WEEK
8
“The Rest of the World Will Be Dead”

Ownership of a good milch cow is a valuable means of . . . preventing pellagra, and should be encouraged to the utmost.
—Dr. Joseph Goldberger

“You want me to fly to South Carolina to talk to a book club? Come on, Michael, I’m trying to bake bread here.” Not to mention hang on to my day job, from which I’d have to take two days off for this event. I had never turned down a request from my publicist, but this one seemed a little unreasonable (nearly as unreasonable as my excuse).

Until he explained that it wasn’t just a book club. It was all of the book clubs in the Charleston area, some seven hundred readers, and the event was their annual luncheon, the literary/social event of the year. They needed a last-minute replacement for Khaled Hosseini, whose novel The Kite Runner had earned more than the gross national product of his native Afghanistan and was about to be released as a movie. Talk about a drop in marquee value!

“No one will even know who I am,” I protested.*

“They will when you’re done.” Spoken like a true publicist.

Which is how I found myself, seminauseous with stage fright, sitting at a long table with three best-selling authors, all of whom had shared the experience of looking down from the lofty perch of the top—the very top, number one—of the New York Times bestseller list. How to open this fifteen-minute talk had been weighing on me for the entire week. I’d arrived in Charleston the day before and spent hours walking around the beautiful city, admiring its architecture, its gardens and old churches, and its waterfront but not enjoying any of it, owing both to nerves and to the fact that I didn’t have an opening for my talk. As for the gardens, I’d never seen private gardens like these. Everyone in this city was a gardener, and a damned good one at that. What could I (an interloper from New York, no less) tell this southern audience about gardening?

Although my public speaking to date had been limited to places like Florida, New York (which is a town, not a typographical error), in front of barely enough people to field a baseball team, I had learned the importance of grabbing the audience in the first thirty seconds, or you’re toast.

The problem was, I didn’t want to talk about growing tomatoes; my mind was occupied with something else entirely. And it had to do with a slip of paper I had tucked away and recently found in my desk. A single word was written on it: “pellagra.”

I wanted to tell the Charleston gentry how fortunate they were to be here at all; how as recently as seventy years ago, the bread that the people of South Carolina were eating was responsible for skin lesions, insanity, and death. That people with full stomachs were mysteriously dying of malnutrition. That governors of this proud state were both the fiercest critics of the New Yorker who saved thousands of South Carolinians’ lives and the first to adopt his cure. This event had brought me to ground zero of one of the most fascinating epidemiological stories in our nation’s history. I hadn’t figured all of it out yet myself—especially the bread part—but I was starting to put the pieces together.

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If you’ve ever been in the American South, one of the first things you notice is that people are big. Traveling through Alabama, South Carolina, Georgia, Mississippi, the places where most of college football’s offensive linemen seem to come from, you don’t see a lot of people, black or white, rich or poor, who seem malnourished. Yet many of these people are the grandchildren and great-grandchildren of the tenant farmers and mill workers who died by the thousands of malnutrition in the richest nation in the world in the first quarter of the twentieth century.

The disease they were dying from was pellagra. This was the reason, remember, cited by the King Arthur Flour Baker’s Hotline for the presence of niacin in every bag of flour and every loaf of bread sold in the United States. Although seen occasionally in Italy for centuries, pellagra was relatively unknown in the United States until about 1908 and even then was largely confined to the South, where it was known as the disease of the four Ds: dermatitis, diarrhea, dementia, and death. Much like AIDS in the 1980s, it arrived on the scene as a mystery disease. There seemed to be no rhyme or reason to why one neighbor caught it and another did not. If contracted, it was horrifying. The first symptoms were often a severe dermatitis—a rash on the face, arms, and hands—which was followed by diarrhea and, when the illness progressed, severe dementia. The lucky ones reached the fourth D and died.

Because pellagra was most frequently found among poor Italian peasants who subsisted mainly on polenta and, in this country, among poor Southerners who consumed large amounts of corn in the form of grits, corn bread, and mush, it was widely believed to be caused by ingesting an unidentified fungus that grows on corn. This seemed reasonable because another fungus, called ergot, which grows on rye and other grains, was known to cause similar skin and psychological symptoms (later in the century, chemists would isolate LSD from ergot).

By 1914, pellagra, almost unknown in America five years earlier, was the second-leading cause of death in South Carolina. In just five southern states, the mystery disease was killing some four thousand people a year and infecting hundreds of thousands more. The government convened a blue-ribbon panel of scientists that discounted the corn connection, concluding that pellagra was caused by an infectious disease carried by a microorganism. Their reasoning? In the southern United States, pellagra was a common condition in prisons, insane asylums, and orphanages, whose residents lived in close quarters, often without proper sanitation. But which microorganism, and how to fight it, they couldn’t say, so the U.S. Public Health Service, initially slow to wake to the worsening epidemic, put their best man on the job.

That would be Dr. Joseph Goldberger, a Jewish immigrant from Hungary raised on New York’s Lower East Side. Goldberger had built a reputation for himself in combating the infectious diseases of the day—yellow fever, dengue, typhus, diphtheria—yet he was shocked by what he saw in the Carolinas, Mississippi, Alabama, Georgia, and Kentucky: orphans with cracked, hardened skin covered with lesions so severe they could not use their hands; asylums filled with skeletal figures staring through hollow eyes, disfigured, without bowel control, and insane.

Something else struck Goldberger. Wherever he saw pellagra, he saw cotton. As far as the eye could see, cotton, growing right up to the front steps of the wretched shacks of their sharecropper owners. The South was a cotton economy. If you didn’t grow it, you worked with it in the mill. Sharecropper or miller, you barely made a living, and you spent what little money you made on the overpriced food at the company store. Under pressure to increase production, every available square foot of land was planted with cotton, as home vegetable plots were squeezed out and orchards cleared.

Goldberger also noticed that pellagra struck in clusters. At one Jackson, Mississippi, orphanage that Goldberger visited, he found that 168 of the 211 children had the disease. It was like the plague. Except for one troubling detail: all of the staff, many of whom spent up to fourteen hours a day with their patients—even sleeping in the same dormitory—were healthy. Odd, this didn’t act like the plague.

Goldberger became convinced that a dietary deficiency, not infection, was the culprit. He tested his theory by performing an experiment at two orphanages in Mississippi, adding a daily ration of fourteen ounces of milk to each child’s diet.* Within weeks, the telltale rashes started to fade.

Anticipating that skeptics would claim that some other unknown factor might have been responsible for the apparent cure, Goldberger designed another experiment, the converse of the orphanage trial. To absolutely prove that pellagra was a nutritional deficiency, he devised an experiment to induce pellagra by putting volunteers on a deficient diet. Goldberger’s first challenge in conducting this clinical trial, which would be nearly impossible to replicate in our current age of institutional review boards and federal guidelines, was finding recruits. Imagine trying to sign up volunteers today for a study in which you attempt to induce AIDS; pellagra had the same social stigma in 1915.

Goldberger found his volunteers at Rankin State Prison Farm, eight miles east of Jackson, Mississippi, where the governor’s promise of parole at the conclusion of the six-month experiment was enough incentive for twelve inmates—half of them convicted murderers serving life sentences—to accept the risk. The political risk for Governor Earl Brewer was almost as great. Releasing a half-dozen murderers to the streets was as unpopular then as now, but Brewer knew his state was in trouble: the incidence of pellagra was up 50 percent over the previous year, with no end in sight.

On April 19, 1915, Goldberger put the twelve inmates on a diet similar to that which he’d seen at the orphanages: biscuits, grits, gravy, corn bread, coffee, and fried mush made from cornmeal. The only vegetable was cabbage, most likely included to prevent scurvy. Within weeks, the inmates reported feeling listless, but there was no trace of pellagra. Four months passed—still no pellagra. Goldberger was growing despondent. The trial was nearing its end, and he was only six weeks away from going home disgraced, when pellagra appeared in one of the prisoners. Then another, and another. Goldberger brought in independent doctors to confirm the diagnosis: half of the inmates had pellagra.

It was a complete triumph for Goldberger, yet the essential question still remained: What vitamin (the term was just coming into vogue) were these pellagrins lacking? Or put another way, what vitamin in a healthy diet (including milk and fresh vegetables) was the pellagra preventative (what Goldberger called the PP factor)? Other mysteries swirled. Why had pellagra increased in incidence so much in recent years? And why in particular was it hitting cotton workers so hard? Much work remained to be done, and Goldberger was ready to dig in, but unbelievably, the debate over pellagra’s cause was not yet over.

The “infectionists,” the infectious disease proponents, were not giving in. They conceded that the test diet was deficient but argued that it had simply weakened the inmates to such an extent that it made them susceptible to contracting pellagra from whatever microorganism carries it. Why were scientists and politicians so determined to cling to the infectious disease theory? Historians have speculated that to acknowledge that the pellagra epidemic was caused by malnutrition was to admit that the South couldn’t feed its people. Only fifty years removed from slavery, the New South, driven by leaders like Huey Long and culturally active cities like Charleston, was trying to rebuild its image, to gain the respect of not only the North but the rest of the world. The embarrassing fact that malnutrition was indirectly the second-leading cause of death of South Carolinians was not the story they wanted to tell the world or even themselves. And they certainly did not want to hear it from a New York Jew, particularly one who was becoming increasingly vocal about the social causes of the disease, indicting the sharecropper system and the monoculture of King Cotton, which had pushed out local vegetable farms. The angry citizenry of one Georgia city telegraphed their senator: WHEN THIS PART OF GEORGIA SUFFERS FROM A FAMINE THE REST OF THE WORLD WILL BE DEAD.

They were confusing famine with malnutrition.

Goldberger had had enough of these attacks. He devised a desperate experiment to shut up these “blind, selfish, jealous, prejudiced asses,” as he described them, once and for all. If pellagra was infectious, then he would do everything in his power to contract it. First he gave himself a blood transfusion from a pellagrin. Then he ingested scrapings taken from several victims’ open sores. Not dead yet, he and fourteen other volunteers (including his wife, who insisted on joining him) made up dough “capsules,” flour balls mixed with festering skin lesions, nasal secretions, blood, and even diarrhea from active pellagrins—worse, even, than eating at, say, your local fast food joint—and washed it all down with bicarbonate of soda. Goldberger hosted five of what they called their “filth parties” (what else they did at these parties was not documented).

This is beyond remarkable—even putting aside the volunteers’ enormous faith in Goldberger’s pellagra theory, consider the diseases they could have contracted from these weakened, immune-suppressed pellagrins! Yet not one of the sixteen party-goers displayed any pellagra symptoms. After the final gathering, Goldberger wrote in his journal, “Never again.”

The experiment had its intended effect. The infectionists were quelled (for the most part; some clung to their beliefs into the late 1930s). Now Goldberger could turn his attention to the real mystery: What substance—vitamin or mineral—was lacking in the pellagrins’ diet? What was the elusive PP factor? More dietary experiments determined it was present in great quantities in dried yeast, a food that could be manufactured cheaply, and by persuading the Red Cross to distribute yeast as a food supplement after a 1927 flood devastated impoverished areas of coastal Mississippi, a tragic pellagra epidemic was avoided.

Still, even though a preventative was known, the disease continued its rampage, peaking in the Depression years of 1929 and 1930, when pellagra, no longer confined to the rural South, claimed two hundred thousand victims. Unfortunately, Goldberger would never live to learn the identity of his PP factor, for he died young, not of typhus or diphtheria or yellow fever or dengue or any of the other dangerous tropical diseases he exposed himself to in the service of this nation’s health, but of cancer, at the age of fifty-four. Precisely my age as I faced this group of South Carolinians. And like Goldberger, a New Yorker among Southerners.

I was still working out the connection between pellagra and bread, but I would’ve loved to tell this story of an unsung American hero to the seven hundred people seated in front of me. Some of them might well have had living relatives who remembered when South Carolina became the first state in the nation to mandate the enrichment of bread and flour, but I knew this group was hoping for a lighthearted talk on gardening. I heard my name spoken, followed by polite applause (naturally—Charleston has been named the most polite city in the United States), and I walked to the lectern. I had never found a satisfactory opening, so I decided to just speak the truth and tell them what had been troubling me about the talk I had to give.

“Yesterday I had a chance to walk through your beautiful city for a few hours,” I began nervously, my New York accent hanging heavy over the enormous hall. “And do you know, I counted approximately one thousand three hundred and thirty-seven gardens?” I paused. “Each one nicer than mine.”

They roared in appreciation. The rest was easy.