From Girált to the Lower East Side
Joseph Goldberger was born on July 16, 1874, into a Jewish family in Girált, a small town in Sáros County in the Kingdom of Hungary, today Giraltovce in Slovakia. He was the youngest of six children. In 1883, when he was nine, his family emigrated to the United States and settled on Manhattan’s Lower East Side, the crowded immigrant neighbourhood where hundreds of thousands of Eastern European Jews made their first American homes.
He finished high school and entered the City College of New York intending to become an engineer. A chance encounter in 1892 turned his interest to medicine, and he transferred to Bellevue Hospital Medical College, now part of New York University’s school of medicine, graduating with honours in 1895. He opened a private practice in Wilkes-Barre, Pennsylvania, but found it unsatisfying and restless work.
An epidemic fighter
In 1899 Goldberger joined the US Marine Hospital Service, soon renamed the Public Health Service and an ancestor of today’s National Institutes of Health. His first post was at the Port of New York, examining newly arrived immigrants for infectious diseases such as tuberculosis. Over the next dozen years he went wherever the service needed a detective: Mexico, Puerto Rico, Mississippi and Louisiana, fighting yellow fever, typhus, dengue and typhoid. He caught yellow fever, dengue and typhoid himself in the course of the work.
He gained a reputation for cracking cases that had baffled others, sometimes in days. In 1909 he published research on a skin infection caused by a tiny mite, and with John F. Anderson he studied how measles and typhus spread. When the Surgeon General, Rupert Blue, needed someone for one of the service’s hardest problems, he wrote to Goldberger in February 1914 that he was preeminently fit for the work.
The riddle of pellagra
Pellagra was then sweeping the American South. Its victims suffered what doctors called the four Ds: a scaly, burning rash on skin exposed to the sun, diarrhoea, dementia and, in the end, death. The symptoms came back each spring and worsened every year. Asylums filled with pellagrins whose minds had failed; some sufferers took their own lives rather than face the madness they feared. By 1912 South Carolina alone had reported 30,000 cases. Between about 1906 and 1940 some three million Americans developed the disease and roughly 100,000 died of it.
This was the golden age of germ theory, and most experts assumed pellagra was infectious, spread by insects or poor sanitation, or caused by spoiled corn. In 1912 and 1913 the Thompson-McFadden Commission studied mill villages in Spartanburg County, South Carolina, and concluded that pellagra was a contagious intestinal disease. Goldberger, who had never seen a case, read everything he could and went to look. Within months he noticed what others had missed: in asylums and orphanages the inmates got pellagra but the doctors, nurses and attendants who lived alongside them did not. A germ would not respect that line. Diet would. The sick ate the cheap staples of Southern poverty, the three Ms of meal, meat (fatback) and molasses, while the staff ate better.
Proving it
Goldberger set out to test his idea. With federal funds he added fresh meat, milk, eggs, vegetables and beans to the diet of two orphanages in Jackson, Mississippi, where pellagra was rampant. Within weeks there were no new cases, and almost all the sick children recovered. At the Georgia State Sanitarium, the South’s largest asylum, he ran a study with a control group: patients kept on the usual food went on falling ill, while those given a varied diet recovered. When the money for better food ran out after the studies, pellagra came back.
To show that diet alone could cause the disease, he arranged with Governor Earl Brewer of Mississippi in 1915 to recruit healthy volunteers at the Rankin State Prison Farm, which had no pellagra, in return for pardons. For about six months the men ate a monotonous diet of cornmeal, grits, fat and syrup. Six of the eleven who completed the study developed pellagra. Critics still insisted on infection, so in 1916 Goldberger held what he called filth parties: he, his wife Mary, his assistant and other volunteers swallowed capsules made from the skin scales, excreta and other material of pellagra patients and injected themselves with patients’ blood. None of them got pellagra.
From 1916 he and his team carried out a landmark survey of seven cotton-mill villages in South Carolina, recording what each family ate and earned. Pellagra followed income: the poorest families had many times the rate of the best-paid. The studies are still taught as a model of how economics, social conditions and health intersect.
Resistance in the South
Goldberger’s conclusion was unwelcome. Many doctors were committed to the germ theory, and Southern politicians and newspapers resented a Northern doctor declaring that their region’s disease was a product of its poverty and its sharecropping and mill-wage economy. When cotton prices collapsed in 1920 he publicly warned that pellagra would surge in 1921, and it did; the Public Health Service spoke of a veritable famine developing in the Cotton Belt. His call for food relief was denounced as an insult to Southern honour.
His methods would not pass ethical review today. The Rankin prisoners were offered freedom in exchange for being made ill, some later described their suffering and wanted to quit, and the self-experiments were done without any outside oversight. A modern review in a medical journal notes that his methods fell short of today’s standards, while concluding that his dedication saved and improved innumerable lives.
Brewer’s yeast and the cure
In the 1920s Goldberger turned to finding the missing ingredient, which he called the P-P (pellagra-preventive) factor. Working with dogs, which develop a similar disease called black tongue, he found that brewer’s yeast, cheap enough for the poorest family, prevented and cured the condition. In 1927 the Mississippi River flooded catastrophically, and with it came the threat of mass pellagra among the flood’s survivors. Goldberger oversaw the Red Cross’s distribution of brewer’s yeast across the flooded regions; most pellagrins recovered within weeks. The Red Cross continued the programme for years.
In 1928 he wrote that it was beyond reasonable doubt that pellagra is a vitamin deficiency disease. He did not live to see the factor named. In 1937 Conrad Elvehjem at the University of Wisconsin identified it as nicotinic acid, now called niacin, the B vitamin abundant in yeast.
How it changed the world
Goldberger’s work turned pellagra from a mystery into a preventable disease of poverty, and it pointed public health toward a new kind of remedy: changing what people eat. When the United States prepared for war, President Franklin Roosevelt convened the National Nutrition Conference for Defense in 1941, which led to a programme to enrich wheat flour with vitamins and iron, niacin among them. According to the US Centers for Disease Control and Prevention, better diets, economic recovery and the enrichment of flour with niacin brought the near elimination of pellagra by the end of the 1940s. Today most American doctors have never seen a case.
The lesson reaches far beyond one disease. Enriched flour and fortified foods now protect people in many countries from deficiency diseases, and pellagra still appears where diets collapse, in refugee camps, among people with alcoholism, and in poor regions that depend on untreated maize. Goldberger’s mill-village studies are a founding text of social epidemiology, the science of how poverty itself makes people sick.
Jewish immigrant, American public servant
Goldberger was a Jewish immigrant who rose through the public schools and free City College of New York, and he spent his career in federal service, often far from any Jewish community. The historian Alan Kraut, author of Goldberger’s War, observed that a Jewish doctor from New York who had come from Hungary might seem an odd choice to lead a Southern campaign, but that his experience fighting epidemics, his laboratory skill and his marriage to a Southern woman made him the right one. The hostility he met in the South mixed regional pride, resistance to his message about poverty and suspicion of an outsider.
He was married to Mary, who shared his convictions so completely that she volunteered at the filth parties.
Death and legacy
Goldberger fell ill suddenly and died of kidney cancer in Washington, D.C., in January 1929, at the age of 54. He had devoted fifteen years to pellagra. Congress passed a special bill granting his widow a pension of $125 a month in recognition of the value of his work. He had been nominated for the Nobel Prize four times. His story was told in Paul de Kruif’s 1928 book Hunger Fighters and in a 1940 short film directed by Fred Zinnemann, A Way in the Wilderness, and his papers are held at the National Library of Medicine.
His legacy is measured in the absence of a disease. The asylum wards once filled with pellagrins are gone, and the four Ds have faded into textbook history in the countries that enrich their food. More than that, Goldberger showed that the causes of illness can lie in wages, land and food as much as in microbes, and that a public health officer’s job includes saying so, however unwelcome the message.
Sources & further reading
The unwavering doctor who unraveled a medical mystery, International Journal of Women’s Dermatology (PMC) · The American South’s Deadly Diet, Discover Magazine · Achievements in Public Health, 1900–1999: Safer and Healthier Foods, CDC MMWR · Joseph Goldberger, Wikipedia · Researched from the sources above and checked against them. Spotted an error? Tell us.
A life of tikkun olam. This is part of tikkun olam, the Jewish idea of repairing the world, and every one of us can add to it.