Leaders all over the South were scrambling to find a cure for the dreaded pellagra until they discovered what that cure might cost them. That’s when the campaign of denial began. A century-old fight over public health feels fresh as a morning headline as we wrestle with a new threat, with equally simple remedies that upset Southern values. Disease is personal. Pandemic is politics.
Joseph Goldberger was sent to the South in 1914 on a mission from the US Department of Public Health to investigate an outbreak of pellagra. Pellagra is a terrible illness, starting with skin lesions, then advancing to diarrhea, dementia and in about 40% of cases, death. The disease, already well known among poorer populations in Southern Europe, had been documented in the South in 1908. By 1912, more than 30,000 cases had been identified in South Carolina alone.
Now we know that pellagra is caused by a niacin deficiency, usually rising from a corn-based diet. Native Americans used a process called nixtamalization, soaking corn in ash or lime to convert it to hominy, which released more of its nutritional value. Without that step, corn can be a weak source of nutrition. Pellagra was common among poor Southerners, mostly tenant farmers, the incarcerated or mill workers. Tenant farmers were expected to devote all of their available land to cotton, with landlords blocking them developing food plots. This left them dependent on the cheapest available source of calories, a diet of cornmeal, molasses and salt pork. Similarly, mill workers were often limited to whatever food was available in the company store, at the cheapest price, mostly corn with little variety
Goldberger was initially welcomed. Southern leaders expected him to blame the disease on an infection, or even better, on a contaminant in corn imported from the Yankee Midwest. Instead, his experiments backed up his initial suspicion that pellagra was a nutritional deficiency. Goldberg published his findings in 1915, demonstrating that pellagra was a consequence of a poorly diversified corn diet, and could be remedied by adding a few fresh foods. His conclusion wasn’t novel, matching the recommendations of earlier researchers in Europe, but his report sparked angry denials.
An earlier commission of Southern researchers in 1909 had reached an erroneous conclusion more welcome to Southern planters and mill owners – pellagra was an infectious disease, spread either by flies or adulterated corn. It could, therefore, be remedied by educating the poor toward better sanitary habits and/or regulating imports from the hated North. Goldberg’s discoveries instead tied the disease to Southern economic practices that were producing wealth for a few powerful people. Wealthy Southerners worked to promote their preferred diagnosis.
In response to Goldberger’s research, planters and mill owners launched a campaign of pellagra denial. His conclusions were framed as an attack on the “Southern way of life” by “damyankees.” Seale Harris, Director of the Alabama Medical College, published an editorial that appeared in Southern newspapers deriding the “pellagra scare, which was not justified by facts, does the South a gross injustice” and “misrepresents the realities of the South.” For years he spread denial of Goldberger’s findings, claiming that the majority of physicians disagreed with them. Southern politicians ignored Goldberg’s recommendations and flipped their earlier position, insisting now that pellagra wasn’t a problem at all. As Goldberger’s conclusions were incorporated into official Federal policy, the Georgia Senate passed a resolution denouncing the “slanderous” accusation that pellagra was an issue in the South. Unsurprisingly, the disease spread wildly over the next two decades as poverty worsened. By 1928, pellagra which was now a fully preventable illness, was one of the leading causes of death in many Southern states.
The pellagra outbreak was only alleviated by the arrival of a new menace, the boll weevil. Weevil infestations performed the work that policy-makers resisted, changing the economic landscape of the South. By wrecking the cotton industry, it removed poor tenant farmers from cotton monoculture and shut down many of the worst mill towns. After a brief resurgence of the cotton industry in the early 30’s, the Depression and the New Deal finished the work of reshaping Southern economics. By the 1940’s cotton was no longer king and pellagra was fading from memory.
The playbook deployed to blunt pellagra remedies didn’t emerge from nowhere. Southern leaders had honed this machinery of evasion and denial just a few years earlier, defeating a Northern effort to eradicate hookworm. Like Goldberger, Charles Stiles had been sent to the South by the US Public Health service in 1908, to investigate “the disease of the cracker.” Stiles was the first to identify hookworm in the US, finding it in 1902 in samples from Texas and West Virginia.
Hookworm infestations seldom kill, but can cause severe anemia and cognitive defects. Combined with pellagra, the impact of a hookworm infestation could be devastating. Though the reach of pellagra was relatively limited, in the early 20th century up to 40% of population in the South carried the hookworm parasite. The worm’s complex lifecycle depended on access to humans, usually through bare feet, and transmission through untreated sewage. Sufferers could experience cognitive decline, lethargy, and strange urges to eat unusual things. They were often derided as “dirt eaters.” Hookworms were particularly successful in the kind of poor, sandy soils where landless whites and blacks were often relegated.
While state governments in the South dithered, the Rockefeller Foundation in 1909, organized the Rockefeller Sanitary Commission to eradicate the parasite. Working with Stiles, the commission adopted an innovative plan meant to go beyond eradicating hookworm. In order to give the effort a sheen of local support, the RSC would only operate in states that established a health commission, and in counties that also established local health infrastructure. They worked through those health commissions to educate, dispense treatments, and press for improved sanitation infrastructure.
At first the RSC was well-received by local people. Several states and counties set up bureaucracies to assist the commission in their goal of identifying and treating hookworm infestations. However, as the focus turned toward broader public health goals, like clean water, sewer infrastructure and poverty, resistance grew.
The “National League for Medical Freedom” had been formed in 1910 to protect the interests of snake-oil salesman and quack doctors against a growing national movement in favor of tide of food and drug regulation. They worked hard in Arkansas to stir up opposition to the creation of a state public health unit, essential for participating in the Rockefeller hookworm program. When the Arkansas legislature finally passed a bill approving the project in 1911, the physical bill was stolen before the Governor could sign it. After the Governor signed a copy of the bill, the state attorney general intervened to determine the law invalid.
A newspaper editorial in Raleigh captured the prevailing mood:
Many of us in the South are getting tired of being exploited by advertisements that exaggerate conditions . . . Let us not canonize Standard Oil Rockefeller by putting laurels on his head because he seeks to buy the appreciation of the people whom he has been robbing for a quarter of a century.
Passing out medicine or encouraging people to wear shoes was tolerable. Pressing Southern governments to continue to fund public health infrastructure created some resentment. Pointing out the connection between absent public infrastructure and squalid health conditions was more than the South’s wealthy were willing to tolerate.
The Rockefeller Foundation wrapped up their work in the South in 1914. Hookworm infestations had been greatly reduced, and new public awareness of the importance of shoes and proper waste disposal helped around the margins. But as with pellagra, failure to adopt the kind of comprehensive public health and sanitation infrastructure voters took for granted elsewhere let hookworm remain. By 1930, hookwork infestations had rebounded, remaining widely prevalent in the South. Like pellagra, hookworm would only fade when the decline of cotton and the rise of federal health and infrastructure intervention changed the economics of Southern life.
One might imagine that the wealthy would have as much interest in public health as anyone else. What good is it to be rich if you have to live in a disease-ridden backwater? However, there’s another dimension to consider. Not all industries need a healthy public for success. Some paths to wealth and power hinge on a divided and impoverished public, unable to organize to promote their interests. Extractive businesses that profit from wringing money from an asset, like cash-crop farming, mining and oil gain far more from keeping their costs down than they would from any form of improvement in the world around them. The economy in the South remains defined today by the prominence of extractive capital over innovation or knowledge industries.
Powerful government entities, under the influence of a liberal democracy, provide a gateway to badly needed organization for workers and the poor. The more powerful a democratic government becomes, the more leverage that government carries against the wealthy. Living in a disease-ridden environment is of little concern to many wealthy families if it secures their relative power against the emergence of real democratic organization. For many influential Southerners, the spread of COVID is less worrying than the spread of democracy.
Government investment in public health is a particular threat to predatory wealth because of the mindset it imbues. The more the public learns about hookworm, pellagra, teen pregnancy or COVID, the greater the awareness of our inherent, inescapable interconnectedness. Public health initiatives hinge on teaching basic biology. The more people understand our biology the harder it is to keep us divided and therefore politically weak.
COVID-19 arrived on our shores as an illness that could infect anyone regardless of class, wealth, education or influence. As a result, it hit hard in its earliest days in our wealthiest places, our cities with the strongest connections to the world. In the spring of 2020 New York, Los Angeles and Boston faced a terrible toll of infection and death while the quiet South watched with detachment. That detachment wouldn’t last.
COVID-19 is no longer a disease that could touch anyone equally. Like hookworm and pellagra, solid public health infrastructure can allow people to avoid this plague. Periodic lockdowns, mask rules, vaccinations and contact tracing will limit COVID’s reach until it’s constrained to our cultural and political backwaters. COVID-19 is on its way to becoming our newest pellagra, a disease we only worry about when we venture into the poorly governed hinterland.
The business lobby is pushing to gut COVID-19 related public health initiatives. ALEC has formulated a collection of model bills aimed at rolling back local public health powers that took a century to establish, and which have still barely taken hold in the South. These efforts are little threat in states with Democratic majorities, but in the South they are almost certain to become law, succeeding once again in wrecking efforts to place the well being of citizens ahead of predatory business models. Under the guise of “liberty” these campaigns are working to undermine the entire public health edifice.
Our newest outbreak of a deadly COVID variant began in the Ozarks, moving now down the Mississippi into Louisiana and spreading across the Deep South. Duval County, Florida, home to Jacksonville, is now logging more new COVID infections each day than New York City. That’s not a per capita metric, but the raw number of infections. On a per capita basis, the Duval County’s infection rate is roughly 1000% times higher than New York City. San Francisco is averaging fewer new cases per day, in raw numbers, than Mobile County, Alabama. Across the South, as more infectious variants take hold and infection numbers skyrocket in rural areas, the region’s “liberal” cities remain havens. Austin, Houston and San Antonio are seeing slower spread than their suburbs, and much slower spread than their poorly vaccinated surrounding rural counties.
Disease is personal. Pandemic is politics. Texas’ Neo-Confederate Lt. Governor summarized the South’s approach to public health in a starkly candid manner back in March of 2020. He explained that good citizens were willing to sacrifice their lives to protect business interests, which are naturally much more important than any ordinary person’s survival. Public health activism is always a threat to predatory business models. Whether the disease is pellagra or COVID, once the unwashed rabble begins to understand how we’re all connected, the threat to those extractive businesses cannot be contained.
Predators are thriving in this environment of weak public health. Professional grifter Joseph Mercola moved his phony medical practice from Chicago, where his business was threatened by relentless regulatory scrutiny, to the huckster paradise of Florida back in 2015. Safe now in the arms of Dixie, Mercola can rake in millions on phony COVID cures and vaccine denial becoming one of the country’s most prominent and successful COVID predators. His new home, Lee County , Florida, is logging more new COVID cases each day than Philadelphia and Boston combined. As the years pass, we can expect COVID to be a disease that bubbles along in America’s backwaters, continuing to threaten more settled areas by allowing new variants to emerge.
A medical research team discovered a hookworm infestation among poor residents of Lowndes County, Alabama in 2017. Infected residents were living in areas with no central sewage treatment and no functioning septic tanks. In response, the Alabama Department of Public Health issued a wholly predictable denial, insisting that no problem exists. Though many millions of dollars in relief money has been raised from private donors in an effort to remedy what should be a government problem, to date conditions have not improved.
The connection between hookworm, pellagra and COVID in Southern politics demonstrates a stark reality. Politics is always a matter of life and death.