Pellagra: A plague of Indian maize and Western economics

Pellagra is a rare disease now, but in the early 20th century and before it existed as an epidemic disease. Like many, it had its source in the Columbian exchange. Unlike most such diseases, it was not spread by any microbe. Rather, pellagra is a nutritional deficiency disease, caused by a lack of niacin and nutrients that aid in the production of niacin. It reached epidemic proportions in Italy, the United States, and elsewhere following the spread of corn--minus nutrient-maximizing processing techniques that developed and spread among indigenous Americans and plus agricultural, ecological, and economic circumstances that landed large portions of the population without appropriate nutritional variety.

This blog examines the development and transfer of indigenous knowledge in general and specific practices that prevent pellagra in particular, the adoption of corn but not the practices that made it safe by Western societies, the changes in food production that created epidemic pellagra, and the eventually-successful attempts of Western societies to solve the epidemics through medical science. Economic modernization and ideological biases shaped the course of the epidemics and the form of response in the West.

Conditions for an Epidemic

Today, pellagra “has vanished” even in Southeast Asia, where malnutrition is exceptionally high¹. While outbreaks continue to threaten refugee populations deprived of niacin--one began in Kuito, Angola in 1999 and was predicted among Rwandan refugees in 1995 ^2, these outbreaks hardly compare to the epidemics that affected tens of thousands to over a hundred thousand of the poor a year in 19th century northern Italy and the early 20th century southern United States ^3,4,5.

The diet that created these epidemics was one of degerminated, non-nixtamalized corn and little else. Though corn formed a large component of many indigenous Americans' diets, they lived in agroecosystems with access to game, legumes, and other foods ^6. Similarly, the poorest of U.S. Southerners, living far from railroads, grew their own vegetables and suffered lower rates of pellagra than prevailed in towns surrounded by cotton plantations ^7. And pellagra in Italy followed modernization of agriculture, creating proletariat farm workers who grew corn for their own consumption and everything else for sale ^8.

Differences in corn processing between indigenous and epidemic-affected societies exacerbated the problems of poor diet. Native Americans used limewater and other alkaline substances in preparing corn in a process known as nixtamalization, which increases nutrient availability in corn.

Degerminating corn further reduces its nutritional value. Bollet traces the introduction of corn milling technology in the U.S. that involves degermination to the very beginning of the 20th century, preceding the epidemic of a disease that was not endemic to the U.S. previously ^9. This also explains the difference between pellagra rates in cotton-textile towns supplies by rail with corn ground where the new milling process was introduced on the one hand, and more rural areas where corn was stone-ground locally with germ on ^10. Traditional knowledge had something to say about this as well: according to Bollet, stone-ground corn retains a reputation for good health in the South ^11.

A traditional water-powered mill

All three of these causes involved a lessening of the intertwining of people's lives and the production of food they ate. Cash crop monocultures and proletarization meant that most of the agricultural products people were growing were not for their own consumption--or the consumption of people in their own socioeconomic class and geographic region. The loss of nixtamalization when corn was passed from indigenous societies to European and Euro-American cultures reflected a change in the cultural position of corn, from sacred and long agriculturally-central to a crop that was eaten "formed into bread so revolting that the very pigs recoil from it," as one 19th century commentator put it ^12. Pellagra outbreaks followed times when other crops became less available, either shortly before harvest or when other crops failed or increased in price ^13, 14. This reflected the low status of corn (surely justified by the association with pellagra), which was usually only favored by the poor when other choices were absent. The lack of reverence for corn production allowed Midwestern milling technologies to create degerminated corn for shipment to far-away populations who, divorced from the production of their own dietary staple, were unable to insist upon milling the whole kernel.

Although poverty was the overarching cause of the pellagra epidemics and many other health crises, in this case at least the problem was one of a certain kind of poverty, poverty in the context of societies in the middle of advancing agriculture and agricultural processing along the lines of monoculture and mass production without much caution for side-effects. 

1. Sanjay Kumar, "Southeast Asia's Burden of Nutritional Disorders," The Lancet 355 (2000): 52. Accessed at http://www.lexisnexis.com.ezproxy.westminstercollege.edu/lnacui2api/api/version1/getDocCui?lni=3Y8V-1180-00CP-4359&csi=154080&hl=t&hv=t&hnsd=f&hns=t&hgn=t&oc=00240&perma=true 
2. Sophie Baquet et al, "Pellagra Outbreak in Kuito, Angola," The Lancet 355 (2000): 1829-1830. Accessed February 20, 2012 http://www.lexisnexis.com.ezproxy.westminstercollege.edu/lnacui2api/api/version1/getDocCui?lni=40B1-PRT
 3.  James Jackson Jarves, "Italy and Her Dark Side: A Frightful Scourge Poverty Has Caused
There," The New York Times, June 19, 1881. Accessed at http://query.nytimes.com/mem/archive-free/pdf?res=9B05EEDE103CEE3ABC4152DFB066838A699FDE
4. Massimo Livi-Bacci, "Fertility, Nutrition, and Pellagra: Italy during the Vital Revolution." The Journal of Interdisciplinary History 16, no. 3 (1986): 446. Accessed at http://www.jstor.org/stable/204498
5. Alfred J. Bollet, Plagues and Poxes: The Impact of Human History on Epidemic Disease. (New York: Demos Medical Publishing: 2004.), 158.
6. Ibid., 168.
7. Ibid., 168.
8. Livi-Bacci, 441.
9. Bollet, 169.
10. Ibid., 169.
11. Ibid., 169.
12. "Article 5 -- No Title," The New York Times, May 12, 1881. Accessed at http://query.nytimes.com/mem/archive-free/pdf?res=9900EEDA133CEE3ABC4A52DFB366838A699FDE
13. Bollet, 156.
14.  Livi-Bacci,  441.

Reflections on Maize in Indian Culture ("Spanish Missionary," ca. 16th century)

As I labor to bring divine clarity to the Indians of the new Spanish territory in America, I have had to learn their languages well, and heard many of their histories. One subject that particularly interests me, and as I know well, many of the curious at home, is that of the Indian staple, maize, and its development. In many of the cultures I have come across, maize is revered as a power source and even plays a role in the creation myths of the people. I have heard, for instance, that the Indians in the South believe that they were created from maize dough. Certainly, a grand variety of products are made from this vegetable, from bread to honey to wine; it is indispensable to these cultures.¹ These facts lead me to believe that maize has indeed been with the Indians for a very long time and that this accounts for their intimate knowledge of it; for even savages, given enough time, will adapt and respond to what they perceive in their natural surroundings, and even have an impact on them. We have seen examples of this in the Eastern cultures, who periodically burn the forests surrounding their villages in order to allow growth of more useful species and get rid of undergrowth.²

Just as we do, the Indians pass their knowledge down to future generations – though truthfully their method is not so reliable as written word, being often outlandish tales. Many Europeans do not place importance upon these stories, but I have carefully listened to them and they have led me to conclude that there was, in fact, a civilization here before any of the cultures we now
encounter. This civilization must have been the source of the corn which the Indians now tend and depend on. The Indians tell their tales not only to outsiders, but to each other, and in this way knowledge is passed between groups; and so, across the new continent, one finds similar fields and foods despite the different cultures and climates. One also finds similar tools for processing the maize: stone tools for grinding the kernels, which have been named the "mano" and "metate," and are essential for the production of Indian bread. I may be excused, then, for surmising that maize processing techniques have been shared and, through experiments of many groups over many years, best practices have come to light.³

1. Linda S Cordell, Wolcott Toll, Mollie S. Toll and Thomas C. Windes. “Archaeological Corn from Pueblo Bonito, Chaco Canyon, New Mexico: Dates, Contexts, Sources,” American
Antiquity 73 (2008): 491-511. Accessed at http://www.jstor.org/stable/25470501.

2. H. Thomas Foster II, Bryan Black, and Marc D. Abrams. "A Witness Tree Analysis of Effects of Native American Indians on the Pre-European Settlement Forests in East-Central Alabama," Human Ecology 32 (2004): 27-47. Accessed at http://www.jstor.org/pss/4603501.

3. Kent G. Lightfoot and William S. Simmons. “Culture Contact in Protohistoric California: Social Contexts of Native and European Encounters,” Journal of California and Great Basin Anthropology 20 (1998): 138-170. Accessed at http://www.jstor.org/stable/27825674.
(image from http://www.angelfire.com/realm/shades/nativeamericans/apalachee.htm)

Cultural Exchanges ("British Report," ca. 17th century)

When one travels across the New World, one may come to a realization about the nature of the exchanges between cultures: the natives provide mostly food stuffs and simple goods, while the European colonists provide more technological goods.¹ Why, then, is this so? After a broad survey of all three powers’ efforts in America, we have come to several conclusions.

The first, of course, is that as the emissaries of such advanced countries as Great Britain, who have known all the advances of the eighteenth century, the colonists do not have anything to learn from primitive, “savage” technology.² We bring them the benefits of metal working, gunpowder, and true religion; their mixed-crop fields, “Indian wheat,”³ and stone tools are paltry in return. With our advanced tools we have shaped thelandscape of the New World as the natives could never have dreamed. Were we toadapt their technologies, more inclined to give way to nature than to control it, surely we would not make as much progress towards cities and European civilization.

Naturally, our British brothers especially long for the comforts of home when they come to this wild country; therefore they understandably opt to bring over familiar goods such as wheat rather than resign themselves to the primitive and hostile environment on the new continent. Wheat has long been the staple of the European table and remains, in the view of many, nutritionally superior to the maize which is grown across the New World; so that colonists may plant wheat not only of adesire to remember their accustomed surroundings and palate, but to save themselves from the itching and scabs that can occur from eating “Indian bread” when one is not used to it.

Second, it must be admitted that in some instances the difficulties of language do arise, and that a trade good may be conveyed with limited vocabulary, while a practice may be traded less easily unless one understands well the language of the savages, or they the tongues of Europe. When one is shown corn made into a fine meal, like flour, one may easily surmise its value; but to know how it was made into meal takes a detailed description, which may only come if those trading have a thorough understanding of one another. It is also prudent to note here that in some areas our colonists face natives who have become increasingly hostile, unwilling to share processes and increasingly unwilling to trade at all.⁵

In addition, it has come to our understanding that, in many American cultures, it is the women who are in charge of such things as weaving and food processing.⁶ Yet, naturally, our colonists and traders deal with the men mostly, and do not conduct business with the women as a matter of course. It seems the women play a larger role in altering the environment of the natives, at least in the areas near their camps. Our men, by merit both of acquaintance with European, efficient agricultural practices, and of the heightened strength and reason that comes with their sex, have chosen not to follow their lead.

1. Diane E Silvia, “Native American and FrenchCultural Dynamics on the Gulf Coast,” HistoricalArchaeology 36 (2002): 26-35; Lightfoot, Kent G. and William S. Simmons.
“Culture Contact in Protohistoric California: Social Contexts of Native and
European Encounters.” Journal ofCalifornia and Great Basin Anthropology 20 (1998): 138-170. Accessed at http://www.jstor.org/stable/27825674.

2. Luis Millones Figueroa, “The Staff of Life: Wheat and ‘Indian bread’ in the New World,” Colonial Latin American Review 19 (2010): 301-322. (pg 305)

3. Figueroa, “The Staff of Life,” pg 307.

4. Figueroa, “The Staff of Life.”

5. Joshua Piker, “Colonists and Creeks: Rethinking the Pre-Revolutionary Southern Backcountry,” The Journal of Southern History 70 (2004): 503-540. Accessed at http://www.jstor.org/stable/27648476.

6. Katherine A. Spielmann, “Glimpses of Gender in the American Southwest,” Journal of
Anthropological Research 51 (1995): 91-99. Accessed at http://www.jstor.org/pss/3630249.

(image found at http://www2.maxwell.syr.edu/plegal/history/ballardwq1.html)

Native Knowledge and Environmental Interaction

Often a line is drawn between “Western” or European ways of
thinking and more traditional, sometimes “primitive” ways of thinking. For
example, in the European cultures that were exploring and colonizing America
from the fifteenth century onward, knowledge was stored and transferred through
writing. In most Native American cultures of the time, however, there were no
forms of writing. How, then, were they sharing their knowledge and building
upon it?

Though native cultures did not necessarily write down what
they learned, they did have a very strong oral tradition. It is recognized that
stories could be passed down by generations with only minor alterations, and
that these stories formed the basis of spirituality; but what is less
recognized, it seems, is the knowledge these stories brought with them,
especially about revered subjects – say, animals, or maize. Stories tell, for instance,
the proper ways to use and dispose of hunted animals, and to keep a balance in
hunting certain species.¹ There are also many stories about maize and its
importance in creation and sustenance of people.² These stories and this reverence
for maize may have led people to take care in the ways they planted and
processed corn, adhering to ancient traditions as they did when hunting sacred
animals.

The use of many plants, not only maize, was integral to many Native American cultures.³ It has been seen that when tribes were forced to move as colonies and later the U.S. expanded, Native Americans were quickly able to identify useful plants in their new surroundings. They did this
especially through talking to local tribes and finding plants that looked similar to plants they knew (and usually were in the same family).⁴ This adaptability and quick response to the surrounding environment has been noted in many other studies of native use of changing resources as well – for example, fluctuating levels of salmon.⁵

When a culture centers on being in tune with the environment, placing environmental elements like plants and animals on the same level as humans, it follows that the people are very sensitive to their effects on the environment, as well as its effects on them. If native people became
sick, for example, they would quickly look to an environmental cause and change
their ways according to what they believe is the answer. This is not to say that they knew what the true cause was, but that they looked for causes in the environment and their interactions with it. This differs from cultures which place themselves above nature and tend to look for other causes of disease or ill-health before environmental effects. Many European cultures at the time,
for example, attributed disease to the wrath of God or, later, to socioeconomic
status. Because Native American cultures focused on living with the environment, they were prepared to respond to environmental damages, such as nutritional deficiency, in a way that alleviated the cause rather than attempting to subjugate it or redirect it.



1. Dave Aftademilian, "Toward a Native
American Theology of Animals: Creek and Cherokee Perspectives," Cross
Currents 61 (2011): 191-207. Accessed at http://web.ebscohost.com/ehost/detail?sid=071cbf78-aa8e-4272-8165-2e2019be8bfd%40sessionmgr104&vid=3&hid=122&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=aph&AN=60975843

2. Linda S Cordell, “Archaeological Corn from
Pueblo Bonito, Chaco Canyon, New Mexico: Dates, Contexts, Sources.”

3. Maurizio G. Paoletti, et al, "Edible and Tended Wild Plants,
Traditional Ecological Knowledge and Agroecology," Critical Reviews In
Plant Sciences 30 (2011): 198-225. Accessed at: http://web.ebscohost.com/ehost/detail?sid=40567e1b-5f12-44b3-878fad9a39cb55c2%40sessionmgr114&vid=1&hid=122&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=aph&AN=60294114

4. R. Alfred Vick, "Cherokee Adaptation to the Landscape of the West
and Overcoming the Loss of Culturally Significant Plants," American
Indian Quarterly 35 (2011): 394-417. Accessed at: http://web.ebscohost.com/ehost/detail?sid=01ee90dd-8a68-4c4b-9b16-f3cab5387225%40sessionmgr115&vid=1&hid=122&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=aph&AN=63154678

5. Benedict J Colombi, “Salmon and the Adaptive Capacity of Nimiipuu (Nez
Perce) Culture to Cope with Change,” The
American Indian Quarterly, 36 (2012): 75-97. Accessed at http://muse.jhu.edu.ezproxy.westminstercollege.edu/journals/american_indian_quarterly/v036/36.1.colombi.html

Search for a Cure

 The medical mystery of pellagra dates back to 1736, when Spanish royal physician Pedro Casal first described the disorder in Oviedo, Spain. He noted its association with poverty and corn, but believed the cause to be contamination of the corn  ^1.

A distinctive symptom of pellagra still known as Casal's necklace or the Casal collar

The idea that an infectious agent in spoiled corn carried pellagra remained prominent among Western doctors and politicians for the next two hundred years.
 

James Jackson Jarves, a correspondent to the New York Times in 1881 writing about Italy, expresses the common range of insight and confusion about pellagra prior to its final cause being determined:

Hitherto cretinism has appeared to be the most frightful misery that could afflict humanity as a disease, but it is limited as to locality and extent. Compared to the pellagra it is child's play in its capacity of torturing and destroying humanity. And yet Governments and communities can prevent the rise and spread of the latter on the easiest terms of nature, practically enforced in the spirit of justice and love of your neighbor in the Christ-sense. Bad food and bad lodging are the exciting causes of pellagra; good nourishment the remedy and preventive. But if the peasant's chief or exclusive diet is cornmeal, good or bad, as he obtains it in Italy, he seems to be marked out as the victim of the pellagra, while a change to wheaten flour, slightly cooked meat, and pure light wine either prevents, cures, or alleviates it. It would be interesting to know if an exclusive diet of sound corn-meal in American would produce the same disease there as in Italy. If maize be eaten unripe, rotten, or otherwise injured, as with any other spoiled food, it is to be expected that disease of some kind will ensure. In Italy the prevailing opinion now is that corn-meal or any quality as an exclusive diet is the chief exciting cause of pellagra, and a change of food the prevention or remedy.

In Jarves's view, pellagra is caused by an exclusive corn diet of whatever quality, or maybe by spoiled corn and bad lodging, and in any case “the same misery, innutritious, scanty diet, filthy habitations, foul water, damp or chilly climate, prevail alike in two places, and one is afflicted with the plague and the other is free.” ^2 The correlations of pellagra with poverty and corn consumption are clear, but the details are vague, and the exact cause uncertain. 

 

An early 20th century epidemic in the US stimulated medical investigation that finally revealed the true cause of pellagra. The first US cases were reported by Dr. George H. Searcy in 1907. In scarcely over a decade, the epidemic reached a hundred thousand annual reported new cases ^3.

Like other observers, Searcy noted the connection between pellagra and diet. His institutionalized “colored insane” patients never infected the hospital staff, and the dietary link was confirmed when he substituted wheat and potatoes for the molasses and corn products fed to the inmates ^4.

The American medical institution responded to the epidemic, organizing a conference on the subject that met in late 1908 with the support of the governor of South Carolina. The Second National Conference on Pellagra the following year spawned the National Association for the Study of Pellagra ^5. The political attention to the disease was not always helpful, however, since political pressure as well as trends in medical research insisted upon an infectious cause, rather than a nutritional and economic one--Dr. James Babcock, co-organizer of the first National Conference on Pellagra, was fired by the state government in 1914 for damaging the state's reputation by publicizing the disease ^6. An infectious cause would be more palatable to politicians than emphasis on the clear association with poor diet and poverty.

Researchers were biased for a more level-headed reason: infectious microbes usually were the answer. During the time period, medicine was discovering the causes of “typhoid fever, lobar pneumonia, tuberculosis, cerebrospinal meningitis, syphilis, Asiatic cholera, malaria, amebic dysentery, scarlet fever, tetanus, and diphteria” ^7. With so many major diseases caused by the presence of something tiny--rather than the absence of something smaller--infection seemed likely. Add to that the rapid spread of the US epidemic and the conclusions of the Thompson-McFadden Pellagra Commission, which concluded that cases appeared in proximity to other cases and under poor sanitary conditions (ignoring the correlation of these factors with a cheap, monotonous, corn and molasses-based diet), and an infectious disease seemed plausible ^8.

Dr. Joseph Goldberger (image from history.nih.gov)

When in 1914, Dr. Joseph Goldberger replaced his infection-focused predecessor as the Surgeon General's pellagra-research appointee, a new direction of research opened up. A yellow fever and dengue fever survivor and epidemiologist, Goldberger used his own and others' observations of staff immunity in pellagra-plagued institutions like orphanages and insane asylums to rule out a communicable infectious agent ^9. He honed in on dietary inequities between affected and non-affected, and from there experimented on increasing variety of diets in institutions and thus curing pellagra there. Although his findings supported hypothesis, the Southern Medical Association and the Association for the Study of Pellagra responded with hostility. He responded by experimentally inducing the disease in inmates by dietary changes and later failing to induce the disease in himself and colleagues who injected or consumed potentially-infectious body materials from pellagrins. For all his pains and feces-eating, skeptics remained ^10.

However, by establishing that pellagra was a dietary deficiency disease, Goldberger was on the path to ending the epidemic--even when a healthy, balanced diet was not available. A series of accidental discoveries involving canine pellagra led Goldberger to brewer's yeast as a treatment and prophylactic: he had the Red Cross provide yeast to prevent an outbreak among victims of the Great Flood of 1927 ^11. Yeast became a popular clinical treatment, followed by injections in the late 1930s ^12.

Niacin was finally identified as the specific nutrient lacking in pellagrins in 1938 ^13. This time the embarrassment of politicians about having malnourished populations was productive: state laws ordered the enrichment of many common foods with niacin and other nutrients commonly involved in deficiencies ^14.

The United States solved pellagra not by ameliorating the inadequacies in the processing methods they invented and applied to a crop adopted from other cultures, nor by directly addressing the inequities of food distribution and the problem of monoculture in their societies, but by extending their reliance on science and technology through vitamin supplementation. The emphasis on scientific explanations eventually solved the mystery of pellagra and produced several treatment paths, but for a while helped block treatment through varying diet because of a narrow-minded focus on infectious agents.

Cereal box showing supplementation with niacinamide to 25% RDA of niacin

1. Alfred J. Bollet, Plagues and Poxes: The Impact of Human History on Epidemic Disease. (New York: Demos Medical Publishing: 2004.), 156.
2. James Jackson Jarves, "Italy and Her Dark Side: A Frightful Scourge Poverty Has Caused
There," The New York Times, June 19, 1881. Accessed at http://query.nytimes.com/mem/archive-free/pdf?res=9B05EEDE103CEE3ABC4152DFB066838A699FDE
3. Bollet, 158.
4. Ibid., 158.
5. Ibid., 160.
6. Ibid., 161.
7. Ibid., 162.
8. Ibid., 162.
9. Ibid., 163.
10. Ibid., 163-4.
11. Ibid., 166-7.
12. Ibid., 167.
13. Waldemar Kaempffert, "Authorities Sure of Pellagra Cure; New Tests Confirm Finding That Nicotinic Acid Offers a Reliable Specific," The New York Times, March 20, 1938. Accessed at http://select.nytimes.com/gst/abstract.html?res=F60A16F93D55157A93C2AB1788D85F4C8385F9&scp=1&sq=pellagra+kaempffert&st=p
14. Bollet, 167. 

Conclusion

From the processing and exchange of corn in the New World to widespread disease and misattribution in Europe, we have seen pellagra develop. Though one of the less-told stories of the Columbian Exchange, the presence of and reactions to pellagra can tell much about societies at the time. While Native American societies tended view disease as a punishment earned by mistreatment of the environment, and therefore respected the environment and their own time-tested ways of dealing with it, the Europeans took a more removed view. Even knowing the dietary cause of pellagra, they looked to socioeconomic and medical causes rather than the relationship between humans and environment - food production being a central part of that. This removal from not only the environment but from the processing of the corn itself (as many bought cornmeal ready-made and did not know that preparing it properly could help prevent malnutrition) made it difficult for the Europeans to understand pellagra or put an end to its effects. In contrast, the Native Americans - though they did suffer from malnutrition, in some cases - were able to sustain a diet based in large part on maize for thousands of years by paying close attention to the processing of corn and their interactions with the environment around them. With this in mind, one of the lessons of the pellagra epidemic might be to pay attention to the contexts of exchanged goods and disease - not only social context, but environmental context as well.

Bibliography

Aftandilian, Dave. "Toward a Native American Theology of Animals: Creek and Cherokee Perspectives." Cross Currents 61 (2011): 191-207. Accessed at http://web.ebscohost.com/ehost/detail?sid=071cbf78-aa8e-4272-8165-2e2019be8bfd%40sessionmgr104&vid=3&hid=122&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=aph&AN=60975843

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