Am J Epidemiol 2004; 159:211-212.
Copyright © 2004 by the Johns
Hopkins Bloomberg School of Public Health
BOOK REVIEWS |
Goldberger’s War: The Life and Work of a Public Health Crusader
Global Health, School of Public Health and Health Services, The George Washington University, Washington, DC 20037
By Alan M. Kraut
ISBN 0-374-13537-1, Farrar, Straus and Giroux, New York, New York (Telephone: 212-741-6900, Fax: 212-206-5340, e-mail: fsg.publicity@fsgbooks.com, Web site: http://www.fsgbooks.com), 2003, 336 pp., $25 (hardcover)
This book about one of the most well regarded early epidemiologists in the United States covers not only Dr. Joseph Goldberger’s long history of investigations of disease outbreaks and his research as Public Health Service Officer of the Hygienic Laboratory (the precursor of the National Institutes of Health) but also his personal life as an immigrant Jew who married the grandniece of Confederate President Jefferson Davis. Highlighted is his role in solving the puzzle of pellagra—a disease whose cause and cure had eluded the world for centuries.
Of particular interest to faculty and students of public health, preventive medicine, and public policy is the book’s interface of science and health policy. Like his earlier book, Silent Travelers: Germs, Genes, and the Immigrant Menace (1), Professor Kraut illuminates the political climate operative at the time and its effect on the public’s health. In particular, this book provides insights into the "culture" of the US Public Health Service in the early part of the 1900s.
Goldberger was born on July 16, 1874, in Giralt, Hungary, and he emigrated to the United States in 1881. He entered The City College of New York at age 16 years with hopes of a career in civil engineering but transferred to medical school and earned an MD degree in 1895.
Goldberger joined the United States Marine Hospital Service (later the US Public Health Service (PHS)) in 1899. Ironically, the immigrant from central Europe began his Public Health Service career inspecting immigrants in the port of New York. However, it was not long before his epidemiologic skills earned Goldberger the reputation of a tenacious and clever epidemic fighter.
For several years, he served as a quarantine officer at various ports, including Tampico and Vera Cruz, Mexico. There he studied yellow fever and its transmission by mosquitoes and assisted Dr. Milton Rosenau, chief of the PHS Hygienic Laboratory, in yellow fever and malaria studies. That led to his assignment for the major portion of his PHS career at the Service’s Hygienic Laboratory.
The work was dogged, dangerous, gritty, and gory—typical of the epidemiology of infectious diseases. Goldberger contracted practically every disease he investigated: dengue fever in Texas; yellow fever in New Orleans, Louisiana; and typhus in Mexico.
Despite the importance of his other work, Goldberger’s fame rests on his solving the puzzle of pellagra. That disease took him to the mental institutions, orphanages, and prisons of the US South.
Pellagra was not described in America until 1906, but it erupted quickly into an epidemic in the South. From 1906 until 1940, 3 million cases and 100,000 deaths are estimated to have occurred just in the states that reported cases.
Theories of its etiology abounded. However, when Goldberger was assigned to the pellagra problem, it was considered an infectious disease of unknown etiology.
Goldberger’s theory on pellagra contradicted commonly held medical opinions. His observations in mental hospitals, orphanages, and cotton mill towns convinced him that germs did not cause the disease. In such institutions, inmates contracted the disease but staff never did. Goldberger knew from his years of experience working on infectious diseases that germs did not distinguish inmates from employees.
He tested his hypothesis in three ways. The first was a prospective treatment study in a Mississippi orphanage where almost 50 percent of the orphans had pellagra. Goldberger started an enriched feeding program that included milk, meat, eggs, and fresh vegetables on one ward, keeping another ward as a control group. The prevalence of pellagra dropped to zero in the "treated" ward but stayed the same in the control ward.
The second test was to actually produce pellagra, which he did in the infamous Rankin Farm experiment, engineered by Goldberger and Mississippi Governor Earl Brewer. Eleven Mississippi convicts, murderers, embezzlers, and forgers—all of whom were serving long terms—agreed to a regimen of light work and a diet of biscuits, mush grits, syrup, coffee, corn bread, cabbage, sweet potatoes, and rice for 6 months in return for their freedom.
By the fourth month, however, they were too weak to work. By the sixth month, five of the 11 men had pellagra. Several dermatologists were brought in to make the actual diagnosis to avoid the appearance of a conflict of interest on Goldberger’s part.
If poor diet resulting from poverty among southern tenant farmers and mill workers was the root cause of pellagra, then the only real cure was social reform, especially changes in the land tenure system. A dramatic drop in cotton prices in 1920 and the attendant decrease in the income of many southerners occasioned a spike in the number of reported pellagra cases. Goldberger publicly predicted dire public health consequences for 1921, when there might be as many as 100,000 pellagra cases, including 10,000 deaths, and even worse for 1922. Goldberger was proved correct. There was a dramatic increase in pellagra and in the number of deaths, although not quite as many as he had predicted.
During the 1920s, Goldberger continued research to identify what he called the "pellagra preventive factor." He learned that a small amount of dried brewer’s yeast prevented the disease as effectively and more cheaply than fresh, lean meat; milk; and vegetables. He also began laboratory experiments on dogs after learning that black-tongue disease was the canine equivalent of pellagra.
Goldberger spent the rest of his career trying to solve the pellagra puzzle, looking for the nutritional element that could prevent it. He never found it. In 1928, Joseph Goldberger fell gravely ill of hypernephroma, a rare form of cancer. He died on January 17, 1929.
"He craved travel and adventure" is how Dr. Myron Schultz, a fellow parasitologist, described Goldberger’s life. He got both and, along the way, glory, too. For his federal work, he was nominated five times for the Nobel Prize. His investigations were models for present and future generations of public health workers.
During the next decade, Conrad A. Elevjhem found that a deficiency of nicotinic acid, better known as B vitamin niacin, resulted in canine black-tongue disease. In studies conducted in Alabama and Cincinnati, Ohio, Dr. Tom Spies found that nicotinic acid cured human pellagra patients as well. Tulane University (New Orleans) scientists discovered that the amino acid tryptophan was a precursor to niacin. When niacin was added to commercial foods such as bread to "fortify" them, it prevented the scourge of the South. Today, pellagra has been all but banished, except for infrequent occurrences during times of famine and displacement.
This book provides a remarkable snapshot of the application of epidemiologic principles to the enhancement of public health in the United States in the first third of the 1900s. The author’s linkage of the personal life of a "public health crusader" with his scientific discoveries makes it a fascinating as well as instructive document.
REFERENCES
- Kraut AM. Silent travelers: germs, genes, and the immigrant menace. Baltimore, MD: Johns Hopkins University Press, 1995.
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