Pellagra

“There was no treatment for pellagra, aside from an improved diet, and ... we can’t improve the peasants’ diet. That’s not our job. We’re doctors.”

Episode Transcript

JEREMY: Hello and welcome to another episode of Eat This Podcast with me, Jeremy Cherfas. (00:06):
undefined
This is the last episode in the current series, and I'm taking the opportunity to look closely at a problem of food
and ill health, which I think is a cracking example of the huge difficulty involved in answering what seems like a very simple

question (00:30):
what causes a disease? To help me, I spoke to David Gentilcore,
a professor of early modern history at Ca' Foscari University in Venice,
and Dana Landress, an assistant professor in the Department of Medical History and Bioethics at the Department of History at the University

(00:51):
of Wisconsin, Madison. The disease in question is pellagra, and they studied it in Italy and in the US.
P ellagra used to be very serious, although you may not have heard of it.

DAVID GENTILCORE: At one point in the 1880s, it was affecting 100,000 people, but those are 100,000 documented cases. (01:07):
undefined
That means 100,000 peasants who've gone to see their doctor and the doctor has made a note of it,
you know, provided this data to the authorities.
So we can imagine that was only the tip of the iceberg.

(01:28):
So that would have been the 1880s, 1890s.
And that's when admittance to the insane asylums in northern Italy also reached their peak.
So basically half of the inmates of these asylums would be suffering from pellagrous insanity.

JEREMY: And in the US. (01:45):
undefined

DANA LANDRESS: It is one of the leading causes of morbidity and mortality across the South in the early 20th century. (01:47):
undefined
And so, for instance, in Alabama there are a number of years in the 1910s where it is the leading cause of death.
In South Carolina, it ranks as top three, and in places like Louisiana,
it ranks as top four causes of death.

(02:09):
But for the most part, that data is concentrated on urban areas that are collecting sort of epidemiological tracking data at these and sort
of major urban areas like New Orleans, like Spartanburg, South Carolina,
like Atlanta. But we know that this is a disease that impacts rural communities as well.
And we have rough estimates from the US Public Health Service data, which suggests that pellagra was impacting about 100,000 people per

(02:38):
year up until about the mid 1940s. So the kind of end of the world Second World War.

JEREMY: Note that date. Not that long ago. And yet, from being a scourge less than a century ago, (02:43):
undefined
pellagra is now almost unheard of. Today, we know for
sure that at one level at least, the cause of pellagra is a lack of vitamin B3,

(03:06):
known as niacin. But there are many other ways to think of the cause of the disease,
which is what this episode is all about.
Anyway. Pellagra was first described in 1735 among poor peasant farmers in northern Spain.
And in Italy, in the 1760s, they tended to say that it first appeared about a generation ago,

(03:32):
so maybe the 1740s. But what is pellagra?

DAVID GENTILCORE: The first apparent symptom, and what gives the name to the disease in Italian, (03:38):
undefined
is the peeling off of the skin from the upper chest, the forearms and the lower legs.
But it's more than just like, you know, a sunburn.
It's actually the whole epidermis peeling off.

(04:00):
Very painful, leaving scarring underneath.
Gives the name pellagra -- pelle agra, meaning rough skin -- which is essentially what the peasants called
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,

(04:22):
since it was a new disease and there was no medical, you know, no fancy Latin or Greek name for it.

DANA LANDRESS: Clinicians typically call it symptoms the four D's diarrhoea, dermatitis, (04:28):
undefined
dementia, and, if left untreated, death.

JEREMY: Not nice at all. The big question, of course, was what exactly was pellagra? (04:37):
undefined

DAVID GENTILCORE: You remember the initial phases of Covid. (04:43):
undefined
You know, if we're going to get anywhere with this, we need to know exactly what it is.
And obviously in the 1760s, there is no way other than observation.
They are very good, very, you know, good observers, trying to create a clinical picture of the disease.

(05:06):
So they're very attentive. But the key issue for them is how to classify,
what kind of disease ... Is it even new?
Has it already existed? But we just didn't know.
Is it a form of leprosy? Is it a form of scurvy?
Is it a form of ergotism? And then, no, no, it's symptoms don't fit in with any of these.

(05:32):
So it must be new. Okay, so if it's new, what exactly is it?
And then, what do we do about it?

JEREMY: One early clue was that it was associated with maize, and also that it seemed to afflict only very poor people. (05:42):
undefined
Maize, remember, was still a relatively new crop in Europe, one that farmers had taken to with enthusiasm.

DAVID GENTILCORE: Maize is a fabulous crop. I mean, it grows where other crops won't. (05:59):
undefined
It has a shorter growing season than, say, wheat.
It has really high yields. But where people want to turn it into flour and where
they consume it in the form of polenta, that's what causes it.

(06:22):
I mean, in terms of the social classes, we're essentially talking about landless labourers,
landless peasants, field hands, tenant farmers, and people who don't really have much choice what to grow.
Because if you're only growing that and maize becomes a cash crop, so you want to grow it.

(06:46):
You know, it makes economic sense, but maybe at the expense of growing just other fruits and vegetables,
which would have staved off pellagra.
By the 1790s early 1800s, it's clear there's a link between maize cultivation,

(07:08):
diet, and this new disease. They don't know what the mechanism is yet.
They don't know what the link is. They don't know what the causal relationship is yet,
but they see a correlation. And then you get two big theories emerging by the middle of the 19th century,

(07:30):
which they fight it out for decades.

JEREMY: In some respects, it's a bit of an unfair fight because the competitors are pretty badly matched. (07:32):
undefined

DAVID GENTILCORE: On the one hand, you have Cesare Lombroso, infamous founder of anthropological criminology (07:39):
undefined
and Lombroso is the most famous scientist in Italy.
Yeah. He's the second most read Italian author after Collodi, who wrote Pinocchio.

(08:02):
Right. So he's very, very famous. He's a tireless correspondent.
And as soon as you attack him, the very next day, he's got a counterattack in some local newspaper.
You know, he never lets up.

JEREMY: So that's Lombroso, super famous, super pugnacious and super wrong. (08:16):
undefined
But I'm getting ahead of myself.

DAVID GENTILCORE: He posits that it's tainted maize. That's the problem. (08:24):
undefined
It's infected maize, a bit like ergotism and rye, okay.
In ergotism it's a fungus that attacks the rye.
He posited something like that. He even in in his laboratory in the 1890s,

(08:45):
he claimed to have discovered something which he called pellagrosine.
He even gave it a name and said, this is the causal agent.
All we have to do is eliminate this fungus from maize, we've solved the problem.
We just make sure that when the maize is harvested, it's fully ripe.

(09:09):
That before it's milled, it's fully dried.
There's no mould or anything on it.
And then when it's made into polenta, we have to make sure the polenta itself doesn't go mouldy.

JEREMY: Lambroso is extremely convincing, not least because anyone can see that when poor peasants make polenta, (09:22):
undefined
what they tend to do is make a big batch once a week.
They have a huge loaf of the stuff, and each meal, everyone gets a slice.
And because polenta is pretty moist, by the end of the week, it is pretty green and furry.

(09:45):
But the real beauty of Lombroso's idea of something toxic in the maize is that it lends itself to simple technical solutions.

DAVID GENTILCORE: So we don't have to eradicate peasant poverty. (09:55):
undefined
We don't have to worry about maize cultivation, production and so on.
It won't attack the financial interests.

JEREMY: His view then was that it was something toxic growing on the maize. (10:05):
undefined
The alternative view, not nearly as simple, was that there was something missing from the diet,
and particularly from maize.

DAVID GENTILCORE: There's something wrong with polenta that doesn't give people adequate nourishment. (10:19):
undefined
There's something deficient, something lacking.
But the people who propounded this view did not have laboratory technology,
didn't even have the language that we have to talk about, I don't know,

(10:43):
proteins, amino acids. That's language that we develop in the early 20th century.
So that explanation wasn't nearly as convincing.

JEREMY: But here's the thing, both Lombroso and his main opponent, Clodomiro Bonfiglio, (10:53):
undefined
are working in insane asylums, which is where most of the really bad cases of pellagra ended up.
Lombroso is in Pavia, near Milan, and Bonfiglio is director of the provincial asylum in Ferrara.

DAVID GENTILCORE: So they have this in common, you know, and they're both ... (11:14):
undefined
It's often, you know, it's easy to depict Lombroso as kind of the bad guy,
you know, but actually both of them are really socially committed.
They have their heart in the right place. They're really working hard to find a cure,

(11:34):
or cause and a cure, for this disease.
It's just that Lombroso, by insisting that his was the only possible explanation,
really throws science, puts science in the wrong direction for, well,
40 years I guess .

JEREMY: We'll come back to Lombroso and his cures. (11:52):
undefined
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.
There's this chap, Luis Sambon. Half English, half Italian.

(12:13):
He's originally a gynaecologist in Rome, but he goes to London and ends up at the London School of Hygiene and
Tropical Medicine. There he comes under the spell of people like Sir Ronald Ross,
and the idea that diseases like malaria can be transmitted by insects.

(12:34):
He's also taken up by the wealthy pharmacologist Sir Henry Wellcome.

DAVID GENTILCORE: Wellcome hired him, Sambon, to go off looking for antiquities, because Wellcome was a great purchaser of anything antique, (12:40):
undefined
anything to do with the history of medicine, which he was fascinated by.
And so Sambon would go on these trips to Italy, ostensibly to buy up books and manuscripts and

(13:04):
any ancient artefacts he could lay his hands on.
But he had this passion for pellagra at the time.
He goes to the Roman Campagna to work on malaria with a small group.
He's obviously a brilliant, you know, brilliant ideas person.

(13:25):
And so he simply superimposes one map on top of another.
You know, as an epidemiologist, he's thinking about the geographical spread.
Where does pellagra manifest? Oh, look, there's an insect that has the same more or less the same spread.
It's another case of it being very convincing, Very persuasive.

(13:50):
B ut so is Sambon. He's a very ... You read his articles and you think.
Oh, yeah, that's that's perfectly reasonable .

JEREMY: Sambon's very persuasive theory, that pellagra is caused by a parasite spread by a blackfly, (14:02):
undefined
doesn't get much traction in Italy.
Across the Atlantic, it's a different story.

DAVID GENTILCORE: When pellagra breaks out -- breaks out -- when it appears, first appears in the US, (14:15):
undefined
he's one of the first people they invite over because he seems to have the answer .
A new disease, a new explanation. The Americans love it, you know.
Oh, the Italians have had pellagra for years. They haven't been able to solve the problem.
We need a new approach. It's an off the wall ...

(14:39):
I mean, normally, like I say in one of my publications, he's normally just a footnote in history.
I think it's fascinating that he gains a kind of notoriety for a few years,
and then that's it. He has his, you know, whatever, 15 minutes of fame.
And then, you know.

JEREMY: Of course, when the Americans say that the Italians haven't been able to solve the problem, (15:01):
undefined
they're being very reductionist. The solution is a better diet.
But that isn't a good enough explanation.
It's too fuzzy. Many Italians knew perfectly well that a better diet could reverse the symptoms of pellagra,
though they did also try drugs of different kinds.

(15:24):
Lombroso himself treated it with compounds of lead and arsenic, and he recommended bathing in salt water.

DAVID GENTILCORE: Can you imagine taking a salt bath when your whole, you know, epidermis is peeled off? (15:34):
undefined
How nice that would have been? It wasn't about treating the patients themselves.
Rather, what they thought were the causes.
But if you're saying, okay, the causes are what Lombroso says the causes are,

(15:56):
then we need to treat the causes of tainted maize.
We need to make sure there's no mould on the maize.
So we set up these huge drying ovens for the kernels to dry before they're milled.
Or we set up soup kitchens to ensure the peasants get other foods to eat.

JEREMY: Experimental science did get a brief look in. (16:16):
undefined
One of the places getting good results with a diet was a hospice north of Venice,
where pellagra sufferers were given better food.
Lambroso didn't think too much of that, so he issued a challenge.

DAVID GENTILCORE: The founder of this hospice and Lombroso are corresponding, and Lombroso says, (16:32):
undefined
here, you take 30 of my patients and half of them you treat with the remedies I give you,
the arsenic, the lead and so on. Half you treat however you want.
And so the founder of the hospital's name is Costantigris, he says, okay,

(16:55):
I'll give them the restorative diet that I've come up with, and the other 15 I'll treat.
The 15 he treated with the medicines got worse.
His 15 were all released from hospital, pronounced cured.
And he communicated this to Lombroso, at which point Lombroso stopped writing to him.

(17:17):
So, you know, Lombroso had only one possible solution in mind, and it was medical.

JEREMY: David Gentilcore, a nd I'll be coming back to him in a while. (17:27):
undefined
But it's time to turn now to Dana Landress, because while doctors in Italy and other maize-
growing areas in Europe had become familiar with pellagra by the end of the 19th century,
in the U.S. i t first really becomes apparent in the summer of 1906.

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. (17:53):
undefined
You have physicians who sort of retroactively write into the US Public Health Service and say,
you know, I was a physician at Andersonville Prison, for instance, during the Civil War.

(18:14):
And I saw this disease that was mysterious in 1864, 1865.
And we only now have the language to be able to diagnose that as pellagra.
Had I known then what I know now, we would have sort of taken different measures amid the war to combat it.

JEREMY: Officials in the U.S. really weren't sure what to make of this new disease. (18:29):
undefined
Beginning in 1909, South Carolina hosted a series of conferences each year with invited international guests,
including Louis Sambon, but five years later there was still no real agreement.
Some people liked Sambon's idea that it was spread by insects.

(18:51):
Others really weren't sure.

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 (18:54):
undefined
epidemic in the United States, which is to say that there is no consensus .
From 1906 to roughly 1914 there are three principal theories that all have traction in U.S.

(19:15):
medical circles. One is the corn toxin theory.
Another is the insect vector theory.
And then, of course, you have the dietary deficiency disease, which is also beginning to gain traction in this period.
And it's a bit amorphous during the first outbreak in 1906.
But those are the primary sort of three theories.
And I would say that there is no consensus.

JEREMY: Into that mess. The young US Public Health Service inserted the man generally accepted as the hero of the story. (19:38):
undefined

DANA LANDRESS: Doctor Joseph Goldberger is appointed, beginning in the summer of 1914, (19:47):
undefined
to do essentially a tour of the southern United States, trying to gain preliminary epidemiological data.
And so as part of this tour in 1914, he begins to track incidents of pellagra at places like state
hospitals, orphanages and asylums.

JEREMY: Goldberger noted that the most severe outbreaks afflicted poor people, (20:09):
undefined
often working in cotton mill towns in the south.
He focused on a couple of orphanages in the Deep South.

DANA LANDRESS: The orphanage study actually takes place at two institutions, two religious affiliated orphanages in Mississippi. (20:22):
undefined
And the idea here really is to design a therapeutic kind of intervention.
And so Goldberger begins tracking how frequently the children are eating the kinds of foods they are eating.
A rough sketch of the kind of caloric intake they're getting on a daily basis,

(20:44):
and he quickly discovers that the food that they are eating is nutritionally replete.

JEREMY: Nutritionally replete. I had to correct my original understanding of the word replete. (20:51):
undefined
It means filled up, but not in a good way.
A nutritionally replete diet is one that fills you up, but that doesn't offer much nourishment.
And Goldberger is really struck by the fact that only the orphans, not the staff looking after them,

(21:11):
get pellagra. So it's unlikely to be either a pathogen or a toxin.

DANA LANDRESS: And he begins to supplement their diet with leafy green vegetables, with lean meats, (21:18):
undefined
with legumes, peas. And he finds that this very quickly remedies the outbreak and that within a year,
neither institution has any new cases of the disease.
So this is kind of the first confirmation that Goldberger has that pellagra might not be infectious.

JEREMY: Of course, the Italian doctors could have told him that a better diet would work. (21:45):
undefined
But Goldberger persevered, and his next experiment was to try and induce pellagra by changing the diet.

DANA LANDRESS: This experiment is conducted with 11 white male convicts at a prison farm in Mississippi that is known as Rankin State Prison (21:57):
undefined
Farm. It's about 20 miles east of the capital of Jackson, Mississippi.
And this is a non therapeutic experiment that is intended to produce pellagra's dermal lesions in convicts by feeding them a calorically

(22:20):
and nutritionally replete diet.

JEREMY: Remember, nutritionally replete means filling but not nourishing. (22:24):
undefined
And it doesn't go well.

DANA LANDRESS: Unfortunately, about three months into the experiment, there are no clinical symptoms of pellagra that are produced among the (22:30):
undefined
convicts. And so Goldberger and his assistant doctor George Wheeler make the decision to actually cut back by about 500 calories,
the amount of food that the prisoners are consuming to try and induce this disease.

JEREMY: The problem turned out to be something extremely mundane. (22:50):
undefined

DANA LANDRESS: We now know that coffee has small trace amounts of niacin, and that the prisoners were actually consuming coffee once, (22:55):
undefined
sometimes twice a day.

JEREMY: And coffee might explain why only six of the 11 prisoners ended up producing definite signs of pellagra. (23:04):
undefined
But it was good enough for Goldberger and for the Mississippi state governor,
who issued the pardons that were promised to the men in exchange for their volunteering.

DANA LANDRESS: In his pardon slips. Governor Brewer describes this as a pardon given for meritorious contributions to public health and to service of (23:23):
undefined
humanity.

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 (23:32):
undefined
governor were now free to rejoin society after just a few months of deprivation.
Leaving that aside, they did help Goldberger to prove his theories, and that was welcomed.

(23:58):
A headline in The Watchman and Southron newspaper in December 1915 announced A Cause and Cure of Pellagra,
and outside the South, colleagues were quick to applaud Goldberger.

DANA LANDRESS: You have many individuals who praise Goldberger very widely for this finding. (24:13):
undefined
They believe that this is the confirmation that the medical establishment needed to understand the etiology of pellagra.
Outside of the South, he is widely lauded for the success of the prison experiment and its implications in this kind of treating

(24:34):
pellagra.

JEREMY: In pellagra's heartland, however, there was opposition. (24:35):
undefined
The very same edition of The Watchman and Southron, right next to its news of the cause and cure of pellagra,
contained a story from a meeting of the Southern Medical Association that spoke of "sharp differences of opinion".

(24:56):
Goldberger needed to prove, beyond a shadow of a doubt, that pellagra was not caused by a pathogen that could be transmitted
from person to person. And so, in the best tradition of medical experiments,
he invited some colleagues to parties.

DANA LANDRESS: These are essentially what are known as the filth parties that are done in Spartanburg, (25:14):
undefined
South Carolina. And so he recruits not only himself and two advisory clinicians from the US Public Health Service,
but also a couple of patients who had been admitted to the hospital at Spartanburg,
South Carolina. And, perhaps most famously, his wife, Mary Farrar Goldberger,

(25:36):
who in being a very devoted spouse wanted to support her husband's research endeavours.
Most essentially, the idea is to provide even more compelling evidence that the disease is not infectious,
but rather caused by by dietary insufficiency.

JEREMY: How did they do that? The clue is in the name. (25:51):
undefined

DANA LANDRESS: The Filth Parties. (25:55):
undefined

JEREMY: And be warned, it gets gross. (25:56):
undefined

DANA LANDRESS: They essentially take the scabs scraped from the dermal lesions of pellagra patients who had been admitted to the Spartanburg Pellagra (25:59):
undefined
Hospital. They take urine samples, they take faecal samples, and they orally ingest them.
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,

(26:21):
which seems fairly mild given the context of the experiment.
E veryone is fine, you know, there are no lasting symptoms.
And again, it's just an attempt to really try and stave away these recalcitrant critics that Goldberger has faced in the southern medical
community.

JEREMY: I think he knew perfectly well what he was doing. (26:39):
undefined
A later newspaper headline said Scientist Risked Death to Give Mankind Life .
But I'm pretty sure that by this stage, Goldberger was certain in his own mind that pellagra was not
contagious. His first subject was himself, alone and in private, and he didn't become ill.

(27:03):
So while Goldberger was praised by colleagues in the North and ultimately nominated for the Nobel Prize four times,
things were not so rosy down in Dixie.

DANA LANDRESS: People like James Haynes, who is the state health officer of South Carolina, (27:15):
undefined
continue to adhere to this insect vector theory.
And as late as the 1950s and 60s, you have individuals in Alabama who still want to suggest that pellagra is
an infectious disease, but that maybe there's some sort of underlying dietary mechanism going on.

(27:38):
And so in very particular kinds of circles in the Deep South, the insect vector theory continues to hold traction for a number of
years.

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. (27:53):
undefined
So why, when the medical evidence seemed so clear cut to everyone else,
why was Goldberg's explanation rejected?

DANA LANDRESS: Pellagra is bad for business. Pellagra is a disease that has a strong connotation with regional poverty. (28:10):
undefined
It has a strong connotation with lethargy and laziness.
And if you have a workforce that is plagued with a particular disease,

(28:31):
it is much easier to introduce a kind of technical intervention, such as a fly trap or a screened door,
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,
and the labour conditions under which they are working.
And so the short answer is that pellagra is bad for business.

JEREMY: The fact is, economics and society at large has a huge impact on pellagra. (28:51):
undefined
In the US South, the boll weevil destroyed the cotton crop in the 1920s,
but because they weren't growing so much cotton, they had space for a few vegetables.
Good food became more available despite a drop in incomes, and pellagra receded.

(29:14):
In Italy too, long before, economics had the opposite effect, when landlords started to change their agreements with their tenants
from sharecropping to rent in cash.
David Gentilcore.

DAVID GENTILCORE: The success of maize as a cash crop brings about a transformation in the whole economy. (29:28):
undefined
So rather than, say, have a kind of tenant farmer arrangement that they made,
that was traditional, there's a move towards paying rent in cash, which has a real detrimental

(29:54):
effect on on peasant well-being. It essentially brings them into debt because in a bad
year, your rent is ... See, in the former system of like tenant farming,
if it was a bad year and you had to give over a third of the crop, well,
you just gave them less, but it was still a third.

(30:16):
Whereas with a set rent, if it's a bad year, you can't pay the rent.
You go into debt and that just gets worse and worse.

JEREMY: The effects of bad years were disastrous, with emigration out of northern Italy to the tune of 2 million people. (30:25):
undefined
But that mass emigration actually helped with pellagra at home.

DAVID GENTILCORE: Ironically, it's the mass emigration that eventually contributes to the decline of pellagra, (30:41):
undefined
because the emigrants send back remittances.
And that cash, that little cash that's available, means that you can actually choose what to eat.
And invariably, the peasants choose not to eat polenta when given the choice.

(31:04):
I mean, it's simply a question of wanting more variety, I think.

JEREMY: Still, while I take Dana Landress's point that pellagra was bad for business, (31:08):
undefined
the mill owners and the like were supported by the medical establishment who refused to see the obvious.

DANA LANDRESS: I think this is actually an instance where in some cases you have to follow the money, (31:21):
undefined
and many of these physicians were in professional and personal circles with the kind of mill managers and other kinds of owners,
who believed that the best way to kind of alleviate regional poverty was to attract business,

(31:42):
and that this was going to be the ultimate cure for pellagra.

JEREMY: The great thing about science, of course, is that it doesn't care what you believe. (31:46):
undefined
Pursuing what he called the pellagra preventative vitamin, not least because the generic better diet was too expensive for most
institutions, Goldberger established that dried brewer's yeast contained plenty of it,

(32:07):
whatever it was. And he put that knowledge to use .
In the wake of the Great Mississippi Flood of 1927, three cents worth of dried yeast in their food saved hundreds of
thousands of people from pellagra. The alternative, according to one newspaper report,

(32:28):
would have been a dollar of fresh food, which in any case was not easily available after the flood.
Goldberger died of kidney cancer in 1929.
In 1937, Doctor Conrad Elvejhem at the University of Wisconsin finally identified what he'd been calling vitamin G --

(32:54):
for Goldberger. It was vitamin B3, niacin.
So you can say pellagra is caused by lack of niacin.
You can also say it's caused by industrial capitalism.
And to that mix, you can add that it was caused by Eurocentric arrogance.

(33:16):
The indigenous people of the Americas, who subsisted on corn for centuries never showed any signs of anything
resembling pellagra, even in times of want.
And that's because they learn to process their maize with an alkaline solution,
often by soaking the kernels in water containing dissolved lime or wood ash.

(33:44):
That process is called nixtamalisation.
After the Nahuatl words for lime ashes and uncooked corn dough, the same word that gives us tamales.
The Europeans who adopted maize as a cash crop with glee simply ignored indigenous techniques like nixtamalisation.

(34:05):
Even Cesare Lombroso threw out the evidence available to him.

DAVID GENTILCORE: In fact, Lombroso in one of his studies, does mention the Indios, he says, (34:10):
undefined
of Mexico. He says, well, you know, they don't get pellagra.
Why not? And his answer was, well, obviously the maize there is a better quality.
It doesn't get mould. He's still ...
You know, in a circular argument like that, you can't win.

(34:31):
He's always got the answer. And yet, if they had observed maize in its place of origin,
you know, we have early descriptions where the Spanish conquistadors are writing these accounts of discovery.
They described traditional ways of producing.

(34:51):
But Europeans aren't interested. They just want to turn it into flour.
There's this obsession we have in Europe with bread, with milling, means that they can only see maize in this one way.
They have to, yeah, treat it like wheat.

JEREMY: Goldberger's experimental approach squarely demonstrated that pellagra was caused by a dietary deficiency, (35:09):
undefined
regardless of what actually caused the deficient diet.
But did it have any impact back in Italy?

DAVID GENTILCORE: No, because people knew that already. (35:25):
undefined
I mean, the hospital doctors all knew, and they write this on the records quite clearly.
Oh, so-and-so is cured, but he'll go back to his diet and we'll see him again before long.
Even before they knew about about niacin, hospital doctors simply knew from experience,

(35:45):
give them a decent diet. The one thing that determines this, though, is if they can stop the diarrhoea.
And there's no way in this period to stop diarrhoea.
So if the patient gets better, can keep the food down, can digest it,
they get better. Quite simple. So even before Goldberger, they know that as a reality.

(36:10):
By Goldberger's time, in Italy pellagra has practically disappeared.
Nobody's really investigating it anymore.

JEREMY: The Italian government ignored social factors and took Lombroso's advice to heart. (36:18):
undefined
In 1904, they passed the first law to combat pellagra, which mandated big drying ovens in maize growing areas.
Cases had in any case, started to decline a decade or so before .

(36:38):
Peasants began to organise and demand better conditions.
And of course, there were the remittances sent home by the millions of Italians who emigrated.
Italy had quietly vanquished pellagra.

DAVID GENTILCORE: Ultimately, it's the First World War. (36:52):
undefined
And then there's another paradox. You would think, oh, conditions would get worse during the war.
But no, the Italian government buys in lots of wheat from abroad in 1915,
which essentially subsidizes the price of bread.
And so these peasants, finally they can afford bread.

(37:13):
So naturally they they opt for that.
Mussolini, in 1927, he's celebrating five years of fascist rule.
And he's very smug. He's able to say, we've solved this problem, the Americans haven't.
Meaning, by his time, pellagra was history.

(37:36):
The government had nothing to do with it, it has to be said.
Medical science had very little to do with it.
It was simply improving peasant conditions that were behind that.
So it wasn't politics. And it wasn't really a medical intervention because there was no treatment for

(37:56):
pellagra aside from an improved diet.
And even Lombroso said, we can't improve the peasants' diet.
That's that's not our job. We're doctors.

JEREMY: Well, whose job is it, then? For pellagra, the answer is quite easy. (38:11):
undefined
Governments said that some foods have to be fortified with added niacin,
and that solved the problem. Today we look back on pellagra as a distant memory.
Will we one day be able to do the same for, say, type two diabetes?

(38:34):
With current ill health linked to food, where the whole point of food manufacturers is to get us to eat more,
which kind of cause do you focus on?
Biochemical, Economic? Societal?
I don't have answers, but I'd love to know what you think.

(38:56):
You can email me -- Jeremy @eat this podcast.com -- or leave a comment on the website at eatthispodcast.com .
My profound thanks to Dana Landress and David Gentilcore for their help in making this episode.
I'm taking a break over the summer; back in a couple of months.

(39:18):
There are more than 300 episodes in the archive in case you miss the show.
And be sure to subscribe wherever you get your podcasts so you don't miss the return.
If you're already subscribed to Eat This N ewsletter, then that will alert you when the podcast is back.
And in the meantime, I'll continue to share interesting stuff that I find every week.

(39:43):
If you want to sign up for that, head over to eatthispodcast.com/subscribe and you'll find a link at the bottom of
the page. My thanks again to supporters for allowing me to make everything freely available,
including written transcripts and subtitles.

(40:06):
For now though, from me, Jeremy, surface and Eat This podcast.
Goodbye and thanks for listening.