Pellagra, a disease which is characterized by diarrhea, dermatitis, dementia, and finally, death (the four D’s), is believed to have been first described by Gasper Casal, a doctor in Asturias, Spain, in 1735. It was seen in southern Europe and the Mediterranean area for two centuries before it appeared in the United States. In 1906, it was described in America, where it quickly became an epidemic. From 1906 until 1940, there were over three million cases and at least 100,000 deaths from the disease.
It is now known that pellagra is caused by a deficiency of Niacin, or Vitamin B3. It is easily treated and cured with dietary supplementation of the vitamin. However, pellagra was a mystery at the time of the epidemic. At first, doctors looked to historical opinions that had developed in Europe, thinking that pellagra was caused by ingestion of spoiled corn. By the 1910’s, however, the opinion developed among medical experts that pellagra was an infectious disease. In 1912, the privately endowed Thompson-McFadden Commission sent researchers to Spartanburg, South Carolina, to investigate the epidemiology, or causes, distributions, and patterns of development, of pellagra.
After several years of surveys, the Thompson-McFadden researchers concluded that pellagra was an infectious disease, and was related to the poor sanitary conditions of the South. However, this conclusion was soon to be proven wrong.
In 1914, Dr. Joseph Goldberger, a physician and epidemiologist, was assigned by the Surgeon General to study pellagra. Goldberger had observed the progression of the disease in mental hospitals, cotton mill towns and orphanages, and he was convinced that the origin of pellagra was not infectious, but was instead related to diet. To test his hypothesis, he first did a prospective treatment study in a Mississippi orphanage. He used two wards for the experiment, starting an enriched feeding program on one ward that included meat, milk, eggs and vegetables, and keeping the other ward with its former diet as the control group. Pellagra disappeared in the ward with the enriched feeding, but remained the same in the control ward.
In his second experiment, Goldberger actually tried to produce pellagra in his human subjects. In the Rankin Farm experiment, eleven Mississippi convicts in prison agreed to follow a special diet for six months in exchange for their freedom. The diet consisted of biscuits, grits, corn bread, cabbage, sweet potatoes, rice, syrup and coffee. By the fourth month on the diet, the prisoners were too weak to work, and five of the eleven men had developed pellagra.
Goldberger also did experiments on himself and on co-workers to show that pellagra was not an infectious disease that could be transferred from one person to another. He and his associates did studies with dogs, and in 1926, the preventive factor of pellagra, while not specifically isolated, was found to be a member of the B-group of vitamins. Dr. Goldberger died in January of 1929, and the exact curative factor for pellagra had not yet been found.
During the time that Goldberger was doing his research, some efforts were being made to ameliorate the pellagra epidemic that were based upon his dietary theories. He proposed the distribution of yeast extract supplements, which contained B vitamins, throughout Red Cross Stores in the South. However, the Red Cross Stores had gained a bad reputation among many of the poor blacks because of incidents that occurred after the great floods of 1927. In his book, “Blues Fell This Mornin’”, Paul Oliver, historian and biographer of the blues musical genre, describes how “Negroes who entered the Red Cross food stations were seized and put into forced labor…Negro refugees under armed guards did the entire work on the Vicksburg levees and the treatment of the suffering homeless people was less than human.” A prison song sung by farm labor inmates, “Cornbread, meat and black molasses”, describes fairly accurately the pellagra-generating diet that was consumed by many of the South’s poor.
After Dr. Goldberger’s death, the specific vitamin deficiency responsible for causing pellagra was finally isolated and found to be nicotinic acid, or niacin. Conrad Elvehjem, a professor of agricultural chemistry at the University of Wisconsin, found that nicotinic acid cured black tongue disease in dogs, a disease that was considered to be analogous to pellagra. Soon thereafter, researcher Tom Spies discovered that niacin also cured pellagra in humans.
At this point, one might well wonder why pellagra became such a serious epidemic in the American South in the early 1900’s, when cultures in other areas ate a similar, corn-based diet, but did not get sick. In Mexico, for example, and among many Native American tribes, corn was the main ingredient of the diet. The answer lies in the way these people processed their corn. The American farmers had brought with them the corn milling methods of the Old World, including southern Europe, where pellagra had flourished in past centuries. In the Old World methods (which were actually technologically more advanced), corn was not treated to free protein-bound niacin. However, Mexicans and Native Americans knew the secret of nixtamalization, or the cooking and steeping of corn in alkaline water. This alkaline water processing releases the niacin in mature corn that is bound to proteins, making it available nutritionally.
During the course of his work with pellagra, Dr. Goldberger met with some resistance from Southern politicians and wealthier Southerners because they were in denial about the problem of malnutrition. There was also social stereotyping of the Southern poor as being “lazy”. This may have been the reason why pellagra was first studied as a possible infectious disease, so that the occurrence and spread of the disease could be blamed on such factors as bad sanitation and the general “dirtiness” of the poor. In fact, most of the Southern poor simply could not afford a good diet, or did not have consistent access to nutritious foods. Besides niacin, proteins containing the animo acid, tryptophan, are also important in preventing the disease. However, once it was found that niacin deficiency was the key cause of pellagra, flour producers began to enrich both white and corn flour with the vitamin, and because of this, the distribution of brewer’s yeast, and increasing prosperity after World War II, the pellagra epidemic finally came to an end.
If left untreated, pellagra will cause death within four to five years. Foods high in niacin are beef liver, red meat, fish, eggs, milk, sunflower seeds, fortified breads and cereals, legumes, and of course, brewer’s yeast. Since pellagra is a disease of malnutrition, it still exists in poor areas of the world today. In Africa, the Republic of Angola, which has been at war for decades, has had many clinical cases of pellagra due to conditions of poverty and war. As it did in the American South in the early 1900’s, the serious public health problem of pellagra still serves as a barometer that measures the terrible effects of war, poverty and malnutrition on the ability of people everywhere to lead civilized and empowered lives.