Early 20th century saw the outbreak of a deadly mysterious disease, pellagra that could cause anything from fever to dementia to death. The disease that had killed over 100,000 people by the end of 1914 was shrouded in deep mystery because of the fact that the epidemic was largely limited to the South and was exclusively affecting the peasant class. It was indeed a poor man's disease and conventional wisdom suggested it had something to do with sanitary conditions.
"Pellagra, a classic dietary deficiency disease caused by insufficient niacin, was noted in the South after the Civil War. Then considered infectious, it was known as the disease of the four Ds: diarrhea, dermatitis, dementia, and death. The first outbreak was reported in 1907. In 1909, more than 1000 cases were estimated based on reports from 13 states. One year later, approximately 3000 cases were suspected nationwide based on estimates from 30 states and the District of Columbia. By the end of 1911, pellagra had been reported in all but nine states, and prevalence estimates had increased nearly ninefold. During 1906- 1940, approximately 3 million cases and approximately 100,000 deaths were attributed to pellagra." (5)
At that time, physicians attributed massive impact of the disease on its contagious and infectious nature, something that had hitherto been unexamined by the medical circles or research groups. The worst hit area was Mississippi where it appeared that the incidence of pellagra increased every time cotton prices went down and every time flood hit the Mississippi coast.
"In 1915, the Mississippi State Board of Health captured the nature of the medical crisis by reporting that during the previous year, pellagra had "caused more deaths than typhoid fever, smallpox, measles, scarlet fever, influenza, epidemic cerebrospinal meningitis, and acute poliomyelitis combined." (Harkness, 1996)
Alan Kraut's book, 'Goldberger's War: The Life and Work of a Public Health Crusader' studies the outbreak of pellagra and the efforts made by Dr. Joseph Goldberger to offer correct etiology and cure for the same. What began as a medical war against pellagra turned into a personal crusade against poverty and political manipulation. Goldberger had never imagined that a disease that had become "the scourge of the South" (p. 97) and whose correct causes and cure every politician in the country was apparently seeking could become a contentious and controversial political issue when correct etiology was offered.
Kraut draws heavily upon Goldberger's letters to his wife, Mary, histories by Elizabeth W. Etheridge and Daphne A. Roe and Goldberger's previous published work to convince the reader of the sincerity and selflessness of a public health crusader who worked hard for complete eradication of a fatal poor man's disease.
Goldberger's belonged to the group of people who called themselves progressives and it was this one belief he shared with his father-in-law as Kraut states: "The compassionate and rational approach to public policy that characterized Progressivism was a bond that overcame the men's differences in region and religion." (206). While the Southern elite, some women groups and even black attorneys tried to stop Goldberger for offering an etiology and cure grounded in food and nutrition, it was essentially due to Progressives that Goldberger managed to advance his research on the disease.
The year 1914 marked the official beginning of this crusade when U.S. Public Health assigned Joseph Goldberger to task of studying pellagra's causes and to explain its presumably infectious nature. During the first three weeks of his research, Goldberger carefully observed pellagra-infected patients and their environment.
By the end of the research, he came up with four extremely important observations. He noticed that a) all pellagra patients belonged to rural areas b) poverty played an important role c) poor diet was the most influential factor and d) none of the nurses or doctors had contracted the disease. Goldberger findings proved the disease was not contagious and was closely associated with "three-m diet -- meat [salt pork], meal [cornmeal], and molasses [especially sorghum]" (222)
Goldberger found that immunity of hospital staff was connected with proper diet and the ability to choose from variety of nutritional items. He discovered that quantity of food intake was not as important in this case as the variety and choices of meals available: "But healthy choices depend on knowing what is healthy, being able to afford a nutritious diet, having access to wholesome and nutritious food, and, finally, being willing to alter old eating habits, many of them deeply rooted in ethnic or regional traditions and ensnared in complicated webs of class behaviors." (p. 3).
In short, Goldberger offered the hypothesis that pellagra with a high morality rate was actually not caused by any germ as was previously believed. Instead poor three-m diet was mainly responsible for the outbreak. "In linking pellagra to a faulty diet (later identified by other researchers as a niacin deficiency), Goldberger dramatically swept aside the common belief that this was but another infectious disease whose etiology would be unraveled by microbiology."
This theory however did not gained quick acceptance in the South because of various political reasons and the fact that it was offered by a Northerner only angered Southerners further. In those days, the sanity or germ theory appeared more scientific and less politically problematic; thus Southern elite tried to instigate the public against Goldberger's hypothesis to deflect charges against South's poverty-ridden socio-economic environment.
However Goldberger continued his Progressive struggle against poverty and was helped by other like-minded people on his way. One such person was Earl Brewer, Mississippi governor who ignored the elitist protests and granted Goldberger the permission to recruit twelve prison inmates for a human experiment.
The fact that Goldberger's research included human experimentation and often put helpless people like asylum and prison inmates and orphans at risk is probably the most disturbing aspect of the crusade. For example from 1915 to 1926, inmates from Georgia state asylum were repeatedly used for human experiments. These mentally deranged black women "had little choice about whether they would participate," and this makes Goldberger's research ruthlessly ambitious.
In 1915's experiment with Rankin Prison Farm inmates, Brewer offered complete pardon to these human subjects at the end of the experiment in his attempt to help Goldberger discover the cause and cure since Mississippi had been badly hit by the disease. During this experiment, subjects were kept in clean environment. They were given three-m diet consisting of biscuits, grits, rice, beans and yams. After the 9-month study, 6 out of 11 inmates were found infected with pellagra. While a quick resumption of proper nutritional diet cured all infected inmates, this experiment resulted in massive political uproar and public outcry.
Brewer was accused of staging the whole drama to release two prisoners who were his friends and Goldberger was accused of torturing the innocent helpless people. In Goldberger's defense, Kraut maintains that the man accidentally stumbled upon explosive issue i.e. politics of social and economic deprivation. While Progressives tried to help the federal agencies and people like Goldberger in their crusade against poverty, Southern elite simply refused to accept his poor diet hypothesis sparking massive political controversy.
"Because pellagra's victims were poor and socially unconnected, Goldberger's original cure, a diet rich in lean meat, eggs, and milk, was considered unacceptable because it was too expensive. Returning to the federal government's Hygienic Laboratory in Washington, Goldberger validated a model of the disease in dogs and showed that brewer's yeast, at pennies a day, could do as well as the expensive diet. Political barriers, however, impeded the adoption of this inexpensive remedy. The result was that the total conquest of pellagra was delayed until 25 years after Goldberger's discovery of a cure and ten years after his death." (Roth, 2004)
It is indeed tragic to learn that Goldberger's research was so badly affected by political issues…