18. 540 Ibid., p. 8. 541 Ibid., p. 9. 542 Ibid., p. 12 and p. 18. 543 Katherine Pence, ‘Grounds for Discontent? Coffee from the Black Market to the Kaffeeklatsch in the GDR’, in Communism Unwrapped: Consumption in Cold War Eastern Europe, ed. by Paulina Bren and Mary Neuberger (Oxford: Oxford University Press, 2012), pp. 197-225 (p.207).

133 research’) played a large part in Ulbricht’s plans to reform and revive the GDR’s economy, and the prevailing idea was for research to have, first and foremost, an economic benefit.544 Ulbricht’s mantra was always ‘überholen ohne einzuholen’ (overtake without catching up); it was understood that the GDR was on a different path to that of the West, so they could not be ‘catching up’ as such, but would ultimately be ahead once the work was complete.545 At the 8th Party Conference in 1971, Honecker dropped this term.546 The Central Institutes were designed as focal points for research, where resources could be pooled to provide the competitive edge that the SED desired. In the same year that the Institute for Diabetes was given its new title of ‘Central Institute’, the first draft of the neutrally named ‘Research Project “Diabetes Mellitus”’ was sent to the Ministry of Health for discussion. Despite its rather matter-of-fact title, the principle present in its content of becoming ‘world-leading’ was clear. Research activities had been plentiful at Karlsburg, but had not always led to very much, and certainly did not have the anticipated economic reverberations that the Ministry had hoped for.

The planned economy was central to the research being carried out towards the end of the 1960s at the (Central)Institute, and had been, to a lesser extent, in the earlier years as a result of social hygienic impulses. This can be seen across the board, and not just in diabetes research.547 The (Central)Institute heeded the demands made by Ulbricht for scientific innovation to improve the GDR’s economic fortunes even before the start of the Research Project. For each piece of research undertaken, a form from the Central Office of Statistics had to be completed. All forms included the heading ‘economic plan for science and technology’, forcing the author to explain what benefit the research would have for the economy.548 Diabetes research did not necessarily alter the functioning of the economy, but the ever-present themes of keeping people in work and preventing invalidity could be used where relevant. It did feel at times that those at Karlsburg were clutching at straws when justifying the economic

544 In West Germany, they were more inclined to use the American term ‘Big Science’ as opposed to ‘Groβforschung’(GDR) to denote ‘pioneering’ research. See: Agnes Charlotte Tandler, ‘Visionen einer sozialistischen Groβforschung in der DDR 1968-1971’, in Antworten auf die amerikanische Herausforderung: Forschung in der Bundesrepublik und der DDR in den “langen” siebziger Jahren, ed. by Gerhard A. Ritter, Margit Szöllösi –Janze and Helmuth Trischler (Frankfurt and New York: Campus Verlag, 1999), pp. 361-375 (p.361). 545 Reindl, p. 345. 546 Mark Landsman, Dictatorship and Demand: The Politics of Consumerism in East Germany (Cambridge, MA and London: Harvard University Press, 2005), p. 214. 547 Kristie Macrakis, ‘Introduction: Interpreting East German Science’ in Science under Socialism: East Germany in Comparative Perspective, ed. by Kristie Macrakis and Dieter Hoffmann (Cambridge, MA and London: Harvard University Press, 1999), pp. 1-24 (p.16). 548 SAPMO-BArch DQ1/23746 – Aufgabenstellung des Diabetes-Institutes Karlsburg für das Jahr 1968, 27/12/67 [‘Volkswirtschaftsplan 1968 Plan Wissenschaft und Technik Themenblatt’].

134 significance of their research. For example, Lippmann completed a form for his research theme entitled ‘Diabetes mellitus and Pregnancy’, in which he mentioned that the economic benefits were that there would be fewer days of work lost for pregnant diabetics and fewer deaths of offspring (corresponding to the SED’s pro-natalist agenda), pedalling the same now rather mundane narrative of maintaining people’s working capacities. 549

According to Agnes Charlotte Tandler, the delay in drafting the large research projects until 1970 was due to the SED discovering that the research performances in the GDR were seriously insufficient and that there was a lack of awareness of the world standard. The ‘Pionier- und Spitzenleistung’ (pioneering and peak achievement) would only be reached when a comparison could be drawn between the current domestic performance and the world standard.550 Tandler’s comments fit very neatly into the series of correspondence that took place within diabetes research leading up to the Research Project, and also help to explain why here, too, it only came to fruition at the end of 1970. The Ministry of Health focused intensely on ascertaining the current standard of research in diabetes within the GDR, and it did this through posing a set of questions to three different experts within diabetology, all, quite possibly, with varying relationships to the regime. Between January and February 1970, ‘questions reflecting the standing of medical research in the area of diabetes’ were sent to Bibergeil, Schliack and Lohmann (originally proposed to lead the then Institute by the Problemkommission).551 Each diabetologist received exactly the same questions independently. The first question required a response concerning the overall standard of research in the world. The second question asked about the situation in the Eastern Bloc, and the third question addressed only the GDR. All three questions had to be applied to every area of research that the diabetologists discussed.

By asking three people separately, the Ministry were keen to get a reliable and honest impression of the GDR’s situation from people capable of voicing different opinions. On a scale of positive to negative, Bibergeil was the most positive and Lohmann the most negative, with Schliack praising areas that were, naturally, within his own area of epidemiology. Bibergeil charted the current trends in research worldwide very broadly, including aspects like genetic research and early diagnosis, but admitted that there were some problems regarding the exchange of information with research centres in other countries, creating difficulties for those

549 Ibid [first sheet]. 550 Tandler, p. 369. 551 SAPMO-BArch DQ109/94 – Fragespiegel zum Stand der medizinischen Forschung auf dem Gebiet des Diabetes mellitus (D.m.), 2/2/1970 [Bibergeil, Schliack, 3/2/1970 and Lohmann, 30/1/1970].

135 at Karlsburg to chart what research was being done elsewhere.552 He was diverting the blame away from the Central Institute, claiming that this was a matter out of their hands. He used the same justification for sketchy views on the work done in the Eastern Bloc, but praised research activities involving pre-diabetes, animal testing and diabetes in pregnancy based on what was witnessed during study trips to the Soviet Union. Bibergeil also made some contradictory statements, implying that he was trying to sanitise the situation somewhat. He mentioned that the GDR was ahead with early diagnosis but elements needed to be added urgently. If this was the case, they should surely not be ahead.553 He regarded the East German diabetes care system as highly complementary to the research carried out and that it would be easy in the future to translate the research into practice.

Meanwhile, in his account, Schliack focused on the worldwide developments in prophylaxis, synthetic insulin and oral anti-diabetic tablets. Unlike Bibergeil, Schliack was fairly dismissive of the work conducted in the Eastern Bloc, but noted the excellent Soviet and Eastern European colleagues within the diabetology expert groups.554 It was, however, Lohmann who was far more upfront than Bibergeil and Schliack on the assessment of world trends and how the GDR measured up; he argued decisively that the most important findings had been made in western European countries.555 Until the mid-nineteen-1960s, he believed that, during the time of ‘Katsch, Mohnike’ and others, the GDR had been near the top but was currently of the opinion that they were ‘around five years behind’ the world level, and a little less behind with research into diabetic complications.556 Not having been given the opportunity to lead at Karlsburg after Mohnike’s death, Lohmann may have decided to reveal exactly what he thought about the overinflated status of the Central Institute. In fact, if one takes Tandler’s assessment of East German Groβforschung into account in reference to the SED’s disappointment at the unimpressive state of research, Lohmann’s comments may well be the most honest, if also the most undiplomatic, of the three.

The Ministry was continually frustrated by the lack of understanding and acceptance of what the situation was really like within diabetes research and how the GDR compared internationally. The value placed on research and the idea that it would enhance the GDR’s

552 SAPMO-BArch DQ109/94 – Fragespiegel zum Stand der medizinischen Forschung auf dem Gebiet des Diabetes mellitus (D.m.), 2/2/1970, [Bibergeil, pp.1-4]. 553 Ibid., [Bibergeil, p.2]. 554 Ibid., [Schliack, p.2]. 555 Ibid., [Lohmann, p.1]. 556 Ibid., [Lohmann, p.2].

136 reputation on the world stage further aggravated their concern. Innovative research provided excellent propaganda material, too, with the March 1969 edition of Deine Gesundheit containing, amongst other articles on diabetes, a three-page illustrative spread by Lippmann entitled ‘Way of the Modern Diabetes Research’. Yet, throughout the article, he only touched on broad world trends and not whether the GDR was ‘world-leading’ or in keeping with the world standard.557 This could have been tacit acknowledgement that the GDR had work to do. The Ministry voiced considerable disquiet at the irresolute nature of the approach to research at Karlsburg, which had, in essence, been confirmed by Bibergeil’s defensive reaction to the set of questions given. They set about mounting pressure on the Central Institute and controlling the course of research; a list of demands sent to Karlsburg included better international cooperation, the introduction of pioneering and world-class work, and the development of socialist scientific organisation.558

The first draft of the perspective plan for the ‘Research Project’, received by the Ministry in October 1970, attempted to stick closely to these demands. The introduction of Elektronische Datenverarbeitung (computer technology) featured as a pressing issue, as did the need to identify external influences such as healthy lifestyle and ‘risk factors’, as well as ‘risk groups’.559 This stemmed from the American risk factor approach, which was adopted worldwide. It was strongly integrated (certainly in principle) into the system of East German ambulatory and stationary diabetes care on the ground and signifies the Central Institute’s willingness to acknowledge a global trend that also happened to be easily compatible with state socialism. It was included in the ‘pioneering’ and prophylactic sections of the draft.560 A bold proclamation of the GDR as having been the ‘pacemaker’ in the system of diabetes care for twenty years prompted an equally bold question mark written by a member of the Ministry in the margin.561 There were predictable inclusions, such as research into new types of insulin, a call for the optimisation of diagnostic techniques in the pre-manifestation phase of diabetes, and a long-term study of the role of genetics in diabetes. In relation to pre-diabetes, a more intriguing addition was that of the World Health Organisation (WHO) criteria on testing and

557 Hans-Georg Lippmann, ‘Wege der modernen Diabetesforschung’, Deine Gesundheit, 3 (1969), 70-2 (pp.70- 2). 558 SAPMO-BArch DQ109/32 – Orientierung für die Ausarbeitung des Volkswirtschaftsplanes 1971, Planteil Wissenschaft und Technik, written by Dr. Loechel, leader of the main department of research within the Ministry of Health, 18/6/70, p.2. 559 SAPMO-BArch DQ109/32 – Perspektivplanangebot 1971-1975 zum Forschungsprojekt ‘Diabetes mellitus’, HAN Zentralinstitut für Diabetes ‘Gerhardt Katsch’ Karlsburg, p.1. 560 Ibid., p. 5. 561 Ibid., p. 3.

137 examination. Mention of the WHO reinforced the strong desire to be recognised as an integral part of the international community of medical professionals well before the GDR’s membership in 1973.562

The draft contained key information included in the Ministry’s demands, but it did not appear to be well-organised and did not fit together as a coherent whole, and the Ministry detected this. One of the officials charged with evaluating the draft, Dr. Riβmann, wrote to Bibergeil in November, expressing opinions that were not at all complimentary.563 Bibergeil was accused, as director of the project and key author, of providing evasive answers, and there was disappointment that ‘proposed research’ mentioned in the draft had not been carried out long before; the example cited was genetic research.564 Bibergeil was told that he had not made the Council for Planning and Coordination aware of what constituted being ‘world-leading’, reducing his proposals to mere words on a page.565 The criticism was heightened to such a degree that Riβmann questioned what the Central Institute had been doing for the past twenty years, and asked why so little world-class research had been produced hitherto.566

Seven concluding points by the Ministry explained why they could not accept this draft in its present form. They were concerned that there was no focus on the international standard, a necessary precondition for the Research Project, whose main objective was to generate ‘world-class’ research.567 In February 1971, the Ministry sent a list of rules for the ‘re-working of the Plan for the Research Project “Diabetes”’. They argued that there needed to be a study at Karlsburg establishing the exact world level compared to that of the Central Institute. It seemed that the Ministry had consulted VEB Berlin-Chemie, where they were told that insulin biosynthesis was of primary concern on the world stage; hence, this was included as one of the research topics they wanted to see at the Central Institute.568 Consulting another body, the pharmaceutical company, suggests that they were not entirely convinced that Bibergeil was admitting the weaknesses at the Central Institute.569 The failings of the first draft of the Research Project raise the question as to whether a better qualified, although less politically

562 SAPMO-BArch DQ109/32 – Perspektivplanangebot 1971-1975 zum Forschungsprojekt ‘Diabetes mellitus’, HAN Zentralinstitut für Diabetes ‘Gerhardt Katsch’ Karlsburg, p.8. 563 SAPMO-BArch DQ109/255 – Stellungnahme des Präsidiums des Rates an den Minister für Gesundheitswesens zum Projekt Diabetes mellitus, Projektleiter: Prof. Bibergeil (Leiter der Arb. Gr. D. Präsidiums: Dr. Riβmann). 564 Ibid., p. 2. 565 Ibid., p. 2. 566 Ibid., p. 2. 567 Ibid., p. 3. 568 SAPMO-BArch DQ109/32 – Festlegungen zur Überarbeitung des Planangebotes “Diabetes”, 10/2/1971. 569 Ibid.

138 loyal or inclined individual, would have done a better job of the proposal, which, inadvertently, would have worked with rather than against the aims of the regime.

The Ministry of Health’s additions and corrections to the Research Project were incorporated in an improved version of the draft sent by Bibergeil in March 1971.570 There was a much greater sense of purpose and direction to this draft than the first one. It began by listing three key outcomes of the Project: to optimise early diagnosis; to clarify the aetiology of diabetes; and to improve the therapy and prevention of the disease. It then proceeded to explain how pioneering and world-class results were to be achieved, which included an in-depth exploration of the world standard in fertile areas of research (for example, genetics and insulin biosynthesis).571 This new draft managed to focus not only on the research conducted at the Central Institute but also that conducted at the Zentralstelle (exploring diet, muscular activity and social environments), and there was an evident will to collaborate more with colleagues from across the GDR with specialist areas of expertise.572 This had not been seen in the previous draft, which had been more limited in scope to the clinical and experimental areas present at Karlsburg with only a nod to epidemiological and pharmaceutical issues. Two fairly elaborate diagrams added to the aesthetic appeal of the presentation, the first displaying the ‘basic concept’ of the Project, and the second, the general plan for 1971, including direct reference to each point in the main discussion of the Project.573 There was a clear attempt to engender some confidence at the Ministry through these diagrams, which seemed to display a new air of clarity and reiterated that their suggestions had been included. In the diagram on basic concepts, a scale was drawn between the three broad areas of research (genetic primary defect, diabetes preliminary stages, and manifest diabetes) to indicate how far each area was a long, medium or short-term goal.574

In spite of the inclusion of neat diagrams which visualised the written content of the Project, their function was little more than that, simply there to make the Project look more ambitious than it actually intended to be. The idea of ‘keeping up’ with the West, and understanding and following supposed global standards, compartmentalised the thinking surrounding the Research Project. The first draft had not convinced those in authority but the

570 SAPMO-BArch DQ109/32 – Forschungsprojekt “Diabetes mellitus” (Nr. 602), Ergänzungen und Korrekturen zum Planangebot und Pflichtenheft 1971, 2/3/71. 571 Ibid., pp. 1-2. 572 Ibid., p. 4. 573 Ibid., pp. 5-6. 574 Ibid., p.5.

139 revised version had a superficial quality whilst lacking the innovative spirit that had underpinned the ethos at Karlsburg when Katsch had founded it in 1947. Ulbricht’s message of moving ahead of the West, but by taking a different path, was a contradiction in terms, and the Research Project, especially in its later form, embodied this contradiction. The near obsession with obtaining and achieving the world standard inevitably meant having to replicate what research was being done elsewhere instead of allowing an organic development which might have been more original, possibly more innovative and rooted in the special state socialist path that Ulbricht demanded. Honecker’s succession to Ulbricht signalled a change of course, but it did not affect the ambition for the GDR to be a world leader in science and technology.575 Kristie Macrakis emphasises Honecker’s glorification of science and technology and ‘the advancement of “key technologies”’ and areas of science. She also notes that ‘given that Honecker had been responsible for overseeing state security in the Central Committee [of the SED]’, the way to obtain sound knowledge of international research was through the expansion of the security service, along with ‘a marked increase in scientific-technological espionage’ in the 1970s.576 More traditional methods of assessing the world standard were the ‘study trips’ abroad and attendance at international conferences, where delegations from East and West appeared to cut across the Iron Curtain.

Painting a positive picture of East German diabetology: trips abroad and visits made by international specialists

A positive portrayal of the GDR, both domestically and towards the wider world, was believed to be paramount in the quest for international status. The SED and the Ministry of Health had to be sure that an East German delegation visiting a conference in the West included those with the right political attitude. Peter Sperlich observes that East Germans travelling abroad almost always went in groups and there was rarely anyone allowed to go on their own.577 Rainer Hohlfeld argues that in genetic and biomedical research, ‘membership of the SED was an important, though not necessary, criterion for…appointment as travel cadre’, but that, nevertheless, there were many restrictions which impacted on the possibilities for East German

575 Tandler, p. 375. Tandler argues that the term ‘Groβforschung’ completely disappeared after 1971, but the large research projects seen under Ulbricht were allowed to continue albeit with less financial support. 576 Kristie Macrakis, ‘Espionage and Technology Transfer in the Quest for Scientific-Technical Prowess’, in Science under Socialism: East Germany in Comparative Perspective, ed. by Kristie Macrakis and Dieter Hoffmann (Cambridge, MA and London: Harvard University Press, 1999), pp. 82-124 (p.94). 577 Peter Sperlich, The East German Social Courts: Law and Popular Justice in a Marxist-Leninist Society (Westport, CT and London: Praeger, 2007), p. 20.

140 scientists to ‘measure their work directly against international competition’.578 These points can be applied to diabetologists more specifically. As had been stressed by the Ministry with regard to the ‘Research Project “Diabetes Mellitus”’, there had been very little explanation of the international standard in the drafts of the project, a result, perhaps, of diabetologists not being able to travel abroad to assess it for themselves.

In diabetology, there seems to be a greater degree of success than within the broader area of genetics and biomedicine in relation to networking. This might be in part due to the specialist nature of the discipline. Schliack and the Zentralstelle in Berlin had been potentially marginalised by the powers given to the Central Institute in Karlsburg yet were highly adept at participating in ‘European’ research groups. Schliack’s skills in representing the GDR effectively, taking on leadership positions in such groups (according to his own reports), allowed him to gain respect from the Ministry and circumvent some of the issues associated with the concentration of power in Karlsburg. He was also an example of a ‘travel cadre’ who was not a member of the SED, but was still granted permission to attend conferences in non- socialist countries, possibly on account of an already solid presence within the international community of diabetes epidemiology or his other ‘social activities’, such as the advisory role he held within the Ministry of Health on diabetes matters.579 The garnering of ‘political capital (as a kind of social capital)’, to use Bourdieu’s theory, without party membership was not uncommon in the medical ‘field’.580 Founding and Aufbau generations of doctors like Schliack were, as has been established, particularly distant from the SED in comparison to those in other fields, but some were clearly also willing to act pragmatically for the sake of their careers.581

Correspondence with the Ministry of Health revealed that Schliack attended conferences in many countries before, during and after the Prague Spring. The invitations to these conferences were from people who became involved in the ‘European Diabetes Epidemiology Study Group’, which was an important community within diabetes epidemiology, and included

578 Rainer Hohlfeld, ‘Between Autonomy and State Control: Genetic and Biomedical Research’, in Science under Socialism: East Germany in Comparative Perspective, ed. by Kristie Macrakis and Dieter Hoffmann (Cambridge, MA and London: Harvard University Press, 1999), pp. 247-268 (p.265). Hohlfeld argues that other ‘social activities’ instead of membership of the Party, such as membership of a ‘bloc party’ or trade union, could allow someone to travel. 579 Hohlfeld, p. 265. 580 Thomas Koch and Michael Thomas, ‘The Social and Cultural Embeddedness of Entrepreneurs in Eastern Germany’, in Restructuring Social Networks in Post-socialism: Legacies, Linkages, and Localities, ed. by Gernot Grabher and David Stark (Oxford: Oxford University Press, 1997), pp. 242-262 (p.249). 581 For the application of Bourdieu’s field theory, see: Michael Meyen and Anke Fiedler, ‘Journalists in the German Democratic Republic (GDR): A collective biography’, Journalism Studies, 14:3 (2013), 321-335 (p.331).

141 specialists from both Eastern and Western Europe.582 Schliack was the East German delegation leader at an October 1967 conference in Zagreb, then in the former Republic of Yugoslavia, which was liberal in comparison to the rest of the Eastern Bloc and had much freer borders.583 Therefore, those attending the conference had to be assessed by the Ministry in the same stringent fashion as would have been the case if they had been going to non-socialist countries.

An application was sent to the Department of International Relations within the Ministry of Health, naming those who were taking part (Schliack and the head of the laboratory at the Zentralstelle, Dr. Honigmann), the dates of the conference, the location, and theme (which was diabetes diagnosis, screening and social medical problems).584 Attached to the application was a longer text written by a member of the Ministry explaining the reasons why this conference was important and what they wanted from the visit. Central to the text was the standardisation of screening, testing and pre-diabetes examinations, and that Schliack and Honigmann should take on an active role in dictating the standards. The Ministry believed that by attending this conference and capitalising on Schliack’s expertise, the GDR could shore up its current ‘leading role’ in screening and diagnosis, and attempt to form a special international group that could be part of the International Diabetes Federation. 585 Schliack had also presented a document about the reasons for the invitation to the diabetes symposium in Zagreb, where he reiterated what had been said by the Ministry about the Zentralstelle working to determine binding standards for diabetes screenings, which would be outlined at the symposium.586 Schliack pointed out that the theme of the symposium was firmly within his ‘social medicine’ expertise; from Karlsburg only the statistician, E. Jutzi, had been invited (but would not attend). The Ministry raised this matter, too, in a small, handwritten passage granting Schliack and Honigmann permission to attend the conference, which mentioned that ‘the issues discussed are primarily those of the Zentralstelle’.587

582 SAPMO-BArch DQ1/23746 – Reisebericht über die III. Tagung der European Diabetes Epidemiology Study Group der Europäischen Gesellschaft zum Studium des Diabetes 24.9 bis 29.9.1968 Edinburgh/England [it should say ‘Schottland’]; SAPMO BArch DQ1/23746 – Begründung für eine Reise nach Edinburgh/Aberdeen/Groβbritannien, 31/7/68 [also lists the members of the study group, including those from Britain, Yugoslavia and West Germany]. 583 SAPMO-BArch DQ1/23746 – ‘Reisebericht’ [for a conference in Zagreb, Yugoslavia ‘vom 21. bis 31. Oktober 1967’]. 584 SAPMO-BArch DQ1/4343 – Abteilung Internationale Verbindungen [Department of International Connections], Ministry of Health – Betr.: Internationales Diabetes-Symposion, Zagreb. 585 Ibid., p. 2. 586 Ibid., p. 1. 587 Ibid., p. 1.

142

Schliack, along with Bibergeil, Lippmann, a representative from VEB Berlin-Chemie, and several other diabetologists from across the GDR, also attended the Sixth International Diabetes Federation Congress in Stockholm, Sweden, in July 1967, which was arguably the biggest and most prestigious conference in the calendar of East German diabetologists.588 Soon after, Schliack went to the Fourth Swiss Diabetes Society meeting on 25 January 1968 in Bern.589 Following each conference or trip, it was obligatory for East German delegates to write a Reisebericht (trip report) outlining the impact that the East German delegation had had at the conference, what had been discussed, and how the GDR attendees had been received. In his report on the Bern meeting, Schliack remarked that he had been received with warmth by his Swiss colleagues, and the discussions on diagnostic and epidemiological problems of diabetes had been fruitful. He also stated confidently that his talks had aroused considerable interest and lively discussion.590 He drew upon his ‘personal relationships’ with international colleagues to establish an opportunity for the exchange of experiences. This gave the impression to the Ministry that he, as an East German doctor, appeared to be highly influential on the international stage, which in turn shed a positive light on the GDR.

With this in mind, he emphasised that he had been allowed to attend a Swiss Doctors’ Association Meeting, where it had been stated that Swiss GPs had complained about having to treat diabetics in individual practices. Schliack was plainly insinuating here that in Switzerland there was a need for ‘East German-style’ treatment in specialist polyclinics and in a more centrally organised fashion.591 This could only have been music to the ears of the Ministry and the SED. He also implied that the conference had been exclusive insofar as foreign guests had had to be personally invited; according to Schliack, the welcoming speech had announced him as the ‘guest of honour’, highlighting his status there.592 The exclusivity of the conference had allowed him to come into contact with other doctors of ‘importance’, which he had capitalised on by meeting the representative of the World Health Organisation (WHO), Dr. Bridgman, to whom he had handed statistical material about diabetes in the GDR.593 It is very difficult to know for sure how far the reports by Schliack were an accurate representation of what happened at these conferences. This, however, is not really what makes these reports

588 SAPMO-BArch DQ1/4343 – VI Kongreβ der Internationalen Diabetes-Federation 29.5.67 vom 30.7- 4.8.1967 in Stockholm/Schweden. 589 SAPMO-BArch DQ1/23746 – Reisebericht 4. Tagung der Schweizerischen Diabetesgesellschaft am 27.1.1968 in Genf und Vortrag in der Med. Klinik in Bern 25.1.1968 [written by Schliack]. 590 Ibid., p. 1. 591 Ibid., p. 1. 592 Ibid., p. 2. 593 Ibid., pp. 2-3.

143 interesting. What is crucial is Schliack’s firm emphasis on recognition and prestige of the GDR, which in turn highlights the regime’s desire to be seen as an accepted player on the world stage.

Where Schliack appeared to be at his most influential abroad was during the trip to the Third Meeting of the European Diabetes Epidemiology Study Group of the European Society for the Study of Diabetes.594 This was held in Edinburgh, Aberdeen and London from 24-29 September 1968, and Schliack had been appointed to chair the conference.595 Once again, he was accompanied by Honigmann who does not appear to have attended any of the conferences without him. It is not clear whether Honigmann was a Party member or not, but Sperlich’s comment about East Germans travelling in groups is relevant here; Honigmann might have been tasked to keep an eye on Schliack and what was being said at the conferences he attended, although this cannot be ascertained for certain. They both arrived late at the conference in the UK because the British Foreign Office would not initially grant them a visa due to the GDR’s involvement with the Warsaw Pact’s military intervention in Prague.596 Schliack remarked that the British hosts had liaised with the Foreign Office to ensure that the visas were granted, and that the ‘DDR-Hilfsmaβnahmen’ (a euphemism for the GDR’s actions as part of the Warsaw Pact) had not interfered with the discussion.597 These British hosts included Dr. Harry Keen and Dr. Jarrett, the former having been interviewed as part of the ‘Diabetes Stories’ oral history project funded by the Wellcome Trust in which he discusses Schliack and the positive impression he had of his work.598 The GDR delegation, on account of its late arrival, missed the first day in Edinburgh, when Schliack and Honigmann had been supposed to talk about their contributions, along with the announcement of Schliack’s election as chair. Instead, Dr. Keen allegedly read out what they had intended to say.599

The trip to the UK prompted an extensive report from Schliack containing language which was telling of the (official) East German opinion on international relations. Even though he was not a member of the SED, he carefully chose his words so that they chimed with the expectations of the Ministry of Health and the SED. When listing all of those involved in the European Study Group, he referred to one of the doctors as being from the Selbständige

594 SAPMO-BArch DQ1/23746 – Reisebericht über die III. Tagung der European Diabetes Epidemiology Study Group der Europäischen Gesellschaft zum Studium des Diabetes 24.9 bis 29.9.1968 Edinburgh. 595 Ibid., p. 1. 596 Ibid., p. 1. 597 Ibid., p. 4. 598 ‘Harry Keen’, Diabetes Stories, Transcript 11, http://www.diabetes-stories.com/transcript.asp?UID=52#(11) [accessed 13/07/17]. 599 SAPMO-BArch DQ1/23746 – Reisebericht über die III. Tagung der European Diabetes Epidemiology Study Group der Europäischen Gesellschaft zum Studium des Diabetes 24.9 bis 29.9.1968 Edinburgh, p.1.

144

Politische Einheit Westberlin (independent political unit of West Berlin), rather than simply ‘West Berlin’ or ‘West Germany’.600 The 1964 Soviet-East German ‘Treaty of Friendship, Mutual Assistance and Cooperation’, included an agreement in Article 6 for both states to view West Berlin as a ‘free city’ to protect East German sovereignty.601 The aforementioned phrase was used until the Eighth Party Conference of the SED in June 1971, when the new leader, Honecker, decided to drop the term.602 Following on from his reference to the West Berlin doctor, Schliack also tapped into insecurities over the GDR having been continually ostracised by NATO countries by highlighting that the delegation had been treated as an official group from the GDR and had not experienced any discrimination. This was prior to the point at which West Germany finally recognised the existence of the GDR in December 1972 through their pursuit of Ostpolitik (détente). Other NATO countries followed suit, with Britain doing so in 1973.603

Schliack’s account of his trip to the UK contained much more detail than his trips to Yugoslavia and Switzerland, which might have been related to the GDR’s views of the UK’s healthcare system. Despite being part of the capitalist sphere, its decidedly ‘progressive’ healthcare system drew some praise from the East German Ministry of Health, so much so that the GDR was actually keen to learn something from it and collaborate more with British colleagues.604 Dr. Krüger of the Ministry responded to an application from Karlsburg to send a representative to visit London by agreeing that such a trip was necessary due to the noteworthy work being carried out in diabetes care there. The importance placed on learning English, not only for attending conferences in the English-speaking world, but also since it was the main lingua franca at all of the significant international conferences, was noticeable in the Ministry of Health documents. In, for example, the 1970 Annual Report of the Central Institute, Bibergeil stressed the need for regular intensive courses in English for at least 16 members of staff.605 The ability to communicate in English helped, of course, to involve the East German delegations in conferences, which also meant that they were less likely to be a marginal entity,

600 Ibid., p.2. 601 Manfred Wilke, The Path to the Berlin Wall: Critical Stages in the History of Divided Germany, trans. by Sophie Perl (Oxford and New York: Berghahn, 2014), p. 329. 602 Rolf Italiaander, Die neuen Herren der alten Welt (Düsseldorf and Vienna: Econ Verlag, 1972), p. 423. 603 Merrilyn Thomas, ‘“Aggression in Felt Slippers”: Normalisation and the Ideological Struggle in the Context of Détente and Ostpolitik’, in Power and Society in the GDR, 1961-79: The ‘Normalisation of Rule’? (Oxford and New York: Berghahn, 2009), pp. 33-51 (p.33 and p.42). 604 SAPMO BArch DQ1/23745 – Hauptabteilung System der Medizinischen Betreuung (Krüger) and Hauptabteilung Forschung (Dr. Mischke): Reiseantrage des Institutes für Diabetes in Karlsburg für 1970. 605 SAPMO-BArch DQ1/10824 – Zentralinstitut für Diabetes ‘Gerhardt Katsch’ Karlsburg und Garz, Jahresbericht 1970, p.13.

145 an insecurity still pervading the ranks of the SED even after recognition of the GDR’s status as an independent polity was fully acknowledged. Curiously, the emphasis on proficiency in English, and at this particular time, raises questions about political and ideological consistencies in the GDR. English was very much the language of capitalism, and this was stressed by Ulbricht and Honecker within the realm of culture. The clamping down on rock music towards the end of the 1960s, and the campaign in the early 1970s under Honecker to sing in German displayed a contradictory attitude toward the English language.606 The distinctly different aims within culture and medicine suggest that the attitude toward it was dependent on the goal of its use; in the event of a medical conference inside or outside the GDR, the use of English contributed politically to international prestige and legitimacy. In culture, however, English was associated with subversive art that worked against the ideals of socialism.

Diabetologists like Schliack fulfilled obligations to forge good links with the UK and others whilst not being a Party member, but there were others who felt the full force of the GDR’s travel restrictions, which proved that the GDR put up barriers for itself in terms of international cooperation in addition to those brought about by the Western reaction to events such as the military invasion of Prague. The level of scepticism toward allowing medical professionals to attend conferences abroad can be seen in attempts to encourage diabetologists to remain in the GDR or collaborate further with the Eastern Bloc. A paradoxical attitude emerged, where, on the one hand, there were demands for better cooperation with the West and improved knowledge of the world standard, and on the other, discouragement from visiting too many capitalist destinations and allowing too many people to attend conferences there. In the 1971 prospective plan for the Central Institute, which was part of the ‘Research Project “Diabetes Mellitus”’, Bibergeil and Dr. Lüdtke (scientific organiser) outlined the ‘required study journeys and visits’ to ‘the following institutions in capitalist countries’.607 Beside this statement, there was a large exclamation mark, presumably included by a member of the Ministry reading the text. At the end of the discussion on where they would be visiting and why, handwritten text in thick pen read ‘9 KA-Reisen!’ (nine journeys to capitalist countries!).608 The seemingly sharp reaction underscored the cautious sentiment within the Ministry, namely that encouragement

606 For the association of English with capitalism, see: Patrick Wagner, Englischunterricht in der DDR im Spiegel der Lehrwerke (Bad Heilbrunn: Klinkhardt Verlag, 2016), p. 103 and p. 357. 607 SAPMO-BArch DQ109/32 – Planangebot 1971 zum Forschungsprojekt Nr. 602 “Diabetes mellitus”, HAN: Zentralinstitut für Diabetes “Gerhardt Katsch”, p.3. 608 Ibid., p.14.

146 for cooperation should not supersede the willingness to remain focused on the socialist cause and the ‘special path’ called for by Ulbricht. Although it has been mentioned earlier that GDR delegations often travelled in groups, Bibergeil suggested in July 1971 prior to a conference held in Southampton, that he should make a voice recording of parts of the event to avoid the need to send additional delegates. 609 This request was granted by the Minister of Health, Mecklinger.610 Bibergeil also argued that recording the most important contributions would allow East German scientists who were not in attendance to receive better information about the world standard.611 This was evidently a tactic to reduce the numbers of people attending conferences in capitalist countries whilst at the same time attempting to alleviate the problems in areas where the GDR was ‘behind’ by giving specialists access to the information presented at a conference abroad without having to allow them to travel to the West.

Western visitors repeatedly showed interest in East German diabetology. As far as epidemiology was concerned, the Zentralstelle, with undoubted expertise in this field, was visited by those from abroad, including Dr. Harry Keen.612 The Central Institute, as the ‘showcase’ for diabetes care and research in the GDR with an increasingly large number of politically loyal cadres, played host to a whole range of important guests. In addition, influential political figures, largely from countries with whom the GDR had good diplomatic relations, were sent there for treatment. The mayor of Tripoli in Lebanon had been treated there as well as the wife of a sheikh, both of whom brought with them valuable hard currency that the GDR could use abroad.613 The Karlsburger Symposia, started by Mohnike in 1962, were the signature conference for diabetes hosted in the GDR, where foreign diabetologists were invited to discuss primarily research activities. An article in the pharmaceutical journal, Medicamentum, about the 7th Karlsburger Symposium reported that there had been 33 scientists/doctors in attendance from twelve socialist and non-socialist countries. This particular symposium had a noticeable focus on pharmaceuticals, and, to display the best of the East German pharmaceutical industry, VEB Berlin-Chemie and VEB Arzneimittelwerk

609 SAPMO-BArch DQ109/32 – EASD – Kongreβ in Southampton (England) 15. – 17. September 1971, from Bibergeil to Dr. Loechel (director of the research department of the Ministry of Health), 5/7/71. 610 SAPMO-BArch DQ109/32 – Permission for video recording granted by Dr. Loechel. The sending of pictorial materials to conference organisers in Southampton, which was also requested by Bibergeil, was denied, however. Letter dated 27/7/71. 611 SAPMO-BArch DQ109/32 – EASD – Kongreβ in Southampton (England) 15. – 17. September 1971, from Bibergeil to Dr. Loechel (director of the research department of the Ministry of Health), 5/7/71. 612 ‘Harry Keen’, Diabetes Stories, Transcript 11, http://www.diabetes-stories.com/transcript.asp?UID=52#(11) [accessed 13/07/17]. 613 SAPMO-BArch DQ1/23745 – ‘Ihr Schreiben vom 9.1.69’ written by Krüger to the ‘Leiterin der Abteilung Haushalt’ (leader of the finance department) of the Institute for Diabetes, 11/2/69.

147

Dresden (AWD) had ‘information stalls’ for insulin preparations and oral anti-diabetic tablets (Maninil and Buformin).614 This carefully managed organisation epitomised the desire to create a ‘façade of order and efficiency’.615 Each Symposium contained a range of topics, with emphasis sometimes placed on those that were considered to be areas of strength, such as diabetes in pregnancy, which had been championed since the Katsch era.

Already ahead of the rest? Changing perceptions of prevention and organisation in ambulatory and stationary care

Unlike with diabetes research, the outward confidence expressed about the system of diabetes care (ambulatory and stationary) and its position in the world was ever-present in the Ministry of Health files. In a meeting between several high-ranking diabetologists concerning the fight against diabetes, which included Bibergeil and Schliack, it was argued that the system of identifying and caring for diabetics was ‘unique on the entire earth’.616 The perception of the GDR’s efforts in screening as pioneering, with other countries supposedly following their example in large numbers, as well as the ‘leading’ position they occupied in the detection of diabetes morbidity, were just a few instances where hyperbole was used to emphasise status and solidify the belief that the GDR could have a competitive edge on the world stage.617 Expressions of confidence were at their most assured in reference to diabetes in pregnancy. This was arguably a niche that was originally developed by Katsch in which expertise was cultivated, largely at Karlsburg. On the occasion of the European Diabetic Pregnancy Study Group meeting in Madrid (September 1972), a report about the care for pregnant diabetics at the Central Institute for Diabetes claimed that the 1,809 pregnant diabetics who had been treated there over a timespan of twenty years constituted the largest group of such patients cared for at one single institution anywhere in Europe.618 The report also included other countries, the USA and Denmark, where concentration of pregnant diabetics had happened, but was quick to denounce their efforts as being nowhere near the scale seen in the GDR, where many (over forty percent of cases) had been treated at the same place (the Central Institute)

614 H. Fiedler, ‘VII. Karlsburger Symposium über Diabetesfragen’, Medicamentum, 13 (1972), 188-189 (p.188). 615 Grieder, The German Democratic Republic, p. 128. 616 SAPMO-BArch DQ1/10824 – Aktennotiz über durchgeführte Beratungen vom 16.-23.1.1969, ‘16.1.1969: Diabetes mellitus, seine Bekämpfung im abgestimmten und abgestuften System’. 617 SAPMO-BArch DQ1/13868 – Integration der Spezialversorgung in das abgestufte System der gesundheitlichen Betreuung by Dr. W. Schmincke and Dr. O. Günther. 618 SAPMO-BArch DQ109/33 – Auswertung und abgeleitete Empfehlungen zwanzigjähriger Arbeit des Zentralinstituts für Diabetes “Gerhardt Katsch” Karlsburg auf dem Gebiet der Betreuung und Entbindung diabetischer Schwangerer sowie der Aufzucht ihrer Neugeborenen, p.1.

148 with all the relevant expertise and careful oversight.619 It was emphasised that concentrating patients at Karlsburg enabled care to be delivered ‘through the control of the state’ (staatliche Kontrolle). The use of state control was discussed in a positive light, celebrating the fact that perinatal mortality was down due to limiting diabetic women to one pregnancy only. 620 The concluding remarks were as positive in tone as the whole report, judging the treatment overall in the GDR of pregnant diabetics to be exemplary and amongst the best in the world, thanks to the efforts by doctors from the pregnancy ward at the Central Institute, who were rewarded with admittance to the internationally renowned Diabetic Pregnancy Study Group.621

Whether these comments were well-founded or not, what must be noted is that, in spite of the outward confidence expressed about East German diabetes care by the Ministry and diabetologists, there was beneath the surface also underlying criticism of the Dispensaire System, screening and diabetes advice centres that rendered this confidence superficial. In the same way that expressions of confidence were motivated by the wish to be seen as internationally successful, so too was the desire to rectify faults of the system which did not allow doctors to act on the key principles underpinning the East German healthcare system. The Dispensaire System, in some ways, was proving to be a victim of its own success in the sense that more and more cases of diabetes were detected whilst the facilities and structures in place did not alter to fit these new circumstances. Ensuing debates over persistent problems experienced in diabetes advice centres relating to overcrowding and a disproportionate staff to patient ratio (too many patients and too few staff) led to scrutiny of the intensely specialist orientation of diabetes care. The speed with which new specialists could be trained simply did not keep up with the rapid growth in patient numbers, and lack of sufficiently qualified medical personnel affected the majority of diabetes advice centres throughout 1969.622

From the beginning, health theorists, particularly social hygienists, took pride in the fact that a complicated disease like diabetes could be treated in the GDR by someone who had undertaken the examination in the sub-specialism of diabetology; they were the highly specialist individuals who would have to undergo two years of additional training after becoming a Facharzt (interior medicine specialist), and a much longer period of training than a general practitioner. This level of specialisation, they believed, was at the root of preventative

619 Ibid., p. 3. 620 Ibid., p. 1, p. 4 and p. 10. 621 Ibid., p. 13. 622 SAPMO-BArch DQ1/13868 – Bericht der Bezirksstelle für Diabetes für das Jahr 1967-Bezirk Dresden, 6/3/1968.

149 health, and encouraged diabetics to be reintegrated into the workplace.623 The increased use of screening, driven by the Ministry of Health during the period of Störfreimachung and after, had, on the one hand, been a source of pride and was seen to have fulfilled the aim of early diagnosis. Yet, on the other, it caused a flood of new cases, many of which were non-insulin dependent diabetics. Of those, a large number were not considered to be complicated cases (they only needed to be treated by diet alone).624 For the first time, serious questions were asked about a new role played by non-specialist doctors, namely general practitioners or Hausärzte. It became a hot topic in the go-to journal for doctors, Das deutsche Gesundheitswesen. Whether this was a logical solution, or whether it was related to what was seen elsewhere in the world, cannot be judged for certain. Healthcare systems that were very much on the GDR’s radar, such as West Germany and the UK, utilised general practice extensively in the care of diabetics at this time.625 This may have caused the Ministry and diabetologists to consider whether it might have been possible to give GPs a role in diabetes care in the GDR, too, thus relieving some of the pressure on the system.

Ideas developed as early as the end of 1966 in the ‘Programme for the fight against diabetes’, which was checked and signed by the influential deputy minister of health, Mecklinger.626 It gave instruction that when a diabetic was discharged from hospital after a metabolic check, both the diabetologist and the GP should be notified. Questions were then raised more intensely after 1970 about where the GP could fit into the ‘further development of care for those suffering from diabetes’. There were suggestions that ordinary doctors should test their patients for diabetes and take an active role in Reihenuntersuchungen.627 An article featured in Das deutsche Gesundheitswesen by Dr. Dempe and Dr. Bauch also argued that the GP should take a greater level of responsibility in the identification of symptoms present in the patients they treated.628 Those who were initially quite wary of the introduction of GPs into the care for diabetics, namely Schliack, highlighted the socioeconomic costs that might be generated if treatment were left to GPs with inadequate knowledge of the disease.629 However,

623 SAPMO-BArch DQ1/13868 – Bildungsprogramm: Subspezialisierung für Diabetologie 1973. 624 SAPMO-BArch DQ1/5281 – Programm zur Bekämpfung des Diabetes mellitus 1966, p.16 [Effektivität des Programms]. 625 Ibid., p. 12 [Aufgaben der stationären Einrichtungen bei der Behandlung der Zuckerkranken]. 626 Ibid., [cover of programme]. 627 SAPMO-BArch DQ1/10824 – Grundsätze zur Weiterentwicklung der Betreuung von an ‘Diabetes mellitus Erkrankten’ (Modell eines abgestuften System der Diabetikerbetreuung), p.1. 628 A. Dempe and K. Bauch, ‘Klinische und anamnestische Daten der Diabetes – Reihensuche in Karl-Marx- Stadt’, Das deutsche Gesundheitswesen, 27 (1972), 296-302 (p.300). 629 SAPMO BArch DQ1/23749 – Schliack wrote a letter to the Ministry of Health in response to an article that appeared in the medical journal, ‘Humanitas’, about the involvement of GPs in diabetes care (1968).

150 he, too, admitted that there might be a role for them, but that this had to be firmly prophylactic, especially if the patient required more than diet-only treatment. This point of view won out in the end, and this is where the GDR differed from, for example, the UK where GPs actually treated diabetics. This implies then that, although the willingness to discuss a role for GPs in diabetes care appeared to be a fairly radical step forward, this was not allowed to conflict with the leading presence of diabetologists that had always existed in East German diabetes care.

Another reason for the move toward the greater involvement of GPs lay in the weaknesses of the method of screening people for diabetes by testing for sugar in urine (with the help of the Biophan test strips). Dr. Panzram wrote that detecting sugar in the urine should not be classed as an early diagnosis, as it did not tell the diabetologist how long a person had had the disease. Dempe and Bauch produced alarming results during a diabetes Reihenuntersuchung in 1967/8 where newly diagnosed diabetics had been asked whether, and for how long, they had had symptoms commonly associated with diabetes. The responses suggested that more than half of patients said that they had experienced symptoms for at least nine months before diagnosis. As a result, the diabetologists discovered that complications had already started, with 3.1 percent having developed retinopathy.630 Dr. Heinz Schneider agreed with the problems of urine diagnosis and the need for the early detection of symptoms, and added that it was much more successful to test for sugar in the blood than in the urine.631 In many cases of those screened, where test strips had suggested ‘sugar-free urine’, this had for a long time been seen as proof of metabolic integrity when it now became clear that might not have been the case.632 This therefore encouraged a heightened awareness of the need to note symptoms of diabetes such as thirst and weight loss at an early stage, which was where the GP could be incorporated. Once the glitch in the system had been identified (the overlooking of diabetes symptoms), this in turn led to a clearer definition of the role that would be played by GPs. By 1972, it was clear what a GP had to do; Dr. Latotzki in an article on ‘problems of diabetes mellitus in general practice’ created a list of GP responsibilities in diabetes care. They included detecting non-insulin dependent diabetes, recognising an acute manifestation of diabetes, using Biophan test strips (urine) and new Dextronal test strips (blood) for cases he/she

630 Dempe and Bauch, p. 300. 631 Heinz Schneider, ‘Vergleichende Untersuchungen zur Diabeteshäufigkeit der Landbevölkerung in der zweiten Lebenshälfte mit differenten Methoden des Screenings’, Das deutsche Gesundheitswesen, 27 (1972), 2309-2312 (p.2311). 632 G. Panzram, ‘Die klinische Frühdiagnose des Diabetes mellitus’, Das deutsche Gesundheitswesen, 25, (1970), 1157-1161 (p.1157); W. Neuendorf and R. Swarovsky, ‘Sind Reihensuchen nach Diabetes mellitus noch aktuell?’ Das deutsche Gesundheitswesen, 24 (1969), 967-8 (pp.967-8).

151 suspected as having diabetes, and also testing for keto-acedosis. In all cases, however, the responsibility post-diagnosis was no longer in their hands.633

The broadening out of diabetes prophylaxis into the realm of general practice coincided with, and was a likely response to, an influential shift in the thinking on the prevention of chronic diseases in the GDR. The central role played by social hygiene, from the construction of the East German healthcare system to the promotion of screening initiatives, was not threatened much in diabetes care throughout the 1950s and into the 1960s. However, by around 1968/9, rhetoric surrounding prevention initiatives began to change in official, specialist and popular discourse. There was a (re)energised focus on lifestyle and individuals making the right choices. Pre-existing ideas on lifestyle in the Katsch and Mohnike eras were largely based on post-diagnosis cases and for use as treatment measures designed by the diabetologist to prevent complications.634 By the late 1960s, diabetologists depicted lifestyle as a tool to prevent the disease itself and started to emphasise that the power was firmly in the hands of the patient in determining their own destiny.635 Without the appropriate measures being taken in one’s life, they argued, there would be a considerable number of Risikofaktoren (risk factors) associated with the aetiology of non-insulin dependent diabetes, such as adipositas (obesity), and that the general population ought to know about these risks urgently.636 Some diabetologists went a step further, such as Dr. Heinz Schneider, claiming that diabetes should be seen as a risk factorin its own right, especially for the development of cardiovascular disease. The new language of risk and lifestyle appeared to be inspired by a much broader, world-wide strand of epidemiology, the American risk factor approach.

633 H. Latotzki, ‘Probleme des Diabetes mellitus in der allgemeinärztlichen Praxis’, Das deutsche Gesundheitswesen, 27 (1972), 1506-8 (pp.1506-7). 634 See, for example, Mohnike and Katsch’s patient handbook: Gerhardt Katsch and Gerhard Mohnike, Aceton bis Zucker: Nachschlagebuch für Zuckerkranke 6th Edition (Leipzig: Georg Thieme Verlag, 1970). 635 SAPMO-BArch DQ109/33 – Ergebnisbericht an die Leitung des Projektes “Diabetes mellitus” 1972; SAMPO-BArch DQ109/33 – Klinisch-epidemiologische Untersuchungen bei 208 Diabetikern des Bezirkes Erfurt mit mindestens zwangzigjähriger Krankheitsdauer, by Prof. Panzram, Medizinische Akademie Erfurt. 636 Ibid [Ergebnisbericht].

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Figure 10: Placard highlighting obesity as a risk factor for cardiovascular disease and diabetes, 1970 637 The basic tenets of the risk factor approach came as a result of the Framingham Heart Study in Massachusetts, where individuals’ smoking habits, blood pressure, serum lipids, serum glucose and several other factors were examined to see if, and how, they contributed to the development of cardiovascular disease.638 Social hygiene had been very much the domain of epidemiologists, whereas risk factor thinking was far more clinically orientated.639 The continuing emphasis placed on the prevention of invalidity and getting diabetics back to work in the East German healthcare system, originally the product of social hygienic thinking, was also largely responsible for the change in attitude and adoption of the risk factor approach. Although it focused on individuals and not on society as a whole as social hygiene had done, the implication in the GDR that a good socialist citizen took responsibility for his or her health

637 Deutsches Hygiene-Museum, ‘Übergewichtig’, 2001/880 Plakat 638 Robert Aronowitz, Making Sense of Illness: Science, Society and Disease (Cambridge: Cambridge University Press, 1998), p. 118. 639 Carsten Timmermann, ‘Appropriating Risk Factors: The Reception of an American Approach to Chronic Disease in the two German states, c. 1950-1990’, Social History of Medicine, 25:1 (2011), 157-174 (p.159).

153 meant that it was in no great conflict with the aspirations of state socialism.640 Provided that the examination of individuals and their lifestyles could be justified as successful in fulfilling the aims of socialism and the East German healthcare system, doctors could adopt it with relative ease. To allow each citizen to fulfil the duty of healthy living as expected of an ideal ‘socialist personality’, it was the responsibility of medical professionals to educate diabetics and those at risk of developing the disease about its associated risk factors.641 The diabetologist took the lead on this matter, receiving vital information from GPs on a patient’s family history, background and living conditions.642 This emphasis on risk eventually led to new theoretical thinking by East German diabetologists, particularly in Dresden, where the researcher, Dr. Markolf Hanefeld, was instrumental in devising the concept, the ‘Metabolic Syndrome’, which saw diabetes as one of a cluster of diseases caused by the same factors.643

If the East German diabetologists were as interested as they appeared to be in putting the risk factor approach into practice, evidence suggested that they needed to improve educational initiatives. Dr. Kayser of Magdeburg complained about the lack of knowledge on the part of those already suffering from diabetes and that this alone was a risk factorfor the development of complications. He decided to hand out a questionnaire to his patients, this act in itself signifying a greater concern for individual predisposition to developing the disease, to study how much knowledge they had. The majority were aware of what caused diabetes, but fifty-two percent had incorrect ideas about how they might be able to lower blood sugar. Half of all those surveyed believed that schnapps and sauerkraut could reduce blood sugar, and one patient thought that, if he put sugar in his tea, by adding lemon afterwards, this would ‘counteract the sugar’.644 Kayser’s concerns were shared by Professor Panzram, who experimented with a study that aimed to reduce the risks of developing a diabetic coma. This involved giving a leaflet entitled ‘how to avoid a coma’ to 30,000 diabetics in his Bezirk (Erfurt). It was expected that diabetics read this and take appropriate action accordingly.

640 For the general concept of East German ‘disciplinary individualisation of health care’ in 1960s, see: Annette F. Timm, The Politics of Fertility in Twentieth Century Berlin (Cambridge: Cambridge University Press, 2010), p. 288. 641 E. Winkelvoss, S. Benndorf, R. Wendekamm and G. Scharfenberg, ‘Diabetes and Adipositas’, Das deutsche Gesundheitswesen, 4 (1969), 658-661 (p.660). 642 SAPMO-BArch DQ1/5281 – Programm zur Bekämpfung des Diabetes mellitus 1966, p. 11 [Aufgaben der stationären Einrichtungen bei der Behandlung der Zuckerkranken]. 643 Markolf Hanefeld, ‘Das Metabolische Syndrom: Wurzeln, Mythen und Fakten’, in Das Metabolische Syndrom: Ein integriertes Konzept zur Diagnostik und Therapie eines Clusters von Zivilisationskrankheiten (Jena and Stuttgart: Gustav Fischer Verlag, 1996), pp. 15-26 (p.17). 644 H.J. Kayser, ‘Ist der Informationsgrad der Diabetiker ausreichend?’ Das deutsche Gesundheitswesen, 25 (1970), 595-597 (p.597).

154

The risk factor approach marked a significant departure from social hygiene in that it examined individual predisposition rather than working from broad demographic and socioeconomic statistics which informed diabetologists of possible external reasons for diabetes prevalence.645 In spite of the differences between the risk factor approach and social hygiene, they were not necessarily diametrically opposed. The risk factor approach was ‘a quantitative concept’ and was dependent on the gathering of statistical data, as was social hygiene.646 A ‘risk factor’ was defined as ‘a pattern of behaviour or physical characteristic of a group of individuals that increases the probability of the future occurrence of one or more diseases’. 647 In her study of dieting in the GDR, Neula Kerr-Boyle suggests that the adoption of the risk factor approach ‘placed a new onus on the purported links between “overconsumption” and specific illnesses, such as diabetes and heart disease’.648 The identification of such types of behaviour and the resultant risk factorof obesity by diabetologists was apparent by 1969, but the reasons for this behaviour could still be justified by the compromised living conditions observed in social hygiene (with overconsumption of the wrong kinds of food in certain regions due to shortages of fruit and vegetables).

However, in the grand scheme of the GDR’s competition with the West, the introduction of this American import, and its challenge to the ideologically charged social hygiene, was significant. As Jeannette Madarasz-Lebenhagen points out, it ‘led to a convergence of prevention programmes in the two German states’.649 Not only did it symbolise the GDR’s willingness to adopt global concepts so as to maintain or meet the ‘world standard’, but it also demonstrated the GDR’s continuing desire to be considered a fully-fledged state, conforming to the same medical trends as other recognised nations did at that time. Madarasz- Lebenhagen also remarks that for both German states perceptions about healthcare had been manipulated by the ‘global discussion of self-empowerment to deal with risk factors’, adding an element of competition with which the GDR could readily engage.650 The introduction of anglicised terminology into the vocabulary of diabetologists, like, for example, replacing

645 Aronowitz, p. 112. 646 William G. Rothstein, Public Health and the Risk Factor: A History of an Uneven Medical Revolution (Rochester NY.: University of Rochester Press, 2003), p. 2. 647 Rothstein, p. 2. 648 Neula Kerr-Boyle, ‘The Slim Imperative: Discourses and Cultures of Dieting in the German Democratic Republic’, in Becoming East German: Socialist Structures and Sensibilities after Hitler, ed. by Mary Fulbrook and Andrew I. Port (Oxford and New York: Berghahn, 2013), pp. 158-178 (p.166). 649 Jeannette Madarasz-Lebenhagen, ‘Perceptions of Health after World War II: Heart Disease and Risk Factors in East and West Germany, 1945-75’, in Becoming East German: Socialist Structures and Sensibilities after Hitler, ed. by Mary Fulbrook and Andrew I. Port (Oxford and New York: Berghahn, 2013), pp. 121-140 (p.122). 650 Madarasz-Lebenhagen, p. 133.

155

Reihenuntersuchung with ‘screening’, and incorporating such words as ‘clearance’ and ‘long- term diabetes’, confirmed the interest in ‘keeping up’ with what others were saying and doing in the West.651

The ‘ironic, paradoxical and contradictory identity’ of the risk factor approach, and the idea expressed by Carsten Timmermann that ‘risk factors were many things to many people’, provided reassurance to doctors that they could apply it to their work without causing political upheaval.652 In fact, the didactic quality of the risk factor approach actually coincided with the GDR’s ambition to control large portions of its population and enhanced the effectiveness of health propaganda. Since social hygiene focused on the external factors causing disease and not the patients themselves, this gave the regime less scope to tell people directly how they should be living their lives. The new emphasis on individual responsibility encouraged media and propaganda outlets, such as the popular journal, Deine Gesundheit and the German Hygiene Museum (see Figure 9), to channel people’s behaviour to the wishes of the regime.

From June 1968, there was a noticeable increase not only in the number of articles on diabetes, but also a changed language that was even more marked than in official Ministry of Health documents, corresponding with the idea that the risk factor approach could be used as a manipulative propaganda tool. The first reference to lifestyle featured in an article on diet entitled ‘eat as little as you can’, using the informal version of ‘you’ to make a friendly appeal to the readers to change their diet.653 Deine Gesundheit’s March 1969 issue focused entirely on diabetes, featuring a series of articles on the disease. The editor, Gerhard Misgeld, in his foreword, explained why the journal had produced this issue on diabetes. He warned that 25 to 30 people of every 1000 in the population were expected to be at risk of developing it if changes in behaviour, eating, and bodily culture were not successfully established. He added that, for the life of an ordinary East German, the insufficient attention paid to sensible eating habits, failure to engage in regular sporting activity, and the inappropriate use of relaxation time increased the likelihood of developing the disease. He discussed those ‘at risk’ (Gefährdete) and appealed to the subscribers of the journal to consider their own lifestyle.654

651 SAPMO-BArch DQ1/13868 – Berlin, derzeitiger Stand (1968)-Groβstadt Modell. 652 The flexibility of the risk factor approach is mentioned by Robert Aronowitz and Carsten Timmermann. For the reference to its ‘paradoxical identity’, see: Aronowitz, p. 112. For the reference by Timmermann to the ambiguity of risk factors, see: Timmermann, ‘Appropriating Risk Factors’, p. 159. 653 H. Haenel, ‘Iss sowenig du kannst’, Deine Gesundheit, 6 (1968), 174-5. 654 Gerhard Misgeld, ‘Weshalb ein Heft über Diabetes?’ Deine Gesundheit, 3 (1969), 68 (p.68).

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Conclusion

The drive to become internationally competitive led to fundamental shifts in medical thinking, such as the introduction of the American risk factor approach, and prioritising ‘big research’, namely the ‘Research Project “Diabetes Mellitus”. The heightened control of the ruling SED in medical affairs could be witnessed in the substantial political changes at the Central Institute in Karlsburg, embodied by the sole leadership of the loyal Bibergeil, and in the continued insistence on the GDR being ‘world-leading’ in all aspects of diabetes care and research. An integral way in which the strength and position of the GDR within the international community of diabetes specialists could be put on display was through the attendance of a carefully chosen East German delegation at the most important international conferences. These included, for example, the International Diabetes Federation Congress in Sweden in 1970 attended by Bibergeil and the European Diabetes Epidemiology Study Group meetings visited and sometimes led by Schliack. It was during these conferences that the supposed merits of diabetes care and research under state socialism could be showcased to those from the other side of the Iron Curtain. Equally, strictly monitored visits to top places – the Central Institute and/or the Zentralstelle in Berlin – by experts from the West were seen to achieve similar results in amplifying the GDR’s status as a key player on the world stage. Collectively, this gave off the impression to those from outside that the GDR had nothing to hide, but by deciding who was allowed to visit, knowing the purpose of a visit, and making appropriate plans for the foreign entrant, it also implied an underlying insecurity that had always persisted at the top of the political hierarchy about a lack of legitimacy and a tarnished reputation.

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Chapter 4: The Height of the so-called ‘Normalisation’ Period (1973-1980)

Introduction

On 3 May 1971, Erich Honecker took over from Walter Ulbricht as the First Secretary (‘General Secretary’ from 1976) of the Central Committee of the SED, marking the start of ‘mature state socialism’ in the GDR.655 Two months later at the Eighth Party Congress, he announced that his ‘main task’ was to raise East German living standards and increase the size and scope of production. Whilst widening social policy was taking place before Honecker came to power, it took on a new significance and was met with a greater degree of ‘fanfare’ after he succeeded Ulbricht.656 The ‘cornerstone’ of Honecker’s social policy was the establishment of fully-fledged consumer-oriented socialism, subsidising a range of basic goods, from food to clothing, and investing heavily in the building of homes.657 Various welfare improvements were also made, such as extending maternity leave, expanding nursery school and creche facilities so that more mothers could work, and raising pensions by 20 percent.658 The so-called Gemeinsamer Beschluss of September 1973 intended to translate Honecker’s ‘main task’ to the healthcare system more specifically. At the Ninth Party Congress in 1976, these seemingly ambitious social aims were brought under a more rhetorically appropriate term, the ‘unity of economic and social policy’.659 The ultimate goal was to establish the conditions of ‘real- existing socialism’ and to engage in the constant battle to appease the population.660

There were moments in the period of this chapter, 1973 to 1980, when the GDR was arguably at the most stable point in its lifetime. As Jeffrey Kopstein argues, Honecker took ‘what he considered to be a condition of stable SED rule’ and elevated it ‘to a matter of principle’ by promoting so many social benefits.661 Aside from an expansive social policy, there were other important preconditions to this era of perceived stability. Honecker’s approach to foreign policy explored in the previous chapter allowed the GDR to be recognised

655 John Page, ‘Education under the Honeckers’, in Honecker’s Germany: Moscow’s German Ally, ed. by David Childs (Abingdon: Routledge, 1985), pp. 50-60 (p.58). 656 Manfred G. Schmidt and Gerhard A. Ritter, The Rise and Fall of a Socialist Welfare State: The German Democratic Republic (1949-1990) and German Reunification (1989-1994), trans. by David R. Antal and Ben Veghte (Berlin and Heidelberg: Springer Verlag, 2013), p. 65. 657 Jeffrey Kopstein, The Politics of Economic Decline in East Germany (Chapel Hill: University of North Carolina Press, 1997), p. 81. 658 Peter Grieder, The German Democratic Republic: Studies in European History (Basingstoke: Palgrave Macmillan, 2012), p. 73. 659 Kopstein, p.81. 660 Eli Rubin, Amnesiopolis: Modernity, Space, and Memory in East Germany (Oxford: Oxford University Press, 2016), p. 28. 661 Kopstein, p. 81.

158 internationally and reinforced a sense of legitimacy, although whether the GDR was ever fully legitimised as such is debateable. Perhaps even more important was the marked increase in the Stasi as a means of establishing necessary control and quashing opposition. From 1971 to 1982, the number of Stasi personnel increased by 50 percent and the Stasi overall doubled in size throughout Honecker’s time in power.662

The issue of the GDR’s stability has led to debate about the extent to which the GDR was ever ‘normalised’. Fulbrook and several ‘Fulbrookian’ historians have engaged with the concept of ‘the Normalisation of Rule’ and used it to help understand the GDR’s often overlooked ‘middle period’ in a more nuanced fashion.663 The point of ‘normalisation’ is not to judge how far the GDR was actually normal but rather to evaluate to what extent various institutions, organisations and political processes came to be perceived by those living there as ‘second nature’, even if they were only accepted begrudgingly by some.664 Indeed, ‘normalisation’ is a helpful way of understanding why certain aspects of life and society that were not considered normal before, such as importing goods from the West, came to be seen as routine practice later on. Likewise, looking comparatively at other countries, especially liberal Western democracies, can shed light on the supposedly ‘abnormal’ aspects of East German society that were ‘normalised’, like, for example, the shortage economy.665 Whether conditions were truly accepted or not, those working within the healthcare system had found ways of adapting to shortages and came up with compromise solutions that attempted to keep things ticking over.666 This is also heavily linked to Fulbrook’s idea of the ‘Participatory Dictatorship’, where ‘people were at one and the same time both constrained and affected by, and yet also actively and voluntarily carried out, the…social and political system of the GDR’.667

According to Ina Merkel, stabilisation, routinisation, and internalisation are the essential prerequisites for upholding any regime, and there has to be a significant amount of all

662 Barrie Baker, Theatre Censorship in Honecker’s Germany: From Volker Braun to Samuel Beckett (Bern: Peter Lang, 2007), p. 74. 663 Esther von Richthofen, ‘Communication and Compromise: The Prerequisites for Cultural Participation’, in Power and Society in the GDR, 1961-1979: The ‘Normalisation of Rule’? ed. by Mary Fulbrook (Oxford and New York: Berghahn, 2013), pp. 131-150 (p.150). 664 Mary Fulbrook, ‘The Concept of “Normalisation” and the GDR in Comparative Perspective’, in Power and Society in the GDR, 1961-1979: The ‘Normalisation of Rule’? ed. by Mary Fulbrook (Oxford and New York: Berghahn, 2013), pp. 1-32 (p.27). 665 Fulbrook, ‘The Concept’, p. 3. 666 Fulbrook, ‘The Concept’, p. 24. 667 Mary Fulbrook, The People’s State: East German Society from Hitler to Honecker (New Haven and London: Yale University Press, 2005), p. 12.

159 three components to generate ‘normalisation’.668 In line with the concept of the ‘Participatory Dictatorship’, participation is also vital in creating ‘normalised’ conditions. The definition of when ‘normalisation’ in the GDR started and finished must be highlighted for the purposes of this chapter. It is understood that ‘normalisation’ began immediately after the building of the Berlin Wall in 1961 and finished in 1979, yet a good portion of the edited volume devoted to ‘normalisation’ in the GDR focuses on the 1970s, with Mark Allinson’s chapter entitled ‘1977: the GDR’s Most Normal Year?’ a case in point.669 This does not mean that the 1960s are not worth examining in the context of normalisation, but, looking at the trajectory of diabetes care and research, ‘normalisation’ appeared to be much more pronounced in the period explored in this chapter. There was noticeable investment at the Central Institute for Diabetes, an increased tendency to categorise medical facilities and pharmaceuticals into distinct codified areas or fields and attempts to bolster what had already been established. It was as if aspects of diabetes care were solidified, and what was still ‘in progress’ in the 1960s, like screening, had become common parlance. Nevertheless, this period also has the capacity to reveal the economic cracks that begin to appear at the end of the 1970s, gradual erosion of the air of stability cultivated by Honecker, and thus the beginning of the end for ‘normalisation’.

This chapter will therefore explore the developments in diabetes care and research through the lens of ‘normalisation’. It intends to discuss ‘normalisation’ in the context of continuity (consolidating existing features of care or research) and change (in some instances, ‘making normal’ approaches that were not accepted before, and in others, understanding why there was resistance to different ideas). It will first cover the progress of the ‘Research Project “Diabetes Mellitus”’, which had passed directly from the Ulbricht to the Honecker era, and how the framework for research was adapted to fit the emerging narrative of the Eighth Party Congress (somewhat crudely in places). This will be followed by an examination of the final phase of consummating the Central Institute’s position at the helm. The chapter will then grapple more with care on the ground, highlighting areas of the Dispensaire System where change was required, but not always delivered, to create the conditions of so-called ‘real- existing socialism’. It will finally be brought to a close by looking at the state of pharmaceutical

668 Ina Merkel, ‘The GDR – A Normal Country in the Centre of Europe’, in Power and Society in the GDR, 1961-1979: The ‘Normalisation of Rule’? ed. by Mary Fulbrook (Oxford and New York: Berghahn, 2013), pp. 194-203 (p.195). 669 Mark Allinson, ‘1977: The GDR’s Most Normal Year?’ in Power and Society in the GDR, 1961-1979: The ‘Normalisation of Rule’? ed. by Mary Fulbrook (Oxford and New York: Berghahn, 2013), pp. 253-277.

160 consumption, ‘adverse drug reactions’, and the changed rationale of importing medication from the West.

The ‘Research Project “Diabetes Mellitus”’ in the early Honecker years The ‘Research Project’ was essentially a product of Ulbricht’s decentralising and experimental economic reforms of the 1960s, as well as the heightened competition between the GDR and the West (especially West Germany). Ulbricht’s utopian vision of enhancing productivity via a ‘scientific-technical revolution’ differed somewhat from Honecker’s emphasis on social policy and delivering tangible benefits of socialism in the here-and-now.670 The ‘Research Project’ was reconfigured and reorganised to fit the emerging ‘conservative socialist’ agenda endorsed by Honecker at the Eighth Party Congress.671 The term ‘conservative socialism’ implies that there was a return to certain Marxist-Leninist principles on which the GDR was originally founded, i.e. a ‘return to normal’; recentralisation and nationalisation of any remaining private or semi-state-owned businesses occurred to generate a more totalitarian flavour of rule.672 However, it must also be said that privileging consumption, as Honecker did, over production was not as ‘conservative socialist’ a move.673

Ulbricht’s economic reforms were largely abandoned in favour of greater ideological control. After the Eighth Party Congress, the Research Project adopted a politically uniform approach, appearing less chaotic than previous draft versions and more rhetorically aware. Its progress was compiled in a dissertation submitted to the Academy for the Further Education of Doctors in March 1975 entitled ‘Experiences of the leadership and scientific organisation of medical research using the example of the ‘Research Project “Diabetes Mellitus”’.674 The introduction acknowledges that the first draft of the Project was severely criticised by the Ministry of Health, as the previous chapter has uncovered, which came as a ‘wholesome shock’ but was later construed as ‘constructive criticism’. The author argues that it consisted of too

670 Peter Grieder, The East German Leadership, 1946-1973: Conflict and Crisis (Manchester and New York: Manchester University Press, 1999), p. 192. 671 Peter Grieder, ‘“When your neighbour changes his wallpaper”: the ‘Gorbachev factor’ and the collapse of the German Democratic Republic’, in The 1989 Revolutions in Central and Eastern Europe: From Communism to Pluralism, ed. by Kevin McDermott and Matthew Stibbe (Manchester and New York: Manchester University Press, 2013), pp. 73-94 (p.80). 672 Kopstein, p. 75. 673 Jonathan R. Zatlin, The Currency of Socialism: Money and Political Culture in East Germany (Cambridge: Cambridge University Press, 2007), p. 68. 674 SAPMO-BArch DQ103/325 - Anonymous, Abschlußbelegarbeit zum zweijährigen Zusatzstudium für Leitungskader im Gesundheits- und Sozialwesen, Akademie für Ärztliche Fortbildung der DDR 2. Kurs (1973- 1975), 27. March 1975, pp. 1-27.

161 many unrelated topics which were not geared towards the overall health-political goals.675 In contrast, the latest version supposedly put the health-political agenda at its core and took account of the character of medical research in a socialist society.676 A significant obstacle during the Ulbricht years of the Project had been the difficulty of determining precise world standard(s). Following the GDR’s admittance to the World Health Organisation in September 1973, diabetologists had much better access to international data and were now able to relate the standards of research on the Project to ‘those of the WHO’, which was altogether more convincing as far as the Ministry was concerned. 677

The newfound political clarity of the Project was helped further by the Gemeinsamer Beschluss (‘joint resolution’) calling for the ‘improvement of medical care for the population’, which was ratified following the agreement of the Politbüro, the Council of Ministers and the trade unions.678 The Beschluss stipulated the forthcoming tasks for and improvements of the healthcare system, including a promise to invest in healthcare institutions and highly specialised medical centres.679 In relation to research, it stated that the causes and conditions of disease and health must be established to ensure a rise in productivity.680 This can be seen directly in the Project, where there were persistent efforts to explore the genetic predisposition to developing diabetes in addition to the influence of a person’s environment, diet and social situation, all ‘important elements of Marxist-Leninist thinking’.681 The Beschluss also called for research in each respective medical area to be led by one institution, which, for the Project, was undoubtedly the Central Institute.682 It is clear that these political guidelines on healthcare set by the highest political authorities ‘normalised’ what had previously been a disjointed programme of research into diabetes, gave the Project a more politically polished appearance despite the scientific content not changing a great deal from the original first draft, and made it palatable to those scrutinising it at the Ministry.

675 SAPMO-BArch DQ103/325 - Anonymous, Abschlußbelegarbeit, p.3. 676 Ibid., p. 4. 677 Ibid., p. 20. 678 Lutz Wienhold, Arbeitsschutz in der DDR: Kommunistische Durchdringung fachlicher Konzepte (Hamburg: Disserta Verlag, 2014), p. 314. 679 Horst Spaar, ‘Gesundheitspolitik als Teil des sozialpolitischen Programms’, in Dokumentation zur Geschichte des Gesundheitswesens der DDR Teil V: Das Gesundheitswesen der DDR in der Periode der weiteren Gestaltung der entwickelten sozialistischen Gesellschaft und unter dem Kurs der Einheit von Wirtschafts- und Sozialpolitik (1971-1981), ed. by Horst Spaar and Dietmar Funke (Berlin: Trafo Verlag, 2002), pp. 25-45 (pp.28-9). 680 Spaar, p. 29. 681 SAPMO-BArch DQ103/325 - Anonymous, Abschlußbelegarbeit, p.5. 682 Spaar, p. 25.

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The technological challenges presented in the 1969 first draft of the Project, specifically in electronic data processing, remained in the 1975 dissertation, but there were signs of significant improvement if the content is to be believed. In 1968, VEB Kombinat Robotron in Dresden produced a data processing machine called ‘R300’, which was supposed to be a copy of various American IBM products.683 It was eventually distributed to important scientific institutions across the GDR. Not without its faults (basic software, for example, was not provided), it does appear to have been used extensively in the Project; according to the dissertation, 400 to 500 international diabetes works were put into the computer database and made available to researchers from East Germany and other socialist countries.684 The dissertation suggests that the reliance on importing technological goods from the West had not waned, warning that they should be used sparingly, not because they were costly (although this was certainly the case) but on account of the ‘dire state’ of the capitalist economic system after the oil crisis.685

A new technological invention by the Nuclear Institute in Rossendorf ignited hopes of independence from the West. They had developed a testing kit to determine insulin levels in the blood, and this was already being exported to other socialist countries. 686 The GDR’s ideas of grandeur, that is, considering themselves to be ‘world-leading’ and internationally at the forefront, persisted, but it was clear that their belonging to the WHO allowed for more action to justify, at least in part, some of these bold claims.687 Becoming a member of WHO was a boost in confidence and a diplomatic victory. The tone was less about wanting to prove that the GDR was a legitimate player and more about how scientists could make the results of the Project count on the world stage, and, as Madarasz-Lebenhagen remarks on cardiovascular disease, this is where ‘the WHO proved especially crucial’.688 In order to maintain the international reputation of the GDR, the results had to be made known. Naturally, publications in international journals and attendance at conferences still formed a vital part of disseminating the Project’s work and representing, as the dissertation asserts, ‘our’ scientists, but there were

683 SAPMO-BArch DQ103/325 - Anonymous, Abschlußbelegarbeit., p.10. 684 Ibid., p. 10. 685 Ibid., p. 14. 686 Ibid., p. 16. 687 SAPMO-BArch DQ103/325 - Anonymous, Abschlußbelegarbeit, p.3 [‘pioneering work with diabetic pregnancy’]. 688 Jeannette Madarasz-Lebenhagen, ‘Perceptions of Health after World War II: Heart Disease and Risk Factors in East and West Germany, 1945-75’, in Becoming East German: Socialist Structures and Sensibilities after Hitler, ed. by Mary Fulbrook and Andrew I. Port (Oxford and New York: Berghahn, 2013), pp. 121-140 (p.129).

163 new interest groups with whom those on the Project could connect that worked on behalf of WHO, like the European Diabetes Pregnancy Study Group.689

A further development from the formative years of the Project in terms of international cooperation and leadership is the increasing willingness to cooperate with other COMECON countries. This is surprisingly peripheral in the late 1960s, possibly due to growing unrest in Czechoslovakia and later in Poland in 1970.690 Positioning the GDR as a leader and coordinator of other Eastern-Bloc countries and relying more on that market could offset the unrealistic aspirations of the GDR as ‘world-leading’. This shift towards a greater consideration of the Eastern-Bloc also fits with the change in approach towards the Soviet Union which occurred when Honecker succeeded Ulbricht. Ulbricht was known for, as Martin McCauley points out, ‘almost legendary flexibility vis-à-vis the Soviet Union’ and did not accept its leadership as readily as Honecker, which was partly the cause of his downfall.691 He believed that the GDR could be a leading socialist state in its own right, much to the chagrin of the Soviet Union. Honecker meanwhile wanted the GDR to be ‘forever and irrevocably allied’ to the Soviet Union, and the emphasis placed on cooperation with other Eastern-Bloc countries was, again, a return to the ‘conservative socialism’ on which his ticket to power was based.692 A 1974 diagram of the Project’s ‘cooperation partners’ includes centres in the GDR (such as Erfurt, Dresden, Halle, Leipzig and various institutions in East Berlin) but also four major centres in socialist countries, which were in Leningrad (Soviet Union), Warsaw (Poland), Prague (Czechoslovakia) and Sofia (Bulgaria).693 Ties with Romania were forged by 1979. Political and ideological work was deemed a high priority of the Project, and the dissertation’s author believes that cooperation with other socialist countries, and the results gained from ‘socialist integration’, could be championed by East German delegations at international conferences in non-socialist countries, where the two systems, capitalist and state socialist, would be pitted against one another. 694

689 SAPMO-BArch DQ103/325 - Anonymous, Abschlußbelegarbeit, p.20. 690 A.J.McAdams, Germany Divided: From the Wall to Reunification (Princeton: Princeton University Press, 1994), p. 92. 691 Martin McCauley, ‘The German Democratic Republic’, in Leadership and Succession in the Soviet Union, Eastern Europe and China, ed. by Martin McCauley and Stephen Carter (Abingdon: Routledge, 2015), pp. 64- 80 (p.65). 692 Catherine Epstein, The Last Revolutionaries: German communists and their century (Cambridge, MA. and London: Harvard University Press, 2003), p. 184. 693 SAPMO-BArch DQ103/325 - Anonymous, Abschlußbelegarbeit, p.8a. 694 Ibid., p. 21.

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The bulk of the 1975 dissertation is relatively optimistic and instilled a sense of hope in the Project as it outlined concrete achievements and projections for its next phase, 1976- 1980. Overall, then, the Project appeared to be a mainstay feature of the nationwide coordination of diabetes research, with the Central Institute, as always, at the helm. From 1977, there was a degree of disgruntlement from participants of the Project regarding the financial resources available.695 For example, money appeared to be so tight that those attending meetings had to pay for their own food apart from drinks and snacks. At meetings held in East Berlin, where everything was more expensive than in Karlsburg, participants had to pay for everything, snacks included. In November 1979, a letter from a member of the Ministry of Health to the Central Institute advised that they no longer had the financial means available for any further material incentives.696 This went directly against the spirit of optimism outlined by the author of the dissertation on the Project, will have done little to spur participants on, and foreshadows a financially testing time for the GDR, from which it never fully recovered.

Clinics I, II and III: the ‘normalisation’ of the Central Institute for Diabetes Attempts from 1967 to establish the Central Institute as the unequivocal leader of diabetes care and research in the GDR were largely successful. As the central coordinator of the Research Project, answerable to the Ministry of Health, and frequently referred to simply as the ZID, there was no disputing its leading status by 1973. The Karlsburger Symposien continued to demonstrate that the Central Institute was the focal point for all international dealings and cooperation. The 10th Karlsburger Symposium was even linked to the International Diabetes Congress in Vienna.697 The Central Institute benefited from Honecker’s call in his ‘main task’ to invest in healthcare institutions and the special fund featured in the Gemeinsamer Beschluss for the development of specialist medical facilities. This financial backing allowed for the investment and organisational measures that could, potentially, take it to the next level, where it could become the leading coordinator of diabetes care and research not only for the GDR but also for other countries in the Eastern Bloc.698 Those from neighbouring countries were reportedly sending patients to the Central Institute for special treatment, and their doctors

695 SAPMO-BArch DQ1/26358 – Letter from Bibergeil to Dr. Schönheit of the Ministry of Health dated 3/9/79, p.1. 696 SAPMO-BArch DQ1/26358 – Letter from Dr. Schönheit of the Ministry of Health to Bibergeil dated 27/11/79, p.2. 697 SAPMO-BArch DQ1/26358 – Volkswirtschaftsplan 1979: Planteil Verbesserung der Arbeits – und Lebensbedingungen. 698 SAPMO-BArch DQ1/26355 – Fünfjahrplan 1976-1980, Zentralinstitut für Diabetes, p.7.

165 received extensive training there.699 The confidence generated by an immediate upswing in economic performance after Honecker came to power prompted those at the Central Institute to take a long, hard look at its organisational structure and identify areas that needed to be bolstered or modified.

The Ministry of Health received a report from the Central Institute about the ‘further development of the clinical area of juvenile diabetes’, criticising heavily the children’s hospital and clinic in Garz, set apart from the main site of the Central Institute on the Island of Rügen.700 Those at Garz had previously been reprimanded for not following political obligations, in particular the concept of ‘socialist competition’, and it appeared that the clinic’s very existence in Garz was in jeopardy. The report first mentions, using an obligatory grandiose statement, that the children’s hospital was ‘the only clinic of its kind in the world’ with special treatment devoted to juvenile diabetics.701 However, it did not, at the same time, ‘correspond to the demands of medical care and research of international standard’.702 In fact, the damning assessment of Garz continues by adding that the state of the buildings was poor, the sanitary and kitchen facilities were primitive, and in the summer months ‘110 percent’ of beds were in use, forcing some children to sleep in Notbetten (possibly camp beds).703 As a result of these shortcomings, it was decided in May 1974 that all care for juvenile diabetics should be moved to Karlsburg.704 The justification for this move was medical, economic and political; moving corresponded to the demand by the SED and the government to concentrate research in one place, followed Honecker’s general economic agenda of centralisation, and continued the need to control politically all aspects of the Central Institute. 705

Transferring juvenile diabetes care over to Karlsburg coincided with a streamlining of the clinical areas into a numerically ordered system. Once the institutional arrangements and necessary investment had been decided, the clinic for diabetic children would be called Klinik II.706 A stationary facility for insulin-dependent adult diabetics with complications was to form Klinik I, and, finally, the coordinating centre for pregnant diabetics would become Klinik III.707

699 SAPMO-BArch DQ1/26355 – Letter from Dr. Fuhrmann, leader of Klinik III, to Dr. Toedtmann of the Ministry, 18/7/1977. 700 SAPMO-BArch DQ1/25843 – Grundsatzentscheidung zum Investitionsvorhaben ‘Erweiterungsbau im Klinikbereich zur hochspezialisierten Behandlung diabetischer Kinder und Jugendlicher in Karlsburg’. 701 Ibid., p. 1. 702 Ibid., p. 2. 703 Ibid., p. 3. 704 Ibid., p. 4. 705 Ibid., p. 4. 706 SAPMO-BArch DQ1/26358 – Fünfjahrplan 1976-1980, Zentralinstitut für Diabetes, p.3. 707 Ibid., p. 2; SAPMO-BArch DQ1/26358 - Volkswirtschaftsplan 1978, Zentralinstitut für Diabetes, p.4.

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These distinct areas of expertise at the Central Institute had developed over the decades since its foundation, and categorising them in this way served to formalise and confirm their existence. The fundamental reorganisation of the Central Institute required significant investment, which the Ministry of Health was willing to give, fitting with the broader context of hospital construction and expansion of existing healthcare facilities across the country.708

Figure 11: Taking blood samples from patients at the Central Institute for Diabetes (Klinik I), October 1978 709

The bed shortage at the children’s hospital in Garz had been a pressing issue for some time, considering that so many children had to stay there for prolonged periods. Klinik II was therefore on the list of ‘top priorities for investment and values’ in the Central Institute’s five- year-plan, comprising a new Kinderklinik along with a Kinderkombination, a separate building with a dining room capable of catering for up to 380 people.710 This was designed for patients, staff, guests, and diabetic school pupils. The boarding school at Putbus had also begun to struggle with the volume of patients requiring long and short-term education but continued to

708 Alexander Burdumy, ‘Reconsidering the Role of the Welfare State Within the German Democratic Republic’s Political System’, Journal of Contemporary History, 48:4 (Oct. 2013), 872-889 (p.878). 709 Bundesarchiv Bild 183-T1024-0300. 710 SAPMO-BArch DQ1/26358 – Fünfjahrplan 1976-1980, Zentralinstitut für Diabetes, p. 7; SAPMO-BArch DQ1/25843 – Grundsatzentscheidung zum Investitionsvorhaben, p.7.

167 exist. To solve the problem of educating children who needed to remain at Karlsburg for a long time (for medical and ‘social’ reasons, such as poor home life), a new boarding school was erected in the immediate vicinity of Kliniken I and II.711 The existing clinic in Garz was to be turned into a permanent holiday camp for diabetic children.712

The ambitious nature of these institutional developments, the likes of which had not occurred since the days of Katsch, should nonetheless be seen in conjunction with familiar production problems and shortages, which were as ‘normalised’ as the undisputed leadership status of the Central Institute. Zatlin points out that Honecker’s consumerist approach ‘may have curried popular favour’ but also inadvertently ‘laid bare the material limitations of the planned economy’.713 A reference to the ‘fertiggestellte Kinderklinik’ in a letter written by Mecklinger to the Bezirk Rostock in September 1978 implies that Klinik II had been completed by this point.714 The purpose of the letter, though, was to ask the Bezirk Rostock to do something about the delay to the building work for the Kinderkombination, which seemed to have stalled. Mecklinger remarked that it was an extremely important part of the dietary provision for Klinik II and that those in the Bezirk had to ensure that it was finished soon.715 Although the Central Institute received significant investment from the Ministry of Health, they were at the mercy of locally administered, state-owned construction firms. Andre Steiner highlights the ‘centralistic control’ as a reason why new projects were not always entirely ‘finished’; in order to persuade the relevant political authorities to invest and include a project in the overall economic plan, the scope of it in an initial draft was deliberately underestimated.716 When the project started and hidden costs emerged, keeping up with schedules and demand proved to be challenging.717 A protocol dated 13 October 1977 on the ‘completion of the Klinik II TV Internat [boarding school]’ listed the difficulties faced, including a lack of painters, heating and ventilation concerns, no road building and lack of

711 SAPMO-BArch DQ1/25843 – Protokoll zur Kontrollberatung am 8.11. 1977 zum Investvorhaben “Klinik II TV Internat”, 9/10/1977, pp.1-2. 712 SAPMO-BArch DQ1/25843 – Grundsatzentscheidung zum Investitionsvorhaben, p. 5. 713 Zatlin, The Currency of Socialism, p. 68. 714 SAPMO-BArch DQ1/25843 – Letter from the Minister of Health, Ludwig Mecklinger, to a representative of Rostock Council, 12/09/78. 715 Ibid. 716 Andre Steiner, The Plans That Failed: An Economic History of East Germany, 1945-1989, trans. by Ewald Osers (Oxford and New York: Berghahn, 2010), p. 151. 717 Steiner, p. 151.

168 furnishings. The scheduled completion of the boarding school was supposed to be 30 November, but it appeared highly likely that that target would be missed.718

However, the three Kliniken took on the roles and responsibilities expected of leading, nationally recognised medical departments. Klinik I tested new depot and other modern insulins and worked as the main partner with Berlin-Chemi.e.719 The optimisation of prophylactic measures and training for diabetics took place here, and all methods were rolled out to diabetes advice centres across the country. New insulins were also tested in Klinik II, and it coordinated all of the children’s holiday camps in the East German Bezirke and even in other socialist countries.720 Klinik III, completed in March 1977, was, it seems, the most influential of the three, and its greater purpose is telling of the enduring confidence of the GDR’s capabilities and expertise in this area, perhaps not entirely without justification. There were prominent centres specialising in the care for pregnant diabetics in Leipzig, Halle, Karl-Marx-Stadt, Dresden and Kaulsdorf (East Berlin), which made Klinik III’s coordination efforts more efficient.721 Forty percent of all pregnant diabetics in the GDR were treated at Klinik III with the remaining sixty percent distributed to the other five centres, revealing, therefore, the centralising efforts employed by the Central Institute.722

Gynaecologists from the GDR and other socialist countries were specially trained to treat pregnant diabetics ‘within the framework of the WHO’.723 Klinik III was already participating in various international organisations, including the European Diabetes Pregnancy Study Group, and they were in the process of setting up bi- and multilateral cooperation with other socialist countries in research.724 A state-of-the-art animal testing facility was also proposed and listed as an ‘urgent’ priority for investment in September 1977. Since it was indispensable to the all-important Research Project, any ‘internationally-leading’ and ‘praxiswirksame’ research relating to the clinical areas covered by the Kliniken could not be conducted in former ‘stables’ and ‘cellar rooms’, described candidly as being well below

718 SAPMO-BArch DQ1/25843 – Protokoll zur Beratung am 13.10.77 über die Fertigstellung des Investvorhaben “Klinik II, TV Internat” in Karlsburg, 14/19/77, pp.1-2. 719 SAPMO-BArch DQ1/26355 – Hinweise für die Ausarbeitung des Fünfjahrplanes 1976-1980 für das Zentralinstitut für Diabetes Karlsburg, p.1. 720 Ibid., p. 2. 721 SAPMO-BArch DQ112/94 – ‘Diabetologen Tagung Dresden 1980’: handwritten notes from the meeting by Dr. Matthes of the Ministry of Health, ‘5 Zentren’, p.4. 722 SAPMO-BArch DQ112/94 – Stand und Perspektive der Betreuung schwangerer Diabetikerinnen in der DDR (1977), p.1. 723 SAPMO-BArch DQ1/26355 – Letter from Dr. Fuhrmann, head of Klinik III, to Dr. Toedtmann of the Ministry, 18/7/77, p.1. 724 Ibid., p. 2.

169 international standards.725 However, the Ministry was only alerted to this in 1977, at which time there was a significant decline in the efficiency of investments, and consequently the animal testing facility remained an approved idea but had still not become reality two years later.726

The creation of the Kliniken and a possible new animal testing facility was driven not only by investment but also by an increased number of staff. According to Alexander Burdumy, 60,000 staff joined the healthcare sector between 1970 and 1976.727 The increase in staff was especially noticeable in Klinik II. 55 qualified staff and 9 apprentices were employed in a bid to make this the leading facility for juvenile diabetes care. On paper, this looks like a substantial number, yet the 45 members of staff employed at Garz who were supposed to be absorbed by Klinik II in the end failed to move across ‘for personal and objective reasons’.728 As the political character of Garz had already been criticised, its personnel may not have been perceived to be politically loyal enough to fit the mould at the Central Institute. Attracting staff to work at the Central Institute presented some considerable challenges, bearing in mind its location in an isolated, sparsely populated region of the country. In spite of Honecker’s move away from Ulbricht’s regionalism, disparities were still striking. East Berlin enjoyed a privileged status, with an altogether higher standard of living. It proved to be a magnet for doctors, as Burdumy illustrates using statistics on the ratio of doctors to citizens. In East Berlin, there were 42.5 doctors for every 10,000 citizens whereas the GDR average was only 22.8.729

Towards the latter half of the 1970s, the Central Institute was struggling to persuade the Ministry to grant permission to employ the projected number of staff required, although this was related to financial constraints on the Ministry’s part and not a reflection of the Central Institute’s status as such. Bibergeil wrote several letters to the Ministry asking for more staff. Staff shortages hit Klinik III badly; in the 1978 plan for the Central Institute, there were reportedly no midwives on hand and specialists had to do the work themselves.730 Anaesthetists were not always on site, frequently taking over 60 minutes to arrive when called upon. In the newborn wing, there was only one inexperienced paediatrician and 3 of the 7 nurses could not

725 SAPMO-BArch DQ1/25053 – Aufgabenstellung zum Investitionsvorhaben “Bau eines Tierzuchthauses” im Zentralinstitut für Diabetes “Gerhardt Katsch” Karlsburg, pp.1-5. 726 SAPMO-BArch DQ1/25053 – Protokoll über die Standortberatung am 14.9.1977 für das Investitionsvorhaben Tierzuchthaus des Institutes für Diabetes Karlsburg in Karlsburg, 25/11/1977; Steiner, p.151. 727 Burdumy, p. 878. 728 SAPMO-BArch DQ1/26358 – Ak – Plan 1978, zentraler Bereich, Bezirk Rostock, 8/10/77, pp.1-2. 729 Burdumy, p. 878. 730 SAPMO-BArch DQ1/26355 – Volkswirtschaftsplan 1978, p.8.

170 work shifts due to family commitments. It appears that many of these problems fell on deaf ears; the Ministry’s response was to criticise heavily the report written by Bibergeil and the head of Klinik III, Dr. Fuhrmann, requesting that better use of existing staff be made.731 Again, it was a sign that Honecker’s ambitious social policies added a mere gloss to longstanding issues of staff shortages with which so many of those at the Central Institute and beyond were familiar, viewing shortages and the need to improvise as more ‘normal’ than working in an environment of plenty.

Extensive measures needed to be taken to encourage people to work at Karlsburg, but they were somewhat counteracted by the stringent ‘political, social and medical’ criteria in place for the appointment of cadres.732 Provision of decent housing, centrepiece of Honecker’s social programme, was the key strategy for enticing the best (but most politically trusted) staff to work at the Central Institute. New investment in detached and terraced housing coupled with ongoing investment in the building of flats were mentioned explicitly as methods to draw in new staff and to keep existing personnel at Karlsburg.733 80 new flats were reserved for 40 members of staff at Klinik II. For some, leaving East Berlin appeared to be a sacrifice. Two new specialists coming to Klinik III wanted to keep their flats in Berlin, which was roundly rejected by the Ministry.734 Despite the scale of Honecker’s Housing Programme, shortages persisted and no one was allowed to have more than one house or flat, so the options were either to rent a room at Karlsburg and keep the flat in Berlin, or to move completely to a flat in Karlsburg and give up the one in Berlin.735 To some extent, the Central Institute’s location and difficulties to recruit staff served to dampen an otherwise ‘normalised’ state of existence at the helm.

‘A highly qualified, highly specialised, high achieving, highly complicated and highly organised system of care’736: the Dispensaire System’s capacity to deliver ‘real-existing socialism’ to diabetics The focus on a smooth transition between prophylaxis, diagnosis, treatment and metaphylaxis remained the overall mission of the Dispensaire System, staying true to its 1950s roots. In the

731 SAPMO-BArch DQ1/26355 – Jointly written letter from Bibergeil and Fuhrmann about staff shortages at Klinik III, June 1977. 732 SAPMO-BArch DQ1/26358 – Inhaltliche Aufgabenstellung zur Staatlichen Auflage 1979 des Zentralinstitutes für Diabetes “Gerhardt Katsch” Karlsburg, p.6. 733 SAPMO-BArch DQ1/25843 – Antrag auf Einrichtung von Einfamilienhäusern, 21/11/1979, pp. 1-2. 734 SAPMO-BArch DQ1/26358 – Letter from Dr. Ehler of the Ministry to Bibergeil in response to his original 8/9/77 request for the flats, 17/9/77. 735 Ibid. 736 K. Kuminek, ‘Die Einbeziehung des Facharztes für Allgemeinmedizin in wichtige Teile der Dispensairebetreuung’, Das deutsche Gesundheitswesen, 29 (1974), 1213-16 (p.1214).

171 area of prophylaxis, screening techniques continued to be refined and expanded, but emphasis on ‘borderline’ cases, preventing the onset of diabetes, and targeting the working population still governed thinking. The risk factor approach as opposed to social hygiene was more entrenched in those performing screening by the mid-1970s, dictating who should be screened and used as an educational initiative in the popular health journal, Deine Gesundheit.737 The fact that not much changed in the way that the Dispensaire System functioned, and that it was very much the ‘normalised’ approach to diabetes care on the ground, proved to be increasingly problematic. This, in turn, demonstrates that normalisation and stability did not always go hand-in-hand. In the medical journal, Das deutsche Gesundheitswesen, and in correspondence with the Ministry, doctors voiced concerns about the capabilities of the Dispensaire System to cope with the volume and range of health issues. Discussions on how to improve the system centred in particular on the introduction of GPs to specialist care, a matter that had been raised in the previous decade but had been firmly dismissed by Schliack and other colleagues. It was always assumed that diabetics and those with other complicated conditions should be treated only by specialists and that any health problem not related to diabetes should be left to the GP to sort. As screening initiatives for diabetes were expanding exponentially, reportedly involving over 500 staff nationwide, the Dispensaire System suffered from miscommunication between doctors and too much pressure placed on specialists to treat seemingly minor cases.738

A leading doctor of a regional ambulatory centre, Dr. Kuminek, wrote an engaging and revealing piece in Das deutsche Gesundheitswesen in June 1974 about the development and subsequent problems of the Dispensaire System.739 At its core, he argues, the system demonstrated a ‘pillar ideology’, grouping diseases in strictly separate categories and organising them vertically.740 Kuminek believed that this had had significant advantages in the early period of the East German healthcare system but in the long-term had made care less effective because there had been frequent parallel treatment by different doctors, necessary information had not been passed on from one doctor to another, and resources had not been used optimally. This ‘pillar ideology’ could be seen in how diabetologists framed the discussion of Dispensaire care, referring to the ‘Dispensairebetreuung [Dispensaire care]

737 SAPMO-BArch DQ112/94 – Betr.: Begründung des Antrages auf Druckgenehmigung des im oGTT-Multi- Screenings anzuwendenden Patientenfragebogens, 14.03.1977, [Anhang/attachment]: D. Michaelis, ‘Forschen für den Diabetiker’, Deine Gesundheit, 1 (1976), 26-7 (pp.26-7); E. Zander, ‘Diabetiker-Herzen’, Deine Gesundheit, 5 (1976), 152-3 (p.152). 738 SAPMO-BArch DQ1/26358 – Volkswirtschaftsplan 1979 – Planteil Verbesserung der Arbeits-und Lebensbedingungen, p.1. 739 Kuminek, pp. 1213-16. 740 Kuminek, p. 1214.

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Diabetes mellitus’ and assuming that the onus was on diabetes care rather than its place within a much broader system.741 Highlighting the shortcomings of the Dispensaire System was one thing but coming up with a solution that enhanced its performance was another. Kuminek considered greater inclusion of GPs to be the ‘answer’ and argued that the basic principle of ‘the GP looks after the sick person, the specialist looks after the disease’ had to change. Instead, there needed to be much closer cooperation between GP and specialist for the benefit of the patient.742

To get an understanding of the preconceived notion of the supremacy of specialists, another article mounts a case to suggest that in the current climate, GPs were not ready to be allowed to treat diabetics beyond the mundane issues. This article, written by Dr. Panzram, the regional head diabetologist of Erfurt, uses the example of the diabetic coma to demonstrate why GPs should not be involved yet in the treatment of diabetics.743 Panzram analysed the treatment administered to coma cases by different doctors: GPs; interior medicine specialists, and diabetologists. Unsurprisingly, his findings reveal that 100 percent of coma cases treated by diabetologists were managed correctly. Interior medicine specialists also fared well, treating 21 out of 24 cases correctly, but GPs were noticeably out of touch. He had calculated that only 47.1 percent of coma cases received the right treatment, and in 25 percent of the cases, the doctor did not even notice that the patient had suffered a diabetic coma. In a further 9.4 percent, there was a serious delay until the correct diagnosis was made.744 His conclusions do not totally dismiss the importance of GPs but reveal considerable reservations towards a change.

Including GPs in diabetes care was discussed continually by diabetologists and those at the Ministry, with evidence of a great deal of talking and not much action. In 1974, Bibergeil presented an outline of ‘the tasks of GPs’, which consisted of screening urine and blood sugar, monitoring people at risk, and advising diabetics about diet, lifestyle and social issues.745 There were to be very clear boundaries to define what GPs could or could not do. They were to monitor patients whose diabetes was controlled by dietary methods alone, and the possibility was raised that they might also play a part in the care of patients treated with oral anti-diabetic

741 SAPMO-BArch DQ1/13868 – Report from Bibergeil to Ministry of Health on ‘Dispensairebetreuung/Diabetes mellitus’, 3.7.1974. 742 Kuminek, p. 1215. 743 G. Panzram, ‘Prophylaktische Konsequenzen einer epidemiologischen Studie über das Coma diabetikum’, Das deutsche Gesundheitswesen, 28 (1973), 1359-1363. 744 Panzram, p. 1362. 745 SAPMO-BArch DQ1/13868 – Report from Bibergeil to Ministry of Health on ‘Dispensairebetreuung/Diabetes mellitus’, 3.7.1974, pp.3-4.

173 tablets. However, they were not allowed to prescribe tablets or insulin except when faced with a coma case or if a patient had lost his or her insulin. They had to report all acute illnesses to the diabetologist, and pregnant diabetics had to be treated and monitored only by the diabetologist.746 Although there was recognition that circumstances were such that the help of GPs would be needed, serious reservations as to their capabilities remained obvious. The following year, attitudes seemed to soften a little, and Bibergeil wrote to the Ministry that the further step-by-step integration of GPs into care, helped by a systematic qualification of GPs in diabetes issues, was integral to the ‘further development’ of the fight against diabetes.747

At a meeting of all the regional head diabetologists in April 1977, extensive discussion about the role of GPs took place, signifying the magnitude of the issue and the realisation that they were required in the system.748 However, reflections on their ‘step-by-step integration’ are not complimentary and reveal a lack of progress made. Cooperation between GPs and diabetologists varied wildly between regions.749 Dr. Wegner, the head diabetologist for Cottbus, reported using GPs much more than before and found that the reduction of burden on specialists was very positive.750 Schliack, an early advocate of strictly specialist care, had attended the annual meeting of the society of GPs, where he claims that GPs had voiced concern that they knew too little about diabetes, but that they had also expressed a willingness to cooperate with diabetologists.751 They had asked that training be provided, but only now in 1977 was a training programme even proposed, and in July 1978 a book for GPs on diabetes was produced by Dr. Bruns and others.752 Several years after the need to integrate GPs had first been raised, not much appeared to have happened, apart from in a handful of regions like Cottbus. Even in February 1980, there was still talk of integrating GPs, a sign that progress was decidedly slow.753 In interviews with four insulin-dependent diabetic patients, when asked about the role of GPs in the care of their diabetes, all stated that, if any, they played at best a minimal role. They, too, viewed the specialist as the principal figure, reflecting the prevailing

746 Ibid., pp. 4-5. 747 SAPMO-BArch DQ1/13868 – Thesen Schwerpunkte für die Weiterentwicklung der Diabetesbekämpfung in der DDR 1976/80, 24/2/1975. 748 SAPMO-BArch DQ1/13868 – Kurzprotokoll der Arbeitstagung der Beratenden Diabetologen der Bezirksärzte vom 11.- 13.4.1977 in Rostock, pp.1-7. 749 Ibid., p. 1. 750 Ibid., p. 2. 751 Ibid., p. 3. 752 Ibid., p. 2. 753 SAPMO-BArch DQ112/94 – Kurzprotokoll über die Sitzung des Fachbeirats für Diabetes beim Ministerium für Gesundheitswesen vom 13.2.1980 in Berlin, p.3.

174 attitude toward the specialist and complicated conditions within the Dispensaire System.754 In the case of the GP and diabetes care, slow progress was not caused by financial issues. Indeed, the inclusion of GPs was supposed to help save money. Clearly, opinions that were formed at the beginning of the GDR’s lifetime helped shape irrevocably those expressed two decades later; continuity and resistance to change ‘normalised’ attitudes.

The GP was not the only figure needed to alleviate the burdens on diabetologists. The well-established ‘mid-level’ members of staff like the specially-trained ‘diabetes nurses’, who came to prominence during the ‘Störfreimachung period’, saw their role and presence expand in an even greater climate of ‘consumer socialism’. In fact, their duties in the care for diabetics were invariably more wide-ranging and hands-on than those of a GP. Bibergeil sent a document to the Ministry which contained a ‘function plan’ for all diabetes nurses across the country. It divided their duties into the themes of ‘consultations’, ‘social care and advice’, ‘specialist care of particular patient groups’, ‘working together with other institutions’ (holiday camps, sanatoria and old people’s homes), ‘organisational and secretarial work’, and ‘prophylactic tasks’. 755 A diabetes nurse sat in on appointments with the diabetologist, taking blood pressure, weighing the patient, collecting urine samples, and giving dietary advice both before and after consultation. Honecker’s reduction in the price of basic consumer goods presented problems with diet control, and products specifically marketed for diabetics only added to these (‘diabetic beer’ was excessively high in both calories and alcohol).756 The diabetes nurse also made routine visits to homes to assess the diabetics’ environment and analysed these visits with the diabetologists. Unlike the GP, who had to steer clear of those with diabetic complications, the nurse kept tabs on Longterm-Diabetiker, patients with complications, pregnant diabetics, and diabetics in jobs involving specific risks (the examples listed are delivery driver, tram driver and builder).757

Diabetes nurses had few strictly clinical powers, which explains the demand for GPs to be included. Yet, their role as advisor, carer and secretary highlights how important they proved to be to the specialist, relieving them of administrative tasks and keeping patient records in order, vital in the statistics-driven, prevention-oriented system. Despite not having the weight

754 Interview with patient M.B, 29 May 2017; interview with patient U.W., 7 August 2017; interview with patient K.K., 15 August 2017, and interview with patient K.S., 14 February 2018. 755 SAPMO-BArch DQ1/13868 – Funktionsplan der (Kreis) Diabetesfürsorgerin, 28/7/1975, written by Bibergeil, pp.1-2. 756 Ibid., p. 1. 757 Ibid., p. 2.

175 of medical responsibility that a specialist or GP had, they had to be relied upon all the same. They were entrusted to give the additional payment of 13 Marks to all diabetics so that they could buy the appropriate foods for their diet. Several diabetics benefited from Honecker’s social programme; diabetics on benefits and on the lowest pensions were now entitled to an extra 18 Marks.758

Figure 12: Diabetes nurse dealing with a patient admission at the Central Institute for Diabetes, 1978759

The SED’s efforts to promote free time and leisure activities are evident in the rapid expansion of holiday facilities and camps for diabetics in the regions after Honecker came to power. The original holiday camp on the island of Rügen was supposed to be the catalyst for a wider range of facilities for diabetics away from their home setting, but nationwide expansion only seemed to be instigated after 1973.760 It started with a winter camp at Karl-Marx-Stadt

758 SAPMO-BArch DQ1/13868 – Protokoll der Arbeitstagung der Beratenden Diabetologen der Bezirksärzten am 27. /28. 5. 1979 in Potsdam, Anlage 3. 759 SLUB Dresden, Deutsche Fotothek, Norbert Vogel (DS 71680237). 760 E. Lüdtke, E Rattmann and G. Mögling, ‘Die soziale und medizinische Bedeutung der Dauer- und Ferienbetreuung von Schülern mit Diabetes mellitus’, Das deutsche Gesundheitswesen, 31 (1976), 944-46 (p.946).

176 followed by a series of summer camps in the Bezirke, such as a new holiday camp in Cottbus, which was profiled in Das deutsche Gesundheitswesen in 1976.761 The vast majority of holiday camps were designed for younger diabetics; the GDR’s Marxist-Leninist status quo had always emphasised the importance of youth and the future, but Honecker approached ‘Jugendpolitik’ with renewed vigour. Given the emergence of a distinct youth culture and a generation of young people who had grown up exclusively in the GDR, the opportunities to use holiday camps as a political vehicle were plentiful.762 The function of these camps was not the same as that of the sanatoria; they genuinely promoted leisure rather than strictly rehabilitation and were linked to ‘core socialist theories’ such as nurturing the enigmatic concept of the ‘socialist personality’.763 In the 1970s, it was expected that citizens were ‘all-round developed socialist personalities’ who held a scientific world-view, were intellectually agile, were comradely and collective in outlook, had solid moral values, and always remained hard-working.764 The camps championed Katsch’s enduring principle of diabetics needing to learn that they were ‘conditionally healthy’.765 Living up to the ideals of a socialist personality meant that a healthy lifestyle was non-negotiable.

Aside from these political goals, the practical aim from their inception was to ‘normalise’ diabetic children and encourage them to feel that they could fulfil all the duties of any good socialist citizen. In schools, diabetics were not allowed to participate in sports and games classes which could leave them feeling left out and ‘different’ from their non-diabetic peers.766 The additional holiday places generated in the 1970s allowed for larger scale ‘normalisation’ of young diabetics as they could access holiday facilities more easily and were able to attend a holiday camp at least once. To reinforce socialist comradeship, a three-year agreement was made with Polish holiday camps.767 In Cottbus, a friendship meeting with Polish ‘pioneers’ had already taken place by April 1976 (when the profile on the holiday camp was written). A method of turning these diabetics into ideal ‘socialist personalities’ was to train

761 Christa Scholz, ‘Erste Erfahrungen bei der Durchführung eines Ferienlagers für diabetische Kinder im Komplex der Dispensairebetreuung’, Das deutsche Gesundheitswesen, 31 (1976), 731-733 (p.732). 762 Dan Wilton, ‘The “Societalisation” of the State: Sport for the Masses and Popular Music in the GDR’, in Power and Society in the GDR, 1961-1979: The ‘Normalisation of Rule’? ed. by Mary Fulbrook (Oxford and New York: Berghahn, 2009), pp. 102-129 (pp.106-108). 763 Lüdtke, Ratzmann and Mögling, p. 946. 764 Angela Brock, ‘Producing the “Socialist Personality”? Socialisation, Education, and the Emergence of New Patterns of Behaviour’ in Power and Society in the GDR, 1961-1979: The ‘Normalisation of Rule’?, ed. by Mary Fulbrook (Oxford and New York: Berghahn, 2009), pp. 220-252 (pp.220 and 223). 765 Scholz, p. 732. 766 Patient B.B, ‘Süßes Blut und ich lebe immer noch’ (unpublished account, Schwerin, December 2012), p. 3. 767 Lüdtke, Ratzmann and Mögling, p. 946.

177 them to act as helpers at the camp, demonstrating core leadership skills and acting on behalf of a group.768

One diabetic has written about his experiences at holiday camps both as a participant and a helper.769 Diagnosed in 1961 at the age of 4, his experience of camps started in the 1960s at Putbus. He remarks that the flavour and character of them changed in the 1970s. He recalls that they were extremely strict with respect to diet and injection times in the 1960s but implies that they were less authoritarian from the 1970s onwards. The presence of diabetic helpers in the later years was significant in making the environment pleasant; they had taken part in holiday camps themselves and diabetic children could talk to them not only about their condition but also about general matters. The patient comments that, since the majority of those involved in the organisation of camps were diabetics, they fostered a collective of ‘equals amongst equals cared for by equals’. This also meant that no participant could hide behind his/her illness; when he recalls one participant saying, ‘I can’t do that, I’m a diabetic’, other participants responded by saying that they were diabetics, too.770

Despite the political potential of holiday camps, it must be said that it was not their first and foremost purpose to indoctrinate participants. In many ways they were comparable to similar camps for diabetic children which existed in countries with different political systems, most notably the United States.771 Their focus was on providing a real holiday experience whilst improving metabolic management at the same time; from the point of view of the state, it was, however, an added bonus that they attempted to instil an attitude that fitted the definition of a ‘socialist personality’. Positive interpretations of the camps by participants, one recalling ‘wonderful weeks’ and ‘great memories’, would naturally improve opinions about the GDR and give off the impression of ‘real-existing socialism’, which was exactly what Honecker would have wanted.772 Yet, they were also of medical benefit, encouraging diabetics to associate their disease with a normal setting rather than a hospital or clinic and improving their psychological wellbeing as a result.

768 Scholz, p. 732. 769 Patient K.K. ‘Zur Geschichte der Rehabilitationssommerferienlager für Kinder und Jugendliche mit Diabetes mellitus im Osten Deutschlands von 1956 bis zur Wiedervereinigung’ (unpublished account, Berlin, February 2015), pp. 2-3. 770 Ibid., p. 3. 771 Peter Hürter, Diabetes bei Kindern und Jugendlichen: Klinik, Therapie, Rehabilitation: Zweite, vollständig überarbeitete und erweiterte Auflage (Berlin and Heidelberg: Springer Verlag, 1982), p. 319. 772 Ralf Yamamoto, Wie wär’s mal mit was Süßem: Geschichten mit dem Diabetes (Hamburg: Tredition Verlag, 2014), p. 171.

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The pharmacy of the Eastern Bloc? Insulins, oral anti-diabetic tablets and the continued dilemma of imports Individuals in and structures of the Dispensaire System dictated its capacities and limits, but so too did the required medication and equipment. The phenomenon of importing pharmaceuticals and chemicals from other countries, particularly those on the other side of the Iron Curtain, still persisted in the 1970s and on an increasingly larger scale than ever before. The policy of Störfreimachung explored in Chapter 2 revealed a clear opposition to the principle of importing goods from the West and a willingness to put that principle before the health of diabetics. Back then, importing medication was met with aversion, considered distinctly ‘abnormal’ by the highest political authorities (although not necessarily by those on the receiving end of the policy) which meant that something had to be done to remove the GDR’s reliance on imported goods altogether. Once it became apparent by 1964 that the GDR could not completely cut itself off from the West economically, there was a rather begrudging acceptance on the part of the SED that importing goods had to continue.

In September 1973, a meeting of the Central Review Committee for Drug Traffic (ZGA) of the Ministry of Health took place to discuss current perspectives on insulin and oral anti- diabetic tablets in the GDR.773 This was held at the Institute for Drugs (IFAR). ZGA and IFAR had been established in the late nineteen forties and early 1950s to monitor the supply of pharmaceuticals.774 They feature prominently in this period of diabetes care as they had to deal with growing demands to import medication (as well as substances contained within domestically produced alternatives) and keep the GDR more in line with international standards following its membership of the WHO. During that meeting, it was argued that new patients should not be put onto the latest ill-fated home-grown depot insulin, Deponal-Insulin, unless VEB Berlin-Chemie could develop a more suitable version by 1974. If it could not, imports would be necessary.775 Later in the meeting, it was again said that until Berlin-Chemie could produce a ‘mono-compound insulin’, the latest insulin on the market in the West, 100 patients with allergic reactions would have to use imports.776 There is a feeling of resignation from the minutes of this meeting. There appeared to be little fight or desire to oppose imports

773 SAPMO-BArch DQ1/14471 – Protokoll der Sitzung des ZGA-Unterausschusses “Insulin and orale Antidiabetika” am 17.9.1973. 774 Ariane Retzar, ‘Handling adverse drug reactions: state influence on access and availability of medicines in the former German Democratic Republic (GDR), 1949 to 1990’, Pharmaceutical Historian, 47:4 (2017), 75-80 (p.75). 775 SAPMO-BArch DQ1/14471 – Protokoll der Sitzung des ZGA-Unterausschusses “Insulin and orale Antidiabetika” am 17.9.1973, p.2. 776 Ibid., p. 3.

179 and it now seemed that it was quite ‘normal’ to view them as a requirement to fill the gaps and insufficiencies in East German pharmaceutical production.

Stephan Brockmann makes the point that in the 1950s and 1960s, enthusiasm was generated by the feeling of constructing a socialist state, but when Honecker came to power, there was now a sense of addressing ‘more intensely …the everyday lives, hopes and dreams of individual people’.777 Ulbricht’s mantra of sacrificing today for the good of tomorrow was no longer plausible in a state that had existed for well over two decades. The purpose of using the term ‘real-existing socialism’ was, as Eli Rubin asserts, to ‘give the working class a taste of utopia in the here and now’ and instil in them a loyalty ‘to the vision of an ultimate socialist utopia’.778 This could not be tarnished by an outright denial of medication needed to maintain the health, happiness and productivity of those who needed it, namely diabetics in this case. If it could only be sourced from the West, it had to be imported. As many imported insulins worked more effectively (and this was acknowledged frequently in official correspondence) there had to be some assurance that diabetologists could prescribe them to diabetics when needed, or at the very least, that they were given unreservedly to those with special conditions. This was addressed by making greater use of the Nomenklatur system of categorising pharmaceuticals, which was rather helpful in designating clearly what medication came from abroad and to whom it should be given.779 The extensive use of Nomenklaturen, first introduced in 1965, immediately after the end of the policy of Störfreimachung, also confirms that imported medication was now firmly embedded within the wider process of pharmaceutical provision.

There were four Nomenklaturen ranging from A to D. Nomenklatur A included all pharmaceuticals that were as a rule domestically produced, readily available and could be prescribed by any doctor.780 Medication placed in the Nomenklatur B was for special treatments and could only be prescribed if the therapeutic goal was not achieved by medications from Nomenklatur A. If a prescription for a Nomenklatur B arrived at the pharmacy, the pharmacist was expected to point the doctor to comparable medications from Nomenklatur A.781 The final decision always rested with the doctor, however. Classification of medication in Nomenklatur

777 Stephan Brockmann, A Critical History of German Film (Rochester, N.Y.: Camden House, 2010), p. 260. 778 Rubin, Amnesiopolis, p. 28. 779 SAPMO-BArch DQ1/14471 – Protokoll der außerordentlichen Sitzung des ZGA-UA “Antidiabetika” am 19.12.74, p. 1 (medications listed as ‘Nomenklatur A’ and ‘C’). 780 Ulrich Vater and Christoph Friedrich, Die Entwicklung des Apothekenwesens in der DDR (Jena and Quedlinburg: Verlag Bussert and Stadeler, 2010), p.72. 781 Vater and Friedrich, p. 72.

180

C was made by the Ministry of Health following recommendation by the ZGA. The Ministry set down the criteria for which conditions or in which situations such medications could be prescribed and sometimes determined the parts of the healthcare system that could prescribe a Nomenklatur C medication. For certain diseases like diabetes, they could only be prescribed to patients at the relevant advice centre by a specialist. 782 For the prescribing doctors, the prescription criteria for Nomenklatur C were much stricter than for Nomenklatur B, and often reasons for prescribing had to be provided alongside the prescription. 783 Nomenklatur C consisted of imports from predominantly non-socialist countries and was stored in the Bezirksapotheken (regional pharmacies) or in hospital pharmacies. 784 Classifying medication in this way was declared to be ‘a scientific way’ of prescribing, but in reality, it was just an expression of the shortage economy. Due to the fact that imported medication was bought using scarce foreign currency, their availability was therefore limited. It led to considerable bureaucracy for doctors and pharmacists and meant that patients had to wait much longer for their medication. Even one category higher was Nomenklatur D, and applications to prescribe from this category had to be approved by different institutions and the whole process was even more time-consuming.785

By 1973, imports were rationalised not necessarily on political principle as they had been previously, but on a more pragmatic economic basis, which only served to accentuate that they were now part of standard procedure, and that carefully planned economic measures had to be taken to factor in their use in diabetes treatment. During the frequent meetings held at the IFAR, where key diabetologists, such as Prof. Bibergeil, Dr. Schliack and Prof. Bruns, were present, alongside representatives from the East German pharmaceutical companies, the attitude toward imported insulins was by no means blasé. On 27 September 1974, one such meeting was held at the IFAR, where there was reference to the fact that demands for improvement in East German pharmaceutical production had been made ‘for years’.786 As ever, attempts were begun to create a domestic alternative by mimicking Western developments, in the hope that the need to import could be reduced in that way. Clearly, though, by 1974, it had

782 Vater and Friedrich, p. 72. 783 Vater and Friedrich, p. 72. 784 Thomas R Müller, Psychiatrie in der DDR: Erzählungen von Zeitzeugen (Frankfurt am Main: Mabuse Verlag, 2006), p. 57. 785 Vater and Friedrich, p. 72. 786 SAPMO-BArch DQ1/14471 – Ergebnisprotokoll der außerordentlichen Beratung des ZGA-UA über die Perspektive des Insulinsortimentes am 27.9.1974 im IFAR, p.2.

181 become an uphill battle to create an insulin domestically that would come anywhere near the standard of the desirable, and, quite simply, superior Western products.

The West German Hoechst insulin used in the early 1960s was still present in treatment, but there were new insulins from the Danish pharmaceutical company, Novo, that captured the imagination of many diabetologists and had become very popular throughout the GDR. Different types of insulin were needed depending on the treatment therapy and the patient. The Deponal insulin was supposed to be the GDR’s answer to Novo’s Rapitard insulin, which combined a shorter and longer acting insulin agent to create a ‘semi-lente’ (medium depot) effect.787 There was also an international drive to create purer insulin in the form of mono- compound and mono-species insulins.788 Novo’s mono-compound insulin was another semi- lente, and, as a result of its properties, was reserved for specific patients in the GDR, namely juvenile diabetics, those with allergies to other insulins, type 2 diabetics with insulin resistance, and pregnant diabetics.789 It was not a question of why imports should be avoided as it had been in the early 1960s but rather to whom imports should be given, presupposing their necessity. Berlin-Chemie had begun to produce mono-species insulin at the end of 1974, consisting of bovine insulin only. The Indikation (instruction for use) for a mono-species insulin was that it should be given specifically to those prone to allergic reactions. 790 A ‘special meeting’ of the ZGA in December 1974, at which Schliack was present, emphasised the multiplicity of depot and short-acting insulins produced by Novo, and how enticing they appeared to East German diabetologists. Novo’s depot and short-acting insulin ranges were described as a Palette and earmarked for ‘testing and research’ so that the GDR could produce its own versions of these seemingly coveted insulins.791

Recognising that Berlin-Chemie would struggle to produce alternatives on its own, efforts were made to engage more with other COMECON countries to work on a collaborative project to produce at least a handful of Novo’s Palette, in particular the semi-lente variants. The special meeting of the ZGA insisted that collaboration was needed between the GDR’s Berlin-Chemie, Poland’s pharmaceutical company, Polfa, and Czechoslovakia’s SPOFA. The

787 SAPMO-BArch DQ1/14471 – Protokoll der außerordentlichen Sitzung des ZGA-UA “Insulin u. orale Antidiabetika” vom 28.8.1975, pp.1-2. 788 SAPMO-BArch DQ1/14471 – Protokoll der Sitzung des Zentralen Gutachterauschusses, Unterausschuß “Insulin und orale Antidiabetika” vom 19.8.1976, pp.2-4. 789 SAPMO-BArch DQ1/14771 – Protokoll der außerordentlichen Sitzung des ZGA-UA “Antidiabetika” am 19.12.74, p.1. 790 Ibid., p.2. 791 Ibid., pp. 2-3.

182 drive to cooperate with neighbouring Eastern-Bloc countries underscored the shift in economic policy under Honecker, whereby, according to Ralf Ahrens, attempts to limit borrowing from the West were undertaken ‘by increasing trade with the East’.792 In the context of ‘normalisation’, this could help to foster an ‘East’ German identity by recognising the state’s place as a key player in the Eastern Bloc, as well as alleviating familiar economic burdens.

Unlike Western imports, which actively filled gaps in technology and quality, the same could not be said for those from neighbouring countries to the East of the GDR’s borders, as seen in this depot insulin dilemma.793 At the end of 1974 when this special meeting of the ZGA took place, no date had been set for the collaboration. By August of the following year, Berlin- Chemie had started to produce samples of a bovine semi-lente insulin. Plans were made in a further ZGA ‘special meeting’ to compare these samples with those of Polish, Czech and Novo semi-lente versions to see how much work needed to be done.794 According to the ‘mündlich vorgetragenen Aussagen’ (orally-presented statements), the Czech semi-lente did not deliver optimal blood sugar results, and it was suspected that the same was the case for the Polish version.795 Until there was any substantial progress at all with the making of an alternative and/or securing imports of a Czech/Polish lente insulin if it was good enough, imports of Novo’s costly Palette of insulins had to continue.796 Some domestic insulins like B-Insulin (modelled on Hoechst), which was still commonly prescribed, and the unreliable Deponal insulin (which was initially planned to be phased out completely due to a series of complaints about its depot effect) could be used for certain patients.797 Eventually, batches of semi-lente insulin from Polfa and SPOFA arrived but by this time, Berlin-Chemie had started to make progress producing its own. This is demonstrated by the ZGA’s comments that SPOFA insulin needed to be used up and any waste should be given to Berlin-Chemie, implying that

792 Ralf Ahrens, ‘Debt, Cooperation, and Collapse: East German Foreign Trade in the Honecker Years’, in The East German Economy, 1945-2010: Falling Behind or Catching Up? ed. by Hartmut Berghoff and Uta Andrea Balbier (Cambridge: Cambridge University Press, 2013), pp. 161-176 (p.168). 793 The GDR’s inability to depend on the Eastern-Bloc market can be seen in the area of computer technology: Gary L. Geipel, ‘Politics and Computers in the Honecker Era’, in Science under Socialism: East Germany in Comparative Perspective, ed. by Kristie Macrakis and Dieter Hoffman (Cambridge MA and London: Harvard University Press), pp. 230-246 (p.233). 794 SAPMO-BArch DQ1/14471 – Protokoll der außerordentlichen Sitzung des ZGA-UA “Insulin u. orale Antidiabetika” vom 28.8.1975, pp.1-2. 795 SAPMO-BArch DQ1/14471 – Protokoll der Sitzung des Zentralen Gutachterausschusses, Unterausschuß “Insulin und orale Antidiabetika” vom 19.8.1976. 796 SAPMO-BArch DQ1/14471 – Protokoll der außerordentlichen Sitzung des ZGA-UA “Insulin u. orale Antidiabetika” vom 28.8.1975, p.2. 797 SAPMO-BArch DQ1/14771 – Protokoll der außerordentlichen Sitzung des ZGA-UA “Antidiabetika” am 19.12.74, p.1.

183 diabetologists on the ground were not happy to use the insulin permanently.798 Polfa had also been tried on patients using B-Insulin, but the switch was so dramatic that their metabolism had ‘decomposed’.799 A July 1975 meeting of the ZGA suggested that the regional diabetologists had ordered too much Novo-Rapitard and had significantly over-prescribed, in some cases exceeding planned levels of consumption by 12 percent.800 In January 1977, there continued to be substantial differences between planned and actual amounts of Novo-Rapitard used, with Schwerin using three times as much as it should have.801

In spite of the strict planning encouraged by the Nomenklatur categories, diabetologists seem to have been against the call to limit imports, as they had been in the early 1960s during the period of Störfreimachung, on account of a similarly contradictory ideological situation. On the one hand, doctors could limit the use of imported insulins to fulfil economic obligations, but on the other, they were pressed, now more than ever, to create ‘real-existing socialism’ for their patients, something which required a certain amount of imports, a price that was perhaps worth paying in the short-term. The optimism created by Honecker’s promises in the ‘unity of economic and social policy’ allowed for ‘a kind of new-dawn atmosphere’, as Andre Steiner puts it, but with that also came higher expectations and an anticipation of significant day-today improvements on the horizon.802 Creating images of stability and authenticity to lift the mood was as important as attempting to generate actual conditions. A publication by the pharmaceutical journal, Medicamentum, presented a list of insulins produced by socialist countries. In a section of the minutes of an August 1976 ZGA ‘special meeting’ entitled ‘foreign insulins from the non-socialist economic area’, it was suggested that a list of insulins produced in capitalist countries should be compiled, but this should be shielded from the public and reserved only for the purpose of diabetologists when treating foreign patients.803

Berlin-Chemie continued its quest to produce at least one reasonable replacement for the costly Novo insulins, the majority of which were classified as Nomenklatur C. The result of these efforts, the new Berlinsulin, made its first appearance in reports and meetings toward

798 SAPMO-BArch DQ1/14471 – Protokoll der Sitzung des ZGA-Unterausschusses “Insulin und orale Antidiabetika” vom 31.1.1977, p.4. 799 SAPMO-BArch DQ1/14471 – Protokoll der Sitzung des Zentralen Gutachterausschusses, Unterausschuß “Insulin und orale Antidiabetika” vom 19.8.1976, p.1. 800 SAPMO-BArch DQ1/14471 – Protokoll der Sitzung des ZGA-Unterausschusses “Insulin u. orale Antidiabetika” vom 10.7.1975, p.2. 801 SAPMO-BArch DQ1/14471 – Protokoll der Sitzung des ZGA-Unterausschusses “Insulin und orale Antidiabetika” vom 31.1.1977, p.4. 802 Steiner, The Plans, p. 144. 803 SAPMO-BArch DQ1/14471 – Protokoll der Sitzung des Zentralen Gutachterausschusses, Unterausschuß “Insulin und orale Antidiabetika” vom 19.8.1976, p.3.

184 the end of 1976.804 At yet another meeting of the ZGA, which included Dr. Schliack, Dr. Schilling from the Sanatorium Saalfeld, and Dr. Hanefeld from Dresden, the assessment of Berlinsulin was quietly optimistic. The latest tests on animals had revealed that there were no significant differences between Berlinsulin and Novo-lente.805 Testing of the Polish lente from Polfa had revealed unsatisfactory results and those present at the meeting were buoyed by the performance of Berlinsulin in contrast.806 In order to put Berlinsulin to the test properly, its efficacy now had to be demonstrated in trials involving human participants. Suggestions were made that patients at the diabetes-only sanatoria could be the first to try it, considering that they were in the process of adapting to fit new insulin regimes anyway.807 Following the results of a series of tests, the conclusions presented in January 1977 confirmed that Berlinsulin exhibited various characteristics similar to Novo-lente, but that it was considerably different from B-Insulin. Many diabetics on B-Insulin regimes would have to change their eating habits substantially if they were to use Berlinsulin.808

In July 1977, it was finally decided that Berlinsulin was good enough to replace Novo- lente, with a handwritten comment at the bottom of the report of the ZGA meeting stating that Berlinsulin was needed by the healthcare system and that that need had now been fulfilled.809 Berlinsulin did not require the use of imported substances; a depot effect was produced without the use of the Fremdstoff (foreign substance) surfen. There was also an alleged improvement in purity, with few skin reactions noticed in patients on whom the insulin had been tried, a matter which had troubled diabetologists when using other domestic insulins, such as B- or Deponal Insulin.810 The development of Berlinsulin parallels that of B-Insulin some ten years earlier, where, following a prolonged process, the GDR did finally come up with something to replace and (roughly) mimic the preferred imported Western insulin, which previously had been Hoechst, and was currently Novo-lente. Establishing what appears to have been routine behaviour serves to justify that the process of copying a Western product and being at least conscious of developments in the capitalist countries had become a ‘normalised’ course of action.

804 Ibid., p. 1. 805 Ibid., pp. 1-2. 806 Ibid., p.1. 807 Ibid., p.1. 808 SAPMO-BArch DQ1/14471 – Protokoll der Sitzung des ZGA-Unterausschusses “Insulin und orale Antidiabetika” vom 31.1.1977, p.3. 809 SAPMO-BArch DQ1/14471 – Protokoll der Sitzung des ZGA-Unterausschusses “Insulin und orale Antidiabetika” vom 3.6.1977, p.4. 810 Ibid., p. 4.

185

Insulin consumption in the early years of Honecker’s time in power has shown the presence of routine, internalised behaviour and (attempts at) stability; Berlinsulin was a reasonable, but imperfect, answer to avoiding imports of Western insulin, and steadied the ship somewhat. Nevertheless, the economic burden of importing goods from the West was so great that by the end of the 1970s, the GDR’s economic situation looked troubling. It was not helped by the 1973 oil crisis and subsequent world recession, which severely reduced the income of hard currency generated by exports to the West.811 All aspects of ‘normalisation’ were exposed to disturbing changes. Kopstein notes that ‘within the central organs, the first panicky meetings about debt took place toward the end of 1978’, and by December 1979, ‘Honecker spoke…with unusual semipublic candor’ on the subject of anticipated price rises.812 It was in this changing climate that the continued use of a controversial oral anti-diabetic tablet produced by Arzneimittelwerk Dresden (AWD), known as Buformin retard, was approved. Oral anti- diabetic tablets were not as central to the discussion of imported goods as insulin, which, to some extent, was a consequence of the GDR not being especially ‘behind’ from the inception of their use in non-insulin dependent diabetes treatment in the 1950s. Here, too, the GDR was not entirely independent of imports, with the oral anti-diabetic tablet, Maninil, also produced by AWD, containing a chemical that had to be imported.813 This was a likely factor in influencing the decision to continue the use of Buformin, the production of which was not reliant on any components from abroad. Buformin nonetheless had the potential of causing serious, possibly life-threatening, side-effects.

From 1969, reporting any issues that arose following the use of a particular drug was possible using a report form.814 Ariane Retzar’s study of ‘adverse drug reactions’ in the GDR demonstrates that ‘in order to increase the number of reports, several actions were taken’ which led to a sharp rise from 140 in 1973 to 403 in 1977. Numbers remained at a higher level from then on, amounting to an average figure of 335 for the years 1969 to 1989.815 Although Retzar does not offer a reason for the change in approach, the GDR’s membership of the WHO may have played a part in this increase in formal reporting. The guidelines about what constituted adverse reactions became more precise as the 1970s progressed, and Ludwig Mecklinger called

811 Ray Stokes, ‘From Schadenfreude to Going-Out-of-Business Sale: East Germany and the Oil Crisis of the 1970s’, in The East German Economy, 1945-2010: Falling Behind or Catching Up? ed. by Hartmut Berghoff and Uta Andrea Balbier (Cambridge: Cambridge University Press, 2013), pp. 131-144 (p.142). 812 Kopstein, p. 89. 813 Retzar, ‘Handling adverse drug reactions’, p. 77. 814 Retzar, ‘Handling adverse drug reactions’, p. 76. 815 Retzar, ‘Handling adverse drug reactions’, p. 76.

186 for all ‘incidents’ resulting from the use of a particular medication to be reported in 1975.816 Retzar has profiled several drugs where a significant number of adverse reaction reports were filed, including the oral anti-diabetic tablet, Buformin. In some cases, observations from East German doctors were enough to conclude that a particular drug caused an adverse reaction when used. However, Retzar rightly argues that Buformin was different in that the ‘IFAR, the ZGA and the Ministry of Health had to rely on developments in other countries in order to draw conclusions’ about adverse reactions.817 Until October 1977, there were no reports from East German diabetologists about its propensity to cause lactic acidosis, a potentially deadly condition, in those who took the drug in certain quantities.818 Buformin belonged to the group of biguanides and was by this time a well-established oral anti-diabetic tablet in the GDR alongside Maninil and Orabet.819 In fact, of the range of oral anti-diabetic tablets on offer, Buformin was the most popular. In 1977, it had the largest share of oral anti-diabetic tablets prescribed in the GDR with 38 percent of the total. In March 1978, this had fallen slightly to 35.4 percent, with 31.4 percent of diabetics for Maninil and 33 percent for Orabet.820 In terms of the proportion of Buformin used in comparison to other oral anti-diabetic tablets, it was highly prolific but not wholly dominant.

In the same month and year as these figures were compiled, West Germany decided to withdraw two biguanides, Phenformin and Buformin, on account of the frequent and deadly cases of lactic acidosis. Other countries in the West also took them off the market, including Canada, Norway, the USA, Switzerland, Denmark, France, Austria and Ireland. Buformin was not available at all in the United Kingdom but Phenformin was withdrawn in 1977. Austria, Ireland and Belgium continued to use medication that contained Buformin.821 The East German Ministry of Health was particularly prompted by the decision of the neighbouring country and greatest rival, West Germany, which was raised in a scheduled meeting of the ZGA to discuss how the GDR should proceed.822 Professor Haller of the Carl-Gustav-Carus Universitätsklinik Dresden, the GDR’s foremost expert in oral anti-diabetic tablets, presented a list of Entscheidungsvarianten (possible decisions that could be made), which were quite telling of

816 Retzar, ‘Handling adverse drug reactions’, p. 76. 817 Retzar, ‘Handling adverse drug reactions’, p. 77. 818 Ariane Retzar, Erfassung und Bewertung von unerwünschten Arzneimittelwirkungen: ein Beitrag zur Arzneimittelsicherheit in der DDR (Stuttgart: Wissenschaftliche Verlagsgesellschaft, 2016), p. 229. 819 Retzar, Erfassung, p. 227. 820 820 SAPMO-BArch DQ1/14471 – Protokoll der ordentlichen Sitzung des ZGA-Unterausschusses “Insulin und orale Antidiabetika” vom 7.3.1978, p. 4; Retzar, Erfassung, p. 232. 821 Retzar, Erfassung, p.229. 822 SAPMO-BArch DQ1/14471 – Protokoll der ordentlichen Sitzung des ZGA-Unterausschusses “Insulin und orale Antidiabetika” vom 7.3.1978, p.4.

187 the immediate and instinctive thought processes of East German diabetologists and pharmaceutical representatives. The first potential option was to stop using Buformin if the AWD could produce correspondingly more Maninil, bearing in mind, however, that an imported raw material was required in its production. The second option was to continue using Buformin under strict guidelines set by the ZGA. The third was to consult with other COMECON ministries of health and to try to establish a common position. Finally, it was suggested that the introduction of blood lactate measurements to monitor and prevent the onset of lactic acidosis should be accelerated, with a standard method already being prepared at the Zentralstelle by Dr. Honigmann, thereby assuming that Buformin should not be discontinued. The concluding paragraph to these options states that those in attendance would have to arrive at a ‘health-political decision’; it added that, scientifically speaking, Buformin could be used but ‘international developments’ could not be ignored.823

The outline of all these varied options highlights how torn those present at the ZGA meeting were about Buformin. East German insulin developments had demonstrated clear attempts to keep abreast of international trends. The banning of Buformin could easily be considered the latest trend, and one that the GDR could not, and should not, ignore. The ‘health- political decision’ was more complex than ever before in that the GDR could go directly against a trend, upsetting an already precarious balance that had existed between meeting political and economic demands of domestic production while simultaneously fulfilling state socialist preventative healthcare aims. Contemporary Western studies of biguanides can help to explain why they were withdrawn in the West. A 1978 West German study had analysed the cases of 330 diabetics suffering from lactic acidosis following the consumption of three biguanides (Metformin, Phenformin and Buformin), 50.8 percent of whom died as a result. It argued that ‘lactic acidosis occurred with all three drugs while being used in a normal therapeutic dose’.824 A British article from 1978 cautions against the lumping together of biguanides, arguing that all three produce different metabolic reactions. Indeed, the respective authors based at Southampton General Hospital in the UK add that lactic acidosis actually overshadows a number of other problems caused by biguanides. They also mention that all drugs carry risk, and that ‘although the mortality of lactic acidosis is high, the risk to the individual patient is small’.825 Still, they discovered that evident discrepancies in the three biguanides meant certain

823 Ibid., pp. 4-5. 824 D. Luft, R. M. Schmülling, and M. Eggstein, Lactic Acidosis in Biguanide-Treated Diabetes: A Review of 330 Cases’, Diabetologia 14 (1978), 75-87 (p.75). 825 M. Nattrass and K.G.M.M. Alberti, ‘Biguanides’, Diabetologia, 14 (1978), 71-74 (p.72).

188 biguanides were substantially worse than others, with Buformin not comparing favourably in their study.826 The countries with ‘heavy prescribing of Metformin’, like France or Switzerland, experienced few cases of lactic acidosis, in ‘stark contrast to the incidence of lactic acidosis during phenformin and buformin therapy’. 827

The issues associated with Phenformin and Buformin, especially lactic acidosis, were worrying enough to encourage mass withdrawal of both oral anti-diabetic tablets across Western Europe and North America by 1978. It was now time for the ZGA to come to a decision on what should happen in the GDR. It appears that several of the Entscheidungsvarianten were explored. The ZGA considered information on Buformin from abroad but this was mostly in the guise of why it was justified to continue using Buformin in a controlled manner, rather than the aforementioned contemporary articles on why it should not be used.828 Eventually, the ZGA concluded that Buformin should continue to be used, albeit under strict conditions and accompanied by standard blood lactate measuring,829 This sounded like a relatively sound compromise to the problem of Buformin. However, a small aside that some laboratories did not have the capacity to test for lactic acidosis, particularly in sanatoria, looked rather ominous. The minutes from the meeting of all East German diabetologists in Dresden in March 1980 stated that there had been 11 reported cases of lactic acidosis, 5 of which had resulted in death. There might also have been several unreported cases.830

In a ‘special meeting’ on 3 August 1978, Buformin was reported to be in use, but that Kontraindikationen (withholding the medication from certain patients where there was serious risk of harm being caused) remained in place.831 Beneath the surface, there is one potential economic reason why the GDR did not follow suit and ban a medication that they were well aware could cause serious harm. Maninil did not cause lactic acidosis and could have been the logical replacement. Its use did indeed rise at the expense of Buformin but did not replace it. It was simply not possible to produce sufficient amounts of Maninil on grounds of cost; the vital ingredient which had to be imported from the West was unaffordable in the larger quantities

826 Nattrass and Alberti, pp. 72-3. 827 Nattrass and Alberti, p. 73. 828 SAPMO-BArch DQ1/14471 – Protokoll der außerordentlichen Sitzung des Vorstandes des ZGA-UA “Insulin und orale Antidiabetika” vom 3.8.1978, pp.2-3. 829 Ibid., p. 3. 830 SAPMO-BArch DQ112/94 – ‘Diabetologen Tagung Dresden 1980’: handwritten notes from the meeting by Dr. Matthes of the Ministry of Health, p.9. 831 SAPMO-BArch DQ1/14471 – Protokoll der außerordentlichen Sitzung des Vorstandes des ZGA-UA “Insulin und orale Antidiabetika” vom 3.8.1978, p.2.

189 which would have been required.832 This must also be seen in the context of countless imported insulins still in use, not only for insulin-dependent cases, but also for non-insulin dependent type 2 diabetics. Meeting minutes mentioned that in ambulatory care, because of the issues surrounding biguanides, far too many patients had been taken off Buformin and switched to insulin, which was seen as problematic; as Retzar explains, the whole point of continuing to use Buformin was to relieve dependency on costly insulins.833

The Buformin debate shows that the creation of ‘real-existing socialism’ and a consumer society were on the backburner by this stage. In the case of Buformin, there was a weighing up of the costs involved in replacing it with Maninil on the one hand, and the savings which could be made by continued use of Buformin, albeit under strict conditions, on the other. The scale of the debt was such that to create any semblance of stability, being financially prudent was now more important than giving people safer and effective medication. Yet, this was a risk and the decision made to continue using Buformin perhaps foreshadows the economic turmoil of the GDR’s final decade. The decision not to follow suit when the West banned Buformin, in spite of the risks involved, marks a departure from what had become ‘normal’ over the previous decade or so. Since the end of Störfreimachung, it had been ‘normal’ to try to give patients the safest medication which could be made available, even if this involved importing from the West. Now, for the first time, financial constraints force a departure from this ‘normality’.

Conclusion

This chapter has revealed the ‘normalised’ features of diabetes care and research, from continuity projects (the ‘Research Project’) to the consolidation of decades-old systems and institutions. After the building of the Berlin Wall, pre-existing and newly emerging patterns were gradually internalised and routinised. The Central Institute underwent a course of centralisation and streamlining so as to reinforce its position as the lead, which was, in some ways, continuing its restoration at the helm following a brief period of uncertainty in the 1960s. The Research Project was at the heart of coordinating diabetes research, accepted as the principal piece of communication to the Ministry about the latest developments nationwide and future plans. The Dispensaire System was at the forefront of coordinating diagnosis, care and

832 SAPMO-BArch DQ1/14471 – Protokoll der ordentlichen Sitzung des ZGA-Unterausschusses “Insulin und orale Antidiabetika” vom 7.3.1978, p.4 [‘Für die Glybenklamid/Maninil-Produktion wird aus dem NSW ein Importrohstoff benötigt’]. 833 SAPMO-BArch DQ1/14471 – Protokoll der außerordentlichen Sitzung des Vorstandes des ZGA-UA “Insulin und orale Antidiabetika” vom 3.8.1978, p.3.

190 rehabilitation, as it had been since 1954; in fact, practices and behaviours present in the system were normalised to such a degree that important suggestions to make it better were not pursued with any great vigour, namely the increased involvement of GPs in the care for diabetics. This would have been highly complementary to the expansion of holiday camps, another 1950s creation and asset, it seems, within the Dispensaire System where people other than specialists started to exert influence within the care for patients affected by the disease. Following the upheaval of Störfreimachung, pharmaceutical imports were no longer seen as anathema to the socialist cause, and they became deeply embedded in economic planning, as demonstrated by the use of the Nomenklatur System. Were it not for the signs of economic turmoil on the horizon from 1977, witnessed in the case of Buformin (the justification for its use in treatment), the subsequent decade, which will be explored in the forthcoming chapter, would not have been so distinctly ‘abnormal’, with a slow, but sure, decline of all these normalised features.

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Chapter 5: The Final Curtain for Diabetes Care and Research ‘East German Style’

Introduction

In the 1981 directive of the Zentralstelle für Diabetes und Stoffwechselkrankheiten, it was argued that the main focus of the institution was to make more effective use of the ever- shrinking resources at their disposal.834 This taps into an overarching shift in tone and outlook at the beginning of the GDR’s final decade. Exactly when the turning point to existential crisis arose has been debated by historians, who have proposed years ranging from 1977 to 1982.835 The judgement by Mark Allinson and Peter Grieder that 1977 marked the start of the perpetual economic decline is certainly most applicable to diabetes care.836 It can be said that the decision to continue the use of Buformin in 1977/78 was a profound and ominous sign, where cost- cutting was privileged over optimum treatment for diabetics.837 Investment, improvisation and making-do, which had allowed for the perceived ‘normalisation’ of the middle period, could not succeed in papering over cracks, or rather gaping holes. The plans laid out at the 10th Party Conference of the SED, to which the Zentralstelle directive was referring, encouraged an ‘intensification’ of resources and a ‘rationalisation’ of labour, both terms alluding to the unsettling economic conditions of the early 1980s.838 According to John Garland, the GDR’s economic progress was now ‘based on increasing output and labour productivity while simultaneously reducing energy and material consumption’, a somewhat oxymoronic combination.839 Applied to the healthcare system, it effectively meant a ‘trade-off between social protection and economic performance’, as Manfred Schmidt puts it.840

834 SAPMO-BArch DQ119/734 – Die Notwendigkeit der Wissenschaftlichen Arbeitsorganisation im Gesundheitswesen der DDR unter spezifischen Bedingungen der Volkswirtschaft in den 80er Jahren: Die Analyse des Istzustandes in der Zentralstelle für Diabetes 1981, pp. 1-10. 835 Peter Grieder, The German Democratic Republic: Studies in European History (Basingstoke: Palgrave Macmillan, 2012), p. 80. 836 Grieder, The German Democratic Republic, p. 80; Mark Allinson, ‘1977: The GDR’s Most Normal Year?’ in Power and Society in the GDR: The ‘Normalisation of Rule’? ed. by Mary Fulbrook (Oxford and New York: Berghahn, 2013), pp. 253- 277 (p.253); Mark Allinson also cited in Grieder, The German Democratic Republic, p. 80. 837 By the end of the 1980s, Buformin was still in use but was no longer widespread, as the citation of the Diabetiker-Jahresstatistik 1988 in an April 1989 report suggests: SAPMO-BArch DQ1/13869 – Protokoll der Arbeitstagung der Beratenden Ärzte für Diabetologie der Bezirksärzte vom 26. und 27. April 1989 in Bitterfeld/ Bez. Halle, p.6. 838 Ian Jeffries and Manfred Melzer, ‘The Economic Strategy of the 1980s and the Limits to Possible Reforms’, in The East German Economy, ed. by Ian Jeffries and Manfred Melzer (London, New York and Sydney: Croom Helm, 1987), pp. 41-50 (p.46). 839 John Garland, ‘The GDR’s strategy for “intensification”’, Studies in Comparative Communism, Vol. 20, Issue 1 (1987), 3-7 (p.3). 840 Manfred G. Schmidt, ‘Social Policy in the German Democratic Republic’, in The Rise and Fall of a Socialist Welfare State: The German Democratic Republic (1949-1990) and German Unification (1989-1994), ed. by

192

Wasem, Mill and Wilhelm argue that the investment called for in the Gemeinsamer Beschluss only scratched the surface, focusing on prestigious buildings and not on the core functions of the healthcare system.841 By 1980, the new emphasis on frugality and being financially efficient was a shift back to the Ulbricht policies that had been roundly rejected in Honecker’s costly ‘main task’. Investment in the healthcare system had increased in the 1970s, but as a proportion relative to the economy as a whole it was low. Between 1971 and 1975, spending on healthcare made up 0.6 percent of the GDR’s investments. That figure rose to 0.8 percent between 1976 to 1980 but fell back to 0.6 percent from 1981 onwards.842 Rising demand in healthcare in the 1980s led to Mecklinger complaining to the Council of Ministers about old vehicles and poor buildings. Regarding pharmaceuticals and particularly medical equipment, provisions were so scarce in 1988 that Kurt Hager, chief SED ideologue, wrote to Honecker to point out the situation. Instead of providing the investment needed, Mecklinger was blamed and sacked for economic failings affecting areas far beyond healthcare.843

The East German economy was exposed to external and internal pressures from the late 1970s. The dawn of globalisation and a growing engagement of individual state socialist economies with the world market seriously undermined COMECON integration.844 The Soviet Union started selling crude oil to non-socialist countries following the second oil crisis of 1979, and reduced oil subsidies to the GDR, resulting in a sharp rise in oil prices and consumer goods.845 The GDR’s response was to turn to the highly polluting domestic brown coal deposits in an attempt to cover energy demands as cheaply as possible. Needless to say, this would affect health and wellbeing, and, like the decision on Buformin, was another more prolific example of putting the economy before people’s health. The GDR’s indebtedness, touched upon in the previous chapter, had reached new heights by 1982, peaking at 25.1 billion Valutamarks.846 Achieving Honecker’s ‘main task’ involved an over-reliance on raw materials,

Manfred G. Schmidt and Gerhard A. Ritter, trans. by David R. Antal and Ben Veghte (Berlin and Heidelberg: Springer Verlag, 2013), pp. 23-166 (p.109). 841 Jürgen Wasem, Doris Mill and Jürgen Wilhelm, ‘Drittes Kapitel: Sozialpolitische Entwicklungen, Thema 6 – Gesundheitspolitische Entwicklungen und Problemlagen im Bereich der ambulanten und stationären Gesundheitsversorgung’, in Geschichte der Sozialpolitik in Deutschland, 1971-1989, Deutsche Demokratische Republik: Bewegung in der Sozialpolitik, Erstarrung und Niedergang, ed. by Christoph Boyer, Klaus-Dietmar Henke and Peter Skyba (Baden-Baden: Nomos Verlag, 2008), pp. 382-3 (p.382). For the impact of the Gemeinsamer Beschluss, see Chapter 4 of this thesis. 842 Wasem, Mill and Wilhelm, p. 378. 843 Wasem, Mill and Wilhelm, p. 378. 844 Gareth Dale, Between State Capitalism and Globalisation: The Collapse of the East German Economy (Bern: Peter Lang, 2004), p. 216. 845 André Steiner, The Plans that Failed: An Economic of the GDR, 1945-1989, trans. by Ewald Osers (Oxford and New York: Berghahn, 2010), p. 186. 846 Steiner, The Plans, p. 163.

193 many of which had to be imported, and, as Steiner points out, there was a ‘lack of international competitiveness of the GDR’s investment goods sector’.847

Imports were of principal concern, a matter which seems to have determined the activities and possibilities of diabetologists almost entirely throughout the GDR’s lifetime. The GDR faced an enormous trade deficit of an estimated 40 billion Valutamarks with Western countries as a result of imports far exceeding the value of exports.848 They also faced a grave risk of racking up a deficit with the Soviet Union, on whose raw materials they depended in return for deliveries of manufactured goods.849 This prompted Honecker’s closest economic advisors, Günter Mittag and Gerhard Schürer, to explain in writing to him in March 1977 that more had been consumed than had been produced. Honecker rejected their assertions and saw them as a personal and ideological attack.850 It only adds to the argument that 1977 was the crunch year economically speaking and set up the decade that followed.

From the beginning of the 1980s, reference is made repeatedly to the need for NSW- Importablösung, that is, replacing capitalist imports with domestic goods and imports from socialist countries.851 The reformed rationale of imports in the years of ‘normalisation’, when such products as imported insulins were expected to fill gaps in domestic production, was no longer acceptable unless the GDR wanted to speed up the process of insolvency. Importablösung of the 1980s represents a return to the Störfreimachung era of the 1960s, only the circumstances of the latter were distinctly different from the former.852 The policy of Störfreimachung was enacted at the time of socialist construction when the future still lay in wait. There was optimistic rhetoric of ‘moving ahead’ of the West and creating an alternative path to high consumption rates. However, by the early 1980s, the GDR was suffering from, as Maier puts it, ‘long-term disabilities imposed by socialist production’ and the impact of past decisions.853 The ‘“unequal interdependence” with the West’ was as much a reality as it was a fear.854

847 Steiner, The Plans, p. 162. 848 Steiner, The Plans, p. 162. 849 Steiner, The Plans, p. 162. 850 Hans-Hermann Hertle and Stefan Wolle, Damals in der DDR: der Alltag im Arbeiter- und Bauernstaat (Munich: Goldmann Verlag, 2006), p. 191. Schürer continued to warn Honecker of the rising debt well into the 1980s. 851 On Importablösung and its meaning, see: Birgit Wolf, Sprache in der DDR: ein Wörterbuch (Berlin and New York: Walter de Gruyter, 2000), p. 99. 852 For details of the policy of Störfreimachung, see Chapter 2 of this thesis. 853 Charles S. Maier, Dissolution: The Crisis of Communism and the End of East Germany (Princeton, N.J.: Princeton University Press, 1997), p. 60. 854 Dale, Between State Capitalism, p. 218.

194

One would think that the economic issues alone should have, in the end, sealed the fate of the GDR. The fatal blow was a lethal concoction of the severe economic problems outlined above and substantial political change. Fulbrook summarises the Honecker era as consisting of ‘odd combinations of repression and relative toleration’.855 The influence of the Stasi and sensitivity to oppositional voices, demonstrated by the expulsion of influential lyricist, Wolf Biermann, in 1976, revealed a deeply repressive side.856 At the same time, there were also, as Fulbrook states, concessions made to the Protestant Church, denoting the constant balancing act required to generate political stability. A poignant development for diabetics, and one that implied, as Fulbrook describes it, ‘relative toleration’, was the formation of an organised patient group or Aktiv. Those who represented the group at meetings were invariably politically reliable Genossen, which in turn gave them licence to be upfront and incisive in their complaints to the Ministry of Health and diabetologists.857 When the existence of a patient group had been called for in the past, it had been dismissed as completely unnecessary by the Ministry of Health. This new development was a calculated risk, creating the impression of tolerance and openness but also prompting an opportunity for a collective oppositional voice when conditions in polyclinics were progressively more challenging.858

The catalyst for significant change undoubtedly came in the form of Gorbachev’s coming to power in the Soviet Union in 1985. Recognising the Soviet Union’s economic turmoil, he embarked on a new, pragmatic policy of restructuring (perestroika), which involved attempts to promote freedom of expression (glasnost).859 Gorbachev was a dynamic and fresh force in contrast to the ‘geriatric leaders of the Soviet bloc’, as David Childs remarks. 860 At the 11th Party Conference of the SED in 1986, Honecker chose not to focus on Gorbachev’s new direction in the Soviet Union and instead focused on the GDR’s capabilities of being a ‘leader’ in modern technologies, like computers, microelectronics, robotics and nuclear

855 Mary Fulbrook, A History of Germany 1918-2014: A Divided Nation, Fourth Edition (Hoboken, NJ.: Wiley- Blackwell, 2015), p. 181. 856 G. Ann Stamp Miller, The Cultural Politics of the German Democratic Republic: The Voices of Wolf Biermann, Christa Wolf, and Heiner Müller (Irvine, CA.: Brown Walker Press, 2004), pp.71-100. 857 SAPMO-BArch DQ1/13869 - Niederschrift über die 2. Beratung zur materiellen Sicherung der Diabetikerversorgung mit Vertretern des Patientenaktivs Berlin am 21. 6. 89, p.1 858 Examples include the decline of hospital buildings in: SAPMO-BArch DQ1/13869 – Protokoll der Arbeitstagung der Beratenden Ärzte für Diabetologie der Bezirksärzte vom 26. und 27. April 1989 in Bitterfeld/Bez. Halle, p.1. 859 Mike Dennis, The Stasi: Myth and Reality (Abingdon: Taylor and Francis, 2003), p. 225. 860 David Childs, The Fall of the GDR: Germany’s Road to Unity (London and New York: Routledge, 2014), p. 56.

195 energy.861 Outwardly defiant, the ‘geriatrics’ of the SED found it difficult to keep up with rapid developments. For the first time, several diabetologists who were not granted permission to attend international conferences held in the capitalist world, or conferences that included delegates from capitalist countries, were suddenly allowed to do so.862 Ironically, at the end of the GDR’s lifetime, the Central Institute for Diabetes and the work conducted by diabetologists reached a peak in terms of international recognition. The Central Institute became a ‘WHO Collaborating Centre’ in 1986, and visitors from a broader range of countries came to Karlsburg. Peculiar sensitivities, particularly toward West Germany, remained, but openness overshadowed the minimal control that the SED could muster.863

This chapter seeks to chart the final years of diabetes care ‘East German-style’. It will first explore a second attempt in the GDR’s history to relieve dependency on imports from the West (Importablösung), and how insulins were implicated yet again. Attention will subsequently shift to the view of patients, their expression of a decline in provisions and treatment, as well as their mobilisation in the Patientenaktiv. Patient Eingaben, correspondence between members of the Patientenaktiv and those in the Ministry of Health, and official meetings on diabetes matters attended by Patientenaktiv representatives will all be used to help uncover issues that were of pressing concern to diabetics in their everyday lives in the final decade. The various ‘inspections’ undertaken by officials to see for themselves how far care on the ground had deteriorated involved interviewing patients and getting under the skin of the work of staff at the diabetes advice centres. Battles faced at home and also abroad will therefore be the focus of the ‘diabetologists’ view’.

Importablösung: a return to the 1960s?

The concept of replacing imported goods with those that were domestically produced was a deeply familiar phenomenon to all those involved in the care for diabetics by 1980, including the patients themselves. The term ‘Importablösung’ (import replacement), coined at the start of the 1980s, stated more matter-of-factly than Störfreimachung (‘making free from disturbance’) what needed to be done. It had a tone of resignation about it, unlike the more

861 David Childs, Germany in the Twentieth Century (RLE: German Politics) (London and New York: Routledge, 2015), p. 229. 862 For example, additions were made to the travel cadre for the International Danube Symposia: SAPMO- BArch DQ101/572a 2 of 2 – Letter from Michaelis of the Central Institute to the General Secretary of the Medical-Scientific Societies at the Ministry of Health, Gen. Bühlert, 22/12/81. 863 SAPMO-BArch DQ117/30 T2v2 – Festival Event and Scientific Session on the Occasion of the Inauguration of the Central Institute of Diabetes ‘Gerhardt Katsch’ Karlsburg, GDR, as WHO-Collaborating Centre, 31 Oct. 1986.

196 strident Störfreimachung, where it was assumed that imports were a ‘disturbance’ that the GDR could do without.864 Importablösung was not as much an issue of political principle as it was an economic necessity; Steiner writes that in the 1980s, ‘imports were to be reduced in order to lower the GDR’s debts to the West’.865 The aim of matching imported insulins on quality, purity and efficacy was at no point since the Störfreimachung era truly fulfilled. As Schliack remarked in 1982, attempts to become independent from imports had existed since 1960 but the number of patients on imported Hoechst insulin had remained unchanged. He went on to state that replacing Novo-Rapitard had not been possible because of a lack of an alternative.866 The development of GDR insulins took time, as had been the case with B-Insulin, the answer to Hoechst insulin, and Berlinsulin of the 1970s, a more half-hearted replacement of the Novo- lente insulins.

The length of time taken to develop insulins of comparable quality created a situation whereby diabetes care in the GDR was slowly, and later more rapidly, playing catch-up with the West. An appearance of being behind was less apparent when B-Insulin was created in the 1960s. The international market of insulins was much less developed, and Hoechst was undoubtedly the preferred choice in the two Germanies before and after the building of the Berlin Wall. The diabetologist, Ruth Menzel, based at the Central Institute, concluded that GDR insulins corresponded to international standards until the end of the 1960s but had subsequently fallen increasingly behind.867 After Honecker came to power, the Nomenklatur system of pharmaceutical classification was utilised much more frequently than it had been, a signal that all was not well with the GDR’s capabilities to produce insulins that were deemed suitable to use on many patients.

Two major developments in diabetes care worldwide had occurred by the early 1980s that could not be met properly in the GDR: the large-scale production of ‘human’ insulins, and diabetics testing their own blood sugar and measuring insulin accordingly (self-monitoring).868 Diabetologists warned in 1983 that the international standing of the GDR depended on the existence of Humaninsulin within their range of insulins, and East German patients would soon

864 See Chapter 2 of this thesis for a definition of Störfreimachung. 865 Steiner, The Plans, p. 185. 866 SAPMO-BArch DQ1/13868 – Protokoll der Arbeitstagung der Beratenden Ärzte vom 20. und 21. 5. 1982 in Leipzig, p. 5. 867 SAPMO-BArch DQ1/14472 – Clinical study by the Central Institute led by Dr. Ruth Menzel, October 1989. 868 Although not strictly ‘human’, these insulins are mostly produced by, as Arthur Teuscher explains, ‘genetically modified E.coli bacteria or yeast cells with the human insulin gene spliced in their genome’. The first was produced by E. Lilly in 1982. See: Arthur Teuscher, Insulin-A Voice for Choice (Basel: Karger Publishers, 2007), p. 6.

197 demand to be treated with it.869 The frustration of East German diabetologists in their quest to keep up stemmed from the fact that their knowledge of these new trends always existed but the tools at their disposal did not. This was even more glaring than ever and made for an antagonistic relationship with the Ministry of Health which progressively worsened as reunification neared.

A rise in candid handwritten annotations from Ministry officials to the reports they received serves to suggest this. An example can be seen in the report of a meeting of diabetologists, including Schliack, in March 1981, where they outline what plans should be put in place for GDR insulins and medical equipment for diabetics.870 The focus of their attention was to improve the purity and neutrality (non-acidic) of GDR insulins. For depot insulins in particular, stability was deemed an issue. They also recommended necessary imports to maintain standards, like disposable syringes and injection needles from Sweden, and a device for self-monitoring which could be kept at various diabetes centres. In response to the first import suggestion, a comment in the margin from an official at the Ministry reads ‘No, that is not doable’. To the second, another comment says ‘No, not realistic’.871 The intransigence displayed by these dismissive comments demonstrates the expectation that diabetologists had to work with the products of VEB Berlin-Chemie, even if it did not allow them to provide their patients with the treatment they hoped to give.

As mentioned previously, the reason why this task was such a challenge had very little, if anything, to do with scientific understanding. In discussions about insulin therapy and the state of research, diabetologists knew the methods of producing a Humaninsulin prototype, which included genetic engineering and semisynthesis (replacing an amino acid in pig insulin).872 Hence, it is important to point out that the task to create better quality GDR insulins able to replace imports was based on factors out of the hands of diabetologists, such as ‘worn- out machinery’ at VEB Berlin-Chemi.e.873 Bibergeil complains to the Ministry that production

869 SAPMO-BArch DQ1/14472 – Letter from Bibergeil to Mecklinger dated 3/10/1983; Meeting regarding the strategy of insulin therapy and state of research – ‘Semi-synthesis of Humaninsulin’ including Profs. Bibergeil and Oehme and doctors Schulze, Matthes and Kreibich [date not shown on document but position in files and context implies that it is likely this meeting took place at the beginning of 1983]. 870 SAPMO-BArch DQ1/14471 1 of 3 – Meeting of diabetologists, 17/3/18, including Schliack, Gerecke (chair), Kreibich, Menzel, Maaz, Verlohren, Bruns and Schilling. 871 Ibid., pp. 1-2. 872 SAPMO-BArch DQ1/14472 – Meeting regarding the strategy of insulin therapy and state of research – ‘Semi-synthesis of Humaninsulin’ including Profs. Bibergeil and Oehme and doctors Schulze, Matthes and Kreibich (c. beginning of 1983). 873 SAPMO-BArch DQ1/14472 – Official visit to VEB Berlin Chemie by Alfred Neumann (deputy of Willi Stoph, Chairman of the Council of Ministers) and discussion about quality and production problems related to insulins, 8/8/1988.

198 conditions at VEB Berlin-Chemie had not kept pace with international developments, and this repeatedly led to quality problems. The amount of waste at the firm was staggering, as discovered following an official visit to Berlin-Chemi.e. In the production of Humaninsulin, a reported 75 percent of insulin was lost in the production process. Even in highly purified pig insulin, the waste was 25 percent.874 This was hardly the ‘rationalised’ and ‘intensified’ production called for at the 10th Party Conference.

Diabetologists sought to establish first what the quality of GDR insulins was really like, and second to address qualitative issues once they had been discerned. Novo’s Monotard, Rapitard and Actrapid were the most popular imported insulins and were targeted for replacement.875 The GDR alternatives were branded L-SNC (to replace Monotard and Rapitard) and SNC (to replace Actrapid) insulins. Neither, it seemed, came close to matching those from Novo in the end, although SNC was the better of the two. The Importablösekonzeption of September 1982 called for Actrapid to be removed from the GDR’s registered medications list and replaced with SNC.876 Seven months later, Dr. Ruth Menzel sent a report to the Ministry about the clinical experiences with SNC across the GDR. She believed there to be no major differences between SNC and Actrapid in the effect on blood sugar levels, but there were a few allergic reactions to SNC as well as issues of consistency in the quality of batches.877 This was a significant observation and emphasised an evident distinction between the positive discovery of a functional GDR alternative and the negative results of mass production at VEB Berlin-Chemi.e.

L-SNC insulin proved a challenge to produce, let alone perfect. Menzel reported in September 1983 that the GDR was ‘a long way behind in longer acting insulins’.878 Other diabetologists and representatives of both VEB Berlin-Chemie and the Institute for Drugs stated that GDR depot insulins did not even measure up to those of other socialist countries, with Bulgaria and Czechoslovakia having produced decent, purified depot insulins.879 In March 1984, diabetologists were very direct with the Ministry and admitted that Importablösung could

874 Ibid. 875 SAPMO-BArch DQ1/14471 3 of 3 - Protokoll der Sitzung des ZGA-Unterausschusses, ‘Importablösekonzeption- MC Insuline’, 14.9.1982. 876 Ibid. 877 SAPMO-BArch DQ1/14471 3 of 3 - Protokoll der ordentlichen Sitzung des ZGA-Unterausschusses vom 12.4.1983. 878 SAPMO-BArch DQ1/14472 – Report of the 2nd Interdisciplinary meeting on insulin problems in Heringsdorf, Sept. 1983. 879 Ibid. The Czech purified insulin from Spofa was considered very good, but it is highly likely that the company was not producing large enough amounts to export to the GDR.

199 not be achieved and the imports of Novo-Monotard therefore had to continue in 1984/85.880 A ‘special meeting’ of the ZGA was organised in December 1984 to discuss a study, led by Menzel, into how L-SNC measured up against the insulin it needed to replace. This would be a double-blind study and involved comparing L-SNC with Novo-Monotard on patients. One insulin would be labelled ‘x’ and the other ‘z’.881 The testing of western medication using East German patients is topical in German historiography and current media but historians and journalists have focused especially on the GDR making money from trialling new western medication on behalf of western pharmaceutical companies.882 Diabetics were involved in these sorts of trials, especially from 1983, as Rainer Erices, Andreas Frewer and Antje Gumz have discovered with the case of the oral anti-diabetic tablet, Acarbose, from Bayer, which generated 240,000 Valutamarks and involved 1,940 patients between the years 1983 and 1990.883 Ariane Retzar has also found a case where those with rheumatoid arthritis and type 1 diabetes tested an Immunmodulator, Ciamexon, from Boehringer Mannheim.884 As regards insulins, a ZGA meeting in November 1981 referred to free-of-charge samples of an NPH- Insulin from another Danish company, Nordisk, arriving at the IFAR which would be sent on to the Sanatorium Saalfeld for testing.885 It was apparent, in these instances, that generating hard currency to relieve the GDR’s debts was a motivating factor, as well as learning how western medication worked so that it could be emulated.

However, this particular trial by Menzel was not the same, nor was the aim to generate income directly from it (rather, indirectly by leading, it was hoped, to Importablösung). Here, it was not the western medication that was untested. Menzel’s study involved human participants, and one would expect the appropriate regulations to be in place. In their work on clinical trials in the GDR, Erices, Frewer and Gumz explain that, after a long search, they have

880 SAPMO-BArch DQ1/14471 3 of 3 - Protokoll der ordentlichen Sitzung des ZGA-Unterausschusses vom 20.3.1984. 881 SAPMO-BArch DQ1/14471 3 of 3 – Außerordentliche Sitzung des ZGA-Unterausschusses, 10.12.1984. 882 See, for example: Benedikt Peters, ‘West-Pharmafirmen ließen Medikamente in der DDR testen: Das Risiko der Anderen’, Der Tagesspiegel, 28.12.12, https://www.tagesspiegel.de/politik/west-pharmafirmen-liessen- medikamente-in-der-ddr-testen-das-risiko-der-anderen/7565844.html [accessed 01/10/18]. 883 Rainer Erices, Andreas Frewer and Antje Gumz, ‘Versuchsfeld DDR: Klinische Prüfungen westlicher Pharmafirmen hinter dem Eisernen Vorhang’, in Medizinethik in der DDR: Moralische und menschenrechtliche Fragen im Gesundheitswesen, ed. by Andreas Frewer and Rainer Erices (Stuttgart: Franz Steiner Verlag, 2015), pp. 129-144 (p.133). 884 Ariane Retzar, Erfassung und Bewertung von unerwünschten Arzneimittelwirkungen: Ein Beitrag zur Arzneimittelsicherheit in der DDR (Stuttgart: Wissenschaftliche Verlagsgesellschaft, 2016), pp. 133-5. 885 SAPMO-BArch DQ1/14471 3 of 3 - Protokoll der ordentlichen Sitzung des ZGA-Unterausschusses vom 17.11.81. N.B ‘Novo-Nordisk’ is now one company but until 1989 Novo and Nordisk were two separate companies competing with one another: Jocelyn E Mackie, ‘Novo-Nordisk: The Triple Bottom Line’, in Bioindustry Ethics, ed. by David L. Finegold et. al (Amsterdam: Elsevier Academic Press, 2005), pp. 301-330 (p.302).

200 found no evidence of written or oral consent from patients.886 There is, in the case of Menzel’s study, no physical evidence in the Ministry of Health files regarding any patient consent, either. Menzel did make specific mention of the Declaration of Helsinki, Appendix IV on Human- Experimentation Code of Ethics, and that written agreement from the patients was obtained following clear information about the test.887 This is in keeping with the findings of Erices, Frewer and Gumz, who conclude that ‘the files suggest that the GDR attempted to conduct trials according to international ethical standards’.888 Still, the fact that written consent has not been found means that it cannot be established for certain that patients signed a formal agreement to take part in the trial.

To some extent, a degree of patient autonomy can be seen in the struggle to recruit patients for trials where a GDR insulin was tested against imported ones, which also implies that they were not forced into them.889 Werner et al, in their study of clinical trials, reveal that the demands for new therapies in the 1980s by patients made it more likely that they would have been willing to take part readily if only the testing of a Western insulin were guaranteed.890 The legitimate reasons for not participating in Menzel’s study were reported sympathetically. According to Menzel and Bibergeil, it was ‘understandably difficult’ to persuade patients with a stable metabolism on their current insulins to participate in the trials.891 Several patients who experienced ‘metabolic decomposition’ decided to drop out as a result. The study needed to last at least 12 months since the immunogenic quality of both insulins tested could only be assessed after 9 months.892 Participants would be in it for the long haul but would have to return to their previous insulin therapy after the trial was over.

At the side of the comment explaining that some patients were stable on their current therapies, a familiar handwritten scrawl appeared that sarcastically reads ‘imported?’ in reference to the insulins they were using.893 The Ministry failed to appreciate the clinical steps needed before diabetologists could prove that L-SNC was ready to replace Monotard.

886 Rainer Erices, Andreas Frewer and Antje Gumz, ‘Testing ground GDR: Western pharmaceutical firms conducting clinical trials behind the Iron Curtain’, Journal of Medical Ethics, 41:7 (2015) 529-33 (p.531). 887 SAPMO-BArch DQ1/14471 3 of 3 – ‘Klinische Prüfung (III) von L-Insulin SNC (VEB Berlin-Chemie)’ by Dr. Ruth Menzel, 16/8/1985. 888 Erices, Frewer and Gumz, ‘Testing ground GDR’, p. 531. 889 SAPMO-BArch DQ1/14472 – Clinical study by the Central Institute led by Menzel comparing imported insulins with GDR ones, including Humaninsulin, Oct. 1989. 890 Anja Werner, Christian König, Jan Jenkow and Florian Steger, Arzneimittelstudien westlicher Pharmaunternehmen in der DDR, 1983-1990 (Leipzig: Leipzig University Verlag, 2016), pp. 24-5. 891 SAPMO-BArch DQ1/14472 – Letter jointly authored by Bibergeil and Menzel to Probst of the Ministry of Health, 23/4/1984, p.2. 892 Ibid., p.2. 893 Ibid., p.2.

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Unfortunately, Menzel was soon aware during the study that the insulin labelled ‘z’ was L-SNC due to evident shortcomings not seen in the already proven Monotard. Earlier tests had shown that L-SNC worked like Monotard but as the study progressed it did not appear to act identically. A recurrence of the problem of variability relating to different production batches was demonstrated. Sometimes ‘z’ insulin worked well and at other times not.894 This had already been noted by Menzel in her clinical observations of the other GDR insulin, SNC. More unexpectedly, and equally alarming, were the progressively more frequent and strong allergic skin reactions in some participants, which had not been noted by diabetologists when administering imported Monotard to patients and thus did not manifest when participants were given ‘x’ insulin.895 The recommendation to the Ministry, which, unsurprisingly, did not go down well, was to allow the study to run for the whole of 1985 and give time after the study to assess areas for improvement before administering L-SNC to patients. The Ministry official simply wrote ‘far too late’. 896 Bibergeil and Menzel advised that it would be a long process to switch diabetics over to L-SNC and that it was not suitable for problem cases. They feared that rolling out L-SNC too quickly would result in a dip in the quality of diabetes care and irreparable damage to people’s trust in the healthcare system. 897 In the long-term, if the Ministry expected Importablösung to be a success, it would involve patience and persuasiveness (encouraging doctors to see the importance of Importablösung). Bibergeil concluded by stating that focusing on L-SNC was logical but it should be seen as one of a range of insulins the GDR would need to produce if it were to address Western development sufficiently. 898

Contrary to the recommendations of Bibergeil and Menzel, the Ministry seemed to have other ideas about the speed of Importablösung. Two months after their letter to the Ministry in April 1984, another letter was sent by an official at the Ministry, Dr. Probst, to VEB Berlin- Chemie, charting a timeframe for Importablösung and the introduction of L-SNC insulin. According to Probst, the projected time for the replacement of imported depot insulins (i.e. Novo-Monotard and Rapitard) was ‘as early as 1985’ and that imported insulin worth a total

894 SAPMO-BArch DQ1/14471 3 of 3 – Außerordentliche Sitzung des ZGA-Unterausschusses vom 10.12.1984. 895 Ibid. 896 Ibid. 897 SAPMO-BArch DQ1/14471 3 of 3 - ‘Klinische Prüfung (III) von L-Insulin SNC (VEB Berlin-Chemie)’ by Dr. Ruth Menzel, 16/8/1985. 898 SAPMO-BArch DQ1/14472 – Letter jointly authored by Bibergeil and Menzel to Probst of the Ministry of Health, 23/4/1984.

202 of 416,000 Valutamarks could be replaced.899 This completely ignored both diabetologists’ advice and failed to consider that Menzel’s important study to check whether L-SNC was safe to use was only due to finish in November 1985. When the trial was eventually concluded, a meeting of diabetologists resolved that L-SNC should be registered in mid-1986 and used in a very controlled manner.900 Dictated by economics, the Ministry could not accept the ‘delay’ and attempted to clamp down on the use of imported insulins. The Ministry’s behaviour coincided with the publication of an alleged ‘poison list’ of imported medications that were not supposed to be prescribed.901 In a similarly dogmatic fashion to the early years of Störfreimachung, a situation of ‘domestic product first’ arose, and as in that earlier period, diabetologists responded with messages of caution.

Recalling the ‘metabolic derailments’ of patients moved onto domestic insulins from Hoechst in the early 1960s, diabetologists voiced their caution even more forthrightly when it came to L-SNC insulin. One has to consider that, in the end, B-Insulin had at the time of its development not been that much worse than the insulin it had been replacing. The gap between L-SNC and Novo-Monotard was, however, worryingly large and justified their caution. At ZGA in November 1986, both diabetologists and representatives of the pharmaceutical industry called for L-SNC insulin to be banned from use in the first quarter of 1987 due to its lack of quality.902 Menzel explained to the Ministry in June 1988 that in spite of consistent efforts by diabetologists, the envisaged Importablösung could not happen because both the practical use and double-blind studies not only of L-SNC but also of SNC insulin had revealed inconsistencies and lack of quality.903 Diabetologists had therefore been vindicated in their judgement that the introduction of L-SNC in 1985 was wishful thinking.

As for the development of Humaninsulin, it was a similar scenario, and, with all the waste caused in production at VEB Berlin-Chemie, Bibergeil complained to Mecklinger’s successor, Thielmann, that the GDR could only produce human insulins genetically ‘for later than the year 2000’.904 There was a clear spiralling effect in terms of waste and inefficiencies.

899 SAPMO-BArch DQ1/14472 – Letter from Dr. Probst of the Ministry of Health to OPhR Nelde, Director of VEB Berlin-Chemie. 900 SAPMO-BArch DQ1/14471 3 of 3 – Sitzung des ZGA-Unterausschusses vom 12.11.1985. 901 Wasem, Mill and Wilhelm, p. 387. 902 SAPMO-BArch DQ1/14471 3 of 3 - Sitzung des ZGA-Unterausschusses vom 13.11.1987. 903 SAPMO-BArch DQ1/14471 3 of 3 – Additional document by Menzel on 14/6/88 about Importablösung and L-SNC/SNC insulins in response to the ‘Außerordentliche Sitzung des ZGA-Unterausschusses’ on 31/5/88. 904 SAPMO-BArch DQ1/14472 – Official visit to VEB Berlin Chemie by Alfred Neumann (deputy of Willi Stoph, Chairman of the Council of Ministers) and discussion about quality and production problems related to insulins, 8/8/1988.

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A severe shortage of pig pancreases used in production ensued, as the inefficient process of purifying the insulins at VEB Berlin-Chemie led to less insulin being extracted per pancreas. Mass production of purified insulins (SNC and L-SNC), not to mention Humaninsulin, was hampered by this shortage and only increased dependency on imports.905 Statistically, use of imported insulins rose for most of the decade. After 1982, its use increased by 5.8 percent in 1983/4, by 8.2 percent in 1984/5, and then fell slightly in 1985/6, but still being 0.7 percent above the levels in 1982.906 This could have been the immediate result of SNC’s introduction, slowly replacing Novo-Actrapid, and L-SNC’s impending registration. The following year’s statistics, however, made for grim reading, and confirmed the aforementioned problems experienced in mass production at VEB Berlin-Chemie; the consumption of imported insulins rose by 15.6 percent.907

Importablösung, as far as insulin and pharmaceuticals more broadly were to go by, was thus a nonstarter. In relation to medical equipment, the picture was ‘far worse’, as Wasem, Mill and Wilhelm explain, and they judge the GDR’s ‘medical-technical base’ in the 1980s to be ‘very poor’. Basic instruments, they add, either did not exist or there were not enough of them. Medical technology has been singled out in scholarship as the ‘creeping crisis factor’ and ‘Achilles heel’ of the East German healthcare system in the final decade.908 Even Mecklinger’s sacking centred on the GDR’s failure to produce adequate medical equipment and technology. The chances of reducing reliance on imports and replacing them with domestic goods, when they existed, were evidently even slimmer than in the area of pharmaceuticals. Problems with medical-technical equipment stemmed from the early 1960s, when the GDR began to fall behind. Up until then, as Bause and Matauschek argue, the GDR did keep up with the West, citing a meeting of the German Society for Biomedical Technology at Siemens in Kiel in 1964, where East German technology was still praised.909 Medical-technical issues which arose during the Störfreimachung era, such as faulty urine test strips at the regional diabetes advice

905 SAPMO-BArch DQ1/14472 – Minutes of an interdisciplinary meeting on insulin problems in Miersdorf, January 1986; SAPMO-BArch DQ1/15405 – Letter from the Minister for Chemical Industry, Wyschofsky, to the Chairman of the Council of Ministers, Willi Stoph, 21 June 1988. 906 SAPMO-BArch DQ1/15405 - Bericht über die Kontrolle zur Sicherung der Versorgung mit Insulinen im SVPM, 9/6/1988, p.1. 907 Ibid., p.1. 908 Ulrich Bause and Jochen Matauschek, ‘Zum Stand der Medizintechnik in der DDR’, in Das Gesundheitswesen in der DDR: Aufbruch oder Einbruch? Denkanstöße für eine Neuordnung des Gesundheitswesens in einem deutschen Staat, ed. by Wilhelm Thiele (Sankt Augustin: Asgard-Verlag Hippe, 1990), pp. 197-202 (p.197); ‘Achillesferse des Gesundheitswesens’ in: Florian Bruns, ‘Krankheit, Konflikte und Versorgungsmängel: Patienten und ihre Eingaben im letzten Jahrzehnt der DDR’, Medizinhistorisches Journal 47 (2012), 335-367 (p.357). 909 Bause and Matauschek, p. 197.

204 centres, reveal that the GDR started falling behind at a slightly earlier stage in this area than was the case with insulins and oral anti-diabetic tablets. The reason given by Bause and Matauschek for the failings in production is that a decision was made within COMECON to instruct individual economies to produce specific types of medical equipment that could be shared across member states.910 The GDR thus stopped producing certain equipment it had produced before and was then more reliant on what other Eastern Bloc countries were producing. The medical-technical base by 1980 was, as a consequence of almost two decades of struggle, decidedly weak.

In the minutes of a 1986 meeting of regional diabetologists, Bibergeil bemoaned the GDR’s position on diabetic self-monitoring, estimating them to be ‘several years behind’.911 Reflections on the new technical devices in the November 1986 ZGA special meeting hammered home Bibergeil’s claim. Production of disposable syringes was considered ‘desirable’ but could not be realised ‘in the foreseeable future’, and on 5 November 1989, diabetologists put forward a plan for 10 million disposable syringes to be imported.912 Injection needles of 0.4 mm diameter were also listed as ‘desirable’ but not able to be realised, bearing in mind that the thickness of injection needles had the potential to make injecting insulin very unpleasant and painful.913 Test strips, as had been the case in the 1960s, were problematic both in quality and quantity. The latest GDR test strip used was the Glukosignal and a special session of the 1985 regional diabetologists’ gathering was devoted to their introduction. Approximately 1.5 million of them were required in 1986, according to diabetologists’ estimates, a figure that looked highly unlikely to be achieved, considering that the pharmaceutical Kombinat, GERMED, only planned for 650,000 to be produced.914

910 Bause and Matauschek, p. 197. 911 SAPMO-BArch DQ1/13868 – Protokoll der Arbeitsberatung der Beratenden Ärzte für Diabetologie der Bezirksärzte vom 7. Mai 1986 in Schmalkalden, p. 4. 912 SAPMO-BArch DQ1/14471 3 of 3 – Letter from Bibergeil to Thielmann (Mecklinger’s successor as Minister of Health), 5/11/89. 913 SAPMO-BArch DQ1/14471 3 of 3 - Sitzung des ZGA-Unterausschusses vom 13.11.1987. 914 SAPMO-BArch DQ1/13868 – Information über die Nachkontrolle zur Gewährleistung der Diabetikerbetreuung und -versorgung, Komitee der Arbeiter-und-Bauern-Inspektion, 13. Februar, 1986. N.B ‘Kombinate’ were the mergers of smaller companies undertaken at the end of the 1970s.

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Figure 13: Glass syringe produced in the 1970s and 1980s by VEB Injecta Steinach915

Disposable syringes, thin injection needles and reliable test strips were basic equipment for Western diabetics by the 1980s. Supply and demand in the GDR’s economy was ‘subordinated to needs that the party [SED], in its role as arbiter of production, determined’ as Jonathan Zatlin points out in his discussion of automobiles.916 The SED had to define what were ‘real’ needs, a difficult task when thinking about the whole population.917 Basic foodstuffs, housing and employment were obvious choices, but the intricacy of the various medical needs could be lost in this grand narrative. Ultimately, diabetics could manage with thick needles and syringes they had to sterilise themselves at home, but as pensioners frequently came back from West Germany with disposable syringes, they were fully aware that far better equipment was available on the other side of the Iron Curtain.918 It was also the expectation of diabetologists that they would adopt new technologies to ensure up-to-date treatment like self- monitoring. This was why Bibergeil explained to the Ministry that knowledge of the world

915 Deutsches Hygiene-Museum, ‘Spritze Uni-Rekord’, 2013/868. 916 Jonathan Zatlin, ‘The Vehicle of Desire: The Trabant, the Wartburg, and the End of the GDR’, German History, 15:3 (1997), 358-380 (pp. 365-6). 917 Zatlin, ‘The Vehicle of Desire’, p. 363. 918 SAPMO-BArch DQ1/13868 – Diabetologen Tagung, Dresden, 25-26 March 1980, handwritten minutes by Dr. Toedtmann of the Ministry of Health, p. 4.

206 standard, be it that of diabetologists or patients, caused serious ideological problems, and only added to the problematic nature of Importablösung, which seemed to restrict any developments in diabetes treatment on the scale of progress required to match the standards of modern diabetes treatment in the West.919

The patients’ view: everyday life of diabetics in the final decade as portrayed in Eingaben and by members of the Patientenaktiv

The concerns illustrated above over supply and demand featured in a new wave of Eingaben written by diabetics throughout the decade. The set of Eingaben sent to the Ministry of Health during the period of Störfreimachung focused on changes to insulin therapies and Umstellungen. During the GDR’s first serious trial of autarky, these Eingaben confirmed that political officials were proactive in reducing dependence on insulins from the West. Eingaben written during the GDR’s second attempt at autarky were, however, much less concerned with insulins, probably because relatively few people were eventually changed onto L-SNC and SNC, and the quantity of imported insulin increased rather than decreased. In his study of health-related Eingaben specifically from the 1980s, Florian Bruns believes that those written between 1980 and 1986 can be divided into four broad categories. The first relates to ‘medical care’, asking questions about the arrangement of specialist therapy for serious diseases as well as complaining about the behaviour of doctors and medical staff in the healthcare system. The second covers the ‘provision of medication and resources’, which includes requests for and complaints about equipment and unavailable medication. The third comprises those that were within the subject of ‘social care’, examples being waiting times in health facilities and a lack of Kindergarten places. Lastly, the fourth denotes Eingaben that were written by doctors and not by patients, although these will not be analysed in this section.920

These categories are useful and generate a fairly comprehensive picture of the sorts of topics and themes discussed. The category of ‘provision of medication and resources’ covers some of the Eingaben sent by diabetics. Hartmut Bettin, in a further study of Eingaben on medical topics, has discovered at least 16 relating to the shortcomings of needles, syringes and other technical equipment sent by diabetics, which reflected the dangers and limits of Importablösung.921 What are decidedly more difficult to fit into Bruns’ categories are the

919 SAPMO-BArch DQ1/13869 – Protokoll der Arbeitstagung der Beratenden Ärzte für Diabetologie der Bezirksärzte am 4.10.1988 in Berlin, p. 1. 920 Bruns, ‘Krankheit, Konflikte und Versorgungsmängel’, pp. 345-6. 921 Hartmut Bettin, ‘Zwischen Verdüsterung und Verklärung: Eingabenanalysen des Ministeriums für Gesundheitswesen (MfG) der DDR als Quelle zur Beschreibung von Problemschwerpunkten und

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Eingaben from diabetics complaining about the range and quantity of diet foods, which did not, unlike the Eingaben discovered by Bettin or indeed those discussed during the Störfreimachung period, end up at the Ministry of Health. These were dealt with instead by the local political authorities, Honecker’s office and the Council of Ministers. They could fall loosely under the category of ‘social care’ as dietary foods are not medical treatment as such but they are conducive to good therapy, blurring the boundaries of Bruns’ designated categories. Complaints on consumer goods had for the first time overtaken those on housing shortages, indicative of an ‘intensified politicization of…citizen complaints in the 1980s’, as Paul Betts points out, based on how contentious consumerism had always been in the GDR since the Störfreimachung period.922

Renewed efforts worldwide in the late 1970s to create structured educational programmes for diabetics, which can be seen in the GDR with a new working group of diabetelogists entitled ‘Education’, could be partially responsible for the rise in demand for special diet products.923 Access to the right kinds of food in ordinary East German shops was by now notoriously difficult. Jutta Voigt claims that per year the average East German ate 96 kilos of meat, 43 kilos of sugar, 15.7 kilos of butter, and 307 eggs, making them the leaders (‘Weltspitze’) in (over)consumption.924 These figures look worse when factoring in the fat content of the meat and butter that people were consuming. Alice Weinreb has discovered that pre-war, low fat sausage was ‘difficult to come by’, and that butter was on average 70 percent fat throughout the GDR’s lifetime.925 Since ‘variety and freshness were…not among the virtues of the GDR food regime’, as Paul Freedman explains, especially in these economically trying times, it was little wonder that diet shops and foods were of special importance to the increasingly health-conscious East German diabetics.926

Bewältigungsstrategien im DDR-Gesundheitswesen’, Medizinhistorisches Journal, 51:4 (2016), 327-363 (pp.353-4). 922 Paul Betts, Within Walls: Private Life in the German Democratic Republic (Oxford: Oxford University Press, 2010), p. 190. 923 SAPMO-BArch DQ1/13868 – Protokoll der Arbeitsberatung der Beratenden Ärzte für Diabetologie der Bezirksärzte vom 7. Mai 1986 in Schmalkalden, p. 5. 924 Jutta Voigt cited in Paul Freedman, ‘Luxury Dining in the Later Years of the German Democratic Republic’, in Becoming East German: Socialist Structures and Sensibilities after Hitler, ed. by Mary Fulbrook and Andrew Port (Oxford and New York: Berghahn, 2013), pp. 179-200 (p.180). Reference to ‘Weltpitze’ taken directly from Voigt: Jutta Voigt, Der Geschmack des Ostens: Vom Essen, Trinken und Leben in der DDR (Berlin: Aufbau Verlag 2005), p. 10. 925 Alice Weinreb, ‘It Tastes like the East…: The Problem of Taste in the GDR’, Imaginations, 8:1 (2017): https://journals.library.ualberta.ca/imaginations/index.php/imaginations/article/view/29383/pdf [accessed 05/10/18], 114-125 (pp.121-2). 926 Freedman, p. 180.

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The range and availability of diet foods in the regions were a source of anger in a large batch of Eingaben by diabetics. Most, though not all, authors followed the usual pattern of the ‘model biography’ of a committed socialist citizen, which encouraged them to criticise fervently.927 Eingaben would begin first by making a Genossen status clear, or, as Bruns has also discovered, using informalities such as ‘ihr’, ‘du’ and ‘unser’ to address the Central Committee, the Council of Ministers, Honecker and the state.928 People’s expectations about health and wellbeing had been raised by all the promises of the previous decade encapsulated in the Unity of Economic and Social Policy. Honecker had focused on making people’s lives better, but what if they were now getting worse? One Eingabe from parents of a diabetic child in Teltow, for example, demonstrated this dilemma by saying that the provision of dietary food ‘does not meet the standards of a socialist lifestyle’.929 Their expectations of a ‘socialist lifestyle’ had clearly been fostered by Honecker’s promises.

Questions about the GDR’s legitimacy that Honecker had wanted to eradicate resurfaced with a vengeance.930 Paul Betts notes that by the 1970s and 1980s, ‘gone was the restrained and respectful tone’ in Eingaben.931 Dissatisfaction was voiced vociferously, and, more so than ever before, diabetics were not simply asking questions about the state and the meaning of socialism, but also of what they saw as abuses of power among those at the top. This was criticism on a different scale and featured openly in the Eingaben from 1985, the year that Gorbachev took over in the Soviet Union. An author of an Eingabe dated August 1985 pointed out numerous shortages and contended that it should only be possible to obtain diet products with a Diabetikerausweis as too many non-diabetics were buying considerable amounts of products marked for diabetics in shops.932 Not satisfied that her letter had been sent to the authorities in Dresden rather than Berlin, she sent a further Eingabe which offers a real window onto how people critiqued the GDR at this point.933 She argued that basic diet goods like cracker bread were a shortage product in Dresden and that people in East Berlin had no idea how bad things were there. She then added that ordinary people had to go from shop to shop in their local area in order to find products whereas party functionaries could go to Berlin

927 This has also been discovered by Florian Bruns in: F. Bruns, p. 347. 928 F. Bruns, pp. 347-8 and 350. 929 SAPMO-BArch DY30/18103 – Eingabe from H-W.B and U.B, Teltow, 11/3/86, p. 1. The authors make the link with socialist lifestyle by saying: ‘Unser Anliegen geht dahin, dass die Versorgung von Diabetikernährmitteln in unseren Geschäften nicht den Stand einer sozialistischen Lebensweise hat’. 930 F. Bruns, p. 344. 931 Betts, p. 189. 932 SAPMO-BArch DY30/18103 – Eingabe from G.H. of Dresden, 9/8/85. 933 SAPMO-BArch DY30/18103 – Eingabe from G.H. of Dresden, 3/9/85.

209 and take advantage of the better situation there.934 This taps into what Freedman says about the ‘physical and mental costs’ of procuring appropriate food in the GDR at the end of the decade.935 The author of the Eingabe then decisively declares that Dresden was clearly ‘not a socialist city’.936 She even suggested a solution for Dresden to ‘awake from its slumber’; the Central Committee should stop reading reports about successes (which, as a good socialist citizen, she was sure were true) and start hearing about problems and shortages.937

These gaps in provision irked many other diabetics. An Eingabe from G.H of Nerchau (near Leipzig) had observed that the situation with diet products in the local shop had been much better in previous years, confirmed by the abundance shown in Figure 13 from 1973, and had asked the manager of the shop to order more products, which she claimed to have done, but nothing had arrived. Having read an article in the Neues Deutschland newspaper about the 65 varieties of products available for diabetics, G.H. complained that many of these had never been seen in their local town.938 This Eingabe also made a similar argument to the author from Dresden about the distribution of goods, asking why diabetics living in the country were treated differently to those in towns and cities, and why things were less good in rural areas. The account of the situation in Dresden, one of the GDR’s biggest cities after East Berlin, serves to suggest that, outside Berlin, the problems were actually universal and that, whilst worse in rural areas, provision was still bad everywhere. The Eingabe from G.H. finished with quotes from Honecker about reliable provision of basic foods, including dietary ones, and about the importance of taking Eingaben seriously, concluding that there should be no bureaucratic and heartless behaviour from the state toward the citizens.939

934 ‘Wenn man Berliner spricht, die legen die Ohren an, was es alles bei uns nicht bezw. evtl. mit viel Lauferei gibt. Offenbar fahren unsere Funktionäre nach Berlin einkaufen oder andere besser geleitete Städte’, in Ibid. 935 Freedman, p. 180. 936 ‘Dresden war und ist und bleibt ‘Residenzstadt’ aber keine sozialistische Großstadt’, in SAPMO-BArch DY30/18103 – Eingabe from G.H. of Dresden, 3/9/85. 937 ‘Deshalb lege ich Wert darauf, daß Ihr nicht nur Erfolgsmeldungen bekommt (die sicher stimmen) sondern auch mal erfahrt, wo es fehlt, und helft, dass Dresden aus seinem Trott erwacht’, in Ibid. 938 ‘Laut “Neues Deutschland” sind für den Diabetiker 65 Artikel im laufenden Angebot. Nußmus gleich welcher Art, Pudding u.a. haben wir in Nerchau noch nie gesehen’, in SAPMO-BArch DY30/18103 – Eingabe from G.H of Nerchau (Leipzig), 28/11/84. 939 Ibid.

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Figure 14: A specialist shop selling the East German brand of diet foods, ‘Sucrosin’, October 1973940

Even though diabetics were writing to complain about diet products, they were also taking the opportunity to discuss profound issues they had with the state and its direction. The comments made about a lack of egalitarianism and regional disparities, issues which had existed for many decades, show that they were now rather more conspicuous. Links to relatives in the West and the usefulness of generating hard currency meant that some people received more commodities than others.941 Wolfgang Harich, an outspoken philosopher and journalist, joked that the distribution of wealth no longer corresponded to the mantra ‘to each according to his labour’ but rather ‘to each according to where their aunt [i.e. relatives in the West] lives’.942 The 1980s became, as Freedman discusses, an era of ‘social differentiation’ where the Zielkultur (target culture), a term used by the SED to refer to the end product of socialist equality, was clearly missed.943 After, as Andrew Port puts it, the ‘constant barrage of official rhetoric about the way in which socialism had successfully helped reduce material disparities

940 Bundesarchiv Bild 183-M1023-0024. 941 ‘Da ich nicht zu den Bürgern der DDR zähle die Westverwandtschaft haben, bin ich auf das Angebot bei uns angewiesen’, in SAPMO-BArch DY30/18103 – Eingabe from J.B. of Magdeburg, 1/12/86. 942 Cited in Gareth Dale, Popular Protest in East Germany, 1945-1989 (London and New York: Routledge, 2006), p. 83. 943 Freedman, p. 181.

211 and eradicate social inequality’, authors of the Eingaben recognised what a socialist society should look like but were not seeing it in reality.944 They were instead observing the current hypocrisies surrounding a relatively minor issue, diet foods, through their everyday experiences as diabetics. Questions were again raised, as they were with regard to Importablösung and medical equipment, about ‘basic’ and ‘real’ needs under socialism. The parents from Teltow asked what they should give to their daughter on days of celebration. All they could see were non-diabetic chocolates in Christmas wrapping (they wrote the Eingabe on 11 March).945 As parents, they wanted the best for their child, and a few diabetic treats would have been nice, which were only ‘Pfennigsartikel’ rather than ‘Tausendmarksartikel’, terms used by the author from Dresden to describe the basic status of diet products.946

When they were available, many of the products for diabetics, from diabetic chocolate, jams and cake to alcoholic beverages, were not desirable. The parents from Teltow bought diabetic cakes for their daughter on 26 December and when they got home found that they were out-of-date and mouldy. When they returned to the shop the following day and exchanged them for 6 other cakes, they too were mouldy. Their third attempt was also unsuccessful.947 Longstanding food transportation and storage issues were likely to blame.948 The jam allegedly caused diarrhoea when consumed in moderate quantities.949 Several complaints were made about the sandy consistency and taste of the chocolate. The Institute for Market Research in Leipzig estimated that approximately a third of consumers described this chocolate as unpleasant.950 All of the domestically produced sweet goods were made from the GDR’s own sweetener, Sorbit (sorbitol). Fructose, which was requested by the authors from Teltow, was in short supply and had to be imported. An Eingabe by J.B. from Magdeburg recalled a gift of an excellent diabetic chocolate from Austria, which tasted totally different from that produced in the GDR. He proposed the possibility of this diabetic chocolate appearing in the expensive,

944 Andrew Port, Conflict and Stability in the German Democratic Republic (Cambridge: Cambridge University Press, 2007), p. 239. 945 ‘Was machen wir mit unseren Kindern zu Festtagen, Einschulungen etc. Hier finden wir noch jetzt Konfekt in Weihnachtsverpackung’, in SAPMO-BArch DY30/18103 – Eingabe from H-W.B and U.B, Teltow, 11/3/86. 946 ‘Es war mir ein Bedürfnis darauf aufmerksam zu machen, daß bei aller Anerkennung der Notwendigkeit, Einzelhandelsumsatz nicht nur mit Tausendmarksartikeln gesteigert werden darf…man darf die “Pfennigsartikel” nicht vergessen’, in SAPMO-BArch DY30/18103 – Eingabe from G.H of Dresden, 9/8/85. 947 ‘Als der 3. Versuch scheiterte, schalteten wir die Arbeitshygiene Potsdam Lund…ein’, in SAPMO-BArch DY30/18103 – Eingabe from H-W.B and U.B, Teltow, 11/3/86. 948 Freedman, p. 180. 949 ‘Sorgen bereitet die Diabetiker-Marmelade, da sie Durchfall hervorrruft’, in: SAPMO-BArch DY30/18103 – Eingabe from G.H of Nerchau (Leipzig), 28/11/84. 950 SAPMO-BArch DL102/1846 – Report by the Institut für Marktforschung, December 1986, p. 2.

212 luxury Delikat shops where he believed several sweets from capitalist countries were sold. 951 The response to his suggestion from the Central Committee was dismissive, refuting firstly that capitalist goods were sold in these shops, which supposedly contained only luxurious GDR produced goods, and secondly, that there were plans to add diabetic products made with fructose which were going to be provided to the DiabetikerAktiv for testing in December 1986.952

The new national patient group for diabetics, the Aktiv, wanted to take a constructive role in communicating patients’ concerns to diabetologists and members of government. The Eingaben could be a powerful tool to voice a collective concern, and were invariably responded to by relevant government departments, but they did not prompt any great urgency to solve the problems they outlined. The earlier Eingabe sent by G.H. of Nerchau led to a meeting with a regional representative of the Department for Trade and Provision, but the representative only concluded by saying ‘we want to help but we do not know how’. The enquiries by G. H. into diabetic jam did not lead anywhere either. 953 Although, as Hester Vaizey explains, East German citizens had been ‘invited to air views’, the responses from the Central Committee to Eingaben were regularly vague and nondescript, suggesting, on one occasion, that an issue ‘will be dealt with before the 11th Party Conference’, and, on another, that effort was being made ‘to raise quality, increase production and widen the product range’.954 Membership of the Aktiv gave diabetics the chance to get involved more directly and speak face-to-face with those delivering their care.955

Diabetologists pressed for an expansion of the Patientenaktiv. For them, it was an opportunity to hear concerns and try to act on them, even if complaints relayed by the Aktiv members often only confirmed their own observations of the situation in the advice centres. According to a 1987 report by diabetologist Dr. Schulz, the topics discussed by the Patientenaktiv included the quality of medication and technical equipment, dietary products,

951 ‘Durch Zufall bekam ich eine Diabetikerschokolade aus Österreich geschenkt. Der glatte Gegensatz zu unserer Schokolade. Diese schmeckte ausgezeichnet, aber dort wird kein Sorbit sondern Fruktose verwendet’, in SAPMO-BArch DY30/18103 – Eingabe from J.B of Magdeburg, 1/12/86. 952 SAPMO-BArch DY30/18103 – Response to the Eingabe dated 1/12/86 from J.B of Magdeburg. 953 ‘Eine Beauftragte… klärte mich auf. Ergebnis: Wir wollen helfen, wissen aber nicht wie’, in SAPMO-BArch DY30/18103 – Eingabe from G.H of Nerchau (Leipzig), 28/11/84. 954 Hester Vaizey, Born in the GDR: Living in the Shadow of the Wall (Oxford: Oxford University Press, 2014), p. 164; SAPMO-BArch DY30/18103 – Response to the Eingabe dated 28/11/84 by G.H. of Nerchau; SAPMO- BArch DY30/18103 – Response to the Eingabe dated 12/5/87 by K.D. of Mittweida. 955 SAPMO-BArch DQ1/13869 – Letter from M.A. of the Patientenaktiv for diabetics to the department of pharmacy and medical technology, 8/6/88.

213 training for diabetics, and ambulatory and stationary care. 956 They were also allowed to take part in meetings with representatives from government, industry and the Warenzeichenverband (Trademark Association).957 From the point of view of the SED, allowing the Patientenaktiv to liaise with members of the Ministry of Health and diabetologists could prevent the group from developing into an underground outlet of opposition.958 This new way of communicating complaints maintained a degree of trust in the regime, even when there were visible signs of decay.959 Conversely, the fact that patients were attending meetings with government representatives gave the Aktiv an official flavour and therefore added pressure to deal with their complaints.

Towards the latter half of the 1980s, attentions of the Aktiv turned to the provision of medical equipment and the worsening condition of rooms at the diabetes advice centres. As well as sending representatives to various meetings held at the Ministry of Health, members of the Aktiv corresponded with the relevant department heads at the Ministry. This correspondence was not the same as Eingaben; it was addressed directly to specific contacts in the Ministry whom they had probably met before, likely at meetings. One particular series of correspondence of a member of the Aktiv from Dresden reveals in-depth discussions that had taken place between patients about various problem cases and issues.960 The letters paint a vivid and rather bleak picture of what was seen and experienced on the ground. Patients had voiced concerns that doctors were not overseeing diabetic complications properly, which were allegedly ignored or viewed as unavoidable. The Aktiv member who had written to the Ministry mentioned that she had had numbness in three fingers of her right hand but had to fight hard to receive treatment for it.961 She discussed cases of patients who had developed complications that could have been prevented, such as a 40-year-old diabetic with such high blood pressure

956 SAPMO-BArch DQ1/13869 – Protokoll der Sitzung der Problemkommission für Diabetes beim MfGe am 11.11.1987, p.4. 957 Aktiv members were clearly listed as attendees in various meetings, such as: SAPMO-BArch DQ1/13869 – Protokoll der Sitzung der Problemkommission für Diabetes beim MfGe Berlin, am 23.4.1988; SAPMO-BArch DQ1/13868 – Protokoll der Sitzung des Fachbeirates für Diabetes beim MfGe am 19.3.1987, p. 2 [‘Arbeitsweise des Patientenaktivs’ section]. 958 SAPMO-BArch 13869 – Protokoll der Arbeitstagung der Beratenden Ärzte für Diabetologie der Bezirksärzte am 4. 10. 1988 in Berlin, p. 2. 959 Concept of communication possibilities reinforcing trust in: Vaizey, p. 164. 960 SAPMO-BArch DQ1/13869 – Letter from M.A of the Patientenaktiv for diabetes to the Deputy Minister for Health, Dr. Schneidewind, 14/2/88; Letter from the head of the department for pharmacy and medical technology, Haeßner, to M.A, 10/3/88; Letter from M.A. of the Patientenaktiv for diabetes to Haeßner, 8/6/88. 961 SAPMO-BArch DQ1/13869 – Letter from M.A of the Patientenaktiv for diabetes to the Deputy Minister for Health, Dr. Schneidewind, 14/2/88, p. 2.

214 that he had a stroke and was paralysed on one side of his body.962 Another diabetic had continuously high blood sugar levels which had led to blindness. She had not been informed of the danger of diabetes having an adverse effect on his eyes.963

Patients therefore took the time to communicate their concerns to the Ministry. It is also true that officials tried to find out for themselves what patients thought about their care by ordering the Committee of the Workers’ and Peasants’ Organisation to carry out various ‘inspections’ of healthcare facilities. These inspections are prolific in Ministry of Health documents from 1980 onwards, with at least five major nationwide inspections into diabetes care throughout the decade and smaller inspections in between.964 Described by Patrick Major as ‘a trouble-shooting ombudsman to monitor the state apparatus’, the organisation scrutinised how diabetes advice centres functioned on a day-to-day basis.965

During one major inspection in 1984, they interviewed over 1000 diabetics to assess areas of weakness and aspects of care that required improvement. They compiled a report that was sent to the Ministry outlining the main points uncovered in interviews and made suggestions for moving forward.966 Apart from the failings of medical-technical equipment and diet foods already discussed in the context of the Eingaben, patients expressed concerns that they did not always see the doctor when attending a check-up. It was estimated that only thirty to forty percent of the patients interviewed nationwide saw a doctor during the same visit to the diabetes centre, which had caused some anxiety.967 When they did see the diabetologist, they were satisfied with the care that they received. Longstanding contact created very good relations between the patients and the diabetologists, but patients started to get the sense that they were ‘on a conveyor belt’ since the diabetologist could devote much less time to them than they were used to (approximately 2 to 3 minutes, according to the Aktiv).968 High waiting times were repeatedly reported, with more than 60 percent of patients saying that they had

962 SAPMO-BArch DQ1/13869 – Letter from M.A of the Patientenaktiv for diabetes to the Deputy Minister for Health, Dr. Schneidewind, 14/2/88, p. 3. 963 Ibid., p. 3. 964 Inspections included: SAPMO-BArch DQ1/13868 – Information über die Nachkontrolle zur Gewährleistung der Diabetikerbetreuung und -versorgung, Komitee der Arbeiter-und-Bauern-Inspektion, 13/02/86; Information zur Kontrolle über die Gewährleistung und Versorgung der Diabetiker, 12/07/84; Bericht zur Kontrolle des Leistungsvermögens der Diabetikerzentralen, 23/03/82. 965 Patrick Major, Behind the Berlin Wall: East Germany and the Frontiers of Power (Oxford: Oxford University Press, 2010), p. 18. 966 SAPMO-BArch DC14/1961 – Einschätzung der Kontrolle über die Gewährleistung der Versorgung und Betreuung der Diabetiker, Komitee der Arbeiter-und-Bauern-Inspektion, 2/8/84, p.1. 967 Ibid., p.1. 968 SAPMO-BArch DQ1/13869 – Problemkommission, 9/3/1989.

215 waited on average three hours for their appointments and, in extreme cases, for six hours.969 To solve these problems, the committee’s overall recommendation was that GPs should be involved systematically in the care for non-insulin-dependent diabetics.970 As has been seen, GP involvement had been a distinct aim from the early 1970s, but was clearly not entirely successful after now over a decade of trying. Shortages of staff proved to be influential not only in the care received by diabetics but also in how it was delivered by diabetologists, an issue to which the following section will turn.

The diabetologists’ view part I: struggles at home

The need for so many Workers’ and Peasants’ Organisation inspections was a statement itself that diabetes care and the healthcare system in general were malfunctioning. Having interviewed patients, the organisation placed even greater focus on the work of diabetologists and how it was affected by a range of aggravating circumstances. The efforts to employ a larger number of staff in the 1970s did not reap many benefits. The healthcare system had become a financially unattractive area of work, according to Wasem, Mill and Wilhelm. People believed they could earn more money in similarly skilled jobs with fewer demands and less responsibility.971 This was particularly the case with the mittlere medizinische Personal like the diabetes nurses, diet assistants and the laboratory technicians, who were, like in the Störfreimachung period, badly needed due to rising numbers of patients and demand for care, but in short supply. On top and indeed because of unattractive salaries, the latter half of the 1980s saw a surge in the emigration of medical personnel. The Stasi were extremely concerned when doctors travelled abroad and saw occurrences such as missed return flights as possible emigration attempts, as reported about a female member of staff at the Central Institute who had missed her flight from New York to Berlin in June 1986 despite being in possession of a boarding card.972 According to Bethany Hicks, an estimated 4,000 doctors sought asylum in West Germany between 1985 and 1989.973 Emigration was most acute as a problem in Dresden,

969 SAPMO-BArch DC14/1961 – Die Gewährleistung der Versorgung und Betreuung von Diabetikern, Komitee der ABI, 17/7/84. 970 Ibid. 971 Wasem, Mill and Wilhelm, p. 385. 972 BStU, MfS, BV Rst, KD Greifswald, Nr. 324 - Zuarbeit zum Referat vor leitenden Kadern, Reise- und Auslandskadern des ZID Karlsburg, p. 0152. 973 Bethany E Hicks, ‘Germany After the Fall: Migration, Gender and East-West Identities’ (unpublished doctoral thesis, University of Michigan, 2010), p. 124.

216 with Charles Maier quoting Honecker’s warning that ‘if we let out all doctors who want to leave, public health would collapse in Dresden’.974

It is inevitable, then, that diabetologists in the advice centres would have been completely overburdened. The ratios of patients to diabetologists epitomised the task at hand. The nationwide inspection of 1984 found that there were 3,200 diabetics to one diabetologist in the Kreis Hoyerswerda, and 3,010 diabetics in Cottbus. 975 In Stralsund, one diabetologist had to care for 2,307 diabetics from the town and a further 820 from the surrounding Kreis.976 According to the overall conclusions of the 1984 inspection, 80 percent of the checked Kreise had a lack of capacity to deal with the number of patients.977 Staff appeared to be aging somewhat, which did not make for any long-term stability. The reported average age of diabetologists in Halle was fifty-five (considered ‘too high’), and in two Kreisen within the Bezirk Magdeburg, an interior medicine specialist of pension age had to fill in for an absent diabetologist.978 ‘Filling in’ using retired personnel was a running theme; in Schwerin, a forty- year-old diabetic had an eye check-up by a 74-year-old ophthalmologist.979 The diabetes nurses were also said to be ‘zu 30-100 Prozent überaltert’ and could retire at any moment, but there did not appear to be any replacements lined up.980 Considering that they, too, filled in for diabetologists and others, which explains why patients complained about not always seeing a doctor, it appears that staff working in the advice centres were universally overworked.

Two diabetologists, Dr. Stöwhas and Dr. Zander, made a working visit to three industrial Bezirke, Dresden, Karl-Marx-Stadt and Halle, and found that there were too few well-qualified staff and a lack of motivation to get the sub-specialism in diabetology, which had been such a crucial feature since the early days of East German diabetes care. For a system that took so much pride in treating diabetics using diabetologists as opposed to endocrinologists or Internisten, it really was a blow to see that only fifty percent of diabetics were treated by qualified diabetologists in these Bezirke.981 The philosophy of treating diabetes only by

974 Maier, p. 138. 975 SAPMO-BArch DC14/1961 – Bericht über die Kontrolle zur Gewährleistung der medizinischen Betreuung der Diabetiker, Arbeiter-und-Bauern-Inspektion, Bezirkskomitee (Cottbus), 19/6/84. 976 SAPMO-BArch DC14/1961 – Bericht zur Kontrolle über die Sicherung der medizinischen Betreuung der Diabetiker, p.1. 977 SAPMO-BArch DC14/1961 – Einschätzung der Kontrolle über die Gewährleistung der Versorgung 978 SAPMO-BArch DQ1/13869 – Protokoll der Arbeitstagung der Beratenden Ärzte für Diabetologie der Bezirksärzte vom 26. und 27. April 1989 in Bitterfeld/Bez. Halle. 979 SAPMO-BArch DQ1/13869 – Protokoll der Arbeitstagung der Beratenden Ärzte für Diabetologie der Bezirksärzte vom 10. Und 11. Juni 1988 in Schwerin, p.4. 980 Ibid., p. 3. 981 SAPMO-BArch DQ1/13869 – Protokoll der Sitzung der Problemkommission für Diabetes am MfGe am 2.3.1989 in Berlin, pp.4-5.

217 specialists was considered innovative and modern in the beginning, but this firm expectation of specialist treatment at outpatient level had been responsible for the resistance to change seen in the previous decade as GP integration was mooted as an addition to what had come to be regarded as the ‘normal’ and settled way of treating diabetics in the GDR. The growing awareness of the need to use GPs to alleviate the burdens on diabetologists and thus create better standards of care for patients came too little, too late for many diabetes advice centres. Some areas had embraced the use of GPs fully, and, when a diabetologist was not on hand to lead the advice centre, diabetics could at least see a qualified doctor.982 Others, however, had not gone far enough and the pressures on diabetologists, who were reported by the Patientenaktiv to be ‘overworked’ and ‘nervous’, proved too great.983 One explanation for the difficulties faced in involving GPs in diabetes care in Halle was slightly less predictable; according to statistics, approximately 70 to 75 percent of GPs were women, and, as a consequence of the Sozialpolitik (providing for extended periods of paid maternity leave), no more than fifty percent of GPs were available at any one time, which was considered to limit the scope of integration and training.984

Diabetologists at the Central Institute faced their own pressures. Mecklinger ordered all health facilities to generate hard currency to maintain standards of care and research by offering special courses for which attendees had to pay, by testing new appliances or medications, and by treating foreign patients.985 As already mentioned, some trials using diabetics to test western medication were conducted at the Central Institute and the Zentralstelle. The Central Institute was equally concerned, however, with the treatment of foreign patients paying in Deutschmarks, the currency of West Germany; it was made even easier to draw in patients from abroad when the Central Institute was awarded the title ‘WHO-Collaborating Centre’. A conversation between representatives of the Central Institute and members of the Ministry in April 1988 explained the procedure for treating foreign patients.986 Patients would be requested to pay a daily rate for their treatment and accommodation. If they needed to use the phone to

982 SAPMO-BArch DQ1/13868 – Information zur Kontrolle über die Gewährleistung der Betreuung und Versorgung der Diabetiker, p. 4. 983 SAPMO-BArch DQ1/13869 – Protokoll der Sitzung der Problemkommission für Diabetes am MfGe am 9.3.1989 in Berlin, p. 1 [‘Aktuelle Fragen zur Diabetikerbetreuung aus der Sicht des zentralen Patientenaktivs’]. 984 SAPMO-BArch DQ1/13869 – Protokoll der Arbeitstagung der Beratenden Ärzte für Diabetologie der Bezirksärzte vom 26. Und 27. April 1989 in Bitterfeld/Bez. Halle, p. 2. 985 SAPMO-BArch DQ1/26367 – Letter from Mecklinger to the leader of the council of the Bezirk Rostock calling for the Central Institute, like all other health facilities, to generate hard currency, 8/3/83; implementation of Mecklinger’s orders put in place in: SAPMO-BArch DQ1/26367 – Inhaltliche Aufgabenstellung zu den Staatlichen Auflagen 1984 des Zentralinstitutes für Diabetes ‘Gerhardt Katsch’ Karlsburg, 7/12/83. 986 SAPMO-BArch DQ1/13869 – Aktennotiz über ein Gespräch zwischen Gen. Prof. Schulz (Klinikdirektor, Zentralinstitut für Diabetes ‘Gerhardt Katsch’) und Gen. J. Runge (ZEB) am 14.04.1988, p. 1.

218 make calls, they would be charged additionally for this. Dr. Schulz described an example of a foreign patient who was a relative of the Libyan Finance Minister. Receiving praise from the Libyans over the standard of the care given, Schulz expressed hope that this would lead to more Libyans coming for treatment and thus more precious hard currency to buy imported machinery and equipment.987 From June 1988, there would be a special building to accommodate foreign patients only in single rooms or in two-room apartments. Relatives of patients would also be provided with accommodation.988 Attempts to attract patients from a range of other countries (those discussed were Kuwait, Sudan and Jordan) were augmented by diabetologists using their own contacts to patients abroad, something which was said to have already played ‘an important role’.989 Although this ‘health tourism’ was troublesome ideologically in that this was a socialist health system providing care in conditions and at a level of service which East German citizens could only dream of, even at the showcase Charité hospital in East Berlin, the Central Institute was thanked profusely by the Ministry for their ability to procure desperately needed hard currency.990

Since Bibergeil’s appointment as ‘executive director’ and then ‘director’ of the Central Institute, it had been confirmed as the politically loyal hub and mouthpiece for the whole of diabetes care and research. The aspirations of the Ministry of Health and those of the Central Institute had not always been aligned during Bibergeil’s time as director, let alone during the time of his predecessors, but, following Gorbachev’s rise to power, political apathy of a new kind and severity had been detected at the Central Institute. One wonders how far the Institute paid no more than lip service to officials and whether its political environment was characterised by rhetoric rather than pure belief, especially on Bibergeil’s part, as someone who was a pragmatic loyalist at best. Stasi informants compiled a report in July 1987 bemoaning a progressive decline in political-ideological work and stating that the situation had worsened from 1986 onward, thereby coinciding with the arrival of the new leadership in the Soviet Union. Younger members of staff at the Central Institute, who were beginning to take over from older Genossen, did not show the same appetite for state socialism and political loyalty. 991 The function of ‘party secretary’ at the Central Institute was described by the informants as being assigned according to the motto ‘one of us will have to do it’. The current

987 Ibid., p. 1. 988 Ibid., pp. 1-2. 989 Ibid., p. 3. 990 Ibid., p. 4. 991 BStU, MfS, BV Rst, KD Greifswald, Nr. 107 - Information über mangelhafte politisch-ideologische Arbeit im ZID Karlsburg, 9.7. 1987, p. 000244.

219 secretary was a young doctor with no clout who was subservient to older colleagues.992 Meetings of the political leadership were often ‘dominated by personal controversies’, and trade union meetings were likewise only discussing medical and personal issues.993 Informants also observed that the party meetings happened at irregular intervals and were poorly attended, citing one meeting where only fifty percent of the Genossen attended on 23 June 1987.994 It was recommended that ‘measures’ ought to be taken to improve political life at the Central Institute; what exact ‘measures’ the authors had in mind, is, however, not made apparent.995

Further signs of disillusionment at the Central Institute were meticulously documented by the Stasi. Two informants based at the Central Institute, using the pseudonyms ‘Horst Lampe’ and ‘Arno Göbel’, produced a handwritten document about the rise in open discussion of controversial topics there. From 15 July 1988, discussions had circulated about the GDR’s involvement in ‘human trafficking’, referring to the fact that the GDR received money from the West German government for Verbleiber (those who did not return from a private or professional visit to the West) and political prisoners. 996 An electrician at the Central Institute who was a party member had reported the presence of an anonymous letter distributed via the internal post to the head of the technical department, also a Genosse.997 The letter contained a discussion about ‘human trafficking’ and had been printed on one of the Central Institute’s EDV printers.998 ‘Arno Göbel’ was responsible for obtaining samples of printed material from all computers at the Central Institute and these would then be compared with copies of the anonymous letter.999 He was also asked to confiscate other related material to stifle discussion.1000 The two IMs said that they would continue their efforts to identify the originators of the letter and focus their attention on ‘three people’ who had failed to express a positive attitude about the GDR in trade union meetings and had been critical about economic issues.1001 The appearance of such a detailed report in Stasi files about those working at the Central Institute being open about their feelings on the state of affairs in the GDR signalled a

992 Ibid., p. 000244. 993 Ibid., p. 000244. 994 Ibid., p. 000244. 995 Ibid., p. 000245. 996BStU, MfS, BV Rst, KD Greifswald, Nr. 324 - ‘Ref 1 Quelle: GMS “Horst Lampe”, IMS “Arno Göbel”, 16.6.88’ [handwritten report by a GM (lower level informant) and an IM (fully-fledged unofficial worker for the Stasi)], p. 0109. 997 Ibid. [Präzisierung zur Information vom 16.6.88 08:30], p. 0110. 998 Ibid., p. 0109. 999 Ibid. [Präzisierung zur Information vom 16.6.88 08:30 – Maßnahmen], p. 0112. 1000 Ibid. [Präzisierung zur Information vom 16.6.88 08:30 – Bewertung], p. 0111. 1001 Ibid. [Präzisierung zur Information vom 16.6.88 08:30- Maßnahmen], p. 0112.

220 loss of fear in people speaking their mind in the new era of ‘Glasnost’, which the Stasi were trying to counteract in their usual underhand and manipulative way.

The diabetologists’ view part II: international recognition at last?

Against the backdrop of domestic economic and political pressures, diabetologists were expected to continue with research and attend (and host) international conferences, bringing with them yet another layer of attempted control. The Central Institute’s international status had now been cemented by its new title, which led to diabetologists in reports being far less effusive in praising their own research as ‘world-leading’ or in keeping with international standards as they had done in the past. Lifting what was essentially a burden of having to convince the Ministry of Health constantly of the international significance of work conducted at the Central Institute encouraged a new clarity and frankness in the assessment of standards. Diabetologists were more willing to say openly what was ‘well behind’ and where improvements were required. The GDR’s dwindling medical-technical base was beginning to impose severe limitations on planned research. Bibergeil was forced to admit that the GDR was now eight to ten years behind international levels in medical-technical equipment. The area of lipidology was regarded as ‘extremely poor’ by Bibergeil in comparison to European standards and laboratory diagnostics needed to correspond to modern demands.1002 There were also problems importing research materials and biochemicals required for certain parts of the Research Project, which was still very much the focal point for all diabetes research.1003

Achieving good results in the laboratories was only part of the research process; making them ‘praxiswirksam’ as Honecker had ordered in the 1970s was the next stage. Rainer Hohlfeld has discovered in the field of biomedical research that ‘the centrally directed demand for practice-oriented research amounted in most cases to nothing more than “reinventing the wheel”’.1004 The ‘critical problem’, according to Bibergeil’s assessment in 1988, was translating the research results into industrial practice. In the creation of L-SNC and SNC, industrial production had a hand in making them distinctly unusable and incapable of replacing

1002 SAPMO-BArch DQ1/13869 – Report by Bibergeil dated 6/5/1989 about the state of diabetes research in the GDR, p. 5 and p. 7. 1003 SAPMO-BArch DQ109/173 – Analytisch-prognostisches Material zum Problemgebiet Diabetes mellitus und Fettstoffwechselstörungen (HFT [Hauptforschungrichtung] M22), p. 2. 1004 Rainer Hohlfeld, ‘Between Autonomy and State Control: Genetic and Biomedical Research’, in Science under Socialism: East Germany in Comparative Perspective, ed. by Kristie Macrakis and Dieter Hoffmann (Cambridge, MA. and London: Harvard University Press, 1999), pp. 247-268 (p.261).

221 the imported variants.1005 The Central Institute was working hard on developing an insulin pump and a new system of testing blood sugar but Bibergeil cautioned that the importance of this work could only be judged properly following its translation into practical treatment.1006 There appeared to be a degree of satisfaction about the research into insulin pumps but producing them at the Kombinate would mean that new, imported technologies would be needed that Bibergeil was sure could not be financed.1007 The implantable insulin pump, planned for production in 1995, remained only a ‘pilot project’ as far as East German industry was concerned.1008

Regional disparities were starker than ever in the quality of research output. Bibergeil remarked that there were a few lone rangers doing good research but without any firm institutional support. Contributions to the Research Project by the Zentralstelle and centres in Karl-Marx-Stadt and Leipzig were all very good, but other areas purportedly demonstrated a lack of willingness on the part of superiors to understand the work conducted by diabetologists.1009 Those outside of the ‘major centres’ for diabetes research, which were the Central Institute, Dresden, the Zentralstelle and Leipzig, did not have much influence on the trajectory of diabetes research and its implementation on the ground.1010 The amount of investment at the Central Institute and the ability to earn hard currency to buy scarce imported machinery will have allowed it to conduct research of higher quality and significance. Even at the Central Institute, though, it was impossible to find the funding for importing an electronic microscope ‘amongst other appliances’ which were not listed in Bibergeil’s report.1011

For all the problems of internal cooperation, diabetologists, particularly those at the Central Institute, were presented with new opportunities to collaborate with those from abroad. The Central Institute’s collaboration duties with other WHO institutions were predicated on its ‘Collaborating Centre’ title and, coupled with the possible infiltrations of Gorbachev’s glasnost, made for a more flexible environment for those diabetologists lucky enough to participate. Statistics of the composition of staff at the Central Institute from October 1987 are interesting reading in this respect. Of those designated as Reisekader (people who could travel

1005 SAPMO-BArch DQ109/173 – Analytisch-prognostisches Material zum Problemgebiet Diabetes mellitus und Fettstoffwechselstörungen (HFR [Hauptforschung M22]), p. 21. 1006 Ibid., p. 18. 1007 Ibid., p. 23. 1008 Ibid., p. 23. 1009 Ibid., p. 7. 1010 Ibid., p. 6. 1011 Ibid., p. 2.

222 to conferences in capitalist countries), only 68 percent were members of the SED (15 out of a total of 22). Another 15 people were currently being prepared for the task of Reisekader, 6 of whom were members of the SED.1012 This demonstrates that expertise was still sometimes put before party loyalty to project a good image of the GDR abroad, as had been the case with allowing Schliack to attend conferences in capitalist countries in the 1960s.

The travel cadre of the Central Institute had a full and varied timetable of international events throughout the decade. The highlight was always the International Diabetes Federation Congresses. The bullish nature of conference reports continued before and after the Central Institute’s new status, if a little more muted than in the previous two decades, and East German diabetologists attending the congresses thought of themselves by the 1980s as international competitors and worthy names on the international stage in their own right. The conference reports therefore do not always give a tangible impression of how influential East German diabetologists really were internationally-speaking. On the one hand, the Karlsburger Symposium of 1979 on ‘diabetes questions’ had attracted the largest number of delegates from both socialist and capitalist countries in the history of the event and was a chance for those whose political beliefs restricted their travel opportunities to IDF Congresses to exchange experiences with international colleagues.1013 On the other hand, the political control exerted by the SED in choosing cadre for trips abroad limited the number of GDR representatives in a delegation. Shortages of funds also meant that East German participants were heavily reliant on travel grants and the payment of accommodation and food by the organisers of conferences.1014 Bibergeil complained that at the IDF Congress in Sydney in 1988, there were 5 East German and 120 West German participants. The GDR had sent 11 to the previous congress in Madrid. 1015 West Germany was naturally a larger, more populous state, but the difference is staggering even when taking this into consideration. The GDR had a healthier representation at the EASD congresses, sending 18 delegates to France in 1988, bearing in mind that this congress was also smaller than IDF ones.1016

1012 SAPMO-BArch DQ1/26243 1 of 4 – Kaderprogramm des Institutsdirektors für den Fünfjahrplanzeitraum 1986-90, Blätte 5-7. 1013 SAPMO-BArch DQ101/572a 2 of 2 – Konzeption zur Schwerpunktgestaltung der internationalen Arbeit der Sektion Diabetes der Gesellschaft für Endokrinologie und Stoffwechselkrankheiten der DDR, p. 4. 1014 Ibid., p. 6. 1015 SAPMO-BArch DQ101/572a 1 of 2 – Berichterstattung 13. Kongreß der Internationalen Diabetes- Föderation, Sydney (Australien), 21. - 20. 11. 1988, p. 3. 1016 SAPMO-BArch DQ101/572 3 of 3 – Kongreß der Europäischen Gesellschaft zum Studium des Diabetes, Paris (EASD), 5. – 9. 9. 1988, p. 1

223

Those attending the IDF and EASD congresses received travel grants from both international societies. To ensure that these were maintained, Bibergeil and Dr. Michaelis (also of the Central Institute) recommended that they invite the General Secretary of the IDF, Dr. J.G.L Jackson from London, to visit the GDR to showcase diabetes care and research.1017 A theme that emerges from conference reports of the 1980s, which had not been approached head- on before, was the idea of acceptance (or lack thereof) in the international community of diabetes specialists. Questions surfaced in reports of IDF congresses about how far some of the delegates from capitalist countries took those from the GDR and other socialist countries seriously, particularly at this point when deep-rooted and visible economic problems were now well and truly defining the image of the Eastern Bloc. Emigration of doctors and scientists did not exactly help the reputation of socialist medical and scientific work, a matter which was reportedly discussed at the 25th EASD Congress in 1989.1018 For the GDR in particular, delegations struggled to define themselves as different from their West German counterparts and at three IDF congresses were reported as listed under ‘Germany’ rather than ‘GDR’ or ‘East Germany’, notwithstanding of course the continuing political sensitivities to being seen as a distinct political entity.1019

In terms of the outside reception of East German scientific work, some scholarship touches on the reunification period to confirm a certain element of prejudice. Mark Walker argues that West Germans ‘often had a negative perception of East German science’ during the reunification process, and Stefan Sperling believes that some in the German Science Council thought of the GDR as a Wissenschaftswüste (scientific desert).1020 At the 12th IDF Congress in Madrid in 1985, Bibergeil wrote that in the discussion of insulin pump studies some ‘politically motivated reservations about the GDR’ could be seen indirectly. When East German diabetologists hosted the 21st Meeting of the Diabetes Epidemiology Study Group, Michaelis concluded in his report that they had succeeded in removing ‘prejudices’ about their

1017 SAPMO-BArch DQ101/572a 2 of 2 – Konzeption zur Schwerpunktgestaltung der internationalen Arbeit der Sektion Diabetes der Gesellschaft für Endokrinologie und Stoffwechselkrankheiten der DDR, p. 6. 1018 SAPMO-BArch DQ101/572 3 of 3 – 25. Jahrestagung der Europäischen Gesellschaft zum Studium des Diabetes (EASD), Lissabon, 19. – 23. Sept. 1989, p. 2. 1019 Ibid., p. 3; SAPMO-BArch DQ101/572a 1 of 2 – Berichterstattung XIII. Kongreß der Internationalen Diabetes-Federation (IDF), Madrid (Spanien), 23. – 28. September 1985, p. 4; DQ101/572a 1 of 2 – 11. Kongreß der Internationalen Diabetes-Federation (IDF), Nairobi/Kenia, 10. – 17. 11. 1982, p. 3. 1020 Mark Walker, ‘Twentieth-Century German Science: Institutional Innovation and Adaptation’, in Companion Encyclopedia of Science in the Twentieth Century, ed. by John Krige and Dominique Pestre (London and New York: Routledge, 2003), pp. 795-821 (p.817); Stefan Sperling, Reasons of Conscience: The Bioethics Debate in Germany (Chicago and London: The University of Chicago Press, 2013), p. 240.

224 work displayed by some who had not visited the GDR before.1021 In their contribution to the ‘Eurodiab project’ as part of the longstanding participation in the European Diabetes Epidemiology Study Group, Michaelis pointed out in a separate report that ‘East-West splits’ needed to be counteracted by the representatives from socialist countries.1022 It could also have been the case that representatives from state socialist countries were driving a wedge between them and those from capitalist countries.

However, an interesting reaction to the election of a new President of the IDF in 1982 could suggest that there was an underlying feeling of gratitude toward those from capitalist countries who made the effort to pay attention to the work of East German diabetologists rather than any great ideological schism. From the start of the Karlsburger Symposien in 1962 and early developments at the Zentralstelle, there were a handful of international contacts who had visited the Central Institute and/or other diabetes centres in the GDR several times and had likewise invited East Germans to visit them. These ‘friends of GDR diabetology’, for want of a better term, did provide the East German diabetologists with a stronger platform on the international stage than they might otherwise have had. Professor Krall of the Joslin Diabetes Center in Boston was the newly elected IDF President for 1982, a move which was welcomed in Bibergeil’s report. Krall had attended several of the Karlsburger Symposien and Bibergeil had visited the Joslin Clinic in 1978.1023 Letters from 1978 have been kept in Ministry of Health files documenting Krall’s insistence to offer complimentary membership of the American Diabetes Association to at least one East German diabetologist to recognise their good work.1024 Complimentary membership had been given to other diabetologists in the past but not to anyone from the GDR. Following his suggestions, it was then offered to Dr. Konrad Seige of Leipzig and also to Bibergeil.1025 Membership of the European Diabetes Epidemiology Study Group ensured that contacts with the UK were maintained and enhanced. Four East German diabetologists attended the 22nd Meeting of the European Diabetes Epidemiology Study Group at the University of Oxford in 1987 led by Dr. J. Mann. During the meeting,

1021 SAPMO-BArch DQ101/572 3 of 3 – 21. Jahrestagung der Europäischen Studiengruppe für Diabetesepidemiologie (E.D.E.S.G.), 21. – 24. Mai 1986, p. 5. 1022 SAPMO-BArch DQ101/572 3 of 3 – 23. Jahrestagung der Europäischen Studiengruppe für Diabetesepidemiologie (E.D.E.S.G.), Glion-sur-Montraux (Schweiz), 1.5. – 4.5. 1988, p. 2. 1023 SAPMO-BArch DQ101/572a 1 of 2 – Document written by Dr. Schönheit for the Ministry of Health in response to Krall’s offer of complimentary membership of the American Diabetes Association, 30.1.79. 1024 SAPMO-BArch DQ101/572a 1 of 2 – Letter from Krall nominating Dr. Konrad Seige as the recipient of complimentary membership of the American Diabetes Association, 8/08/78; Letter from Krall offering free membership of the American Diabetes Association to Bibergeil, 17/10/78. 1025 SAPMO-BArch DQ101/572a 1 of 2 – Letter from Krall to Seige, 8 Aug 1978, p.1; Nomination was accepted by the President of the American Diabetes Association, Fred. W. Whitehouse, on 19 Sept 1978.

225

Professor Harry Keen apparently expressed an interest in the British Diabetes Society working with socialist countries; talks of collaborating with the GDR were already underway following a previous visit to London by Dr. Dempe, head diabetologist for Karl-Marx-Stadt.1026

In the latter half of the 1980s, a ‘second Ostpolitik’, as Timothy Garton Ash called it, saw improved relations with West Germany, typified by the ‘1987 Treaty on Scientific- Technological Cooperation between the FRG [West Germany] and the GDR’.1027 This was spearheaded by Social Democratic politicians in West Germany. Exchange between East and West Germans had been notoriously difficult since the building of the Berlin Wall, not only for diabetologists but also for other scientists and specialists. It was much harder to attend a conference in West Germany (and there were particularly stringent rules for West Berlin) than it was to attend a conference in other western European countries up until the mid-1980s.1028 It was also difficult to invite anyone West German to visit places in the GDR like the Central Institute or other diabetes centres, as had been seen in September 1978 when the Ministry told Bibergeil that an application of a West German diabetes doctor to come to the Central Institute for a working visit would be rejected, as had other applications for West German visitors in the past.1029 Further rapprochement with West Germany opened the door to a new wave of interested West German diabetologists, one of whom was Professor Michael Berger from the Medical Clinic of the University of Düsseldorf Hospital, a founder of the European Diabetes Education Study Group and pioneer of what is now termed in the UK ‘Dose Adjustment For Normal Eating’ (DAFNE).1030 The fact that they shared a common language allowed people like Professor Berger, who had become a celebrated figure for his ideas on diabetes self- management by this time, to converse easily with East German colleagues. He was even interviewed with Michaelis for the East German news agency and represented shifting West German attitudes toward trade and exchange not only with the GDR but also other state socialist countries.1031

1026 SAPMO-BArch DQ101/572 3 of 3 – 22nd Meeting der European Diabetes Epidemiology Study Group, Oxford, 12.04.1987 – 15.04. 1987, p. 3. 1027 The notion of a ‘second Ostpolitik’ and citation of Timothy Garton Ash can be found in: Andreas Glaeser, Divided in Unity: Identity, Germany, and the Berlin Police (Chicago and London: The University of Chicago Press), p. 108. On the Treaty of Scientific-Technical cooperation, see: Hohlfeld, p. 263. 1028 Hohlfeld, p. 263. 1029 SAPMO-BArch DQ101/572a 1 of 2 – Letter from Schönheit, leader of the department for research [and deputy minister of health], to Bibergeil regarding an application of a West German doctor for a long-term working visit to the Central Institute, 22 September 1978, p. 1. 1030 Robert Tattersall, Diabetes: The Biography (Oxford: Oxford University Press, 2009), p. 199. 1031 SAPMO-BArch DQ101/572 3 of 3 – 25. Jahrestagung der Europäischen Gesellschaft zum Studium des Diabetes (EASD), Lissabon, 19. – 23. Sept. 1989, p. 3.

226

The 21st Meeting of the European Diabetes Epidemiology Study Group took place in Potsdam in May 1986, and the subsequent 22nd, 23rd and 24th meetings were held in the UK, Switzerland and Italy respectively.1032 The Potsdam study group meeting happened months before the inauguration of the Central Institute as ‘WHO-Collaborating Centre’ on 31 October, an even bigger occasion in the calendar for that year. A ‘festival event and scientific session’ marked this inauguration, and a programme in English outlined those giving speeches and participating in scientific sessions.1033 As so much of the communication with the WHO was in English, the intensive English courses at the Central Institute for diabetologists and other personnel ensured that they could convey the identity and work of East German diabetology and justify, when applying for ‘Collaborating’ status in the field of diabetes, why it would be appropriate to include the Central Institute. The standard of English in applications and brochures was not always idiomatic but was noticeably competent, grammatically accurate and incorporated international terminology on diabetology well.1034 Bibergeil’s report for the 11th IDF Congress in Nairobi explained that Dr. Fuhrmann, the Central Institute’s head obstetrician, had given an interview on US radio following his presentation about deformities in babies born to diabetic mothers, implying as well that the research topics conducted at the Central Institute were topical and of interest to others on the world stage.1035

The following year, 1987, another big event occurred for diabetologists in the GDR; they were responsible for hosting the EASD Congress in Leipzig, led by the Central Institute.1036 This was not a congress of the stature of the IDF congresses but could certainly be ranked among the important events for diabetologists internationally. If their hosting of these events is taken into consideration, the end of the 1980s was a high point for international recognition and involvement. The scathing remarks of members of the German Science Council during reunification about ‘GDR science’ as a ‘desert’ were offset by findings that

1032 SAPMO-BArch DQ101/572 3 of 3 – 22nd Meeting der European Diabetes Epidemiology Study Group, Oxford, 12.04.1987 – 15.04. 1987, p. 3; 23. Jahrestagung der Europäischen Studiengruppe für Diabetesepidemiologie (E.D.E.S.G.), Glion-sur-Montreux (Schweiz), 1.5. – 4.5. 1988; 24. Jahrestagung der Europäischen Studiengruppe für Diabetesepidemiologie (E.D.E.S.G.), Venedig, Italien, 10.- 13. Mai 1989. 1033 SAPMO-BArch DQ117/30 2 of 2 – Festival Event and Scientific Session on the Occasion of the Inauguration of the Central Institute of Diabetes ‘Gerhardt Katsch’, Karlsburg, GDR, as a WHO-Collaborating Centre. 1034 See, for example, the application submitted to the WHO for ‘Collaborating Centre’ status in diabetes prevention: SAPMO-BArch DQ117/30 2 of 2 – Proposed WHO Collaborating Centres (in the field of diabetes centres) completed form, pp. 1-3. 1035 SAPMO-BArch DQ101/572a 1 of 2 – 11. Kongreß der Internationalen Diabetes-Federation (IDF), Nairobi, Kenia, 10. – 17. 11. 1982, p. 4. 1036 SAPMO-BArch DQ101/572 3 of 3 – 23. Jahrestagung der Europäischen Gesellschaft zum Studium des Diabetes (EASD), 16. – 20. September in Leipzig.

227 suggested that ‘some areas’ had achieved “international levels” such as ‘mathematics, geology, cosmos research, and medicine’, according to Kristie Macrakis.1037

It is difficult to assess the quality of research into and work in the area of diabetes throughout the whole of the GDR’s lifetime, as Macrakis has mentioned for East German science in general, and it is likely to be a futile task to do so.1038 However, it must be noted that East German diabetologists were not shunned in the international community, and the Central Institute was believed to be conducting worthy enough work to be integrated into a network of WHO facilities. By looking generally at ‘science’ rather than specific areas of research and work, the impression of the GDR as considerably isolated is sometimes obtained; one should nevertheless guard against generalisations, as the GDR’s contribution to international organisations varied by discipline and subject area. For example, the experiences of those working in genetic and biomedical research were in many ways similar to those working in diabetes, but Hohlfeld’s interviews reveal difficulties in becoming part of the international community in these areas.1039 In diabetes, specialists published in international journals, and more frequently in the 1980s co-authored articles with diabetologists from other countries like West Germany, the USA, France, Finland and Austria.1040 It was certainly difficult to forge connections with non-socialist contacts if a diabetologist was not considered politically reliable enough to travel abroad, but the chosen travel cadres were involved quite heavily in the international community, as seen by their active participation in a range of study groups and societies.

A relaxation of travel rules in the 1980s did mean that diabetologists who were not usually given the opportunity to attend conferences held abroad, and certainly not in capitalist countries, such as Dr. Heinz Schneider (head diabetologist of Neubrandenburg), were at least allowed to attend international events held in the Eastern Bloc like the International Danube Symposia, where such people as Professor Berger were in attendance.1041 As Fulbrook has

1037 Kristie Macrakis, ‘Introduction: Interpreting East German Science’, in Science under Socialism: East Germany in Comparative Perspective, ed. by Kristie Macrakis and Dieter Hoffmann (Cambridge, MA. and London: Harvard University Press, 1999), pp. 1-24 (p.5). 1038 Macrakis, p. 5. 1039 Hohlfeld, p. 263. 1040 SAPMO-BArch DQ109/173 – HFR “Diabetes und Fettstoffwechselstörungen” (M22) Trägereinrichtung: Zentralinstitut für Diabetes Karlsburg: Beauftragter: OMR Prof. Dr. sc. med. H. Bibergeil, p. 2. 1041 SAPMO-BArch DQ101/572a 2 of 2 – Letter from Dr. Michaelis to Buhlert, General Secretary of the Medical-Scientific Societies at the Ministry of Health, 20/2/1981 [list of new members of the Federation of the Donau Symposia on attachment page 2], pp. 1-2; Berger’s attendance at conferences in the Eastern Bloc can also be found in: Heinz Schneider, Die Normalität des Absurden (Fahrwangen: Spiegelberg Verlag, 2011), pp. 167-8.

228 warned, toleration in the GDR was all relative. The political culture of compromise underpinning the notion of ‘normalisation’, where elements of liberalisation were bestowed on citizens in exchange for a greater degree of state control (the massive increase in the number of unofficial workers for the Stasi) persisted until the end. Reports by the Stasi on travel cadres imply that its control of those permitted to travel to conferences abroad had never been higher than in the late 1980s. A 1987 Stasi document about travel cadres of the Central Institute and the Ernst-Moritz-Arndt University Greifswald explained that susceptibility to the ‘enemy’ (presumably those from capitalist countries) was at its highest due to problems in the healthcare system and the enticing nature of offers made by those from the west as a result; the ‘ideologically weak’ East German delegates attending international conferences were liable to accept these.1042 This prompted wide-ranging surveillance tasks to be conducted by IMs throughout 1988.

Based on the critical observations of the political environment made at the Central Institute, several of their Reisekader were likely to be on the radar. 1043 IMs were requested to spy on Reisekader’s activities in their free time at sports groups, local centres and other social places, and to find out where they and other scientists met privately. They needed to ‘find out what was going on in their heads’, the plans and intentions they had, and what they were dissatisfied with. The Stasi gave several talks to Reisekader of the Central Institute and those driving them to the conferences held in the West. 1044 Ordinarily, this heightened control by the Stasi may well have engendered a cagey and secretive approach by the Reisekader, but the aim to censor and monitor could not prevent open discussions documented in the reports of conferences by Bibergeil and others, where topics like the emigration of doctors were discussed with western colleagues. This clarified that the emergence of an attitude of defiance, even more than disillusionment, counteracted this level of control.

Overall, to say that diabetologists were ‘unable to integrate themselves into international scientific networks or measure their work directly against international competition’ as Hohlfeld has said about biomedics and geneticists, was evidently not true of

1042 BStU, MfS, BV Rst, KD Greifswald, Nr. 473 - Stand und Erfordernisse der weiteren operativen Durchdringung des Schwerpunktbereiches Ausgewählte Reise- und Auslandskader sowie Delegate der Ernst- Moritz-Arndt-Universität und des Zentralinstituts für Diabetes Karlsburg, p. 000234. 1043 BStu, MfS, BV Rst, KD Greifswald, Nr. 227 - Konzeption zur weiteren politisch-operativen Sicherung des Schwerpunktbereiches “Ausgewählte NSA-Reise-und Auslandskader sowie Delegate der Ernst-Moritz-Arndt- Universität Greifswald und des Zentralinstituts für Diabetes Karlsburg, p. 000008. 1044 BStU, MfS, BV Rst, KD Greifswald, Nr. 473 - Stand und Erfordernisse der weiteren operativen Durchdringung des Schwerpunktbereiches, Ausgewählte Reise- und Auslandskader sowie Delegate der Ernst- Moritz-Arndt-Universität und des Zentralinstituts für Diabetes Karlsburg, p. 000234.

229 diabetologists.1045 There is no doubt that possibilities in research at the Central Institute and beyond were curtailed by ongoing economic problems, that some results were likely to be ‘modest’ when compared to international standards, and that there were a few ‘what ifs’ regarding ambitious attempts in such things as insulin pump technology and prototypes. However, a few areas cornered at the beginning, like diabetes in pregnancy and epidemiology (the WHO director of disease prevention and control called the GDR ‘the only country in our [the] region to provide very complete, nationwide epidemiological data on diabetes’), carried weight on the world stage.1046 Macrakis’ argument that ‘ideological aspirations to achieve scientific-technical and economic modernisation’ clashed with ‘the reality of outdated infrastructure and a lack of modern equipment’ captures the dilemma continually faced by diabetologists.1047 This might have left many to ponder what might have been had the reforms of either the Ulbricht or Honecker eras actually worked to achieve technical modernisation. One has to consider that in the period of ‘normalisation’, it was ‘normal’ for diabetologists to be adapting to shortages and medical technical issues, problems which merely came to a head in the 1980s. That diabetologists managed to research at the level they did in an environment of almost perpetual shortage was commendable.

Conclusion

The last decade of diabetes care and research in the GDR was governed almost entirely by the escalation of economic and political pressures that led to the demise of the state. Destiny was out of the hands of both diabetologists and patients. Importablösung took up a substantial amount of energy with very little result and was driven by the inability to fund not only insulin imports, but production equipment and chemicals that would be used to produce insulins domestically. The constant back-and-forth between diabetologists and officials at the Ministry of Health, where diabetologists continued to argue that the quality of current domestic insulins was unsatisfactory, epitomised the futility of the task. Patients also bore the brunt of inefficiencies in East German production, using the abject quality of much needed diet foods as a perfect example for their protest. The economic issues faced in diabetes care, be they at the diabetes advice centres, hospitals or the Central Institute, did not tarnish the doctor-patient relationship. Patients who wrote to the Ministry of Health directed their complaints firmly at

1045 Hohlfeld, p. 264. 1046 SAPMO-BArch DQ117/30 2 of 2 – Festival Event and Scientific Session on the Occasion of the Inauguration of the Central Institute of Diabetes ‘Gerhardt Katsch’, Karlsburg, GDR, as a WHO-Collaborating Centre, p. 10. 1047 Macrakis, p. 22.

230 the political establishment and were aware that the problems frequently experienced in their care (long waiting times, old buildings, blunt injection needles etc.) were not caused by those directly administering it. Political pressures added to an already bleak situation. Pressure was two-sided and was, on the one hand, applied by diabetologists and patients who were expressing demands for democracy and autonomy and the SED and Stasi, on the other, simply responding to this change in the only way they knew. The compromise culture of ‘relative toleration’ had once been crucial in providing the kind of stability seen at its peak in the 1970s. Permitting the existence of a patient group and allowing more diabetologists to go to international conferences abroad were such examples of ‘relative toleration’ but there was no longer the willingness to accept restrictions, political or economic, in return.

231

Conclusion

It is very difficult to observe the chain of events leading up to reunification without the benefit of hindsight and knowing that the end of the GDR’s lifetime was approaching.1048 The history that is told is unavoidably neater and more predictable than contemporaneous accounts and actions would suggest. Prospective planning for the nineteen nineties was commonplace in Ministry of Health files, and there is no evidence that even officials had any premonition of what was to come even a month prior to the fall of the Berlin Wall. This does not mean that signals of substantial change on the horizon were absent, and these should at least be pointed out. The ever-increasing rapprochement between East and West Germany allowed for the infiltration of West German production practices and influences into the East German economy from the beginning of 1989. As the insulin situation had become quite desperate, the only viable solution to save money yet produce an insulin of reasonable quality was for the GDR to start producing insulins from Hoechst AG (and possibly other pharmaceutical companies) under licence.1049 These plans came to fruition after the fall of the Wall, when VEB Berlin-Chemie signed an agreement with Hoechst to produce their insulins.

As diabetology had so often mirrored the GDR’s general diplomatic, economic and political developments, the end-of-an-era feeling was exemplified by the retirement of Schliack in 1986 and Bibergeil, who announced in July 1989 that he intended to retire the following year.1050 Both had made an indelible mark on East German diabetes care and research at different stages and for different reasons. The announcement of Bibergeil’s departure less than four months before the fall of the Wall presaged the move into unknown territory for the Central Institute. His appointment in 1967 had aroused suspicion amongst diabetologists, but he had led the Central Institute for more than twenty years in a steady fashion and had worked toward elevating its position and status even in trying circumstances. Criticised at the beginning as having come from nowhere, he ended his twenty-two-year tenure at the helm as one of the most well-known figures, the spokesman for East German diabetes care at home and abroad. He was never a ‘larger than life’ character as Katsch and Mohnike, his predecessors, had been, but his

1048 For the argument about a lack of predictability, see: Konrad Jarausch, The Rush to German Unity (Oxford and New York: Oxford University Press, 1994), p.3. 1049 SAPMO-BArch DQ1/15405 – Protokoll der außerordentlichen ZGA-UA-Sitzung ‘Insuline/Orale Antidiabetika’ am 14.12.89, p. 2. 1050 Schliack’s retirement in: SAPMO-BArch DQ1/13868 – Protokoll der Arbeitsberatung der Beratenden Ärzte für Diabetologie der Bezirksärzte vom 7. Mai 1986 in Schmalkalden, p. 7; Bibergeil’s retirement in: SAPMO- BArch DQ1/13869 – Letter from Prof. Dr. Schulz to the head of the research department at the Ministry, Prof. Dr. Schumacher, 21/7/89. N.B. Bibergeil carried on until the 01/02/90, as mentioned in a handwritten comment by Schumacher addressing Schulz’s letter.

232 correspondence to the Ministry of Health over the years implied a pragmatic, meticulous and careful approach to leadership. A successor to Bibergeil was not immediately apparent, and a new power struggle seemed to emerge. Professor Schulz, deputy to Bibergeil and leader of Klinik I, agreed to lead the Problemkommission, the organisation within the Ministry of Health charged with the task of overseeing the regional diabetologists and the whole system of diabetes care. He also asked if he could lead the WHO cooperation in which he had already been actively involved. This was granted by the Ministry on the 21 July 1989.1051 Despite the level of responsibility that was by now expected of any director of the Central Institute, he was not actually given this role in addition. The directorship would be going instead to Professor Fischer, who would lead the Central Institute through the reunification process and Wende years.

The Stasi’s report about political disillusionment at the Central Institute (alluded to in Chapter 5) told only part of the story, and there were outright calls for democracy a month before the fall of the Wall. An open letter of the Klinik III trade union group written on 12 October 1989 spelt out that there was ‘a lot happening in our time’.1052 They were indeed right in this assessment; protests and demonstrations were frequent and widespread, with a recorded attendance of between 70,000 and 95,000 at the 9 October demonstration at Leipzig alone.1053 They complained that, had the opinions of others been accepted with tolerance, and had the party and national trade unions been with them, real democracy could have been enacted in the socialist state. They questioned why they were ‘standing in front of closed doors’ and admitted that they could not condemn the peaceful protests that were currently taking place.1054 They wrote that they wanted their children to grow up enjoying all the opportunities offered to them within the framework of ‘humanist ideals’, including the removal of travel restrictions, freedom of opinion, appropriate rewards for performance, the opening up of leadership positions to everyone and changes to the trade and supply system.1055 Steven Pfaff has outlined the clarity with which East Germans understood socialist norms of justice as they has always been

1051 SAPMO-BArch DQ1/13869 – Letter from Prof. Dr. Schulz to the head of the research department at the Ministry, Prof. Dr. Schumacher, 21/7/89 [handwritten confirmation included by Schumacher]. 1052 BStU, MfS, BV Rst, KD Greifswald, Nr. 324 – Abschrift: Offener Brief der Gewerkschaftgruppe Klinik III, Karlsburg, 12. 10. 1989, p. 0161. 1053 Gareth Dale, The East German Revolution 1989 (Manchester and New York: Manchester University Press, 2006), p. 8. 1054 BStU, MfS, BV Rst, KD Greifswald, Nr. 324 – Abschrift: Offener Brief der Gewerkschaftgruppe Klinik III, Karlsburg, 12. 10. 1989, p. 0161. 1055 Ibid., p. 0162.

233 articulated ‘unambiguously’ by the SED.1056 They were calling out here openly and fearlessly everything that they had always known was blatantly undemocratic, dictatorial and therefore unjust about the GDR by state socialist standards, as did thousands of other East Germans by this time. A resultant public party meeting on 23 October could only agree that a ‘process of re-thinking’ was supported by ‘almost all’ East Germans.1057

Efforts to ‘democratise’ the Central Institute, starting with the replacement of the Genosse title with the more uniform Kollege, were swiftly enforced after the fall of the Berlin Wall on 9 November 1989. The Klinik III trade union group letter outlined undemocratic features of the Central Institute and diabetes care, but doctors and patients were prepared to defend the system in which they had worked or had been treated, irrespective of whether democracy was enforced or not. Diabetologists and other specialists reflected on the fact that the system itself was positive and innovative but often suffered under the wrong set of circumstances. The head diabetologist from Halle, Dr. Hempel, wrote a letter to the new Christian Democrat Minister of Health, Dr. Jürgen Kleditzsch, urging him to consider keeping a system that had been ‘tried and tested’.1058 Hempel stated that diabetes care had been one of the most successful branches of East German healthcare and was proof that this kind of organisation worked in providing the regular monitoring care required for diabetics, indicating that there had been factors at play which had undermined it, like medical-technical backwardness, which would not exist following reunification and the adoption of the latest technology.1059 He believed that by preserving the GDR’s state-directed system it could become exemplary for the whole of Germany.1060 A defence not only of the system but of one’s work was a natural reaction for many diabetologists in the face of change.

However, what is rather more striking, and certainly poses a greater challenge to the decisions made during reunification, was the defence of the system by patients, who, having experienced the long waiting times, medical-technical difficulties and overcrowded polyclinics first-hand, still felt the need to emphasise the system’s merits, especially based on what it could become with a more prosperous economic base. Patients were very quick to form a Diabetiker-

1056 Steven Pfaff, Exit-Voice Dynamics and the Collapse of East Germany: The Crisis of Leninism and the Revolution of 1989 (Durham, N.C and London: Duke University Press, 2006), p. 138. 1057 BStU, MfS, BV Rst, KD Greifswald, Nr. 324 – Discussion contribution of the Klinik III trade union group at the public party meeting on 23/10/89, p. 0168. 1058 SAPMO-BArch DQ1/14247 – Letter from Dr. Hempel to the Minister of Health, Dr. Kleditzsch, entitled ‘Betr.: Diabetikerfürsorge’, 9/6/1990, p. 1. 1059 Ibid., p. 1. 1060 Ibid., p. 1.

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Bund to replace the Patientenaktiv in February 1990, and wrote to the new, democratically elected GDR government on 26 June 1990.1061 Members of the Bund and other diabetics wished to protest against all intentions to dissolve the East German system of diabetes care. They gave several reasons to justify their protest. They saw the network of diabetes advice centres as an efficient way of providing regular, free-of-charge medical care by competent staff, including diabetologists, nurses and diet assistants.1062 They had talked to leading representatives of the West German Diabetiker-Bund who, they claimed, agreed that East German diabetes care should be integrated into the healthcare system of a united Germany.1063 They thus demanded that the system of care be preserved and extended, at the very least for all East German diabetics, also preserving the sanatoria and diabetes wards in hospitals.1064 The letter is accompanied by a long list of signatures (146 in total) of Diabetiker-Bund members who backed the arguments made in the letter.1065 These diabetics would not have gone out of their way to compose or sign this letter had they not felt so strongly about the care they had received in the GDR.

The letter sends out a broader message about state socialist healthcare; following the demise of the Eastern Bloc, there needed to be a much deeper and prolonged reflection than had taken place and a look beyond the dictatorial aspects of those states. As post-reunification scholars were immediately preoccupied with the Stasi and its exploits as evidenced in archival documents available for the first time, it produced a one-sided prism through which to view the GDR that historians have now, and are still, breaking down.1066 The Stasi crimes should not be excused in any way, but they should not, at the same time, obscure aspects of state socialism that were not all that peculiar and could be seen as positive in isolation. Several diabetologists who did not commit wholeheartedly to the politics and practices of the SED remained advocates of the system of diabetes care that they had helped to foster and develop. The problems faced in diabetes care were not necessarily the fault of the system and its organisation. After all, the work of diabetologists and the experiences of patients often reflected the political

1061 Formation of the Diabetikerbund in: SAPMO-BArch DQ1/13869 – Letter from B. Schirmer of the Ministry of Health to Fischer; Protest letter written by East German members of the Bund: SAPMO-BArch DQ1/14247 – Protest-Erklärung, 26/06/90. 1062 SAPMO-BArch DQ1/14247 – Protest-Erklärung, 26/06/90, p. 1. 1063 Ibid., p. 1. 1064 Ibid., p. 1. 1065 Ibid., pp. 2-4. 1066 On the issue of totalitarian narratives, see: Andrew Port, ‘The Banalities of East German Historiography’, in Becoming East German: Socialist Structures and Sensibilities after Hitler, ed. by Mary Fulbrook and Andrew Port (Oxford and New York: Berghahn, 2013), pp. 1-32 (pp.1-2).

235 landscape around them, confirming how influential external rather than internal factors were in shaping capabilities and possibilities.

Sometimes the politics of the GDR proved to be useful to diabetologists and the development of diabetes care. From the early days of the ideologically-driven social hygiene, the new healthcare system appeared to be ambitious, carefully constructed and quite forward- looking, conscious of the rise of chronic diseases even when infectious ones were still prevalent by swiftly putting the Dispensaire System into place. This was crucial in creating a fluid connection between diagnosis, treatment and rehabilitation which suited the needs of diabetic patients. The socialist rationale of prevention and Marxist emphasis on keeping people in work provided additional impetus to focus on early detection through a credible, nationwide screening programme and national disease registries, for which the GDR received praise from the WHO. Although political restrictions prevented some diabetologists from travelling abroad, the urge to cement the GDR’s status as an independent polity allowed for the research and work of East German diabetologists to be represented on the world stage.

Conversely, there were moments where the political decisions taken by the SED were extremely unhelpful. A series of dubious economic policies were the most troublesome, from the policy of Störfreimachung, which was destructive for patients and frustrating to those treating them, to Honecker’s wishful thinking on social spending, finishing with a return to another autarkic inspired policy, Importablösung. Noticeable inadequacies in production and the poor quality of medical-technical equipment seemed to last throughout the entirety of the GDR’s lifetime, and had been so deeply embedded in the psyche of doctors that their reports, as well as those written by the Ministry of Health, spoke rather placidly by the 1970s about shortages of syringes, needles and other diabetes accessories as if it were a ‘normal’ state of affairs. This only changed when the speed of development in the West in the 1980s laid bare how far the GDR was lagging behind in medical technology by that stage. With regards to clinical and experimental research, these economic issues limited the scope of what might have been done, and those in the Ministry of Health could see through some of Bibergeil’s vague and bold claims about the ‘world-leading’ results obtained at the Central Institute. This makes it incredibly difficult to assess how effective the GDR’s management of diabetes really was, as the system was never properly given the chance to be tried long-term in a capitalist liberal democracy, as alluded to by those so bent on defending it.

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Along with the political decisions taken, which each chapter of this thesis has uncovered, it can be argued that diabetes care and research in the GDR morphed into a distinctly East German model, reflecting its geographic and political position at the crossroads of East and West. Ideas from nineteen twenties left-wing Weimar German health reforms, tinged with a Soviet influence, gave the healthcare system, and in turn, diabetes care, an unmistakeably socialist character. The introduction of new facilities and institutions seen across the Eastern Bloc and already tried in the Soviet Union, like the polyclinic, where so many ‘diabetes advice centres’ were housed, reinforced the eastern flavour of diabetes care in the GDR. Although much of social hygiene was rooted in Weimar German thinking, there was continuity in personnel from the era that immediately preceded the GDR’s foundation. Gerhardt Katsch was a unique individual and the GDR benefited from his wealth of experience in setting up institutions for diabetics.

The thirst for keeping up with what was going on in the West and on the world stage, driven both by the striving mentality of Katsch following the creation of the (Central)Institute and by a broader competitive spirit that the SED had fostered from the beginning of the 1960s, focused attention on trends that were not always specifically state socialist. Adopting such ideas as the American risk factor approach to look more at individual cases was a good example. The GDR’s specific disparities also raise the question of how equal the system was, equality being an important state socialist preoccupation. Having relatives in the West made it easier to access better quality medication and equipment. Many of the diabetes advice centre reports from the ‘Störfreimachung period’ onward revealed the regional variability in the standards of care delivered to patients, with northerly rural areas often coming off worse, where, ironically, shortages of fruit and vegetables were also pronounced. Honecker exacerbated regional disparities by further establishing East Berlin, the gateway for many westerners, as a showcase city or the ‘display window of socialism’, to use Khrushchev’s phrase. The standard of living was naturally much better there than it was in the rest of the GDR. Eingaben sent by diabetics in the final decade made this clear, as one illustrated the gulf between Dresden (a large city in its own right) and Berlin.

Gerhard Ritter believes that the de Mazière administration, the freely elected grand coalition formed on 9 April 1990, would have entertained the idea of including certain features of the East German healthcare system such as the fluid link between outpatient and inpatient

237 facilities and the focus on preventive medicine.1067 The FRG Social Democrats echoed some of what Dr. Hempel said and, in spite of the inability to achieve absolute equality, were especially keen on the ‘social achievements’ of East German healthcare with a view of making West Germany’s healthcare system more egalitarian.1068 As these West German politicians looked at the East German healthcare system from the outside and deemed it to have some redeeming qualities, this validates some of the arguments made in defence of retaining aspects of East German diabetes care. Plans to incorporate elements of the East German approach into a reunified German healthcare system were nonetheless quashed by health insurances and doctors’ groups. West German doctors’ associations were ‘preoccupied with the commercial basis of private practice’, as Stephen Padgett claims, and ambulatory care (i.e. polyclinics) was subject to almost total transformation due to massive differences to the West German, pre-war notion of private practice.1069 The final nail in the coffin for the East German healthcare system and diabetes care was the State Treaty of 18 May 1990, setting in stone the ‘step-by-step change’ of East German healthcare to bring it in line with the West German model.1070 The appraisal of the East German healthcare system during reunification and voices of opposition to the changes highlight the credibility of what had been set up in the GDR to treat and manage diabetes, but, rather regrettably, the writing was on the wall for diabetes care ‘East German style’ soon after the fall of the Wall.

This thesis has therefore explored what can safely be considered a novel system of diabetes care behind the Iron Curtain. Whilst attempting to reserve binary judgement on whether this system was ‘good’ or ‘bad’, it has charted the continued political influences shaping the development of the system, the multiple foundations on which it was built and the people who helped shape it. As a relatively holistic history, tapping into systemic structures, the work and thoughts of doctors as well as the responses of patients, the thesis is not consciously ‘top-down’ or ‘bottom-up’ in approach. It has proved that the subject of diabetes is an ideal snapshot of the political landscape of the GDR at micro and macro level, which in turn has demonstrated an East German, as opposed to simply state socialist, way of dealing with health and chronic diseases. Prevention was an overriding mission since the days of Katsch and with a more suitable economic environment may well have seen improved results.

1067 Gerhard Ritter, The Price of German Unity: Reunification and the Crisis of the Welfare State, trans. by Richard Deveson (Oxford: Oxford University Press, 2011), p. 183. 1068 Ritter, p. 181. 1069 Stephen Padgett, Organizing Democracy in Eastern Germany: Interest Groups in Post-Communist Society (Cambridge: Cambridge University Press, 2000), p. 68. 1070 Ritter, p. 181.

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The sanatoria, holiday camps for children and the boarding school all sought to ensure that diabetics were, as Katsch always said, ‘conditionally healthy and able to work’, not ‘chronically ill’. This mantra persisted until the end, as concerned diabetics wishing to procure the right diet foods revealed that they saw themselves as ‘conditionally healthy’ people. The relationship between chronic diseases and prevention remains topical in modern debates on creating a healthcare system fit ‘for the Twenty-First Century’. Only very recently the BBC reported that the NHS, a healthcare system with similar social motives to that of the GDR, will be embarking on a long-term ten-year prevention plan which ‘could save 500,000 lives through preventing diseases like strokes, heart problems and cancer, and spotting them earlier’. 1071 Using language that almost mirrors that used in the GDR, the scale and scope of Reihenuntersuchungen, epitomised by Dr. Krüger testing over 386,000 people in the region of Schwerin between the years 1961 and 1962, is perhaps food for thought.

As contributions to the knowledge and understanding of East German healthcare continue to grow, there are various avenues one could take beyond what has been explored here. It would be interesting, for example, to undertake a more in-depth examination of particular groups of individuals working within the healthcare system, as Ernst’s study on medical professionals up to 1961 has done, focusing on the frequently neglected later period of the GDR’s lifetime. This would reveal the diversity of opinion toward healthcare in the GDR in a variety of different medical fields or specialties, which would also determine that the healthcare system was by no means a monolith. There is a great deal of potential for patient driven studies to look more carefully at how the East German healthcare system was received. This could certainly help, although not necessarily solve, the issue of assessing the merits and drawbacks of the healthcare system with enhanced validity. As the conclusion to this thesis has highlighted, a fresh, contemporary look at the process of reunifying the two German healthcare systems would be extremely welcome. Why was so much of the GDR healthcare system (and diabetes care) dismissed? What, if anything, has been kept or reintroduced more recently, and why? Was excluding certain preventative aspects of East German healthcare a missed opportunity, particularly given that in Germany today, the charitable organisation, Deutsche Diabetes Hilfe, suggests that, on average, cases of diabetes are diagnosed eight to ten years too late?1072 As clouded judgements subside, with those, on the one hand, who immediately took

1071 ‘NHS long-term plan: Focus on prevention “could save 500,000 lives”’, BBC News, 7th January 2019, https://www.bbc.co.uk/news/health-46777387 [accessed 08/01/19]. 1072 ‘Diabetes in Zahlen, Deutschland’, Deutsche Diabetes Hilfe, https://www.diabetesde.org/ueber_diabetes/was_ist_diabetes_/diabetes_in_zahlen [accessed 07/01/19].

239 the view of the GDR as a ‘scientific desert’, and on the other, those who rabidly defended everything about the state, it is now more than ever that historians can explore in a more balanced fashion the ways in which the GDR looked after its people.

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BIBLIOGRAPHY

Unpublished primary sources

➢ Archives

Documents from the Bundesarchiv Berlin Lichterfelde

SAPMO – Stiftung Archiv der Parteien und Massenorganisationen der DDR im Bundesarchiv/ Foundation Archive of the Parties and Mass Organisations of the GDR in the Federal Archives

BArch – Bundesarchiv/ Federal Archives

1. Files from DQ1 – Ministerium für Gesundheitswesen / Ministry of Health (1945- 1949) 1950-1990

• Diabetiker – Fürsorge – bzw. Beratungsstellen: Statistische Berichte

SAPMO-BArch DQ1/4445 – Berichtsjahr 1951 bis 1953

SAPMO-BArch DQ1/20569 - Berichtsjahre 1957 und 1958

SAPMO-BArch DQ1/20570 - Berichtsjahr 1958

SAPMO-BArch DQ1/2907 – Berichtsjahr 1961, Bd.1 Bezirke Cottbus, Frankfurt (Oder), Magdeburg, Neubrandenburg, Potsdam, Rostock, Schwerin SAPMO-BArch DQ1/2908 – Berichtsjahr 1961, Bd.2 Berlin und Bezirke Dresden, Erfurt, Gera, Halle, Karl-Marx-Stadt, Leipzig, Suhl SAPMO-BArch DQ1/4429 –Berichtsjahr 1962, Bd. 1 Berlin und Bezirke Dresden, Erfurt, Gera, Halle, Karl-Marx-Stadt, Leipzig, Suhl SAPMO-BArch DQ1/4428 –Berichtsjahr 1962, Bd. 2 Bezirke Cottbus, Frankfurt (Oder), Magdeburg, Neubrandenburg, Potsdam, Rostock, Schwerin

• Auswirkung und Behebung chronischer Ernährungsmängel

SAPMO-BArch DQ1/21426 – Potsdam – Rehbrücke: Anstalt für Vitaminprüfung, Auswirkung und Behebung chronischer Ernährungsmängel (1954-1957); Anstalt zur Erforschung und Behandlung der Zuckerkrankheit Garz und Karlsburg bzw. Institut für Diabetes Karlsburg: Jahresberichte 1955 und 1959 sowie verschiedene Berichte zur Diabetesforschung (1955-1962).

• (Zentral)Institut für Diabetes ‘Gerhardt Katsch’ Karlsburg, Garz und Putbus

241

SAPMO-BArch DQ1/3151 – Bd. 1 (1959-1955)

SAPMO-BArch DQ1/21526 – Bd. 2 (1959-1963)

SAPMO-BArch DQ1/23140 – Bd. 3 (1964-1967)

SAPMO-BArch DQ1/23745 – Bd. 4 Forschungsprojekte (1966-1968); Karlsburger Symposion über Diabetesfragen (1968)

• SAPMO-BArch DQ1/4216 - Errichtung, Leitung und Organisation verschiedener Institute (1950-1952)

• SAPMO-BArch DQ1/960 – Schriftwechsel M Zetkins als Vizepräsident der DZVfG bzw. Leiter der HA Wissenschaft: Reiseberichte und Aktennotizen (1946-1949)

• SAPMO-BArch DQ1/2777 - Konstituierung und Beratungen des Verwaltungsrates des Diabetikerheimes und Forschungsinstituts Karlsburg sowie Schriftwechsel mit Instituten zu Forschungsaufträgen (1950-1952)

• SAPMO-BArch DQ1/4215 – Schriftwechsel des Ministers Steidle mit verschiedenen Einrichtungen des Gesundheitswesens, staatlichen Dienststellen und Privatpersonen: Tätigkeit des Ministers Luitpold Steidle v.a. in der Öffentlichkeit

• SAPMO-BArch DQ1/3108 – Nutzung wissenschaftlich-technischer Ergebnisse (1959-1966)

• Betreuung von Diabetikern (1959-1969)

SAPMO-BArch DQ1/21525 – Bd. 1 Fachausschuss für Diabetes, 1959-1962; Arbeitstagungen der Bezirksdiabetesärzte, 1960-1962

SAPMO-BArch DQ1/4343 – Bd. 2 Statistiken; Vordrucke, 1962-1969 SAPMO-BArch DQ1/4344 – Bd. 4 Ausgabe von Insulin-Spritzbestecken; Versorgung mit Insulin, 1962-1969

SAPMO-BArch DQ1/4346 – Bd. 5 Eingaben, 1962-1969 SAPMO-BArch DQ1/4345 – Bd. 6 Tagungen der Bezirksdiabetologen; Herstellung von Sorbit

• Diabetes mellitus – Erforschung und Bekämpfung (1955-1969)

SAPMO-BArch DQ1/23748 – Bd. 2 Vereinbarung zwischen Universität Greifswald und Zentralinstitut für Diabetes Karlsburg, 1968-1969; Problemkommission für Endokrinologie und

242

Stoffwechselkrankheiten, 1964-1968; Empfehlungen zur Diagnostik und Therapie des Diabetes mellitus, 1966-1968; Schriftwechsel mit Räten der Bezirke, 1964-1969

• SAPMO-BArch DQ1/21162 – Versorgung von Diabetikern (1961-1962) Versorgung mit Insulin; Herstellung von Archadose • SAPMO-BArch DQ1/6702 – Versorgung und Betreuung von Diabetikern (1961- 1964) Eingaben zu Diätnahrungsmitteln; Versorgung mit Insulin; Rehabilitation

• Gesundheitsschutz, Leitungsvorlagen und Berichte des Ministeriums (1964-1968)

SAPMO-BArch DQ1/5281 – Bd. 1 Klima-Kurreisen mit der MS ‘Völkerfreundschaft’, 1965; Weiterbildung der Ärzte und Zahnärzte, 1966; Aufklärung eines Todesfalles in der Poliklinik des Hauses der Ministerien bzw. Im VP-Krankenhaus Berlin, 1966; Bekämpfung von Diabetes, 1967; Berufliche Auslastung für Ärzte, 1967; Beschäftigungsverbote für Frauen und Jugendliche, 1967 SAPMO-BArch DQ1/10824 – Tuberkulose-, Endokrinologie und Diabetes – Analysen und Forschungsziele (Dr. Tischendorf, HA Medizinische Betreuung)

• Fachgebiet Diabetes – Allgemeines und Verschiedenes (1963-1990) SAPMO BArch DQ1/23749 – Bd. 2 Studienreisen ins Ausland und von Ausländern, 1968-1969; Ökonomische Betrachtungen zur Diabetesbekämpfung, 1968; Rekonstruktion des Bereichs Garz des Instituts für Diabetes, 1968 SAPMO-BArch DQ1/23746 – Bd. 3 Bemühungen Karl Handfests, Luisenthal-Saar, um Beteiligung von Diabetologen der DDR an westdeutschen Veröffentlichungen, 1966-1968 SAPMO-BArch DQ1/13868 – Bd. 4 ABI-Kontrollen 1982, 1984, 1986; Fachbeirat Diabetes beim Ministerium; Betreuung schwangerer Diabetikerinnen; Beratungen der beratenden Diabetologen der Bezirksärzte (1971-1990) SAPMO-BArch DQ1/13869 – Bd. 5 Ferienbetreuung von Diabetikern; Betreuung von schwangeren Diabetikerinnen; Problemkommission Diabelogie beim Ministerium; Beratungen der beratenden Diabetologen für Diabetes, 1988; Materielle Sicherung der Versorgung von Diabetikern, 1987-1990

• Unterausschuss ‘Insuline und orale Antidiabetika’ (1974-1989) SAPMO-BArch DQ1/14471 (parts 1 to 3) – Einschätzung der Versorgungssituation mit Insulin, 1987

• Volkswirtschaftsplanung, Teil Wissenschaft und Technik: Aufstellungen der Bezirke (1964-1985) SAPMO-BArch DQ1/26355 – Zentralinstitut für Diabetes: Fünfjahrplan (1976-1980) SAPMO-BArch DQ1/26358 – Zentralintut für Diabetes: Volkswirtschaftsplan 1979

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SAPMO-BArch DQ1/25053 – Zentralinstitut für Diabetes ‘Gerhardt Katsch’ Karlsburg – Bau eines Tierzuchthauses (1979-1980)

• Karlsburg – Zentralinstitut für Diabetes – Dokumentation der Planung und Umsetzung verschiedener Investitionsvorhaben (1976-1986) SAPMO-BArch DQ1/25843 – Bd. 1 Neubau eines Tierzuchthauses zur Erhöhung des Bestandes an Versuchstieren und zur Erweiterung des Versuchstierspektrums; Initiativprogramm ‘Eigenheime’, 1976-1986

• SAPMO-BArch DQ1/26243 – Lohnpolitische Maßnahmen sowie Struktur-und Stellenplanung dem Ministerium unterstellter und nachgeordneter Einrichtungen, 1981-1990

• SAPMO-BArch DQ1/14472 – Erweiterung der Insulinpalette und der Diabetikerversorgung – Forschung und Entwicklung, 1983-1990

• SAPMO-BArch DQ1/15405 – Versorgung mit Insulin, Protokolle des Zentralen Gutachterausschusses zur Aktualisierung des Insulinsortiments, 1989

2. Files from DQ101 – Generalsekretariat der medizinisch-wissenschaftlichen Gesellschaften beim Ministerium für Gesundheitswesen

• Mitgliederakten (1961-1990) SAPMO-BArch DQ101/572 (parts 1 to 3) Bd. 9 Europäische Vereinigung zum Studium des Diabetes (EASD); Internationale Liga für Dermatologie; Internationale Gesellschaft für Chemometrie; Rat für internationale Organisationen der medizinischen Wissenschaft (CIOMS) SAPMO-BArch DQ101/572a (parts 1 and 2) Bd. 23 Europäische Gesellschaft für Kniegelenkschirurgie und Arthroskopie; Internationale Gesellschaft für Dentalforschung (IADR); Internationale Diabetes-Föderation (IDF); Amerikanische Joslin-Diabetes-Stiftung; Internationale Gesellschaft für Pädiatrische Dermatologie; Internationale Gesellschaft für Tropendermatologie

3. File from DQ103 – Akademie für Ärztliche Fortbildung der DDR

• SAPMO-BArch DQ103/325 – Abschlußbelegarbeit zum zweijährigen Zusatzstudium für Leitungskader im Gesundheits- und Sozialwesen, Akademie für Ärztliche Fortbildung der DDR 2. Kurs (1973-1975)

4. Files from DQ109 – Rat für medizinische Wissenschaften beim Ministerium für Gesundheitswesen

244

• Sitzungen, Projekte und Schriftwechsel (1957-1971) SAPMO-BArch DQ109/210 – Bd. 1 Endokrinologie und Stoffwechselkrankheiten (früher Fachausschuss für Diabetes), 1957-1971

• SAPMO-BArch DQ109/94 – Medizinische Virusforschung und Impfschutz, Herzchirurgie, Bluthochdruck – Krankheiten, Rheumatologie, Diabetes mellitus, Krebsforschung, Gerontologie, Nierentransplantation und künstliche Niere

• Diabetes mellitus (1970-1974) SAPMO-BArch DQ109/32 – Bd. 1, 1970-1971 SAPMO-BArch DQ109/33 – Bd. 2, 1972-1974

• Medizinische Forschungsschwerpunkte bzw. Hauptforschungsrichtungen, Konzeptionen und Programme (1968-1986) SAPMO-BArch DQ109/255 – Bekämpfung und Verhütung der Tuberkulose und der kardiorespiratorischen Insuffizienz; Diabetes mellitus; Präventive Stomatologie; Chronische Niereninsuffizienz, 1970

• Analytisch-prognostische Bewertung der zentralen medizinischen Forschungsvorhaben für die Jahre 1991-2000

SAPMO-BArch DQ109/173 – Bd. 1 M21 – Arbeitsbedingte Erkrankungen; M22 – Diabetes und Fettstoffwechselstörungen; M23 – Gastroenterologie; M24 – Komplexprogramm der medizinischen Forschung einschließlich naturwissenschaftlicher Grundlagen der Medizin; M25 – Grippe und andere ausgewählte Infektionskrankheiten; M27 – Karies und Periodontalerkrankungen; M28 – Künstlicher Organersatz und Biomaterialien, 1988

5. File from DQ112 – Institut für Medizinische Statistik und Datenverarbeitung

• SAPMO-BArch DQ112/94 – Kuren, Tuberkuloseregister, Tuberkulose- Schutzimpfungen, Diabetikerbetreuung (1977-1990)

6. Files from DQ117 – Nationales WHO-Büro des Ministerium für Gesundheitswesen SAPMO-BArch DQ117/30 (parts 1 and 2)

7. Files from DC14 – Komitee der Arbeiter- und Bauern-Inspektion SAPMO-BArch DC14/1961 – Diabetiker – Betreuung und Versorgung (1984-1986) Bd.1

245

8. Files from DQ119 – Fachschule für Gesundheits- und Sozialwesen ‘Prof. Dr. K. Gelbke’, Potsdam SAPMO-BArch DQ119/734

Documents from the Stasi-Unterlagen-Archiv BStu – Der Bundesbeauftragte für die Unterlagen des Staatssicherheitsdienstes der ehemaligen Deutschen Demokratischen Republik/ Federal Commissioner for the Records of the State Security Service of the former German Democratic Republic KD Greifswald – Kreisdienststelle Greifswald, MfS-Bezirksverwaltung Rostock

• BStU, MfS, BV Rst, KD Greifswald, Nr. 107 – Parteiinformation • BStU, MfS, BV Rst, KD Greifswald, Nr. 324 – Zuarbeit zum Referat vor leitenden Kadern, Reise- und Auslandskadern des ZID Karlsburg

• BStU, MfS, BV Rst, KD Greifswald, Nr. 473 – Auswertung der Dienstkonferenzen des Leiters der BV und Einschätzungen der Arbeitsergebnisse

• BStu, MfS, BV Rst, KD Greifswald, Nr. 227 – Konzeption zur Sicherung des Schwerpunktbereiches ‘Ausgewählte Reise- und Auslandskader sowie Delegaten der Universität Greifswald und des Zentralinstituts für Diabetes (ZID) Karlsburg in das Nichtsozialistisches Wirtschaftsgebiet (NSW)’

➢ Oral history interviews

• Doctors Dr. M. Anders, Berlin (29 May 2017 and 28 May 2018) Dr. E. Austenat, Berlin (16 August 2016, 14 February 2017 and 16 August 2017) Prof. W. Bruns, Berlin (7 April 2016, 31 May 2016, 1 June 2017 and 18 August 2017)

Prof. M. Hanefeld, Dresden (10 August 2016) Dr. V. Schliack, Berlin (27 August 2016) Prof. K. Lürmann, Cottbus (15 August 2016) Dr. P. Singer, Berlin (30 May 2017) Dr. H. Schneider, Berlin (6 April 2016, 1 June 2016, 11 August 2016, 31 May 2017, 9 August 2017, 17 August 2017, 15 Februrary 2018, 30 May 2018) Dr. H.J. Verlohren, Makranstädt (8 August 2017)

Dr. B. Wegner, Cottbus (15 August 2016)

246

Dr. J. Ziegelasch (31 May 2018)

• Patients Patient K.K, Berlin (15 August 2017)

Patient K.S, Templin (14 February 2018) Patient M.B, Berlin (29 May 2017) Patient P.Z, Pasewalk (11 August 2017) Patient U.W, Berlin (7 August 2017)

Published primary sources

➢ Newspaper and journal articles

East German newspapers and journals:

Berliner Medizinische Rundschau Berliner Zeitung Das deutsche Gesundheitswesen (later Zeitschrift für klinische Medizin) Deine Gesundheit Medicamentum Neues Deutschland Zeitschrift für die gesamte innere Medizin

International diabetes journal:

Diabetologia (published by West German Springer Verlag)

Anonymous, ‘“Die Welt” muss ihre Lüge widerrufen’, Berliner Zeitung, 11th January 1961, Jahrgang 17, Ausgabe 11

Anonymous, ‘Prof. Dr. Katsch gestorben’, Neues Deutschland, 9th March 1961, Jahrgang 16, Ausgabe 68

247

Böhme, H. S., ‘Diabetes Suchaktion im Kreis Nordhausen (Bezirk Erfurt)’, Das deutsche Gesundheitswesen, 19 (1964), 188-192

Dempe, A. and K. Bauch, ‘Klinische und anamnestische Daten der Diabetes – Reihensuche in Karl-Marx-Stadt’, Das deutsche Gesundheitswesen, 27 (1972), 296-302

Engelmann, H., ‘Beitrag zur Praxis der Diabetes-Reihenuntersuchung (Radeberg 1963)’, Das deutsche Gesundheitswesen, 19 (1964), 1319-1323

Fiedler, H., ‘VII. Karlsburger Symposium über Diabetesfragen’, Medicamentum, 13 (1972), 188- 189

Günther, Otfried, ‘Warum Schulheim für zuckerkranke Kinder?’ Das deutsche Gesundheitswesen, 7 (1952), 988-990

Haenel, H, ‘Iss sowenig du kannst’, Deine Gesundheit, 6 (1968), 174-5

Kayser, H.J., ‘Ist der Informationsgrad der Diabetiker ausreichend?’ Das deutsche Gesundheitswesen, 25 (1970), 595-597

König, Ursula, ‘Jeder 10. ist Diabetiker’, Berliner Medizinische Rundschau, 2 (1965), 16-17

Krüger, H.U, ‘Erfahrungen und Ergebnisse der Reihenuntersuchungen auf Diabetes mellitus im Bezirk Schwerin in den Jahren 1961/2’, Das deutsche Gesundheitswesen, 19 (1964), 500-506

Krüger, H. U., ‘Reihenuntersuchung auf Diabetes mellitus bei Kindern’, Das deutsche Gesundheitswesen 20 (1965), 781-2

Kuminek, K., ‘Die Einbeziehung des Facharztes für Allgemeinmedizin in wichtige Teile der Dispensairebetreuung’, Das deutsche Gesundheitswesen, 29 (1974), 1213-16

Latotzki, H., ‘Probleme des Diabetes mellitus in der allgemeinärztlichen Praxis’, Das deutsche Gesundheitswesen, 27 (1972), 1506-8

Lippmann, Hans-Georg, ‘Wege der modernen Diabetesforschung’, Deine Gesundheit, 3 (1969), 70-2

Luft, D., R. M. Schmülling, and M. Eggstein, ‘Lactic Acidosis in Biguanide-Treated Diabetes: A Review of 330 Cases’, Diabetologia, 14 (1978), 75-87

248

Lüdtke, E., E Rattmann and G. Mögling, ‘Die soziale und medizinische Bedeutung der Dauer- und Ferienbetreuung von Schülern mit Diabetes mellitus’, Das deutsche Gesundheitswesen, 31 (1976), 944-46

Michaelis, D., ‘Forschen für Diabetes’, Deine Gesundheit, 1 (1976), 26-7

Misgeld, Gerhard, ‘Weshalb ein Heft über Diabetes?’ Deine Gesundheit, 3 (1969), 68

Mohnike, Gerhard, ‘Sozialmedizinische Diabetesfragen’, Das deutsche Gesundheitswesen, 9 (1954), 286-292

Nattrass, M. and K.G.M.M. Alberti, ‘Biguanides’, Diabetologia, 14 (1978), 71-74

Neuendorf, W. and R. Swarovsky, ‘Sind Reihensuchen nach Diabetes mellitus noch aktuell?’ Das deutsche Gesundheitswesen, 24 (1969), 967-8

Panzram, G., ‘Die klinische Frühdiagnose des Diabetes mellitus’, Das deutsche Gesundheitswesen, 25 (1970), 1157-1161

Panzram, G., ‘Prophylaktische Konsequenzen einer epidemiologischen Studie über das Coma diabetikum’, Das deutsche Gesundheitswesen, 28 (1973), 1359-1363

Porstmann, W., ‘Die Kriegsaglykosurie der Diabetiker’, Das deutsche Gesundheitswesen, 8 (1953), 1003-8

Redetzky, Hermann, ‘Aufgaben und Ziele der Sozialhygiene innerhalb der medizinischen Wissenschaft’, Zeitschrift für die gesamte innere Medizin, 2 (1947), 1141-1143

Redetzky, Hermann, ‘Die soziale Bedeutung des Diabetes mellitus und seine Berücksichtigung in sozialmedizinischer Hinsicht, Das deutsche Gesundheitswesen, 7 (1952), 152-7

Schneider, Heinz, ‘Vergleichende Untersuchungen zur Diabeteshäufigkeit der Landbevölkerung in der zweiten Lebenshälfte mit differenten Methoden des Screenings’, Das deutsche Gesundheitswesen, 27 (1972), 2309-2312

Scholz, Christa, ‘Erste Erfahrungen bei der Durchführung eines Ferienlagers für diabetische Kinder im Komplex der Dispensairebetreuung’, Das deutsche Gesundheitswesen, 31 (1976), 731-733

Von Knorre, G., ‘Diabetes Reihenuntersuchung im Landkreis Oschersleben, 1961-2’, Das deutsche Gesundheitswesen, 19 (1964), 593-597

249

Winter, Kurt, ‘Die Bedeutung der öffentlichen ambulanten Betreuung’, Das deutsche Gesundheitswesen, 7 (1952), 1621-1623

Zander, E., ‘Diabetiker-Herzen’, Deine Gesundheit, 5 (1976), 152-3

➢ Books and mauscripts published in the GDR

Beyer, Alfred, ‘V. Teil: Arbeit und Arbeitsproduktivität’, in Lehrbuch der Sozialhygiene, ed. by Kurt Winter and Alfred Beyer (East Berlin: VEB Verlag Volk und Gesundheit, 1953), pp. 273- 326

Egon Brauns and Peter Wulfert, “Bisher ein äuβert trauriges Kapitel”: diabetische Kinder – die Herausforderung wird angenommen’, in Karlsburg: Ein Dorf und sein Institut, ed. by the Institut für Diabetes ‘Gerhardt Katsch’ and Peter Wulfert (Karlsburg: Institut für Diabetes, 1990), pp. 44-48 (pp. 46-7)

---, ‘Erstes Deutsches Diabetikerheim – Ein mühseliger Beginn’, in Karlsburg: Ein Dorf und sein Institut, ed. by the Institut für Diabetes ‘Gerhardt Katsch’ and Peter Wulfert (Karlsburg: Institut für Diabetes, 1990), pp. 40-43

---, ‘Der Start für das groβe Institut – Die Fundamente werden errichtet’, in Karlsburg: Ein Dorf und sein Institut, ed. by the Institut für Diabetes ‘Gerhardt Katsch’ and Peter Wulfert (Karlsburg: Institut für Diabetes, 1990), pp. 54-8

---, „Glückliche Kombination: Klinik und Forschung unter einem Dach“ – ein erstarkendes Institut‘, in Karlsburg: Ein Dorf und Sein Institut, ed. by Peter Wulfert (Karlsburg: Institut für Diabetes, Karlsburg. 1989)

---, “Malen Sie es notfalls weiβ an” – Sorgen der neuen Schloβherren’, in Karlsburg: Ein Dorf und sein Institut, ed. by the Institut für Diabetes ‘Gerhardt Katsch’ and Peter Wulfert (Karlsburg: Institut für Diabetes, 1990), pp. 49-54

Erdmann, Gustav, Die Ernst-Moritz-Arndt Universität Greifswald und ihre Institute (Greifswald: Pressestelle der Universität, 1959)

250

Fischer, E., L. Rohland und D. Tutzke, Für das Wohl des Menschen, Band II: Dokumente zur Gesundheitspolitik der Sozialistischen Einheitspartei Deutschlands (East Berlin, VEB Verlag Volk und Gesundheit, 1979)

Katsch, Gerhardt, Gerhard Mohnike and H. J. John, Aceton bis Zucker: Nachschlagebuch für Zuckerkranke First Edition, (Leipzig: Georg Thieme Verlag, 1957)

Katsch, Gerhardt and Gerhard Mohnike, Aceton bis Zucker: Nachschlagebuch für Zuckerkranke Sixth Edition (Leipzig: Georg Thieme Verlag, 1970)

Lübken, Wulf, ‘Originalbericht von Wulf Lübken’, in Gerhardt Katsch, Begründer des ersten deutschen Diabetikerheims und der Diabetikerfürsorge: Bericht von Wulf Lübken als Wissenschaftliche Reparationsleistung an die Sowjetische Militäradministration Deutschland (SMAD), ed. by Günther and Ralf Ewert (Berlin: Pro BUSINESS, 2008), pp. 25-186

Müller, Friedrich, ‘Die sozialhygienische Bedeutung des Diabetes mellitus’, in Lehrbuch der Sozialhygiene, ed. by Kurt Winter and Alfred Beyer (East Berlin: VEB Verlag Volk und Gesundheit, 1953), pp. 493-501

Schernthaner, G., ‘Ӓtiologie und Pathologie des Diabetes mellitus’, in Diabetes mellitus: Ein Nachschlagewerk für die diabetologische Praxis, Mit Beiträgen von 25 Fachwissenschaftlern, ed. by Horst Bibergeil (Jena: VEB Gustav Fischer Verlag, 1989), 118-144

Schliack, Volker, Statistisch-klinische Diabetesfragen (Leipzig: Geest und Portig, 1953)

Solov’ev, Zinovij Petrovic, ‘Thesen zu dem Vortrag: “Die prophylaktischen Aufgaben der therapeutischen Betreuung”, in Fragen der Sozialhygiene und des Gesundheitswesen (Ausgewählte Werke), ed. by Kurt Winter (East Berlin: VEB Verlag Volk und Gesundheit, 1975), pp. 118-123

Winter, Kurt and Alfred Beyer, ‘I. Teil: Einführung, Geschichtliche Entwicklung, Inhalt und Definition der Sozialhygiene’, in Lehrbuch der Sozialhygiene, ed. by Kurt Winter and Alfred Beyer (East Berlin: VEB Verlag Volk und Gesundheit, 1953), pp. 1-22

Winter, Kurt,‘Bedeutung und Organisation stationärer Einrichtungen’, in Lehrbuch der Sozialhygiene, ed. by Kurt Winter and Alfred Beyer (East Berlin: VEB Verlag Volk und Gesundheit, 1953), pp. 153-159

251

Winter, Kurt, ‘Die Organisation der ambulanten Betreuung’, in Lehrbuch der Sozialhygiene, ed. by Kurt Winter and Alfred Beyer (East Berlin: VEB Verlag Volk und Gesundheit, 1953), pp. 166-202

Winter, Kurt, ‘Die Sozialversicherung in der UdSSR’, in Lehrbuch der Sozialhygiene, ed. by Kurt Winter and Alfred Beyer (East Berlin: VEB Verlag Volk und Gesundheit, 1953), pp. 249- 256

Winter, Kurt, Alexander Mette und Gerhard Misgeld, Der Arzt in der sozialistischen Gesellschaft (East Berlin: Akademie-Verlag, 1958)

Winter, Kurt, Soziologie für Mediziner (East Berlin: VEB Verlag Volk und Gesundheit, 1973)

➢ Pre- and post-GDR publications

Hanefeld, Markolf, ‘Das Metabolische Syndrom: Wurzeln, Mythen und Fakten’, in Das Metabolische Syndrom: Ein integriertes Konzept zur Diagnostik und Therapie eines Clusters von Zivilisationskrankheiten (Jena and Stuttgart: Gustav Fischer Verlag, 1996), pp. 15-26

Semashko, Anton, Health Protection in the USSR: The New Soviet Library II (London: Victor Gollancz, 1934)

➢ Post-reunifcation reflections by East German diabetologists

Bruns, Waldemar, ‘Die Geschichte der Diabetologie in der DDR’, Festschrift 50 Jahre Deutsche Diabetes Gesellschaft, ed. by Die Deutsche Diabetes Gesellschaft, Erhard Siegel and Dietrich Garlichs (Stuttgart: Die Deutsche Diabetes Gesellschaft, 2014), pp. 68-79

Bruns, Waldemar, Dietrich Michaelis and Heinz Schneider, ‘Arbeitstherapie’, in Bericht der Historischen Kommission der Deutschen Diabetes Gesellschaft zur ‘Gerhardt-Katsch- Medaille’, ed. by Peter Hürter, pp. 19-20

Bruns, Waldemar, Dietrich Michaelis and Heinz Schneider, ‘Insulinbehandlung’, in Bericht der Historischen Kommission der Deutschen Diabetes Gesellschaft zur ‘Gerhardt-Katsch- Medaille’, ed. by Peter Hürter (Berlin: Deutsche Diabetes Gesellschaft, 2004), pp. 17-19

Bruns, Waldemar, Heinz Schneider and Dietrich Michaelis, ‘Die Namensgebung der “Gerhardt- Katsch-Medaille” und Zwangssterilisation von Diabetikern’, in Bericht der Historischen Kommission der Deutschen Diabetes Gesellschaft zur ‘Gerhardt-Katsch-Medaille’, ed. by Peter Hürter (Berlin: Die Deutsche Diabetes Gesellschaft, 2004), 1-16

252

Bruns, Waldemar, Konrad Seige, Horst Bibergeil, Ruth Menzel and Günther Panzram, Die Entwicklung der Diabetologie im Osten Deutschlands von 1945 bis zur Wiedervereinigung, ed. by Die Deutsche Diabetes Gesellschaft (Hildesheim: Wecom, 2004)

Schneider, Heinz, ‘Ein deutscher Diabetologe mit Weltgeltung: Professor Dr. Gerhard Mohnike (1918-1966) aus Karlsburg in Vorpommern’, Ärzteblatt Mecklenburg-Vorpommern 3 (2010)

Schneider, Heinz, ‘Die Diabetikerbetreuung im Osten Deutschlands 1945 bis 1989’, in Subkutan: Die Zeitschrift von Diabetikern für Diabetiker Sonderheft, ed. by der Subkutan- Verbund des Deutschen Diabetiker Bundes (Berlin: DDB, 2001), 46-51

Katsch, Gerhardt, ‘6th February 1947 entry’, in Gerhardt Katsch, Greifswalder Tagebuch, 1946- 47, ed. by Dirk Alvermann and Irmfried Gabe (Kiel: Ludwig Verlag, 2007), p. 8

➢ Memoirs and diaries

Austenat, Elke, Und drüben wird es besser: Die Austenats – Eine Deutsche Familie – Teil II (Berlin: AWA Publishing, 2016)

Bruns, Waldemar, and Günther H. W. Preuße, Opus 99…und andere Fragmente aus der Geschichte der deutsch-russischen Familie Bruns: Versuch einer literarischen Annäherung (Berlin: Trafo Verlagsgruppe, 2014)

Schneider, Heinz, Die Normalität des Absurden (Fahrwangen: Spiegelberg Verlag, 2011)

Yamamoto, Ralf, Wie wär’s mal mit was Süßem: Geschichten mit dem Diabetes (Hamburg: Tredition Verlag, 2014)

➢ Websites

‘Harry Keen’, Diabetes Stories, Transcript 11, http://www.diabetes- stories.com/transcript.asp?UID=52#(11) [accessed 13/07/17].

Published and unpublished secondary literature

Ahrens, Ralf, ‘Debt, Cooperation, and Collapse: East German Foreign Trade in the Honecker Years’, in The East German Economy, 1945-2010: Falling Behind or Catching Up? ed. by

253

Hartmut Berghoff and Uta Andrea Balbier (Cambridge: Cambridge University Press, 2013), pp. 161-176

Allinson, Mark, ‘1977: The GDR’s Most Normal Year?’ in Power and Society in the GDR, 1961- 1979: The ‘Normalisation of Rule’? ed. by Mary Fulbrook (Oxford and New York: Berghahn, 2013)

---, ‘More from less: Ideological Gambling with the Unity of Economic and Social Policy in Honecker’s GDR’, Central European History, 45 (2012), 102-127

Arndt, Melanie, Gesundheitspolitik im geteilten Berlin 1948 bis 1961 (Cologne, Weimar and Vienna: Böhlau Verlag, 2009)

Aronowitz, Robert A., Making Sense of Illness: Science, Society and Disease (Cambridge: Cambridge University Press, 1998)

Baker, Barrie, Theatre Censorship in Honecker’s Germany: From Volker Braun to Samuel Beckett (Bern: Peter Lang, 2007)

Balz, Viola, ‘“Für einen Aktivisten wie mich muß es in einem sozialistischen Staat doch effektive Medikamente geben”: Psychopharmaka und Konsumenteninteresse in der DDR’, NTM Zeitschrift für Geschichte der Wissenschaften, Technik und Medizin, 21.3 (2013), 245-271

Baum, Renate, ‘Out of the Rubble: Political Values and Reconstruction’, in Political Values and Health Care: The German Experience, ed. by Donald W. Light and Alexander Schuller (Cambridge, MA: MIT Press, 1986), pp. 239-256

Bause, Ulrich and Jochen Matauschek, ‘Zum Stand der Medizintechnik in der DDR’, in Das Gesundheitswesen in der DDR: Aufbruch oder Einbruch? Denkanstöße für eine Neuordnung des Gesundheitswesens in einem deutschen Staat, ed. by Wilhelm Thiele (Sankt Augustin: Asgard- Verlag Hippe, 1990), pp. 197-202

Bell, David and Joanne Hollows, ‘Making Sense of Ordinary Lifestyles’, in Ordinary Lifestyles: Popular Media, Consumption and Taste, ed. by David Bell and Joanne Hollows (Maidenhead: Open University Press, 2005), pp. 1-20

Berger, Stefan and Norman Laporte, Friendly Enemies: Britain and the GDR, 1949-1990 (Oxford and New York: Berghahn, 2010)

254

Berghoff, Hartmut and Uta Andrea Balbier, ‘From Centrally-Planned Economy to Capitalism Avant-Garde? The Creation, Collapse, and Transformation of a Socialist Economy’, in The East German Economy, 1945-2010: Falling Behind or Catching Up?, ed. by Hartmut Berghoff and Uta Andrea Balbier (Cambridge: Cambridge University Press, 2013), pp. 3-16

Bettin, Hartmut, ‘Zwischen Verdüsterung und Verklärung: Eingabenanalysen des Ministeriums für Gesundheitswesen (MfG) der DDR als Quelle zur Beschreibung von Problemschwerpunkten und Bewältigungsstrategien im DDR-Gesundheitswesen’, Medizinhistorisches Journal, 51:4 (2016), 327-363

Betts, Paul, Within Walls: Private Life in the German Democratic Republic (Oxford: Oxford University Press, 2010)

Bielka, Heinz, Die Medizinisch-Biologischen Institute Berlin-Buch: Beiträge zur Geschichte (Berlin and Heidelberg: Springer Verlag, 1997)

Bliss, Michael, The Discovery of Insulin: 25th Anniversary Edition (Chicago: University of Chicago Press, 2007)

Bouvier, Beatrix, Die DDR – ein Sozialstaat? Sozialpolitik in der Ära Honecker (Bonn: Verlag J.H.W. Dietz Nachf., 2002)

Brock, Angela, ‘Producing the “Socialist Personality”? Socialisation, Education, and the Emergence of New Patterns of Behaviour’ in Power and Society in the GDR, 1961-1979: The ‘Normalisation of Rule’? ed. by Mary Fulbrook (Oxford and New York: Berghahn, 2009), pp. 220-252

Brockmann, Stephan, A Critical History of German Film (Rochester, N.Y.: Camden House, 2010)

Bruns, Florian, ‘Krankheit, Konflikte and Versorgungsmängel: Patienten und ihre Eingaben im letzten Jahrzehnt der DDR’, Medizinhistorisches Journal, 47:4 (2012), 335-367

Bundesministerium für innerdeutsche Beziehungen, Peter Christian Ludz and Johannes Kuppe (eds.), DDR Handbuch (Cologne: Verlag Wissenschaft und Politik, 1975)

Burdumy, Alexander, ‘Reconsidering the Role of the Welfare State Within the German Democratic Republic’s Political System’, Journal of Contemporary History, 48:4 (2013), 872- 889

255

Childs, David, Germany in the Twentieth Century (RLE: German Politics) (London and New York: Routledge, 2015)

---, The Fall of the GDR: Germany’s Road to Unity (London and New York: Routledge, 2014)

Crew, David F., ‘Consuming Germany in the Cold War: Consumption and National Identity in East and West Germany, 1949-1989, an Introduction’, in Consuming Germany in the Cold War, ed. by David F. Crew (Oxford and New York: Berg, 2003), pp. 1-20

Dale, Gareth, Between State Capitalism and Globalisation: The Collapse of the East German Economy (Bern: Peter Lang, 2004)

---, The East German Revolution 1989 (Manchester and New York: Manchester University Press, 2006)

Dehne, Harald, ‘Consumption and Consumerism in the German Democratic Republic’, in Everyday Life in Mass Dictatorship: Collusion and Evasion, ed. by Alf Lüdtke (London: Palgrave Macmillan, 2016), pp. 147-164

Dennis, Mike and Jonathan Grix, Sport under Communism: Behind the East German ‘Miracle’ (Basingstoke: Palgrave Macmillan, 2012)

Dennis, Mike, The Stasi: Myth and Reality (Abingdon: Taylor and Francis, 2003)

Dittrich, Michael, ‘Die Rolle der wissenschaftlichen Schule von Gerhardt Katsch (1887-1961) für die Entwicklung der Diabetesforschung: Ein Beitrag zur Geschichte der Diabetologie’ (unpublished doctoral thesis, Ernst-Moritz-Arndt University of Greifswald, 1981)

Donohue, Julie, ‘A History of Drug Advertising: The Evolving Roles of Consumers and Consumer Protection’, Milbank Quarterly, 84:4, 659-699

Epstein, Catherine, The Last Revolutionaries: German communists and their century (Cambridge, MA. and London: Harvard University Press, 2003)

Erices, Rainer, Andreas Frewer and Antje Gumz, ‘Testing ground GDR: Western pharmaceutical firms conducting clinical trials behind the Iron Curtain’, Journal of Medical Ethics, 41:7 (2015) 529-33

---, ‘Versuchsfeld DDR: Klinische Prüfungen westlicher Pharmafirmen hinter dem Eisernen Vorhang’, in Medizinethik in der DDR: Moralische und menschenrechtliche Fragen im

256

Gesundheitswesen, ed. by Andreas Frewer and Rainer Erices (Stuttgart: Franz Steiner Verlag, 2015), pp. 129-144

Ernst, Anna-Sabine, ‘Die beste Prophylaxe ist der Sozialismus: Ärzte und medizinische Hochschullehrer in der SBZ/DDR 1945-1961 (Münster: Waxmann, 1997)

Ewert, Günter, Ralf Ewert and Jürgen Boettiger, Der jüdische Familienhintergrund des Greifswalder Internisten Prof. Dr. Gerhardt Katsch und das Naziregime (Berlin: Pro BUSINESS, 2014)

Fenemore, Mark, Sex, Thugs and Rock ‘n’ Roll: Teenage Rebels in Cold-War East Germany (Oxford and New York: Berghahn, 2007)

Feudtner, Chris, ‘A disease in motion: diabetes history and the new paradigm of transmuted disease’, Perspectives in biology and medicine, 39:2 (1996), 158-170

---, Bittersweet: Insulin, and the Transformation of Illness (Chapel Hill, NC. : University of North Carolina, 2003)

Foitzik, Jan, ‘Funktionale Aspekte der Organisation und der Tätigkeit der SMAD’, in SMAD- Handbuch, Die Sowjetische Militäradministration in Deutschland 1945-1945, ed. by Wladimir P. Koslow, Horst Möller, Sergei W. Mironienko, Alexandr O. Tschubarjan and Hartmut Weber (Munich: Oldenbourg, 2009), pp. 36-51

Freedman, Paul, ‘Luxury Dining in the Later Years of the German Democratic Republic’, in Becoming East German: Socialist Structures and Sensibilities after Hitler, ed. by Mary Fulbrook and Andrew Port (Oxford and New York: Berghahn, 2013), pp. 179-200

Fulbrook, Mary, ‘The Concept of “Normalisation” and the GDR in Comparative Perspective’ in Power and Society in the GDR, 1961-1979: ‘The Normalisation of Rule?’, ed. by Mary Fulbrook (Oxford and New York: Berghahn, 2013), pp. 1-32

---, A History of Germany 1918-2014: A Divided Nation (Fourth Edition) (Hoboken, N.J: Wiley Blackwell, 2015)

---, The People’s State: East German Society from Hitler to Honecker (New Haven and London: Yale University Press, 2008)

257

Garbe, Irmfried, ‘Der Mensch’, in Gerhardt Katsch, Greifswalder Tagebuch 1946-47, ed. by Dirk Alvermann and Irmfried Garbe (Kiel: Ludwig Verlag, 2008), pp. 31-52

Garland, John, ‘The GDR’s strategy for “intensification”’, Studies in Comparative Communism, 20:1 (1987), 3-7

Geipel, Gary L., ‘Politics and Computers in the Honecker Era’, in Science under Socialism: East Germany in Comparative Perspective, ed. by Kristie Macrakis and Dieter Hoffman (Cambridge MA and London: Harvard University Press), pp. 230-246

Glaeser, Andreas, Divided in Unity: Identity, Germany, and the Berlin Police (Chicago and London: The University of Chicago Press)

Greene, Jeremy A., Prescribing by Numbers: drugs and the definition of disease (Baltimore: Johns Hopkins University Press, 2008)

Grieder, Peter, The East German Leadership 1946-73: Conflict and Crisis (Manchester and New York: Manchester University Press, 1999)

---, The German Democratic Republic: Studies in European History (Basingstoke: Palgrave Macmillan, 2012)

---, ‘“When your neighbour changes his wallpaper”: the ‘Gorbachev factor’ and the collapse of the German Democratic Republic’, in The 1989 Revolutions in Central and Eastern Europe: From Communism to Pluralism, ed. by Kevin McDermott and Matthew Stibbe (Manchester and New York: Manchester University Press, 2013), pp. 73-94

Gross Solomon, Susan, ‘Introduction: Germany, Russia, and the Medical Cooperation between the Wars’, in Doing Medicine Together: Germany and Russia Between the Wars, ed. by Susan Gross Solomon (Toronto: University of Toronto Press, 2006), pp. 3-31

Hampel, Benedikt, Geist des Konzils oder Geist von 1968?: Katholische Studentengemeinden im geteilten Deutschland der 1960er Jahre, Band 20 (Münster: LIT Verlag, 2017)

Harsch, Donna, ‘Medicalized Social Hygiene?: Tuberculosis Policy in the German Democratic Republic’, Bulletin of the History of Medicine, 86.3 (2012), 393-423

---, ‘Socialism Fights the Proletarian Disease: East German Efforts to Overcome Tuberculosis in a Cold-War Context’, in Becoming East German: Socialist Structures and Sensibilities after

258

Hitler, ed. by Andrew I Port and Mary Fulbrook (Oxford and New York: Berghahn, 2013), pp. 141-157

---, Revenge of the Domestic: Women, the Family, and Communism in the German Democratic Republic (Princeton and Oxford: Princeton University Press, 2007)

Harych, Horst, ‘Zur Zukunft der Polikliniken und der ambulanten Versorgung in der DDR’, in Das Gesundheitswesen der DDR: Aufbruch oder Einbruch? Denkanstöβe für eine Neuordnung des Gesundheitswesens in einem deutschen Staat, ed. by Wilhelm Thiele (St. Augustin: Asgard- Verlag, 1990), pp. 99-104

Heidemann, Christin and Christa Scheidt-Nave, ‘Prävalenz, Inzidenz und Mortalität von Diabetes mellitus bei Erwachsenen in Deutschland – Bestandsaufnahme zur Diabetes- Surveillance’, Journal of Health Monitoring, 2:3 (2017), 98-121

Heldmann, Philipp, Herrschaft, Wirtschaft, Anoraks: Konsumpolitik in der DDR der Sechzigerjahre (Göttingen: Vandenhoeck and Ruprecht, 2004)

Hertle, Hans-Hermann and Stefan Wolle, Damals in der DDR: der Alltag im Arbeiter- und Bauernstaat (Munich: Goldmann Verlag, 2006)

Hicks, Bethany E, ‘Germany After the Fall: Migration, Gender and East-West Identities’ (unpublished doctoral thesis, University of Michigan, 2010)

Hoffman, Dieter, ‘Robert Havemann: Antifascist, Communist, Dissident,’ in Science under Socialism: East Germany in Comparative Perspective, ed. by Kristie Macrakis and Dieter Hoffman (Cambridge, MA.: Harvard University Press, 1999), pp. 269-285

Hohlfeld, Rainer, ‘Between Autonomy and State Control: Genetic and Biomedical Research’, in Science under Socialism: East Germany in Comparative Perspective, ed. by Kristie Macrakis and Dieter Hoffmann (Cambridge, MA and London: Harvard University Press, 1999), pp. 247- 268

Hong, Young-Sun, ‘Cigarette Butts and the Building of Socialism in East Germany’, Journal of Central European History, 35:3, 327-344

---, Cold War Germany, the Third World and the Global Humanitarian Regime (Cambridge: Cambridge University Press, 2015)

259

Hürter, Peter, Diabetes bei Kindern und Jugendlichen: Klinik, Therapie, Rehabilitation: Zweite, vollständig überarbeitete und erweiterte Auflage (Berlin and Heidelberg: Springer Verlag, 1982)

Italiaander, Rolf, Die neuen Herren der alten Welt (Düsseldorf and Vienna: Econ Verlag, 1972)

Jarausch, Konrad, ‘Care and Coercion: The GDR as a Welfare Dictatorship’, in Dictatorship as Experience: Towards a Socio-cultural History of the GDR, ed. by Konrad Jarausch, trans. by Eve Duffy (Oxford and New York: Berghahn, 1999), pp. 47-72

---, The Rush to German Unity (Oxford and New York: Oxford University Press, 1994)

Jeffries, Ian and Manfred Melzer, ‘The Economic Strategy of the 1980s and the Limits to Possible Reforms’, in The East German Economy, ed. by Ian Jeffries and Manfred Melzer (London, New York and Sydney: Croom Helm, 1987), pp. 41-50

Judt, Tony, Postwar: A History of Europe since 1945 (London: Pimlico, 2007)

Jung, Helmuth, ‘Political Values and the Regulation of Hospital Care’, in Political Values and Health Care: The German Experience, ed. by Donald W. Light and Alexander Schuller (Cambridge, MA: MIT Press, 1986), pp. 289-324

Karlsch, Rainer, ‘National Socialist Autarky Projects and the Postwar Industrial Landscape’, in The East German Economy, 1945- 2010: Falling Behind Or Catching Up? ed. by Hartmut Berghoff and Uta Balbier (Cambridge: Cambridge University Press, 2013), pp. 77-79

Kerr-Boyle, Neula, ‘The Slim Imperative: Discourses and Cultures of Dieting in the German Democratic Republic’, in Becoming East German: Socialist Structures and Sensibilities after Hitler, ed. by Mary Fulbrook and Andrew I. Port (Oxford and New York: Berghahn, 2013), pp. 158-178

---, Orders of eating and eating disorders: food, bodies and anorexia nervosa in the German Democratic Republic, 1949-1990 (unpublished PhD thesis, University College London, 2012)

Klöppel, Ulrike and Matthias Hoheisel, ‘“Wunschverordnung” oder objektiver “Bevölkerungsbedarf”?: Zur Wahrnehmung des Tranquilizer-Konsumenten in der DDR (1960- 1970)’, NTM Zeitschrift für Geschichte der Wissenschaften, Technik und Medizin, 21:3, 213-244

Koch, Thomas and Michael Thomas, ‘The Social and Cultural Embeddedness of Entrepreneurs in Eastern Germany’, in Restructuring Social Networks in Post-socialism: Legacies, Linkages,

260 and Localities, ed. by Gernot Grabher and David Stark (Oxford: Oxford University Press, 1997), pp. 242-262

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APPENDIX 1

‘How is diabetes care in the GDR organised?’, Institut für Film, Bild und Ton, DDR, TK13.1 (image courtesy of Dr. Heinz Schneider). This laminate film sheet (designed for use with an overhead projector) illustrates succinctly the hierarchical structure of diabetes care and the responsibilities of key institutions for various branches of care. Above the diagram, it reads ‘the system of diabetes care offers every diabetic regular treatment, regular check-ups and lifelong care’. The Ministry of Health had overall control, which explains why it features at the top. The Central Institute for Diabetes sat directly below it, overseeing the sanatoria (right) and the centres for pregnant diabetics (left).

273

APPENDIX 2

‘How are the diabetes treatment centres distributed in the GDR?’, Institut für Film, Bild und Ton, DDR, TK13.2 (image courtesy of Dr. Heinz Schneider). This laminate film sheet was created to explain where the main treatment facilities were, including centres for pregnant diabetics (Entbindungszentren), regional and district advice centres, holiday places and sanatoria. The Central Institute for Diabetes is in the North East and can be seen at the top right-hand corner of the map.

274

APPENDIX 3

Volker Schliack, Statistisch-klinische Diabetesfragen (Leipzig: Geest und Portig, 1953), p. 25. A demographic pyramid featured in Volker Schliack’s early book on the use of statistics, which was designed to help assess the prevalence of diabetes. It reveals the typical social hygienic preoccupation with gender, age and place. The pyramid shows comparative data of known cases of men (left) and women (right) with diabetes in Leipzig, Dresden and Vienna. It also includes data for the whole of the Soviet Zone (before the GDR was founded) in 1946. The noticeably lower rates in 1946 of diabetes in older people informed East German diabetologists about the effect of diet on the development of non-insulin-dependent diabetes.

275

APPENDIX 4

SAPMO-BArch DQ1/20569 – example of a diabetes advice centre report from Pasewalk in the Bezirk (region) Neubrandenburg, 1958. The report features cases managed by the advice centre throughout 1957. Advice centres were provided with forms like this one by the Ministry of Health. Each report would include the total number of: male and female diabetics registered at the centre; the breakdown of their age; how many deaths there were due to diabetes and its complications; other causes of death; and the various types of treatment administered (diet-only, insulin, oral anti-diabetic tablets and combination treatment). A written analysis of these figures and the issues faced at the advice centre would follow overleaf.

276

APPENDIX 5

V. Schliack and H. Schüler, ‘Diabetes’, in Das Gesundheitswesen der Deutschen Demokratischen Republik 1973, 8. Jahrgang, ed. by Kurt Winter (East Berlin: Akademie für Ärztliche Fortbildung, 1973), pp. 102-119 (p. 105). A longitudinal graph demonstrating the rapid rise of diabetes in the GDR between 1958 and 1972. By 1972, it was estimated that 220 of every 10,000 people had diabetes. This graph also features the difference between the newly diagnosed (Zugänge) and deaths (Abgänge).

277

APPENDIX 6

Ursula Lotz, ‘Epidemiologische Studie zur Prognose (Krankheitsdauer) des Diabetes mellitus unter Berücksichtigung von Diabetestyp bzw. Therapieform an 26 073 Patienten, mit Hilfe des Berliner EDV-Projektes “Ambulante Diabetikerbetreuung”’, (unpublished doctor of medical sciences dissertation, Akademie für Ärztliche Fortbildung der DDR, Berlin, 1984), p. 34. Two graphs showing the rates of type 1 diabetes or insulin-dependent diabetes mellitus (IDDM) at the top and type 2 diabetes or non-insulin-dependent diabetes mellitus (NIDDM) at the bottom in selected areas of East Berlin. The breakdown of männlich (male) and weiblich (female) feature in both. A wealth of new ambulatory statistics was compiled following a large epidemiological study led by the Zentralstelle für Diabetes und Stoffwechselkrankheiten in Berlin (1984).

278

APPENDIX 7

279

APPENDIX 8

V. Schliack, ‘Sozialmedizinische Fragen bei Diabetes mellitus’, in Diabetes mellitus: Ein Nachschlagewerk für die diabetologische Praxis, Third Edition, ed. by Horst Bibergeil (Jena: Gustav Fischer Verlag, 1989), pp. 674-689 (p. 679). Pie charts from 1985 illustrating the breakdown of diabetics by age, gender and type (insulin or non-insulin-dependent). Both pie charts illustrate the proportion of diabetics of ‘working age’ (im berufsfähigen Alter), as well as of those who are not (either pensioners or children/young adults). This reinforces the notion of diabetics being seen as ‘conditionally healthy and able to work’ throughout the lifetime of the GDR.

280

APPENDIX 9

V. Schliack, ‘Sozialmedizinische Fragen bei Diabetes mellitus’, in Diabetes mellitus: Ein Nachschlagewerk für die diabetologische Praxis, Third Edition, ed. by Horst Bibergeil (Jena: Gustav Fischer Verlag, 1989), pp. 674-689 (p. 675). Demographic pyramid showing the total rates of male and female diabetics by 1985. The total number of men with diabetes (225,310) and women (412,010) shows that there were significantly more female diabetes patients.

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APPENDIX 10

G. Panzram and R. Zabel-Langhennig, ‘Epidemiologie und Prognose des Diabetes mellitus’, in Diabetes mellitus: Ein Nachschlagewerk für die diabetologische Praxis, Third Edition, ed. by Horst Bibergeil (Jena: Gustav Fischer Verlag, 1989), pp. 145-165 (p. 147). This is a table of diabetes prevalence in several countries based on data from screenings or national registers. It was based on statistics produced for the WHO Study Group on Diabetes Mellitus in Geneva (1985). The GDR’s national diabetes register indicated that 374 out of 10,000 had diabetes in 1984, which is 154 more than in 1972 (see Appendix 5). Another state socialist country, Yugoslavia, also produced similarly comprehensive data, resulting in a slightly higher rate than the GDR. Clearly, the scope of data collection varied significantly from country to country making it difficult to assess how the GDR ultimately measured up in terms of diabetes prevalence.

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