1 00:00:06,960 --> 00:00:12,600 JEREMY: Hello and welcome to another episode of Eat This Podcast with me, Jeremy Cherfas. 2 00:00:14,320 --> 00:00:21,360 This is the last episode in the current series, and I'm taking the opportunity to look closely at a problem of food 3 00:00:21,480 --> 00:00:30,520 and ill health, which I think is a cracking example of the huge difficulty involved in answering what seems like a very simple 4 00:00:30,520 --> 00:00:38,760 question: what causes a disease? To help me, I spoke to David Gentilcore, 5 00:00:38,800 --> 00:00:43,160 a professor of early modern history at Ca' Foscari University in Venice, 6 00:00:43,320 --> 00:00:51,680 and Dana Landress, an assistant professor in the Department of Medical History and Bioethics at the Department of History at the University 7 00:00:51,680 --> 00:01:00,080 of Wisconsin, Madison. The disease in question is pellagra, and they studied it in Italy and in the US. 8 00:01:00,080 --> 00:01:06,420 P ellagra used to be very serious, although you may not have heard of it. 9 00:01:07,060 --> 00:01:15,740 DAVID GENTILCORE: At one point in the 1880s, it was affecting 100,000 people, but those are 100,000 documented cases. 10 00:01:15,740 --> 00:01:21,260 That means 100,000 peasants who've gone to see their doctor and the doctor has made a note of it, 11 00:01:21,300 --> 00:01:24,540 you know, provided this data to the authorities. 12 00:01:24,540 --> 00:01:28,780 So we can imagine that was only the tip of the iceberg. 13 00:01:28,980 --> 00:01:32,420 So that would have been the 1880s, 1890s. 14 00:01:32,700 --> 00:01:39,260 And that's when admittance to the insane asylums in northern Italy also reached their peak. 15 00:01:39,540 --> 00:01:45,060 So basically half of the inmates of these asylums would be suffering from pellagrous insanity. 16 00:01:45,860 --> 00:01:46,900 JEREMY: And in the US. 17 00:01:47,260 --> 00:01:53,700 DANA LANDRESS: It is one of the leading causes of morbidity and mortality across the South in the early 20th century. 18 00:01:53,860 --> 00:02:02,230 And so, for instance, in Alabama there are a number of years in the 1910s where it is the leading cause of death. 19 00:02:02,230 --> 00:02:06,590 In South Carolina, it ranks as top three, and in places like Louisiana, 20 00:02:06,590 --> 00:02:09,230 it ranks as top four causes of death. 21 00:02:09,350 --> 00:02:19,070 But for the most part, that data is concentrated on urban areas that are collecting sort of epidemiological tracking data at these and sort 22 00:02:19,070 --> 00:02:23,670 of major urban areas like New Orleans, like Spartanburg, South Carolina, 23 00:02:23,910 --> 00:02:29,310 like Atlanta. But we know that this is a disease that impacts rural communities as well. 24 00:02:29,310 --> 00:02:38,270 And we have rough estimates from the US Public Health Service data, which suggests that pellagra was impacting about 100,000 people per 25 00:02:38,270 --> 00:02:43,310 year up until about the mid 1940s. So the kind of end of the world Second World War. 26 00:02:43,670 --> 00:02:50,590 JEREMY: Note that date. Not that long ago. And yet, from being a scourge less than a century ago, 27 00:02:50,910 --> 00:03:00,650 pellagra is now almost unheard of. Today, we know for 28 00:03:00,650 --> 00:03:06,290 sure that at one level at least, the cause of pellagra is a lack of vitamin B3, 29 00:03:06,450 --> 00:03:12,410 known as niacin. But there are many other ways to think of the cause of the disease, 30 00:03:12,490 --> 00:03:14,650 which is what this episode is all about. 31 00:03:17,050 --> 00:03:25,250 Anyway. Pellagra was first described in 1735 among poor peasant farmers in northern Spain. 32 00:03:25,490 --> 00:03:32,650 And in Italy, in the 1760s, they tended to say that it first appeared about a generation ago, 33 00:03:32,890 --> 00:03:37,810 so maybe the 1740s. But what is pellagra? 34 00:03:38,490 --> 00:03:44,690 DAVID GENTILCORE: The first apparent symptom, and what gives the name to the disease in Italian, 35 00:03:45,650 --> 00:03:53,650 is the peeling off of the skin from the upper chest, the forearms and the lower legs. 36 00:03:54,090 --> 00:03:57,210 But it's more than just like, you know, a sunburn. 37 00:03:57,260 --> 00:04:00,300 It's actually the whole epidermis peeling off. 38 00:04:00,940 --> 00:04:04,892 Very painful, leaving scarring underneath. 39 00:04:04,892 --> 00:04:13,220 Gives the name pellagra -- pelle agra, meaning rough skin -- which is essentially what the peasants called 40 00:04:13,220 --> 00:04:22,100 it. And it's curious, it's one of those rare cases where a peasant name for a disease becomes the official medical name for the disease, 41 00:04:22,100 --> 00:04:28,580 since it was a new disease and there was no medical, you know, no fancy Latin or Greek name for it. 42 00:04:28,940 --> 00:04:33,900 DANA LANDRESS: Clinicians typically call it symptoms the four D's diarrhoea, dermatitis, 43 00:04:33,900 --> 00:04:36,820 dementia, and, if left untreated, death. 44 00:04:37,260 --> 00:04:43,020 JEREMY: Not nice at all. The big question, of course, was what exactly was pellagra? 45 00:04:43,340 --> 00:04:46,100 DAVID GENTILCORE: You remember the initial phases of Covid. 46 00:04:46,900 --> 00:04:51,300 You know, if we're going to get anywhere with this, we need to know exactly what it is. 47 00:04:51,340 --> 00:04:56,640 And obviously in the 1760s, there is no way other than observation. 48 00:04:57,800 --> 00:05:06,360 They are very good, very, you know, good observers, trying to create a clinical picture of the disease. 49 00:05:06,480 --> 00:05:13,560 So they're very attentive. But the key issue for them is how to classify, 50 00:05:13,560 --> 00:05:15,760 what kind of disease ... Is it even new? 51 00:05:16,080 --> 00:05:18,080 Has it already existed? But we just didn't know. 52 00:05:18,120 --> 00:05:21,760 Is it a form of leprosy? Is it a form of scurvy? 53 00:05:22,560 --> 00:05:32,000 Is it a form of ergotism? And then, no, no, it's symptoms don't fit in with any of these. 54 00:05:32,880 --> 00:05:38,960 So it must be new. Okay, so if it's new, what exactly is it? 55 00:05:39,560 --> 00:05:41,320 And then, what do we do about it? 56 00:05:42,240 --> 00:05:51,240 JEREMY: One early clue was that it was associated with maize, and also that it seemed to afflict only very poor people. 57 00:05:51,760 --> 00:05:59,610 Maize, remember, was still a relatively new crop in Europe, one that farmers had taken to with enthusiasm. 58 00:05:59,770 --> 00:06:04,130 DAVID GENTILCORE: Maize is a fabulous crop. I mean, it grows where other crops won't. 59 00:06:04,530 --> 00:06:07,810 It has a shorter growing season than, say, wheat. 60 00:06:08,770 --> 00:06:18,650 It has really high yields. But where people want to turn it into flour and where 61 00:06:18,650 --> 00:06:22,290 they consume it in the form of polenta, that's what causes it. 62 00:06:22,730 --> 00:06:28,730 I mean, in terms of the social classes, we're essentially talking about landless labourers, 63 00:06:29,810 --> 00:06:38,690 landless peasants, field hands, tenant farmers, and people who don't really have much choice what to grow. 64 00:06:39,650 --> 00:06:46,090 Because if you're only growing that and maize becomes a cash crop, so you want to grow it. 65 00:06:46,370 --> 00:06:55,230 You know, it makes economic sense, but maybe at the expense of growing just other fruits and vegetables, 66 00:06:56,070 --> 00:06:58,310 which would have staved off pellagra. 67 00:06:59,110 --> 00:07:07,750 By the 1790s early 1800s, it's clear there's a link between maize cultivation, 68 00:07:08,990 --> 00:07:14,590 diet, and this new disease. They don't know what the mechanism is yet. 69 00:07:14,590 --> 00:07:18,630 They don't know what the link is. They don't know what the causal relationship is yet, 70 00:07:20,150 --> 00:07:30,110 but they see a correlation. And then you get two big theories emerging by the middle of the 19th century, 71 00:07:30,110 --> 00:07:32,390 which they fight it out for decades. 72 00:07:32,870 --> 00:07:39,150 JEREMY: In some respects, it's a bit of an unfair fight because the competitors are pretty badly matched. 73 00:07:39,790 --> 00:07:49,390 DAVID GENTILCORE: On the one hand, you have Cesare Lombroso, infamous founder of anthropological criminology 74 00:07:49,910 --> 00:07:54,680 and Lombroso is the most famous scientist in Italy. 75 00:07:55,000 --> 00:08:02,360 Yeah. He's the second most read Italian author after Collodi, who wrote Pinocchio. 76 00:08:02,400 --> 00:08:08,520 Right. So he's very, very famous. He's a tireless correspondent. 77 00:08:08,520 --> 00:08:14,520 And as soon as you attack him, the very next day, he's got a counterattack in some local newspaper. 78 00:08:14,720 --> 00:08:16,560 You know, he never lets up. 79 00:08:16,680 --> 00:08:22,240 JEREMY: So that's Lombroso, super famous, super pugnacious and super wrong. 80 00:08:22,480 --> 00:08:24,080 But I'm getting ahead of myself. 81 00:08:24,640 --> 00:08:29,280 DAVID GENTILCORE: He posits that it's tainted maize. That's the problem. 82 00:08:29,280 --> 00:08:35,360 It's infected maize, a bit like ergotism and rye, okay. 83 00:08:35,400 --> 00:08:38,520 In ergotism it's a fungus that attacks the rye. 84 00:08:38,960 --> 00:08:45,360 He posited something like that. He even in in his laboratory in the 1890s, 85 00:08:45,360 --> 00:08:50,440 he claimed to have discovered something which he called pellagrosine. 86 00:08:51,440 --> 00:08:55,100 He even gave it a name and said, this is the causal agent. 87 00:08:55,620 --> 00:09:03,020 All we have to do is eliminate this fungus from maize, we've solved the problem. 88 00:09:03,660 --> 00:09:08,220 We just make sure that when the maize is harvested, it's fully ripe. 89 00:09:09,140 --> 00:09:12,780 That before it's milled, it's fully dried. 90 00:09:12,820 --> 00:09:15,060 There's no mould or anything on it. 91 00:09:15,300 --> 00:09:21,180 And then when it's made into polenta, we have to make sure the polenta itself doesn't go mouldy. 92 00:09:22,060 --> 00:09:29,540 JEREMY: Lambroso is extremely convincing, not least because anyone can see that when poor peasants make polenta, 93 00:09:29,700 --> 00:09:33,180 what they tend to do is make a big batch once a week. 94 00:09:33,500 --> 00:09:38,180 They have a huge loaf of the stuff, and each meal, everyone gets a slice. 95 00:09:38,500 --> 00:09:44,340 And because polenta is pretty moist, by the end of the week, it is pretty green and furry. 96 00:09:45,100 --> 00:09:54,600 But the real beauty of Lombroso's idea of something toxic in the maize is that it lends itself to simple technical solutions. 97 00:09:55,120 --> 00:09:57,720 DAVID GENTILCORE: So we don't have to eradicate peasant poverty. 98 00:09:57,960 --> 00:10:01,920 We don't have to worry about maize cultivation, production and so on. 99 00:10:01,960 --> 00:10:04,400 It won't attack the financial interests. 100 00:10:05,200 --> 00:10:09,160 JEREMY: His view then was that it was something toxic growing on the maize. 101 00:10:09,520 --> 00:10:15,720 The alternative view, not nearly as simple, was that there was something missing from the diet, 102 00:10:15,880 --> 00:10:18,200 and particularly from maize. 103 00:10:19,000 --> 00:10:25,560 DAVID GENTILCORE: There's something wrong with polenta that doesn't give people adequate nourishment. 104 00:10:25,960 --> 00:10:31,320 There's something deficient, something lacking. 105 00:10:33,080 --> 00:10:38,120 But the people who propounded this view did not have laboratory technology, 106 00:10:38,160 --> 00:10:43,200 didn't even have the language that we have to talk about, I don't know, 107 00:10:43,240 --> 00:10:49,360 proteins, amino acids. That's language that we develop in the early 20th century. 108 00:10:50,200 --> 00:10:53,290 So that explanation wasn't nearly as convincing. 109 00:10:53,810 --> 00:10:58,770 JEREMY: But here's the thing, both Lombroso and his main opponent, Clodomiro Bonfiglio, 110 00:10:59,250 --> 00:11:05,930 are working in insane asylums, which is where most of the really bad cases of pellagra ended up. 111 00:11:06,050 --> 00:11:13,410 Lombroso is in Pavia, near Milan, and Bonfiglio is director of the provincial asylum in Ferrara. 112 00:11:14,130 --> 00:11:17,290 DAVID GENTILCORE: So they have this in common, you know, and they're both ... 113 00:11:17,530 --> 00:11:22,650 It's often, you know, it's easy to depict Lombroso as kind of the bad guy, 114 00:11:23,890 --> 00:11:29,250 you know, but actually both of them are really socially committed. 115 00:11:30,130 --> 00:11:34,530 They have their heart in the right place. They're really working hard to find a cure, 116 00:11:34,530 --> 00:11:36,730 or cause and a cure, for this disease. 117 00:11:37,170 --> 00:11:43,250 It's just that Lombroso, by insisting that his was the only possible explanation, 118 00:11:43,770 --> 00:11:49,170 really throws science, puts science in the wrong direction for, well, 119 00:11:49,170 --> 00:11:51,270 40 years I guess . 120 00:11:52,470 --> 00:11:55,150 JEREMY: We'll come back to Lombroso and his cures. 121 00:11:55,190 --> 00:12:03,910 But there's one final twist from the Italian point of view that has the bizarre effect of putting science in America back 40 years. 122 00:12:08,870 --> 00:12:12,790 There's this chap, Luis Sambon. Half English, half Italian. 123 00:12:13,910 --> 00:12:20,870 He's originally a gynaecologist in Rome, but he goes to London and ends up at the London School of Hygiene and 124 00:12:20,870 --> 00:12:27,350 Tropical Medicine. There he comes under the spell of people like Sir Ronald Ross, 125 00:12:27,390 --> 00:12:33,390 and the idea that diseases like malaria can be transmitted by insects. 126 00:12:34,790 --> 00:12:39,790 He's also taken up by the wealthy pharmacologist Sir Henry Wellcome. 127 00:12:40,590 --> 00:12:49,190 DAVID GENTILCORE: Wellcome hired him, Sambon, to go off looking for antiquities, because Wellcome was a great purchaser of anything antique, 128 00:12:49,240 --> 00:12:53,440 anything to do with the history of medicine, which he was fascinated by. 129 00:12:54,560 --> 00:13:03,120 And so Sambon would go on these trips to Italy, ostensibly to buy up books and manuscripts and 130 00:13:04,240 --> 00:13:07,240 any ancient artefacts he could lay his hands on. 131 00:13:07,960 --> 00:13:11,760 But he had this passion for pellagra at the time. 132 00:13:12,480 --> 00:13:19,800 He goes to the Roman Campagna to work on malaria with a small group. 133 00:13:20,600 --> 00:13:24,720 He's obviously a brilliant, you know, brilliant ideas person. 134 00:13:25,520 --> 00:13:29,840 And so he simply superimposes one map on top of another. 135 00:13:30,840 --> 00:13:35,120 You know, as an epidemiologist, he's thinking about the geographical spread. 136 00:13:35,120 --> 00:13:44,040 Where does pellagra manifest? Oh, look, there's an insect that has the same more or less the same spread. 137 00:13:44,280 --> 00:13:49,780 It's another case of it being very convincing, Very persuasive. 138 00:13:50,260 --> 00:13:56,900 B ut so is Sambon. He's a very ... You read his articles and you think. 139 00:13:56,900 --> 00:14:00,940 Oh, yeah, that's that's perfectly reasonable . 140 00:14:02,020 --> 00:14:08,620 JEREMY: Sambon's very persuasive theory, that pellagra is caused by a parasite spread by a blackfly, 141 00:14:09,020 --> 00:14:11,620 doesn't get much traction in Italy. 142 00:14:12,020 --> 00:14:14,700 Across the Atlantic, it's a different story. 143 00:14:15,220 --> 00:14:19,220 DAVID GENTILCORE: When pellagra breaks out -- breaks out -- when it appears, first appears in the US, 144 00:14:19,620 --> 00:14:24,940 he's one of the first people they invite over because he seems to have the answer . 145 00:14:24,940 --> 00:14:29,700 A new disease, a new explanation. The Americans love it, you know. 146 00:14:29,860 --> 00:14:33,740 Oh, the Italians have had pellagra for years. They haven't been able to solve the problem. 147 00:14:34,060 --> 00:14:39,220 We need a new approach. It's an off the wall ... 148 00:14:39,220 --> 00:14:45,380 I mean, normally, like I say in one of my publications, he's normally just a footnote in history. 149 00:14:46,140 --> 00:14:52,070 I think it's fascinating that he gains a kind of notoriety for a few years, 150 00:14:53,230 --> 00:14:58,230 and then that's it. He has his, you know, whatever, 15 minutes of fame. 151 00:14:58,230 --> 00:14:59,710 And then, you know. 152 00:15:01,430 --> 00:15:06,830 JEREMY: Of course, when the Americans say that the Italians haven't been able to solve the problem, 153 00:15:07,030 --> 00:15:10,830 they're being very reductionist. The solution is a better diet. 154 00:15:11,310 --> 00:15:13,670 But that isn't a good enough explanation. 155 00:15:13,670 --> 00:15:20,830 It's too fuzzy. Many Italians knew perfectly well that a better diet could reverse the symptoms of pellagra, 156 00:15:20,950 --> 00:15:24,190 though they did also try drugs of different kinds. 157 00:15:24,510 --> 00:15:33,870 Lombroso himself treated it with compounds of lead and arsenic, and he recommended bathing in salt water. 158 00:15:34,350 --> 00:15:39,630 DAVID GENTILCORE: Can you imagine taking a salt bath when your whole, you know, epidermis is peeled off? 159 00:15:39,910 --> 00:15:45,670 How nice that would have been? It wasn't about treating the patients themselves. 160 00:15:45,970 --> 00:15:48,970 Rather, what they thought were the causes. 161 00:15:50,330 --> 00:15:55,730 But if you're saying, okay, the causes are what Lombroso says the causes are, 162 00:15:56,090 --> 00:15:59,810 then we need to treat the causes of tainted maize. 163 00:16:00,130 --> 00:16:03,130 We need to make sure there's no mould on the maize. 164 00:16:03,130 --> 00:16:09,530 So we set up these huge drying ovens for the kernels to dry before they're milled. 165 00:16:09,810 --> 00:16:15,810 Or we set up soup kitchens to ensure the peasants get other foods to eat. 166 00:16:16,450 --> 00:16:19,290 JEREMY: Experimental science did get a brief look in. 167 00:16:19,490 --> 00:16:24,570 One of the places getting good results with a diet was a hospice north of Venice, 168 00:16:24,690 --> 00:16:27,450 where pellagra sufferers were given better food. 169 00:16:27,810 --> 00:16:32,130 Lambroso didn't think too much of that, so he issued a challenge. 170 00:16:32,810 --> 00:16:37,490 DAVID GENTILCORE: The founder of this hospice and Lombroso are corresponding, and Lombroso says, 171 00:16:37,490 --> 00:16:45,010 here, you take 30 of my patients and half of them you treat with the remedies I give you, 172 00:16:46,230 --> 00:16:50,710 the arsenic, the lead and so on. Half you treat however you want. 173 00:16:51,910 --> 00:16:55,190 And so the founder of the hospital's name is Costantigris, he says, okay, 174 00:16:55,190 --> 00:17:01,470 I'll give them the restorative diet that I've come up with, and the other 15 I'll treat. 175 00:17:02,550 --> 00:17:05,750 The 15 he treated with the medicines got worse. 176 00:17:06,430 --> 00:17:11,110 His 15 were all released from hospital, pronounced cured. 177 00:17:11,670 --> 00:17:17,150 And he communicated this to Lombroso, at which point Lombroso stopped writing to him. 178 00:17:17,310 --> 00:17:25,470 So, you know, Lombroso had only one possible solution in mind, and it was medical. 179 00:17:27,030 --> 00:17:31,430 JEREMY: David Gentilcore, a nd I'll be coming back to him in a while. 180 00:17:31,910 --> 00:17:38,230 But it's time to turn now to Dana Landress, because while doctors in Italy and other maize- 181 00:17:38,230 --> 00:17:43,270 growing areas in Europe had become familiar with pellagra by the end of the 19th century, 182 00:17:43,630 --> 00:17:49,800 in the U.S. i t first really becomes apparent in the summer of 1906. 183 00:17:53,760 --> 00:18:02,640 DANA LANDRESS: It's my own view that pellagra was endemic in the US South prior to the first recognition in the summer of 1906. 184 00:18:02,640 --> 00:18:09,160 You have physicians who sort of retroactively write into the US Public Health Service and say, 185 00:18:09,640 --> 00:18:14,040 you know, I was a physician at Andersonville Prison, for instance, during the Civil War. 186 00:18:14,040 --> 00:18:18,920 And I saw this disease that was mysterious in 1864, 1865. 187 00:18:18,920 --> 00:18:22,640 And we only now have the language to be able to diagnose that as pellagra. 188 00:18:22,680 --> 00:18:28,880 Had I known then what I know now, we would have sort of taken different measures amid the war to combat it. 189 00:18:29,360 --> 00:18:34,040 JEREMY: Officials in the U.S. really weren't sure what to make of this new disease. 190 00:18:34,400 --> 00:18:42,560 Beginning in 1909, South Carolina hosted a series of conferences each year with invited international guests, 191 00:18:42,560 --> 00:18:48,060 including Louis Sambon, but five years later there was still no real agreement. 192 00:18:48,300 --> 00:18:51,780 Some people liked Sambon's idea that it was spread by insects. 193 00:18:51,900 --> 00:18:53,860 Others really weren't sure. 194 00:18:54,620 --> 00:19:02,940 DANA LANDRESS: I would sort of suggest that debates over pellagra's etiology really actually come to symbolize the the highly contentious nature of this 195 00:19:02,980 --> 00:19:07,628 epidemic in the United States, which is to say that there is no consensus . 196 00:19:07,628 --> 00:19:15,300 From 1906 to roughly 1914 there are three principal theories that all have traction in U.S. 197 00:19:15,300 --> 00:19:18,660 medical circles. One is the corn toxin theory. 198 00:19:18,700 --> 00:19:21,460 Another is the insect vector theory. 199 00:19:21,900 --> 00:19:27,820 And then, of course, you have the dietary deficiency disease, which is also beginning to gain traction in this period. 200 00:19:27,820 --> 00:19:31,820 And it's a bit amorphous during the first outbreak in 1906. 201 00:19:32,060 --> 00:19:34,540 But those are the primary sort of three theories. 202 00:19:34,660 --> 00:19:37,100 And I would say that there is no consensus. 203 00:19:38,020 --> 00:19:46,630 JEREMY: Into that mess. The young US Public Health Service inserted the man generally accepted as the hero of the story. 204 00:19:47,110 --> 00:19:51,150 DANA LANDRESS: Doctor Joseph Goldberger is appointed, beginning in the summer of 1914, 205 00:19:51,550 --> 00:19:58,590 to do essentially a tour of the southern United States, trying to gain preliminary epidemiological data. 206 00:19:59,310 --> 00:20:05,270 And so as part of this tour in 1914, he begins to track incidents of pellagra at places like state 207 00:20:05,270 --> 00:20:09,030 hospitals, orphanages and asylums. 208 00:20:09,990 --> 00:20:14,550 JEREMY: Goldberger noted that the most severe outbreaks afflicted poor people, 209 00:20:14,590 --> 00:20:17,470 often working in cotton mill towns in the south. 210 00:20:17,910 --> 00:20:21,790 He focused on a couple of orphanages in the Deep South. 211 00:20:22,590 --> 00:20:29,510 DANA LANDRESS: The orphanage study actually takes place at two institutions, two religious affiliated orphanages in Mississippi. 212 00:20:29,710 --> 00:20:34,430 And the idea here really is to design a therapeutic kind of intervention. 213 00:20:34,430 --> 00:20:40,590 And so Goldberger begins tracking how frequently the children are eating the kinds of foods they are eating. 214 00:20:40,710 --> 00:20:44,210 A rough sketch of the kind of caloric intake they're getting on a daily basis, 215 00:20:44,210 --> 00:20:47,970 and he quickly discovers that the food that they are eating is nutritionally replete. 216 00:20:51,090 --> 00:20:55,690 JEREMY: Nutritionally replete. I had to correct my original understanding of the word replete. 217 00:20:56,050 --> 00:20:59,090 It means filled up, but not in a good way. 218 00:20:59,570 --> 00:21:06,010 A nutritionally replete diet is one that fills you up, but that doesn't offer much nourishment. 219 00:21:06,370 --> 00:21:11,850 And Goldberger is really struck by the fact that only the orphans, not the staff looking after them, 220 00:21:11,970 --> 00:21:18,290 get pellagra. So it's unlikely to be either a pathogen or a toxin. 221 00:21:18,810 --> 00:21:25,930 DANA LANDRESS: And he begins to supplement their diet with leafy green vegetables, with lean meats, 222 00:21:26,130 --> 00:21:33,570 with legumes, peas. And he finds that this very quickly remedies the outbreak and that within a year, 223 00:21:33,610 --> 00:21:36,810 neither institution has any new cases of the disease. 224 00:21:36,890 --> 00:21:44,500 So this is kind of the first confirmation that Goldberger has that pellagra might not be infectious. 225 00:21:45,540 --> 00:21:49,540 JEREMY: Of course, the Italian doctors could have told him that a better diet would work. 226 00:21:49,820 --> 00:21:56,980 But Goldberger persevered, and his next experiment was to try and induce pellagra by changing the diet. 227 00:21:57,220 --> 00:22:07,220 DANA LANDRESS: This experiment is conducted with 11 white male convicts at a prison farm in Mississippi that is known as Rankin State Prison 228 00:22:07,220 --> 00:22:11,140 Farm. It's about 20 miles east of the capital of Jackson, Mississippi. 229 00:22:11,540 --> 00:22:20,500 And this is a non therapeutic experiment that is intended to produce pellagra's dermal lesions in convicts by feeding them a calorically 230 00:22:20,500 --> 00:22:23,260 and nutritionally replete diet. 231 00:22:24,100 --> 00:22:28,220 JEREMY: Remember, nutritionally replete means filling but not nourishing. 232 00:22:28,700 --> 00:22:30,100 And it doesn't go well. 233 00:22:30,340 --> 00:22:36,540 DANA LANDRESS: Unfortunately, about three months into the experiment, there are no clinical symptoms of pellagra that are produced among the 234 00:22:36,540 --> 00:22:44,760 convicts. And so Goldberger and his assistant doctor George Wheeler make the decision to actually cut back by about 500 calories, 235 00:22:44,760 --> 00:22:49,840 the amount of food that the prisoners are consuming to try and induce this disease. 236 00:22:50,280 --> 00:22:54,680 JEREMY: The problem turned out to be something extremely mundane. 237 00:22:55,200 --> 00:23:02,880 DANA LANDRESS: We now know that coffee has small trace amounts of niacin, and that the prisoners were actually consuming coffee once, 238 00:23:02,880 --> 00:23:04,080 sometimes twice a day. 239 00:23:04,080 --> 00:23:12,480 JEREMY: And coffee might explain why only six of the 11 prisoners ended up producing definite signs of pellagra. 240 00:23:12,760 --> 00:23:16,960 But it was good enough for Goldberger and for the Mississippi state governor, 241 00:23:17,080 --> 00:23:22,400 who issued the pardons that were promised to the men in exchange for their volunteering. 242 00:23:23,160 --> 00:23:31,400 DANA LANDRESS: In his pardon slips. Governor Brewer describes this as a pardon given for meritorious contributions to public health and to service of 243 00:23:31,400 --> 00:23:32,240 humanity. 244 00:23:32,800 --> 00:23:40,850 JEREMY: Which is all fine and dandy. But a lot of the locals were incensed that these white-collar criminals who happened to be friends of the 245 00:23:40,850 --> 00:23:47,530 governor were now free to rejoin society after just a few months of deprivation. 246 00:23:50,970 --> 00:23:57,090 Leaving that aside, they did help Goldberger to prove his theories, and that was welcomed. 247 00:23:58,170 --> 00:24:07,090 A headline in The Watchman and Southron newspaper in December 1915 announced A Cause and Cure of Pellagra, 248 00:24:07,730 --> 00:24:12,610 and outside the South, colleagues were quick to applaud Goldberger. 249 00:24:13,810 --> 00:24:19,170 DANA LANDRESS: You have many individuals who praise Goldberger very widely for this finding. 250 00:24:19,170 --> 00:24:26,650 They believe that this is the confirmation that the medical establishment needed to understand the etiology of pellagra. 251 00:24:26,690 --> 00:24:34,130 Outside of the South, he is widely lauded for the success of the prison experiment and its implications in this kind of treating 252 00:24:34,130 --> 00:24:34,850 pellagra. 253 00:24:35,130 --> 00:24:39,470 JEREMY: In pellagra's heartland, however, there was opposition. 254 00:24:39,710 --> 00:24:46,950 The very same edition of The Watchman and Southron, right next to its news of the cause and cure of pellagra, 255 00:24:47,270 --> 00:24:55,670 contained a story from a meeting of the Southern Medical Association that spoke of "sharp differences of opinion". 256 00:24:56,470 --> 00:25:04,750 Goldberger needed to prove, beyond a shadow of a doubt, that pellagra was not caused by a pathogen that could be transmitted 257 00:25:04,750 --> 00:25:10,550 from person to person. And so, in the best tradition of medical experiments, 258 00:25:10,750 --> 00:25:13,550 he invited some colleagues to parties. 259 00:25:14,230 --> 00:25:18,630 DANA LANDRESS: These are essentially what are known as the filth parties that are done in Spartanburg, 260 00:25:18,630 --> 00:25:25,910 South Carolina. And so he recruits not only himself and two advisory clinicians from the US Public Health Service, 261 00:25:25,910 --> 00:25:31,270 but also a couple of patients who had been admitted to the hospital at Spartanburg, 262 00:25:31,270 --> 00:25:36,270 South Carolina. And, perhaps most famously, his wife, Mary Farrar Goldberger, 263 00:25:36,270 --> 00:25:41,610 who in being a very devoted spouse wanted to support her husband's research endeavours. 264 00:25:41,810 --> 00:25:47,650 Most essentially, the idea is to provide even more compelling evidence that the disease is not infectious, 265 00:25:47,650 --> 00:25:50,770 but rather caused by by dietary insufficiency. 266 00:25:51,530 --> 00:25:55,370 JEREMY: How did they do that? The clue is in the name. 267 00:25:55,650 --> 00:25:56,930 DANA LANDRESS: The Filth Parties. 268 00:25:56,970 --> 00:25:59,690 JEREMY: And be warned, it gets gross. 269 00:25:59,930 --> 00:26:07,610 DANA LANDRESS: They essentially take the scabs scraped from the dermal lesions of pellagra patients who had been admitted to the Spartanburg Pellagra 270 00:26:07,610 --> 00:26:14,450 Hospital. They take urine samples, they take faecal samples, and they orally ingest them. 271 00:26:15,010 --> 00:26:21,490 A nd, you know, like some of the some of the patients and some of the PHS clinicians report things like a headache or nausea, 272 00:26:21,490 --> 00:26:25,770 which seems fairly mild given the context of the experiment. 273 00:26:27,130 --> 00:26:30,330 E veryone is fine, you know, there are no lasting symptoms. 274 00:26:30,330 --> 00:26:38,580 And again, it's just an attempt to really try and stave away these recalcitrant critics that Goldberger has faced in the southern medical 275 00:26:38,580 --> 00:26:39,420 community. 276 00:26:39,820 --> 00:26:42,940 JEREMY: I think he knew perfectly well what he was doing. 277 00:26:43,220 --> 00:26:48,900 A later newspaper headline said Scientist Risked Death to Give Mankind Life . 278 00:26:49,500 --> 00:26:56,020 But I'm pretty sure that by this stage, Goldberger was certain in his own mind that pellagra was not 279 00:26:56,020 --> 00:27:02,940 contagious. His first subject was himself, alone and in private, and he didn't become ill. 280 00:27:03,980 --> 00:27:11,140 So while Goldberger was praised by colleagues in the North and ultimately nominated for the Nobel Prize four times, 281 00:27:11,380 --> 00:27:14,940 things were not so rosy down in Dixie. 282 00:27:15,660 --> 00:27:19,700 DANA LANDRESS: People like James Haynes, who is the state health officer of South Carolina, 283 00:27:19,740 --> 00:27:22,860 continue to adhere to this insect vector theory. 284 00:27:23,740 --> 00:27:32,380 And as late as the 1950s and 60s, you have individuals in Alabama who still want to suggest that pellagra is 285 00:27:33,700 --> 00:27:38,320 an infectious disease, but that maybe there's some sort of underlying dietary mechanism going on. 286 00:27:38,320 --> 00:27:45,040 And so in very particular kinds of circles in the Deep South, the insect vector theory continues to hold traction for a number of 287 00:27:45,040 --> 00:27:45,720 years. 288 00:27:53,760 --> 00:28:01,240 JEREMY: Like I said at the outset, the way you think about the cause of a disease can determine the way you think about a cure. 289 00:28:01,880 --> 00:28:06,480 So why, when the medical evidence seemed so clear cut to everyone else, 290 00:28:06,680 --> 00:28:09,960 why was Goldberg's explanation rejected? 291 00:28:10,960 --> 00:28:19,600 DANA LANDRESS: Pellagra is bad for business. Pellagra is a disease that has a strong connotation with regional poverty. 292 00:28:19,800 --> 00:28:24,760 It has a strong connotation with lethargy and laziness. 293 00:28:25,360 --> 00:28:31,000 And if you have a workforce that is plagued with a particular disease, 294 00:28:31,200 --> 00:28:38,450 it is much easier to introduce a kind of technical intervention, such as a fly trap or a screened door, 295 00:28:38,610 --> 00:28:44,650 than it is to actually have to change people's wages and the food that they're consuming and the landscape in which they operate, 296 00:28:44,650 --> 00:28:47,210 and the labour conditions under which they are working. 297 00:28:47,330 --> 00:28:50,690 And so the short answer is that pellagra is bad for business. 298 00:28:51,450 --> 00:28:56,850 JEREMY: The fact is, economics and society at large has a huge impact on pellagra. 299 00:28:57,130 --> 00:29:02,250 In the US South, the boll weevil destroyed the cotton crop in the 1920s, 300 00:29:02,730 --> 00:29:08,330 but because they weren't growing so much cotton, they had space for a few vegetables. 301 00:29:08,810 --> 00:29:14,330 Good food became more available despite a drop in incomes, and pellagra receded. 302 00:29:14,850 --> 00:29:23,410 In Italy too, long before, economics had the opposite effect, when landlords started to change their agreements with their tenants 303 00:29:23,410 --> 00:29:26,330 from sharecropping to rent in cash. 304 00:29:26,690 --> 00:29:27,570 David Gentilcore. 305 00:29:28,930 --> 00:29:36,950 DAVID GENTILCORE: The success of maize as a cash crop brings about a transformation in the whole economy. 306 00:29:37,550 --> 00:29:44,421 So rather than, say, have a kind of tenant farmer arrangement that they made, 307 00:29:44,421 --> 00:29:54,270 that was traditional, there's a move towards paying rent in cash, which has a real detrimental 308 00:29:54,270 --> 00:30:04,150 effect on on peasant well-being. It essentially brings them into debt because in a bad 309 00:30:04,190 --> 00:30:08,750 year, your rent is ... See, in the former system of like tenant farming, 310 00:30:08,750 --> 00:30:12,950 if it was a bad year and you had to give over a third of the crop, well, 311 00:30:12,950 --> 00:30:15,590 you just gave them less, but it was still a third. 312 00:30:16,350 --> 00:30:21,910 Whereas with a set rent, if it's a bad year, you can't pay the rent. 313 00:30:22,030 --> 00:30:24,990 You go into debt and that just gets worse and worse. 314 00:30:25,870 --> 00:30:34,480 JEREMY: The effects of bad years were disastrous, with emigration out of northern Italy to the tune of 2 million people. 315 00:30:35,040 --> 00:30:40,040 But that mass emigration actually helped with pellagra at home. 316 00:30:41,040 --> 00:30:47,600 DAVID GENTILCORE: Ironically, it's the mass emigration that eventually contributes to the decline of pellagra, 317 00:30:47,600 --> 00:30:51,080 because the emigrants send back remittances. 318 00:30:51,640 --> 00:30:58,720 And that cash, that little cash that's available, means that you can actually choose what to eat. 319 00:31:00,120 --> 00:31:04,880 And invariably, the peasants choose not to eat polenta when given the choice. 320 00:31:04,920 --> 00:31:08,200 I mean, it's simply a question of wanting more variety, I think. 321 00:31:08,800 --> 00:31:13,920 JEREMY: Still, while I take Dana Landress's point that pellagra was bad for business, 322 00:31:13,920 --> 00:31:21,280 the mill owners and the like were supported by the medical establishment who refused to see the obvious. 323 00:31:21,960 --> 00:31:26,000 DANA LANDRESS: I think this is actually an instance where in some cases you have to follow the money, 324 00:31:26,240 --> 00:31:35,340 and many of these physicians were in professional and personal circles with the kind of mill managers and other kinds of owners, 325 00:31:35,340 --> 00:31:42,020 who believed that the best way to kind of alleviate regional poverty was to attract business, 326 00:31:42,500 --> 00:31:45,740 and that this was going to be the ultimate cure for pellagra. 327 00:31:46,100 --> 00:31:50,060 JEREMY: The great thing about science, of course, is that it doesn't care what you believe. 328 00:31:53,660 --> 00:32:01,300 Pursuing what he called the pellagra preventative vitamin, not least because the generic better diet was too expensive for most 329 00:32:01,300 --> 00:32:07,580 institutions, Goldberger established that dried brewer's yeast contained plenty of it, 330 00:32:07,580 --> 00:32:13,580 whatever it was. And he put that knowledge to use . 331 00:32:13,580 --> 00:32:22,500 In the wake of the Great Mississippi Flood of 1927, three cents worth of dried yeast in their food saved hundreds of 332 00:32:22,500 --> 00:32:28,140 thousands of people from pellagra. The alternative, according to one newspaper report, 333 00:32:28,420 --> 00:32:34,800 would have been a dollar of fresh food, which in any case was not easily available after the flood. 334 00:32:40,040 --> 00:32:44,320 Goldberger died of kidney cancer in 1929. 335 00:32:44,680 --> 00:32:54,400 In 1937, Doctor Conrad Elvejhem at the University of Wisconsin finally identified what he'd been calling vitamin G -- 336 00:32:54,400 --> 00:32:58,720 for Goldberger. It was vitamin B3, niacin. 337 00:32:59,800 --> 00:33:03,880 So you can say pellagra is caused by lack of niacin. 338 00:33:04,240 --> 00:33:07,920 You can also say it's caused by industrial capitalism. 339 00:33:08,240 --> 00:33:13,440 And to that mix, you can add that it was caused by Eurocentric arrogance. 340 00:33:16,480 --> 00:33:24,640 The indigenous people of the Americas, who subsisted on corn for centuries never showed any signs of anything 341 00:33:24,640 --> 00:33:28,240 resembling pellagra, even in times of want. 342 00:33:30,330 --> 00:33:35,810 And that's because they learn to process their maize with an alkaline solution, 343 00:33:36,050 --> 00:33:41,730 often by soaking the kernels in water containing dissolved lime or wood ash. 344 00:33:44,650 --> 00:33:48,370 That process is called nixtamalisation. 345 00:33:48,770 --> 00:33:56,290 After the Nahuatl words for lime ashes and uncooked corn dough, the same word that gives us tamales. 346 00:33:56,650 --> 00:34:05,290 The Europeans who adopted maize as a cash crop with glee simply ignored indigenous techniques like nixtamalisation. 347 00:34:05,650 --> 00:34:10,290 Even Cesare Lombroso threw out the evidence available to him. 348 00:34:10,570 --> 00:34:17,410 DAVID GENTILCORE: In fact, Lombroso in one of his studies, does mention the Indios, he says, 349 00:34:17,410 --> 00:34:20,690 of Mexico. He says, well, you know, they don't get pellagra. 350 00:34:21,250 --> 00:34:26,450 Why not? And his answer was, well, obviously the maize there is a better quality. 351 00:34:26,450 --> 00:34:28,890 It doesn't get mould. He's still ... 352 00:34:28,930 --> 00:34:31,470 You know, in a circular argument like that, you can't win. 353 00:34:31,470 --> 00:34:39,470 He's always got the answer. And yet, if they had observed maize in its place of origin, 354 00:34:40,310 --> 00:34:47,230 you know, we have early descriptions where the Spanish conquistadors are writing these accounts of discovery. 355 00:34:47,830 --> 00:34:51,510 They described traditional ways of producing. 356 00:34:51,510 --> 00:34:56,750 But Europeans aren't interested. They just want to turn it into flour. 357 00:34:57,030 --> 00:35:05,190 There's this obsession we have in Europe with bread, with milling, means that they can only see maize in this one way. 358 00:35:05,190 --> 00:35:08,230 They have to, yeah, treat it like wheat. 359 00:35:09,790 --> 00:35:17,190 JEREMY: Goldberger's experimental approach squarely demonstrated that pellagra was caused by a dietary deficiency, 360 00:35:17,430 --> 00:35:20,790 regardless of what actually caused the deficient diet. 361 00:35:21,350 --> 00:35:24,510 But did it have any impact back in Italy? 362 00:35:25,310 --> 00:35:27,150 DAVID GENTILCORE: No, because people knew that already. 363 00:35:27,190 --> 00:35:32,400 I mean, the hospital doctors all knew, and they write this on the records quite clearly. 364 00:35:32,840 --> 00:35:38,480 Oh, so-and-so is cured, but he'll go back to his diet and we'll see him again before long. 365 00:35:38,920 --> 00:35:45,720 Even before they knew about about niacin, hospital doctors simply knew from experience, 366 00:35:45,720 --> 00:35:52,840 give them a decent diet. The one thing that determines this, though, is if they can stop the diarrhoea. 367 00:35:53,720 --> 00:35:56,200 And there's no way in this period to stop diarrhoea. 368 00:35:56,680 --> 00:36:02,720 So if the patient gets better, can keep the food down, can digest it, 369 00:36:02,760 --> 00:36:09,640 they get better. Quite simple. So even before Goldberger, they know that as a reality. 370 00:36:10,360 --> 00:36:14,480 By Goldberger's time, in Italy pellagra has practically disappeared. 371 00:36:14,520 --> 00:36:17,520 Nobody's really investigating it anymore. 372 00:36:18,400 --> 00:36:24,000 JEREMY: The Italian government ignored social factors and took Lombroso's advice to heart. 373 00:36:24,400 --> 00:36:32,980 In 1904, they passed the first law to combat pellagra, which mandated big drying ovens in maize growing areas. 374 00:36:33,780 --> 00:36:38,922 Cases had in any case, started to decline a decade or so before . 375 00:36:38,922 --> 00:36:42,060 Peasants began to organise and demand better conditions. 376 00:36:42,300 --> 00:36:48,180 And of course, there were the remittances sent home by the millions of Italians who emigrated. 377 00:36:48,540 --> 00:36:51,860 Italy had quietly vanquished pellagra. 378 00:36:52,740 --> 00:36:54,700 DAVID GENTILCORE: Ultimately, it's the First World War. 379 00:36:54,780 --> 00:36:59,260 And then there's another paradox. You would think, oh, conditions would get worse during the war. 380 00:36:59,700 --> 00:37:05,820 But no, the Italian government buys in lots of wheat from abroad in 1915, 381 00:37:05,980 --> 00:37:09,980 which essentially subsidizes the price of bread. 382 00:37:10,540 --> 00:37:13,300 And so these peasants, finally they can afford bread. 383 00:37:13,740 --> 00:37:16,660 So naturally they they opt for that. 384 00:37:17,300 --> 00:37:24,620 Mussolini, in 1927, he's celebrating five years of fascist rule. 385 00:37:25,100 --> 00:37:31,070 And he's very smug. He's able to say, we've solved this problem, the Americans haven't. 386 00:37:31,790 --> 00:37:35,390 Meaning, by his time, pellagra was history. 387 00:37:36,470 --> 00:37:39,470 The government had nothing to do with it, it has to be said. 388 00:37:39,830 --> 00:37:42,190 Medical science had very little to do with it. 389 00:37:42,190 --> 00:37:46,350 It was simply improving peasant conditions that were behind that. 390 00:37:46,950 --> 00:37:56,510 So it wasn't politics. And it wasn't really a medical intervention because there was no treatment for 391 00:37:56,510 --> 00:37:59,470 pellagra aside from an improved diet. 392 00:37:59,470 --> 00:38:02,950 And even Lombroso said, we can't improve the peasants' diet. 393 00:38:02,950 --> 00:38:05,830 That's that's not our job. We're doctors. 394 00:38:11,110 --> 00:38:15,790 JEREMY: Well, whose job is it, then? For pellagra, the answer is quite easy. 395 00:38:15,950 --> 00:38:20,950 Governments said that some foods have to be fortified with added niacin, 396 00:38:21,070 --> 00:38:27,330 and that solved the problem. Today we look back on pellagra as a distant memory. 397 00:38:28,330 --> 00:38:33,530 Will we one day be able to do the same for, say, type two diabetes? 398 00:38:34,370 --> 00:38:40,050 With current ill health linked to food, where the whole point of food manufacturers is to get us to eat more, 399 00:38:40,570 --> 00:38:43,290 which kind of cause do you focus on? 400 00:38:43,770 --> 00:38:47,890 Biochemical, Economic? Societal? 401 00:38:51,730 --> 00:38:56,450 I don't have answers, but I'd love to know what you think. 402 00:38:56,810 --> 00:39:03,810 You can email me -- Jeremy @eat this podcast.com -- or leave a comment on the website at eatthispodcast.com . 403 00:39:05,930 --> 00:39:13,130 My profound thanks to Dana Landress and David Gentilcore for their help in making this episode. 404 00:39:13,970 --> 00:39:17,810 I'm taking a break over the summer; back in a couple of months. 405 00:39:18,290 --> 00:39:23,650 There are more than 300 episodes in the archive in case you miss the show. 406 00:39:23,890 --> 00:39:29,500 And be sure to subscribe wherever you get your podcasts so you don't miss the return. 407 00:39:31,940 --> 00:39:38,020 If you're already subscribed to Eat This N ewsletter, then that will alert you when the podcast is back. 408 00:39:38,020 --> 00:39:43,660 And in the meantime, I'll continue to share interesting stuff that I find every week. 409 00:39:43,900 --> 00:39:51,900 If you want to sign up for that, head over to eatthispodcast.com/subscribe and you'll find a link at the bottom of 410 00:39:51,900 --> 00:40:00,460 the page. My thanks again to supporters for allowing me to make everything freely available, 411 00:40:00,460 --> 00:40:03,980 including written transcripts and subtitles. 412 00:40:06,740 --> 00:40:11,500 For now though, from me, Jeremy, surface and Eat This podcast. 413 00:40:11,740 --> 00:40:14,020 Goodbye and thanks for listening.